Aims. The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip. Patients and Methods. Patient aged > 60 years undergoing surgery for a hip fracture were identified in the 2016 National Surgical Quality Improvement Program (NSQIP) Hip Fracture Targeted Procedure Dataset. Analysis of the effect of restricted weight-bearing on adverse events, delirium, infection, transfusion, length of stay, return to the operating theatre, readmission and mortality within 30 days postoperatively were assessed. Multivariate regression analysis was used to adjust for confounding demographic, comorbid and procedural characteristics. Results. Of the 4918 patients who met inclusion criteria, 3668 (63.53%) were allowed to weight-bear as tolerated postoperatively. Controlling for patient and procedural factors, multivariate odds of any adverse event, major adverse event, delirium, infection, transfusion, length of stay ≥ 75th percentile (six days) and mortality within 30 days were all higher in patients with weight-bearing restrictions. Notably, there were no differences for thromboembolic events, return to the operating theatre or readmission within 30 days between the groups. Conclusion. Elderly patients with a fracture of the hip with postoperative weight-bearing restrictions have a significantly greater risk of developing most adverse events compared with those who are encouraged to weight-bear as tolerated. These findings emphasize the importance of immediate weight-bearing as tolerated to optimize the outcome in these frail patients; however nearly 25% of surgeons fail to meet this evidence-based guideline. Cite this article: Bone Joint J 2018;100-B:1377–84

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. The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services. Methods. A multicentre retrospective study was conducted of patients undergoing hip or knee arthroplasty during the first wave of the COVID-19 pandemic (1 March 2020 to 31 March 2020) with a minimum of 60 days follow-up. Patient demographics, American Society of Anesthesiologists grade, procedure type, primary or revision, length of stay (LOS), COVID-19 test status, and postoperative mortality were recorded. A subgroup of patients (n = 211) who had not presented to healthcare services after discharge were contacted and questioned as to whether they had symptoms of COVID-19. Results. Five (0.5%) of 1,073 patients who underwent hip or knee arthroplasty tested positive for SARS-CoV-2 postoperatively. When adjusting for confounding factors, increasing LOS (p = 0.022) was the only significant factor associated with developing COVID-19 following surgery and a stay greater than three days was a reliable predictor with an area under the curve of 81% (p = 0.018). There were three (0.3%) deaths in the study cohort and the overall mortality rate attributable to COVID-19 was 0.09% (n = 1/1,073), with one (20%) of the five patients with COVID-19 dying postoperatively. Of the 211 patients contacted, two had symptoms within two to 14 days postoperatively with a positive predictive value of 31% and it was therefore estimated that one patient may have had undiagnosed COVID-19. Conclusion. The rate of postoperative COVID-19 was 0.5% and may have been as high as 1% when accounting for those patients not presenting to healthcare services, which was similar to the estimated population prevalence during the study period. The overall mortality rate secondary to COVID-19 was low (0.09%), however the mortality rate for those patients developing COVID-19 was 20%. Cite this article: Bone Joint J 2021;103-B(4):681–688

Aims. The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). Methods. This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. Results. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). Conclusion. While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J 2021;103-B(3):500–506

Aims. The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. Methods. Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. Results. There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. Conclusion. An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323–329

Aims. Although there is increasing legalization of the use of cannabis in the USA, few well-powered studies have evaluated the association between cannabis use disorder and outcomes following primary total hip arthroplasty (THA). Thus, the aim of this study was to determine whether patients who use cannabis and undergo primary THA have higher rates of in-hospital length of stay (LOS), medical complications, implant-related complications, and costs. Methods. Using an administrative database, patients with cannabis use disorder undergoing primary THA were matched to a control group in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 23,030 patients (3,842 in the study group matched with 19,188 in the control group). The variables which were studied included LOS, 90-day medical complications, two-year implant-related complications, and 90-day costs of care. Mann-Whitney U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. Results. We found that patients in the study group had a significantly longer mean LOS compared with the controls (four days vs three days; p < 0.0001).The study group also had a significantly higher incidence and odds of developing medical (23.0 vs 9.8%, OR 1.6; p < 0.0001) and implant-related complications (16 vs 7.4%, OR 1.6; p < 0.0001) and incurred significantly higher mean 90-day costs ($16,938.00 vs $16,023.00; p < 0.0001). Conclusion. With the increasing rates of cannabis use, these findings allow orthopaedic surgeons and other healthcare professionals to counsel patients with cannabis use disorder about the possible outcomes following their THA, with increased hospital stays, complications, and costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):111–115

Objectives. We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. Methods. We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. Results. A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. Conclusion. We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design. Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction. Cite this article: Bone Joint Res 2023;12(7):447–454

Aims. Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care. Methods. Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes. Results. Between 2017 and 2021, the number of annual hip fractures increased from 6,675 to 7,797 (15%), with a rise in incidence from 313 to 350 per 100,000 (11%) for the at-risk population. By 2029, a combined average projection forecast the annual number of hip fractures at 10,311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. Based upon these projections, assuming discharge rates remain constant, the total overall length of hospital stay following hip fracture in Scotland will increase by 60,699 days per annum, incurring an additional cost of at least £25 million per year. Approximately five more acute hip fracture beds may be required per hospital to accommodate this increased activity. Conclusion. Projection modelling demonstrates that hip fracture burden and incidence will increase substantially by 2029, driven by an ageing population, with substantial implications for health and social care services. Cite this article: Bone Joint J 2024;106-B(1):62–68

Aims. Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. Methods. Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. Results. Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). Conclusion. Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113–118

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. In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations. Methods. Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation. Results. Of 21,610 aseptic revision TKAs evaluated, 530 were discharged within 24 hours. Short-stay patients were younger (63.1 years (49 to 78) vs 65.1 years (18 to 94)), with lower BMI (32.3 kg/m. 2. (17 to 47) vs 33.6 kg/m. 2. (19 to 54) and lower ASA grades. Diabetes, chronic obstructive pulmonary disease, hypertension, and cancer were all associated with a hospital stay over 24 hours. Single component revisions (56.8% (n = 301) vs 32.4% (n = 6,823)), and shorter mean operating time (89.7 minutes (25 to 275) vs 130.2 minutes (30 to 517)) were associated with accelerated discharge. Accelerated discharge was not associated with 30-day readmission and reoperation. Conclusion. Accelerated discharge after revision TKA did not increase short-term complications, readmissions, or reoperations. Further efforts to decrease hospital stays in this setting should be evaluated. Cite this article: Bone Joint J 2022;104-B(12):1323–1328

Aims. Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI. Methods. A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies. Results. The patient demographic characteristics did not differ significantly between the groups. At a mean follow-up of 4.2 years, the treatment failure for reinfection for one-stage and two-stage revision was five (16.7%) and 15 patients (20.0%) (p = 0.691), and for septic re-revision was four (13.3%) and 11 patients (14.7%) (p = 0.863), respectively. No significant differences were observed between one-stage and two-stage revision for 30- 60- and 90-day readmissions (10.0% vs 8.0%; p = 0.714; 16.7% vs 9.3%; p = 0.325; and 26.7% vs 10.7%; p = 0.074), one-year mortality (3.3% vs 4.0%; p > 0.999), and amputation (3.3% vs 1.3%; p = 0.496). Conclusion. In this non-randomized study, one-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision. This suggests culture negativity may not be a contraindication to one-stage revision arthroplasty for chronic culture-negative PJI in selected patients. Cite this article: Bone Joint J 2021;103-B(3):515–521

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

Aims. The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA. Methods. The National Inpatient Sample was queried for primary THAs (2008 to 2017) which were categorized into RA-THA, CA-THA, and M-THA. Past and projected use, demographic characteristics distribution, income, type of insurance, location, and healthcare setting were compared among the three cohorts. In-hospital complications, LOS, discharge disposition, and in-hospital costs were compared between propensity score-matched cohorts of M-THA versus RA-THA and M-THA versus CA-THA to adjust for baseline characteristics and comorbidities. Results. RA-THA and CA-THA did not exhibit any clinically meaningful reduction in mean LOS (RA-THA 2.2 days (SD 1.4) vs 2.3 days (SD 1.8); p < 0.001, and CA-THA 2.5 days (SD 1.9) vs 2.7 days (SD 2.3); p < 0.001, respectively) compared to their respective propensity score-matched M-THA cohorts. RA-THA, but not CA-THA, had similar non-home discharge rates to M-THA (RA-THA 17.4% vs 18.5%; p = 0.205, and 18.7% vs 24.9%; p < 0.001, respectively). Implant-related mechanical complications were lower in RA-THA (RA-THA 0.5% vs M-THA 3.1%; p < 0.001, and CA-THA 1.2% vs M-THA 2.2%; p < 0.001), which was associated with a significantly lower in-hospital dislocation (RA-THA 0.1% vs M-THA 0.8%; p < 0.001). Both RA-THA and CA-THA demonstrated higher mean higher index in-hospital costs (RA-THA $18,416 (SD $8,048) vs M-THA $17,266 (SD $8,396); p < 0.001, and CA-THA $20,295 (SD $8,975) vs M-THA $18,624 (SD $9,226); p < 0.001, respectively). Projections indicate that 23.9% and 3.2% of all THAs conducted in 2025 will be robotic arm- and computer-assisted, respectively. Projections indicated that RA-THA use may overtake M-THA by 2028 (48.3%) and reach 65.8% of all THAs by 2030. Conclusion. Technology-assisted THA, particularly RA-THA, may provide value by lowering in-hospital early dislocation rates and and other in-hospital metrics compared to M-THA. Higher index-procedure and hospital costs warrant further comprehensive cost analyses to determine the true added value of RA-THA in the episode of care, particularly since we project that one in four THAs in 2025 and two in three THA by 2030 will use RA-THA technology. Cite this article: Bone Joint J 2021;103-B(9):1488–1496

