Aims. The principle strategies of fracture-related infection (FRI) treatment are debridement, antimicrobial therapy, and implant retention (DAIR) or debridement, antimicrobial therapy, and implant removal/exchange. Increasing the period between fracture fixation and FRI revision surgery is believed to be associated with higher failure rates after DAIR. However, a clear time-related cut-off has never been scientifically defined. This systematic review analyzed the influence of the interval between fracture fixation and FRI revision surgery on success rates after DAIR. Methods. A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in PubMed (including MEDLINE), Embase, and Web of Science Core Collection, investigating the outcome after DAIR procedures of long bone FRIs in clinical studies published until January 2020. Results. Six studies, comprising 276 patients, met the inclusion criteria. Data from this review showed that with a short duration of infection (up to three weeks) and under strict preconditions, retention of the implant is associated with high success rates of 86% to 100%. In delayed infections with a fracture fixation-FRI revision surgery interval of three to ten weeks, absence of recurrent infection was reported in 82% to 89%. Data on late FRIs, with a fracture fixation-FRI revision surgery interval of more than ten weeks, are scarce and a success rate of 67% was reported. Conclusion. Acute/early FRI, with a short duration of infection, can successfully be treated with DAIR up to ten weeks after osteosynthesis. The limited available data suggest that chronic/late onset FRI treated with DAIR may be associated with a higher rate of recurrence. Successful outcome is dependent on managing all aspects of the infection. Thus, time from fracture fixation is not the only factor that should be considered in treatment planning of FRI. Due to the heterogeneity of the available data, these conclusions have to be interpreted with caution. Cite this article: Bone Joint J 2021;103-B(2):213–221

Aims. Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models. Methods. Literature research was performed on PubMed and Embase databases. Keywords used for search criteria were “bone AND biofilm”. Information on the species of the animal model, bacterial strain, evaluation of biofilm and bone infection, complications, key findings on observations, prevention, and treatment of biofilm were extracted. Results. A total of 43 studies were included. Animal models used included fracture-related infections (ten studies), periprosthetic joint infections (five studies), spinal infections (three studies), other implant-associated infections, and osteomyelitis. The most common bacteria were Staphylococcus species. Biofilm was most often observed with scanning electron microscopy. The natural history of biofilm revealed that the process of bacteria attachment, proliferation, maturation, and dispersal would take 14 days. For systemic mono-antibiotic therapy, only two of six studies using vancomycin reported significant biofilm reduction, and none reported eradication. Ten studies showed that combined systemic and topical antibiotics are needed to achieve higher biofilm reduction or eradication, and the effect is decreased with delayed treatment. Overall, 13 studies showed promising therapeutic potential with surface coating and antibiotic loading techniques. Conclusion. Combined topical and systemic application of antimicrobial agents effectively reduces biofilm at early stages. Future studies with sustained release of antimicrobial and biofilm-dispersing agents tailored to specific pathogens are warranted to achieve biofilm eradication. Cite this article: Bone Joint Res 2022;11(10):700–714

Aims. The preoperative diagnosis of periprosthetic joint infection (PJI) remains a challenge due to a lack of biomarkers that are both sensitive and specific. We investigated the performance characteristics of polymerase chain reaction (PCR), interleukin-6 (IL6), and calprotectin of synovial fluid in the diagnosis of PJI. Methods. We performed systematic search of PubMed, Embase, The Cochrane Library, Web of Science, and Science Direct from the date of inception of each database through to 31 May 2021. Studies which described the diagnostic accuracy of synovial fluid PCR, IL6, and calprotectin using the Musculoskeletal Infection Society criteria as the reference standard were identified. Results. Overall, 31 studies were identified: 20 described PCR, six described IL6, and five calprotectin. The sensitivity and specificity were 0.78 (95% confidence interval (CI) 0.67 to 0.86) and 0.97 (95% CI 0.94 to 0.99), respectively, for synovial PCR;, 0.86 (95% CI 0.74 to 0.92), and 0.94 (95% CI 0.90 to 0.96), respectively, for synovial IL6; and 0.94 (95% CI 0.82 to 0.98) and 0.93 (95% CI 0.85 to 0.97), respectively, for synovial calprotectin. Likelihood ratio scattergram analyses recommended clinical utility of synovial fluid PCR and IL6 as a confirmatory test only. Synovial calprotectin had utility in the exclusion and confirmation of PJI. Conclusion. Synovial fluid PCR and IL6 had low sensitivity and high specificity in the diagnosis of PJI, and is recommended to be used as confirmatory test. In contrast, synovial fluid calprotectin had both high sensitivity and specificity with utility in both the exclusion and confirmation of PJI. We recommend use of synovial fluid calprotectin studies in the preoperative workup of PJI. Cite this article: Bone Joint J 2022;104-B(3):311–320

Aims. The aim of this meta-analysis is to assess the association between exchange of modular parts in debridement, antibiotics, and implant retention (DAIR) procedure and outcomes for hip and knee periprosthetic joint infection (PJI). Methods. We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane library from inception until May 2021. Random effects meta-analyses and meta-regression was used to estimate, on a study level, the success rate of DAIR related to component exchange. Risk of bias was appraised using the (AQUILA) checklist. Results. We included 65 studies comprising 6,630 patients. The pooled overall success after DAIR for PJI was 67% (95% confidence interval (CI) 63% to 70%). This was 70% (95% CI 65% to 75%) for DAIR for hip PJI and 63% (95% CI 58% to 69%) for knee PJI. In studies before 2004 (n = 27), our meta-regression analysis showed a 3.5% increase in success rates for each 10% increase in component exchange in DAIR for hip PJI and a 3.1% increase for each 10% increase in component exchange for knee PJI. When restricted to studies after 2004 (n = 37), this association changed: for DAIR for hip PJI a decrease in successful outcome by 0.5% for each 10% increase in component exchange and for DAIR for knee PJI this was a 0.01% increase in successful outcome for each 10% increase in component exchange. Conclusion. This systematic review and meta-regression found no benefit of modular component exchange on reduction of PJI failure. This limited effect should be weighed against the risks for the patient and cost on a case-by-case basis. The association between exchange of modular components and outcome changed before and after 2004. This suggests the effect seen after 2004 may reflect a more rigorous, evidence-based, approach to the infected implant compared to the years before. Level of Evidence: Level III. Cite this article: Bone Jt Open 2021;2(10):806–812

Aims. A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery. Methods. A total of 11 databases were examined using the COre, Standard, Ideal (COSI) protocol. Bibliographic searches (no chronological or linguistic restriction) were conducted using, among other methods, the Patient, Intervention, Comparison, Outcome (PICO) template. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for flow diagram and checklist. Final reading of the complete texts was conducted in English, French, and Spanish. Classification of papers was completed within five levels of evidence (LE). Results. There were a total of 621 hits (526 COre; 95 Standard, Ideal) for screening identification, and 107 records were screened. Overall 67 full-text articles were assessed for eligibility, and 21 articles were included for the study question. A total of 46 full-text articles were excluded with reasons. No studies could be included in quantitative synthesis (meta-analyses), and there were many confounding variables including surgeons’ experience, prosthesis models used, and surgical technique. Conclusion. Patients with hip fracture and with a viral infection in the upper respiratory tract or without major clinical symptoms should be operated on as soon as possible (LE: I-III). There is no evidence that patients with coronavirus disease 2019 (COVID-19) should be treated differently. In relation to pneumonia, its prevention is a major issue. Antibiotics should be administered if surgery is delayed by > 72 hours or if bacterial infection is present in the lower respiratory tract (LE: III-V). In patients with hip fracture and urinary tract infection (UTI), delaying surgery may provoke further complications (LE: I). However, diabetic or immunocompromised patients may benefit from immediate antibiotic treatment. Cite this article: Bone Joint Res 2020;9(12):884–893

Aims. The diagnosis of periprosthetic joint infection (PJI) has always been challenging. Recently, D-dimer has become a promising biomarker in diagnosing PJI. However, there is controversy regarding its diagnostic value. We aim to investigate the diagnostic value of D-dimer in comparison to ESR and CRP. Methods. PubMed, Embase, and the Cochrane Library were searched in February 2020 to identify articles reporting on the diagnostic value of D-dimer on PJI. Pooled analysis was conducted to investigate the diagnostic value of D-dimer, CRP, and ESR. Results. Six studies with 1,255 cases were included (374 PJI cases and 881 non-PJI cases). Overall D-dimer showed sensitivity of 0.80 (95% confidence interval (CI) 0.69 to 0.87) and specificity of 0.76 (95% CI 0.63 to 0.86). Sub-group analysis by excluding patients with thrombosis and hyper-coagulation disorders showed sensitivity of 0.82 (95% CI 0.70 to 0.90) and specificity of 0.80 (95% CI 0.70 to 0.88). Serum D-dimer showed sensitivity of 0.85 (95% CI 0.76 to 0.92), specificity of 0.83 (95% CI 0.74 to 0.90). Plasma D-dimer showed sensitivity of 0.67 (95% CI 0.60 to 0.73), specificity of 0.58 (95% CI 0.45 to 0.72). CRP showed sensitivity of 0.78 (95% CI 0.72 to 0.83), specificity of 0.81 (95% CI 0.72 to 0.87). ESR showed sensitivity of 0.68 (95% CI 0.63 to 0.73), specificity of 0.83 (95% CI 0.78 to 0.87). Conclusion. In patients without thrombosis or a hyper-coagulation disorder, D-dimer has a higher diagnostic value compared to CRP and ESR. In patients with the aforementioned conditions, D-dimer has higher sensitivity but lower specificity compared to ESR and CRP. We do not recommend the use of serum D-dimer in patients with thrombosis and hyper-coagulation disorders for diagnosing PJI. Serum D-dimer may perform better than plasma D-dimer. Further studies are needed to compare serum D-dimer and plasma D-dimer in arthroplasty patients. Cite this article: Bone Joint Res 2020;9(10):701–708

Aims. To assess the diagnostic value of C-reactive protein (CRP), leucocyte count (LC), and erythrocyte sedimentation rate (ESR) in late fracture-related infection (FRI). Materials and Methods. PubMed, Embase, and Cochrane databases were searched focusing on the diagnostic value of CRP, LC, and ESR in late FRI. Sensitivity and specificity combinations were extracted for each marker. Average estimates were obtained using bivariate mixed effects models. Results. A total of 8284 articles were identified but only six were suitable for inclusion. Sensitivity of CRP ranged from 60.0% to 100.0% and specificity from 34.3% to 85.7% in all publications considered. Five articles were pooled for meta-analysis, showing a sensitivity and specificity of 77.0% and 67.9%, respectively. For LC, this was 22.9% to 72.6%, and 73.5% to 85.7%, respectively, in five articles. Four articles were pooled for meta-analysis, resulting in a 51.7% sensitivity and 67.1% specificity. For ESR, sensitivity and specificity ranged from 37.1% to 100.0% and 59.0% to 85.0%, respectively, in five articles. Three articles were pooled in meta-analysis, showing a 45.1% sensitivity and 79.3% specificity. Four articles analyzed the value of combined inflammatory markers, reporting an increased diagnostic accuracy. These results could not be pooled due to heterogeneity. Conclusion. The serum inflammatory markers CRP, LC, and ESR are insufficiently accurate to diagnose late FRI, but they may be used as a suggestive sign in its diagnosis

Aims. Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery. Materials and Methods. Databases were searched to identify eligible studies and 13 were identified for inclusion. Results. Overall, the quality of the studies was poor. A single trial suggested that wound healing is quicker when a gentamicin-impregnated collagen sponge was implanted at time of surgery, with no difference in length of stay or rate of amputation. Results from studies with high risk of bias indicated no change in wound healing when a gentamicin-impregnated sponge was implanted during transmetatarsal amputation, but a reduction in the incidence of wound breakdown (8% vs 25%, not statistically significant) was identified. A significant cost reduction was identified when using an antimicrobial gel to deliver antibiotics and anti-biofilm agents (quorum-sensing inhibitors) compared with routine dressings and systemic antibiotics. Analyses of case series identified 485 patients who were treated using local antibiotic delivery devices. The rates of wound healing, re-operation, and mortality were comparable to those that have been previously reported for the routine management of these infections. Conclusion. There is a lack of good-quality evidence to support the use of local antibiotic delivery devices in the treatment of foot infections in patients with diabetes. Cite this article: Bone Joint J 2018;100-B:1409–15

Aims. Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and it has been suggested that the choice of bearing surface may influence the risk of PJI after THA. The objective of this meta-analysis was to compare the rate of PJI between metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC) bearings. Patients and Methods. Electronic databases (Medline, Embase, Cochrane library, Web of Science, and Cumulative Index of Nursing and Allied Health Literature) were searched for comparative randomized and observational studies that reported the incidence of PJI for different bearing surfaces. Two investigators independently reviewed studies for eligibility, evaluated risk of bias, and performed data extraction. Meta-analysis was performed using the Mantel–Haenzel method and random-effects model in accordance with methods of the Cochrane group. Results. Our search strategy revealed 2272 studies, of which 17 met the inclusion criteria and were analyzed. These comprised 11 randomized controlled trials and six observational studies. The overall quality of included studies was high but the observational studies were at high risk of bias due to inadequate adjustment for confounding factors. The overall cumulative incidence of PJI across all studies was 0.78% (1514/193 378). For each bearing combination, the overall incidence was as follows: MoP 0.85% (1353/158 430); CoP 0.38% (67/17 489); and CoC 0.53% (94/17 459). The meta-analysis showed no significant difference between the three bearing combinations in terms of risk of PJI. Conclusion. On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. Future research, including basic science studies and large, adequately controlled registry studies, may be helpful in determining whether implant materials play a role in determining the risk of PJI following arthroplasty surgery. Cite this article: Bone Joint J 2018;100-B:134–42

Aims. The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following revision total knee arthroplasty (rTKA). Methods. A systematic search of MEDLINE and Embase was completed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The studies were required to include a population of index rTKAs. Primary or secondary outcomes had to be re-revision. The association between preoperative factors and the effect on the risk for re-revision was also required to be reported by the studies. Results. The search yielded 4,847 studies, of which 15 were included. A majority of the studies were retrospective cohorts or registry studies. In total, 26 significant risk factors for re-revision were identified. Of these, the following risk factors were consistent across multiple studies: age at the time of index revision, male sex, index revision being partial revision, and index revision due to infection. Modifiable risk factors were opioid use, BMI > 40 kg/m. 2. , and anaemia. History of one-stage revision due to infection was associated with the highest risk of re-revision. Conclusion. Overall, 26 risk factors have been associated with an increased risk of re-revision following rTKA. However, various levels of methodological bias were found in the studies. Future studies should ensure valid comparisons by including patients with identical indications and using clear definitions for accurate assessments. Cite this article: Bone Jt Open 2024;5(8):644–651

Aims. To determine whether obesity and malnutrition have a synergistic effect on outcomes from skeletal trauma or elective orthopaedic surgery. Methods. Electronic databases including MEDLINE, Global Health, Embase, Web of Science, ScienceDirect, and PEDRo were searched up to 14 April 2024, as well as conference proceedings and the reference lists of included studies. Studies were appraised using tools according to study design, including the Oxford Levels of Evidence, the Institute of Health Economics case series quality appraisal checklist, and the CLARITY checklist for cohort studies. Studies were eligible if they reported the effects of combined malnutrition and obesity on outcomes from skeletal trauma or elective orthopaedic surgery. Results. A total of eight studies (106,319 patients) were included. These carried moderate to high risk of bias. Combined obesity and malnutrition did not lead to worse outcomes in patients undergoing total shoulder arthroplasty or repair of proximal humeral fractures (two retrospective cohort studies). Three studies (two retrospective cohort studies, one case series) found that malnourishment and obesity had a synergistic effect and led to poor outcomes in total hip or knee arthroplasty, including longer length of stay and higher complication rates. One retrospective cohort study pertaining to posterior lumbar fusion found that malnourished obese patients had higher odds of developing surgical site infection and sepsis, as well as higher odds of requiring a revision procedure. Conclusion. Combined malnutrition and obesity have a synergistic effect and lead to poor outcomes in lower limb procedures. Appropriate preoperative optimization and postoperative care are required to improve outcomes in this group of patients. Cite this article: Bone Joint J 2024;106-B(10):1044–1049

Aims. Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. Methods. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. Results. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. Conclusion. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations. Cite this article: Bone Joint J 2023;105-B(1):21–28

Aims. Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations. Methods. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, Cinahl, and Cochrane reviews were searched for relevant papers. Papers analyzing surgical treatment for failed ankle arthroplasties were included. All papers were reviewed by two authors. Overall, 34 papers met the inclusion criteria. A meta-analysis of proportions was performed. Results. Six papers analyzed all-cause reoperations of revision ankle arthroplasties, and 14 papers analyzed failures of conversion of a TAA to fusion. It was found that 26.9% (95% confidence interval (CI) 15.4% to 40.1%) of revision ankle arthroplasties required further surgical intervention and 13.0% (95% CI 4.9% to 23.4%) of conversion to fusions; 14.4% (95% CI 8.4% to 21.4%) of revision ankle arthroplasties failed and 8% (95% CI 4% to 13%) of conversion to fusions failed. Conclusion. Revision of primary TAA can be an effective procedure with improved functional outcomes, but has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. In those who undergo conversion of TAA to fusion, there are high rates of nonunion. Further comparative studies are required to compare both operative techniques. Cite this article: Bone Jt Open 2022;3(7):596–606

Aims. This systematic review aims to compare the precision of component positioning, patient-reported outcome measures (PROMs), complications, survivorship, cost-effectiveness, and learning curves of MAKO robotic arm-assisted unicompartmental knee arthroplasty (RAUKA) with manual medial unicompartmental knee arthroplasty (mUKA). Methods. Searches of PubMed, MEDLINE, and Google Scholar were performed in November 2021 according to the Preferred Reporting Items for Systematic Review and Meta-­Analysis statement. Search terms included “robotic”, “unicompartmental”, “knee”, and “arthroplasty”. Published clinical research articles reporting the learning curves and cost-effectiveness of MAKO RAUKA, and those comparing the component precision, functional outcomes, survivorship, or complications with mUKA, were included for analysis. Results. A total of 179 articles were identified from initial screening, of which 14 articles satisfied the inclusion criteria and were included for analysis. The papers analyzed include one on learning curve, five on implant positioning, six on functional outcomes, five on complications, six on survivorship, and three on cost. The learning curve was six cases for operating time and zero for precision. There was consistent evidence of more precise implant positioning with MAKO RAUKA. Meta-analysis demonstrated lower overall complication rates associated with MAKO RAUKA (OR 2.18 (95% confidence interval (CI) 1.06 to 4.49); p = 0.040) but no difference in re-intervention, infection, Knee Society Score (KSS; mean difference 1.64 (95% CI -3.00 to 6.27); p = 0.490), or Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (mean difference -0.58 (95% CI -3.55 to 2.38); p = 0.700). MAKO RAUKA was shown to be a cost-effective procedure, but this was directly related to volume. Conclusion. MAKO RAUKA was associated with improved precision of component positioning but was not associated with improved PROMs using the KSS and WOMAC scores. Future longer-term studies should report functional outcomes, potentially using scores with minimal ceiling effects and survival to assess whether the improved precision of MAKO RAUKA results in better outcomes. Cite this article: Bone Joint J 2022;104-B(5):541–548

Aims. To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA). Methods. Studies were selected based on the following criteria: 1) study design (retrospective cohort studies, prospective cohort studies, retrospective comparative studies, prospective comparative studies, and randomized controlled studies (RCTs)); 2) study population (patients with femoral neck fracture); 3) intervention (DM-THA or BHA); and 4) outcomes (complications during postoperative follow-up and clinical results). Pooled meta-analysis was carried out to evaluate the dislocation rate after DM-THA and to compare outcomes between DM-THA and BHA. Results. A total of 17 studies (ten cohort studies on DM-THA and seven comparative studies of DM-THA and BHA) were selected. These studies included 2,793 patients (2,799 hips), made up of 2,263 DM-THA patients (2,269 hips) and 530 BHA patients (530 hips). In all, 16 studies were analyzed to evaluate dislocation rate after DM-THA. The cumulative dislocation rate was 4% (95% confidence interval (CI) 3 to 5). Seven studies were analyzed to compare the rates dislocation and surgical-site infection. The rate of dislocation was significantly lower in the DM-THA group than in the BHA group (risk ratio (RR) 0.3; 95% CI 0.17 to 0.53, p < 0.001, Z −4.11). There was no significant difference in the rate of surgical-site infection between the two groups (p = 0.580). Six studies reported all-cause reoperations. The rate of reoperation was significantly lower in the DM-THA group than in the BHA group (RR 0.5; 95% CI 0.32 to 0.78, p = 0.003, Z −3.01). Five studies reported one-year mortality. The mortality rate was significantly lower in the DM-THA group than in the BHA group (RR 0.58 95% CI 0.45 to 0.75, p < 0.0001, Z −4.2). Conclusion. While the evidence available consisted mainly of non-randomized studies, DM-THA appeared to be a viable option for patients with displaced fractures of the femoral neck, with better reported rates of dislocation, reoperation, and mortality than BHA. Cite this article: Bone Joint J 2020;102-B(11):1457–1466

Aims. It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery. Methods. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis. Results. A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores. Conclusion. Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618–630

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Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture.

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This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur.

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Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years.

Literature surrounding artificial intelligence (AI)-related applications for hip and knee arthroplasty has proliferated. However, meaningful advances that fundamentally transform the practice and delivery of joint arthroplasty are yet to be realized, despite the broad range of applications as we continue to search for meaningful and appropriate use of AI. AI literature in hip and knee arthroplasty between 2018 and 2021 regarding image-based analyses, value-based care, remote patient monitoring, and augmented reality was reviewed. Concerns surrounding meaningful use and appropriate methodological approaches of AI in joint arthroplasty research are summarized. Of the 233 AI-related orthopaedics articles published, 178 (76%) constituted original research, while the rest consisted of editorials or reviews. A total of 52% of original AI-related research concerns hip and knee arthroplasty (n = 92), and a narrative review is described. Three studies were externally validated. Pitfalls surrounding present-day research include conflating vernacular (“AI/machine learning”), repackaging limited registry data, prematurely releasing internally validated prediction models, appraising model architecture instead of inputted data, withholding code, and evaluating studies using antiquated regression-based guidelines. While AI has been applied to a variety of hip and knee arthroplasty applications with limited clinical impact, the future remains promising if the question is meaningful, the methodology is rigorous and transparent, the data are rich, and the model is externally validated. Simple checkpoints for meaningful AI adoption include ensuring applications focus on: administrative support over clinical evaluation and management; necessity of the advanced model; and the novelty of the question being answered.

Cite this article: Bone Joint J 2022;104-B(12):1292–1303.

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The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

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Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool.

Aims. The aims of this systematic review were to assess the learning curve of semi-active robotic arm-assisted total hip arthroplasty (rTHA), and to compare the accuracy, patient-reported functional outcomes, complications, and survivorship between rTHA and manual total hip arthroplasty (mTHA). Methods. Searches of PubMed, Medline, and Google Scholar were performed in April 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included “robotic”, “hip”, and “arthroplasty”. The criteria for inclusion were published clinical research articles reporting the learning curve for rTHA (robotic arm-assisted only) and those comparing the implantation accuracy, functional outcomes, survivorship, or complications with mTHA. Results. There were 501 articles initially identified from databases and references. Following full text screening, 17 articles that satisfied the inclusion criteria were included. Four studies reported the learning curve of rTHA, 13 studies reported on implant positioning, five on functional outcomes, ten on complications, and four on survivorship. The meta-analysis showed a significantly greater number of cases of acetabular component placement in the safe zone compared with the mTHA group (95% confidence interval (CI) 4.10 to 7.94; p < 0.001) and that rTHA resulted in a significantly better Harris Hip Score compared to mTHA in the short- to mid-term follow-up (95% CI 0.46 to 5.64; p = 0.020). However, there was no difference in infection rates, dislocation rates, overall complication rates, and survival rates at short-term follow-up. Conclusion. The learning curve of rTHA was between 12 and 35 cases, which was dependent on the assessment goal, such as operating time, accuracy, and team working. Robotic arm-assisted total hip arthroplasty was associated with improved accuracy of component positioning and functional outcome, however no difference in complication rates or survival were observed at short- to mid-term follow-up. Overall, there remains an absence of high-quality level I evidence and cost analysis comparing rTHA and mTHA. Cite this article: Bone Joint J 2021;103-B(6):1009–1020

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To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

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The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used.

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Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

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Robotic-assisted unicompartmental knee arthroplasty (R-UKA) has been proposed as an approach to improve the results of the conventional manual UKA (C-UKA). The aim of this meta-analysis was to analyze the studies comparing R-UKA and C-UKA in terms of clinical outcomes, radiological results, operating time, complications, and revisions.

Aims. Patients with metabolic syndrome (MetS) are known to be at increased risk of postoperative complications, but it is unclear whether MetS is also associated with complications after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Here, we perform a systematic review and meta-analysis linking MetS to postoperative complications in THA and TKA. Methods. The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to the guidelines of the Meta-analysis of Observational Studies in Epidemiology (MOOSE). We assessed the methodological quality of each study using the Newcastle-Ottawa Scale (NOS), and we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Data were extracted and meta-analyzed or qualitatively synthesized for several outcomes. Results. Ten cohort studies involving 1,352,685 patients were included. Qualitative analysis suggested that MetS was associated with a higher incidence of cardiovascular events, and meta-analysis showed that MetS increased the risk of all-cause complications (risk ratio (RR) 1.55, 95% confidence interval (CI) 1.28 to 1.89), surgical site infection (SSI; RR 2.99, 95% CI 1.30 to 6.90), urinary tract infection (UTI; RR 2.58, 95% CI 1.03 to 6.43), and 30-day readmission (RR 1.45, 95% CI 1.33 to 1.59). There was insufficient evidence for assessing an association between MetS and venous thromboembolism events, pulmonary or gastrointestinal complications, or mortality. Conclusion. Patients with MetS undergoing THA and TKA are at increased risk of all-cause complications, cardiovascular complications, SSI, UTI, and 30-day readmission. Surgeons should be aware of the increased risk of these complications in MetS, and presurgical protocols for these complications should give special consideration to MetS patients. Cite this article:Bone Joint Res. 2020;9(3):120–129

Aims. This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691). Results. Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively). Conclusion. ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7–15

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Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

Aims. The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. Materials and Methods. We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). Results. This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. Conclusion. The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489–1497

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Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries.

Aims. Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA). Methods. We performed a systematic review of all English language articles on THA-DMC published between 2010 and 2019 in the MEDLINE, EMBASE, and Cochrane databases. After the application of rigorous inclusion and exclusion criteria, 23 studies dealing with patients who underwent treatment for a femoral neck fracture using THA-DMC were analyzed for the rate of dislocation. Secondary outcomes included reoperation, periprosthetic fracture, infection, mortality, and functional outcome. The review included 7,189 patients with a mean age of 77.8 years (66.4 to 87.6) and a mean follow-up of 30.9 months (9.0 to 68.0). Results. THA-DMC was associated with a significantly lower dislocation rate compared with both THA (OR 0.26; 95% CI 0.08 to 0.79) and HA (odds ratio (OR) 0.27; 95% confidence interval (CI) 0.15 to 0.50). The rate of large articulations and of intraprosthetic dislocation was 1.5% (n = 105) and 0.04% (n = 3) respectively. Conclusion. THA-DMC when used in patients with a femoral neck fracture is associated with a lower dislocation rate compared with conventional arthroplasty options. There was no increase in the rates of other complication when THA-DMC was used. Future cost analysis and prospective, comparative studies are required to assess the potential benefit of using THA-DMC in these patients. Cite this article: Bone Joint J 2020;102-B(7):811–821

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The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature.

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Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

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Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.

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Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA.

Aims. There is inconsistent evidence on whether prior spinal fusion surgery adversely impacts outcomes following total hip arthroplasty (THA). We conducted a systematic review and meta-analysis to assess the association between pre-existing spinal fusion surgery and the rate of complications following primary THA. Methods. We searched MEDLINE, Embase, Web of Science, and Cochrane Library up to October 2019 for randomized controlled trials (RCTs) and observational studies comparing outcomes of dislocation, revision, or reasons for revision in patients following primary THA with or without pre-existing spinal fusion surgery. Furthermore, we compared short (two or less levels) or long (three or more levels) spinal fusions to no fusion. Summary measures of association were relative risks (RRs) (with 95% confidence intervals (CIs)). Results. We identified ten articles corresponding to nine unique observational studies comprising of 1,992,366 primary THAs. No RCTs were identified. There were 32,945 cases of spinal fusion and 1,752,362 non-cases. Comparing prior spinal fusion versus no spinal fusion in primary THA, RRs (95% CI) for dislocation was 2.23 (1.81 to 2.74; seven studies), revision 2.14 (1.63 to 2.83; five studies), periprosthetic joint infection 1.71 (1.53 to 1.92; four studies), periprosthetic fracture 1.52 (1.28 to 1.81; three studies), aseptic loosening 1.76 (1.54 to 2.01; three studies), and any complications 2.82 (1.37 to 5.80; three studies) were identified. Both short and long spinal fusions, when compared with no fusion, were associated dislocation, revision, or reasons for revision. Conclusions. Patients with prior spinal fusion are at risk of adverse events following primary THA. Measures that reduce the risk of these complications should be considered in this high-risk population when undergoing primary THA. These patients should also be counselled appropriately around their risks of undergoing THA. Cite this article: Bone Joint J 2020;102-B(6):664–670

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This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

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Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA).

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This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

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The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

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The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone.

Aims. We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis. Materials and Methods. A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently. Results. A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low. Conclusions. There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature

Aims. The aim of this review was to evaluate the available literature and to calculate the pooled sensitivity and specificity for the different alpha-defensin test systems that may be used to diagnose prosthetic joint infection (PJI). Materials and Methods. Studies using alpha-defensin or Synovasure (Zimmer Biomet, Warsaw, Indiana) to diagnose PJI were identified from systematic searches of electronic databases. The quality of the studies was evaluated using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) tool. Meta-analysis was completed using a bivariate model. Results. A total of 11 eligible studies were included. The median QUADAS score was 13 (interquartile range 13 to 13) out of 14. Significant conflicts of interest were identified in five studies. The pooled sensitivity for the laboratory alpha-defensin test was 0.95 (95% confidence interval (CI) 0.91 to 0.98) and the pooled specificity was 0.97 (95% CI 0.95 to 0.98) for four studies with a threshold level of 5.2 mgl. -1. The pooled sensitivity for the lateral flow cassette test was 0.85 (95% CI 0.74 to 0.92) and the pooled specificity was 0.90 (95% CI 0.91 to 0.98). There was a statistically significant difference in sensitivity (p = 0.019), but not specificity (p = 0.47). Conclusion. Laboratory-based alpha-defensin testing remains a promising tool for diagnosing PJI. The lateral flow cassette has a significantly lower performance and pooled results are comparable to the leucocyte esterase test. Further studies are required before the widespread adoption of the lateral flow cassette alpha-defensin test. Cite this article: Bone Joint J 2018;100-B:703–11

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The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture.

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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.

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We conducted a systematic review and meta-analysis to compare the mortality, morbidity, and functional outcomes of cemented versus uncemented hemiarthroplasty in the treatment of intracapsular hip fractures, analyzing contemporary and non-contemporary implants separately.

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The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

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To systematically review the outcomes and complications of cosmetic stature lengthening.