Aims. The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents. Methods. We present a retrospective, matched-pair study of teenagers with anterior glenohumeral instability treated with an arthroscopic Bankart repair (ABR) or an arthroscopic Latarjet (AL) procedure with a minimum two-year follow-up. Preoperative demographic and clinical features, factors associated with dislocation, and complications were collected. Recurrence, defined as dislocation or subluxation, was established as the primary outcome. Clinical and functional outcomes were analyzed using objective (Rowe), and subjective (Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE)) scores. Additionally, the rate of return to sport was assessed. Results. A total of 51 adolescents were included, of whom 46 (92%) were male, with 17 (33%) in the Latarjet group and 34 (66%) in the Bankart group. The mean age at time of surgery was 18 years (15 to 19). There were no intraoperative complications. At a median follow-up of nine years (IQR 2 to 18), recurrence was observed in 12 patients in the Bankart group (35.3%) and one patient in the Latarjet group (5.9%) (p = 0.023). Satisfactory postoperative outcomes were obtained, with mean Rowe, WOSI, and SANE scores noted at 95 (10 to 100), 325 (25 to 1,975), and 87.5 (10 to 100), respectively. Most patients (29 in the Bankart group (85.3%) and 16 in the Latarjet group (94.1%)) were able to return to sport (p = 0.452). Conclusion. The ABR and AL procedures both obtain satisfactory clinical and functional outcomes in the treatment of anterior glenohumeral instability in adolescents with a low complication rate. However, the ABR is associated with a significantly higher recurrence rate. Cite this article: Bone Jt Open 2024;5(11):1041–1048

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Aims

For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis.

Aims. Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group. Methods. The inclusion criteria consisted of patients who underwent simultaneous or staged bilateral TKA after prior unilateral DFO between 1972 and 2023. The type of osteotomy performed, osteotomy hardware fixation, implanted TKA components, and revision rates were recorded. Postoperative outcomes including the Forgotten Joint Score-12 (FJS-12), Tegner Activity Scale score, and subjective knee preference were also obtained at final follow-up. Results. A total of 21 patients underwent bilateral TKA following unilateral DFO and were followed for a mean of 31.5 years (SD 11.1; 20.2 to 74.2) after DFO. The mean time from DFO to TKA conversion was 13.1 years (SD 9.7) with 13 (61.9%) of DFO knees converting to TKA more than ten years after DFO. There was no difference in arthroplasty implant systems employed in both the DFO-TKA and TKA-only knees (p > 0.999). At final follow-up, the mean FJS-12 of the DFO-TKA knee was 62.7 (SD 36.6), while for the TKA-only knee it was 65.6 (SD 34.7) (p = 0.328). In all, 80% of patients had no subjective knee preference or preferred their DFO-TKA knee. Three DFO-TKA knees and two TKA-only knees underwent subsequent revision following index arthroplasty at a mean of 12.8 years (SD 6.9) and 8.5 years (SD 3.8), respectively (p > 0.999). Conclusion. In this self-matched study, DFOs did not affect subsequent TKA function as clinical outcomes, subjective knee preference, and revision rates were similar in both the DFO-TKA and TKA-only knees at mean 32-year follow-up. Cite this article: Bone Jt Open 2024;5(11):1013–1019

Aims. Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation. Methods. This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available. Conclusion. The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care. Cite this article: Bone Jt Open 2024;5(11):1020–1026

Aims. The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair. Methods. We reviewed prospectively collected data from the UK National Ligament Registry for patients who underwent primary ACLR between January 2013 and December 2022. Patients were categorized into five groups: isolated ACLR, ACLR with medial meniscus (MM) repair, ACLR with MM resection, ACLR with lateral meniscus (LM) repair, and ACLR with LM resection. Linear regression analysis, with isolated ACLR as the reference, was performed after adjusting for confounders. Results. From 14,895 ACLR patients, 4,400 had two- or five-year Knee injury and Osteoarthritis Outcome Scores (KOOS) available. At two years postoperatively, the MM repair group demonstrated inferior scores in KOOS pain (β = −3.63, p < 0.001), symptoms (β = − 4.88, p < 0.001), ADL (β = − 2.43, p = 0.002), sport and recreation (β = − 5.23, p < 0.001), quality of life (QoL) (β = − 5.73, p < 0.001), and International Knee Documentation Committee (β = − 4.1, p < 0.001) compared with the isolated ACLR group. The LM repair group was associated with worse KOOS sports and recreation scores at two years (β = − 4.264, p < 0.001). At five years, PROMs were comparable between the groups. At five years, PROMs were comparable between the groups. Participants undergoing ACLR surgery within 12 weeks from index injury demonstrated superior PROMs at two and five years. Conclusion. Our study showed that MM repair, and to a lesser extent LM repairs in combination with ACLR, were associated with inferior patient-reported outcome measures (PROMs) compared to isolated ACLR at two years postoperatively, while meniscal resection groups exhibited comparable outcomes. However, by five years postoperation, no significant differences in PROMs were evident. Further longer-term, cross-sectional studies are warranted to investigate the outcomes of ACLR and concomitant meniscal surgery

Aims. Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. Methods. A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups. Results. A total of 36 patients were included in the study. Group 1 comprised 13 patients, while Group 2 comprised 23 patients. The mean age at index surgery was four years (1 to 13). The mean duration of follow-up was 4.85 years (1.75 to 14). All patients in Group 1 achieved bony union at a mean of three months (1.5 to 4), but ten of 23 patients in Group 2 had nonunion of the pseudarthrosis (p = 0.006). None of the patients in Group 1 had a refracture, while seven of 13 patients who achieved bony union in Group 2 suffered a refracture (p = 0.005). None of the patients in Group 1 had a limb length discrepancy of more than 2 cm, while ten of 23 patients in Group 2 have a limb length discrepancy of more than 2 cm (p = 0.006). In Group 1, four of 13 patients had a complication, while 16 of 23 patients in Group 2 had a complication (p = 0.004). Excluding removal of implants, four of 13 patients in Group 1 had to undergo additional surgery, while 18 of 23 patients in Group 2 had to undergo additional surgery following the index surgery (p = 0.011). Conclusion. A good index surgery of excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for CPT achieves union and minimizes complications such as refractures, limb length discrepancy, and need for additional surgeries

Aims

While residual fixed flexion deformity (FFD) in unicompartmental knee arthroplasty (UKA) has been associated with worse functional outcomes, limited evidence exists regarding FFD changes. The objective of this study was to quantify FFD changes in patients with medial unicompartmental knee arthritis undergoing UKA, and investigate any correlation with clinical outcomes.

Aims. In 2015, we published the results of our ceramic-on-metal (CoM) total hip arthroplasties (THAs) performed between October 2007 and July 2009 with a mean follow-up of 34 months (23 to 45) and a revision rate of 3.1%. The aim of this paper is to present the longer-term outcomes. Methods. A total of 264 patients were reviewed at a mean of 5.8 years (4.6 to 7.2) and 10.1 years (9.2 to 10.6) to determine revision rate, pain, outcome scores, radiological analysis, and blood ion levels. Those who were unwilling or unable to travel were contacted by telephone. Results. The all-cause revision rate at six years was 3.1% (eight THAs), increasing to 8.8% (18 THAs) at ten years. Of these, there were four and then seven bearing-related revisions at six and ten years, respectively. There was a statistically significant deterioration in the visual analogue scale pain score and Oxford Hip Score (OHS) between six and ten years. There were 18 CoM THAs in 17 patients who had a cobalt or chromium level over 4 ppb and ten CoM THAs in nine patients who had a cobalt or chromium level higher than 7 ppb with a statistically significant increase in chromium levels only between the two timepoints. Overall, 84 stems (39.1%) had significant radiolucent lines at ten years compared to 65 (25.5%) at six years. Conclusion. When compared to the original review, there has been a significant deterioration in pain score, OHS, radiograph appearance, and, most critically, survival has fallen to 91.2%, which does not meet the Orthopaedic Data Evaluation Panel (ODEP) 10 A* 95% threshold. Although this bearing is no longer on the market, 2.5% were bearing-related revisions, which have relevance to the discussion around modular dual-mobility implants that have a similar metal interface

Aims

Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA.

Aims. Though most humeral shaft fractures heal nonoperatively, up to one-third may lead to nonunion with inferior outcomes. The Radiographic Union Score for HUmeral Fractures (RUSHU) was created to identify high-risk patients for nonunion. Our study evaluated the RUSHU’s prognostic performance at six and 12 weeks in discriminating nonunion within a significantly larger cohort than before. Methods. Our study included 226 nonoperatively treated humeral shaft fractures. We evaluated the interobserver reliability and intraobserver reproducibility of RUSHU scoring using intraclass correlation coefficients (ICCs). Additionally, we determined the optimal cut-off thresholds for predicting nonunion using the receiver operating characteristic (ROC) method. Results. The RUSHU demonstrated good interobserver reliability with an ICC of 0.78 (95% CI 0.72 to 0.83) at six weeks and 0.77 (95% CI 0.71 to 0.82) at 12 weeks. Intraobserver reproducibility was good or excellent for all analyses. Area under the curve in the ROC analysis was 0.83 (95% CI 0.77 to 0.88) at six weeks and 0.89 (95% CI 0.84 to 0.93) at 12 weeks, indicating excellent discrimination. The optimal cut-off values for predicting nonunion were ≤ eight points at six weeks and ≤ nine points at 12 weeks, providing the best specificity-sensitivity trade-off. Conclusion. The RUSHU proves to be a reliable and reproducible radiological scoring system that aids in identifying patients at risk of nonunion at both six and 12 weeks post-injury during non-surgical treatment of humeral shaft fractures. The statistically optimal cut-off values for predicting nonunion are ≤ eight at six weeks and ≤ nine points at 12 weeks post-injury

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Reconstruction after osteoarticular resection of the proximal ulna for tumours is technically difficult and little has been written about the options that are available. We report a series of four patients who underwent radial neck to humeral trochlea transposition arthroplasty following proximal ulnar osteoarticular resection.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care. Cite this article: Bone Joint J 2024;106-B(11):1206–1215

Aims. We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients. Methods. A retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up. Results. We included 428 primary aTSAs with a mean follow-up of 2.4 years (SD 0.6). Our cohort consisted of 251 non-smokers, 138 former smokers who quit a mean 21 years (SD 14) prior to surgery (25 pack-years (SD 22)), and 39 current smokers (23 pack-years (SD 20)). At two- to four-year follow-up, former smokers had less favourable SPADI, SST, and FE strength compared to non-smokers, and current smokers had less favourable SPADI, SST, ASES score, UCLA score, Constant-Murley score, FE, abduction, and ER strength compared to non-smokers. Non-smokers exhibited higher revision-free survival rates at two, five, eight, and ten years postoperatively compared to former smokers and current smokers, who had similar rates. Conclusion. Our study suggests that smoking has a negative effect on aTSA functional outcomes that may persist even after quitting. Cite this article: Bone Joint J 2024;106-B(11):1263–1272

Aims. A review of the literature on elbow replacement found no consistency in the clinical outcome measures which are used to assess the effectiveness of interventions. The aim of this study was to define core outcome domains for elbow replacement. Methods. A real-time Delphi survey was conducted over four weeks using outcomes from a scoping review of 362 studies on elbow replacement published between January 1990 and February 2021. A total of 583 outcome descriptors were rationalized to 139 unique outcomes. The survey consisted of 139 outcomes divided into 18 domains. The readability and clarity of the survey was determined by an advisory group including a patient representative. Participants were able to view aggregated responses from other participants in real time and to revisit their responses as many times as they wished during the study period. Participants were able to propose additional items for inclusion. A Patient and Public Inclusion and Engagement (PPIE) panel considered the consensus findings. Results. A total of 45 respondents completed the survey. Nine core mandatory domains were identified: ‘return to work or normal daily role’; delivery of care was measured in the domains ‘patient satisfaction with the outcome of surgery’ and ‘would the patient have the same operation again’; ‘pain’; ‘revision’; ‘elbow function’; ‘independence in activities of daily living’; ‘health-related quality of life’; and ‘adverse events’. ‘Elbow range of motion’ was identified as important by consensus but was felt to be less relevant by the PPIE panel. The PPIE panel unanimously stated that pain should be used as the primary outcome domain. Conclusion. This study defined core domains for the clinical outcomes of elbow replacement obtained by consensus from patients, carers, and healthcare professionals. Pain may be used as the primary outcome in future studies, where appropriate. Further work is required to define the instruments that should be used. Cite this article: Bone Joint J 2024;106-B(11):xxx–xxx

Aims. Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA. Methods. MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated. Results. The initial search elicited 3,166 results and, following removal of duplicates and screening, 13 studies with a total of 1,042 RSAs were identified. An increase in shoulder scores pre- to postoperatively was reported in all the studies. Following revision of a RSA to a further RSA, there was a significant increase in the American Shoulder and Elbow Surgeons Score (mean difference 20.78 (95% CI 8.16 to 33.40); p = 0.001). A re-revision rate at final follow-up ranging from 9% to 32%, a one-year re-revision rate of 14%, and a five-year re-revision rate of 23% were reported. The complication rate in all the studies was between 18.5% and 36%, with a total incidence of 29%. Conclusion. This is the largest systematic review of the outcomes following revision of a RSA. We found an improvement in functional outcomes after revision surgery, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure. Cite this article: Bone Joint J 2024;106-B(11):1293–1300

Aims. Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE. Methods. This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE. Results. A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade. Conclusion. The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade. Cite this article: Bone Joint J 2024;106-B(11):1249–1256

Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty.

Cite this article: Bone Joint J 2024;106-B(11):1321–1326.

Aims. In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow. Methods. A total of 11 patients in whom removal of a RHA without reimplantation was undertaken as a revision procedure were reviewed at a mean follow-up of 8.4 years (6 to 11). The range of motion (ROM) and stability of the elbow were recorded. Pain was assessed using a visual analogue scale (VAS). The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiological examination included the assessment of heterotopic ossification (HO), implant loosening, capitellar erosion, overlengthening, and osteoarthritis. Complications and the rate of further surgery were also recorded. Results. The indications for removal of the implant were stiffness in five patients, aseptic loosening in five, and pain attributed to the RHA in three. The mean time interval between RHA for trauma to removal was ten months (7 to 21). Preoperatively, three patients had overlengthening of the implant, three had capitellar erosion, six had HO, and four had radiological evidence of loosening. At the final follow-up, the mean the flexion-extension arc improved significantly by 38.2° (95% CI 20 to 59; p = 0.002) and the mean arc of prono-supination improved significantly by 20° (95% CI 0 to 72.5; p = 0.035). The mean pain VAS score improved significantly by 3.5 (95% CI 2 to 5.5; p = 0.004). The mean MEPS improved significantly by 27.5 (95% CI 17.5 to 42.5; p = 0.002). The mean OES improved significantly by 9 (95% CI 2.5 to 14; p = 0.012), and the mean DASH score improved significantly by 23.5 (95% CI 7.5 to 31.6; p = 0.012). Ten patients (91%) had HO and osteoarthritis. Two patients underwent further surgery due to stiffness and pain, respectively. Conclusion. Simple removal of the implant at revision surgery following a failed RHA introduced following trauma provides satisfactory mid-term results with an acceptable risk of complications. Osteoarthritis, instability, and radioulnar impingement were not problems in this series. Cite this article: Bone Joint J 2024;106-B(11):1327–1332

Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347

Aims

The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids.

Aims

The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different.

Aims. The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature. Methods. A bibliometric search of journals’ online archives and multiple databases was undertaken in March 2024, to identify articles using qualitative research methods in the top 12 trauma and orthopaedic journals based on the 2023 impact factor and SCImago rating. The bibliometric search was conducted and reported in accordance with the preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO). Results. Of the 7,201 papers reviewed, 136 included qualitative methods (0.1%). There was no significant difference between the journals, apart from Bone & Joint Open, which included 21 studies using qualitative methods, equalling 4% of its published articles. Conclusion. This study demonstrates that there is a very low number of qualitative research papers published within trauma and orthopaedic journals. Given the increasing focus on patient outcomes and improving the patient experience, it may be argued that there is a requirement to support both quantitative and qualitative approaches to orthopaedic research. Combining qualitative and quantitative methods may effectively address the complex and personal aspects of patients’ care, ensuring that outcomes align with patient values and enhance overall care quality

Aims

This multicentre retrospective observational study’s aims were to investigate whether there are differences in the occurrence of radiolucent lines (RLLs) following total knee arthroplasty (TKA) between the conventional Attune baseplate and its successor, the novel Attune S+, independent from other potentially influencing factors; and whether tibial baseplate design and presence of RLLs are associated with differing risk of revision.

Aims. The aim of this study was to review the provision of total elbow arthroplasties (TEAs) in England, including the incidence, the characteristics of the patients and the service providers, the types of implant, and the outcomes. Methods. We analyzed the primary TEAs recorded in the National Joint Registry (NJR) between April 2012 and December 2022, with mortality data from the Civil Registration of Deaths dataset. Linkage with Hospital Episode Statistics-Admitted Patient Care (HES-APC) data provided further information not collected by the NJR. The incidences were calculated using estimations of the populations from the Office for National Statistics. The annual number of TEAs performed by surgeons and hospitals was analyzed on a national and regional basis. Results. A total of 3,891 primary TEAs were included. The annual incidence of TEA was between 0.72 and 0.82 per 100,000 persons before 2020 and declined to 0.4 due to a decrease in elective TEAs during the COVID-19 pandemic, with a slight recovery in 2022. Older patients, those of white ethnicity and females, were more likely to undergo TEA. Those who underwent elective TEA had a median wait of between 89 (IQR 41 to 221) and 122 days (IQR 74 to 189) in the years before 2021, and this increased to 183 days (IQR 66 to 350) in 2021. The number of TEAs performed by surgeons per annum remained unchanged, with a median of two (IQR 1 to 3). The median annual number of TEAs per region was three to six times higher than the median annual case load of the highest volume hospital in a region. Patients in the lowest socioeconomic group had a higher rate of serious adverse events and mortality (11%) when undergoing TEA for acute trauma. Conclusion. In England, TEA is more common in older age groups, those of white ethnicity, and females. The COVID-19 pandemic affected the incidence of elective TEA and waiting times, and the provision of TEA has not yet recovered. The Getting it Right First Time recommendation of centralizing services to one centre per region could result in up to a six-fold increase in the number of TEAs being performed in some centres. Cite this article: Bone Joint J 2024;106-B(11):1312–1320

Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Aims

The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years.

Aims. We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR). Methods. We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years). Results. We identified 14,960 DRF patients, 8,339 (55.7%) of whom underwent early surgical fixation (mean 2.9 days (SD 1.8)). In contrast, 4,042 patients (27.0%) underwent delayed fixation between eight and 14 days (mean 10.2 days (SD 2.2)), 1,892 (12.7%) between 14 and 21 days (mean 17.5 days (SD 1.9)) and 687 (4.6%) > 21 days (mean 24.8 days (SD 2.4)) post-fracture. Patients who underwent delayed fixation > 21 days post-fracture had a higher odds of reoperation (odds ratio (OR) 1.33 (95% CI 1.11 to 1.79) vs early fixation). This worsened for patients aged > 60 years (OR 1.69 (95% CI 1.11 to 2.79)). We found no difference in the odds of reoperation for patients who underwent delayed fixation within eight to 14 or 15 to 21 days post-fracture (vs early fixation). Conclusion. These data suggest that DRF patients with fractures with unacceptable reduction following CR should be managed within three weeks to avoid detrimental outcomes. Prospective studies are required to confirm these findings. Cite this article: Bone Joint J 2024;106-B(11):1257–1262

Aims. Machine learning (ML), a branch of artificial intelligence that uses algorithms to learn from data and make predictions, offers a pathway towards more personalized and tailored surgical treatments. This approach is particularly relevant to prevalent joint diseases such as osteoarthritis (OA). In contrast to end-stage disease, where joint arthroplasty provides excellent results, early stages of OA currently lack effective therapies to halt or reverse progression. Accurate prediction of OA progression is crucial if timely interventions are to be developed, to enhance patient care and optimize the design of clinical trials. Methods. A systematic review was conducted in accordance with PRISMA guidelines. We searched MEDLINE and Embase on 5 May 2024 for studies utilizing ML to predict OA progression. Titles and abstracts were independently screened, followed by full-text reviews for studies that met the eligibility criteria. Key information was extracted and synthesized for analysis, including types of data (such as clinical, radiological, or biochemical), definitions of OA progression, ML algorithms, validation methods, and outcome measures. Results. Out of 1,160 studies initially identified, 39 were included. Most studies (85%) were published between 2020 and 2024, with 82% using publicly available datasets, primarily the Osteoarthritis Initiative. ML methods were predominantly supervised, with significant variability in the definitions of OA progression: most studies focused on structural changes (59%), while fewer addressed pain progression or both. Deep learning was used in 44% of studies, while automated ML was used in 5%. There was a lack of standardization in evaluation metrics and limited external validation. Interpretability was explored in 54% of studies, primarily using SHapley Additive exPlanations. Conclusion. Our systematic review demonstrates the feasibility of ML models in predicting OA progression, but also uncovers critical limitations that currently restrict their clinical applicability. Future priorities should include diversifying data sources, standardizing outcome measures, enforcing rigorous validation, and integrating more sophisticated algorithms. This paradigm shift from predictive modelling to actionable clinical tools has the potential to transform patient care and disease management in orthopaedic practice. Cite this article: Bone Joint J 2024;106-B(11):1216–1222

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This study aimed to investigate the optimal sagittal positioning of the uncemented femoral component in total knee arthroplasty to minimize the risk of aseptic loosening and periprosthetic fracture.

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Aims. The aim of this study was to determine whether obesity had a detrimental effect on the long-term performance and survival of medial unicompartmental knee arthroplasties (UKAs). Methods. This study reviewed prospectively collected functional outcome scores and revision rates of all medial UKA patients with recorded BMI performed in Christchurch, New Zealand, from January 2011 to September 2021. Patient-reported outcome measures (PROMs) were the primary outcome of this study, with all-cause revision rate analyzed as a secondary outcome. PROMs were taken preoperatively, at six months, one year, five years, and ten years postoperatively. There were 873 patients who had functional scores recorded at five years and 164 patients had scores recorded at ten years. Further sub-group analysis was performed based on the patient’s BMI. Revision data were available through the New Zealand Joint Registry for 2,323 UKAs performed during this time period. Results. Obese patients (BMI > 30 kg/m. 2. ) were 3.1 years younger than non-obese patients (BMI < 30 kg/m. 2. ) at the time of surgery (mean age of obese patients 65.5 years (SD 9.7) and mean age of non-obese patients 68.6 years (SD 10.1)). Preoperatively, obese patients tended to have significantly lower functional scores than non-obese patients, which continued at five and ten years postoperatively. At these timepoints, obese patients had significantly lower scores for most PROMs measured compared to non-obese patients. However, there was no significant difference in the improvement of any of these scores after surgery between obese and non-obese patients. There was no significant difference in revision rates between obese and non-obese patients at any time. All-cause revision rate for obese patients was 0.73 per 100 observed component years compared to 0.67 in non-obese patients at ten years. There was also no significant difference in the aseptic loosening rate between groups. Conclusion. Our study supports the use of UKAs in obese patients, with similar benefit and survival compared to non-obese patients at ten years

Aims. The aims were to assess whether joint-specific outcome after total knee arthroplasty (TKA) was influenced by implant design over a 12-year follow-up period, and whether patient-related factors were associated with loss to follow-up and mortality risk. Methods. Long-term follow-up of a randomized controlled trial was undertaken. A total of 212 patients were allocated a Triathlon or a Kinemax TKA. Patients were assessed preoperatively, and one, three, eight, and 12 years postoperatively using the Oxford Knee Score (OKS). Reasons for patient lost to follow-up, mortality, and revision were recorded. Results. A total of 94 patients completed 12-year functional follow-up (62 females, mean age 66 years (43 to 82) at index surgery). There was a clinically significantly greater improvement in the OKS at one year (mean difference (MD) 3.0 (95% CI 0.4 to 5.7); p = 0.027) and three years (MD 4.7 (95% CI 1.9 to 7.5); p = 0.001) for the Triathlon group, but no differences were observed at eight (p = 0.331) or 12 years’ (p = 0.181) follow-up. When assessing the OKS in the patients surviving to 12 years, the Triathlon group had a clinically significantly greater improvement in the OKS (marginal mean 3.8 (95% CI 0.2 to 7.4); p = 0.040). Loss to functional follow-up (53%, n = 109/204) was independently associated with older age (p = 0.001). Patient mortality was the major reason (56.4%, n = 62/110) for loss to follow-up. Older age (p < 0.001) and worse preoperative OKS (p = 0.043) were independently associated with increased mortality risk. An age at time of surgery of ≥ 72 years was 75% sensitive and 74% specific for predicting mortality with an area under the curve of 78.1% (95% CI 70.9 to 85.3; p < 0.001). Conclusion. The Triathlon TKA was associated with clinically meaningful greater improvement in knee-specific outcome when compared to the Kinemax TKA. Loss to follow-up at 12 years was a limitation, and studies planning longer-term functional assessment could limit their cohort to patients aged under 72 years. Cite this article: Bone Jt Open 2024;5(10):911–919

Aims. The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups. Methods. A prospectively registered (ISRCTN95922938) randomized parallel group trial will be conducted. Elderly patients meeting the inclusion criteria with a dorsally displaced distal radius facture will be randomized (1:1 ratio) to either conservative management (cast without further manipulation) or surgery. Patients will be assessed at six, 12, 26 weeks, and 52 weeks post intervention. The primary outcome measure and endpoint will be the Patient-Rated Wrist Evaluation (PRWE) at 52 weeks. In addition, the abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH), EuroQol five-dimension questionnaire, pain score (visual analogue scale 1 to 10), complications, grip strength (dynamometer), range of motion (goniometer), and radiological assessments will be undertaken. A cost-utility analysis will be performed to assess the cost-effectiveness of surgery. We aim to recruit 89 subjects per arm (total sample size 178). Discussion. The results of this study will help guide treatment of dorsally displaced distal radial fractures in the elderly and assess whether surgery offers functional benefit to patients. This is an important finding, as the number of elderly distal radial fractures is estimated to increase in the future due to the ageing population. Evidence-based management strategies are therefore required to ensure the best outcome for the patient and to optimize the use of increasingly scarce healthcare resources. Cite this article: Bone Jt Open 2024;5(10):920–928

Aims

This study aimed to define the histopathology of degenerated humeral head cartilage and synovial inflammation of the glenohumeral joint in patients with omarthrosis (OmA) and cuff tear arthropathy (CTA). Additionally, the potential of immunohistochemical tissue biomarkers in reflecting the degeneration status of humeral head cartilage was evaluated.

Aims. The Single Assessment Numerical Evalution (SANE) score is a pragmatic alternative to longer patient-reported outcome measures (PROMs). The purpose of this study was to investigate the concurrent validity of the SANE and hip-specific PROMs in a generalized population of patients with hip pain at a single timepoint upon initial visit with an orthopaedic surgeon who is a hip preservation specialist. We hypothesized that SANE would have a strong correlation with the 12-question International Hip Outcome Tool (iHOT)-12, the Hip Outcome Score (HOS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), providing evidence for concurrent validity of the SANE and hip-specific outcome measures in patients with hip pain. Methods. This study was a cross-sectional retrospective database analysis at a single timepoint. Data were collected from 2,782 patients at initial evaluation with a hip preservation specialist using the iHOT-12, HOS, HOOS, and SANE. Outcome scores were retrospectively analyzed using Pearson correlation coefficients. Results. Mean raw scores were iHOT-12 67.01 (SD 29.52), HOS 58.42 (SD 26.26), HOOS 86.85 (SD 32.94), and SANE 49.60 (SD 27.92). SANE was moderately correlated with the iHOT-12 (r = -0.4; 95% CI -0.35 to -0.44; p < 0.001), HOS (r = 0.57; 95% CI 0.53 to 0.60; p < 0.001), and HOOS (r = -0.55; 95% CI -0.51 to -0.58; p < 0.001). The iHOT-12 and HOOS were recorded as a lower score, indicating better function, which accounts for the negative r values. Conclusion. This study was the first to investigate the relationship between the SANE and the iHOT-12, HOS, and HOOS in a population of patients with hip pain at the initial evaluation with an orthopaedic surgeon, and found moderate correlation between SANE and the iHOT-12, HOS, and HOOS. The SANE may be a pragmatic alternative for clinical benchmarking in a general population of patients with hip pain. The construct validity of the SANE should be questioned compared to legacy measures whose content validity has been more rigorously investigated. Cite this article: Bone Jt Open 2024;5(10):904–910

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The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.

Aims

This study examined the relationship between obesity (OB) and osteoporosis (OP), aiming to identify shared genetic markers and molecular mechanisms to facilitate the development of therapies that target both conditions simultaneously.

Aims. A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL. Methods. A total of 39 patients diagnosed with AL who underwent surgery from January 2004 to December 2022 were retrospectively screened for eligibility. Patients with AL were divided into an MIS group and an OSF group. The primary outcomes were union of the lesion on radiograph and CT, as well as the visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores immediately after surgery, and at the follow-up (mean 29 months (standard error (SE) 9)). The secondary outcomes were total blood loss during surgery, operating time, and improvement in the radiological parameters: global and local kyphosis, sagittal vertical axis, sagittal alignment, and chin-brow vertical angle immediately after surgery and at the follow-up. Results. Data for 30 patients with AL were evaluated: 14 in the MIS group and 16 in the OSF group. All patients were followed up after surgery; no nonunion complications or instrumentation failures were observed in either group. No significant differences in the VAS and ODI scores were identified between the two groups. Mean ODI improved from 51 (SE 5) to 17 (SE 5) in the MIS group and from 52 (SE 6) to 19 (SE 5) in the OSF group at the follow-up. There were significant improvements in total blood loss (p = 0.025) and operating time (p < 0.001) between the groups. There was also no significant difference in local kyphosis six months postoperatively (p = 0.119). Conclusion. Early MIS is an effective treatment for AL. MIS provides comparable clinical outcomes to those treated with OSF, with less total blood loss and shorter operating time. Our results support and identify the feasibility of solid immobilization achieved by posterior instrumentation without bone graft via MIS for the treatment of AL. Cite this article: Bone Jt Open 2024;5(10):886–893

Aims

Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery.

Aims. This study examined windswept deformity (WSD) of the knee, comparing prevalence and contributing factors in healthy and osteoarthritic (OA) cohorts. Methods. A case-control radiological study was undertaken comparing 500 healthy knees (250 adults) with a consecutive sample of 710 OA knees (355 adults) undergoing bilateral total knee arthroplasty. The mechanical hip-knee-ankle angle (mHKA), medial proximal tibial angle (MPTA), and lateral distal femoral angle (LDFA) were determined for each knee, and the arithmetic hip-knee-ankle angle (aHKA), joint line obliquity, and Coronal Plane Alignment of the Knee (CPAK) types were calculated. WSD was defined as a varus mHKA of < -2° in one limb and a valgus mHKA of > 2° in the contralateral limb. The primary outcome was the proportional difference in WSD prevalence between healthy and OA groups. Secondary outcomes were the proportional difference in WSD prevalence between constitutional varus and valgus CPAK types, and to explore associations between predefined variables and WSD within the OA group. Results. WSD was more prevalent in the OA group compared to the healthy group (7.9% vs 0.4%; p < 0.001, relative risk (RR) 19.8). There was a significant difference in means and variance between the mHKA of the healthy and OA groups (mean -1.3° (SD 2.3°) vs mean -3.8°(SD 6.6°) respectively; p < 0.001). No significant differences existed in MPTA and LDFA between the groups, with a minimal difference in aHKA (mean -0.9° healthy vs -0.5° OA; p < 0.001). Backwards logistic regression identified meniscectomy, rheumatoid arthritis, and osteotomy as predictors of WSD (odds ratio (OR) 4.1 (95% CI 1.7 to 10.0), p = 0.002; OR 11.9 (95% CI 1.3 to 89.3); p = 0.016; OR 41.6 (95% CI 5.4 to 432.9), p ≤ 0.001, respectively). Conclusion. This study found a 20-fold greater prevalence of WSD in OA populations. The development of WSD is associated with meniscectomy, rheumatoid arthritis, and osteotomy. These findings support WSD being mostly an acquired condition following skeletal maturity. Cite this article: Bone Jt Open 2024;5(10):879–885

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The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.

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Optimal glenoid positioning in reverse shoulder arthroplasty (RSA) is crucial to provide impingement-free range of motion (ROM). Lateralization and inclination correction are not yet systematically used. Using planning software, we simulated the most used glenoid implant positions. The primary goal was to determine the configuration that delivers the best theoretical impingement-free ROM.

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The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics.

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This study aimed to demonstrate the promoting effect of elastic fixation on fracture, and further explore its mechanism at the gene and protein expression levels.

Aims. This study aims to evaluate the impact of metabolic syndrome in the setting of obesity on in-hospital outcomes and resource use after total joint replacement (TJR). Methods. A retrospective analysis was conducted using the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years and older with obesity (BMI > 30 kg/m. 2. ) who underwent primary TJR were included. Patients were stratified into two groups with and without metabolic syndrome. The inverse probability of treatment weighting (IPTW) method was used to balance covariates. Results. The obese cohort with metabolic syndrome was significantly older, more likely to be female, had higher rates of Medicare insurance, and more likely to be non-Hispanic Black than the obese cohort without metabolic syndrome. In the unweighted analysis, patients with obesity and metabolic syndrome were more likely to experience cardiac, gastrointestinal, genitourinary, and postoperative anemia complications, had a longer length of stay, and were less likely to be discharged home compared to obese patients without metabolic syndrome. After adjusting for covariates using IPTW, patients with obesity and metabolic syndrome were more likely to experience postoperative anemia complications only and had lower rates of home discharge, but there were no significant differences in any other complication variables or length of stay. Conclusion. Given the variability of metabolic health in obesity, the development of tailored perioperative protocols and recommendations acknowledging this variability in metabolic health in obese patients would ultimately potentially benefit patients and improve outcomes of TJR. Cite this article: Bone Jt Open 2024;5(10):837–843

Aims. The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up. Methods. This study included 297 patients undergoing presumed aseptic single-stage revision THA or TKA at a single treatment centre. All patients with at least three UPCs obtained during revision surgery were treated with minimum three months of oral antibiotics following revision surgery. The prevalence of UPCs and causative microorganisms, the recurrence of periprosthetic joint infections (PJIs), and the infection-free implant survival were established at minimum five years’ follow-up (5.1 to 12.3). Results. Of the 297 patients undergoing aseptic revisions, 37 (12.5%) had at least three UPCs obtained during surgery. The UPC cohort included 23 males (62.2%) and 14 females (37.8%), with a mean age of 71.2 years (47 to 82). Comorbidities included smoking (56.8%), hypertension (48.6%), diabetes mellitus (27.0%), and chronic renal impairment (13.5%). The causative microorganisms included Staphylococcus epidermidis (49.6%), Bacillus species (18.9%), Micrococcus species (16.2%), and Cutibacterium acnes (16.2%). None of the study patients with UPCs developed further PJIs or required further surgical intervention during follow-up. Conclusion. The prevalence of UPCs during presumed aseptic revision THA and TKA was 12.5%. The most common causative microorganisms were of low virulence, and included S. epidermidis, Bacillus species, Micrococcus species, and C. acnes. Microorganism-specific antibiotic treatment for minimum three months’ duration of UPCs in presumed aseptic revision arthroplasty was associated with excellent infection-free implant survival at mid-term follow-up. Cite this article: Bone Jt Open 2024;5(10):832–836

Aims

The optimum type of antibiotics and their administration route for treating Gram-negative (GN) periprosthetic joint infection (PJI) remain controversial. This study aimed to determine the GN bacterial species and antibacterial resistance rates related to clinical GN-PJI, and to determine the efficacy and safety of intra-articular (IA) antibiotic injection after one-stage revision in a GN pathogen-induced PJI rat model of total knee arthroplasty.

Aims. Limited implant survival due to aseptic cup loosening is most commonly responsible for revision total hip arthroplasty (THA). Advances in implant designs and materials have been crucial in addressing those challenges. Vitamin E-infused highly cross-linked polyethylene (VEPE) promises strong wear resistance, high oxidative stability, and superior mechanical strength. Although VEPE monoblock cups have shown good mid-term performance and excellent wear patterns, long-term results remain unclear. This study evaluated migration and wear patterns and clinical and radiological outcomes at a minimum of ten years’ follow-up. Methods. This prospective observational study investigated 101 cases of primary THA over a mean duration of 129 months (120 to 149). At last follow-up, 57 cases with complete clinical and radiological outcomes were evaluated. In all cases, the acetabular component comprised an uncemented titanium particle-coated VEPE monoblock cup. Patients were assessed clinically and radiologically using the Harris Hip Score, visual analogue scale (pain and satisfaction), and an anteroposterior radiograph. Cup migration and polyethylene wear were measured using Einzel-Bild-Röntgen-Analyze software. All complications and associated treatments were documented until final follow-up. Results. Clinical assessment showed persistent major improvement in all scores. On radiological assessment, only one case showed a lucent line (without symptoms). At last follow-up, wear and migration were below the critical thresholds. No cup-related revisions were needed, indicating an outstanding survival rate of 100%. Conclusion. Isoelastic VEPE cups offer high success rates and may prevent osteolysis, aseptic loosening, and the need for revision surgeries in the long term. However, longer follow-up is needed to validate our findings and confirm the advantages offered by this cup. Cite this article: Bone Jt Open 2024;5(10):825–831

Aims

We aimed to determine the concentrations of synovial vancomycin and meropenem in patients treated by single-stage revision combined with intra-articular infusion following periprosthetic joint infection (PJI), thereby validating this drug delivery approach.

The subject of noise in the operating theatre was recognized as early as 1972 and has been compared to noise levels on a busy highway. While noise-induced hearing loss in orthopaedic surgery specifically has been recognized as early as the 1990s, it remains poorly studied. As a result, there has been renewed focus in this occupational hazard. Noise level is typically measured in decibels (dB), whereas noise adjusted for human perception uses A-weighted sound levels and is expressed in dBA. Mean operating theatre noise levels range between 51 and 75 dBA, with peak levels between 80 and 119 dBA. The greatest sources of noise emanate from powered surgical instruments, which can exceed levels as high as 140 dBA. Newer technology, such as robotic-assisted systems, contribute a potential new source of noise. This article is a narrative review of the deleterious effects of prolonged noise exposure, including noise-induced hearing loss in the operating theatre team and the patient, intraoperative miscommunication, and increased cognitive load and stress, all of which impact the surgical team’s overall performance. Interventions to mitigate the effects of noise exposure include the use of quieter surgical equipment, the implementation of sound-absorbing personal protective equipment, or changes in communication protocols. Future research endeavours should use advanced research methods and embrace technological innovations to proactively mitigate the effects of operating theatre noise.

Cite this article: Bone Joint J 2024;106-B(10):1039–1043.

Aims. A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition. Methods. A total of 91 patients were assessed for this trial, of whom 45 were subsequently included and randomized into two groups. One patient was lost to follow-up, leaving 22 patients (24 feet) in each group. The patients in the hyaluronic acid group were treated with three ultrasound-guided injections (one per week) of hyaluronic acid (Osteonil Plus). Those in the corticosteroid group were treated with three ultrasound-guided injections (also one per week) of triamcinolone (Triancil). The patients were evaluated before treatment and at one, three, six, and 12 months after treatment. The primary outcome measure was the visual analogue scale for pain (VAS). Secondary outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complications. Results. Both groups showed significant improvement in VAS and AOFAS scores (p < 0.05) after 12 months. The corticosteroid group had a significantly greater reduction in VAS and increase in AOFAS scores compared with the hyaluronic acid group, at one, three, and six months, but with no significant difference at 12 months. There were no complications in the hyaluronic acid group. There were minor local complications in six patients (six feet) (25.0%) in the corticosteroid group, all with discolouration of the skin at the site of the injection. These minor complications might have been due to the three weekly injections of a relatively high dose of corticosteroid. No patient subsequently underwent excision of the neuroma. Conclusion. An ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton’s neuroma at many timepoints. Thus, a corticosteroid injection should be regarded as a primary option in the treatment of these patients, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated. Cite this article: Bone Joint J 2024;106-B(10):1093–1099

The October 2024 Shoulder & Elbow Roundup360 looks at: Proximal humeral fractures with vascular compromise; Outcomes and challenges of revision arthroscopic rotator cuff repair: a systematic review; Evaluating treatment effectiveness for lateral elbow tendinopathy: a systematic review and network meta-analysis; Tendon transfer techniques for irreparable subscapularis tears: a comparative review; Impact of subscapularis repair in reverse shoulder arthroplasty; Isolated subscapularis tears strongly linked to shoulder pseudoparesis; Nexel and Coonrad-Morrey total elbow arthroplasties show comparable revision rates in New Zealand study; 3D MRI matches 3D CT in assessing bone loss and shoulder morphology in dislocation cases.

The October 2024 Arthroplasty Roundup³⁶⁰ looks at: Breaking the mould: female representation in arthroplasty surgery remains low, with elbow leading the way; Post COVID-19: where are we with the 'catch up' in England and Wales?; Prevalence and clinical impact of sarcopenia in patients undergoing total joint replacement: a systematic review and a meta-analysis; Total joint replacement and sleep: the state of the evidence.

The October 2024 Children’s orthopaedics Roundup. 360. looks at: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures: the FORCE trial; Percutaneous Achilles tendon tenotomy in clubfoot with a blade or a needle: a single-centre randomized controlled noninferiority trial; Treatment of hip displacement in children with cerebral palsy: a five-year comparison of proximal femoral osteotomy and combined femoral-pelvic osteotomy in 163 children; The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients; Retention versus removal of epiphyseal screws in paediatric distal tibial fractures: no significant impact on outcomes; Predicting the resolution of residual acetabular dysplasia after brace treatment in infant DDH; Low prevalence of acetabular dysplasia following treatment for neonatal hip instability: a long-term study; How best to distract the patient?

The October 2024 Trauma Roundup. 360. looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims. Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery. Methods. A systematic review and meta-analysis was performed using the PubMed, EMBASE, Orthosearch, and Cochrane databases with the following search terms: ((shoulder or glenohumeral) and (dislocation or subluxation) and arthroscopic and (Bankart or stabilisation or stabilization) and (redislocation or re-dislocation or recurrence or instability)). Methodology followed the PRISMA guidelines. Data and outcomes were synthesized by two independent reviewers, and papers were assessed for bias and quality. Results. Overall, 35 studies including 7,995 shoulders were eligible for analysis, with a mean follow-up of 32.7 months (12 to 159.5). The rate of post-stabilization instability was 9.8% in first-time dislocators, 9.1% in recurrent dislocators, and 8.5% in a mixed cohort. A descriptive analysis investigated the influence of recurrent instability or age in the risk of instability post-stabilization, with an association seen with increasing age and a reduced risk of recurrence post-stabilization. Conclusion. Using modern arthroscopic techniques, patients sustaining an anterior shoulder dislocation without glenoid bone loss can expect a low risk of recurrence postoperatively, and no significant difference was found between first-time and recurrent dislocators. Furthermore, high-risk cohorts can expect a low, albeit slightly higher, rate of redislocation. With the findings of this study, patients and clinicians can be more informed as to the likely outcomes of arthroscopic stabilization within this patient subset. Cite this article: Bone Joint J 2024;106-B(10):1141–1149

Aims

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months.

Aims

The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA.

The October 2024 Knee Roundup. 360. looks at: Managing the unexpected: treatment of intraoperative medial collateral ligament injuries; Identifying subgroups of patients that may benefit from robotic arm-assisted total knee arthroplasty: secondary analysis of data from a randomized controlled trial; Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial; Cartilage regeneration and long-term survival in medial knee osteoarthritis patients treated with high tibial osteotomy and osteochondral autologous transfer system; Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes; Long-term outcomes of multiligament knee injuries in American football players

The October 2024 Foot & Ankle Roundup³⁶⁰ looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?.

Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

Aims. This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification. Methods. We conducted a retrospective analysis of 162 knees (162 patients) that received treatment for PJI post-TKA with combined IV and topical antibiotic infusions at a single academic hospital from 1 January 2010 to 31 December 2022. The incidence of AKI was evaluated using the KDIGO criteria, focussing on the identification of significant predictors and the temporal pattern of AKI development. Results. AKI was identified in 9.26% (15/162) of the cohort, predominantly presenting as stage 1 AKI, which was transient in nature and resolved prior to discharge. The analysis highlighted moderate anaemia and lower baseline serum creatinine levels as significant predictors for the development of AKI. Notably, the study found no instances of severe complications such as wound dehiscence, skin erosion, or the need for haemodialysis following treatment. Conclusion. The findings suggest that the combined use of IV and topical antibiotic therapy in the management of PJIs post-TKA is associated with a low incidence of primarily transient stage 1 AKI. This indicates a potentially favourable renal safety profile, advocating for further research to confirm these outcomes and potentially influence treatment protocols in PJI management. Cite this article: Bone Joint Res 2024;13(10):525–534

Aims. The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care. Methods. An established Delphi approach with predetermined steps and degree of agreement based on a standardized protocol was used to determine consensus. The steering group members and Delphi survey participants included members from the British Society of Children’s Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP). The statements included definition, assessment, treatment indications, nonoperative and operative interventions, and outcomes. Descriptive statistics were used for analysis of the Delphi survey results. The AGREE checklist was followed for reporting the results. Results. A total of 227 participants (54% APCP and 46% BSCOS members) completed the first round, and 222 participants (98%) completed the second round. Out of 54 proposed statements included in the first round Delphi, 17 reached ‘consensus in’, no statements reached ‘consensus out’, and 37 reached ‘no consensus’. These 37 statements were then discussed, reworded, amalgamated, or deleted before the second round Delphi of 29 statements. A total of 12 statements reached ‘consensus in’, four ‘consensus out’, and 13 ‘no consensus’. In the final consensus meeting, 13 statements were voted upon. Five were accepted, resulting in a total of 31 approved statements. Conclusion. In the aspects of practice where sufficient evidence is not available, a consensus statement can provide a strong body of opinion that acts as a benchmark for excellence in clinical care. This statement can assist clinicians managing children with ITW to ensure consistent and reliable practice, and reduce geographical variability in practice and outcomes. It will enable those treating ITW to share the published consensus document with both carers and patient groups. Cite this article: Bone Joint J 2024;106-B(10):1190–1196

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available. Cite this article: Bone Joint J 2024;106-B(10):1100–1110

Aims. The Coronal Plane Alignment of the Knee (CPAK) classification has been developed to predict individual variations in inherent knee alignment. The impact of preoperative and postoperative CPAK classification phenotype on the postoperative clinical outcomes of total knee arthroplasty (TKA) remains elusive. This study aimed to examine the effect of postoperative CPAK classification phenotypes (I to IX), and their pre- to postoperative changes on patient-reported outcome measures (PROMs). Methods. A questionnaire was administered to 340 patients (422 knees) who underwent primary TKA for osteoarthritis (OA) between September 2013 and June 2019. A total of 231 patients (284 knees) responded. The ­Knee Society Score 2011 (KSS 2011), Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), and Forgotten Joint Score-12 (FJS-12) were used to assess clinical outcomes. Using preoperative and postoperative anteroposterior full-leg radiographs, the arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated and classified based on the CPAK classification. To investigate the impact on PROMs, multivariable regression analyses using stepwise selection were conducted, considering factors such as age at surgery, time since surgery, BMI, sex, implant use, postoperative aHKA classification, JLO classification, and changes in aHKA and JLO classifications from preoperative to postoperative. Results. The preoperative and postoperative CPAK classifications were predominantly phenotype I (155 knees; 55%) and phenotype V (73 knees; 26%), respectively. The change in the preoperative to postoperative aHKA classification was a significant negative predictive factor for KOOS-12 and FJS-12, while postoperative apex proximal JLO was a significant negative predictive factor for KSS 2011 and KOOS-12. Conclusion. In primary TKA for OA, preoperative and postoperative CPAK phenotypes were associated with PROMs. Alteration in varus/valgus alignment from preoperative to postoperative was recognized as a negative predictive factor for both KOOS-12 and FJS-12. Moreover, the postoperative apex proximal JLO was identified as a negative factor for KSS 2011 and KOOS-12. Determining the target alignment for each preoperative phenotype with reproducibility could improve PROMs. Cite this article: Bone Joint J 2024;106-B(10):1059–1066

Aims. To determine whether obesity and malnutrition have a synergistic effect on outcomes from skeletal trauma or elective orthopaedic surgery. Methods. Electronic databases including MEDLINE, Global Health, Embase, Web of Science, ScienceDirect, and PEDRo were searched up to 14 April 2024, as well as conference proceedings and the reference lists of included studies. Studies were appraised using tools according to study design, including the Oxford Levels of Evidence, the Institute of Health Economics case series quality appraisal checklist, and the CLARITY checklist for cohort studies. Studies were eligible if they reported the effects of combined malnutrition and obesity on outcomes from skeletal trauma or elective orthopaedic surgery. Results. A total of eight studies (106,319 patients) were included. These carried moderate to high risk of bias. Combined obesity and malnutrition did not lead to worse outcomes in patients undergoing total shoulder arthroplasty or repair of proximal humeral fractures (two retrospective cohort studies). Three studies (two retrospective cohort studies, one case series) found that malnourishment and obesity had a synergistic effect and led to poor outcomes in total hip or knee arthroplasty, including longer length of stay and higher complication rates. One retrospective cohort study pertaining to posterior lumbar fusion found that malnourished obese patients had higher odds of developing surgical site infection and sepsis, as well as higher odds of requiring a revision procedure. Conclusion. Combined malnutrition and obesity have a synergistic effect and lead to poor outcomes in lower limb procedures. Appropriate preoperative optimization and postoperative care are required to improve outcomes in this group of patients. Cite this article: Bone Joint J 2024;106-B(10):1044–1049

The October 2024 Spine Roundup³⁶⁰ looks at: Analysis of risk factors for non-fusion of bone graft in anterior cervical discectomy and fusion: a clinical retrospective study; Does paraspinal muscle mass predict lumbar lordosis before and after decompression for degenerative spinal stenosis?; Return to work after surgery for lumbar disk herniation: a nationwide registry-based study; Can the six-minute walking test assess ambulatory function impairment in patients with cervical spondylotic myelopathy?; Complications after adult deformity surgery: losing more than sleep; Frailty limits how good we can get in adult spine deformity surgery.

The Cochrane Collaboration has produced three new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner. These are relevant to a wide range of musculoskeletal specialists, and include reviews in lateral elbow pain, osteoarthritis of the big toe joint, and cervical spine injury in paediatric trauma patients.

Aims

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model.

Aims. To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome. Methods. This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients’ odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates. Results. A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%). Conclusion. Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates. Cite this article: Bone Joint J 2024;106-B(10):1182–1189

The October 2024 Research Roundup. 360. looks at: Fracture risk among stroke survivors according to post-stroke disability status and stroke type; Noise-induced hearing loss: should surgeons be wearing ear protection during primary total joint replacement?; Intravenous dexamethasone in hip arthroscopy can enhance recovery; Patient-reported outcomes following periprosthetic joint infection of the hip and knee: a longitudinal, prospective observational study; When should surgery take place after weight loss?; Which type of surgery is the hardest physically and mentally?

Aims. The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Methods. Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Results. Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Conclusion. Irrespective of the patient’s age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved. Cite this article: Bone Joint J 2024;106-B(10):1158–1164

Aims

This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder.

Aims. The aims of this study were to validate the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds for Western Ontario Shoulder Instability Index (WOSI), Rowe score, American Shoulder and Elbow Surgeons (ASES), and visual analogue scale (VAS) scores following arthroscopic Bankart repair, and to identify preoperative threshold values of these scores that could predict the achievement of MCID and PASS. Methods. A retrospective review was conducted on 131 consecutive patients with anterior shoulder instability who underwent arthroscopic Bankart repair between January 2020 and January 2023. Inclusion criteria required at least one episode of shoulder instability and a minimum follow-up period of 12 months. Preoperative and one-year postoperative scores were assessed. MCID and PASS were estimated using distribution-based and anchor-based methods, respectively. Receiver operating characteristic curve analysis determined preoperative patient-reported outcome measure thresholds predictive of achieving MCID and PASS. Results. MCID thresholds were determined as 169.6, 6.8, 7.2, and 1.1 for WOSI, Rowe, ASES, and VAS, respectively. PASS thresholds were calculated as ≤ 480, ≥ 80, ≥ 87, and ≤ 1 for WOSI, Rowe, ASES, and VAS, respectively. Preoperative thresholds of ≥ 760 (WOSI) and ≤ 50 (Rowe) predicted achieving MCID for WOSI score (p < 0.001). Preoperative thresholds of ≤ 60 (ASES) and ≥ 2 (VAS) predicted achieving MCID for VAS score (p < 0.001). A preoperative threshold of ≥ 40 (Rowe) predicted achieving PASS for Rowe score (p = 0.005). Preoperative thresholds of ≥ 50 (ASES; p = 0.002) and ≤ 2 (VAS; p < 0.001) predicted achieving PASS for the ASES score. Preoperative thresholds of ≥ 43 (ASES; p = 0.046) and ≤ 4 (VAS; p = 0.024) predicted achieving PASS for the VAS. Conclusion. This study defined MCID and PASS values for WOSI, Rowe, ASES, and VAS scores in patients undergoing arthroscopic Bankart repair. Higher preoperative functional scores may reduce the likelihood of achieving MCID but increase the likelihood of achieving the PASS. These findings provide valuable guidance for surgeons to counsel patients realistically regarding their expectations. Cite this article: Bone Joint J 2024;106-B(10):1118–1124

The October 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Does the primary surgical approach matter when choosing the approach for revision total hip arthroplasty?; Time to achieve the minimal clinically important difference in primary total hip arthroplasty: comparison of anterior and posterior surgical approaches; To scope or not to scope: arthroscopy as an adjunct to PAO does not provide better clinical outcomes at one year than PAO alone; Re-exploring horizons in hip resurfacing: two-year results of a ceramic-on-ceramic hip resurfacing; Association between tranexamic acid and decreased periprosthetic joint infection risk in patients undergoing total hip and knee arthroplasty; Octogenarians fare well: in revision for infection age is not a bar.