Aims. Revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) are complex procedures with higher rates of re-revision, complications, and mortality compared to primary TKA and THA. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes of rTKA and rTHA. Methods. The revision arthroplasty network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming rTKA and rTHA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, revision procedures carried out between April 2011 and March 2018 (allowing two-year follow-up) from the five network hospitals were compared to all other hospitals in England. Age, sex, and mean Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within one year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years, and median length of hospital stay. Results. A total of 57,621 rTHA and 33,828 rTKA procedures were performed across England, of which 1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within the network. Re-revision rates within one year for rTHA were 7.3% and 6.0%, and for rTKA were 11.6% and 7.4% pre- and postintervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for rTHA and from 11.7% to 9.7% for rTKA for the rest of England. In comparative interrupted time-series analysis for rTKA there was a significant immediate improvement in one-year re-revision rates for the revision network compared to the rest of England (p = 0.024), but no significant change for rTHA (p = 0.504). For the secondary outcomes studied, there was a significant improvement in trend for one- and two-year complication rates for rTHA for the revision network compared to the rest of England. Conclusion. Re-revision rates for rTKA and complication rates for rTHA improved significantly at one and two years with the introduction of a revision arthroplasty network, when compared to the rest of England. Most of the outcomes studied improved to a greater extent in the network hospitals compared to the rest of England when comparing the pre- and postintervention periods. Cite this article: Bone Joint J 2023;105-B(6):641–648

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p <  0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. . In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark. Cite this article: Bone Joint J 2014;96-B:1649–56

Aims. Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m. 2. ) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m. 2. ) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach. Methods. This retrospective cohort study observes peri- and postoperative outcomes of MO and HW patients who underwent a primary, unilateral THA with the ABMS approach. Data from surgeries performed by three surgeons at a single institution was collected from January 2013 to August 2020 and analyzed using Microsoft Excel and Stata 17.0. Results. This study compares 341 MO to 1,140 HW patients. Anaesthesia, surgery duration, and length of hospital stay was significantly lower in HW patients compared to MO. There was no difference in incidence of pulmonary embolism, periprosthetic fracture, or dislocation between the two groups. The rate of infection in MO patients (1.47%) was significantly higher than HW patients (0.14%). Preoperative patient-reported outcome measures (PROMs) show a significantly higher pain level in MO patients and a significantly lower score in functional abilities. Overall, six-week and one-year postoperative data show higher levels of pain, lower levels of functional improvement, and lower satisfaction scores in the MO group. Conclusion. The comorbidities of obesity are well studied; however, the implications of THA using the ABMS approach have not been studied. Our peri- and postoperative results demonstrate significant improvements in PROMs in MO patients undergoing THA. However, the incidence of deep infection was significantly higher in this group compared with HW patients. Cite this article: Bone Jt Open 2023;4(5):299–305

Aims. This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?. Methods. Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients. Results. In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001). Conclusion. Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade. Cite this article: Bone Joint Res 2022;11(8):541–547

Aims. Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture. Methods. A systematic literature search was conducted in August 2022. ONS was defined as high protein-based diet strategies containing (or not containing) carbohydrates, fat, vitamins, and minerals. Randomized trials documenting ONS in older patients with hip fracture (aged ≥ 50 years) were included. Two reviewers evaluated study eligibility, conducted data extraction, and assessed study quality. Results. There were 812 studies identified, of which 18 studies involving 1,522 patients met the inclusion criteria. The overall meta-analysis demonstrated that ONS was associated with significantly elevated albumin levels (weighted mean difference (WMD) 1.24 (95% confidence interval (CI) 0.95 to 1.53)), as well as a significant risk reduction in infective complications (odds ratio (OR) 0.54 (95% CI 0.39 to 0.76)), pressure ulcers (OR 0.54 (95% CI 0.33 to 0.88)), and total complications (OR 0.57 (95% CI 0.42 to 0.79)). Length of hospital stay (LOS) was also significantly reduced (WMD -2.36 (95% CI -4.14 to -0.58)), particularly in rehabilitation LOS (WMD -4.17 (95% CI -7.08 to -1.26)). There was a tendency towards a lower mortality risk (OR 0.93 (95% CI 0.62 to 1.4)) and readmission (OR 0.52 (95% CI 0.16 to 1.73)), although statistical significance was not achieved (p = 0.741 and p = 0.285, respectively). The overall compliance with ONS ranged from 64.7% to 100%, but no factors influencing compliance were identified. Conclusion. This meta-analysis is the first to quantitatively demonstrate that ONS could nearly halve the risk of infective complications, pressure ulcers, total complications, as well as improve serum albumin and reduce LOS. ONS should be a regular and integrated part of the perioperative care of these patients, especially given that the compliance with ONS is acceptable. Cite this article: Bone Joint J 2023;105-B(11):1149–1158