Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

Purpose. The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. Methods. We conducted a retrospective query of a private payer insurance claims database of prospectively collected data (PealDiver). Our search included the Current Procedural Terminology Codes (CPT) and International Classification of Disease (ICD) ninth edition codes for Total Shoulder Arthroplasty (TSA), Hemiarthroplasty (HA) and Reverse Shoulder Arthroplasty (RSA). Medical comorbidities were also searched for through ICD codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease (COPD), cirrhosis, depression and chronic kidney disease (CKD) (excluding end stage renal disease). The study period comprised claims from 2010 to 2014. The reimbursement charges of the day of surgery, 90-day global period and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted trough analysis of variance (ANOVA) when the data was normally distributed or through Kruskal-Wallis comparison when it was not. An alpha value of less than 0.05 was deemed as significant. Results. Comorbidities did not have a significant effect on same day reimbursements (Figure 1), but instead caused a significant effect on the 90-day global period reimbursements in the TSA and RSA cohorts (figure 2). For TSA and RSA the highest reimbursed patients at the 90-day period following surgery were the ones that had a diagnosis of Hepatitis C followed by atrial fibrillation and later COPD. For HA the same was true in the following order: Hepatitis C, Cirrhosis and atrial fibrillation (Figure 3). Conclusion. Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day. For figures/tables, please contact authors directly.

Obesity and the diseases linked to it such as diabetes have been associated with higher complication rates and increased medical costs following total hip arthroplasty (THA). Due to the rising prevalence of obesity and the adverse impact it has on the development of osteoarthritis, there has been a worldwide surge in the number of obese patients presenting for THA procedures, including those morbidly obese (BMI > 40) and those who are super-obese (BMI > 50). The Reward. When THA is successful (as is true for the majority of morbidly obese patients) the operation is just as dramatically effective as it is for other patients. Excellent pain relief and dramatically improved function is the result, even though obese patients generally achieve a lower overall level of function than non-obese patients. Morbidly obese patients with a successful THA and without early complications are some of the most grateful of patients. This is especially true if they have been denied surgery for prolonged periods due to their weight and have had to bear severe joint changes and symptoms during a long period of time leading up to arthroplasty. The Risks. There is a nonlinear increase in complications, reoperations, and especially infection with increasing BMI that begins between a BMI of 25 to 30, and rises thereafter with a relative inflection point in some incidence curves for complications at around a BMI of 40. This has caused some surgeons to suggest a BMI of 40 as an upper limit for elective hip arthroplasty. Risks continue to rise after a BMI of 40 and when the BMI is over 50, in our series 52% of patients had at least one complication. Of these 24% had at least one major complication and 33% at least one minor complication with some suffering more than one complication overall. These data make it reasonable to ask whether the outcomes in some morbidly obese patients might be improved by weight loss, bariatric surgical intervention and other measures aimed at optimizing the multiple companion comorbidities and medical conditions (such as diabetes) that often accompany excess weight. Unfortunately there has been limited information to date on the best means for optimizing of these patients, and as important the effectiveness of these interventions, so that the timing and performance of the eventual arthroplasty procedures might have the highest possible success rate. The Costs. The adverse impact of obesity on medical resource utilization and costs associated with THA has been well documented, Due to longer initial length of stay, greater resource utilization, higher early complication rates and any readmissions and reoperations the costs for even a single individual patient can climb dramatically. In a review of data on primary THA patients from our institution, even after adjusting for age, sex, type of surgery, and other comorbidities, for every 5 unit increase in BMI beyond 30 kg/m2 there was an associated $500 higher cost of hospitalization and an increase of $900 in 90-day total costs (p=0.0001). The Future. The numbers of morbidly obese patients with severe osteoarthritis presenting for possible THA will only continue to increase in the years ahead. Comprehensive multidisciplinary programs are urgently needed to better manage obese patients with weight reduction options, optimization of medical comorbidities, and treatment of any associated issues, such as protein malnutrition. When end-stage joint changes and symptoms occur we must have such help to maximise the benefit and reduce the complications of hip arthroplasty in this high risk patient population

Introduction. Functional scores are used to clinically assess total hip arthroplasty (THA) and for comparative purposes in the orthopaedic literature. Previous research has highlighted patient age, gender and underlying diagnosis as potential sources of bias but comorbidity has not been considered. The Functional Comorbidity Index (FCI) is a published epidemiological tool which correlates disease with associated physical function deficit. It scores 18 conditions: one point for each, total score 0–18. Method & Results. We analysed 41 fully cemented primary THAs in patients ≤55 years at time of surgery with a minimum 10 years follow up. Past medical history was collected via thorough case note review. Patients were assessed using the SF-12 questionnaire, Harris Hip and WOMAC indexes. The study population consisted of 29 patients: 12 women, 17 men. Mean age: 45 years (range 22–53). All patients received cemented polished Corin TaperFit stem with polyethylene Ogee cup. Mean follow up 13.4 years (range 10.2–17.7). FCI scores ranged 0–3 (12 hips=0; 19 hips=1, 5 hips=2, 5 hips=4). A Pearson's product-moment correlation coefficient was calculated to assess the relationship between co-morbidity and hip function score using all three indexes. SF-12 score: Mean (M) =88.7; Standard Deviation (SD) =19.3; Range 0–166. Mean by FCI subgroup: 0=91, 1=96, 2=76.8, 3=68.6 (r=−0.407). HHS: M=83.8; SD=17.0; Range 45–100. Mean by FCI subgroup: 0=94.7; 1=88.2, 2=63.5, 3=54.6 (r= −0.813). WOMAC: M=79.1; SD=20.7; Range 34–100. Mean by FCI subgroup: 0=94.4, 1=91.72, 2=48.8, 3=37.4 (r=−0.812). Discussion & Conclusion. Satisfaction was extremely high with 98% of patients “extremely likely” to recommend this treatment to friends or family. Increasing FCI score correlated with decreasing hip function scores in all three indexes. This study suggests a strong negative correlation between patient comorbidity and hip function scores in THA patients. When comparing functional scores, particularly across patient and implant groups, adjustment for patient comorbidities should be made to ensure balanced evaluation

Background/Purpose of study. The increasing aging of the population will see a growing number of patients presenting for spine surgery with appropriate indications but numerous medical comorbidities. This complicates decision-making, requiring that the likely benefit of surgery (outcome) be carefully weighed up against the potential risk (complications). We assessed the influence of comorbidity on the risks and benefits of spine surgery. Methods. 3′699 patients with degenerative lumbar disorders, undergoing surgery with the goal of pain relief, completed the multidimensional Core Outcome Measures Index (COMI; scored 0–10) before and 12 months after surgery. At 12mo they also rated the global treatment outcome and their satisfaction. Using the Eurospine Spine Tango Registry, surgeons documented surgical details, American Society of Anesthesiologists (ASA) scores and surgical/general complications. Results. 29.8% patients were rated ASA1 (normal healthy), 44.8% ASA2 (mild/moderate systemic disease), 25.0% ASA3 (severe) and 0.4% ASA4 (life-threatening). In going from ASA1 to ASA3 (ASA4 group too small), surgical complications increased significantly from 3.6% to 11.1% and general complications increased from 2.3% to 12.6%; 12-month outcomes showed a corresponding decline, with a good global outcome being reported by 78% ASA1 patients, 76% ASA2, and 68% ASA3. Satisfaction with treatment was 87%, 85%, and 79%, respectively and reduction in COMI, 4.2±2.9, 3.7±3.0, and 3.3±3.0 points, respectively. Conclusion. The negative impact of comorbidity on the outcome of spine surgery has not been well investigated/quantified to date. The ASA grade may be helpful in producing algorithms for decision-making and preoperative counselling regarding the corresponding risks and benefits of surgery. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Functional scores are used to clinically assess total hip arthroplasty (THA) and for comparative purposes in orthopaedic literature. Previous pilot work has highlighted patient comorbidity as a potential source of bias in addition to the often-examined factors of age, gender and underlying diagnosis. We analysed prospectively collected data relating to 217 primary THAs (Tayside Arthroplasty Audit Group database). Sample size was calculated from previous pilot data (significance level 5%, power 80%, effect size 0.25). Proportional stratified sampling was performed including all patient age groups (≤40, 41–55, 56–65, >65) and four fixation classes (cemented, hybrid, uncemented and Birmingham resurfacing). Five year Harris Hip Function Score (HHFS) was the dependent variable; age, sex, underlying diagnosis, BMI, pre-operative HHFS and comorbidity (Functional Comorbidity Index; range 0–8) were co-variates/co-factors. In univariate analysis, FCI accounted for 11% of the variation in HHFS at 5 years. Regarding patients with FCI 0–1 as a reference group, patients with greater comorbidity had lower HHFS at 5 years (FCI 2–3: −3.95; FCI 4–5: −7.21, FCI ≥6: −6.92). In a multivariable model of HHFS at 5 years, FCI group, diagnosis, pre-operative HHFS, patient age and BMI were significant. HHFS at 5 years was significantly higher in FCI group 0–1 than any other category (2–3 P=0.006, 4–5 P<0.001, ≥6 P=0.002). In total, the model accounted for 29% of variability in HHFS at 5 years. This is the first statistically robust study to examine the effect of comorbidity on THA function. These results strongly suggest that increasing patient comorbidity is associated with poorer THA function when measured using HHS. Two significant conclusions can be drawn:. Patient comorbidity should be taken into account pre-operatively when considering potential future THA function. When comparing across implants, failure to give specific consideration to comorbidity of patient groups will limit relevance and weight of findings

