Aims. Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure. Methods. We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test. Results. A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052). Conclusion. Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention. Cite this article: Bone Joint J 2024;106-B(2):189–194

Aims. Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas. Methods. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Results. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Conclusion. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival. Cite this article: Bone Joint J 2023;105-B(5):575–582

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

Aims. This multicentre retrospective observational study’s aims were to investigate whether there are differences in the occurrence of radiolucent lines (RLLs) following total knee arthroplasty (TKA) between the conventional Attune baseplate and its successor, the novel Attune S+, independent from other potentially influencing factors; and whether tibial baseplate design and presence of RLLs are associated with differing risk of revision. Methods. A total of 780 patients (39% male; median age 70.7 years (IQR 62.0 to 77.2)) underwent cemented TKA using the Attune Knee System) at five centres, and with the latest radiograph available for the evaluation of RLL at between six and 36 months from surgery. Univariate and multivariate logistic regression models were performed to assess associations between patient and implant-associated factors on the presence of tibial and femoral RLLs. Differences in revision risk depending on RLLs and tibial baseplate design were investigated with the log-rank test. Results. The conventional and novel Attune baseplates were used in 349 (45%) and 431 (55%) patients, respectively. At a median follow-up of 14 months (IQR 11 to 25), RLLs were present in 29% (n = 228/777) and 15% (n = 116/776) of the tibial and femoral components, respectively, and were more common in the conventional compared to the novel baseplate. The novel baseplate was independently associated with a lower incidence of tibial and femoral RLLs (both regardless of age, sex, BMI, and time to radiograph). One- and three-year revision risk was 1% (95% CI 0.4% to 1.9%)and 6% (95% CI 2.6% to 13.2%), respectively. There was no difference between baseplate design and the presence of RLLs on the the risk of revision at short-term follow-up. Conclusion. The overall incidence of RLLs, as well as the incidence of tibial and femoral RLLs, was lower with the novel compared to the conventional tibial Attune baseplate design, but higher than in the predecessor design and other commonly used TKA systems. Cite this article: Bone Joint J 2024;106-B(11):1240–1248

Aims

Bacteriophages infect, replicate inside bacteria, and are released from the host through lysis. Here, we evaluate the effects of repetitive doses of the Staphylococcus aureus phage 191219 and gentamicin against haematogenous and early-stage biofilm implant-related infections in Galleria mellonella.

Aims

We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton.

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While a centralized system for the care of patients with a sarcoma has been advocated for decades, regional variations in survival remain unclear. The aim of this study was to investigate regional variations in survival and the impact of national policies in patients with a soft-tissue sarcoma (STS) in the UK.

Mortality following revision hip surgery for periprosthetic fracture (PPF) has been reported to be as high as 60% at 5 years. The aim of this study was to determine the mortality rate for PPF revisions, compared to revision for aseptic loosening or infection at our tertiary referral centre. Revision arthroplasty procedures performed for PPF, aseptic loosening or infection between January 2014 and December 2015 at our institution were identified using a prospectively collected PPF referral database and locally collected NJR data. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications, and Kaplan-Meier failure (mortality) at 1 & 5 years post-operative (with log-rank test for equality). There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery from injury for PPF was 8 days (95% CI, 6–16). Single-stage procedures were performed in 84% of PPF, 42% of infection and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group (p<0.001). Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The Kaplan-Meier estimate of 1-year mortality were: PPF = 0%; infection = 2.8% (0.7–11.1%); aseptic = 0.9% (0.2–3.5%). 5-year mortality estimates were: PPF = 17.1% (8–34%), infection = 8.7% (4–18.3%), aseptic = 12% (8.4–17%). Log-rank test of equality was not significant, p=0.833. Despite the PPF group having an average delay to surgery of 8 days, higher ASA grades and more admissions to HDU there was no significant difference in mortality rates between the groups at 1 and 5 years postoperatively. Using a coherent MDT approach with dedicated healthcare professionals this service demonstrates a low post operative mortality rate which merits further investment and development

