Aims. The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. Methods. From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. Results. The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). Conclusion. The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648–1655

Aims. The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. Methods. We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification. Results. The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05). Conclusion. Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence. Cite this article: Bone Joint J 2023;105-B(12):1314–1320

Aims. Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL. Methods. We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves. Results. The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains. Conclusion. In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis. Cite this article: Bone Joint J 2023;105-B(2):166–171

Aims. Adverse spinal motion or balance (spine mobility) and adverse pelvic mobility, in combination, are often referred to as adverse spinopelvic mobility (SPM). A stiff lumbar spine, large posterior standing pelvic tilt, and severe sagittal spinal deformity have been identified as risk factors for increased hip instability. Adverse SPM can create functional malposition of the acetabular components and hence is an instability risk. Adverse pelvic mobility is often, but not always, associated with abnormal spinal motion parameters. Dislocation rates for dual-mobility articulations (DMAs) have been reported to be between 0% and 1.1%. The aim of this study was to determine the early survivorship from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of patients with adverse SPM who received a DMA. Methods. A multicentre study was performed using data from 227 patients undergoing primary total hip arthroplasty (THA), enrolled consecutively. All the patients who had one or more adverse spine or pelvic mobility parameter had a DMA inserted at the time of their surgery. The mean age was 76 years (22 to 93) and 63% were female (n = 145). At a mean of 14 months (5 to 31) postoperatively, the AOANJRR was analyzed for follow-up information. Reasons for revision and types of revision were identified. Results. The AOANJRR reported two revisions: one due to infection, and the second due to femoral component loosening. No revisions for dislocation were reported. One patient died with the prosthesis in situ. Kaplan-Meier survival rate was 99.1% (95% confidence interval 98.3 to 100) at 14 months (number at risk 104). Conclusion. In our cohort of patients undergoing primary THA with one or more factor associated with adverse SPM, DM bearings conferred stability at two years’ follow-up. Cite this article: Bone Joint J 2022;104-B(7):820–825

Aims. To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period. Methods. This observational cohort study used electronic health record data from all patients undergoing preoperative screening for primary TKA at a Northern Netherlands hospital between 2009 and 2020. In this timeframe, three perioperative care transitions were divided into four periods: Baseline care (Joint Care, n = 171; May 2009 to August 2010), Function-tailored (n = 404; September 2010 to October 2013), Fast-track (n = 721; November 2013 to May 2018), and Prehabilitation (n = 601; June 2018 to December 2020). In-hospital recovery was measured using inpatient recovery of activities (IROA), length of stay (LOS), and discharge to preoperative living situation (PLS). Multivariable regression models were used to analyze the impact of each perioperative care transition on in-hospital recovery. Results. The four periods analyzed involved 1,853 patients (65.9% female (1,221/1,853); mean age 70.1 years (SD 9.0)). IROA improved significantly with each transition: Function-tailored (0.9 days; p < 0.001 (95% confidence interval (CI) -0.32 to -0.15)), Fast-track (0.6 days; p < 0.001 (95% CI -0.25 to -0.16)), and Prehabilitation (0.4 days; p < 0.001 (95% CI -0.18 to -0.10)). LOS decreased significantly in Function-tailored (1.1 days; p = 0.001 (95% CI -0.30 to -0.06)), Fast-track (0.6 days; p < 0.001 (95% CI -0.21 to -0.05)), and Prehabilitation (0.6 days; p < 0.001 (95%CI -0.27 to -0.11)). Discharge to PLS increased in Function-tailored (77%), Fast-track (91.6%), and Prehabilitation (92.6%). Post-hoc analysis indicated a significant increase after the transition to the Fast-track period (p < 0.001 (95% CI 3.19 to 8.00)). Conclusion. This study highlights the positive impact of different perioperative care procedures on in-hospital recovery of patients undergoing primary TKA. Assessing functional recovery, LOS, and discharge towards PLS consistently, provides hospitals with valuable insights into postoperative recovery. This can potentially aid planning and identifying areas for targeted improvements to optimize patient outcomes. Cite this article: Bone Joint J 2024;106-B(6):573–581