In a recent study, 54.5% of patients reporting to arthroplasty clinics in the US were obese. We performed a recent literature review to determine how obesity impacts outcomes in total hip and knee arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient.

Specifically, obese patients have shown increased rates of infection, dislocation, need for revision, wound dehiscence, increased operative time and prolonged hospital stay. Additionally, obese TKA patients have been shown to have increased rates of aseptic loosening, thromboembolic events, wound complications, and cardiopulmonary events.

Worsening severity of obesity seems to correlate with worsening outcomes and super obesity (BMI>50) has been identified as an independent risk factor for complications. Patients with BMI>35 have shown to be 6.7 times more likely to develop infection after TKA. Patients with BMI>40 have a 3.35 times higher rate of revision for deep infection than those with BMI<35. The odds ratio for major complications increases dramatically beyond BMI>45.

How can we improve outcomes in the obese patient? Preoperative care for the obese patient involves nutritional counseling, incorporating weight loss methods, physical therapy, metabolic workup and diagnosis and management of frequent comorbid conditions (OSA, DM2, HTN, HLD, malnutrition, renal failure). Identifying and managing comorbidities is especially important given that some comorbidities such as malnutrition have been shown to be as strong or even stronger an independent risk factor for postoperative TJA complications than obesity. In some cases higher complications were seen which some authors attribute to bariatric patients remaining in a catabolic state after weight loss.  

We know that obesity and its associated comorbid conditions do have worse outcomes and increased complications in TJA patients. We also know that complications proportionately increase with increasing severity of obesity. The super-obese population is at the greatest risk of complication following TJA and preoperative screening and management is essential in reducing complications. Although weight loss is important, bariatric data has shown that it does not solve the problem of obesity in itself and the patient's metabolic state is likely a more important issue. Implant selection is important and strong consideration should be given to avoiding direct anterior approach in the THA obese patient. Understanding of obesity specific complications and treatment options is crucial for patient counseling and optimization to ensure successful treatment in obese TJA patients.

Purpose

To evaluate comorbidity and health-related quality of life in patients with idiopathic scoliosis.

Aim: We determined 90 days mortality following primary total hip replacement (THR) and examined the impact of age and level of comorbidity.

Methods: We used data from the nationwide population based Danish Hip Arthroplasty Registry between 1 January 1995 and 31 December 2004. Each THR patient was matched according to gender and age on the time of surgery with 3 persons from the general population randomly sampled using the Danish Civil Registration system, resulting in a total of 44 818 THA patients and 120 883 controls. We used a Cox regression analyses to computed age and comorbidity specific mortality rates (MR) and mortality rate ratio (MRR) with 95% Confidence Intervals (CI) for THR patients compared with the general population, as well as Number Needed to Harm (NNH).

Results: The MRs for THR patients relative to those for the general population were highest in the patients younger than 60 years, corresponding to an adjusted MRR of 3.6 (95% CI: 2.2–5.5). Similar, an adjusted MRR was 1.2 (95% CI: 1.0–1.4) in patients aged 80 years and over. The THR patients younger than 60 years had more comorbidity than the controls, whereas distribution of comorbidity was equal in all other age groups. MRRs increase with comorbidity level for both THR patients and controls in all age groups. MRR for THR patients vs. controls within high comorbidity level aged below 60 years and aged 80 years and over was 3.5 (1.3–9.8) and 0.7 (0.5–0.9), respectively. However, hospitalisation with particularly cardio–og cerebrovasculaar disease before surgery increase mortality risk for both age groups, whereas hospitalisation with cancer increase mortality risk for patients younger than 60 years and decrease it for patients aged 80 years and over.

Conclusions: Overall mortality of THR patients relative to those in the general population was higher 90 days after surgery. Our findings apply particularly for THR patients aged 10 to 59 and 80 years and over. Although THR patients aged 80 years and over with high comorbidity level had lower mortality than corresponding persons from the general population, some particular groups of medical condition prior to surgery is associated with increased mortality risk whereas other medical conditions are associated with decreased mortality risk. We should be careful in making clinical decisions based on the Charslon comorbidity index; subgroups analyses may be necessary.

Further, we will present data on 90 days cause of death following primary THR and predictors for death, including age, gender and comorbidity (analyses are not finished yet).

Background: Due to reported high rates of complications in Total Disc Replacement Swiss health care system demanded an obligatory national Health Technology Assessment-registry for Total Disc Replacement. Thus, SWISSspine was founded in 2003 to assess efficiency, cost effectiveness, safety and find predictors of co-morbidity for surgical outcome.

Study design and Methods: In an observational multi center mode data were collected from March 2005 to August 2008 with detailed frequency statistics. Preoperative assessment, 3 month and 1 year FU using EQ-5D, NASS-Instrument and co-morbidity-forms for patients were applied. The surgeons administered OR- and FU-forms. Statistics: multivariate regression analysis.

Patient sample: 427 interventions with 497 implants.

Results: A significant reduction of back pain: 71 to 31 (p< 0.001) and leg pain 54.7 to 20.7 (p< 0.001) was documented (VAS, 1year postop). Quality of life measured in EQ-5D increased from 0.32 to 0.73. Opiate-usage decreased from 31.7% to 7.7%. Increasing ROM and re-established lordosis were seen. Overall 19 complications occurred, 12 revisions were performed. It was revealed that medicamentous treated depression had a negative influence on the outcome.

Conclusions: SWISSspine as a mandatory instrument was successfully implemented in the treatment-program of degenerative lumbar disc-diseases. The results provide evidence for patients benefit. Back- as well as leg pain was reduced. Complication- and revision rates were low. Medicamentous treated depression seems to have a negative influence on postoperative pain outcome in TDR. Our results obtained from SWISSspine provide a reasonable potential supporting surgeon in decision making for TDR especially in patients with medicamen-tous treated depression.

Introduction and Objectives: Our aim is to study the effects of these two factors on functional recovery of patients undergoing surgery for extracapsular hip fracture.

Materials and Methods: A multi-centre study involving 3 hospitals was done on 163 patients presenting with extracapsular hip fractures who were treated using IMHS sliding nail/screws. Six months of postoperative follow-up was done to evaluate Charlson’s index comorbidity, pre-fracture functionality,and postoperative functionality at 3 and 6 months using Parker and Palmer’s test and the hospitalization index. Functional progression was evaluated in terms of comorbidity using comparison of means. To study the impact of hospitalisation, a comparision of mean scores for hospitalised and non-hospitalised patients was performed.

Results: The final analysis was done using data from 127 patients. Of this sample, 109 patients were not hospitalised before the fracture, and 18 had been hospitalised. There were no significant differences in average Charlson’s index scores between hospitalised and non-hospitalised patients. Functionality at 3 months was 3.97 for non-hospitalised patients and 2.0 for hospitalised patients; at 6 months scores were 4.56 for non- hospitalised patients and 2.38 for hospitalised (p< 0.005). Patients with a Charlson score greater than 2 had a loss of function of 2.16 points at 3 months and 1.58 at 6 months (p< 0.005). Patients with a Charlson score less than or equal to 2 had a functional loss of 1.82 points at 3 months and 1.26 at 6 months (p< 0.005).

Discussion and Conclusions: Hospitalised patients had greater loss of function than non-hospitalised patients, independent of their previous health status. Patients with greater comorbidity had greater loss of function compared to patients with less severe previous pathology.

Aims. The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture. Methods. Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching. Results. Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010). Conclusion. The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection. Cite this article: Bone Joint Res 2023;12(5):331–338

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery. A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”. Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation

Aims. The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods. This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results. There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion. The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies. Cite this article: Bone Joint J 2024;106-B(1):77–85

Aims. The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. Methods. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. Results. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Conclusion. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus. Cite this article: Bone Jt Open 2024;5(9):785–792

Bone regeneration and repair are crucial to ambulation and quality of life. Factors such as poor general health, serious medical comorbidities, chronic inflammation, and ageing can lead to delayed healing and nonunion of fractures, and persistent bone defects. Bioengineering strategies to heal bone often involve grafting of autologous bone marrow aspirate concentrate (BMAC) or mesenchymal stem cells (MSCs) with biocompatible scaffolds. While BMAC shows promise, variability in its efficacy exists due to discrepancies in MSC concentration and robustness, and immune cell composition. Understanding the mechanisms by which macrophages and lymphocytes – the main cellular components in BMAC – interact with MSCs could suggest novel strategies to enhance bone healing. Macrophages are polarized into pro-inflammatory (M1) or anti-inflammatory (M2) phenotypes, and influence cell metabolism and tissue regeneration via the secretion of cytokines and other factors. T cells, especially helper T1 (Th1) and Th17, promote inflammation and osteoclastogenesis, whereas Th2 and regulatory T (Treg) cells have anti-inflammatory pro-reconstructive effects, thereby supporting osteogenesis. Crosstalk among macrophages, T cells, and MSCs affects the bone microenvironment and regulates the local immune response. Manipulating the proportion and interactions of these cells presents an opportunity to alter the local regenerative capacity of bone, which potentially could enhance clinical outcomes. Cite this article: Bone Joint Res 2024;13(9):462–473

Aims. This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality. Methods. Data on 37,394 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked to data from the Norwegian Patient Registry, Statistics Norway, and characteristics of acute care hospitals. Cox regression analysis was performed to estimate risk factors associated with mortality. The Wald statistic was used to estimate and illustrate relative importance of risk factors, which were categorized in modifiable (healthcare-related) and non-modifiable (patient-related and socioeconomic). We calculated standardized mortality ratios (SMRs) comparing deaths among hip fracture patients to expected deaths in a standardized reference population. Results. Mean age was 80.2 years (SD 11.4) and 67.5% (n = 25,251) were female. Patient factors (male sex, increasing comorbidity (American Society of Anesthesiologists grade and Charlson Comorbidity Index)), socioeconomic factors (low income, low education level, living in a healthcare facility), and healthcare factors (hip fracture volume, availability of orthogeriatric services) were associated with increased mortality. Non-modifiable risk factors were more strongly associated with mortality than modifiable risk factors. The SMR analysis suggested that cumulative excess mortality among hip fracture patients was 16% in the first year and 41% at six years. SMR was 2.48 for the six-year observation period, most pronounced in the first year, and fell from 10.92 in the first month to 3.53 after 12 months and 2.48 after six years. Substantial differences in median survival time were found, particularly for patient-related factors. Conclusion. Socioeconomic, patient-, and healthcare-related factors all contributed to excess mortality, and non-modifiable factors had stronger association than modifiable ones. Hip fractures contributed to substantial excess mortality. Apparently small survival differences translate into substantial disparity in median survival time in this elderly population. Cite this article: Bone Joint J 2022;104-B(7):884–893

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

Two-stage exchange revision total hip arthroplasty performed in case of infection has been considered during many years the gold standard for treatment of chronic infection. Nevertheless, during the last decade, concerns have risen regarding its safety and its efficiency. The purpose of our study was to, first investigate the spacer complications, then to analyze their risks factors. We retrospectively included 125 patients with chronic hip periprosthetic joint infection who underwent a two stage exchange revision arthroplasty performed between January 2013 and December 2019. All spacer complications were systematically collected and risk factors were analyzed. Statistical evaluation were performed using the Student and Mann-Whitney tests. Our study confirms the hypothesis of a high-risk strategy with 42% of patients who had a mechanical spacer failure and a 20% recurrence of infection during the average two years period of follow-up. We found a high rate of spacer migration (23%) and a low rate of spacer fracture (8%) compared to literature. The most important finding was that the majority of spacer complications and failures were found in a population with high medical comorbidities as highlighted by the ASA, Charlson and Lee score associations, as well as with the cardiac, pulmonary, kidney or hepatic chronic conditions. This study showed that a two-stage hip exchange revision is a high-risk procedure regarding complications and mechanical failures of PMMA spacers. In patients with high medical comorbidities, other strategies may be considered and interdisciplinary cooperation with other facilities are needed to identify and control each risk factor

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction