Aims. The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury. Patients and Methods. We enrolled 177 adult patients who sustained an isolated proximal humeral fracture into the study and invited them to complete PROMs at their initial outpatient visit within one week of injury, between two and four weeks, and between six to nine months after injury. There were 128 women and 49 men; the mean age was 66 years (. sd. 16; 18 to 95). In all, 173 patients completed the final assessment. Bivariate analysis was performed followed by multivariable regression analysis accounting for multicollinearity using partial R. 2. , correlation matrices, and variable inflation factor. Results. Many variables within a week of injury and between two and four weeks after injury correlated with six- to nine-month PROMs in bivariate analysis. Kinesiophobia measured within a week of injury (Tampa Scale for Kinesiophobia-11: partial R. 2. = 0.14; p = 0.000) and self-efficacy measured between two and four weeks (Pain Self-efficacy Questionnaire-2: partial R. 2. = 0.266; p < 0.001) were the strongest predictors of limitations (measured by Patient Reported Outcome Measurement Information System Upper Extremity Physical Function Computer Adaptive Test (PROMIS UE)) at six to nine months in multivariable analysis. Similar findings were observed with other types of PROM. Regression models accounted for a substantial amount of variance in all PROMs at both timepoints (e.g. 66% of the overall variance within one week, and 70% within two to four weeks for PROMIS UE at six to nine months). . Conclusion. Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy (developing resilience and more effective coping strategies) within a month. Such factors are modifiable using enhanced communication skills and cognitive behavioural treatments. These findings could be a catalyst for the routine assessment and treatment of psychological and social factors in the management of patients with fractures. Cite this article: Bone Joint J 2019;101-B:715–723

Aims. The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort. Patients and Methods. All ACL reconstructions, primary and revision, that were recorded in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of VTE was determined by entries between the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of anticoagulants. Risk factors, outcome, and the use of thromboprophylaxis were analyzed. Descriptive statistics with multivariate analysis were used to describe the findings. Results. The cohort consisted of 26 014 primary and revision ACL reconstructions. There were 89 deep venous thromboses (DVTs) and 12 pulmonary emboli (PEs) with a total of 95 VTEs (0.4 %). Six patients with a PE had a simultaneous DVT. The only independent risk factor for VTE was age greater than or equal to 40 years (odds ratio 2.31, 95% confidence interval 1.45 to 3.70; p < 0.001). Thromboprophylaxis was prescribed to 9461 patients (36%) and was equally distributed between those with and those without a VTE (37.9% vs 36.4%). All patient-reported outcome measures (PROMs) one and two years postoperatively were significantly lower in those with VTE. Conclusion. The incidence of VTE following ACL reconstruction is 0.4%, and the only significant risk factor is age. Patients with VTE had worse postoperative clinical outcome than patients without VTE. We recommend against the routine use of thromboprophylaxis, but it should be considered in older patients

Aims. The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial. Methods. PROMs including the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS), EuroQol five-dimension (EQ-5D), satisfaction, net promoter score and data regarding re-rupture, and venous thromboembolic rates were collected for patients randomized to receive either operative or nonoperative treatment for acute Achilles tendon rupture in a previous study. Of the 80 patients originally randomized, 64 (33 treated surgically, 31 nonoperatively) patients were followed up at a mean of 15.7 years (13.4 to 17.7). Results. There was no statistically significant difference between operatively and nonoperatively treated patients, in SMFA Dysfunction Index (median 1.56 (interquartile range (IQR) 0 to 5.51) vs 1.47 (IQR 0 to 5.15); p = 0.289), SMFA Bother Index (2.08 (IQR 0 to 12.50) vs 0.00 (IQR 0 to 6.25); p = 0.074), ATRS (94 (IQR 86 to 100) vs 95 (IQR 81 to 100); p = 0.313), EQ-5D-5L (1 (IQR 0.75 to 1) vs 1 (IQR 0.84 to 1); p = 0.137) or EQ-5D health today visual analogue score (85 (IQR 72.5 to 95) vs 85 (IQR 8 to 95); p = 0.367). There was no statistically significant difference between operative and nonoperative groups in terms of satisfaction (84% vs 100%; p = 0.119) or willingness to recommend treatment to friends or family (79% vs 87%; p = 0.255). Four nonoperative patients and two in the operative group sustained a re-rupture (p = 0.306). Conclusion. Both patient groups reported good results at long-term follow-up. The findings give no evidence of superior long-term patient reported outcomes (as measured by the SMFA) for surgical treatment over nonoperative treatment. There was no demonstrable difference in other patient reported outcome measures, satisfaction, or re-rupture rates at long-term follow-up. Cite this article: Bone Joint J 2020;102-B(7):933–940

