Aims. The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up. Methods. A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted. Results. The ROM (p < 0.001), CS (p < 0.001), and DASH score (p < 0.001) showed significant improvements after shoulder arthroplasty for both implants. There were no differences between the groups treated with stemmed or stemless shoulder prosthesis with respect to the mean CS (79.2 (35 to 118) vs 74.4 (31 to 99); p = 0.519) and DASH scores (11.4 (8 to 29) vs 13.2 (7 to 23); p = 0.210). The ten-year unadjusted cumulative survival rate was 95.3% for the stemmed anatomical shoulder prosthesis and 91.5% for the stemless shoulder prosthesis and did not differ between the treatment groups (p = 0.251). The radiological evaluation of the humeral components in both groups did not show loosening of the humeral implant. The main reason for revision for each type of arthroplasties were complications related to the glenoid. Conclusion. The use of anatomical stemless shoulder prosthesis yielded good and reliable results and did not differ from anatomical stemmed shoulder prosthesis over a mean period of ten years. The differences in periprosthetic humeral bone adaptations between both implants have no clinical impact during the follow-up. Cite this article: Bone Joint J 2021;103-B(7):1292–1300

Aims. Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. Methods. A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. Results. A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m. 2. (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). Conclusion. Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373–1379

Aims. To determine ten-year failure rates following 36 mm metal-on-metal (MoM) Pinnacle total hip arthroplasty (THA), and identify predictors of failure. Patients and Methods. We retrospectively assessed a single-centre cohort of 569 primary 36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012 according to Medicines and Healthcare Products Regulation Agency recommendations. All-cause failure rates (all-cause revision, and non-revised cross-sectional imaging failures) were calculated, with predictors for failure identified using multivariable Cox regression. Results. Failure occurred in 97 hips (17.0%). The ten-year cumulative failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7). Primary implantation from 2006 onwards (hazard ratio (HR) 4.30; 95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty (HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The effect of implantation year on failure varied over time. From four years onwards following surgery, hips implanted since 2006 had significantly higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to 15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). Conclusion. We observed that 36 mm MoM Pinnacle THAs have an unacceptably high ten-year failure rate, especially if implanted from 2006 onwards or in bilateral MoM hip patients. Our findings regarding implantation year and failure support recent concerns about the device manufacturing process. We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592–600

Aims. The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). Methods. The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts. Results. Patients undergoing TKA had significantly higher rates of manipulation under anaesthesia (3.9% vs 0.9%; p < 0.001), deep vein thrombosis (5.0% vs 3.1%; p < 0.001), pulmonary embolism (1.5% vs 0.8%; p = 0.001), and renal failure (4.2% vs 2.2%; p < 0.001). Revision rates, however, were significantly higher for UKA at five years (6.0% vs 4.2%; p = 0.007) and ten years postoperatively (6.5% vs 4.4%; p = 0.002). Longitudinal-related healthcare costs for patients undergoing TKA were greater than for those undergoing UKA at one year ($24,771 vs $22,071; p < 0.001) and five years following surgery ($26,549 vs $25,730; p < 0.001); however, the mean costs of TKA were comparable to UKA at ten years ($26,877 vs $26,891; p = 0.425). Conclusion. Despite higher revision rates, patients undergoing UKA had lower mean healthcare costs than those undergoing TKA up to ten years following the procedure, at which time costs were comparable. In the era of value-based care, surgeons and policymakers should be aware of the costs involved with these procedures. UKA was associated with fewer complications at one year postoperatively but higher revision rates at five and ten years. While UKA was significantly less costly than TKA at one and five years, costs at ten years were comparable with a mean difference of only $14. Lowering the risk of revision surgery should be targeted as a source of cost savings for both UKA and TKA as the mean related healthcare costs were 2.5-fold higher in patients requiring revision surgery. Cite this article: Bone Joint J 2021;103-B(6 Supple A):23–31

Aims. Joint registries typically use revision of an implant as an endpoint and report survival rates after a defined number of years. However, reporting lifetime risk of revision may be more meaningful, especially in younger patients. We aimed to assess lifetime risk of revision for patients in defined age groups at the time of primary surgery. Methods. The New Zealand Joint Registry (NZJR) was used to obtain rates and causes of revision for all primary total hip arthroplasties (THAs) performed between January 1999 and December 2016. The NZJR is linked to the New Zealand Registry of Births, Deaths and Marriages to obtain complete and accurate data. Patients were stratified by age at primary surgery, and lifetime risk of revision calculated according to age, sex, and American Society of Anesthesiologists (ASA) classification. The most common causes for revision were also analyzed for each age group. Results. The overall, ten-year implant survival rate was 93.6% (95% confidence interval (CI) 93.4% to 93.8%). It was lowest in the youngest age group (46 to 50 years), rising sequentially with increasing age to 97.5% in the oldest group (90 to 95 years). Lifetime risk of revision surgery was 27.6% (95% CI 27.3% to 27.8%) in those aged 46 to 50 years, decreasing with age to 1.1% (95% CI 0.0% to 5.8%) in those aged 90 to 95 years at the time of primary surgery. Higher ASA grades were associated with an increased lifetime risk of revision across all ages. The commonest causes for revision THA were aseptic loosening, infection, periprosthetic fracture, and dislocation. Conclusion. When counselling patients preoperatively, the lifetime risk of revision may be a more meaningful and useful measure of longer-term outcome than implant survival at defined time periods. This study highlights the considerably increased likelihood of subsequent revision surgery in younger age groups. Cite this article: Bone Joint J 2021;103-B(3):479–485

Aims. The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture. Methods. We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671). Results. The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients’ demography or functional outcomes between operative and nonoperative treatments. Conclusion. Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951–957

Aims. The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. Methods. A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy. Results. A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001). Conclusion. SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729–735

Aims. There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome. Patients and Methods. We retrospectively reviewed 29 patients (17 women, 12 men) from our total joint registry who had undergone 31 cemented TKAs after a DFO between 2000 and 2012. Their mean age at TKA was 51 years (22 to 76) and their mean body mass index 32 kg/m. 2. (20 to 45). The mean time between DFO and TKA was ten years (2 to 20). The mean follow-up from TKA was ten years (2 to 16). The prostheses were posterior-stabilized in 77%, varus-valgus constraint (VVC) in 13%, and cruciate-retaining in 10%. While no patient had metaphyseal fixation (e.g. cones or sleeves), 16% needed a femoral stem. Results. The ten-year survivorship was 95% with aseptic loosening as the endpoint, 88% with revision for any reason as the endpoint, and 81% with re-operation for any reason as the endpoint. Three TKAs were revised for instability (n = 2) and aseptic tibial loosening (n = 1). No femoral component was revised for aseptic loosening. Patients under the age of 50 years were at greater risk of revision for any reason (hazard ratio 7; p = 0.03). There were two additional re-operations (6%) and four complications (13%), including three manipulations under anaesthetic (MUA; 10%). The Knee Society scores improved from a mean of 50 preoperatively (32 to 68) to a mean of 93 postoperatively (76 to 100; p < 0.001). Conclusion. A cemented posterior-stabilized TKA has an 88% ten-year survivorship with revision for any reason as the endpoint. No femoral component was revised for aseptic loosening. Patients under the age of 50 years have a greater risk of revision. The clinical outcome was significantly improved but balancing the knee was challenging in 13% of TKAs requiring VVC. Overall, 10% of TKAs needed an MUA, and 6% of TKAs were revised for instability. Cite this article: Bone Joint J 2019;101-B:660–666

Aims. Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. Methods. All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient. Results. In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001). Conclusion. Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems. Cite this article: Bone Joint Open 2020;2(1):16–21

Aims. Limb salvage for pelvic sarcomas involving the acetabulum is a major surgical challenge. There remains no consensus about what is the optimum type of reconstruction after resection of the tumour. The aim of this study was to evaluate the surgical outcomes in these patients according to the methods of periacetabular reconstruction. Methods. The study involved a consecutive series of 122 patients with a periacetabular bone sarcoma who underwent limb-salvage surgery involving a custom-made prosthesis in 65 (53%), an ice-cream cone prosthesis in 21 (17%), an extracorporeal irradiated autograft in 18 (15%), and nonskeletal reconstruction in 18 (15%). Results. The rates of major complications necessitating further surgery were 62%, 24%, 56%, and 17% for custom-made prostheses, ice-cream cone prostheses, irradiated autografts and nonskeletal reconstructions, respectively (p = 0.001). The ten-year cumulative incidence of failure of the reconstruction was 19%, 9%, 33%, and 0%, respectively. The major cause of failure was deep infection (11%), followed by local recurrence (6%). The mean functional Musculoskeletal Tumour Society (MSTS) scores were 59%, 74%, 64%, and 72%, respectively. The scores were significantly lower in patients with major complications than in those without complications (mean 52% (SD 20%) vs 74% (SD 19%); p < 0.001). For periacetabular resections involving the ilium, the mean score was the highest with custom-made prostheses (82% (SD 10%)) in patients without any major complication; however, nonskeletal reconstruction resulted in the highest mean scores (78% (SD 12%)) in patients who had major complications. For periacetabular resections not involving the ilium, significantly higher mean scores were obtained with ice-cream cone prostheses (79% (SD 17%); p = 0.031). Conclusion. Functional outcome following periacetabular reconstruction is closely associated with the occurrence of complications requiring further surgery. For tumours treated with periacetabular and iliac resection, skeletal reconstruction may result in the best outcomes in the absence of complications, whereas nonskeletal reconstruction is a reasonable option if the risk of complications is high. For tumours requiring periacetabular resection without the ilium, reconstruction using an ice-cream cone prosthesis supported by antibiotic-laden cement is a reliable option. Cite this article: Bone Joint J 2021;103-B(4):795–803

Aims. The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). Methods. This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. Results. From 1998 to 2019, 8,301 patients (8,894 knees) underwent RTKA surgery in Scotland (median age at RTKA 70 years (interquartile range (IQR) 63 to 76); median follow-up 6.2 years (IQR 3.0 to 10.2). In all, 4,764 (53.6%) were female, and 781 (8.8%) were treated for infection. Of these 8,894 knees, 957 (10.8%) underwent a second revision procedure. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95% CI 86.5 to 88.1). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was significantly associated with lower risk of re-revision (HR 0.78 (95% CI 0.64 to 0.94, p < 0.001)). The risk of re-revision steadily declined in centres performing > 20 cases per year; risk reduction was 16% with > 20 cases; 22% with > 30 cases; and 28% with > 40 cases. The lowest level of risk was associated with the highest volume centres. Conclusion. The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA. Cite this article: Bone Joint J 2021;103-B(4):602–609

Aims. To assess how the cost-effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) varies with age, sex, and preoperative Oxford Hip or Knee Score (OHS/OKS); and to identify the patient groups for whom THA/TKA is cost-effective. Methods. We conducted a cost-effectiveness analysis using a Markov model from a United Kingdom NHS perspective, informed by published analyses of patient-level data. We assessed the cost-effectiveness of THA and TKA in adults with hip or knee osteoarthritis compared with having no arthroplasty surgery during the ten-year time horizon. Results. THA and TKA cost < £7,000 per quality-adjusted life-year (QALY) gained at all preoperative scores below the absolute referral thresholds calculated previously (40 for OHS and 41 for OKS). Furthermore, THA cost < £20,000/QALY for patients with OHS of ≤ 45, while TKA was cost-effective for patients with OKS of ≤ 43, since the small improvements in quality of life outweighed the cost of surgery and any subsequent revisions. Probabilistic and one-way sensitivity analyses demonstrated that there is little uncertainty around the conclusions. Conclusion. If society is willing to pay £20,000 per QALY gained, THA and TKA are cost-effective for nearly all patients who currently undergo surgery, including all patients at and above our calculated absolute referral thresholds. Cite this article: Bone Joint J 2020;102-B(7):950–958

Aims. To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome. Methods. A total of 325 consecutive domed lateral UKAs undertaken for the recommended indications were included, and their functional and survival outcomes were assessed. The effects of age, weight, activity, and the presence of full-thickness erosions of cartilage in the patellofemoral joint on outcome were evaluated. Results. Median follow-up was seven years (3 to 14), and mean age at surgery was 65 years (39 to 90). Median Oxford Knee Score (OKS) was 43 (interquartile range (IQR) 37 to 47), with 260 (80%) achieving a good or excellent score (OKS > 34). Revisions occurred in 34 (10%); 14 (4%) were for dislocation, of which 12 had no recurrence following insertion of a new bearing, and 12 (4%) were revised for medial osteoarthritis (OA). Ten-year survival was 85% (95% confidence interval (CI) 79 to 90, at risk 72). Age, weight, activity, and patellofemoral erosions did not have a significant effect on the clinical outcome or survival. Conclusion. Domed lateral UKA provides a good alternative to total knee arthroplasty (TKA) in the management of lateral compartment OA. Although dislocation is relatively easy to treat successfully, the dislocation rate of 4% is high. It is recommended that the stability of the bearing is assessed intraoperatively. If the bearing can easily be displaced, the fixed rather than the mobile bearing version of the Oxford lateral tibial component should be inserted instead. Younger age, heavier weight, high activity, and patellofemoral erosions did not detrimentally affect outcome, so should not be considered contraindications. Cite this article: Bone Joint J 2020;102-B(8):1033–1040

Aims. The existing clinical guidelines do not describe a clear indication for adjuvant radiotherapy (RT) in the treatment of superficial soft tissue sarcomas (STSs). We aimed to determine the efficacy of adjuvant RT for superficial STSs. Methods. We retrospectively studied 304 patients with superficial STS of the limbs and trunk who underwent surgical resection at a tertiary sarcoma centre. The efficacy of RT was investigated according to the tumour size and grade: group 1, ≤ 5 cm, low grade; group 2, ≤ 5cm, high grade; group 3, > 5 cm, low grade; group 4, > 5 cm, high grade. Results. The five- and ten-year local recurrence-free survival (LRFS) for all patients was 88% and 81%, respectively. While the efficacy of adjuvant RT was not proven in local control of all patients (five-year LRFS; RT+, 90% versus RT-, 83%; p = 0.074), the LRFS was significantly improved by adjuvant RT in group 2 (five-year LRFS; RT+, 96% versus RT-, 82%; p = 0.019), and group 4 (five-year LRFS; RT+, 87% versus RT-, 73%; p = 0.027). In groups 2 and 4, adjuvant RT significantly reduced the LR risk if the resection margin was clear but less than 5 mm; the LR rate was 7% with adjuvant RT compared with 26% with surgery alone (p = 0.003). There was no statistical relationship with the use of adjuvant RT and survival in every group. Conclusion. Adjuvant RT reduces the risk of local recurrence in patients with superficial high-grade STS regardless of tumour size, especially when resection margin is less than 5 mm. Cite this article: Bone Joint J 2020;102-B(8):1088–1094

Aims. There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. Methods. We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. Results. The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m. 2. ; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. Conclusion. Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247–1253

Between December 1995 and March 2003, 38 adult patients with intermediate or high-grade liposarcoma in a limb were treated by limb-sparing surgery and post-operative radiotherapy. The ten-year local recurrence-free survival was 83%, the ten-year metastasis-free survival 61%, the ten-year disease-free survival 51% and the ten-year overall survival 67%. Analysis of failure and success showed no association with the age of the patients, gender, the location of the primary tumour, the type of liposarcoma and the quality of resection. Our results indicate that liposarcoma may recur even ten years after the end of definitive therapy and may spread to unexpected sites as for soft-tissue sarcoma

Aims. Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution. Methods. A total of 2,721 patients with intracapsular fractures of the femoral neck treated with either a cemented hemiarthroplasty or a THA at a single centre were retrospectively reviewed. The primary outcomes analyzed were readmission for any reason and revision surgery. We secondarily looked at mortality rates. Results. We found no difference in the overall revision rate or rate of infection. However, the rates of readmission due to dislocation, pain, and trochanteric bursitis were significantly higher in the THA group (p = 0.001, p < 0.001, p < 0.001, and p = 0.001, respectively). Conclusion. Our study, comparing the outcomes of neck of femur fractures treated with a cemented hemiarthroplasty and THA, revealed the perceived superiority of THA was not borne out by our results. This should be carefully considered before any radical change in practice regarding the use of THA for displaced intracapsular fractures of the femoral neck. Cite this article: Bone Joint J 2020;102-B(6):693–698

Aims. It is not clear whether anterior knee pain and osteoarthritis (OA) of the patellofemoral joint (PFJ) are contraindications to medial unicompartmental knee arthroplasty (UKA). Our aim was to investigate the long-term outcome of a consecutive series of patients, some of whom had anterior knee pain and PFJ OA managed with UKA. Patients and Methods. We assessed the ten-year functional outcomes and 15-year implant survival of 805 knees (677 patients) following medial mobile-bearing UKA. The intra-operative status of the PFJ was documented and, with the exception of bone loss with grooving to the lateral side, neither the clinical or radiological state of the PFJ nor the presence of anterior knee pain were considered a contraindication. The impact of radiographic findings and anterior knee pain was studied in a subgroup of 100 knees (91 patients). Results. There was no relationship between functional outcomes, at a mean of ten years, or 15-year implant survival, and pre-operative anterior knee pain, or the presence or degree of cartilage loss documented intra-operatively at the medial patella or trochlea, or radiographic evidence of OA in the medial side of the PFJ. In 6% of cases there was full thickness cartilage loss on the lateral side of the patella. In these cases, the overall ten-year function and 15-year survival was similar to those without cartilage loss; however they had slightly more difficulty with descending stairs. Radiographic signs of OA seen in the lateral part of the PFJ were not associated with a definite compromise in functional outcome or implant survival. Conclusion. Severe damage to the lateral side of the PFJ with bone loss and grooving remains a contraindication to mobile-bearing UKA. Less severe damage to the lateral side of the PFJ and damage to the medial side, however severe, does not compromise the overall function or survival, so should not be considered to be a contraindication. However, if a patient does have full thickness cartilage loss on the lateral side of the PFJ they may have a slight compromise in their ability to descend stairs. Pre-operative anterior knee pain also does not compromise the functional outcome or survival and should not be considered to be a contraindication. Cite this article: Bone Joint J 2017;99-B:632–9

Aims. To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture. . Patients and Methods. Between 1992 and 2016, 49 patients (33 male) with mean age of 57 years (25 to 87) underwent cemented THA at a mean of 6.5 years (0.1 to 25) following acetabular fracture. A total of 38 had undergone surgical fixation and 11 had been treated non-operatively; 13 patients died at a mean of 10.2 years after THA (0.6 to 19). Patients were assessed pre-operatively, at one year and at final follow-up (mean 9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant survivorship was assessed. An age and gender-matched cohort of THAs performed for non-traumatic osteoarthritis (OA) or avascular necrosis (AVN) (n = 98) were used to compare complications and patient-reported outcome measures (PROMs). Results. The mean time from fracture to THA was significantly shorter for patients with AVN (2.2 years) or protrusio (2.2 years) than those with post-traumatic OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained and four uncontained defects were managed with autograft (n = 11), bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial fracture management (open reduction and internal fixation or non-operative), timing of THA (> /< one year), and age (> /< 55 years) had no significant effect on OHS or ten-year survival. Six THAs were revised at mean of 12 years (5 to 23) with ten-year all-cause survival of 92% (95% confidence interval 80.8 to 100). THA complication rates (all complications, heterotopic ossification, leg length discrepancy > 10 mm) were significantly higher following acetabular fracture compared with atraumatic OA/AVN and OHSs were inferior: one-year OHS (35.7 versus 40.2, p = 0.026); and final follow-up OHS (33.6 versus 40.9, p = 0.008). . Conclusion . Cemented THA is a reasonable option for the sequelae of acetabular fracture. Higher complication rates and poorer PROMs, compared with patients undergoing THA for atraumatic causes, reflects the complex nature of these cases. Cite this article: Bone Joint J 2017;99-B:1399–1408