Aims. The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes. Methods. We retrospectively identified 256 primary total hip arthroplasties (THAs) that included a DM component (144 Stryker MDM and 112 Zimmer-Biomet G7) in 233 patients, performed between January 2012 and December 2019. Postoperative radiographs were reviewed independently for malseating of the liner by five reviewers. The mean age of the patients at the time of THA was 66 years (18 to 93), 166 (65%) were female, and the mean BMI was 30 kg/m. 2. (17 to 57). The mean follow-up was 3.5 years (2.0 to 9.2). Results. Three liners (1.2%) were malseated, including two MDMs (1.4%) and one G7 (0.9%). No clinical consequence was identified from malseating. The five-year survival free of dislocation was 97.1%, including two DM and one intraprosthetic dislocation. The five-year survival free of revision was 95.4%, with seven revisions. The mean Harris Hip Scores increased from 46 (24 to 69) preoperatively to 81 (40 to 100) at two years postoperatively (p < 0.001). Conclusion. The incidence of DM liner malseating after primary THA was low, with no known clinical consequences at mid-term follow-up. Malseating is not exclusive of design, and these findings emphasize the importance of careful evaluation of the liner after impaction to avoid this complication. Cite this article: Bone Joint J 2022;104-B(5):598–603

Aims. Perthes’ disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes’ disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes’ disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?. Methods. The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6). Results. Ages at onset of Perthes’ disease were < six years (n = 512; 43%), six to seven years (n = 321; 27%), eight to 11 years (n = 261; 22%), and > 11 years (n = 76; 6%), similar to the known age distribution of Perthes’ disease. During childhood, 40% (n = 476) of respondents had at least one surgery. Bracing, weightbearing restriction, and absence of any treatment varied significantly between USA and non-USA respondents (p < 0.001, p = 0.002, and p < 0.001, respectively). As adults, 22% (n = 261) had at least one total hip arthroplasty, and 30% (n = 347) had any type of surgery; both more commonly reported among women (p = 0.002). Conclusion. While there are limitations due to self-sampling, our study shows the feasibility of obtaining a large set of patient-reported data from adults who had childhood Perthes’ from multiple countries. Cite this article: Bone Jt Open 2022;3(5):404–414

Aims. The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods. From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results. At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion. Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572

Aims. Treatment of end-stage anteromedial osteoarthritis (AMOA) of the knee is commonly approached using one of two surgical strategies: medial unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). In this study we aim to investigate if there is any difference in outcome for patients undergoing UKA or TKA, when treated by high-volume surgeons, in high-volume centres, using two different clinical guidelines. The two strategies are ‘UKA whenever possible’ vs TKA for all patients with AMOA. Methods. A total of 501 consecutive AMOA patients (301 UKA) operated on between 2013 to 2016 in two high-volume centres were included. Centre One employed clinical guidelines for the treatment of AMOA allowing either UKA or TKA, but encouraged UKA wherever possible. Centre Two used clinical guidelines that treated all patients with a TKA, regardless of wear pattern. TKA patients were included if they had isolated AMOA on preoperative radiographs. Data were collected from both centres’ local databases. The primary outcome measure was change in Oxford Knee Score (OKS), and the proportion of patients achieving the patient-acceptable symptom state (PASS) at one-year follow-up. The data were 1:1 propensity score matched before regression models were used to investigate potential differences. Results. The matched cohort included 400 patients (mean age 67 years (SD 9.55), 213 (53%) female, mean BMI 30.2 kg/m. 2. , 337 (84%) American Society of Anesthesiologists grade ≤ 2). We found a mean adjusted difference in change score of 3.02 points (95% confidence interval (CI) 1.41 to 4.63; p < 0.001) and a significantly larger likeliness of achieving PASS (odds ratio 3.67 (95% CI 1.73 to 8.45); p = 0.001) both in favour of the UKA strategy. Conclusion. UKA and TKA are both good strategies for treating end-stage AMOA. However, when compared as a strategy, UKA achieved larger improvements in OKS, and were more likely to reach the PASS value at one-year follow-up. Cite this article: Bone Jt Open 2022;3(5):441–447

