Aims. Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. Methods. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. Results. There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. Conclusion. We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320

Aims. The aim of this study was to investigate the distribution of phenotypes in Asian patients with end-stage osteoarthritis (OA) and assess whether the phenotype affected the clinical outcome and survival of mechanically aligned total knee arthroplasty (TKA). We also compared the survival of the group in which the phenotype unintentionally remained unchanged with those in which it was corrected to neutral. Methods. The study involved 945 TKAs, which were performed in 641 patients with primary OA, between January 2000 and January 2009. These were classified into 12 phenotypes based on the combined assessment of four categories of the arithmetic hip-knee-ankle angle and three categories of actual joint line obliquity. The rates of survival were analyzed using Kaplan-Meier methods and the log-rank test. The Hospital for Special Surgery score and survival of each phenotype were compared with those of the reference phenotype with neutral alignment and a parallel joint line. We also compared long-term survival between the unchanged phenotype group and the corrected to neutral alignment-parallel joint line group in patients with Type IV-b (mild to moderate varus alignment-parallel joint line) phenotype. Results. The most common phenotype was Type I-b (mild to moderate varus alignment-medial joint line; 27.1% (n = 256)), followed by Type IV-b (23.2%; n = 219). There was no significant difference in the clinical outcomes and long-term survival between the groups. In Type IV-b phenotypes, the neutrally corrected group showed higher 15-year survival compared with the unchanged-phenotype group (94.9% (95% confidence interval (CI) 92.0 to 97.8) vs 74.2% (95% CI 98.0 to 100); p = 0.020). Conclusion. Constitutional varus was confirmed in more than half of these patients. Mechanically aligned TKA can achieve consistent clinical outcomes and long-term survival, regardless of the patient’s phenotype. The neutrally corrected group had better long-term survival compared with the unchanged phenotype group. Cite this article: Bone Joint J 2024;106-B(5):460–467

Aims. The purpose of this multicentre observational study was to investigate the association between intraoperative component positioning and soft-tissue balancing on short-term clinical outcomes in patients undergoing robotic-arm assisted unicompartmental knee arthroplasty (UKA). Patients and Methods. Between 2013 and 2016, 363 patients (395 knees) underwent robotic-arm assisted UKAs at two centres. Pre- and postoperatively, patients were administered Knee Injury and Osteoarthritis Score (KOOS) and Forgotten Joint Score-12 (FJS-12). Results were stratified as “good” and “bad” if KOOS/FJS-12 were more than or equal to 80. Intraoperative, post-implantation robotic data relative to CT-based components placement were collected and classified. Postoperative complications were recorded. Results. Following exclusions and losses to follow-up, 334 medial robotic-arm assisted UKAs were assessed at a mean follow-up of 30.0 months (8.0 to 54.9). None of the measured parameters were associated with overall KOOS outcome. Correlations were described between specific KOOS subscales and intraoperative, post-implantation robotic data, and between FJS-12 and femoral component sagittal alignment. Three UKAs were revised, resulting in 99.0% survival at two years (95% confidence interval (CI) 97.9 to 100.0). Conclusion. Although little correlation was found between intraoperative robotic data and overall clinical outcome, surgeons should consider information regarding 3D component placement and soft-tissue balancing to improve patient satisfaction. Reproducible and precise placement of components has been confirmed as essential for satisfactory clinical outcome. Cite this article: Bone Joint J 2019;101-B:435–442

Aims. We wished to compare the clinical outcome, as assessed by questionnaires and the rate of complications, in total knee arthroplasty (TKA) undertaken with patient-matched positioning guides (PMPGs) or conventional instruments. Patients and Methods. A total of 180 patients (74 men, 106 women; mean age 67 years) were included in a multicentre, adequately powered, double-blind, randomised controlled trial. The mean follow-up was 44 months (24 to 57). Results. There were no significant or clinically relevant differences between the two groups for all outcome measures (Knee Society Score, p = 0.807; Oxford Knee Score, p = 0.304; Western Ontario and McMaster osteoarthritis index, p = 0.753; visual analogue scale for pain, p = 0.227; EuroQol-5D-3L index score, p = 0.610; EuroQol-5D-3L VAS health, p = 0.968.) There was no difference in the rate of complications (p = 0.291). . Conclusion. PMPGs are already in relatively common use and their short-term clinical results are equal to conventional instrumented TKA. Cite this article: Bone Joint J 2016;98-B:939–44

Aims

The Advance Medial-Pivot total knee arthroplasty (TKA) was designed to reflect contemporary data regarding the kinematics of the knee. We wished to examine the long-term results obtained with this prosthesis by extending a previous evaluation.

Aims. The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures. Methods. A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype. Results. The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype. Conclusion. Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible. Cite this article: Bone Jt Open 2023;4(1):38–46

Aims. The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes. Methods. A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes. Results. A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations. Conclusion. Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment. Cite this article: Bone Joint J 2024;106-B(4):380–386

Aims. The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment. Methods. The type and extent of disc herniation at the time of presentation in 108 patients who underwent anterior discectomy for cervical radiculopathy were analyzed on MRI, using a four-point scale. These were dichotomized into disc bulge and disc herniation groups. Clinical outcomes were evaluated using the Neck Disability Index (NDI), 36-Item Short Form Survey (SF-36), and a visual analogue scale (VAS) for pain in the neck and arm at baseline and two years postoperatively. The perceived recovery was also assessed at this time. Results. At baseline, 46 patients had a disc bulge and 62 had a herniation. There was no significant difference in the mean NDI and SF-36 between the two groups at baseline. Those in the disc bulge group had a mean NDI of 44.6 (SD 15.2) compared with 43.8 (SD 16.0) in the herniation group (p = 0.799), and a mean SF-36 of 59.2 (SD 6.9) compared with 59.4 (SD 7.7) (p = 0.895). Likewise, there was no significant difference in the incidence of disabling arm pain in the disc bulge and herniation groups (84% vs 73%; p = 0.163), and no significant difference in the incidence of disabling neck pain in the two groups (70.5% (n = 31) vs 63% (n = 39); p = 0.491). At two years after surgery, no significant difference was found in any of the clinical parameters between the two groups. Conclusion. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(11):1242–1248

Aims. Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. Methods. This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission. Results. Prolonged total length of stay was found when surgery was performed ≥ 24 hours (median 6 days (interquartile range (IQR) 4 to 9) vs 7 days (IQR 5 to 10); p = 0.001) after admission. No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of 12 hours each, pressure sores and urinary tract infections were diagnosed more frequently when time to surgery increased. Conclusion. Longer time to surgery due to non-medical reasons was associated with a higher incidence of postoperative pressure sores and urinary tract infections when time to surgery was more than 48 hours after admission. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay. Cite this article: Bone Joint J 2022;104-B(12):1369–1378

Aims. Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research. Methods. A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review. Results. A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes. Conclusion. We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area. Cite this article: Bone Joint J 2022;104-B(10):1148–1155

Aims. Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes. Methods. A total of 40 hips in 40 consecutive patients who underwent PAO between May 2016 and July 2018 were included in the study, as further follow-up of the same patients from a previous study. We prospectively evaluated the incidence, severity, and area of symptoms following LFCN injury. We also recorded the clinical scores at one year and ≥ three years postoperatively using the 36-Item Short Form Health Survey (SF-36) and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) scores. Results. A total of 20 patients (50%) had symptoms of a LFCN injury at one year after PAO. At ≥ three years postoperatively, the symptoms had completely resolved in seven of these patients and 13 (33%) had persistent symptoms. The severity and area of symptoms did not significantly differ between one and ≥ three years postoperatively. The JHEQ showed significant differences in the patient satisfaction and mental scores between those with and those without sypmtoms of LFCN injury at ≥ three years postoperatively, while there was no significant difference in the mean SF-36 scores. Conclusion. The incidence of LFCN injury after PAO using an anterior approach is high. The outcome of PAO, ≥ three years postoperatively, is poorer in patients with persistent symptoms from a perioperative LFCN injury, in that patient satisfaction and mental health scores are adversely affected. Cite this article: Bone Joint J 2024;106-B(5 Supple B):11–16

Aims. To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. Methods. We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey. Results. Significant improvements in all clinical outcome categories were found between the preoperative and second-look arthroscopic assessments in both groups (p < 0.001). At the latest follow-up, the mean IKDC and WOMAC scores in the good status group further improved compared with those at the time of second-look arthroscopic surgery (p < 0.001), which was not shown in the poor status group. The mean IKDC (good status, 72.8 (SD 12.5); poor status, 64.7 (SD 12.1); p = 0.002) and mean WOMAC scores (good status, 15.7 (SD 10.8); poor status, 21.8 (SD 13.6); p = 0.004) significantly differed between both groups at the latest follow-up. Moreover, significant correlations were observed between ICRS CRA grades and IKDC scores (negative correlation; p < 0.001) and WOMAC scores (positive correlation; p < 0.001) at the latest follow-up. Good cartilage status was found more frequently in knees with the desired range of 2° to 6° valgus correction than in those with corrections outside this range (p = 0.019). Conclusion. Second-look arthroscopic cartilage status correlated with clinical outcomes after MOHTO at intermediate-term follow-up, despite the relatively small clinical differences between groups. Cite this article: Bone Joint J 2021;103-B(11):1686–1694