Aims. The aim of this study was to compare patient-reported outcome measures (PROMs), radiological measurements, and total hip arthroplasty (THA)-free survival in patients who underwent periacetabular osteotomy (PAO) for mild, moderate, or severe developmental dysplasia of the hip. Patients and Methods. We performed a retrospective study involving 336 patients (420 hips) who underwent PAO by a single surgeon at an academic centre. After exclusions, 124 patients (149 hips) were included. The preoperative lateral centre-edge angle (LCEA) was used to classify the severity of dysplasia: 18° to 25° was considered mild (n = 20), 10° to 17° moderate (n = 66), and < 10° severe (n = 63). There was no difference in patient characteristics between the groups (all, p > 0.05). Pre- and postoperative radiological measurements were made. The National Institute of Health’s Patient Reported Outcomes Measurement Information System (PROMIS) outcome measures (physical function computerized adaptive test (PF CAT), Global Physical and Mental Health Scores) were collected. Failure was defined as conversion to THA or PF CAT scores < 40, and was assessed with Kaplan–Meier analysis. The mean follow-up was five years (2 to 10) ending in either failure or the latest contact with the patient. Results. There was no significant difference in PROMs for moderate (p = 0.167) or severe (p = 0.708) groups compared with the mild dysplasia group. The numerical pain scores were between 2 and 3 units in all groups at the final follow-up (all, p > 0.05). There was no significant difference (all, p > 0.05) in the proportion of patients achieving target correction for the LCEA between groups. The mean correction was 12° in the mild, 15° in the moderate (p = 0.135), and 23° in the severe group (p < 0.001). Failure-free survival at five years was 100% for mild, 79% for moderate, and 92% for severely dysplastic hips (p = 0.225). Conclusion. Although requiring less correction than hips with moderate or severe dysplasia, we found PAO for mild dysplasia to be associated with promising PROMs, consistent with that of the general United States population, and excellent survivorship at five years. Future studies should compare these results with the outcome after arthroscopy of the hip in patients with mild dysplasia. Cite this article: Bone Joint J 2019;101-B(6 Supple B):16–22

Aims. Between 15% and 20% of patients remain dissatisfied following total knee arthroplasty (TKA). The SAIPH knee system (MatOrtho, Surrey, United Kingdom) is a medial ball and socket TKA that has been designed to replicate native knee kinematics in order to maximize the range of movement, stability, and function. This system is being progressively introduced in a stepwise fashion, with this study reporting the mid-term clinical and radiological outcomes. Patients and Methods. A retrospective review was undertaken of the first 100 consecutive patients with five-year follow-up following SAIPH TKA performed by the senior authors. The data that were collected included the demographics of the patients, clinical findings, the rate of intraoperative ligamentous release, patient-reported outcome measures (PROMS), radiological assessment, complications, and all-cause revision. Revision data were cross-checked with a national registry. Results. A total of 100 TKAs in 92 patients were included. Three patients died (three TKAs) and a further two TKAs were revised. Of the remaining 95 TKAs, five-year follow-up data were available for 81 TKAs (85%) in 87 patients. There were significant improvements in all PROMs and high satisfaction. The mean ROM at final follow-up was from 0° (full extension) to 124° flexion. There were seven major complications (7%): one infection, two deep vein thromboses, one cerebrovascular event, and two patients with stiffness requiring a manipulation under anaesthesia. Two patients required a lateral retinacular release to optimize patellar tracking in valgus knees; no additional ligament releases were performed in any patient. Radiological analysis demonstrated no evidence of implant-related complications. Conclusion. These results demonstrate satisfactory clinical and radiological outcomes at five years following a medial ball and socket TKA. The complication and revision rates are consistent with those previously reported for patients undergoing TKA. These results demonstrate the safety and efficacy of the SAIPH Knee TKA system and support its wider use