Aims. Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS. Methods. A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis. Results. Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC. Conclusion. Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients. Cite this article: Bone Jt Open 2024;5(4):350–360

Aims. A higher failure rate has been reported in haematogenous periprosthetic joint infection (PJI) compared to non-haematogenous PJI. The reason for this difference is unknown. We investigated the outcome of haematogenous and non-haematogenous PJI to analyze the risk factors for failure in both groups of patients. Methods. Episodes of knee or hip PJI (defined by the European Bone and Joint Infection Society criteria) treated at our institution between January 2015 and October 2020 were included in a retrospective PJI cohort. Episodes with a follow-up of > one year were stratified by route of infection into haematogenous and non-haematogenous PJI. Probability of failure-free survival was estimated using the Kaplan-Meier method, and compared between groups using log-rank test. Univariate and multivariate analysis was applied to assess risk factors for failure. Results. A total of 305 PJI episodes (174 hips, 131 knees) were allocated to the haematogenous (n = 146) or the non-haematogenous group (n = 159). Among monomicrobial infections, Staphylococcus aureus was the dominant pathogen in haematogenous PJI (76/140, 54%) and coagulase-negative staphylococci in non-haematogenous PJI (57/133, 43%). In both groups, multi-stage exchange (n = 55 (38%) in haematogenous and n = 73 (46%) in non-haematogenous PJI) and prosthesis retention (n = 70 (48%) in haematogenous and n = 48 (30%) in non-haematogenous PJI) were the most common surgical strategies. Median duration of antimicrobial treatment was 13.5 weeks (range, 0.5 to 218 weeks) and similar in both groups. After six years of follow-up, the probability of failure-free survival was significantly lower in haematogenous compared to non-haematogenous PJI (55% vs 74%; p = 0.021). Infection-related mortality was significantly higher in haematogenous than non-haematogenous PJI (7% vs 0% episodes; p = 0.001). Pathogenesis of failure was similar in both groups. Retention of the prosthesis was the only independent risk factor for failure in multivariate analysis in both groups. Conclusion. Treatment failure was significantly higher in haematogenous compared to non-haematogenous PJI. Retention of the prosthesis was the only independent risk factor for failure in both groups. Cite this article: Bone Joint J 2023;105-B(12):1294–1302

Aims. Periprosthetic fungal infections are rare and account for 1–2% of all periprosthetic joint infections (PJI). This study aims at presenting treatment details, clinical and microbiological results in a large single centre cohort. Methods. We retrospectively identified 29 patients (9 total knee replacements (TKA) and 20 total hip replacements (THA) treated for a fungal infection between 2007 and 2019. Microbiological findings, patient demographics and complications were analysed. Statistical analysis was performed using descriptive statistics; non-parametric analysis were performed using the Mann-Whitney U-Test. Infection-free survival was determined using Kaplan-Meier analysis and differences in survival were analysed using the log-rank test. The p value was set at p<0.05 with 95% confidence intervals (95% CI) provided. Results. 28% (8/29) suffered from reinfection. The reinfection-free survival probability was 65% (95% CI 45–85) after a median follow- up period of 28 months (IQR 6 – 39). With the numbers we had, we were not able to detect a difference between THA and TKA re-infections (p=0.517). Four patients underwent amputation, 3 patients had a definitive girdlestone hip and eight patients died after a median of 5 months after first-stage surgery (IQR 1–7). All patients treated had positive synovial fluid or tissue cultures for Candida species. In 22 /29 patients C. albicans, in 3 patients C. parapsilosis, in 2 patients C. glabrata and in 1 patient each C. famata, C. dubliniensis and C. gulliermondii. Polymicrobial bacterial infection was found in 86% of patients with staphylococci in 20 patients, E. coli in 2 patients, vancomycin-resistant enterococci, pseudomonas, acinetobacter and achromobacter species in 1 patient each. When investigating risk factors for reinfection, with the numbers we had we were not able to find a significant difference for patients with polymicrobial infection (p=0.974), azole-resistant Candida (p=0.491), tobacco users (p=0.175), or diabetics (p=0.54). Furthermore, median age (73 vs. 72, p=0.756) and Charlson comorbidity score (6 (interquartile range (IQR) 4–8) vs. 8 (IQR 5–10), p=0.184) were not different between the groups while on the other hand there was a trend for a higher body mass index in patients with reinfection (34 (IQR 31–38) vs. 28 (IQR 25–33), p=0.075). Conclusions. Fungal PJI is associated with poor reinfection free survival, frequent revisions, and high mortality. All infections were caused by Candida spp. in which azole-resistance most be considered when planning treatment. While polymicrobial infection complicated treatment there was no difference in survival. A higher BMI and comorbidity score might be associated with higher risk for reinfections

