Aims. Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. Methods. A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. Results. A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. Conclusion. Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702–1708

Aims. Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

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. Although total knee arthroplasty (TKA) is a highly successful procedure, about 20% of patients remain dissatisfied postoperatively. This proportion is derived from dichotomous models of the assessment of surgical success or failure, which may not reflect the spectrum of outcomes. The aim of this study was to explore differing responses to surgery, and assess whether there are distinct groups of patients with differing patterns of outcome. Methods. This was a secondary analysis of a UK multicentre TKA longitudinal cohort study. We used a group-based trajectory modelling analysis of Oxford Knee Score (OKS) in the first year following surgery with longitudinal data involving five different timepoints and multiple predictor variables. Associations between the derived trajectory groups and categorical baseline variables were assessed, and predictors of trajectory group membership were identified using Poisson regression and multinomial logistic regression, as appropriate. The final model was adjusted for sociodemographic factors (age, sex) and baseline OKS. Results. Data from 731 patients were available for analysis. Three distinct trajectories of outcome were identified: “poor” 14.0%, “modest” 39.1%, and “good” 46.9%. The predicted probability of membership for patients assigned to each trajectory group was high (0.89 to 0.93). Preoperative mental, physical health, and psychosocial factors determined which trajectory is likely to be followed. Poor responders were characterized by a comparatively small number of factors, preoperative expectations of pain and limitations, coping strategies, and a lower baseline physical health status, while the good responders were characterized by a combination of clinical, psychosocial, mental health, and quality of life factors. Conclusion. We identified three distinct response trajectories in patients undergoing TKA. Controlling for baseline score, age, and sex, psychosocial factors such as expectations of pain and limited function and poor coping strategies differentiated the trajectory groups, suggesting a role for preoperative psychosocial support in optimizing the clinical outcome. Cite this article: Bone Joint J 2021;103-B(6):1096–1102

Aims. Adverse local tissue reactions associated with abnormal wear considerably slowed down the general use of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), now limited to a few specialized centres. In this study, we provide the clinical results of 400 consecutive MoM HRAs implanted more than 20 years ago in one such centre. Methods. A total of 355 patients (400 hips) were treated with Conserve Plus HRA between November 1996 and November 2000. There were 96 female (27%) and 259 male patients (73%). Their mean age was 48.2 years (SD 10.9). The University of California, Los Angeles (UCLA) hip scores and 12-item Short Form Survey (SF-12) quality of life scores were reported. Survivorship was assessed using Kaplan-Meier analyses. Results. The mean follow-up was 16.5 years (0.1 to 24.0), including 34 patients (37 hips) who died. The mean UCLA hip scores were 9.3 (2 to 10), 9.1 (3 to 10), 9.0 (3 to 10), and 6.9 (2 to 10) for pain, walking, function, and activity, respectively. The mean SF-12 scores were 48.4 (16.0 to 62.1) for the physical component and 48.5 (10.5 to 66.5) for the mental component, and did not differ from those of the general population of the USA. A total of 60 hips in 55 patients were revised. Using revision for any indication as the endpoint, the Kaplan-Meier survivorship was 83.5% at 20 years. A diagnosis of developmental dysplasia (hazard ratio (HR) 2.199 (95% confidence interval (CI) 1.140 to 4.239); p = 0.019) and a low BMI (HR 0.931 (95% CI 0.873 to 0.994); p = 0.032) were risk factors for revision. Female sex was a risk factor only because of hip dysplasia and small component size. There were no cases of metal sensitivity associated with revision surgery. Radiological analysis showed persistent fixation in all but one hip. Conclusion. The 83.5% 20-year survivorship of this initial series surpasses that of total hip arthroplasties in use 20 years ago in these young patients, suggesting satisfactory lifelong durability of the device for almost all of the remaining patients. Cite this article: Bone Joint J 2021;103-B(7 Supple B):25–32

Aims. This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries. Methods. Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken. Results. For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m. 2. (SD 7.7) and 32.5 kg/m. 2. (SD 7.0). The proportion of THA and TKA patients who reported their joint as ‘much better’ was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were ‘satisfied’ or ‘very satisfied’ with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported ‘dissatisfied’ or ‘very dissatisfied’ with their surgery. Conclusion. Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open 2021;2(6):422–432

Aims. Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue. Methods. Between October 2010 and July 2018, 102 patients with a mean age of 43 years (19 to 67), including 101 males, underwent distal biceps tendon repair less than six weeks after the injury, using cortical button fixation. The primary short-term outcome measure was the rate of complications. The primary long-term outcome measure was the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes included the Oxford Elbow Score (OES), EuroQol five-dimension three-level score (EQ-5D-3L), satisfaction, and return to function. Results. Eight patients (7.8%) had a major complication and 34 (33.3%) had a minor complication. Major complications included re-rupture (n = 3; 2.9%), unrecovered nerve injury (n = 4; 3.9%), and surgery for heterotopic ossification (n = 1; 1.0%). Three patients (2.9%) overall required further surgery for a complication. Minor complications included neurapraxia (n = 27; 26.5%) and superficial infection (n = 7; 6.9%). A total of 33 nerve injuries occurred in 31 patients (30.4%). At a mean follow-up of five years (1 to 9.8) outcomes were available for 86 patients (84.3%). The median QuickDASH, OES, EQ-5D-3L, and satisfaction scores were 1.2 (IQR 0 to 5.1), 48 (IQR 46 to 48), 0.80 (IQR 0.72 to 1.0), and 100/100 (IQR 90 to 100), respectively. Most patients were able to return to work (81/83, 97.6%) and sport (51/62,82.3%). Unrecovered nerve injury was associated with an inferior outcome according to the QuickDASH (p = 0.005), OES (p = 0.004), EQ-5D-3L (p = 0.010), and satisfaction (p = 0.024). Multiple linear regression analysis identified an unrecovered nerve injury to be strongly associated with an inferior outcome according to the QuickDASH score (p < 0.001), along with infection (p < 0.001), although re-rupture (p = 0.440) and further surgery (p = 0.652) were not. Conclusion. Acute distal biceps tendon repair using cortical button fixation was found to result in excellent patient-reported outcomes and health-related quality of life. Although rare, unrecovered nerve injury adversely affects outcome. Cite this article: Bone Joint J 2021;103-B(7):1284–1291

Aims. Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment. Methods. A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019. Results. Mean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group. Conclusion. With the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59–66

Aims. To explore the effect of different types of articulating antibiotic-loaded cement spacers in two-stage revision for chronic hip prosthetic joint infection (PJI). Methods. A retrospective cohort study was performed involving 36 chronic PJI patients treated with different types of articulating antibiotic-loaded cement spacers between January 2014 and December 2017. The incidence of complications and the therapeutic effects of different types of antibiotic-loaded articulating cement spacers were compared. Results. A total of 36 patients with chronic hip PJI were included. Of these, 13 patients were treated with spacers with Kirschner wires as an endoskeleton (group I), ten patients were treated with spacers with a cemented femoral prosthesis as an endoskeleton (group II), and 13 patients were treated with cemented femoral prostheses combined with polyethylene sockets as a spacer (group III). All patients were followed for 12 to 60 months, with a mean follow-up period of 26.44 months (SEM 14.09). Infection was controlled in 34 patients (94.44%), and there were no significant differences in the eradication rate among the three groups (p = 0.705), but the risk of complications related to the spacer in group III was significantly lower than that in groups I and II (p = 0.006). Conclusion. Articulating antibiotic-loaded cement spacers is effective in the treatment of chronic hip PJI, but we must pay attention to the occurrence of spacer fracture and dislocation, which can lead to poor joint function. The risk of spacer-related mechanical complications is low, and better joint function can be achieved when using cemented femoral prostheses combined with polyethylene sockets as spacers. Cite this article: Bone Joint Res 2020;9(8):484–492

Aims. Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. Methods. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay. Results. We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87). Conclusion. TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021;103-B(5):830–839

Aims. To analyze outcomes reported in trials of childhood fractures. Methods. OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework. Results. In all, 525 outcomes were identified representing 52 WHO domains. Four domains were reported in more than 50% of trials: structure of upper/lower limb, sensation of pain, mobility of joint function, and health services, systems and policies. The Activities Scale for Kids performance (ASK-p) score was the most common outcome score reported in 6/72 upper limb and 4/28 lower limb trials. Conclusion. There is a diverse range of outcomes reported in trials of childhood fractures covering all areas in the International Classification of Functioning, Disability and Health (ICF) framework. There were three common upper limb and three common lower limb outcomes. In the absence of a core outcome set, we recommend that upper limb trials report pain, range of movement and radiograph appearance of the arm and lower limb trials report pain, radiograph appearance of the leg and healthcare costs to improve consistency of reporting in future trials. Cite this article: Bone Joint Open 2020;1-5:167–174

Aims. Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Methods. The study included 42 consecutive hips in 42 patients (three male and 39 female) who underwent PAO from May 2016 to July 2018. We prospectively evaluated the incidence of LFCN injury at ten days, three months, six months, and one year postoperatively. We also evaluated the clinical scores, including the HHS, SF-36, and JHEQ scores, at one year postoperatively. Results. LFCN injury was observed in 31 of 42 (74%) patients at ten days, of which 11 resolved completely by one year. Incidence decreased gradually, to 25 of 42 (60%) patients at three months, 24 of 42 patients (57%) at six months, and 20 of 42 (48%) patients at one year postoperatively. There was no significant difference in the HHS between patients with and without LFCN injury at one year postoperatively. Regarding the SF-36 and JHEQ, a significant difference in the mental score was recognized between patients with and without LFCN injury, but there were no significant differences in the other clinical scores. Conclusion. The incidence of LFCN injury was 74% at ten days after PAO, and subsequently decreased to 48% at one year. LFCN injury did not influence the hip function as assessed by the HHS, but had a negative impact on mental health at one year. Cite this article: Bone Joint J 2021;103-B(4):659–664

Aims. The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function. Materials and Methods. Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips). Results. Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better. Conclusion. Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. Cite this article: Bone Joint J 2019;101-B:426–434

Aims. It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. Methods. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services. Results. The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group. Conclusion. The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078–1087

Aims. The aim of this study was to explore parents and young people’s experience of having a medial epicondyle fracture, and their thoughts about the uncertainty regarding the optimal treatment. Methods. Families were identified after being invited to participate in a randomized controlled trial of surgery or no surgery for displaced medial epicondyle fractures of the humerus in children. A purposeful sample of 25 parents (22 females) and five young people (three females, mean age 11 years (7 to 14)) from 15 UK hospitals were interviewed a mean of 39 days (14 to 78) from injury. Qualitative interviews were informed by phenomenology and themes identified to convey participants’ experience. Results. The results identify parents’ desire to do the best for their child expressed through two themes: 1) ‘uncertainty’ (being uncertain about the best treatment option); and 2) ‘facilitating recovery’ (sharing the experience). Parents and young people were shocked when confronted with uncertainty about treatment and they felt responsible for the decision. They searched for further information, drew on their own experience, and struggled to weigh up risks of the treatments. Discussion with surgeons provided crucial support for decision-making, and young people were involved to a varying degree. In facilitating recovery, parents balanced increasing activity with protecting their child, but lacked knowledge about pain management, and how to improve strength and function of the arm. They hoped for a return to normal, including competitive sports. Conclusion. Surgeons are aware of the impact of injury on children and their parents; however, they may be less aware of the turmoil created by treatment uncertainty. Confident surgeons who appreciate and contextualize the importance of pre-existing experience and beliefs are best placed to help the family develop confidence to embrace uncertainty, particularly regarding participation in clinical trials. Cite this article: Bone Jt Open 2021;2(6):359–364

Aims. The aim of this meta-analysis was to assess the prognosis after early functional rehabilitation or traditional immobilization in patients who underwent operative or nonoperative treatment for rupture of the Achilles tendon. Methods. PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials (RCTs) from their inception to 3 June 2020, using keywords related to rupture of the Achilles tendon and rehabilitation. Data extraction was undertaken by independent reviewers and subgroup analyses were performed based on the form of treatment. Risk ratios (RRs) and weighted mean differences (WMDs) (with 95% confidence intervals (CIs)) were used as summary association measures. Results. We included 19 trials with a total of 1,758 patients. There was no difference between the re-rupture rate (RR 0.84 (95% CI 0.56 to 1.28); p = 0.423), time to return to work (WMD -1.29 (95% CI -2.63 to 0.05); p = 0.060), and sporting activity (WMD -1.50 (95% CI -4.36 to 1.37); p = 0.306) between the early functional rehabilitation and the traditional immobilization treatment strategies. Early rehabilitation up to 12 weeks yielded significantly better Achilles tendon Total Rupture Scores ((ATRS) WMD 5.11 (95% CI 2.10 to 8.12); p < 0.001). Patients who underwent functional rehabilitation had significantly lower limb symmetry index of heel-rise work ((HRW) WMD -4.19 (95% CI -8.20 to 0.17); p = 0.041) at one year. Conclusion. Early functional rehabilitation is safe and provides better early function and the same functional outcome in the longer term. Cite this article: Bone Joint J 2021;103-B(6):1021–1030

Aims. The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease. Methods. We prospectively identified all patients presenting with recurrence of Dupuytren’s disease who were selected for surgical treatment with repeat limited fasciectomy surgery between January 2013 and February 2015. Patients were assessed preoperatively, and again at a minimum of five years postoperatively. We identified 43 patients who were carefully selected for repeat fasciectomy involving 54 fingers. Patients with severe or aggressive disease with extensive skin involvement were not included; in our practice, these patients are instead counselled and preferentially treated with dermofasciectomy. The primary outcome measured was change in the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were change in finger range of motion, flexion contracture, Semmes-Weinstein monofilament (SWM) values, and overall satisfaction. Results. There was a significant improvement in MHQ scores, across all domains, with a mean overall score increase of 24 points (p < 0.001). The summed flexion contracture across the metacarpophalangeal joint (MCPJ) and the proximal interphalangeal joint (PIPJ) reduced from means of 72.0° (SD 15.9°) to 5.6° (SD 6.8°) (p < 0.001). A significant increase in maximal flexion was seen at the MCPJ (p < 0.001) but not the PIPJ (p = 0.550). The mean overall satisfaction score from the visual analogue scale was 8.9 (7.9 to 10.0). Complications were uncommon although five fingers showed reduced sensibility at final follow-up. Conclusion. Our study shows that repeat limited fasciectomy for selected patients presenting with recurrence of Dupuytren’s disease can be an effective and safe treatment resulting in excellent patient-reported outcomes and levels of satisfaction. Cite this article: Bone Joint J 2021;103-B(5):946–950

Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

Aims. Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. UK treatment varies widely due to lack of scientific evidence. This is the protocol for a randomized controlled equivalence trial of ‘the offer of a soft bandage and immediate discharge’ versus ‘rigid immobilization and follow-up as per the protocol of the treating centre’ in the treatment of torus fractures . Methods. Children aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre. Results. At day one, three, and seven, data on pain, function, QoL, immobilization, and analgesia will be collected. Three and six weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the Wong-Baker FACES pain scale at three days post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardian. Cite this article: Bone Joint Open 2020;1-6:214–221

Aims. Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy. Methods. We carried out a retrospective review of a single surgeon’s prospectively maintained database of cases in which TcMEP monitoring had been used between 2010 and 2017. The upper limbs were used as the control. A true alert was recorded when there was a 50% or more loss of amplitude from the lower limbs with maintained upper limb signals. Patients with true alerts were identified and their case history analyzed. Results. Of the 299 cases reviewed, 279 (93.3%) had acceptable traces throughout and awoke with normal clinical neurological function. No patient with normal traces had a postoperative clinical neurological deficit. True alerts occurred in 20 cases (6.7%). The diagnoses of the alert group included nine cases of adolescent idiopathic scoliosis (AIS) (45%) and six of congenital scoliosis (30%). The incidence of deterioration based on diagnosis was 9/153 (6%) for AIS, 6/30 (20%) for congenital scoliosis, and 2/16 (12.5%) for spinal tuberculosis. Deterioration was much more common in congenital scoliosis than in AIS (p = 0.020). Overall, 65% of alerts occurred during rod instrumentation: 15% occurred during decompression of the internal apex in vertebral column resection surgery. Four alert cases (20%) awoke with clinically detectable neurological compromise. Conclusion. Surgeon-directed TcMEP monitoring has a 100% negative predictive value and allows early identification of physiological cord distress, thereby enabling immediate intervention. In resource constrained environments, surgeon-directed TcMEP is a viable and effective method of intraoperative spinal cord monitoring. Level of evidence: III. Cite this article: Bone Joint J 2021;103-B(3):547–552