Aims. The Coronal Plane Alignment of the Knee (CPAK) classification has been developed to predict individual variations in inherent knee alignment. The impact of preoperative and postoperative CPAK classification phenotype on the postoperative clinical outcomes of total knee arthroplasty (TKA) remains elusive. This study aimed to examine the effect of postoperative CPAK classification phenotypes (I to IX), and their pre- to postoperative changes on patient-reported outcome measures (PROMs). Methods. A questionnaire was administered to 340 patients (422 knees) who underwent primary TKA for osteoarthritis (OA) between September 2013 and June 2019. A total of 231 patients (284 knees) responded. The ­Knee Society Score 2011 (KSS 2011), Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), and Forgotten Joint Score-12 (FJS-12) were used to assess clinical outcomes. Using preoperative and postoperative anteroposterior full-leg radiographs, the arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated and classified based on the CPAK classification. To investigate the impact on PROMs, multivariable regression analyses using stepwise selection were conducted, considering factors such as age at surgery, time since surgery, BMI, sex, implant use, postoperative aHKA classification, JLO classification, and changes in aHKA and JLO classifications from preoperative to postoperative. Results. The preoperative and postoperative CPAK classifications were predominantly phenotype I (155 knees; 55%) and phenotype V (73 knees; 26%), respectively. The change in the preoperative to postoperative aHKA classification was a significant negative predictive factor for KOOS-12 and FJS-12, while postoperative apex proximal JLO was a significant negative predictive factor for KSS 2011 and KOOS-12. Conclusion. In primary TKA for OA, preoperative and postoperative CPAK phenotypes were associated with PROMs. Alteration in varus/valgus alignment from preoperative to postoperative was recognized as a negative predictive factor for both KOOS-12 and FJS-12. Moreover, the postoperative apex proximal JLO was identified as a negative factor for KSS 2011 and KOOS-12. Determining the target alignment for each preoperative phenotype with reproducibility could improve PROMs. Cite this article: Bone Joint J 2024;106-B(10):1059–1066

Aims. It is well described that patients with bone and joint infections (BJIs) commonly experience significant functional impairment and disability. Published literature is lacking on the impact of BJIs on mental health. Therefore, the aim of this study was to assess health-related quality of life (HRQoL) and the impact on mental health in patients with BJIs. Methods. The AO Trauma Infection Registry is a prospective multinational registry. In total, 229 adult patients with long-bone BJI were enrolled between 1 November 2012 and 31 August 2017 in 18 centres from ten countries. Clinical outcome data, demographic data, and details on infections and treatments were collected. Patient-reported outcomes using the 36-Item Short-Form Health Survey questionnaire (SF-36), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at one, six, and 12 months. The SF-36 mental component subscales were analyzed and correlated with infection characteristics and clinical outcome. Results. The SF-36 physical component summary mean at baseline was 30.9 (95% CI 29.7 to 32.0). At one month, it was unchanged (30.5; 95% CI 29.5 to 31.5; p = 0.447); it had improved statistically significantly at six months (35.5; 95% CI 34.2 to 36.7; p < 0.001) and at 12 months (37.9; 95% CI 36.4 to 39.3; p < 0.001). The SF-36 mental component summary mean at baseline was 42.5 (95% CI 40.8 to 44.2). At one month, it was unchanged (43.1; 95% CI 41.4 to 44.8; p = 0.458); it had improved statistically significantly at six months (47.1; 95% CI 45.4 to 48.7; p < 0.001) and at 12 months (46.7; 95% CI 45.0 to 48.5; p < 0.001). All mental subscales had improved by the end of the study, but mental health status remained compromised in comparison with the average USA population. Conclusion. BJIs considerably impact HRQoL, particularly mental health. Patients suffering from BJIs reported considerable limitations in their daily and social activities due to psychological problems. Impaired mental health may be explained by the chronic nature of BJIs, and therefore the mental wellbeing of these patients should be monitored closely. Cite this article: Bone Jt Open 2024;5(9):721–728

Aims. Oxidized zirconium (OxZi) and highly cross-linked polyethylene (HXLPE) were developed to minimize wear and risk of osteolysis in total hip arthroplasty (THA). However, retrieval studies have shown that scratched femoral heads may lead to runaway wear, and few reports of long-term results have been published. The purpose of this investigation is to report minimum ten-year wear rates and clinical outcomes of THA with OxZi femoral heads on HXLPE, and to compare them with a retrospective control group of cobalt chrome (CoCr) or ceramic heads on HXLPE. Methods. From 2003 to 2006, 108 THAs were performed on 96 patients using an OxZi head with a HXLPE liner with minimum ten-year follow-up. Harris Hip Scores (HHS) were collected preoperatively and at the most recent follow-up (mean 13.3 years). Linear and volumetric liner wear was measured on radiographs of 85 hips with a minimum ten-year follow-up (mean 14.5 years). This was compared to a retrospective control group of 45 THAs using ceramic or CoCr heads from October 1999 to February 2005, with a minimum of ten years’ follow-up. Results. Average HHS improved from 50.8 to 91.9 and 51.0 to 89.8 in the OxZi group and control group, respectively (p = 0.644), with no osteolysis in either group. Linear and volumetric wear rates in the OxZi group averaged 0.03 mm/year and 3.46 mm. 3. /year, respectively. There was no statistically significant difference in HHS scores, nor in linear or volumetric wear rate between the groups, and no revision for any indication. Conclusion. The radiological and clinical outcomes, and survivorship of THA with OxZi femoral heads and HXLPE liners, were excellent, and comparable to CoCr or ceramic heads at minimum ten-year follow-up. Wear rates are below what would be expected for development of osteolysis. OxZi-HXLPE is a durable bearing couple with excellent long-term outcomes. Cite this article: Bone Joint J 2024;106-B(3 Supple A):38–43

Aims. The aim of this study was to compare the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) using small and standard baseplates in Asian patients, and to investigate the impact of a mismatch in the sizes of the glenoid and the baseplate on the outcomes. Methods. This was retrospective analysis of 50 and 33 RSAs using a standard (33.8 mm, ST group) and a small (29.5 mm, SM group) baseplate of the Equinoxe reverse shoulder system, which were undertaken between January 2017 and March 2021. Radiological evaluations included the size of the glenoid, the β-angle, the inclination of the glenoid component, inferior overhang, scapular notching, the location of the central cage in the baseplate within the vault and the mismatch in size between the glenoid and baseplate. Clinical evaluations included the range of motion (ROM) and functional scores. In subgroup analysis, comparisons were performed between those in whom the vault of the glenoid was perforated (VP group) and those in whom it was not perforated (VNP group). Results. Perforation of the vault of the glenoid (p = 0.018) and size mismatch in height (p < 0.001) and width (p = 0.013) were significantly more frequent in the ST group than in the SM group. There was no significant difference in the clinical scores and ROM in the two groups, two years postoperatively (all p > 0.05). In subgroup analysis, the VP group had significantly less inferior overhang (p = 0.009), more scapular notching (p = 0.018), and more size mismatch in height (p < 0.001) and width (p = 0.025) than the VNP group. Conclusion. In Asian patients with a small glenoid, using a 29.5 mm small baseplate at the time of RSA was more effective in reducing size mismatch between the glenoid and the baseplate, decreasing the incidence of perforation of the glenoid vault, and achieving optimal positioning of the baseplate compared with the use of a 33.8 mm standard baseplate. However, longer follow-up is required to assess the impact of these findings on the clinical outcomes. Cite this article: Bone Joint J 2023;105-B(11):1189–1195

Aims. This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate. Methods. We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view. Results. There were no significant differences in the initial preoperative demographic characteristics. In both groups, there were significant improvements in postoperative clinical scores (p < 0.001). However, most clinical outcomes, including range of motion measurements (forward elevation, external rotation, internal rotation, and abduction), showed no differences between the pre- and postoperative values. Comparing the postoperative outcomes of both groups, no further improvement from biceps augmentation was found. Group B, although not reaching statistical significance, had more re-tears than group A (30% vs 15%; p = 0.117). Conclusion. In LMRCTs, biceps augmentation provided no significant improvement of an incomplete repair. Therefore, biceps augmentation is not recommended in the treatment of LMRCTs. Cite this article: Bone Joint J 2022;104-B(11):1234–1241

Aims. Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design. Methods. Patients with end-stage osteoarthritis were enrolled in a prospective cohort at a single centre. The cohort consisted of 11 females and 11 males with mean age of 70.6 years (SD 3.5) and BMI of 31.0 kg/m. 2. (SD 5.7). Implant fixation was evaluated using RSA as well as Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score, Oxford Hip Score, Hip disability and Osteoarthritis Outcome Score, 38-item Short Form survey, and EuroQol five-dimension health questionnaire scores at two-year follow-up. At least one acetabular screw was used in all cases. RSA markers were inserted into the innominate bone and proximal femur with imaging at six weeks (baseline) and six, 12, and 24 months. Independent-samples t-tests were used to compare to published thresholds. Results. Mean acetabular subsidence from baseline to 24 months was 0.087 mm (SD 0.152), below the critical threshold of 0.2 mm (p = 0.005). Mean femoral subsidence from baseline to 24 months was -0.002 mm (SD 0.194), below the published reference of 0.5 mm (p < 0.001). There was significant improvement in patient-reported outcome measures at 24 months with good to excellent results. Conclusion. RSA analysis demonstrates excellent fixation with a predicted low risk of revision at ten years of this novel reverse total hip system. Clinical outcomes were consistent with safe and effective hip replacement prostheses. Cite this article: Bone Jt Open 2023;4(5):385–392

Aims. Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO. Methods. In all, 202 consecutive patients who underwent PAO for developmental dysplasia of the hip (DDH) at our institution from 2015 to 2017 were included and followed up at 63 months (SD 10) postoperatively. Of these, 101 with complete data sets entered final analysis. Patients were assessed by questionnaire. Psychological status was measured by Brief Symptom Inventory (BSI-18), health-related quality of life was raised with 36-Item Short Form Survey (SF-36), hip functionality was measured by the short version 0f the International Hip Outcome Tool (iHOT-12), Subjective Hip Value (SHV), and Hip Disability and Outcome Score (HOS). Surgery satisfaction and pain were assessed. Dependent variables (endpoints) were postoperative quality of life (SF-36, HOS quality of life (QoL)), joint function (iHOT-12, SHV, HOS), patient satisfaction, and pain. Psychological distress was assessed by the Global Severity Index (GSI), somatization (BSI Soma), depression (BSI Depr), and anxiety (BSI Anx). Influence of psychological status was assessed by means of univariate and multiple multivariate regression analysis. Results. In multiple multivariate regression, postoperative GSI, BSI Soma, and BSI Depr had a negative effect on postoperative SF-36 (e -2.07, -3.05, and -2.67, respectively; p < 0.001), iHOT-12 (e -1.35 and -4.65, respectively; p < 0.001), SHV (e -1.20 and -2.71, respectively; p < 0.001), HOS QoL (e -2.09 and -4.79, respectively; p < 0.001), HOS Function (e -1.00 and -3.94, respectively; p < 0.001), and HOS Sport (e -1.44 and -5.29, respectively; p < 0.001), and had an effect on postoperative pain (e 0.13 and 0.37, respectively; p < 0.001). Conclusion. Psychological distress, depression, and somatization disorders affect health-related quality of life, perceived joint function, and sports ability. Pain perception is significantly increased by somatization. However, patient satisfaction with surgery is not affected. Cite this article: Bone Jt Open 2023;4(10):758–765

Aims. Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA). Methods. Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications. Results. A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334). Conclusion. Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients. Cite this article: Bone Joint J 2024;106-B(3 Supple A):17–23

Aims. This study aimed to investigate the relationship between changes in patellar height and clinical outcomes at a mean follow-up of 7.7 years (5 to 10) after fixed-bearing posterior-stabilized total knee arthroplasty (PS-TKA). Methods. We retrospectively evaluated knee radiographs of 165 knees, which underwent fixed-bearing PS-TKA with patella resurfacing. The incidence of patella baja and changes in patellar height over a minimum of five years of follow-up were determined using Insall-Salvati ratio (ISR) measurement. We examined whether patella baja (ISR < 0.8) at final follow-up affected clinical outcomes, knee joint range of motion (ROM), and Knee Society Score (KSS). We also assessed inter- and intrarater reliability of ISR measurements and focused on the relationship between patellar height reduction beyond measurement error and clinical outcomes. Results. The ISR gradually decreased over five years after TKA, and finally 33 patients (20.0%) had patella baja. Patella baja at the final follow-up was not related to passive knee ROM or KSS. Interestingly, when we divided into two groups - patella baja and patella normal-alta (ISR ≥ 0.8) - the patella baja group already had a lower patellar height before surgery, compared with the patella normal-alta group. The ISR measurement error in this study was 0.17. Both passive knee flexion and KSS were significantly decreased in the group with a decrease in ISR of ≥ 0.17 at final follow-up. Conclusion. Patellar height gradually decreased over five years of follow-up after TKA. The reduction in patellar height beyond measurement error following TKA was associated with lower clinical outcomes. Cite this article: Bone Jt Open 2021;2(12):1075–1081

Aims. The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique. Methods. This retrospective study analyzed 121 knees in 101 patients. Patient-reported outcome measures (PROMs) were collected preoperatively and one year postoperatively, and were analyzed according to the surgical technique (opening or closing wedge), postoperative mechanical axis deviation (deviations above and below 10% from the target), and achievement of medial joint opening (∆JLCA > 1°). Radiological parameters, including JLCA, mechanical axis deviation, and the difference in JLCA between preoperative standing and supine radiographs (JLCA. PD. ), an indicator of medial soft-tissue laxity, were measured. Cut-off points for parameters related to achieving medial joint opening were calculated from receiver operating characteristic (ROC) curves. Results. Patients in whom the medial joint opening was achieved had significantly better postoperative PROMs compared with those without medial opening (all p < 0.05). Patients who were outliers with deviation of > 10% from the target mechanical axis deviation had significantly similar PROMs compared with patients with an acceptable axis deviation (all p > 0.05). Medial joint opening was affected by postoperative mechanical axis deviation and JLCA. PD. The influence of JLCA. PD. on postoperative axis deviation was more pronounced in a closing wedge than in an opening wedge HTO. Conclusion. Medial joint opening rather than the mechanical axis deviation determined the clinical outcome in patients who underwent HTO. The JLCA. PD. identified the optimal postoperative axis deviation necessary to achieve medial joint opening. For patients with increased laxity, lowering the target axis deviation is recommended to achieve medial joint opening. The target axis deviation should also differ according to the technique of undergoing HTO. Cite this article: Bone Joint J 2024;106-B(3):240–248

Aims. Unicompartmental knee arthroplasty (UKA) is a bone-preserving treatment option for osteoarthritis localized to a single compartment in the knee. The success of the procedure is sensitive to patient selection and alignment errors. Robotic arm-assisted UKA provides technological assistance to intraoperative bony resection accuracy, which is thought to improve ligament balancing. This paper presents the five-year outcomes of a comparison between manual and robotically assisted UKAs. Methods. The trial design was a prospective, randomized, parallel, single-centre study comparing surgical alignment in patients undergoing UKA for the treatment of medial compartment osteoarthritis (ISRCTN77119437). Participants underwent surgery using either robotic arm-assisted surgery or conventional manual instrumentation. The primary outcome measure (surgical accuracy) has previously been reported, and, along with secondary outcomes, were collected at one-, two-, and five-year timepoints. Analysis of five-year results and longitudinal analysis for all timepoints was performed to compare the two groups. Results. Overall, 104 (80%) patients of the original 130 who received surgery were available at five years (55 robotic, 49 manual). Both procedures reported successful results over all outcomes. At five years, there were no statistical differences between the groups in any of the patient reported or clinical outcomes. There was a lower reintervention rate in the robotic arm-assisted group with 0% requiring further surgery compared with six (9%) of the manual group requiring additional surgical intervention (p < 0.001). Conclusion. This study has shown excellent clinical outcomes in both groups with no statistical or clinical differences in the patient-reported outcome measures. The notable difference was the lower reintervention rate at five years for roboticarm-assisted UKA when compared with a manual approach. Cite this article: Bone Joint J 2021;103-B(6):1088–1095

Aims. The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). Methods. The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain. Results. The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%). Conclusion. Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J 2022;104-B(3):401–407

Aims. The aim of this study was to compare the characteristics and outcomes of L-shaped and reverse L-shaped rotator cuff tears. Methods. A total of 82 shoulders (81 patients) after arthroscopic rotator cuff repair were retrospectively enrolled. The mean age of the patients was 62 years (SD 6), 33 shoulders (40.2%) were in male patients, and 57 shoulders (69.5%) were the right shoulder. Of these, 36 shoulders had an L-shaped tear (group L) and 46 had a reverse L-shaped tear (group RL). Both groups were compared regarding characteristics, pre- and postoperative pain, and functional outcomes. Muscle status was assessed by preoperative MRI, and re-tear rates by postoperative ultrasonography or MRI. Results. Patients in group RL were significantly older than in group L (p = 0.008), and group RL was significantly associated with female sex (odds ratio 2.5 (95% confidence interval 1.03 to 6.32); p = 0.041). Mean postoperative pain visual analogue scale (VAS) score was significantly greater (group L = 0.8 (SD 1.5), group RL = 1.7 (SD 2.2); p = 0.033) and mean postoperative American Shoulder and Elbow Surgeons (ASES) score was significantly lower in group RL than group L (group L = 91.4 (SD 13.1), group RL = 83.8 (SD 17.9); p = 0.028). However, postoperative mean VAS for pain and ASES score were not lower than the patient-acceptable symptom state scores. Mean retracted tear length was significantly larger in group L (group L = 24.6 mm (SD 6.5), group RL = 20.0 mm (SD 6.8); p = 0.003). Overall re-tear rate for 82 tears was 11.0% (nine shoulders), and re-tear rates in group L and RL were similar at 11.1% (four shoulders) and 10.9% (five shoulders), respectively (p = 1.000). No significant intergroup difference was found for fatty degeneration (FD) or muscle atrophy. Within group L, postoperative FD grades of supraspinatus and subscapularis worsened significantly (p = 0.034 and p = 0.008, respectively). Mean postoperative pain VAS (male = 1.2 (SD 1.8), female = 1.3 (SD 2.0)) and ASES scores (male = 88.7 (SD 15.5), female = 86.0 (SD 16.8)) were similar in male and female patients (p = 0.700 and p = 0.475, respectively). Regression analysis showed age was not a prognostic factor of postoperative pain VAS or ASES scores (p = 0.188 and p = 0.150, respectively). Conclusion. Older age and female sex were associated with reverse L-shaped tears. Although the postoperative functional outcomes of patients with reverse L-shaped tears were satisfactory, the clinical scores were poorer than those of patients with L-shaped tears. Surgeons should be aware of the differences in clinical outcome between L-shaped and reverse L-shaped rotator cuff tears. Cite this article: Bone Joint J 2022;104-B(3):394–400

Aims. Intraoperative pressure sensors allow surgeons to quantify soft-tissue balance during total knee arthroplasty (TKA). The aim of this study was to determine whether using sensors to achieve soft-tissue balance was more effective than manual balancing in improving outcomes in TKA. Methods. A multicentre randomized trial compared the outcomes of sensor balancing (SB) with manual balancing (MB) in 250 patients (285 TKAs). The primary outcome measure was the mean difference in the four Knee injury and Osteoarthritis Outcome Score subscales (ΔKOOS. 4. ) in the two groups, comparing the preoperative and two-year scores. Secondary outcomes included intraoperative balance data, additional patient-reported outcome measures (PROMs), and functional measures. Results. There was no significant difference in ΔKOOS. 4. between the two groups at two years (mean difference 0.4 points (95% confidence interval (CI) -4.6 to 5.4); p = 0.869), and multiple regression found that SB was not associated with a significant ΔKOOS. 4. (0.2-point increase (95% CI -5.1 to 4.6); p = 0.924). There were no significant differences between groups in other PROMs. Six-minute walking distance was significantly increased in the SB group (mean difference 29 metres; p = 0.015). Four-times as many TKAs were unbalanced in the MB group (36.8% MB vs 9.4% SB; p < 0.001). Irrespective of group assignment, no differences were found in any PROM when increasing ICPD thresholds defined balance. Conclusion. Despite improved quantitative soft-tissue balance, the use of sensors intraoperatively did not differentially improve the clinical or functional outcomes two years after TKA. These results question whether a more precisely balanced TKA that is guided by sensor data, and often achieved by more balancing interventions, will ultimately have a significant effect on clinical outcomes. Cite this article: Bone Joint J 2022;104-B(5):604–612

Aims. Scapular notching is thought to have an adverse effect on the outcome of reverse total shoulder arthroplasty (RTSA). However, the matter is still controversial. The aim of this study was to determine the clinical impact of scapular notching on outcomes after RTSA. Methods. Three electronic databases (PubMed, Cochrane Database, and EMBASE) were searched for studies which evaluated the influence of scapular notching on clinical outcome after RTSA. The quality of each study was assessed. Functional outcome scores (the Constant-Murley scores (CMS), and the American Shoulder and Elbow Surgeons (ASES) scores), and postoperative range of movement (forward flexion (FF), abduction, and external rotation (ER)) were extracted and subjected to meta-analysis. Effect sizes were expressed as weighted mean differences (WMD). Results. In all, 11 studies (two level III and nine level IV) were included in the meta-analysis. All analyzed variables indicated that scapular notching has a negative effect on the outcome of RTSA . Statistical significance was found for the CMS (WMD –3.11; 95% confidence interval (CI) –4.98 to –1.23), the ASES score (WMD –6.50; 95% CI –10.80 to –2.19), FF (WMD –6.3°; 95% CI –9.9° to –2.6°), and abduction (WMD –9.4°; 95% CI –17.8° to –1.0°), but not for ER (WMD –0.6°; 95% CI –3.7° to 2.5°). Conclusion. The current literature suggests that patients with scapular notching after RTSA have significantly worse results when evaluated by the CMS, ASES score, and range of movement in flexion and abduction. Cite this article: Bone Joint J 2020;102-B(11):1438–1445

Aims. The objective of this study was to compare the two-year migration and clinical outcomes of a new cementless hydroxyapatite (HA)-coated titanium acetabular shell with its previous version, which shared the same geometrical design but a different manufacturing process for applying the titanium surface. Methods. Overall, 87 patients undergoing total hip arthroplasty (THA) were randomized to either a Trident II HA or Trident HA shell, each cementless with clusterholes and HA-coating. All components were used in combination with a cemented Exeter V40 femoral stem. Implant migration was measured using radiostereometric analysis (RSA), with radiographs taken within two days of surgery (baseline), and at three, 12, and 24 months postoperatively. Proximal acetabular component migration was the primary outcome measure. Clinical scores and patient-reported outcome measures (PROMs) were collected at each follow-up. Results. Mean proximal migrations at three, 12, and 24 months were 0.08 mm (95% confidence interval (CI) 0.03 to 0.14), 0.11 mm (95% CI 0.06 to 0.16), and 0.14 mm (95% CI 0.09 to 0.20), respectively, in the Trident II HA group, versus 0.11 mm (95% CI 0.06 to 0.16), 0.12 mm (95% CI 0.07 to 0.17), and 0.14 mm (95% CI 0.09 to 0.19) in the Trident HA group (p = 0.875). No significant differences in translations or rotations between the two designs were found in any other direction. Clinical scores and PROMs were comparable between groups, except for an initially greater postoperative improvement in Hip disability and Osteoarthritis Outcome Symptoms score in the Trident HA group (p = 0.033). Conclusion. The Trident II clusterhole HA shell has comparable migration with its predecessor, the Trident hemispherical HA cluster shell, suggesting a similar risk of long-term aseptic loosening. Cite this article: Bone Joint J 2024;106-B(2):136–143

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

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The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair.

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. For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis. Methods. We reviewed 15 patients over a five-year period (January 2017 to December 2022) who had undergone extra-articular resection of the hip joint due to malignant tumour using a custom-made osteotomy guide and 3D-printed endoprosthesis. Each of the 15 patients had a single lesion, with six originating from the acetabulum side and nine from the proximal femur. All patients had their posterior column preserved according to the surgical plan. Results. Postoperative pathological assessment revealed a negative surgical margin was achieved in all patients. At final follow-up, 13.3% (2/15) died and no recurrence occurred. The overall survival was 81.7% at five years. None of the patients showed any signs of aseptic loosening, and no wound healing issues were observed. In total, 20% (3/15) developed complications, with two cases of early hip dislocation and one case of deep infection. The cumulative incidence of mechanical and non-mechanical failure in this series was 13.7% and 9.3%, respectively, at five years. In this cohort, the mean time to full weightbearing was 5.89 (SD 0.92) weeks and the mean Musculoskeletal Tumor Society score was 24.1 (SD 4.4). Conclusion. For patients with a hip joint tumour who met the inclusion criteria and were deemed suitable for posterior column preservation, a custom-made osteotomy guide combined with 3D-printed endoprosthesis is worth performing when treating patients who require extra-articular resection of the hip joint, as it can achieve adequate margin for local control, maximize bone preservation to maintain pelvic ring integrity, reduce the risk of complications by simplifying the surgical procedure, and allow for more precise reconstruction for better function. Cite this article: Bone Jt Open 2024;5(11):1027–1036

Aims. The aim of this study was to assess the influence of obesity on the clinical outcomes and survivorship ten years postoperatively in patients who underwent a fixed-bearing unicompartmental knee arthroplasty (UKA). Patients and Methods. We prospectively followed 184 patients who underwent UKA between 2003 and 2007 for a minimum of ten years. A total of 142 patients with preoperative body mass index (BMI) of < 30 kg/m. 2. were in the control group (32 male, 110 female) and 42 patients with BMI of ≥ 30 kg/m. 2. were in the obese group (five male, 37 female). Pre- and postoperative range of movement (ROM), Knee Society Score (KSS), Oxford Knee Score (OKS), 36-Item Short-Form Health Survey (SF-36), and survivorship were analyzed. Results. Patients in the obese group underwent UKA at a significantly younger mean age (56.5 years (. sd. 6.4)) than those in the control group (62.4 years (. sd. 7.8); p < 0.001). There was no significant difference in preoperative functional scores. However, those in the obese group had a significantly lower ROM (116° (. sd. 15°) vs 123° (. sd. 17°); p = 0.003). Both groups achieved significant improvement in outcome scores regardless of BMI, ten years postoperatively. All patients achieved the minimal clinically important difference (MCID) for OKS and KSS. Both groups also had high rates of satisfaction (96.3% in the control group and 97.5% in the obese group) and the fulfilment of expectations (94.9% in the control group and 95.0% in the obese group). Multiple linear regression showed a clear association between obesity and a lower OKS two years postoperatively and Knee Society Function Score (KSFS) ten years postoperatively. After applying propensity matching, obese patients had a significantly lower KSFS, OKS, and physical component score (PCS) ten years postoperatively. Seven patients underwent revision to total knee arthroplasty (TKA), two in the control group and five in the obese group, resulting in a mean rate of survival at ten years of 98.6% and 88.1%, respectively (p = 0.012). Conclusion. Both groups had significant improvements in functional and quality-of-life scores postoperatively. However, obesity was a significant predictor of poorer improvement in clinical outcome and an increased rate of revision ten years postoperatively

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

Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. Methods. Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. Results. The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). Conclusions. Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications. Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433–438. DOI: 10.1302/2046-3758.67.2000640

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Aims

The first aim of this study was to evaluate whether preoperative renal function is associated with postoperative changes in whole blood levels of metal ions in patients who have undergone a Birmingham Hip Resurfacing (BHR) arthroplasty with a metal-on-metal bearing. The second aim was to evaluate whether exposure to increased cobalt (Co) and chromium (Cr) levels for ten years adversely affected renal function.

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Aims

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

We have investigated whether shape of the knee can predict the clinical outcome of patients after an anterior cruciate ligament rupture. We used statistical shape modelling to measure the shape of the knee joint of 182 prospectively followed patients on lateral and Rosenberg view radiographs of the knee after a rupture of the anterior cruciate ligament. Subsequently, we associated knee shape with the International Knee Documentation Committee subjective score at two years follow-up. The mean age of patients was 31 years (21 to 51), the majority were male (n = 121) and treated operatively (n = 135). We found two modes (shape variations) that were significantly associated with the subjective score at two years: one for the operatively treated group (p = 0.002) and one for the non-operatively treated group (p = 0.003). Operatively treated patients who had higher subjective scores had a smaller intercondylar notch and a smaller width of the intercondylar eminence. Non-operatively treated patients who scored higher on the subjective score had a more pyramidal intercondylar notch as opposed to one that was more dome-shaped. We conclude that the shape of the femoral notch and the intercondylar eminence is predictive of clinical outcome two years after a rupture of the anterior cruciate ligament. Cite this article: Bone Joint J 2014;96-B:737–42