The October 2024 Wrist & Hand Roundup360 looks at: Circumferential casting versus plaster splinting in preventing redisplacement of distal radial fractures; Comparable outcomes for operative versus nonoperative treatment of scapholunate ligament injuries in distal radius fractures; Perceived pain during the reduction of Colles fracture without anaesthesia; Diagnostic delays and physician training are key to reducing scaphoid fracture nonunion; Necrotizing fasciitis originating in the hand: a systematic review and meta-analysis; Study design influences outcomes in distal radial fracture research; Long-term results of index finger pollicization for congenital thumb anomalies: a systematic review; Enhancing nerve injury diagnosis: the evolving role of imaging and electrodiagnostic tools

The October 2024 Oncology Roundup. 360. looks at: Composite reconstruction: is it the answer for pelvic resections?; Can the cartilaginous thickness determine the risk of malignancy in pelvic cartilaginous tumours, and how accurate is the preoperative biopsy of these tumours?; Incidence and survival outcomes of patients with high-grade appendicular bone sarcoma and isolated regional lymph node metastasis; Improved metastatic-free survival after systematic re-excision following complete macroscopic unplanned excision of limb or trunk soft-tissue sarcoma; UK guidelines for the management of soft-tissue sarcomas; Current management of desmoid tumours: a review

Aims. The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS. Methods. From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients’ scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs. Results. A total of 62.3% (1,611/2,586) of the cohort met the criteria for MetS. Both groups showed similar increase in mean OHS (MetS group 22.5 (95% CI 21.8 to 23.1), non-MetS group 22.1 (21.3 to 22.8); p = 0.477) and mean OKS (MetS group 18.0 (17.4 to 18.6), non-MetS group 17.8 (17.0 to 18.7); p = 0.722) at 12 months' follow-up. Between groups, similar improvements were seen for OHS and OKS at three and 24 months postoperatively and for the mean EQ-5D-5L, EuroQol-visual analogue scale (EQ-VAS), UCLA Activity Scale, and FJS at every timepoint. Conclusion. Patients meeting the criteria for MetS obtain the same improvement in PROM scores as individuals without MetS up to 24 months after hip and knee arthroplasty. This is important for the clinician to take into account when assessing and advising patients with MetS. Cite this article: Bone Joint J 2024;106-B(10):1074–1083

Aims. This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening. Methods. We conducted a cohort study of first-time, single-stage revision hip arthroplasties (RHAs) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome. Results. Among 12,961 RHAs there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant’s first RHA (hazard ratio (HR) 1.56 (95% CI 1.15 to 2.12)) and remained significantly elevated for their first 24 cases (HR 1.26 (95% CI 1.00 to 1.58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1.28 (95% CI 1.00 to 1.64)) and 80% greater risk of 90-day mortality (HR 1.81 (95% CI 1.02 to 3.21)) compared to volumes of 20/year. RHAs performed at hospitals which had cumulatively undertaken fewer than 167 RHAs were at up to 70% greater risk of re-revision (HR 1.70 (95% CI 1.12 to 2.59)), and those having undertaken fewer than 307 RHAs were at up to three times greater risk of 90-day mortality (HR 3.05 (95% CI 1.19 to 7.82)). Conclusion. This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHA for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralization of such cases towards higher-volume units and surgeons. Cite this article: Bone Joint J 2024;106-B(10):1050–1058

Aims

This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures.

Aims

To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation.

Aims. The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years. Methods. First MTPJ arthritis was radiologically graded according to the Hattrup and Johnson (HJ) classification. Preoperative and sequential postoperative patient-reported outcome measures (PROMs) were evaluated using the Manchester-Oxford Foot Questionnaire (MOXFQ), and the activities of daily living (ADL) sub-section of the Foot and Ankle Ability Measure (FAAM). Results. Patients were followed up for a mean of 66 months (SD 7.1). Of an initial 66 cases, 16 did not return PROM questionnaires. A total of six failures were noted, with survival of 82%. Overall, significant improvement in both objective scores (MOXFQ and FAAM ADL) was maintained versus preoperatively: 18.2 versus 58.0 (p > 0.001) and 86.2 versus 41.1 (p > 0.001), respectively. The improvement was noted to be less pronounced in males. Subjective scores had deteriorated since early follow-up, with an interval decrease in patient satisfaction from 89% to 68%. Furthermore, a subset of cases demonstrated clinically important interval deterioration in objective scores. However, no specific patient factors were found to be associated with outcomes following analysis. Conclusion. This study represents the longest-term independent follow-up in the literature. It shows reassuring mid-term efficacy of the Cartiva SCI with better-than-expected survival. However, deterioration in scores for a subset of patients and lower satisfaction may predict ongoing failure in this group of patients. Additionally, males were noted to have a lower degree of improvement in scores than females. As such, ongoing observation of the SCI to assess durability and survivability, and identify predictive factors, is key to improving patient selection. Cite this article: Bone Jt Open 2024;5(9):799–805

Aims

Rotator cuff disease (RCD) can considerably decrease quality of life. Here, we investigated whether health-related quality of life (HRQoL) influences the need for surgery in patients with RCD.

Aims. In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance. Methods. A total of 30 patients (60 hips) were included in this study. MRN scans of the pelvis were performed before surgery. The contracture band shape and external rotation angle (ERA) of the proximal femur were also analyzed. Then, the minimally invasive GMC releasing surgery was performed based on the images and measurements, and during the operation, incision lengths, surgery duration, intraoperative bleeding, and complications were recorded; the time of the first postoperative off-bed activity was also recorded. Furthermore, the patients’ clinical functions were evaluated by means of Hip Outcome Score (HOS) and Ye et al’s objective assessments, respectively. Results. The contracture bands exhibited three typical types of shape – feather-like, striped, and mixed shapes – in MR images. Guided by MRN images, we designed minimally invasive approaches directed to each hip. These approaches resulted in a shortened incision length in each hip (0.3 cm (SD 0.1)), shorter surgery duration (25.3 minutes (SD 5.8)), less intraoperative bleeding (8.0 ml (SD 3.6)), and shorter time between the end of the operation and the patient’s first off-bed activity (17.2 hours (SD 2.0)) in each patient. Meanwhile, no serious postoperative complications occurred in all patients. The mean HOS-Sports subscale of patients increased from 71.0 (SD 5.3) to 94.83 (SD 4.24) at six months postoperatively (p < 0.001). The follow-up outcomes from all patients were “good” and “excellent”, based on objective assessments. Conclusion. Preoperative MRN analysis can be used to facilitate the determination of the relationship between contracture band and normal tissues. The minimally invasive surgical design via MRN can avoid nerve damage and improve the release effect. Cite this article: Bone Jt Open 2024;5(9):776–784

Aims

To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design.

Aims. The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. Methods. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. Results. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Conclusion. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus. Cite this article: Bone Jt Open 2024;5(9):785–792

Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

Aims

Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments.

Aims

This study aimed to analyze kinematics and kinetics of the tibiofemoral joint in healthy subjects with valgus, neutral, and varus limb alignment throughout multiple gait activities using dynamic videofluoroscopy.