Aims. The association of auraptene (AUR), a 7-geranyloxycoumarin, on osteoporosis and its potential pathway was predicted by network pharmacology and confirmed in experimental osteoporotic mice. Methods. The network of AUR was constructed and a potential pathway predicted by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and Gene Ontology (GO) terms enrichment. Female ovariectomized (OVX) Institute of Cancer Research mice were intraperitoneally injected with 0.01, 0.1, and 1 mM AUR for four weeks. The bone mineral density (BMD) level was measured by dual-energy X-ray absorptiometry. The bone microstructure was determined by histomorphological changes in the femora. In addition, biochemical analysis of the serum and assessment of the messenger RNA (mRNA) levels of osteoclastic markers were performed. Results. In total, 65.93% of the genes of the AUR network matched with osteoporosis-related genes. Osteoclast differentiation was predicted to be a potential pathway of AUR in osteoporosis. Based on the network pharmacology, the BMD and bone mineral content levels were significantly (p < 0.05) increased in the whole body, femur, tibia, and lumbar spine by AUR. AUR normalized the bone microstructure and the serum alkaline phosphatase (ALP), bone-specific alkaline phosphatase (bALP), osteocalcin, and calcium in comparison with the OVX group. In addition, AUR treatment reduced TRAP-positive osteoclasts and receptor activator of nuclear factor kappa-B ligand (RANKL). +. nuclear factor of activated T cells 1 (NFATc1). +. expression in the femoral body. Moreover, the expressions of initiators for osteoclastic resorption and bone matrix degradation were significantly (p < 0.05) regulated by AUR in the lumbar spine of the osteoporotic mice. Conclusion. AUR ameliorated bone loss by downregulating the RANKL/NFATc1 pathway, resulting in improvement of osteoporosis. In conclusion, AUR might be an ameliorative cure that alleviates bone loss in osteoporosis via inhibition of osteoclastic activity. Cite this article: Bone Joint Res 2022;11(5):304–316

Aims. The aim of this study was to determine whether there is a correlation between the grade of humeral osteoarthritis (OA) and the severity of glenoid morphology according to Walch. We hypothesized that there would be a correlation. Methods. Overal, 143 shoulders in 135 patients (73 females, 62 males) undergoing shoulder arthroplasty surgery for primary glenohumeral OA were included consecutively. Mean age was 69.3 years (47 to 85). Humeral head (HH), osteophyte length (OL), and morphology (transverse decentering of the apex, transverse, or coronal asphericity) on radiographs were correlated to the glenoid morphology according to Walch (A1, A2, B1, B2, B3), glenoid retroversion, and humeral subluxation on CT images. Results. Increased humeral OL correlated with a higher grade of glenoid morphology (A1-A2-B1-B2-B3) according to Walch (r = 0.672; p < 0.0001). It also correlated with glenoid retroversion (r = 0.707; p < 0.0001), and posterior humeral subluxation (r = 0.452; p < 0.0001). A higher humeral OL (odds ratio (OR) 1.17; 95% confidence interval (CI) 1.03 to 1.32; p = 0.013), posterior humeral subluxation (OR 1.11; 95% CI 1.01 to 1.22; p = 0.031), and glenoid retroversion (OR 1.48; 95% CI 1.30 to 1.68; p < 0.001) were independent factors for a higher glenoid morphology. More specifically, a humeral OL of ≥ 13 mm was indicative of eccentric glenoid types B2 and B3 (OR 14.20; 95% CI 5.96 to 33.85). Presence of an aspherical HH in the coronal plane was suggestive of glenoid types B2 and B3 (OR 3.34; 95% CI 1.67 to 6.68). Conclusion. The criteria of humeral OL and HH morphology are associated with increasing glenoid retroversion, posterior humeral subluxation, and eccentric glenoid wear. Therefore, humeral radiological parameters might hint at the morphology on the glenoid side. Cite this article: Bone Jt Open 2022;3(6):463–469

Aims. This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty. Methods. Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type. Results. A total of 584 cases were included. Median age was 79.1 years (interquartile range 72.0 to 86.0), 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The most common AO/OTA type was spiral (352, 60.3%). Metaphyseal split fractures occurred only with PTS stems with an incidence of 10.1%. Male sex was associated with a five-fold reduction in odds of a type C fracture (OR 0.22 (95% CI 0.12 to 0.41); p < 0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51 (95% CI 3.72 to 24.34); p < 0.001) and wedge fracture (OR 3.72 (95% CI 1.16 to 11.95); p = 0.027) compared to PTS stems. Both UCS grade and AO/OTA type differed significantly (p < 0.001 and p = 0.001, respectively) between the revision and fixation groups but a similar proportion of B1 fractures underwent revision compared to fixation (45.3% vs 50.6%). Conclusion. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems have higher odds of bending type fractures (transverse and wedge) compared to PTS stems. There is considerable variation in practice when treating B1 fractures around cemented stems. Cite this article: Bone Jt Open 2021;2(7):466–475

Aims. The aim of this study was to evaluate medium-term outcomes and complications of the S-ROM NOILES Rotating Hinge Knee System (DePuy, USA) in revision total knee arthroplasty (rTKA) at a tertiary unit. Methods. A retrospective consecutive study of all patients who underwent a rTKA using this implant from January 2005 to December 2018. Outcome measures included reoperations, revision for any cause, complications, and survivorship. Patients and implant survivorship data were identified through both local hospital electronic databases and linked data from the National Joint Registry/NHS Personal Demographic Service. Kaplan-Meier survival analysis was used at ten years. Results. A total of 89 consecutive patients (89 knees) were included with 47 females (52.8%) and a median age of 74 years (interquartile range 66 to 79). The main indications were aseptic loosening with instability (39.4%; n = 35) and infection (37.1%; n = 33) with the majority of patients managed through two-stage approach. The mean follow-up was 7.4 years (2 to 16). The overall rate of reoperation, for any cause, was 10.1% (n = 9) with a rate of implant revision of 6.7% (n = 6). Only two cases required surgery for patellofemoral complications. Kaplan-Meier implant-survivorship analysis was 93.3% at ten years, using revision for any cause as an endpoint. Conclusion. This implant achieved high ten-year survivorship with a low complication rate, particularly patellofemoral complications. These can be avoided by ensuring central patella tracking and appropriate tension of the patellofemoral joint in this posterior hinge design. Cite this article: Bone Jt Open 2022;3(3):205–210

Aims. The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip. Methods. This was an anonymized comprehensive cohort study of Perthes’ disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children’s hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. Overall, 371 children (396 hips) were newly affected by Perthes’ disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. Conclusion. Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510–518

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. The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR. Methods. We reviewed the data for a consecutive series of 88 patients (mean age 27.1 years (15 to 49); 65 male (74%) and 23 female (26%)) who underwent single-stage repair of a displaced BH meniscal tear (67 medial (76%) and 21 lateral (24%)) with concomitant hamstring autograft ACLR. The patient-reported outcome measures (PROMs) EuroQol visual analogue scale (EQ-VAS), EuroQol five-dimension health questionnaire (EQ-5D), Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), and Tegner score were recorded at final follow-up. A Kaplan-Meier survival analysis was performed to estimate meniscal repair survivorship. Analyses were performed with different cut-offs for meniscal and ACL injury-to-surgery time (within three weeks, three to ten weeks, and more than ten weeks). Results. Meniscal repair survivorship at a median final follow-up of 55 months (interquartile range (IQR) 24 to 91) was 82% (95% confidence interval 70 to 89). A total of 13 meniscus repairs failed (12 requiring meniscectomy and one requiring a further meniscal repair). At final follow-up, median PROMs were: EQ-VAS 85 (IQR 75 to 90), EQ-5D Index 0.84 (IQR 0.74 to 1.00), KOOS Pain 89 (IQR 80 to 94), KOOS Symptoms 82 (IQR 71 to 93), KOOS Activities of Daily Living 97 (IQR 91 to 100), KOOS Sport and Recreation 80 (IQR 65 to 90), KOOS Quality of Life 69 (IQR 53 to 86), IKDC 82.8 (IQR 67.8 to 90.8), and Tegner 6 (IQR 4 to 7). Two patients underwent revision ACLR following further injuries. One patient had an arthroscopic washout for infection at 11 days post-BH meniscal repair/ACLR. Four patients (4.5%) required a further procedure for stiffness, reduced ROM, and pain, and all were operated on within three weeks of meniscal injury. There was no difference in the interval between meniscal injury and surgery between repairs that failed and those that survived. Conclusion. These data suggest that concomitant ACLR with repair of displaced BH meniscal tears, even if they have been displaced for some time, appears to afford satisfactory PROMs and good survivorship. Repairs within three weeks of meniscal injury may be associated with higher rates of postoperative reintervention for stiffness. Cite this article: Bone Joint J 2022;104-B(6):680–686

Aims. Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature. Methods. A systematic search was conducted in MEDLINE, EMBASE, and Google Scholar databases according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies involving sarcopenic patients who underwent defined orthopaedic surgery and recorded postoperative outcomes were included. The quality of the criteria by which a diagnosis of sarcopenia was made was evaluated. The quality of the publication was assessed using Newcastle-Ottawa Scale. Results. A total of 365 studies were identified and screened, 26 full-texts were reviewed, and 19 studies were included in the review. A total of 3,009 patients were included, of whom 2,146 (71%) were female and 863 (29%) were male. The mean age of the patients was 75.1 years (SD 7.1). Five studies included patients who underwent spinal surgery, 13 included hip or knee surgery, and one involved patients who underwent fixation of a distal radial fixation. The mean follow-up was 1.9 years (SD 1.9; 5 days to 5.6 years). There was wide heterogeneity in the measurement tools which were used and the parameters for the diagnosis of sarcopenia in the studies. Sarcopenia was associated with at least one deleterious effect on surgical outcomes in all 19 studies. The postoperative rate of mortality was reported in 11 studies (57.9%) and sarcopenia was associated with poorer survival in 73% (8/11) of these. The outcome was most commonly assessed using the Barthel Index (4/19), and sarcopenic patients recorded lower scores in 75% (3/4) of these. Sarcopenia was defined using the gold-standard three parameters (muscle strength, muscle quantity or quality, and muscle function) in four studies (21%), using two parameters in another four (21%) and one in the remaining 11 (58%). The methodological quality of the studies was moderate to high. Conclusion. There is much heterogeneity in the reporting of the parameters which are used for the diagnosis of sarcopenia, and evaluating the outcome of orthopaedic surgery in sarcopenic patients. However, what data exist suggest that sarcopenia impairs recovery and increases postoperative mortality, especially in patients undergoing emergency surgery. Further research is required to develop processes that allow the accurate diagnosis of sarcopenia in orthopaedics, which may facilitate targeted pre- and postoperative interventions that would improve outcomes. Cite this article: Bone Joint J 2022;104-B(3):321–330

Aims. The aim of this study was to determine whether total hip arthroplasty (THA) for chronic hip pain due to unilateral primary osteoarthritis (OA) has a beneficial effect on cognitive performance. Methods. A prospective cohort study was conducted with 101 patients with end-stage hip OA scheduled for THA (mean age 67.4 years (SD 9.5), 51.5% female (n = 52)). Patients were assessed at baseline as well as after three and months. Primary outcome was cognitive performance measured by d2 Test of Attention at six months, Trail Making Test (TMT), FAS-test, Rivermead Behavioural Memory Test (RBMT; story recall subtest), and Rey-Osterrieth Complex Figure Test (ROCF). The improvement of cognitive performance was analyzed using repeated measures analysis of variance. Results. At six months, there was significant improvement in attention, working speed and concentration (d2-test; p < 0.001), visual construction and visual memory (ROCF; p < 0.001), semantic memory (FAS-test; p = 0.009), verbal episodic memory (RBMT; immediate recall p = 0.023, delayed recall p = 0.026), as well as pain (p < 0.001) with small to large effect sizes. Attention, concentration, and visual as well as verbal episodic memory improved significantly with medium effect sizes over η. 2. partial. = 0.06. In these cognitive domains the within-group difference exceeded the minimum clinically important difference. Conclusion. THA is associated with clinically relevant postoperative improvement in the cognitive functions of attention, concentration, and memory. These data support the concept of a broad interaction of arthroplasty with central nervous system function. Cite this article: Bone Joint J 2022;104-B(3):331–340

Aims. Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency. Methods. This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared. Results. The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities. Conclusion. Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D. 3. supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261–267

Aims. To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires. Methods. A total of 1,000 participants with equal sex distribution were included and categorized in five age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years. Individuals with spinal pathologies were excluded. Participants completed the Scoliosis Research Society-22 (SRS-22r), visual analogue scale (VAS) for back/leg pain, and the EuroQol five-dimension index (EQ-5D/VAS) questionnaires, and disclosed their age, sex, and occupation. They were also categorized in five professional groups: doctors, nurses, allied health professionals, office workers, and manual workers. Results. The mean age of all participants was 43.8 years (20 to 69). There was no difference in the SRS-22r, EQ-5D, or VAS scores among male and female participants (p > 0.05). There was incremental decrease in SRS-22r total scores as the age increased. The mean EQ-5D index score (0.84) ranged little across the age groups (0.72 to 0.91) but reduced gradually with increasing age. There was difference between the SRS-22r total score (4.51), the individual domain scores, and the EQ-5D score (index: 0.94 and VAS: 89) for the doctors’ group compared to all other occupational categories (p < 0.001). Doctors had a younger mean age of participants, which may explain their improved spinal health. There was no difference in the total or sub-domain SRS-22r and EQ-5D scores between the other four occupational groups. Conclusion. This study provides the first normative data for the SRS-22r, EQ-5D, and VAS for back/leg pain questionnaires among adults in the UK. We recorded an excellent correlation between the three assessment tools with individuals who reported less back and leg pain having better quality of life and greater function. The participants’ age, rather than their sex or profession, appears to be the major determinant for spinal health and quality of life. Cite this article: Bone Jt Open 2022;3(2):130–134