Aims. Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement. Patients and Methods. A total of 47 patients due to undergo TKA were randomized to KA+PSI (n = 24) or MA+CAS (n = 23). In the KA+PSI group, there were 16 female and eight male patients with a mean age of 64 years (. sd. 8). In the MA+CAS group, there were 17 female and six male patients with a mean age of 63 years (. sd. 7). Surgery was performed using cemented, cruciate-retaining Triathlon total knees with patellar resurfacing, and patients were followed up for two years. The effect of alignment on tibial component migration and inducible displacement was analyzed irrespective of study group. Results. There was no difference over two years in longitudinal migration of the tibial component between the KA+PSI and MA+CAS groups (reaching median maximum total point motion migration at two years of 0.40 mm for the KA+PSI group and 0.37 mm for the MA+CAS group, p = 0.82; p = 0.68 adjusted for age, sex, and body mass index (BMI) for all follow-ups). Both groups had mean migrations below acceptable thresholds. There was no difference in inducible displacement (p = 0.34) or PROMS (p = 0.61 for the Oxford Knee Score) between groups. There was no correlation between alignment and tibial component migration or alignment and inducible displacement. These findings support non-neutral alignment as a viable option with this component, with no evidence that it compromises fixation. Conclusion. Kinematic alignment using patient-specific instrumentation in TKA was associated with acceptable tibial component migration, indicating stable fixation. These results are supportive of future investigations of kinematic alignment. Cite this article: Bone Joint J 2019;101-B:929–940

Aims. The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches. Patients and Methods. A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test – Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain. Results. A total of 53 patients were randomized to a suprapatellar approach and 42 to an infrapatellar approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared with the uninjured leg when kneeling in the suprapatellar group compared with the infrapatellar group at all timepoints at all follow-up visits. This reached significance at four months for all timepoints except 30 seconds. It also reached significance at six months at 0 seconds, and for one year at 60 seconds. Conclusion. The suprapatellar surgical approach for antegrade tibial nailing is associated with less anterior knee pain postoperatively compared with the infrapatellar approach. Cite this article: Bone Joint J 2019;101-B:1138–1143

Aims. The purpose of this exploratory study was to investigate if the 24-hour activity profile (i.e. waking activities and sleep) objectively measured using wrist-worn accelerometry of patients scheduled for total hip arthroplasty (THA) improves postoperatively. Patients and Methods. A total of 51 THA patients with a mean age of 64 years (24 to 87) were recruited from a single public hospital. All patients underwent THA using the same surgical approach with the same prosthesis type. The 24-hour activity profiles were captured using wrist-worn accelerometers preoperatively and at 2, 6, 12, and 26 weeks postoperatively. Patient-reported outcomes (Hip Disability and Osteoarthritis Outcome Score (HOOS)) were collected at all timepoints except two weeks postoperatively. Accelerometry data were used to quantify the intensity (sedentary, light, moderate, and vigorous activities) and frequency (bouts) of activity during the day and sleep efficiency. The analysis investigated changes with time and differences between Charnley class. Results. Patients slept or were sedentary for a mean of 19.5 hours/day preoperatively and the 24-hour activity pattern did not improve significantly postoperatively. Outside of sleep, the patients spent their time in sedentary activities for a mean of 620 minutes/day (. sd. 143) preoperatively and 641 minutes/day (. sd. 133) six months postoperatively. No significant improvements were observed for light, moderate, and vigorous intensity activities (p = 0.140, p = 0.531, and p = 0.407, respectively). Sleep efficiency was poor (< 85%) at all timepoints. There was no postoperative improvement in sleep efficiency when adjusted for medications (p > 0.05). Patient-reported outcome measures showed a significant improvement with time in all domains when compared with preoperative levels. There were no differences with Charnley class at six months postoperatively. However, Charnley class C patients were more sedentary at two weeks postoperatively when compared with Charnley class A patients (p < 0.05). There were no further differences between Charnley classifications. Conclusion. This study describes the 24-hour activity profile of THA patients for the first time. Prior to THA, patients in this cohort were inactive and slept poorly. This cohort shows no improvement in 24-hour activity profiles at six months postoperative. Cite this article: Bone Joint J 2019;101-B:415–425

