Aims. Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. Methods. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages. Results. The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively. Conclusion. Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture. Cite this article: Bone Joint J 2023;105-B(7):801–807

Objectives. To review the systemic impact of smoking on bone healing as evidenced within the orthopaedic literature. Methods. A protocol was established and studies were sourced from five electronic databases. Screening, data abstraction and quality assessment was conducted by two review authors. Prospective and retrospective clinical studies were included. The primary outcome measures were based on clinical and/or radiological indicators of bone healing. This review specifically focused on non-spinal orthopaedic studies. Results. Nine tibia studies and eight other orthopaedic studies were considered for systematic review. Of these 17 studies, 13 concluded that smoking negatively influenced bone healing. Conclusions. Smoking has a negative effect on bone healing, in terms of delayed union, nonunion and more complications

Aims. Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients. Patients and Methods. Between September 2013 and July 2014 we conducted a prospective cohort study in which 127 consecutive patients undergoing a planned foot and ankle arthrodesis or osteotomy were included. Patients self-reported their smoking status and were classified as: ‘never smoked’ (61 patients), ‘ex-smoker’ (46 patients), or ‘current smoker’ (20 patients). Urine samples were analysed with cotinine assays and cotinine dipstick tests. Results. There was a high degree of concordance between dipstick and assay results (Kappa coefficient = 0.842, p < 0.001). Compared with the quantitative assay, the dipstick had a sensitivity of 88.9% and a specificity of 97.3%. Patients claiming to have stopped smoking just before surgery had the highest rate of disagreement between reported smoking status and urine testing. Conclusion. Urine cotinine dipstick testing is cheap, fast, reliable, and easy to use. It may be used in place of a quantitative assay as a screening tool for detecting patients who may be smoking. A positive test may be used as a trigger for further assessment and counselling. Cite this article: Bone Joint J 2016;98-B:1418–24

Periosteum is important for bone homoeostasis through the release of bone morphogenetic proteins (BMPs) and their effect on osteoprogenitor cells. Smoking has an adverse effect on fracture healing and bone regeneration. The aim of this study was to evaluate the effect of smoking on the expression of the BMPs of human periosteum. Real-time polymerase chain reaction was performed for BMP-2,-4,-6,-7 gene expression in periosteal samples obtained from 45 fractured bones (19 smokers, 26 non-smokers) and 60 non-fractured bones (21 smokers, 39 non-smokers). A hierarchical model of BMP gene expression (BMP-2 > BMP-6 > BMP-4 > BMP-7) was demonstrated in all samples. When smokers and non-smokers were compared, a remarkable reduction in the gene expression of BMP-2, -4 and -6 was noticed in smokers. The comparison of fracture and non-fracture groups demonstrated a higher gene expression of BMP-2, -4 and -7 in the non-fracture samples. Within the subgroups (fracture and non-fracture), BMP gene expression in smokers was either lower but without statistical significance in the majority of BMPs, or similar to that in non-smokers with regard to BMP-4 in fracture and BMP-7 in non-fracture samples. In smokers, BMP gene expression of human periosteum was reduced, demonstrating the effect of smoking at the molecular level by reduction of mRNA transcription of periosteal BMPs. Among the BMPs studied, BMP-2 gene expression was significantly higher, highlighting its role in bone homoeostasis

Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee. The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p < 0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p < 0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson’s correlation coefficient −0.65, p = 0.004). These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure

We sought to determine whether smoking affected the outcome of reconstruction of the anterior cruciate ligament. We analysed the results of 66 smokers (group 1 with a mean follow-up of 5.67 years (1.1 to 12.7)) and 238 non-smokers (group 2 with a mean follow-up of 6.61 years (1.2 to 11.5)), who were statistically similar in age, gender, graft type, fixation and associated meniscal and chondral pathology. The assessment was performed using the International Knee Documentation Committee form and serial cruciometer readings. Poor outcomes were reported in group 1 for the mean subjective International Knee Documentation Committee score (p < 0.001), the frequency (p = 0.005) and intensity (p = 0.005) of pain, a side-to-side difference in knee laxity (p = 0.001) and the use of a four-strand hamstring graft (p = 0.015). Patients in group 1 were also less likely to return to their original level of pre-injury sport (p = 0.003) and had an overall worse final 7 International Knee Documentation Committee grade score (p = 0.007). Despite the well-known negative effects of smoking on tissue healing, the association with an inferior outcome after reconstruction of the anterior cruciate ligament has not previously been described and should be included in the pre-operative counselling of patients undergoing the procedure

We reviewed 87 patients who had undergone expansive cervical laminoplasty between 1999 and 2005. These were divided into two groups: those who had diabetes mellitus and those who did not. There were 31 patients in the diabetes group and 56 in the control group. Although a significant improvement in the Japanese Orthopaedic Association score was seen in both groups, the post-operative recovery rate in the control group was better than that of the diabetic group. The patients’ age and symptom duration adversely affected the rate of recovery in the diabetic group only. Smoking did not affect the outcome in either group. A logistic regression analysis found diabetes and signal changes in the spinal cord on MRI to be significant risk factors for a poor outcome (odds ratio 2.86, 3.02, respectively). Furthermore, the interaction of diabetes with smoking and/or age increased this risk. We conclude that diabetes mellitus, or the interaction of this with old age, can adversely affect outcome after cervical laminoplasty. However, smoking alone cannot be regarded as a risk factor

Aims. Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing. Methods. We established a custom-made chamber with airflow for rats to inhale cigarette smoke continuously, and tested our hypothesis using a femoral osteotomy model, radiograph and microCT imaging, and various biomechanical and biological tests. Results. In the smoking group, Western blot analysis and immunohistochemical staining revealed less expression of vascular endothelial growth factor (VEGF) and von Willebrand factor (vWF). The smoking group also had a lower microvessel density than the control group. Image and biochemical analysis also demonstrated delayed bone healing. Conclusion. Cigarette smoke inhalation was associated with decreased expression of angiogenic markers in the early bone healing phase and with impaired bone healing. Cite this article:Bone Joint Res. 2020;9(3):99–107