Computer aided Total Hip Arthroplasty (THA) surgery is known to improve implantation precision, but clinical trials have failed to demonstrate an improvement in survivorship or patient reported outcome measures (PROMs). Our aim was to compare the risk of revision, PROMs and satisfaction rates between computer guided and THA implanted without computer guidance. We used the National Joint Registry dataset and linked PROMs data. Our sample included THAs implanted for osteoarthritis using cementless acetabular components from a single manufacturer (cementless and hybrid). An additional analysis was performed limiting the sample size to THAs using cementless stems (fully cementless). The primary endpoint was revision (of any component) for any reason. Kaplan Meier survivorship analysis and an adjusted Cox Proportional Hazards model were used. 41683 non computer guided, and 871 (2%) computer guided cases were included in our cementless and hybrid analysis. 943 revisions were recorded in the non-guided and 7 in the computer guided group (adjusted Log-rank test, p= 0.028). Cumulative revision rate at 10 years was 3.88% (95%CI: 3.59 – 4.18) and 1.06% (95%CI: 0.45 – 2.76) respectively. Cox Proportional Hazards adjusted HR: 0.45 (95%CI: 0.21 – 0.96, p=0.038). In the fully cementless group, cumulative revision rate at 10 years was 3.99% (95%CI: 3.62 – 4.38) and 1.20% (95%CI: 0.52 – 3.12) respectively. Cox Proportional Hazards adjusted HR: 0.47 (95%CI: 0.22 – 1.01, p=0.053). There was no statistically significant difference in the 6-month Oxford Hip Score, EQ-5D, EQ-VAS and success rates. Patient Satisfaction (single-item satisfaction outcome measure) was improved in the computer guided group but this finding was limited by a reduced number of responses. In this single manufacturer acetabular component analysis, the use of computer guided surgery was associated with a significant reduction in the early risk of revision. Causality cannot be inferred in view of the observational nature of the study, and further database and prospective studies are recommended to validate these findings

Population-based studies from the United States have reported that sarcoma patients living in rural areas or belonging to lower socioeconomic classes experience worse overall survival; however, the evidence is not clear for universal healthcare systems where financial resources should theoretically not affect access to standard of care. The purpose of this study was to determine the survival outcomes of soft-tissue sarcoma (STS) patients treated in Ontario, Canada over 23 years and determine if the patient's geographic location or income quintile are associated with survival. We performed a population-based cohort study using linked administrative databases of patients diagnosed with STS between 1993 – 2015. The Kaplan-Meier method was used to estimate 2, 5, 10, 15 and 20-year survival stratified by age, stage and location of tumor. We estimated survival outcomes based on the patient's geographic location and income quintile. The Log-Rank test was used to detect significant differences between groups. If groups were significantly different, a Cox proportional hazards model was used to test for interaction effects with other patient variables. We identified 8,896 patients with biopsy-confirmed STS during the 23-year study period. Overall survival following STS diagnosis was 70% at 2 years, 59% at 5 years, 50% at 10 years, 43% at 15 years, and 38% at 20 years. Living in a rural location (p=0.0028) and belonging to the lowest income quintile (p<0.0001) were independently associated with lower overall survival following STS diagnosis. These findings were robust to tests of interaction with each other, age, gender, location of tumor and stage of disease. This population-based cohort study of 8,896 STS patients treated in Ontario, Canada over 23 years reveals that patients living in a rural area and belonging to the lowest income quintile are at risk for decreased survival following STS diagnosis. We extend previous STS survival reporting by providing 15 and 20-year survival outcomes stratified by age, stage, and tumor location

Over 800 total hip replacement (THR) constructs were implanted in the UK in 2017. To ensure reliable implants are used, a NICE revision benchmark of 5% after 10 years exists. Surgeons are guided in choice by organisations such as the Orthopaedic Data Evaluation Panel (ODEP). Currently, ODEP publishes ratings for stem and cup separately and not for constructs. We used NJR data to investigate whether revision estimates of an individual stem (with all cups) is an accurate indicator of survival of all constructs using that stem. The dataset comprised 234,289 THRs using the most frequently implanted stem between 2004 and 2017. Crude ten-year revision estimates were calculated using Kaplan-Meier for all THRs and for the five most implanted constructs. Adjusted comparisons between individual constructs and the overall stem revision estimate were made using flexible parametric survival analysis. The 10-year crude, revision estimate for all THRs was 2.3% (95% CI 2.2, 2.4). Only four of the most frequently used constructs had long enough follow-up to analyse. 10-year estimates for these constructs ranged from 1.8% (95% CI 1.5, 2.1) to 3.7% (95% CI 3.2, 4.1), a log-rank test revealed strong evidence against the null hypothesis that revision estimates were the same for all constructs (p<0.001). Adjusted for age, sex and ASA, three of the four constructs showed a difference in 10-year revision estimates compared to this stem with all cups (P=0.03, P<0.001, P<0.001). This study suggests 10-year revision estimates for all THRs using the most implanted stem in the NJR are not representative of all constructs involving that stem in crude or adjusted analyses. Current benchmarking systems report survival for the stem in combination with all cups and not for constructs. We suggest that benchmarking ratings basing on revision estimates for THR constructs would provide more accurate information, enabling informed construct decisions

Introduction. Innovations in surgical robotics and navigation have significantly improved implant placement accuracy in total knee arthroplasty (TKA). However, many comparative studies have not been shown to substantially improve revision rates or other clinical outcome scores. We conducted a simulation study based on the reported distribution of patient-specific characteristics and estimated potential effect of coronal plane alignment (CPA) on risk of revision to evaluate the hypothesis that most published study designs in this area have been too underpowered to detect improvements in revision rates. Methods. To model previously reported studies, we generated a series of simulated TKA patient populations, assigning each patient a set of patient-specific factors (age at index surgery, BMI, and sex (Fig.1a)), as well as one surgeon-controlled factor (CPA) (Fig.1b) based on registry data and published literature. We modelled the survival probability for an individual patient at time t as a Gaussian function (exp[-(t/(k∗τ. max. )). 2. ]), where τ. max. (99.5 years) is selected to ensure the mean survival probability of the patient population matched 92% at 15 years. The value of k was adjusted for simulated patients within a range of 0 to 1 as a function of their patient and surgeon-specific factors (Fig.2). To evaluate power associated with a study design, we ran a Monte Carlo simulation generating 10,000 simulated populations of ten different cohort sizes. We divided the patient population into two groups: one group was assigned CPAs governed by the precision of a navigated/robotic approach (σ=1.5°), and the other CPAs governed by the precision of a conventional approach (σ=3°). We then simulated the time to failure for each patient, computed the corresponding Kaplan-Meier survival curves, and applied a Log-Rank test to each study to test for statistical difference. From the 10,000 simulations associated with each cohort size, we determined the percentage of simulated studies that found a statistically significant difference at each time point. Results. Figure 3 shows a contour plot illustrating the probability that a survival analysis with a specific study design would find statistical significance between the conventional and navigated/robotic patient groups. Entries from recently published literature are overlaid for context. No studies achieved statistical significance (p<0.05). Discussion. The effectiveness of navigated/robotic surgery is one of the most controversial debates in orthopedic surgery. The results from this simulation suggest that most revision studies aiming to settle this debate are likely significantly underpowered, falling below the normal 80% threshold. Limitations of this analysis include using only a single surgeon-controlled variable in the survival simulation, and only a single precision for the navigated/robotic approaches. Further studies will include more implant-related risk factors and a wider range of precisions for navigated/robotic procedures. Based on this simulation, it appears the effect size afforded by navigated/robotic surgeries on revision rates in TKA surgery is too small to recommend broad application, especially since adoption could involve added costs and unforeseen risks associated with novelty. Clinically, it may be beneficial to examine the use of robotics/navigation on high-risk patients, where studies are likely to have higher power due to larger effect sizes. For any figures or tables, please contact the authors directly

Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. Patients and Methods. Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. Results. A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). Conclusion. Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use. Cite this article: Bone Joint J 2019;101-B:1570–1577

Background. Total hip arthroplasty (THA) is increasingly used for active patients with displaced intracapsular hip fractures. Dislocation rates in this cohort remain high postoperatively compared to elective practice, yet it remains unclear which patients are most at risk. The aim of this study was to determine the dislocation rate for these patients and to evaluate the contributing patient and surgeon factors. Methods. A five-year retrospective analysis of all patients receiving THA for displaced intracapsular hip fractures from 2013–18 was performed. Data was collected from the institutions' hip fracture database, including data submitted to the National Hip Fracture Database (NHFD). Cox regression analysis and log-rank tests were implemented to evaluate factors associated with THA dislocation. Patient age, sex, ASA grade, surgeon seniority, surgical approach, femoral head diameter and acetabular cup type were all investigated as independent factors. Results. A total of 196 patients, with a mean age of 72 (range 49–90), received THA for hip fracture between 2013–18. A posterior approach, using standard cemented acetabular components and a 28mm femoral head, was used in 133 cases (72%). Fourteen dislocations (7%) were observed during this period, with 5 patients requiring revision surgery. Of these dislocations, all were performed through posterior approaches with standard cemented cups. 28mm femoral heads were used in all cases except one, which used a 32mm femoral head. In Cox regression analysis, ASA grade, but not age or sex, was significantly associated with dislocation (hazard ratio = 4.5; 95% confidence interval 2.0–10.0; p<0.001). On log rank testing no statistically, significant association was found between dislocation and surgeon grade (p=0.85), surgical approach (p=0.31), femoral head size (p=0.85) or cup type (p=0.30). Discussion. This study demonstrates an increased risk of dislocation following THA for hip fracture with higher ASA grades. It may be appropriate to offer more stable implants to this cohort of patients

This is a 15-year follow-up observational study of 4390 patients with 4606 primary total knee replacements (TKRs) implanted in the Trent health region between 1990 and 1992. The operations were performed in 21 hospitals, including both district general and teaching hospitals, with 77 different surgeons as named consultant. The main objective was to analyse the survival of the patients and of the prostheses, and to evaluate what impact different variables have on survival. In addition, the 1480 patients (33.7%) (1556 TKRs) alive at 15 years following operation were sent a self-administered questionnaire which examined their level of satisfaction, of pain, and their quality of life at 15 years. Completed responses were received from 912 TKRs (58.6%). Three survival curves were constructed: a best-case scenario based on the patients entered into the life tables, another included failures not reported in the revision database, and a third worst-case scenario based on all patients lost to follow-up presumed to have had a failed primary TKR. In the best-case scenario survival at 15 years was 92.2%, and in the worst-case scenario was 81.1%. Survival was significantly increased in women and older patients (Mantel-Cox log-rank test, p < 0.005 and p < 0.001, respectively). Revision as a result of infection was required in 40 TKRs (18.8%) representing 0.87% of the original cohort. The limited information available from the questionnaire indicated that satisfaction was less frequent among men, patients with osteoarthritis and those who required revision (chi-squared test, p < 0.05, p < 0.05 and p < 0.0001, respectively). With regard to pain, older patients, females and patients who still had their primary replacement in place at 15 years, reported the least pain (chi-squared test for trends, p < 0.0005, p < 0.005 and p < 0.0001, respectively). The reported quality of life was not affected by any variable

