Study design: We conducted a prospective cohort study of 448 patients with a variety of spinal metastases. Objective. To compare the predictive value of the Tokuhashi scoring system (T12) and its revised edition (T15) for life expectancy both in the entire study group as well as in the various primary tumor subgroups. Summary of background data. In 1990 Tokuhashi and coworkers formulated a one point-addition-type prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy as an adjunct in selecting appropriate treatment. Because the site of the primary tumor influences ultimate survival, the scoring system was revised in 2005 to a total sum of 15 points based on the origin of the primary tumor. Methods. This study included 448 patients with vertebral metastases, all of whom underwent surgical treatment during November 1992 to November 2009 at the Aarhus University Hospital. Data was retrieved from the Aarhus Spinal Metastases Algorithm. Scores based on the T12- and T15 scoring systems were calculated prospectively for each patient. All the patients were divided into three survival groups with different life expectancies according to their score points in both scoring systems. Furthermore, we divided all the patients into different groups dictated by the site of their primary tumor. The predictive value of each scoring system, both in the entire group and in each subgroup determined by the original tumour site, was evaluated by the Log-rank-test. The McNemar's test was used to compare the differences in accuracy rates between these two scoring systems. Survival curves were estimated using the Kaplan-Meier methods. Probability value less than 0.05 was considered statistically significant. Result. For the 448 patients with vertebral metastases, both the T12 and T15 scoring systems showed statistically significant predictive value (T12 group p<0.0001, T15 group p<0.0001, Log-rank test). The correlation between predicted survival period and real survival was significantly higher in T15 (p<0.0001, McNemar's test) than in T12. The further analyses by type of metastases showed that the predictive value of T12 and T15 was found in the prostate (p=0.0003), breast (p=0.0385), other tumor group (p<0.001) and lymphoma (p<0.05). Only T12 displayed predictive value in the colon group (p=0.0011). The accuracy rate of prognosis in T15 was significantly higher in those groups with spinal metastases originating from prostate (p=0.0032), breast (p<0.0001) and lung (p=0.0076). Conclusion. Both the T12 and T15 scoring systems have significant preoperative predictive value in terms of predicting the survival period for the entire vertebral metastases patient group as well as in the prostate, breast, lymphoma, and colon tumor groups. The accuracy rate was significantly improved in T15 for the total study group and in the subgroups of prostate, breast, and lung tumor

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

The relationship between advancing patient age, decreasing bone mineral density and increasing distal radial fracture incidence is well established. Biomechanical and clinical work has shown that the radiographic severity of distal radial fractures is greater in patients with poor bone quality. Between 1991 and 2007, the number of elderly Scots (aged 75 years or more) increased by 18%, and population projections predict a further 82% increase by 2035. This study was conducted to investigate the effect of recent changes in the demographics of our population on the pattern and radiographic severity of distal radial fractures encountered at our institution. The epidemiology of two distinct series of patients (1991–93; 2007–08) suffering distal radial fractures was compared. The patient and radiographic fracture characteristics known to be predictive of fracture instability and severity were compared using the MacKenney formulae, and a subgroup analysis of distal radial fragility fractures was performed. The life expectancy of our catchment population has improved since 1991, and we have encountered a larger number of distal radial fractures occurring in older, more active and functionally independent patients. We identified an increase in the proportion of AO type B fractures, particularly in the oldest patient groups. The radiographic severity of distal radial fractures, especially low energy metaphyseal injuries, has increased. If the current trend in population demographics continues, it seems likely that orthopaedic surgeons will encounter an increasing number of severe distal radial fractures deemed unsuitable for treatment by closed methods

The aim was to perform a cost-utility analysis of total joint replacement in the current environment. Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine in the modern era, has come under recent scrutiny. The National Health Service (NHS) has competing demands and resource allocation is challenging in times of economic restraint. Patients undergoing total hip (n=348) and knee arthroplasty (n=323), from January to July 2010, were entered into a prospective arthroplasty database. A health utility score was derived from the Euroqol (EQ-5D) score preoperatively, and at one year, and was combined with individual life expectancy to derive the Quality-Adujusted-Life-Years (QALYs) gained. Predicted need for revision surgery was Incorporated in the model. The 2011–12 Scottish Tariff was used. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher in THR versus TKR (6.53 vs 4.04 years, p<0.001). The cost per QALY for THR was £1371 (95% CI £1194 to £1614) compared with £2101 (£1762 to £2620) for TKR. Predictors of an increase in QALYs gained were poorer health prior to surgery (p<0.001) and younger age (p<0.001). General health (EQ-5D VAS) showed greater improvement in THR versus TKR (p<0.001). This study provides up to date cost-effectiveness data for total joint replacement. THR and TKR are both extremely clinically and cost-effective interventions, with costs that compare favourably with other medical interventions (e.g. laparoscopic hernia repair vs open: £55,548 per QALY; CHD primary prevention with statins: £21,000)

The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems

BACKGROUND. As life expectancy in the population rises, osteoporotic fractures are seen most frequently in the vertebral column. Percutaneous kyphoplasty is increasingly used for pain reduction and stabilization in these patients, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. OBJECTIVE. To clarify whether kyphoplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. MATERIALS & METHODS. From January 2004 to June 2009, 122 patients (31 males and 91 females), from 56 to 85 years old (mean age 68.5) were treated for 165 osteoporotic vertebral fractures of the thoracic or lumbar spine (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Twelve patients (15 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (75 patients) or conservative treatment by computer-generated randomization codes. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height); and pain relief at 1, 6, 12, 24 months, as measured by VAS score. RESULTS. Percutaneous kyphoplasty resulted in direct and greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was −6,5 after kyphoplasty and −2.4 after conservative treatment, and between baseline and 1 year was −7.2 after kyphoplasty and −3.8 after conservative treatment. No serious complications or adverse events were reported. Apart from the pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with 10% height increases in 88% of fractures, in kyphoplasty group at 2 years. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. 35% of patients treated conservatively, had limitations in everyday activities the first 6 months, whereas additional fractures occurred at the adjacent vertebrae at a rate of 14%. CONCLUSION. In patients with acute osteoporotic vertebral compression fractures and persistent pain, balloon kyphoplasty is effective and safe. Pain relief after kyphoplasty is immediate, is sustained for at least 2 years, and is significantly greater than that achieved with conservative treatment, at an acceptable cost