Aims. Responsiveness and ceiling effects are key properties of an outcome score. No such data have been reported for the original English version of the International Hip Outcome Tool 12 (iHOT-12) at a follow-up of more than four months. The aim of this study was to identify the responsiveness and ceiling effects of the English version iHOT-12 in a series of patients undergoing hip arthroscopy for intra-articular hip pathology at a minimum of one year postoperatively. Methods. A total of 171 consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement (FAI) under the care of a single surgeon between January 2013 and March 2017 were included. iHOT-12 and EuroQol 5D-5L (EQ-5D-5L) scores were available pre- and postoperatively. Effect size and ceiling effects for the iHOT-12 were calculated with subgroup analysis. Results. A total of 122 patients (71.3%) completed postoperative PROMs scores with median follow-up of 24.3 months (interquartile range (IQR) 17.2 to 33.5). The median total cohort iHOT-12 score improved significantly from 31.0 (IQR 20 to 58) preoperatively to 72.5 (IQR 47 to 90) postoperatively (p < 0.001). The effect size (Cohen’s d) was 1.59. In all, 33 patients (27%) scored within ten points (10%) of the maximum score and 38 patients (31.1%) scored within the previously reported minimal clinically important difference (MCID) of the maximum score. Furthermore, nine (47%) male patients aged < 30 years scored within 10% of the maximum score and ten (53%) scored within the previously reported MCID of the maximum score. Conclusion. There is a previously unreported ceiling effect of the iHOT-12 at a minimum one-year follow-up which is particularly marked in young, male patients following hip arthroscopy for FAI. This tool may not have the maximum measurement required to capture the true outcome following this procedure. Cite this article: Bone Joint J 2020;102-B(8):1010–1015

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. . Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects. Cite this article: Bone Joint J 2014;96-B:1478–84

Mobile-bearing unicompartmental knee replacements (UKRs) with a flat tibial plateau have not performed well in the lateral compartment, owing to a high dislocation rate. This led to the development of the Domed Lateral Oxford UKR (Domed OUKR) with a biconcave bearing. The aim of this study was to assess the survival and clinical outcomes of the Domed OUKR in a large patient cohort in the medium term. We prospectively evaluated 265 consecutive knees with isolated disease of the lateral compartment and a mean age at surgery of 64 years (32 to 90). At a mean follow-up of four years (. sd. 2.2, (0.5 to 8.3)) the mean Oxford knee score was 40 out of 48 (. sd. 7.4). A total of 12 knees (4.5%) had re-operations, of which four (1.5%) were for dislocation. All dislocations occurred in the first two years. Two (0.8%) were secondary to significant trauma that resulted in ruptured ligaments, and two (0.8%) were spontaneous. In four patients (1.5%) the UKR was converted to a primary TKR. Survival at eight years, with failure defined as any revision, was 92.1% (95% confidence interval 81.3 to 100). . The Domed Lateral OUKR gives good clinical outcomes, low re-operation and revision rates and a low dislocation rate in patients with isolated lateral compartmental disease, in the hands of the designer surgeons. Cite this article: Bone Joint J 2014;96-B:59–64

Aims

There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

This study aimed to determine the correlation between the amount of maximum flexion and the clinical outcome in 207 Koreans (333 knees) undergoing total knee replacement. The association of maximum flexion with clinical outcome was evaluated one year postoperatively using three scoring systems; the American Knee Society score, Western Ontario McMaster Universities Osteoarthritis index and the Short Form-36. The mean maximum flexion decreased post-operatively at 12 months from 140.1° (60° to 160°) to 133.0° (105° to 150°). Only the social function score of the Short Form-36 correlated significantly with maximum flexion (correlation coefficient = 0.180, p = 0.039). In comparative analyses of subgroups divided by a maximum flexion of 120°, we found no significant differences in any parameters except the social function score of the Short Form-36 (41.9 vs 47.3, p = 0.031). Knees with a maximum flexion of more than 135° had a better functional Western Ontario McMasters Universities Osteoarthritis index score than knees with maximum flexion of 135° or less (17.5 vs 14.3, p = 0.031). We found only weak correlation between the postoperative maximum flexion and the clinical parameters for pain relief, function and quality of life, even in Korean patients. Efforts to increase post-operative maximum flexion should be exercised with caution until concerns relating to high-flexion activities are sufficiently resolved

Aims. Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. Methods. A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. Results. From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. Conclusion. For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160–6

We report the clinical outcome and findings at second-look arthroscopy of 216 patients (mean age 25 years (11 to 58)) who underwent anterior cruciate ligament (ACL) reconstruction or augmentation. There were 73 single-bundle ACL augmentations (44 female, 29 male), 82 double-bundle ACL reconstructions (35 female, 47 male), and 61 single-bundle ACL reconstructions (34 female, 27 male). In 94 of the 216 patients, proprioceptive function of the knee was evaluated before and 12 months after surgery using the threshold to detect passive motion test. Second-look arthroscopy showed significantly better synovial coverage of the graft in the augmentation group (good: 60 (82%), fair: 10 (14%), poor: 3 (4%)) than in the other groups (p = 0.039). The mean side-to-side difference measured with a KT-2000 arthrometer was 0.4 mm (-3.3 to 2.9) in the augmentation group, 0.9 mm (-3.2 to 3.5) in the double-bundle group, and 1.3 mm (-2.7 to 3.9) in the single-bundle group: the result differed significantly between the augmentation and single-bundle groups (p = 0 .013). No significant difference in the Lysholm score or pivot-shift test was seen between the three groups (p = 0.09 and 0.65, respectively). In patients with good synovial coverage, three of the four measurements used revealed significant improvement in proprioceptive function (p = 0.177, 0.020, 0.034, and 0.026). We conclude that ACL augmentation is a reasonable treatment option for patients with favourable ACL remnants. Cite this article: Bone Joint J 2014;96-B:1325–32

Aims

Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity.

Aims

This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA.

This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes. A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group. In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes. Cite this article: Bone Joint J 2013;95-B:81–9

The significance of weight in the indications for unicompartmental knee replacement (UKR) is unclear. Our hypothesis was that weight does not affect the long-term rate of survival of UKRs. We undertook a retrospective study of 212 UKRs at a mean follow-up of 12 years (7 to 22). The patients were distributed according to body mass index (BMI; < vs ≥ 30 kg/m. 2. ) and weight (< vs ≥ 82 kg). Kaplan-Meier survivorship analysis was performed and ten-year survival rates were compared between the sub-groups. Multimodal regression analysis determined the impact of the various theoretical contraindications on the long-term rate of survival of UKR. The ten-year rates of survival were similar in the two weight subgroups (≥ 82 kg: 93.5% (95% confidence interval (CI) 66.5 to 96.3); < 82 kg: 92.5% (95% CI 82.5 to 94.1)) and also in the two BMI subgroups (≥ 30 kg/m. 2. : 92% (95% CI 82.5 to 95.3); < 30 kg/m. 2. : 94% (95% CI 78.4 to 95.9)). Multimodal regression analysis revealed that weight plays a part in reducing the risk of revision with a relative risk of 0.387, although this did not reach statistical significance (p = 0.662). The results relating weight and BMI to the clinical outcome were not statistically significant. Thus, this study confirms that weight does not influence the long-term rate of survival of UKR. Cite this article: Bone Joint J 2013;95-B:1064–8

Aims

To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps.

Aims

Patients with soft-tissue sarcoma (STS) who undergo unplanned excision (UE) are reported to have worse outcomes than those who undergo planned excision (PE). However, others have reported that patients who undergo UE may have similar or improved outcomes. These discrepancies are likely to be due to differences in characteristics between the two groups of patients. The aim of the study is to compare patients who underwent UE and PE using propensity score matching, by analyzing data from the Japanese Bone and Soft Tissue Tumor (BSTT) registry.

Patients with infected arthroplasties are normally treated with a two-stage exchange procedure using polymethylmethacrylate bone cement spacers impregnated with antibiotics. However, spacers may act as a foreign body to which micro-organisms may adhere and grow. In this study it was hypothesised that subclinical infection may be diagnosed with sonication of the surface biofilm of the spacer. The aims were to assess the presence of subclinical infection through sonication of the spacer at the time of a second-stage procedure, and to determine the relationship between subclinical infection and the clinical outcome. Of 55 patients studied, 11 (20%) were diagnosed with subclinical infection. At a mean follow-up of 12 months (interquartile range 6 to 18), clinical failure was found in 18 (32.7%) patients. Of the patients previously diagnosed with subclinical infection, 63% (7 of 11) had failed compared with 25% (11 of 44) of those without subclinical infection (odds ratio 5.25, 95% confidence interval 1.29 to 21.4, p = 0.021). Sonication of the biofilm of the surface of the spacer is useful in order to exclude subclinical infection and therefore contributes to improving the outcome after two-stage procedures

Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

A total of 370 consecutive primary total knee replacements performed for osteoarthritis were followed up prospectively at 6, 18, 36 and 60 months. The Knee Society score and complications (perioperative mortality, superficial and deep wound infection, deep-vein thrombosis and revision rate) were recorded. By dividing the study sample into subgroups based on the body mass index overall, the body mass index in female patients and the absolute body-weight. The outcome in obese and non-obese patients was compared. A repeated measures analysis of variance showed no difference in the Knee Society score between the subgroups. There was no statistically-significant difference in the complication rates for the subgroups studied. Obesity did not influence the clinical outcome five years after total knee replacement

Aims

The direct anterior (DA) approach has been associated with rapid patient recovery after total hip arthroplasty (THA) but may be associated with more frequent femoral complications including implant loosening. The objective of this study was to determine whether the addition of a collar to the femoral stem affects implant migration, patient activity, and patient function following primary THA using the DA approach.

Introduction

There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery.

We report the clinical outcome and survival of 100 total hip arthroplasties with Link RS cementless hip prostheses after a mean of 63 months (51 to 93). The average preoperative Merle d'Aubigne hip score was 9.4 points and the average score at the latest follow-up was 15.3 points. Thirteen prostheses have been revised and seven await revision. Survivorship analysis based on intention to revise showed only 68% survival at seven years (95% CI 53% to 81%). The survivals of femoral and acetabular components verified to be loose at surgery were 78% and 89% respectively at seven years. A number of other patients have pain and it seems likely that there will be substantial reduction in these survival figures in the future

Aims

The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability.

Aims

Dupuytren’s contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition.

Aims

The diversity of femoral morphology renders femoral component sizing in total hip arthroplasty (THA) challenging. We aimed to determine whether femoral morphology and femoral component filling influence early clinical and radiological outcomes following THA using fully hydroxyapatite (HA)-coated femoral components.

Aims

The optimal method of tibial component fixation remains uncertain in total knee arthroplasty (TKA). Hydroxyapatite coatings have been applied to improve bone ingrowth in uncemented designs, but may only coat the directly accessible surface. As peri-apatite (PA) is solution deposited, this may increase the coverage of the implant surface and thereby fixation. We assessed the tibial component fixation of uncemented PA-coated TKAs versus cemented TKAs.

Aims

Treatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones.

Aims

Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge.

This prospective study reports the 15-year survival and ten-year functional outcome of a consecutive series of 1000 minimally invasive Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women, 52%, mean age 66 years; 32 to 88). These were implanted by two surgeons involved with the design of the prosthesis to treat anteromedial osteoarthritis and spontaneous osteonecrosis of the knee, which are recommended indications. Patients were prospectively identified and followed up independently for a mean of 10.3 years (5.3 to 16.6).

At ten years, the mean Oxford Knee Score was 40 (standard deviation (sd) 9; 2 to 48): 79% of knees (349) had an excellent or good outcome. There were 52 implant-related re-operations at a mean of 5.5 years (0.2 to 14.7). The most common reasons for re-operation were arthritis in the lateral compartment (2.5%, 25 knees), bearing dislocation (0.7%, seven knees) and unexplained pain (0.7%, seven knees). When all implant-related re-operations were considered as failures, the ten-year rate of survival was 94% (95% confidence interval (CI) 92 to 96) and the 15-year survival rate 91% (CI 83 to 98). When failure of the implant was the endpoint the 15-year survival was 99% (CI 96 to 100).

This is the only large series of minimally invasive UKAs with 15-year survival data. The results support the continued use of minimally invasive UKA for the recommended indications.

Cite this article: Bone Joint J 2015;97-B:1493–99.

A total of 187 patients with primary osteoarthritis (OA) of the knee undergoing total knee replacement (TKR) were randomly divided into two groups, one of which underwent synovectomy. The patients and assessors were blinded to the randomisation both before and after surgery. The duration of surgery, hospitalisation period, concealed bleeding, drainage volume, blood transfusion rate and range of movement of the knee at three days after the operation were analysed. Patients were followed up at four weeks and 12 months after their operation, and a visual analogue score (VAS) for pain, Knee Society score (KSS) and a patellar ballottement test were compared between the groups.

The mean amount of concealed bleeding was higher in the synovectomy group compared with the control group (1.24 l (0.08 to 3.28) vs 1.03 l (0.16 to 2.94); p = 0.042), as was the mean drainage volume (0.90 l (0.35 to 1.81) vs 0.81 (0.25 to 1.65); p = 0.030). The mean operating time was also higher in the synovectomy group compared with the controls (1.50 hours (1.34 to 1.75) vs 1.41 hours (1.21 to 1.79); p = 0.006). There were no significant differences in blood transfusion rate (p = 0.882), hospital stay (p = 0.805) or range of movement of the knee (p = 0.413) between the two groups. At four weeks and 12 months post-operatively there were no statistically significant differences in any of the measured parameters. We concluded that synovectomy confers no clinical advantages in TKR for primary OA while subjecting patients to higher levels of bleeding and longer operating times.

Cite this article: Bone Joint J 2013;95-B:1197–200.

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries.

We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed.

In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44).

At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury.

Cite this article: Bone Joint J 2013;95-B:548–53.

We report on 397 consecutive revision total hip replacements in 371 patients with a mean clinical and radiological follow-up of 12.9 years (10 to 17.7). The mean age at surgery was 69 years (37 to 93). A total of 28 patients (8%) underwent further revision, including 16 (4%) femoral components. In all 223 patients (56%, 233 hips) died without further revision and 20 patients (5%, 20 hips) were lost to follow-up. Of the remaining patients, 209 (221 hips) were available for clinical assessment and 194 (205 hips) for radiological review at mean follow-up of 12.9 years (10 to 17.7).

The mean Harris Hip Score improved from 58.7 (11 to 92) points to 80.7 (21 to 100) (p <  0.001) and the mean Merle d’Aubigné and Postel hip scores at final follow-up were 4.9 (2 to 6), 4.5 (2 to 6) and 4.3 (2 to 6), respectively for pain, mobility and function. Radiographs showed no lucencies around 186 (90.7%) femoral stems with stable bony ingrowth seen in 199 stems (97%). The survival of the S-ROM femoral stem at 15 years with revision for any reason as the endpoint was 90.5% (95% confidence interval (CI) 85.7 to 93.8) and with revision for aseptic loosening as the endpoint 99.3% (95% CI 97.2 to 99.8).

We have shown excellent long-term survivorship and good clinical outcome of a cementless hydroxyapatite proximally-coated modular femoral stem in revision hip surgery.

Cite this article: Bone Joint J 2014;96-B:730–6.

The outcome of total hip replacement (THR) is potentially affected by the body mass index (BMI) of the patient. We studied the outcome of 2026 consecutive primary cementless THRs performed for osteoarthritis. The mean follow-up was 6.3 years (0 to 11.71) and no patient was lost to follow-up for survival analysis. The patients were divided into two groups according to their BMI as follows: non-obese (BMI < 30 kg/m²) and obese (BMI ≥ 30 kg/m²).

The obese patient undergoing surgery was found to be significantly younger (p < 0.001). The log-rank test for equality of survival showed no difference in the mid-term survival (p = 0.552) with an estimated survival at 11 years of 95.2% (95% CI 92.5 to 98.0) in the non-obese and 96.7% (95% CI 94.9 to 98.5) in the obese groups. The clinical and radiological outcome was determined in a case-matched study performed on 134 obese individuals closely matched with 134 non-obese controls. The non-obese group was found to have a significantly higher post-operative Harris hip score (p < 0.001) and an increased range of movement, but overall satisfaction with surgery was comparable with that of the obese patients. Radiological analysis of the acetabular and femoral components showed no significant differences with regard to radiolucent lines, osteolysis, ingrowth of the femoral component, the acetabular inclination angle or alignment of the femoral component. Our results suggest that the survival of cementless THR is not adversely affected by obesity. Obese patients can therefore be counselled that despite a lower clinical score, they should expect to be satisfied with the result of their THR with a mid-term survival rate equivalent to that of non-obese patients.

Medium-term survivorship of the Oxford phase 3 unicompartmental knee replacement (UKR) has not yet been established in an Asian population. We prospectively evaluated the outcome of 400 phase 3 Oxford UKRs in 320 Korean patients with a mean age at the time of operation of 69 years (48 to 82). The mean follow-up was 5.2 years (1 to 10). Clinical and radiological assessment was carried out pre- and post-operatively. At five years, the mean Knee Society knee and functional scores had increased significantly from 56.2 (30 to 91) pre-operatively to 87.2 (59 to 98) (p = 0.034) and from 59.2 (30 to 93) to 88.3 (50 to 100) (p = 0.021), respectively. The Oxford knee score increased from a mean of 25.8 (12 to 39) pre-operatively to 39.8 (25 to 58) at five years (p = 0.038). The ten-year survival rate was 94% (95% confidence interval 90.1 to 98.0). A total of 14 UKRs (3.5%) required revision. The most common reason for revision was dislocation of the bearing in 12 (3%). Conversion to a total knee replacement was required in two patients who developed osteoarthritis of the lateral compartment.

This is the largest published series of UKR in Korean patients. It shows that the mid-term results after a minimally invasive Oxford phase 3 UKR can yield satisfactory clinical and functional results in this group of patients.

We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 (sd 13.7)) to that found at the latest follow-up (58.0 (sd 12.5)) (p = 0.001). The only statistically significant change in the nine symptom domains of the QLQ-C30 was a reduction in the mean level of pain (from 59.1 to 29.5 (out of 100)) (p < 0.001).

Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.

Peri-acetabular tumour resections and their subsequent reconstruction are among the most challenging procedures in orthopaedic oncology. Despite the fact that a number of different pelvic endoprostheses have been introduced, rates of complication remain high and long-term results are mostly lacking.

In this retrospective study, we aimed to evaluate the outcome of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis after a type 2 or type 2/3 internal hemipelvectomy.

A total of 19 patients (11M:8F) with a mean age of 48 years (14 to 72) were included, most of whom had been treated for a primary bone tumour (n = 16) between 2003 and 2009. After a mean follow-up of 39 months (28 days to 8.7 years) seven patients had died. After a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive, of whom 11 were disease-free. Complications occurred in 15 patients. Three had recurrent dislocations and three experienced aseptic loosening. There were no mechanical failures. Infection occurred in nine patients, six of whom required removal of the prosthesis. Two patients underwent hindquarter amputation for local recurrence.

The implant survival rate at five years was 50% for all reasons, and 61% for non-oncological reasons. The mean Musculoskeletal Tumor Society score at final follow-up was 49% (13 to 87).

Based on these poor results, we advise caution if using the pedestal cup for reconstruction of a peri-acetabular tumour resection.

Cite this article: Bone Joint J 2014;96-B:1706–12.

Haematomas, drainage, and other non-infectious wound complications following total knee replacement (TKR) have been associated with long-term sequelae, in particular, deep infection. However, the impact of these wound complications on clinical outcome is unknown. This study compares results in 15 patients re-admitted for wound complications within 90 days of TKR to 30 matched patients who underwent uncomplicated total knee replacements. Patients with wound complications had a mean age of 66 years (49 to 83) and mean body mass index (BMI) of 37 (21 to 54), both similar to that of patients without complications (mean age 65 years and mean BMI 35). Those with complications had lower mean Knee Society function scores (46 (0 to 100 vs 66 (20 to 100), p = 0.047) and a higher incidence of mild or greater pain (73% vs 33%, p = 0.01) after two years compared with the non re-admitted group. Expectations in patients with wound complications following TKR should be tempered, even in those who do not develop an infection.

Cite this article: Bone Joint J 2014;96-B:619–21.

Between January 1990 and December 2000 we carried out 226 SB Charité III disc replacements for lumbar disc degeneration in 160 patients. They were reviewed at a mean follow-up of 79 months (31 to 161) to determine the clinical and radiological outcome. The clinical results were collected by an independent observer, who was not involved in patient selection, treatment or follow-up, using a combination of outcome measures, including the Oswestry Disability Index. Pain was recorded using a visual analogue score, and the most recent radiographs were reviewed.

Survival of the device was analysed by the Kaplan-Meier method and showed a cumulative survival of 35% at 156 months when radiological failure was taken as the endpoint. The mean improvement in the Oswestry disability index scores after disc replacement was 14% (6% to 21%) and the mean improvement in the pain score was 1.6 (0.46 to 2.73), both falling below the clinically significant threshold. Removal of the implant was required in 12 patients, four because of implant failure.

These poor results indicate that further use of this implant is not justified.

We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation.

From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (sd) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, sd 5) were recruited after a mean follow-up of 50 months (36 to 64).

The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without.

Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA.

Cite this article: Bone Joint J 2015;97-B:1481–7.

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

The Bologna–Oxford (BOX) total ankle replacement (TAR) was developed with the aim of achieving satisfactory pain-free movement of the ankle. To date, only one single multicentre study has reported its clinical results. The aim of this study was to conduct an independent review of its mid-term results.

We retrospectively reviewed a total of 60 prospectively followed patients in whom 62 BOX TARs had been implanted between 2004 and 2008. We used the American Orthopedic Foot and Ankle Society (AOFAS) score to assess the clinical results. Standardised radiographs taken at the time of final follow-up were analysed by two observers. The overall survival was 91.9% at a mean follow-up of 42.5 months (24 to 71). The mean AOFAS score had improved from 35.1 points (sd 16.6; 4 to 73) pre-operatively to 78.0 (sd 10.7; 57 to 100) at final follow-up (p < 0.01). Tibial radiolucencies < 2 mm in width were seen around 16 TARs. Talar radiolucencies < 2 mm were seen around four TARs. A total of 47 patients (78.3%) were very satisfied or satisfied with the outcome. Five patients required revision for functional limitation or continuing pain.

We compared extrusion of the allograft after medial and lateral meniscal allograft transplantation and examined the correlation between the extent of extrusion and the clinical outcome. A total of 73 lateral and 26 medial meniscus allografts were evaluated by MRI at a mean of 32 months (24 to 59) in 99 patients (67 men, 32 women) with a mean age of 35 years (21 to 52). The absolute values and the proportional widths of extruded menisci as a percentage were measured in coronal images that showed maximum extrusion. Functional assessments were performed using Lysholm scores. The mean extrusion was 4.7 mm (1.8 to 7.7) for lateral menisci and 2.9 mm (1.2 to 6.5) for medial menisci (p < 0.001), and the mean percentage extrusions were 52.0% (23.8% to 81.8%) and 31.2% (11.6% to 63.4%), respectively (p < 0.001). Mean Lysholm scores increased significantly from 49.0 (10 to 83) pre-operatively to 86.6 (33 to 99) at final follow-up for lateral menisci (p = 0.001) and from 50.9 (15 to 88) to 88.3 (32 to 100) for medial menisci (p < 0.001). The final mean Lysholm scores were similar in the two groups (p = 0.312). Furthermore, Lysholm scores were not found to be correlated with degree of extrusion (p = 0.242).

Thus, transplanted lateral menisci extrude more significantly than transplanted medial menisci. However, the clinical outcome after meniscal transplantation was not found to be adversely affected by extrusion of the allograft.

Congenital talipes equinovarus is a common anomaly which can now be diagnosed prenatally on a routine ultrasound scan at 20 weeks of gestation. Prenatal counselling is increasingly offered to parents with affected fetuses, but it is difficult to counsel parents if there is a chance that the fetus may not have talipes. Our study correlates the prenatal ultrasound findings of 14 infants diagnosed as having unilateral or bilateral talipes during their routine 20-week ultrasound scan with their clinical findings at birth and the treatment received.

No feet diagnosed as talipes on the ultrasound scan were completely normal at birth and therefore there were no true false-positive results. One foot graded as normal at 20 weeks was found to have a mild grade-1 talipes at birth, but did not require treatment other than simple stretches. A total of 32% of feet required no treatment and so could be considered functional false-positive results on the scan. Serial casting was required by 13% of feet and surgical treatment by 55%. The severity of the talipes is difficult to establish before birth. A number of patients are likely to need surgical treatment, but a proportion will have talipes so mildly that no treatment will be required. In counselling parents at 20 weeks, orthopaedic surgeons need to know whether or not there is a small chance that the ultrasound diagnosis could be wrong and also that the talipes may be so mild that the foot will not require treatment.

We have devised a new scoring system using visual analogue scales (VAS) to determine the functional outcome in 15 patients with 20 displaced intra-articular calcaneal fractures, confirmed by CT. The average follow-up was 19 months.

A VAS was completed separately by the patient, the surgeon and an independent assessor. It showed satisfactory agreement between observers and strong correlations with a General Health Survey (SF36), a pain scale (McGill Pain Questionnaire) and a disease-specific, historical scale for calcaneal fractures (the Rowe score).

We reviewed retrospectively the results in 211 consecutive patients who had undergone limb salvage for bone neoplasia with endoprosthetic reconstruction of the proximal femur (96), distal femur (78), proximal tibia (30) and total femur (7). Their mean age was 50 years (11 to 86) and the mean follow-up period was 37.3 months (1 to 204). A total of 35 (16.6%) prostheses failed. Overall, implant survival was 78% (95% confidence interval (CI) 0.29 to 0.54) at five years, 60% (95% CI 0.93 to 2.35) at ten years and 60% (95% CI 1.27 to 3.88) at 15 years. Survivorship of the limb was 97.6% (95% CI 1.73 to 3.35) at ten years. The gender, age, diagnosis and location of the tumour were not prognostic variables for failure. Modular endoprosthetic replacement in the lower limb is a durable long-term reconstructive option, with the implants generally outlasting the patient.

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scott’s fusion and 19 a Buck’s fusion.

The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (sd 8.7) and 10.7 (sd 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (sd 5.1) to 47.8 (sd 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (sd 3.9) to 55.4 (sd 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity.

We performed a prospective, randomised study to compare the results and rates of complications of primary total knee replacement performed using a quadriceps-sparing technique or a standard arthrotomy in 120 patients who had bilateral total knee replacements carried out under the same anaesthetic. The clinical results, pain scales, surgical and hospital data, post-operative complications and radiological results were compared.

No significant differences were found between the two groups with respect to the blood loss, knee score, function score, pain scale, range of movement or radiological findings. In contrast, the operating time (p = 0.0001) and the tourniquet time (p < 0.0001) were significantly longer in the quadriceps-sparing group, as was the rate of complications (p = 0.0468).

We therefore recommend the use of a standard arthrotomy with the shortest possible skin incision for total knee replacement.

Objectives

The aim of this study was to determine whether there is any significant difference in temporal measurements of pain, function and rates of re-tear for arthroscopic rotator cuff repair (RCR) patients compared with those patients undergoing open RCR.

Studies describing the effect of body mass index (BMI) on the outcome of total hip replacement have been inconclusive and contradictory. We examined the effect of BMI on medium-term outcome in a cohort of 1617 patients who underwent a primary total hip replacement for osteoarthritis. These patients were followed prospectively for five years with the outcomes of dislocation, revision, duration of surgery and deep and superficial infection studied, as well as collecting Harris hip scores (HHS) and Short-Form 36 (SF-36) questionnaires pre-operatively and at review. A multivariate analysis was performed to see whether BMI is an independent predictor of poor outcome.

We found that patients with a BMI of ? 35 kg/m² have a 4.42 times higher rate of dislocation than those with a BMI < 25 kg/m². Increasing BMI is also associated with superficial infection and poorer HHS and SF-36 scores at five years. These trends remain significant even when multivariate analysis adjusts for age, gender, prosthesis, operating consultant, pre-operative HHS and SF-36, and comorbidities including diabetes mellitus, cardiac disease and osteoporosis.

Despite the increased risks, the five-year outcome scores indicate that obese patients have much to gain from total hip replacement. Thus total hip replacement should not be withheld from patients solely on the grounds of an elevated BMI. However, longer-term follow-up of this cohort is required to establish whether adverse outcomes become more evident with time.

We performed a retrospective study to assess the long-term outcome of non-augmented anatomical direct repair of the lateral ankle ligaments, as originally described by Duquennoy et al, for the treatment of chronic lateral instability of the ankle. This procedure aims to restore stability by the re-insertion and tightening of the original talofibular and calcaneofibular ligaments without division of the ligament. We examined the outcome in terms of the post-operative quality of life, the function of the joint and the development of osteoarthritis.

Between 1985 and 2002, 23 patients (11 males, 12 females) with a mean age of 32 years (15 to 58) who had undergone this procedure completed the Short-Form 36 assessment of quality of life and the Olerud and Molander Ankle score for the subjective evaluation of symptoms. Clinical re-evaluation, including examination of the ankle and the completion of the American Orthopaedic Foot and Ankle Society questionnaire was performed on 21 patients after a mean follow-up of 13 years (3 to 22.2). At the final follow-up radiographs of both ankles were taken to assess the development of osteoarthritis.

The mean total Short-Form 36 and Olerud and Molander Ankle scores in 23 patients at final follow-up were 79.6 points (37 to 100) and 81.6 points (40 to 100), respectively. The mean total post-operative American Orthopaedic Foot and Ankle Society score in 21 patients was 89.7 points (72 to 100). We found a significant post-operative reduction in talar tilt and anterior drawer sign (chi-squared test, p < 0.001). The functional outcome of the procedure was excellent in ten patients (48%), good in seven (33%) and fair in four (19%). The results in terms of ankle function and stability did not deteriorate with time and there was little restriction in movement.

This procedure is simple and effective with a very low rate of complications.

We report the theoretical basis of a method to measure axial migration of femoral components of total hip replacements (THR). The use of the top of the greater trochanter and a lateral point on the collar of the stem, allowing for variations of up to 10 degrees rotation of the femur in any direction between successive radiographs, gave a maximum error of 0.37 mm. At a more realistic 5 degrees rotational variation, the error was only 0.13 mm. These data were confirmed in an experimental study using digitisation of points and special software. We also showed that the centre of the femoral head, the stem tip, and the lesser trochanter provided less accurate landmarks. In a second study we digitised a series of radiographs of 51 Charnley and 57 Stanmore THRs; the mean migration rates were found to be identical. We then studied 46 successful stems with a minimum follow-up of eight years and 46 stems which had failed by aseptic loosening at different times. At two years, the successful stems had migrated by a mean of 1.45 +/- 0.68 mm, but the failed cases had a mean migration of 4.32 +/- 2.58 mm (p < 0.0001). Of the successful cases 76% had migrated less than 2 mm, while in the failed group 84% had migrated more than 2 mm. For any particular case migration of more than 2.6 mm at two years had only a 5% chance of continuing success and would therefore merit special follow-up. Only 24% of the eventually successful stems showed migration at the stem-cement interface, but this had happened in every failed stem. We conclude that it would be possible to evaluate a new cemented design of femoral stem over a two-year period by the use of our method and to compare its performance against the reported known standard of the Charnley and Stanmore designs.

Aims. The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system. Methods. We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217). Results. Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%). Conclusion. These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids. Cite this article: Bone Joint J 2023;105-B(6):668–678

Aims. Conflicting clinical results are reported for the ATTUNE Total Knee Arthroplasty (TKA). This randomized controlled trial (RCT) evaluated five-year follow-up results comparing cemented ATTUNE and PFC-Sigma cruciate retaining TKAs, analyzing component migration as measured by radiostereometric analysis (RSA), clinical outcomes, patient-reported outcome measures (PROMs), and radiological outcomes. Methods. A total of 74 primary TKAs were included in this single-blind RCT. RSA examinations were performed, and PROMs and clinical outcomes were collected immediate postoperatively, and at three, six, 12, 24, and 60 months’ follow-up. Radiolucent lines (RLLs) were measured in standard anteroposterior radiographs at six weeks, and 12 and 60 months postoperatively. Results. At five-year follow-up, RSA data from 61 patients were available and the mean maximum total point motion (MTPM) of the femoral components were: ATTUNE: 0.96 mm (95% confidence interval (CI) 0.79 to 1.14) and PFC-Sigma 1.37 mm (95% CI 1.18 to 1.59) (p < 0.001). The PFC-Sigma femoral component migrated more in the first postoperative year, but stabilized thereafter. MPTM of the tibial components were comparable at five-year follow-up: ATTUNE 1.12 mm (95% CI 0.95 to 1.31) and PFC-Sigma 1.25 mm (95% CI 1.07 to 1.44) (p = 0.438). RLL at the medial tibial implant-cement interface remained more prevalent for the ATTUNE at five-year follow-up compared to the PFC-Sigma (20% vs 3%). RLL did not progress over time, and varied between patients at different timepoints for both TKA systems. Clinical outcomes and PROMs improved compared with preoperative scores, and were not different between groups. Conclusion. MTPM migration at five-year follow-up of the femoral and tibial component of the ATTUNE were similar and as low as that of the PFC-Sigma. MTPM migration of both knee implants did not significantly change from one year post-surgery, indicating stable fixation. Long-term ATTUNE performance may be expected to be comparable to the clinically well-performing PFC-Sigma. We have not found evidence of increased tibial component migration as measured by RSA to support concerns about cement debonding and a higher risk of aseptic loosening with the ATTUNE TKA. Cite this article: Bone Joint J 2023;105-B(11):1168–1176

Aims. There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Aims. This study aimed to assess the impact of using the metal-augmented glenoid baseplate (AGB) on improving clinical and radiological outcomes, as well as reducing complications, in patients with superior glenoid wear undergoing reverse shoulder arthroplasty (RSA). Methods. From January 2016 to June 2021, out of 235 patients who underwent primary RSA, 24 received a superior-AGB after off-axis reaming (Group A). Subsequently, we conducted propensity score matching in a 1:3 ratio, considering sex, age, follow-up duration, and glenoid wear (superior-inclination and retroversion), and selected 72 well-balanced matched patients who received a standard glenoid baseplate (STB) after eccentric reaming (Group B). Superior-inclination, retroversion, and lateral humeral offset (LHO) were measured to assess preoperative glenoid wear and postoperative correction, as well as to identify any complications. Clinical outcomes were measured at each outpatient visit before and after surgery. Results. There were no significant differences in demographic data and preoperative characteristics between the two groups. Both groups showed significant improvements in patient-reported outcome measures (visual analogue scale for pain, visual analogue scale for function, American Shoulder and Elbow Surgeons, Constant, and Simple Shoulder Test scores) from preoperative to final assessment (p < 0.001). However, AGB showed no additional benefit. Notably, within range of motion, Group B showed significant postoperative decrease in both external rotation and internal rotation, unlike Group A (p = 0.028 and 0.003, respectively). Both groups demonstrated a significant correction of superior-inclination after surgery, while patients in Group B exhibited a significant decrease in LHO postoperatively (p = 0.001). Regarding complications, Group A experienced more acromial stress fractures (3 cases; 12.5%), whereas Group B had a higher occurrence of scapular notching (24 cases; 33.3%) (p = 0.008). Conclusion. Both eccentric reaming with STB and off-axis reaming with AGB are effective methods for addressing superior glenoid wear in RSA, leading to improved clinical outcomes. However, it is important to be aware of the potential risks associated with eccentric reaming, which include excessive bone loss leading to reduced rotation and scapular notching. Cite this article: Bone Joint J 2024;106-B(3):268–276

Aims. It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting. Methods. In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure. Results. The study included 420 patients. There was no significant difference between the rate of redisplacement of the fracture between the groups: 47% (n = 88) for those treated with a plaster splint and 49% (n = 90) for those treated with a circumferential cast (odds ratio 1.05 (95% confidence interval (CI) 0.65 to 1.70); p = 0.854). Patients treated in a plaster splint reported significantly more pain than those treated with a circumferential cast, during the first week of treatment (estimated mean NRS 4.7 (95% CI 4.3 to 5.1) vs 4.1 (95% CI 3.7 to 4.4); p = 0.014). The rate of complaints relating to the cast, clinical outcomes and PROMs did not differ significantly between the groups (p > 0.05). Compartment syndrome did not occur. Conclusion. Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups. Cite this article: Bone Joint J 2024;106-B(7):696–704

Aims. The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia. Methods. We reviewed patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia who underwent TOA between November 1998 and December 2019. Patient demographic details, osteotomy-related complications, and the modified Harris Hip Score (mHHS) were obtained via medical notes review. Radiological indicators of hip dysplasia were assessed using preoperative and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors of failure. Results. This study included 127 patients (137 hips). Median follow-up period was ten years (IQR 6 to 15). The median mHHS improved from 59 (IQR 52 to 70) preoperatively to 90 (IQR 73 to 96) at the latest follow-up (p < 0.001). The survival rate was 90% (95% CI 82 to 95) at ten years, decreasing to 21% (95% CI 7 to 48) at 20 years. Fair joint congruity on preoperative hip abduction radiographs and a decreased postoperative anterior wall index (AWI) were identified as independent risk factors for failure. The survival rate for the 42 hips with good preoperative joint congruity and a postoperative AWI ≥ 0.30 was 100% at ten years, and remained at 83% (95% CI 38 to 98) at 20 years. Conclusion. Although the overall clinical outcomes of TOA in patients with advanced osteoarthritis are suboptimal, favourable results can be achieved in selected cases with good preoperative joint congruity and adequate postoperative anterior acetabular coverage. Cite this article: Bone Joint J 2024;106-B(8):783–791

Aims. Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients. Methods. A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm. Results. One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively. Conclusion. The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes. Cite this article: Bone Joint J 2024;106-B(4):344–351

Aims. The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up. Methods. From January 2008 to December 2010, 266 TKAs were performed in 169 patients with HBV (HBV group). A total of 169 propensity score–matched patients without HBV were chosen for the control group in a one-to-one ratio. Then, the clinical outcomes, mortalities, implant survival rates, and complications of TKA in the two groups were compared. The mean follow-up periods were 11.7 years (10.5 to 13.4) in the HBV group and 11.8 years (11.5 to 12.4) in the control group. Results. The mean Knee Society scores in the HBV and control groups improved from 37.1 (SD 5.6) and 38.4 (SD 5.4) points preoperatively to 78.1 (SD 10.8) and 81.7 (SD 10.2) points at final follow-up (p = 0.314), while the mean function scores in the HBV and control groups improved from 36.2 and 37.3 points preoperatively to 77.8 and 83.2 points at final follow-up (p = 0.137). Nine knees in the HBV group required revision surgery, including seven due to septic loosening and two due to aseptic loosening. Four knees in the control group required revision surgery, including three due to septic loosening and one due to aseptic loosening. Kaplan–Meier survivorship analysis with the revision of either component as an endpoint in the HBV and control groups estimated 96.6% and 98.5% chances of survival for ten years, respectively (p = 0.160). Conclusion. TKA in patients with HBV infection resulted in good clinical outcomes and survivorship. However, there was a higher revision rate over a minimum ten-year follow-up period compared to TKA in patients without HBV infection. Cite this article: Bone Jt Open 2022;3(6):470–474