Objectives. The patient-rated wrist evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are patient-reported outcome measures (PROMs) used for clinical and research purposes. Methodological high-quality clinimetric studies that determine the measurement properties of these PROMs when used in patients with a distal radial fracture are lacking. This study aimed to validate the PRWE and DASH in Dutch patients with a displaced distal radial fracture (DRF). Methods. The intraclass correlation coefficient (ICC) was used for test-retest reliability, between PROMs completed twice with a two-week interval at six to eight months after DRF. Internal consistency was determined using Cronbach’s α for the dimensions found in the factor analysis. The measurement error was expressed by the smallest detectable change (SDC). A semi-structured interview was conducted between eight and 12 weeks after DRF to assess the content validity. Results. A total of 119 patients (mean age 58 years (. sd. 15)), 74% female, completed PROMs at a mean time of six months (. sd. 1) post-fracture. One overall meaningful dimension was found for the PRWE and the DASH. Internal consistency was excellent for both PROMs (Cronbach’s α 0.96 (PRWE) and 0.97 (DASH)). Test-retest reliability was good for the PRWE (ICC 0.87) and excellent for the DASH (ICC 0.91). The SDC was 20 for the PRWE and 14 for the DASH. No floor or ceiling effects were found. The content validity was good for both questionnaires. Conclusion. The PRWE and DASH are valid and reliable PROMs in assessing function and disability in Dutch patients with a displaced DRF. However, due to the high SDC, the PRWE and DASH are less useful for individual patients with a distal radial fracture in clinical practice. Cite this article: Y. V. Kleinlugtenbelt, R. G. Krol, M. Bhandari, J. C. Goslings, R. W. Poolman, V. A. B. Scholtes. Are the patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) questionnaire used in distal radial fractures truly valid and reliable? Bone Joint Res 2018;7:36–45. DOI: 10.1302/2046-3758.71.BJR-2017-0081.R1

Aims. We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery. Materials and Methods. We conducted a review of registries that are full members of the International Society of Arthroplasty Registries with publicly available annual reports in English. Of the six registries which were included, we compared the reporting of: mean age, definitions for revision and re-operation, reasons for revision, the approach to analysing revisions, and patient-reported outcome measures (PROMs) for primary and revision total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA). Results. Outcomes were infrequently reported for HRA compared with THA and all hip arthroplasties. Revisions were consistently defined, though re-operation was defined by one registry. Implant survival was most commonly reported as the cumulative incidence of revision using Kaplan-Meier survival analysis. Three registries reported patient reported outcome measures. . Conclusion. More consistency in the reporting of outcomes for specific types of procedures is needed to improve the interpretation of joint registry data and accurately monitor safety trends. As collecting additional details of surgical and patient-reported outcomes becomes increasingly important, the experience of established registries will be valuable in establishing consistency among registries while maintaining the quality of data. Take home message: As the volume of joint replacements performed each year continues to increase, greater consistency in the reporting of surgical and patient-reported outcomes among joint replacement registries would improve the interpretation and comparability of these data to monitor outcomes accurately. Cite this article: Bone Joint J 2016;98-B:442–51

Objectives. Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property. Methods. A systematic literature search was performed in PubMed, EMbase, CINAHL and PsycINFO databases to identify relevant clinimetric studies. Two reviewers independently assessed the methodological quality of the studies on measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Level of evidence (strong / moderate / limited / lacking) for each measurement property per PROM was determined by combining the methodological quality and the results of the different clinimetric studies. Results. In all, 19 out of 1508 identified unique studies were included, in which 12 PROMs were rated. The Patient-rated wrist evaluation (PRWE) and the Disabilities of Arm, Shoulder and Hand questionnaire (DASH) were evaluated on most measurement properties. The evidence for the PRWE is moderate that its reliability, validity (content and hypothesis testing), and responsiveness are good. The evidence is limited that its internal consistency and cross-cultural validity are good, and its measurement error is acceptable. There is no evidence for its structural and criterion validity. The evidence for the DASH is moderate that its responsiveness is good. The evidence is limited that its reliability and the validity on hypothesis testing are good. There is no evidence for the other measurement properties. Conclusion. According to this systematic review, there is, at best, moderate evidence that the responsiveness of the PRWE and DASH are good, as are the reliability and validity of the PRWE. We recommend these PROMs in clinical studies in patients with distal radial fractures; however, more clinimetric studies of higher methodological quality are needed to adequately determine the other measurement properties. Cite this article: Dr Y. V. Kleinlugtenbelt. Are validated outcome measures used in distal radial fractures truly valid?: A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Bone Joint Res 2016;5:153–161. DOI: 10.1302/2046-3758.54.2000462

Objectives. This study reports on a secondary exploratory analysis of the early clinical outcomes of a randomised clinical trial comparing robotic arm-assisted unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis of the knee with manual UKA performed using traditional surgical jigs. This follows reporting of the primary outcomes of implant accuracy and gait analysis that showed significant advantages in the robotic arm-assisted group. Methods. A total of 139 patients were recruited from a single centre. Patients were randomised to receive either a manual UKA implanted with the aid of traditional surgical jigs, or a UKA implanted with the aid of a tactile guided robotic arm-assisted system. Outcome measures included the American Knee Society Score (AKSS), Oxford Knee Score (OKS), Forgotten Joint Score, Hospital Anxiety Depression Scale, University of California at Los Angeles (UCLA) activity scale, Short Form-12, Pain Catastrophising Scale, somatic disease (Primary Care Evaluation of Mental Disorders Score), Pain visual analogue scale, analgesic use, patient satisfaction, complications relating to surgery, 90-day pain diaries and the requirement for revision surgery. Results. From the first post-operative day through to week 8 post-operatively, the median pain scores for the robotic arm-assisted group were 55.4% lower than those observed in the manual surgery group (p = 0.040). At three months post-operatively, the robotic arm-assisted group had better AKSS (robotic median 164, interquartile range (IQR) 131 to 178, manual median 143, IQR 132 to 166), although no difference was noted with the OKS. At one year post-operatively, the observed differences with the AKSS had narrowed from a median of 21 points to a median of seven points (p = 0.106) (robotic median 171, IQR 153 to 179; manual median 164, IQR 144 to 182). No difference was observed with the OKS, and almost half of each group reached the ceiling limit of the score (OKS > 43). A greater proportion of patients receiving robotic arm-assisted surgery improved their UCLA activity score. Binary logistic regression modelling for dichotomised outcome scores predicted the key factors associated with achieving excellent outcome on the AKSS: a pre-operative activity level > 5 on the UCLA activity score and use of robotic-arm surgery. For the same regression modelling, factors associated with a poor outcome were manual surgery and pre-operative depression. Conclusion. Robotic arm-assisted surgery results in improved early pain scores and early function scores in some patient-reported outcomes measures, but no difference was observed at one year post-operatively. Although improved results favoured the robotic arm-assisted group in active patients (i.e. UCLA ⩾ 5), these do not withstand adjustment for multiple comparisons. Cite this article: M. J. G. Blyth, I. Anthony, P. Rowe, M. S. Banger, A. MacLean, B. Jones. Robotic arm-assisted versus conventional unicompartmental knee arthroplasty: Exploratory secondary analysis of a randomised controlled trial. Bone Joint Res 2017;6:631–639. DOI: 10.1302/2046-3758.611.BJR-2017-0060.R1

Aims. The purpose of this study was to assess early physical function after total hip or knee arthroplasty (THA/TKA), and the correlation between patient-reported outcome measures, physical performance and actual physical activity (measured by actigraphy). Patients and Methods. A total of 80 patients aged 55 to 80 years undergoing THA or TKA for osteoarthritis were included in this prospective cohort study. The main outcome measure was change in patient reported hip or knee injury and osteoarthritis outcome score (HOOS/KOOS) from pre-operatively until post-operative day 13 (THA) or 20 (TKA). Secondary measures were correlations to objectively assessed change in physical performance (paced-walk, chair-stand, stair-climb tests) at day 14 (THA) or 21 (TKA) and actual physical activity (actigraphy) measured at day 12 and 13 (THA) or 19 and 20 (TKA). . Results. Patients reported improved physical function (HOOS or KOOS) pre-operatively until day 13 (THA) or 20 (TKA) with a mean difference of 7 (95% confidence interval (CI) 1 to 13, p = 0.033) and 6 (95% CI 1 to 12, p = 0.033) percentage points, respectively. By contrast, objectively assessed physical function and activity declined, with no correlations between subjective and objective assessments for either THA or TKA patients (r. 2. ≤ 0.16, p ≥ 0.314). . Conclusions. Early improvement in patient-reported physical function after THA/TKA does not correlate with objectively assessed function, and patient reported outcomes should not be used as the only measure of recovery. . Cite this article: Bone Joint J 2017;99-B:1167–75

Objective. The objective of this study was to explore dimensionality of the Oxford Hip Score (OHS) and examine whether self-reported pain and functioning can be distinguished in the form of subscales. Methods. This was a secondary data analysis of the UK NHS hospital episode statistics/patient-reported outcome measures dataset containing pre-operative OHS scores on 97 487 patients who were undergoing hip replacement surgery. . Results. The proposed number of factors to extract depended on the method of extraction employed. Velicer’s Minimum Average Partial test and the Parallel Analysis suggested one factor, the Cattell’s scree test and Kaiser-over-1 rule suggested two factors. Exploratory factor analysis demonstrated that the two-factor OHS had most of the items saliently loading either of the two factors. These factors were named ‘Pain’ and ‘Function’ and their respective subscales were created. There was some cross-loading of items: 8 (pain on standing up from a chair) and 11 (pain during work). These items were assigned to the ‘Pain’ subscale. The final ‘Pain’ subscale consisted of items 1, 8, 9, 10, 11 and 12. The ‘Function’ subscale consisted of items 2, 3, 4, 5, 6 and 7, with the recommended scoring of the subscales being from 0 (worst) to 100 (best). Cronbach’s alpha was 0.855 for the ‘Pain’ subscale and 0.861 for the ‘Function’ subscale. A confirmatory factor analysis demonstrated that the two-factor model of the OHS had a better fit. However, none of the one-factor or two-factor models was rejected. Conclusion. Factor analyses demonstrated that, in addition to current usage as a single summary scale, separate information on pain and self-reported function can be extracted from the OHS in a meaningful way in the form of subscales. Cite this article: Bone Joint Res 2014;3:305–9

Aims. Modular dual mobility (DM) prostheses in which a cobalt-chromium liner is inserted into a titanium acetabular shell (vs a monoblock acetabular component) have the advantage of allowing supplementary screw fixation, but the potential for corrosion between the liner and acetabulum has raised concerns. While DM prostheses have shown improved stability in patients deemed ‘high-risk’ for dislocation undergoing total hip arthroplasty (THA), their performance in young, active patients has not been reported. This study’s purpose was to assess clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) in young, active patients receiving a modular DM acetabulum and recently introduced titanium, proximally coated, tapered femoral stem design. Patients and Methods. This was a prospective study of patients between 18 and 65 years of age, with a body mass index (BMI) < 35 kg/m. 2. and University of California at Los Angeles (UCLA) activity score > 6, who received a modular cobalt-chromium acetabular liner, highly crosslinked polyethylene mobile bearing, and cementless titanium femoral stem for their primary THA. Patients with a history of renal disease and metal hardware elsewhere in the body were excluded. A total of 43 patients (30 male, 13 female; mean age 52.6 years (. sd. 6.5)) were enrolled. All patients had a minimum of two years’ clinical follow-up. Patient-reported outcome measures, whole blood metal ion levels (ug/l), and periprosthetic femoral BMD were measured at baseline, as well as at one and two years postoperatively. Power analysis indicated 40 patients necessary to demonstrate a five-fold increase in cobalt levels from baseline (alpha = 0.05, beta = 0.80). A mixed model with repeated measures was used for statistical analysis. Results. Mean Harris Hip Scores improved from 54.1 (. sd. 20.5) to 91.2 (. sd. 10.8) at two years postoperatively (p < 0.001). All patients had radiologically well-fixed components, no patients experienced any instability, and no patients required any further intervention. Mean cobalt levels increased from 0.065 ug/l (. sd. 0.03) preoperatively to 0.30 ug/l (. sd. 0.51) at one year postoperatively (p = 0.01) but decreased at two years postoperatively to 0.16 ug/l (. sd. 0.23; p = 0.2). Four patients (9.3%) had a cobalt level outside the reference range (0.03 ug/l to 0.29 ug/l) at two years postoperatively, with values from 0.32 ug/l to 0.94 ug/l. The mean femoral BMD ratio was maintained in Gruen zones 2 to 7 at both one and two years postoperatively using this stem design. At two years postoperatively, mean BMD in the medial calcar was 101.5% of the baseline value. Conclusion. Use of a modular DM prosthesis and cementless, tapered femoral stem has shown encouraging results in young, active patients undergoing primary THA. Elevation in mean cobalt levels and the presence of four patients outside the reference range at two years postoperatively demonstrates the necessity of continued surveillance in this cohort. Cite this article: Bone Joint J 2019;101-B:365–371

The Oxford hip and knee scores (OHS and OKS) are validated patient-reported outcome measures used in patients undergoing total hip replacement (THR), hip resurfacing (HR), total knee replacement (TKR) and unicompartmental knee replacement (UKR). We analysed the absolute OHS and OKS and change in scores following THR, HR, TKR, and UKR performed at one specialist centre. All patients undergoing and completing at least one Oxford score were eligible for inclusion in the study which included 27 950 OHS and 19 750 OKS in 13 682 patients. Data were analysed using non-linear quantile regression. The median absolute Oxford scores for THR, HR, TKR and UKR were pre-operative 68.8% (15.0/48), 58.3% (20.0/48), 66.7% (16.0/48), 60.4% (19.0/48) respectively: and post-operative asymptote was 14.6% (41.0/48), 5.8% (45.2/48), 31.2% (33.0/48), 29.2% (34.0/48). The median asymptotic change from the pre-operative score for THR, HR, TKR and UKR were 47.9% (23.0/48), 47.9% (23.0/48), 33.3% (16.0/48) and 32.4% (15.5/48), respectively. The median time at which no further appreciable change in score was achieved post-operatively was 0.7 years for THR, 1.1 years for HR, 0.9 years for TKR and 1.1 years for UKR. The curves produced from this analysis could be used to educate patients, and to audit the performance of a surgeon and an institution. The time to achieve a stable improvement in outcome varied between different types of joint replacement, which may have implications for the timing of post-operative review. Cite this article: Bone Joint J 2014; 96-B:928–35

Accurate, reproducible outcome measures are essential for the evaluation of any orthopaedic procedure, in both clinical practice and research. Commonly used patient-reported outcome measures (PROMs) have drawbacks such as ‘floor’ and ‘ceiling’ effects, limitations of worldwide adaptability and an inability to distinguish pain from function. They are also unable to measure the true outcome of an intervention rather than a patient’s perception of that outcome. Performance-based functional outcome tools may address these problems. It is important that both clinicians and researchers are aware of these measures when dealing with high-demand patients, using a new intervention or implant, or testing a new rehabilitation protocol. This article provides an overview of some of the clinically-validated performance-based functional outcome tools used in the assessment of patients undergoing hip and knee surgery. Cite this article: Bone Joint J 2014;96-B:1431–5

Aims. This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment. . Patients and Methods. All patients presenting within two weeks of an acute unilateral rupture of the Achilles tendon between July 2012 and July 2015 were considered for the study. In total, 38 patients (nine female, 29 male, mean age 52 years; 29 to 78) completed the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon Total Rupture score (ATRS) six months after the completion of a rehabilitation programme. Results. Patients with a gap ≥ 10 mm with the ankle in the neutral position had significantly greater peak torque deficit than those with gaps < 10 mm (mean 23.3%; 7% to 52% vs 14.3%; 0% to 47%, p = 0.023). However, there was no difference in ATRS between the two groups (mean score 87.2; 74 to 100 vs 87.4; 68 to 97, p = 0.467). There was no significant correlation between gap size and torque deficit (τ = 0.103), suggesting a non-linear relationship. There was also no significant correlation between ATRS and peak torque deficit (τ = -0.305). . Conclusion . This is the first study to identify an association between tendon gap and functional outcome in acute rupture of the Achilles tendon. We have identified 10 mm as a gap size at which deficits in plantarflexion strength become significantly greater, however, the precise relationship between gap size and plantarflexion strength remains unclear. Large, multicentre studies will be needed to clarify this relationship and identify population subgroups in whom deficits in peak torque are reflected in patient-reported outcome measures. . Cite this article: Bone Joint J 2017;99-B:87–93

The Oxford knee score (OKS) is a validated and widely accepted disease-specific patient-reported outcome measure, but there is limited evidence regarding any long-term trends in the score. We reviewed 5600 individual OKS questionnaires (1547 patients) from a prospectively-collected knee replacement database, to determine the trends in OKS over a ten-year period following total knee replacement. The mean OKS pre-operatively was 19.5 (95% confidence interval (CI) 18.8 to 20.2). The maximum post-operative OKS was observed at two years (mean score 34.4 (95% CI 33.7 to 35.2)), following which a gradual but significant decline was observed through to the ten-year assessment (mean score 30.1 (95% CI 29.1 to 31.1)) (p < 0.001). A similar trend was observed for most of the individual OKS components (p < 0.001). Kneeling ability initially improved in the first year but was then followed by rapid deterioration (p < 0.001). Pain severity exhibited the greatest improvement, although residual pain was reported in over two-thirds of patients post-operatively, and peak improvement in the night pain component did not occur until year four. Post-operative OKS was lower for women (p < 0.001), those aged < 60 years (p < 0.003) and those with a body mass index > 35 kg/m. 2. (p < 0.014), although similar changes in scores were observed. This information may assist surgeons in advising patients of their expected outcomes, as well as providing a comparative benchmark for evaluating longer-term outcomes following knee replacement. Cite this article: Bone Joint J 2013;95-B:45–51

We present the development and results of a nationwide, prospective, observational follow-up programme including patient-reported outcome measures (PROMs) for the Swedish Hip Arthroplasty Register. The programme started in 2002 and has gradually expanded to include all units performing total hip replacement in Sweden. The self-administered PROMs protocol comprises the EQ-5D instrument, the Charnley class categorisation and visual analogue scales for pain and satisfaction. These current analyses include 34 960 total hip replacements with complete pre- and one-year post-operative questionnaires. Patients eligible for total hip replacement generally report low health-related quality of life and suffer from pain. One year post-operatively the mean EQ-5D index increased to above the level of an age- and gender-matched population, with a considerable reduction of pain (p < 0.001). Females, younger patients and those with Charnley category C reported a lower EQ-5D index pre-operatively than males, older patients and Charnley category A or B, respectively (all p < 0.001). In a multivariable regression analysis Charnley category C, male gender and higher age were associated with less improvement in health-related quality of life (p < 0.001). Nationwide implementation of a PROMs programme requires a structured organisation and effective data capture. Patients’ response rates to the Registry are good. The continuous collection of PROMs permits local and national improvement work and allows for further health-economic evaluation