We investigated the association of Dupuytren’s contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire. Dupuytren’s contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytren’s contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa. Smoking increases the risk of developing Dupuytren’s contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily

Objectives. The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular. Methods. English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers. Results. Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health. Conclusion. The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures. Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255–265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1

Smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. We studied 811 consecutive patients who had undergone hip or knee arthroplasty, recording current smoking and drinking habits, any history of chronic disease and such intraoperative factors as the type of anaesthesia and the type and duration of surgery. We recorded any postoperative complications occurring before discharge from hospital. There were 232 smokers (28.6%) and 579 non-smokers. We found that smoking was the single most important risk factor for the development of postoperative complications, particularly those relating to wound healing, cardiopulmonary complications, and the requirement of postoperative intensive care. A delay in discharge from hospital was usual for those suffering a complication. In those patients requiring prolonged hospitalisation (> 15 days) the proportion of smokers with wound complications was twice that of non-smokers

Aims. This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. . Methods . We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. . Results . The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. Discussion. Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. Take home message: Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion. Cite this article: Bone Joint J 2016;98-B:125–30

Aims. Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle. Patients and Methods. We retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. The primary outcome was the rate of deep infection and the secondary outcome was any surgical site infection (SSI). Associations with the risk factors and possible confounding variables were analysed univariably and multivariably with backwards elimination. Results. A total of 1043 patients were included; 64 (6.1%) had a deep infection and 146 (14.0%) had SSI. Obesity was strongly associated with both outcomes (odds ratio (OR) 2.21, p = 0.017 and OR 1.68, p = 0.032) in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses. Surprisingly, smoking did not yield statistically significant associations with infections. Conclusion. These findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle. This large study brings new evidence concerning these common risk factors; although prospective studies are needed to confirm causality. Cite this article: Bone Joint J 2017;99-B:225–30

Objectives

The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management.

The April 2024 Wrist & Hand Roundup. 360. looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique

Aims. Thresholds of acceptable early migration of the components in total knee arthroplasty (TKA) have traditionally ignored the effects of patient and implant factors that may influence migration. The aim of this study was to determine which of these factors are associated with overall longitudinal migration of well-fixed tibial components following TKA. Methods. Radiostereometric analysis (RSA) data over a two-year period were available for 419 successful primary TKAs (267 cemented and 152 uncemented in 257 female and 162 male patients). Longitudinal analysis of data using marginal models was performed to examine the associations of patient factors (age, sex, BMI, smoking status) and implant factors (cemented or uncemented, the size of the implant) with maximum total point motion (MTPM) migration. Analyses were also performed on subgroups based on sex and fixation. Results. In the overall group, only fixation was significantly associated with migration (p < 0.001). For uncemented tibial components in males, smoking was significantly associated with lower migration (p = 0.030) and BMI approached significance (p = 0.061). For females with uncemented components, smoking (p = 0.081) and age (p = 0.063) approached significance and were both associated with increased migration. The small number of self-reported smokers in this study warrants cautious interpretation and further investigation. For cemented components in females, larger sizes of tibial component were significantly associated with increased migration (p = 0.004). No factors were significant for cemented components in males. Conclusion. The migration of uncemented tibial components was more sensitive to patient factors than cemented implants. These differences were not consistent by sex, suggesting that it may be of value to evaluate female and male patients separately following TKA. Cite this article: Bone Joint J 2022;104-B(4):444–451

Aims. Mendelian randomization (MR) is considered to overcome the bias of observational studies, but there is no current meta-analysis of MR studies on rheumatoid arthritis (RA). The purpose of this study was to summarize the relationship between potential pathogenic factors and RA risk based on existing MR studies. Methods. PubMed, Web of Science, and Embase were searched for MR studies on influencing factors in relation to RA up to October 2022. Meta-analyses of MR studies assessing correlations between various potential pathogenic factors and RA were conducted. Random-effect and fixed-effect models were used to synthesize the odds ratios of various pathogenic factors and RA. The quality of the study was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization (STROBE-MR) guidelines. Results. A total of 517 potentially relevant articles were screened, 35 studies were included in the systematic review, and 19 studies were eligible to be included in the meta-analysis. Pooled estimates of 19 included studies (causality between 15 different risk factors and RA) revealed that obesity, smoking, coffee intake, lower education attainment, and Graves’ disease (GD) were related to the increased risk of RA. In contrast, the causality contribution from serum mineral levels (calcium, iron, copper, zinc, magnesium, selenium), alcohol intake, and chronic periodontitis to RA is not significant. Conclusion. Obesity, smoking, education attainment, and GD have real causal effects on the occurrence and development of RA. These results may provide insights into the genetic susceptibility and potential biological pathways of RA. Cite this article: Bone Joint Res 2023;12(9):601–614

Aims. Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment. Methods. A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients. Results. LASSO regression analysis selected possible risk factors for SSI, including age, diabetes, operating time, skin graft or flap, resected tumour size, smoking, and radiation therapy. Multivariate analysis revealed that age, diabetes, smoking during the previous year, operating time, and radiation therapy were independent risk factors for SSI. A nomogram was developed based on the results of multivariate logistic regression analysis. In the development cohort, the incidence of SSI was 4.5% in the low-risk group (risk score < 6.89) and 26.6% in the high-risk group (risk score ≥ 6.89; p < 0.001). In the validation cohort, the incidence of SSI was 2.0% in the low-risk group and 15.9% in the high-risk group (p = 0.004). Conclusion. Our nomogram will enable surgeons to assess the risk of SSI in patients with STS. In patients with high risk of SSI, frequent monitoring and aggressive interventions should be considered to prevent this. Cite this article: Bone Joint J 2024;106-B(5):492–500

Aims. This study was designed to characterize the recurrence incidence and risk factors of antibiotic-loaded cement spacer (ALCS) for definitive bone defect treatment in limb osteomyelitis. Methods. We included adult patients with limb osteomyelitis who received debridement and ALCS insertion into the bone defect as definitive management between 2013 and 2020 in our clinical centre. The follow-up time was at least two years. Data on patients’ demographics, clinical characteristics, and infection recurrence were retrospectively collected and analyzed. Results. In total, 314 patients with a mean age of 52.1 years (SD 12.1) were enrolled. After a mean of 50 months’ (24 to 96) follow-up, 53 (16.9%) patients had infection recurrence including 32 tibiae, ten femora, ten calcanea, and one humerus. Of all patients with recurrence, 30 (9.6%) occurred within one year and 39 (12.4%) within two years. Among them, 41 patients needed reoperation, five received antibiotics treatment only, and seven ultimately required amputations. Following multivariable analysis, we found that patients infected with Gram-negative bacilli were more likely to have a recurrence (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.20 to 6.94; p = 0.046) compared to Staphylococcus aureus; segmental bone defects (OR 5.25, 95% CI 1.80 to 15.26; p = 0.002) and smoking (OR 3.00, 95% CI 1.39 to 6.50; p = 0.005) were also independent risk factors for recurrence after treatment. Conclusion. Permanent ALCS might be an alternative strategy for definitive bone defect management in selected osteomyelitis cases. However, the overall high recurrence found suggests that it should be cautiously treated. Additionally, segmental defects, Gram-negative infections, and smoking were associated with an increased risk of infection recurrence. Cite this article: Bone Joint Res 2023;12(8):467–475

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Aims. Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures. Methods. We conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures. Results. We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R. 2. was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R. 2. was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction. Conclusion. The model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion. Cite this article: Bone Jt Open 2023;4(8):584–593

Aims. To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA. Methods. Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models. Results. Of the 5,600 patients included in this study, 342 (6.1%) underwent SDD. The random forest (RF) model performed the best overall, with an internally validated AUC of 0.810. The ten crucial factors favoring SDD in the RF model include operating time, anaesthesia type, age, BMI, American Society of Anesthesiologists grade, race, history of diabetes, rTKA type, sex, and smoking status. Eight of these variables were also found to be significant in the MLR model. Conclusion. The RF model displayed excellent accuracy and identified clinically important variables for determining candidates for SDD following rTKA. Machine learning techniques such as RF will allow clinicians to accurately risk-stratify their patients preoperatively, in order to optimize resources and improve patient outcomes. Cite this article: Bone Jt Open 2023;4(6):399–407

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

Aims. The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods. A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. Results. There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). Conclusion. NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227–235

Aims. The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection. Methods. The medical records of 500 patients (754 fingers) treated for one or more trigger fingers with a steroid injection or with surgical release, between 1 January 2016 and 1 April 2020 with a follow-up of 12 months, were analyzed. Conversion to surgical release was recorded as an unsuccessful treatment after an injection. The effect of patient- and trigger finger-related characteristics on the outcome of an injection was assessed using stepwise manual backward multivariate logistic regression analysis. Results. Treatment with an injection was unsuccessful in 230 fingers (37.9%). Female sex (odds ratio (OR) 1.87 (95% confidence interval (CI) 1.21 to 2.88)), Quinnell stage IV (OR 16.01 (95% CI 1.66 to 154.0)), heavy physical work (OR 1.60 (95% CI 0.96 to 2.67)), a third steroid injection (OR 2.02 (95% CI 1.06 to 3.88)), and having carpal tunnel syndrome (OR 1.59 (95% CI 0.98 to 2.59)) were associated with a higher risk of conversion to surgical release. In contrast, an older age (OR 0.98 (95% CI 0.96 to 0.99)), smoking (OR 0.39 (95% CI 0.24 to 0.64)), and polypharmacy (OR 0.39, CI 0.12 to 1.12) were associated with a lower risk of conversion. The regression model predicted 15.6% of the variance found for the outcome of the injection treatment (R. 2. > 0.25). Conclusion. Factors associated with a worse outcome following a steroid injection were identified and should be considered when choosing the treatment of a trigger finger. In women with a trigger finger, the choice of treatment should take into account whether there are also one or more patient- or trigger-related factors that increase the risk of conversion to surgery. Cite this article: Bone Joint J 2022;104-B(10):1142–1147

Aims. The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. Methods. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results. Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion. Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting. Cite this article: Bone Joint J 2024;106-B(5):475–481

Aims. The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. Methods. Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. Results. A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. Conclusion. Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554

Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion. SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691

Aims. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

Aims. During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. Methods. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Results. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Conclusion. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136–1145

Aims. To examine the relationship of sex steroid hormones with osteopenia in a nationally representative sample of men in the USA. Methods. Data on bone mineral density (BMD), serum sex hormones, dairy consumption, smoking status, and body composition were available for 806 adult male participants of the cross-sectional National Health and Nutrition Examination Survey (NHANES, 1999-2004). We estimated associations between quartiles of total and estimated free oestradiol (E2) and testosterone (T) and osteopenia (defined as 1 to 2.5 SD below the mean BMD for healthy 20- to 29-year-old men) by applying sampling weights and using multivariate-adjusted logistic regression. We then estimated the association between serum hormone concentrations and osteopenia by percentage of body fat, frequency of dairy intake, cigarette smoking status, age, and race/ethnicity. Results. Men in the lowest quartile of total E2 concentrations (< 21.52 pg/ml) had greater odds of osteopenia compared with men in the highest quartile (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.11 to 4.73; p-trend = 0.030). Total and free T were not associated with osteopenia. Low total E2 concentrations were associated with greater odds of osteopenia among non-daily dairy consumers (p-trend = 0.046), current or former smokers (p-trend = 0.032), and younger men (p-trend = 0.031). No differences were observed by race/ethnicity and obesity. Conclusion. In this nationally representative study of the USA, men with lower total E2 were more likely to have osteopenia, which was particularly evident among younger men, men with less-than-daily dairy consumption, and current or former smokers. Cite this article:Bone Joint Res. 2020;9(3):139–145

Aims. Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort. Methods. A population-based cohort of people aged between 40 and 69 years in the UK (the UK Biobank) was studied. People who underwent surgery for RCD were identified through a link with NHS inpatient records covering a mean of eight years after enrolment. Multivariate Cox proportional hazards regression was used to calculate hazard ratios (HRs) as estimates of associations with surgery for RCD accounting for confounders. The risk factors which were considered included age, sex, race, education, Townsend deprivation index, body mass index (BMI), occupational demands, and exposure to smoking. Results. Of the 421,894 people who were included, 47% were male. The mean age at the time of enrolment was 56 years (40 to 69). A total of 2,156 people were identified who underwent surgery for RCD. Each decade increase in age was associated with a 55% increase in the incidence of RCD surgery (95% confidence interval (CI) 46% to 64%). Male sex, non-white race, lower deprivation score, and higher BMI were significantly associated with a higher risk of surgery for RCD (all p < 0.050). Greater occupational physical demands were significantly associated with higher rates of RCD surgery (HR = 2.1, 1.8, and 1.4 for ‘always’, ‘usually’, and ‘sometimes’ doing heavy manual labour vs ‘never’, all p < 0.001). Former smokers had significantly higher rates of RCD surgery than those who had never smoked (HR 1.23 (95% CI 1.12 to 1.35), p < 0.001), while current smokers had similar rates to those who had never smoked (HR 0.94 (95% CI 0.80 to 1.11)). Among those who had never smoked, the risk of surgery was higher among those with more than one household member who smoked (HR 1.78 (95% CI 1.08 to 2.92)). The risk of RCD surgery was not significantly related to other measurements of secondhand smoking. Conclusion. Many factors were independently associated with surgery for RCD, including older age, male sex, higher BMI, lower deprivation score, and higher occupational physical demands. Several of the risk factors which were identified are modifiable, suggesting that the healthcare burden of RCD might be reduced through the pursuit of public health goals, such as reducing obesity and modifying occupational demands. Cite this article: Bone Joint J 2020;102-B(3):352–359

Aims. It is well established that there is a strong association between Perthes’ disease and worsening socioeconomic deprivation. It has been suggested that the primary determinant driving this association is exposure to tobacco smoke. This study aimed to examine this hypothesis. Patients and Methods. A hospital case-control study (n = 149/146) examined the association between tobacco smoke exposure and Perthes’ disease, adjusting for area-level socioeconomic deprivation. Tobacco smoke exposure was assessed by parental questionnaire of smoking habits during pregnancy, and by quantitative assay of current exposure using the urinary cotinine-creatinine ratio, which is a widely used and validated measure of tobacco smoke exposure. Results. The odds of Perthes’ disease significantly increased with reported in utero exposure after adjustment for socioeconomic deprivation (maternal smoking odds ratio (OR) 2.06, 95% confidence interval (CI) 1.17 to 3.63; paternal smoking OR 2.09, 95% CI 1.26 to 3.46). The cotinine-creatinine ratio was significantly greater in cases, OR 1.63 (95% CI 1.09 to 2.43), suggesting a greater ‘dose’ of current tobacco exposure. Conclusion. An association exists between tobacco smoke exposure and Perthes’ disease but we remain unable to disentangle the association with socioeconomic deprivation. Cite this article: Bone Joint J 2017;99-B:1102–8

Aims. The aim of this study was to identify factors associated with poor outcome following coccygectomy on patients with chronic coccydynia and instability of the coccyx. Methods. From the Danish National Spine Registry, DaneSpine, 134 consecutive patients were identified from a single centre who had coccygectomy from 2011 to 2019. Patient demographic data and patient-reported outcomes, including pain measured on a visual analogue scale (VAS), Oswestry Disability Index (ODI), EuroQol five-dimension five-level questionnaire, and 36-Item Short-Form Health Survey questionnaire (SF-36) were obtained at baseline and at one-year follow-up. Patient satisfaction was obtained at follow-up. Regression analysis, including age, sex, smoking status, BMI, duration of symptoms, work status, welfare payment, preoperative VAS, ODI, and SF-36 was performed to identify factors associated with dissatisfaction with results at one-year follow-up. Results. A minimum of one year follow-up was available in 112 patients (84%). Mean age was 41.9 years (15 to 78) and 97 of the patients were female (87%). Regression showed no statistically significant association between the investigated prognostic factors and a poor outcome following coccygectomy. The satisfied group showed a statistically significant improvement in patient-reported outcomes at one-year follow-up from baseline, whereas the dissatisfied group did not show a significant improvement. Conclusion. We did not identify factors associated with poor outcome following coccygectomy. This suggests that neither of the included parameters should be considered contraindications for coccygectomy in patients with chronic coccydynia and instability of the coccyx. Cite this article: Bone Jt Open 2021;2(7):540–544

Aims. The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking. Methods. Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing. Results. A total of 37 micromotion patients and 46 control patients were evaluated. There were no significant differences between groups in terms of age, sex, the proportion of open fractures, or NURD score. There were no nonunions (0%) in the micromotion group versus five (11%) in the control group. The proportion of fractures united was significantly higher in the micromotion group compared to control at 12 weeks (54% vs 30% united; p = 0.043), 18 weeks (81% vs 59%; p = 0.034), and 24 weeks (97% vs 74%; p = 0.005). Structural bone healing scores as assessed by CT scans tended to be higher with micromotion compared to control and this difference reached significance in patients who had biological comorbidities such as smoking. Conclusion. In this pilot study, micromotion fixation was associated with improved healing compared to standard tibial nailing. Further prospective clinical studies will be needed to assess the strength and generalizability of any potential benefits of micromotion fixation. Cite this article: Bone Jt Open 2021;2(10):825–833

Aims. Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI. Materials and Methods. A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Staphylococcus aureus screening, the management of anti-rheumatic medication, perioperative antibiotic prophylaxis, presurgical skin preparation, the operating room environment, irrigant options, and anticoagulation. Results. Poor glycaemic control, obesity, malnutrition, and smoking are all associated with increased rates of PJI. Vitamin D replacement has been shown in preliminary animal studies to decrease rates of PJI. Preoperative Staphylococcus aureus screening and appropriate treatment results in decreased rates of PJI. Perioperative variables, such as timely and appropriate dosage of prophylactic antibiotics, skin preparation with chlorohexidine-based solution, and irrigation with dilute betadine at the conclusion of the operation, have all been associated with reduced rates of PJI. Similarly, aggressive anticoagulation and increased operating room traffic should be avoided to help minimize risk of PJI. Conclusion. PJI remains a serious complication of arthroplasty. Surgeons should be vigilant of the modifiable risk factors that can be addressed in an attempt to reduce the risk of PJI

Aims. Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). Conclusion. The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102–107

Aims. To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. Methods. Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph. Results. A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R. 2. = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three. Conclusion. Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113–121

Aims. Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery. Methods. The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL. Results. For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing. Conclusion. We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL. Cite this article: Bone Jt Open 2021;2(1):22–32

Aims. It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. Methods. We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m. 2. (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m. 2. , n = 512); obese (BMI 30 kg/m. 2. to 39.9 kg/m. 2. , n = 748); and morbidly obese (BMI > 40 kg/m. 2. , n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. Results. Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). Conclusion. With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45–50

Aims. Preoperative nasal Staphylococcus aureus screening and eradication reduces surgical site infections (SSIs) but its impact on reducing early prosthetic joint infection (PJI) remains controversial. This study aims to assess the effect of preoperative nasal S. aureus screening and eradication on the incidence of early PJI in general and S. aureus-induced early PJI. Methods. All primary total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed from January 2006 to April 2018 were retrospectively reviewed for the incidence of early PJI. Demographic parameters, risk factors for PJI (American Society of Anaesthesiologists classification, body mass index, smoking status, and diabetes mellitus) and implant types were collected. A preoperative screening and eradication protocol for nasal colonization of S. aureus was introduced in October 2010. The incidence of early PJI was compared before and after the implementation of the protocol. Missing data were imputed via multiple imputation by chained equations. Inverse probability weighting was used to account for differences between patients in both groups. Weighted univariate logistic regression was used to evaluate the incidence of early PJI for both groups. Results. In total, 10,486 THAs and TKAs were performed in the research period. After exclusion, a cohort of 5,499 screened cases and 3,563 non-screened cases were available for analysis. Overall, no significant reduction in early PJI was found in the screened group (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.55 to 1.11; p = 0.173). However, the incidence of S. aureus-induced PJI was significantly reduced (OR 0.58, 95% CI 0.36 to 0.92; p = 0.027) in the screened group. Conclusion. A preoperative nasal S. aureus screening and eradication protocol did not significantly reduce the overall incidence of early PJI after THA or TKA. However, a decreased incidence of S. aureus-induced early PJI was established. These findings can help to establish better consensus around the value of these screening protocols. Cite this article: Bone Joint J 2020;102-B(10):1341–1348

Aims. To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability. Methods. This was a cross-sectional study of 2,206 subjects along with L1-S1 axial and sagittal MRI. Clinical and radiological information regarding their demographics, workload, smoking habits, anteroposterior (AP) vertebral canal diameter, spondylolisthesis, and MRI changes were evaluated. Mann-Whitney U tests and chi-squared tests were conducted to search for differences between subjects with and without DSS. Associations of LBP and radicular pain reported within one month (30 days) and one year (365 days) of the MRI, with clinical and radiological information, were also investigated by utilizing univariate and multivariate logistic regressions. Results. Subjects with DSS had higher prevalence of radicular leg pain, more pain-related disability, and lower quality of life (all p < 0.05). Subjects with DSS had 1.5 (95% confidence interval (CI) 1.0 to 2.1; p = 0.027) and 1.8 (95% CI 1.3 to 2.6; p = 0.001) times higher odds of having radicular leg pain in the past month and the past year, respectively. However, DSS was not associated with LBP. Although, subjects with a spondylolisthesis had 1.7 (95% CI 1.1 to 2.5; p = 0.011) and 2.0 (95% CI 1.2 to 3.2; p = 0.008) times greater odds to experience LBP in the past month and the past year, respectively. Conclusion. This large-scale study identified DSS as a risk factor of acute and chronic radicular leg pain. DSS was seen in 6.9% of the study cohort and these patients had narrower spinal canals. Subjects with DSS had earlier onset of symptoms, more severe radicular leg pain, which lasted for longer and were more likely to have worse disability and poorer quality of life. In these patients there is an increased likelihood of nerve root compression due to a pre-existing narrowed canal, which is important when planning surgery as patients are likely to require multi-level decompression surgery. Cite this article: Bone Joint J 2021;103-B(1):131–140

Aims. This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy. Methods. Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review. Results. Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers’ compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy. Conclusion. Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822–831

The October 2015 Hip & Pelvis Roundup. 360 . looks at: Smoking and complications in arthroplasty; Smoking cessation beneficial in arthroplasty; Intermediate care and arthroplasty; Do we still need cell salvage?; Femoroacetabular impingement in the Japanese population; Trunnionosis or taperosis and geometry; Decontamination for staphylococcus aureus works!; Policeman or opportunity? Quality improvement with registries; Death rates higher in readmission to other hospitals

Introduction. Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia. Methods. A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student’s t-test and Pearson’s χ2 test were used. The level of statistical significance was set at p ≤ 0.05. Results. The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain. Conclusion. MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations

Objectives. The osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-B ligand (RANKL) balance is of the utmost importance in fracture healing. The aim of this study was therefore to investigate the impact of nonosteogenic factors on OPG and RANKL levels. Methods. Serum obtained from 51 patients with long bone fractures was collected over 48 weeks. The OPG and serum sRANKL (soluble RANKL) concentrations were measured using enzyme-linked immunosorbent assay (ELISA). Smoking habit, diabetes, and alcohol consumption were recorded. Results. Age and sex greatly influenced preoperative serum levels of OPG and sRANKL but differences were even more pronounced during fracture healing. Statistical significance was observed for overall serum levels of OPG (p = 0.001) and sRANKL (p < 0.001) in older men and women (age greater than 50 years). Interestingly, OPG levels increased over time in older women but decreased over time in older men. Conclusion. These data suggest that nonosteogenic factors, most significantly age and sex, have a major impact on sRANKL and OPG levels. Given the established association of OPG and sRANKL levels and nonunion, these findings seem to be of clinical relevance. Cite this article: J. Starlinger, G. Kaiser, A. Thomas, K. Sarahrudi. The impact of nonosteogenic factors on the expression of osteoprotegerin and RANKL during human fracture healing. Bone Joint Res 2019;8:349–356. DOI: 10.1302/2046-3758.87.BJR-2018-0116.R3

Aims. Free vascularised fibular grafting has been used for the treatment of large bony defects for more than 40 years. However, there is little information about the risk factors for failure and whether newer locking techniques of fixation improve the rates of union. The purpose of this study was to compare the rates of union of free fibular grafts fixed with locking and traditional techniques, and to quantify the risk factors for nonunion and failure. Patients and Methods. A retrospective review involved 134 consecutive procedures over a period of 20 years. Of these, 25 were excluded leaving 109 patients in the study. There were 66 men and 43 women, with a mean age of 33 years (5 to 78). Most (62) were performed for oncological indications, and the most common site (52) was the lower limb. Rate of union was estimated using the Kaplan-Meier method and risk factors for nonunion were assessed using Cox regression. All patients were followed up for at least one year. Results. The rate of union was 82% at two years and 97% at five years. Union was achieved after the initial procedure in 76 patients (70%) at a mean of ten months (3 to 19), and overall union was achieved in 99 patients (91%). No surgical factor, including the use of locked fixation or supplementary corticocancellous bone grafts increased the rate of union. A history of smoking was significantly associated with a risk of nonunion. Discussion. Free vascularised fibular grafting is a successful form of treatment for large bony defects. These results suggest that the use of modern techniques of fixation does not affect the risk of nonunion when compared with traditional forms of fixation, and smoking increases the risk of nonunion following this procedure. Cite this article: Bone Joint J 2017;99-B:134–8

Aims. Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results. Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion. We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351

Aims. The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. Patients and Methods. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. Results. A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the ‘safe window’, the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). Conclusion. A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385–1391

Aims. The aim of this study was to investigate the influence of age on the cost-effectiveness of arthroscopic rotator cuff repair. Patients and Methods. A total of 112 patients were prospectively monitored for two years after arthroscopic rotator cuff repair using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Oxford Shoulder Score (OSS), and the EuroQol five-dimension questionnaire (EQ-5D). Complications and use of healthcare resources were recorded. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). Propensity score-matching was used to compare those aged below and above 65 years of age. Satisfaction was determined using the Net Promoter Score (NPS). Linear regression was used to identify variables that influenced the outcome at two years postoperatively. Results. A total of 92 patients (82.1%) completed the follow-up. Their mean age was 59.5 years (. sd. 9.7, 41 to 78). There were significant improvements in the mean DASH (preoperative 47.6 vs one-year 15.3; p < 0.001) and OSS scores (26.5 vs 40.5; p < 0.001). Functional improvements were maintained with no significant change between one and two years postoperatively. The mean preoperative EQ-5D was 0.54 increasing to 0.81 at one year (p < 0.001) and maintained at 0.86, two years postoperatively. There was no significant difference between those aged below or above 65 years of age with regards to postoperative shoulder function or EQ-5D gains. Smoking was the only characteristic that significantly adversely influenced the EQ-5D at two years postoperatively (p = 0.005). A total of 87 were promoters and five were passive, giving a mean NPS of 95 (87/92). The total mean cost per patient was £3646.94 and the mean EQ-5D difference at one year was 0.2691, giving a mean ICER of £13 552.36/QALY. At two years, this decreased further to £5694.78/QALY. This was comparable for those aged below or above 65 years of age (£5209.91 vs £5525.67). Smokers had an ICER that was four times more expensive. Conclusion. Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age. Cite this article: Bone Joint J 2019;101-B:860–866

Aims. To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury. Methods. Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care. Results. The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain. Conclusion. Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047–1054

Aims. The outcomes of total knee arthroplasty (TKA) depend on many factors. The impact of implant design on patient-reported outcomes is unknown. Our goal was to evaluate the patient-reported outcomes and satisfaction after primary TKA in patients with osteoarthritis undergoing primary TKA using five different brands of posterior-stabilized implant. Patients and Methods. Using our institutional registry, we identified 4135 patients who underwent TKA using one of the five most common brands of implant. These included Biomet Vanguard (Zimmer Biomet, Warsaw, Indiana) in 211 patients, DePuy/Johnson & Johnson Sigma (DePuy Synthes, Raynham, Massachusetts) in 222, Exactech Optetrak Logic (Exactech, Gainesville, Florida) in 1508, Smith & Nephew Genesis II (Smith & Nephew, London, United Kingdom) in 1415, and Zimmer NexGen (Zimmer Biomet) in 779 patients. Patients were evaluated preoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Activity Scale (LEAS), and 12-Item Short-Form Health Survey questionnaire (SF-12). Demographics including age, body mass index, Charlson Comorbidity Index, American Society of Anethesiologists status, sex, and smoking status were collected. Postoperatively, two-year KOOS, LEAS, SF-12, and satisfaction scores were compared between groups. Results. Outcomes were available for 4069 patients (98%) at two years postoperatively. In multiple regression analysis, which separately compared each implant group with the aggregate of all others, there were no clinically significant differences in the change of KOOS score from baseline to two-year follow-up between any of the groups. More than 80% of patients in each group were satisfied at this time in all domains. In a multivariate regression model, patients in the NexGen group were the most likely to be satisfied (odds ratio (OR) 1.63; p = 0.006) and Optetrak Logic patients were the least likely to be satisfied (OR 0.60; p < 0.001). Conclusion. TKA provides improvement in function and satisfaction regardless of the type of implant. We could not demonstrate superiority of one design above others across these groups of implants, and any price premium for one above the other systems may not be justified. Healthcare administrators may find these similarities in outcomes helpful when negotiating purchasing contracts. Cite this article: Bone Joint J 2019;101-B(7 Supple C):48–54

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications. Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications. Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement

Aims. Periprosthetic joint infection (PJI) remains a challenging complication following total hip arthroplasty (THA). It is associated with high levels of morbidity, mortality and expense. Guidelines and protocols exist for the management of culture-positive patients. Managing culture-negative patients with a PJI poses a greater challenge to surgeons and the wider multidisciplinary team as clear guidance is lacking. Patients and Methods. We aimed to compare the outcomes of treatment for 50 consecutive culture-negative and 50 consecutive culture-positive patients who underwent two-stage revision THA for chronic infection with a minimum follow-up of five years. Results. There was no significant difference in the outcomes between the two groups of patients, with a similar rate of re-infection of 6%, five years post-operatively. Culture-negative PJIs were associated with older age, smoking, referral from elsewhere and pre-operative antibiotic treatment. The samples in the culture-negative patients were negative before the first stage (aspiration), during the first-stage (implant removal) and second-stage procedures (re-implantation). Conclusion. Adherence to strict protocols for selecting and treating culture-negative patients with a PJI using the same two-stage revision approach that we employ for complex culture-positive PJIs is important in order to achieve control of the infection in this difficult group of patients. Cite this article: Bone Joint J 2018;(1 Supple A)100-B:3–8

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age ≥72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere

Aims. Identifying predictors of compartment syndrome in the foot after a fracture of the calcaneus may lead to earlier diagnosis and treatment. The aim of our study was to identify any such predictors. Patients and Methods. We retrospectively reviewed 303 patients (313 fractures) with a fracture of the calcaneus who presented to us between October 2008 and September 2016. The presence of compartment syndrome and potential predictors were identified by reviewing their medical records. Potential predictors included age, gender, concomitant foot injury, mechanism of injury, fracture classification, time from injury to admission, underlying illness, use of anticoagulant/antiplatelet agents, smoking status and occupation. Associations with predictors were analyzed using logistic regression analysis. Results. Of the 313 fractures of the calcaneus, 12 (3.8%) developed a compartment syndrome. A Sanders type IV fracture was the only strongly associated factor (odds ratio 21.67, p = 0.007). Other variables did not reach statistical significance. Conclusion. A Sanders type IV fracture is the best predictor of compartment syndrome after a fracture of the calcaneus. Cite this article: Bone Joint J 2018;100-B:303–8

Aims. The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis. Patients and Methods. A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame. Results. There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p = 0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042). Conclusion. LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. . Cite this article: Bone Joint J 2017;99-B:494–502

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQOL) outcome by using a Euroqol (EQ-5D) questionnaire in 263 patients who had undergone surgery for herniation of a lumbar disc. Data from the National Swedish Register for lumbar spinal surgery between 2001 and 2002 were used and, in addition, a comparison between our cohort and a Swedish EQ-5D population survey was performed. We analysed the pre- and post-operative quality of life data, age, gender, smoking habits, pain and walking capacity. The mean age of the patients was 42 years (20 to 66); 155 (59%) were men and 69 (26%) smoked. Pre-operatively, 72 (17%) could walk at least 1 km compared with 200 (76%) postoperatively. The mean EQ-5D score improved from 0.29 to 0.70, and the HRQOL improved in 195 (74%) of the patients. The pre-operative score did not influence the post-operative score. In most patients, all five EQ-5D dimensions improved, but did not reach the level reported by an age- and gender-matched population sample (mean difference 0.17). Predictors for poor outcome were smoking, a short pre-operative walking distance, and a long history of back pain

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Aims. The purpose of this study was to evaluate trends in opioid use after unicompartmental knee arthroplasty (UKA), to identify predictors of prolonged use and to compare the rates of opioid use after UKA, total knee arthroplasty (TKA) and total hip arthroplasty (THA). Materials and Methods. We identified 4205 patients who had undergone UKA between 2007 and 2015 from the Humana Inc. administrative claims database. Post-operative opioid use for one year post-operatively was assessed using the rates of monthly repeat prescription. These were then compared between patients with and without a specific variable of interest and with those of patients who had undergone TKA and THA. Results. A total of 4205 UKA patients were analysed. Of these, 1362 patients (32.4%) were users of opioids. Pre-operative opioid use was the strongest predictor of prolonged opioid use after UKA. Opioid users were 1.4 (81.6% versus 57.7%), 3.7 (49.5% versus 13.3%) and 5.5 (35.8% versus 6.5%) times more likely to be taking opioids at one, two and three months post-operatively, respectively (p < 0.05 for all). Younger age and specific comorbidities such as anxiety/depression, smoking, back pain and substance abuse were found to significantly increase the rate of repeat prescription for opioids after UKA. Overall, UKA patients required significantly less opioid prescriptions than patients who had undergone THA and TKA. Conclusion. One-third of patients who undergo UKA are given opioids in the three months pre-operatively. Pre-operative opioid use is the best predictor of increased repeat prescriptions after UKA. However, other intrinsic patient characteristics are also predictive. Cite this article: Bone Joint J 2018;100-B(1 Supple A):62–7

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To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

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This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

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The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA).

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The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

The June 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning did not outperform conventional competing risk modelling to predict revision arthroplasty; Unravelling the risks: incidence and reoperation rates for femoral fractures post-total hip arthroplasty; Spinal versus general anaesthesia for hip arthroscopy: a COVID-19 pandemic- and opioid epidemic-driven study; Development and validation of a deep-learning model to predict total hip arthroplasty on radiographs; Ambulatory centres lead in same-day hip and knee arthroplasty success; Exploring the impact of smokeless tobacco on total hip arthroplasty outcomes: a deeper dive into postoperative complications.

Aims

Cemented hemiarthroplasty is an effective form of treatment for most patients with an intracapsular fracture of the hip. However, it remains unclear whether there are subgroups of patients who may benefit from the alternative operation of a modern uncemented hemiarthroplasty – the aim of this study was to investigate this issue. Knowledge about the heterogeneity of treatment effects is important for surgeons in order to target operations towards specific subgroups who would benefit the most.

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):46–9

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The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

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Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories.

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The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

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The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

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The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.

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The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

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The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

Aims. Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions. . Patients and Methods. A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. . Results. There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). . Conclusion. Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. . Cite this article: Bone Joint J 2016;98-B:1635–41

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Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK.

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Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.

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Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised.

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The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation.

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This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

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To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

The August 2013 Research Roundup. 360 . looks at: passive smoking and bone substitutes; platelet-rich plasma and osteogenesis; plantar fasciitis and platelet-rich plasma: a match made in heaven?; MRSA decolonisation decreases infection rates; gums, bisphosphonates and orthopaedics; PRAISE and partner violence; blunt impact and post-traumatic OA; and IDEAL research and implants

Aims. The aim of the present study was to compare the 30- and 90-day re-admission rates and complication rates of outpatient and inpatient total shoulder arthroplasty (TSA). Patients and Methods. The United States Medicare Standard Analytical Files database was questioned to identify patients who had undergone outpatient or inpatient TSA between 2005 and 2012. Patient characteristics were compared between the two groups using chi-squared analysis. Multivariate logistic regression analysis was used to control for differences in baseline patient characteristics and to compare the two groups in terms of post-operative complications within 90 days and re-admission within 30 days and 90 days. Results. A total of 123 347 Medicare subscribers underwent TSA between 2005 and 2012; 3493 (2.8%) had the procedure performed as an outpatient. A significantly greater proportion of patients who underwent TSA as inpatients were women, had a history of smoking, and had a greater incidence of medical comorbidity including diabetes, coronary artery disease, congestive heart failure, and chronic kidney disease (p < 0.05 for all). Re-admission rates were significantly higher for inpatients at both 30 days (0.83% versus 0.60%, p = 0.016, odds ratio 1.8) and 90 days (2.87% versus 2.04%, p < 0.001, odds ratio 1.8). Complications, including thromboembolic events (p < 0.001) and surgical site infection (p = 0.002), were significantly higher in inpatients. Conclusion. Patients who underwent TSA on an outpatient basis were overall younger and healthier than those who had inpatient surgery, which suggests that patient selection was taking place. After controlling for age, gender, and medical conditions, patients who underwent TSA as outpatients had lower rates of 30- and 90-day re-admission and a lower rate of complications than inpatients. . Cite this article: Bone Joint J 2017;99-B:934–8

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Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.

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The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques.

The June 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients.

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The purpose of this study is to determine an individual’s age-specific prevalence of total knee arthroplasty (TKA) after cruciate ligament surgery, and to identify clinical and genetic risk factors associated with undergoing TKA.

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To evaluate whether low-intensity pulsed ultrasound (LIPUS) accelerates bone healing at osteotomy sites and promotes functional recovery after open-wedge high tibial osteotomy (OWHTO).

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There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures.

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

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Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

The December 2023 Foot & Ankle Roundup³⁶⁰ looks at: Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis; 3D-printed modular endoprosthesis reconstruction following total calcanectomy; Percutaneous partial bone excision in the management of diabetic toe osteomyelitis; Hemiepiphysiodesis is a viable surgical option for Juvenile hallux valgus; Ankle arthroplasty vs arthrodesis: which comes out on top?; Patient-related risk factors for poorer outcome following total ankle arthroplasty; The Outcomes in Ankle Replacement Study.

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

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United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

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The primary objective of this study was to compare the five-year tibial component migration and wear between highly crosslinked polyethylene (HXLPE) inserts and conventional polyethylene (PE) inserts of the uncemented Triathlon fixed insert cruciate-retaining total knee arthroplasty (TKA). Secondary objectives included clinical outcomes and patient-reported outcome measures (PROMs).

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Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR.

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To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.