Aims. There is little information about the optimum number of implants to be used in the surgical treatment of idiopathic scoliosis. Retrospective analysis of prospectively collected data from the Swedish spine register was undertaken to discover whether more implants per operated vertebra (implant density) leads to a better outcome in the treatment of idiopathic scoliosis. The hypothesis was that implant density is not associated with patient-reported outcomes, the correction of the curve or the rate of reoperation. Patients and Methods. A total of 328 patients with idiopathic scoliosis, aged between ten and 20 years at the time of surgery, were identified in the Swedish spine register (Swespine) and had patient reported outcomes including the Scoliosis Research Society 22r instrument (SRS-22r) score, EuroQol 5 dimensions quality of life, 3 level (EQ-5D-3L) score and a Viual Analogue Score (VAS) for back pain, at a mean follow-up of 3.1 years and reoperation data at a mean follow-up of 5.5 years. Implant data and the correction of the curve were assessed from radiographs, preoperatively and a mean of 1.9 years postoperatively. The patients were divided into tertiles based on implant density. Data were analyzed with analysis of variance, logistic regression or log-rank test. Some analyses were adjusted for gender, age at the time of surgery, the flexibility of the major curve and follow-up. Results. The mean number of implants per operated vertebra in the low, medium and high-density groups were 1.36 (1.00 to 1.54), 1.65 (1.55 to 1.75) and 1.91 (1.77 to 2.00), respectively. There were no statistically significant differences in the correction of the curve, the SRS-22r total score, EQ-5D-3L index or number of reoperations between the groups (all p > 0.34). In the SRS-22r domains, self-image was marginally higher in the medium implant density group (p = 0.029) and satisfaction marginally higher in the high implant density group (p = 0.034). Conclusion. These findings suggest that there is no clear advantage in using a high number of implants per operated vertebra in the surgical treatment of patients with idiopathic scoliosis. Cite this article: Bone Joint J 2018;100-B:1080–6

The purposes of this study were to review retrospectively the 25-year survival of cemented and cementless THA for hip dysplasia and to compare the effect of fixation methods on the long-term survival in patients with DDH. We retrospectively reviewed all patients with OA secondary to hip dysplasia treated with a cemented Bioceram hip system between 1981 and 1987, and a cementless cancellous metal Lübeck hip system between 1987 and 1991. The studied subjects were 76 hips of cemented THA (Group-C) and 57 hips of cementless THA (Group-UC). Both hip implants had a 28-mm alumina head on polyethylene articulation. The mean age at operation was 50.5 years (range, 36–60 years) in Group-C and 50.0 years (range, 29–60 years) in Group-UC. The survival at 25 years regarding any revision as the endpoint was 46% in Group-C and 76% in Group-UC. These difference was significant using Log-rank test (P=0.008). The cup survival at 25 years was 47% in Group-C and 83% in Group-UC (P= 0.0003). The stem survivals at 25 years were 95% in Group-C and 92% in Group-UC. (P= 0.416). Cementless THA in patients with DDH showed a higher survival rate at 25 years than cemented THA because of the excellent survival of the acetabular component without cement. We conclude that cementless THA with the cancellous metal Lübeck hip system led to better longevity at 25 years than cemented THA with the Bioceram in patients with OA secondary to DDH