Introduction. treatment of femoral neck fractures in the physically active elderly, is still an open question. The comparison of total replacement and partial hip replacement showed substantial superiority of the first approach than the latter. We can not disregard the problems that THR can lead in the elderly: more surgical time, greater blood loss, major sacrifice of bone in osteoporotic subjects. The Tribofit® acetabular system, has the objective to overcome these problems with the implantation of a single 3mm soft, pliable buffer made of polycarbonate-urethane between the large diameter metal femoral head and the subchondral bone, thus replacing the articular cartilage. The surgical technique includes the reaming of the cartilage layer, the creation of a circumferential groove and the snap-fit insertion of the buffer. The purpose of the prospective study was to evaluate the effectiveness of this approach in the treatment of femoral neck fractures in the elderly. Materials and Methods. from September 2008 to July 2010 we performed 45 implants with the Tribofit® Acetabular Buffer (Active Implants®, Memphis TN, USA). The inclusion criteria for the study were: femoral neck fracture patients over 75 years of age, physically independent before the injury, with good life expectancy, mild or absent arthritis, absence of morphological alterations of the acetabulum. The average age of these patients was 81,2 (75–89), the sex distribution was 36 females and 9 males, with 22 fractures of the left hip and 23 of the right. In all cases an uncemented straight femoral stem was implanted. We recorded per-operative blood loss and intra-per-operative problems encountered. Follow-up were performed at 1, 3, 6 and 12 months post-op with radiographic control and clinical examination. The clinical outcome was objectively measured by the Harris Hip Score, pain Visual Analogue Scale and SF-36 questionnaire. Results. Of the 45 patients, 4 died of unrelated causes and 3 were lost to follow-up (2 due to cognitive impairment and 1 due to peri-prosthetic fracture of the femur). Of the 38 available for follow-up, all were followed at the staged time. No intra-operative problems were registered. The mean HHS for these fractures patients was 74,2 at 6 months and 86 at 12 months (90–80 good; 80–70 fair). The mean pain VAS was 4,3 at 6 months and 2 at 12 months. The mean SF-36 Score was 52,3 at 6 months and 53,2 at 12 months. Of the 38 followed, we had 2 dislocations in the third week post-op while the two patients were in a rehabilitation centre. Open reduction was carried out and in both cases the buffer was not dislodged. Discussion and conclusions. we believe the results with this new type of prosthesis are encouraging and comparable to if not better than other prosthetic options in the literature for this difficult-to-treat patient population

Due to increased life expectancy of human population, the amount of total knee replacements (TKR) is expected to increase. TKR reached a high grade of quality and safety, but most often it fail because of aseptic implant loosening caused by polyethylene (PE) wear debris. Wear is generated at the articulating surfaces, e.g. caused by three body particles, like bone fragments or bone cement particles. The aim of this experimental study was to compare the wear of tibial PE inserts combined with metallic and ceramic femoral components at three body wear situation induced by polymethylmethacrylate (PMMA) and zirconia (ZrO2) particles from the bone cement. Wear testing was performed for 5 Mio load cycles, using tibial standard PE inserts combined with the same CR femoral component, in two different materials, Cobalt Chromium (CoCrMo) and Biolox delta ® ceramic (Multigen Plus Knee System, Lima Corporate, Italy). A knee wear simulator, according to ISO 14243 (EndoLab GmbH, Rosenheim, Germany), was used to carry out the tests. The tests were performed in temperature-controlled test chambers at 37 °C, containing calf serum with a protein content of 30 g/l. Polymethylmethacrylate (PMMA) and zirconia (ZrO2) bone cement particles (Palacos R ®) were manufactured to a size of 30 μm. The three body particles were added at all stations onto the articulating surface of the tibial PE insert (7mg per condyle) at every 500,000 cycles. Wear was determined gravimetrically and the surfaces of tibial inserts were analysed by scanning electron microscope (SEM) after finishing the 5 million cycles. Furthermore, roughness of the PE insert surfaces and the articulating surfaces of the different femoral components were detected and the PE wear particles were analysed by SEM. The average gravimetrical wear rates of the tibial PE inserts in combination with CoCr and Biolox delta ® ceramic femoral components amounted to 6.4 ± 0.9 mg and 2.6 ± 0.4 mg per million cycles, respectively. Beside bone cement particles on the articulating surface of the PE inserts, polished surfaces and scratches were detected by SEM. In comparison to the untreated surfaces of the PE inserts at both material pairings the surface roughness at the articulating areas showed deep scratches and polished regions. Analyses of the metallic femoral components showed scratches at the articulating surfaces, none on ceramics. The present study pointed out the effect of femoral component material in an abrasive three body wear situation on the wear properties of TKR. The wear simulator tests showed that wear of PE inserts under three body wear conditions, in combination with ceramic femoral components, was significantly lower than with metallic femoral components. With regard to anti-allergic properties, ceramic femoral components are promising products for TKR

Aims

Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

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This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

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Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

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We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

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The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

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The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

Aims

The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

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Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery.

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Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated.