Aims. Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. Methods. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up. Results. The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up. Conclusion. Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved. Cite this article: Bone Joint J 2024;106-B(1):46–52

Abstract. Background. In 2018 NICE produced their guidelines with regards to the prevention of hospital-acquired thrombosis which extended the age range to include 16- and 17-years old patients, suggesting that these patients are risk assessed and receive thromboprophylaxis if indicated. We analysed the incidence of VTE in this age group in our institution and found it to be extremely low and often not related to risk factors commonly included in adult risk assessment tools. Methods. We retrospectively reviewed the data of 13,951 patients aged 16- and 17-years of age in our admission database at the University Hospitals of Leicester (UHL) over a period of 7 years between 2013 and 2019. This was cross-referenced with our imaging database which identified scans carried out for suspected Venous Thromboembolism (VTE). Results. There were 1,275 admissions and 12,676-day-case attendances over the study period. Of these, 145 patients had scans for suspected VTE. 13 patients had positive scans and fulfilled the inclusion criteria. Of the 13 positive scans, 10 were excluded and 3 patients were included in the study. Conclusion. This study shows that the risk of VTE in the 16- and 17-year-old age group is extremely low in patients attending hospital (0.1% in admitted patients and 0.007% in day attenders). We question whether routine risk assessment for VTE in this age group, especially using existing adult tools, is efficacious. The guidance acknowledges the evidence for prescribed drugs is both lacking and the prescription for such agents being outside their Licencing Authorisation

Falls and fall-related injuries can have devastating health consequences and form a growing economic burden for the healthcare system. To identify individuals at risk for preventive measures and therapies, fall risk assessment scores have been developed. However, they are costly in terms of time and effort and rely on the subjective interpretation of a skilled professional making them less suitable for frequent assessment or in a screening situation. Small wearable sensors as activity monitor can objectively provide movement information during daily-life tasks. It is the aim of this study is to evaluate whether the activity parameters from wearable monitors correlate with fall risk scores and may predict conventional assessment scores. Physical activity data were collected from nineteen home-dwelling frail elderly (n=19, female=10; age=81±5.6 years, GFI=5.4±1.9, MMSE=27.4±1.5) during waking hours of 4 consecutive days, wearing a wearable 9-axis activity monitor (56×40×15mm, 25g) on the lateral side of the right thigh. The signal was analysed using self-developed, previously validated algorithms (Matlab) producing the following parameters: time spent walking, step count, sit-stand-transfer counts, mean cadence (steps/min), count of stair uses and intensity counts >1.5G. Conventional fall risk assessment was performed using the Tinetti sore (range: 0–28=best), a widely used tool directly determining the likelihood of falls and the Short Physical Performance Battery (SPPB, range: 0–12=best) which measures lower extremity performance as a validated proxy of fall risk. The anxiety to fall during activities of daily living was assessed using the self-reported Short Falls Efficacy Scale-International (FES-I, range: 7–28=worst). Correlations between activity parameters and conventional scores were tested using Pearson's r. The activity parameters (daily means) for the 19 participants were 70.8min (SD=28.7; min-max= 22.8–126.6) of walking, 4427 steps (SD=2344; min-max= 1391–8269) with a cadence 79.3 steps per minute (SD=17.1; min-max=52.8–103.9) and 33.3 sit-stand transfers (SD=9.7; min-max=8.8–48.0). The average Tinetti score was 21.2 (SD=5.1; min-max=10.0–27.0), with SPPB scoring 7.8 (SD=2.4; min-max=3.0–12.0), and FES-I 4.6 (SD=5.1; min-max=7.0–23.0). Strong (r≥0.6) and significant correlations existed between the walking cadence and the Tinetti (r=.60, p=<.01) and SPPB (r=.71, p=<.01) scores. No other correlations were found between the activity parameters and the Tinetti, SPPB and none with the psychological FES-I questionnaire. Conventional fall risk scores and activity data are comparable to literature values and thus representative of home-dwelling frail elderly including a wide range covered for both dimensions. No quantitative activity measure had a predictive value for fall risk assessment. Strongly correlated with Tinetti and SPPB, objectively measured cadence as a qualitative parameter seems a useful parameter for remotely identifying fall risk in frail elderly. The perceived anxiety to falls was not correlated to quantitative and qualitative activity parameters suggesting that this psychological aspect hardly affects activity. Wearable activity monitors seem a valid tool to assess fall risk remotely and thus allow low cost, frequent and large group screening of frail elderly towards a health economically viable tool for a growing societal need. The predictive quality of activity monitored data may be increased by deriving additional qualitative measures from the activity data

Aims. Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. Methods. We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results. A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion. Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65–70

The ATTUNE™ Knee System (DePuy Synthes) comprises of a tibial insert that is made from AOX™, an antioxidant-stabilized polyethylene. The antioxidant used in AOX is pentaerythritol tetrakis [3-(3, 5-di-tertiary butyl-4-hydroxyphenyl)] propionate (PBHP). A biological risk assessment of the degradation products arising from PBHP has been performed. This assessment focuses on the requirements of ISO 10993–1:2009, ISO 14971:2007, and the Medical Device Directive 93/42/EEC. Because the orthopedic implant is a permanent implant, consideration has been given to all relevant endpoints defined by ISO 10993–1 Biological evaluation of medical devices – Part 1: Evaluation and testing within a risk management process. Comprehensive biocompatibility testing including long-term (26 weeks) subcutaneous implantation has been conducted which confirms the biosafety of the polyethylene compound[1]. In addition to the biological safety testing completed, the overall safety and the associated toxicological risk of exposure to degradation products of PBHP has been given due consideration. The guidelines for the Threshold for Toxicological Concern (TTC) provided by The Product Quality Research Institute (PQRI) Leachables and Extractables Working Group were used in the assessment[2]. This working group is a collaboration of chemists and toxicologists from the U.S. Food and Drug Administration (FDA), industry, and academia. The TTC principle allows safety assessment in the absence of substance-specific hazard data, based on very low levels of exposure to that substance. A Margin of Safety (MOS) is calculated as the ratio of the threshold safety value to the actual exposure quantities determined and used in the assessment. A MOS value greater than 1 is typically judged by risk assessors and regulatory bodies to be unlikely to cause harm and the risk may be considered low. The identity of the degradation products as well as the corresponding 30-day leachable quantities from a water:acetone extraction media has been previously reported [3] and provided here (Table 1). The amount of leachables determined from Table 1 for all products were well below the TTC of 150 ng/device and hence no toxicological risks were identified for these compounds. In order to further examine the toxicological risk assessment, aggressive extraction using Dynamic Head Space (DHS) extraction was done and analytical testing was performed on the degradation products of PBHP using gas chromatography/mass spectrometry (GC /MS). These estimated quantities along with literature information from biological safety studies of the chemicals that were identified from the quantitative GC/MS analysis of degradation products of PBHP were used in the review and toxicological assessment per the methodology described in ISO 14971 and ISO 10993–18. The extraction and analysis confirmed the same sixteen compounds previously identified. The quantities and the calculated margins of safety are summarized (Table 2). In conclusion, upon review of actual test results of PBHP degradation products (Table 1), there is little probability that these organic degradation products would cause a systemic reaction and not be safe. Thus, the potential biological hazards identified in ISO 10993–1:2009 due to the quantified leachables have been verified to be minimal with a high Margin of Safety relative to the Threshold of Toxicological Concern

Aim: to determine the proportion of patients with fragility fractures who underwent risk assessment for osteoporosis as a result of their fracture clinic attendance prior to and following reinforcement of guidelines. Methods: The inclusion criteria were defined as: new patients fifty years of age or over sustaining a fragility fracture of their distal radius presenting during two three month periods in 2004 (April to June and October to December). Guidelines for osteoporosis risk assessment (the Northumberland guidelines) were reinforced during the interim period. Patients were identified from hospital records and the notes obtained to confirm the fracture type as fragility. The number assessed during each period was determined from outpatient referral for DEXA records and compared. Patients who had undergone DEXA scanning in the year prior to their fracture clinic attendance were excluded from the analysis. Results: from April to June there were forty-six patients (39 women and 7 men) with a mean age of 73 years while between October and December there were fifty-four patients (48 women and 6 men) with an average age of 68 years. In the April to June cohort 3 patients had already had a DEXA scan prior to fracture clinic attendance. Of the 43 remaining patients 3 were risk assessed for osteoporosis (7%). Within the October to December group two patients had previously undergone DEXA scanning and of the remaining 52 patients 16 (31%) underwent osteoporosis risk assessment. Conclusion: Risk assessment for osteoporosis is still carried out ineffectively by orthopaedic surgeons even following enforcement of guidelines

Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure. Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m. 2. . Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m. 2. in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma (p<0.0001). Despite this, there was no significant reduction in prescribing of LMWH in patients with renal failure with eGFR <30ml/min/1.73m. 2. , (P=0.52). Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding

Our aim was to judge the influence of preoperative psychological disturbance on the outcome of lumbar discectomy. We evaluated 66 patients, before and after operation, using a self-administered questionnaire. Disability was assessed using the Oswestry disability index and psychological disturbance the Distress and Risk Assessment Method (DRAM) score. Patients were classified as normal, at risk or distressed, and the outcome of surgery in the three groups was compared at a follow-up of six months. The mean self-reported preoperative disability was significantly higher in those with psychological disturbance. A total of 54 patients (82%) returned completed postoperative questionnaires. Postoperative disability scores at six months were not significantly different in the three risk groups. Psychological disturbance improved after surgery. Our study suggests that the early outcome of lumbar discectomy is not affected by preoperative psychological disturbance. We conclude that a patient with a symptomatic prolapsed intervertebral disc should not be denied surgery on the basis of preoperative psychological assessment

Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery. Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013. 62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r. s. = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r. s. = −0.64; p<0.001) and reduced echo SF (r. s. = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR. Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure

We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself. We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan. Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment. Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment

To explore a novel machine learning model to evaluate the vertebral fracture risk using Decision Tree model and train the model by Bone Mineral Density (BMD) of different compartments of vertebral body. We collected a Computed Tomography image dataset, including 10 patients with osteoporotic fracture and 10 patients without osteoporotic fracture. 40 non-fracture Vertebral bodies from T11 to L5 were segmented from 10 patients with osteoporotic fracture in the CT database and 53 non-fracture Vertebral bodies from T11 to L5 were segmented from 10 patients without osteoporotic fracture in the CT database. Based on the biomechanical properties, 93 vertebral bodies were further segmented into 11 compartments: eight trabecular bone, cortical shell, top and bottom endplate. BMD of these 11 compartments was calculated based on the HU value in CT images. Decision tree model was used to build fracture prediction model, and Support Vector Machine was built as a compared model. All BMD data was shuffled to a random order. 70% of data was used as training data, and 30% left was used as test data. Then, training prediction accuracy and testing prediction accuracy were calculated separately in the two models. The training accuracy of Decision Tree model is 100% and testing accuracy is 92.14% after trained by BMD data of 11 compartments of the vertebral body. The type I error is 7.14% and type II error is 0%. The training accuracy of Support Vector Machine model is 100% and the testing accuracy is 78.57%. The type I error is 17.86% and type II error is 3.57%. The performance of vertebral body fracture prediction using Decision Tree is significantly higher than using Support Vector Machine. The Decision Tree model is a potential risk assessment method for clinical application. The pilot evidence showed that Decision Tree prediction model overcomes the overfitting drawback of Support Vector Machine Model. However, larger dataset and cohort study should be conducted for further evidence

Introduction:. NICE guidelines state that every patient should be assessed for their VTE risk on admission to hospital. The aim of this study was to determine whether currently recommended risk assessment tools (Nygaard, Caprini, NICE and Plymouth) can correctly identify the patients at risk. Methods:. In a consecutive series of over 750 trauma patients treated with cast immobilisation 23 were found to have suffered a VTE. Their notes were retrospectively reviewed to discover how many had been assessed for their VTE risk on admission. Additionally, the 4 most current Risk Assessment Tools were used to retrospectively score the patients for their VTE risk to determine whether they would have been identified as at risk of sVTE, had the RAMs been used at the time. We also identified a matched group of patients in the same cohort who had not suffered a VTE and they were also retrospectively risk assessed. Results:. NICE (2010), Caprini (2001) and Nygaard (2009) identified 100% of the 750 patients as at risk of sVTE but had a specificity of 0% as only 23 went on to develop VTE. The Plymouth Score (2010) was more specific and identified 56.3% patients of the 23 confirmed VTEs as ‘at risk’. However it would not have recommended prophylaxis in the remaining 46.7 & that did in fact go on to developed VTE. Conclusion:. The tools used in this study have no clinical utility in this patient group. Detailed evaluation of the different RAMs is required in order to improve their discriminatory power. A reliance on NICE, Caprini and Nygaard tools would have required all 750 patients in this group to have been treated with thromboprophylaxis and therefore lacked sensitivity. However the Plymouth Score would have failed to recommend thromboprophylaxis in half of the patients who eventually developed VTE

Introduction. Reducing readmissions after total joint arthroplasty (TJA) is challenging. Pre-operative risk stratification and optimization pre surgical care may be helpful in reducing readmission rates after primary TJA. Assessment of the predictive value of individual modifiable risk factors without a tool to properly stratify patients may not be helpful to the surgical community to reduce the risk of readmission. We developed a scoring system: Readmission Risk Assessment Tool (RRAT) as part of a Perioperative Orthopaedic Surgical Home model that allows for risk stratification in patients undergoing elective primary TJA at our institution. We analyzed the relationship between the RRAT score and readmission following primary hip or knee arthroplasty. Methods. The RRAT, which is scored incrementally based on the number and severity of modifiable comorbidities was used to generate readmission scores for a cohort of 207 readmitted and 2 cohorts of 234 (random and age-matched) non-readmitted patients each. Regression analysis was performed to assess the strength of association between individual risk factors, RRAT score and readmissions. We also calculated the odds and odds ratio (OR) at each level of RRAT score to identify patients with relatively higher risk of readmission. Results. There were 207(2.08%) 30-day readmissions in 9,930 patients over a 6-year period (2008 to 2013). Surgical site infection was the most common cause of readmission (93 cases, 45%). The median RRAT scores were 3 (IQR: 1, 4) and 1 (IQR: 0, 2) for readmitted group and non-readmitted group respectively. The RRAT score was significantly associated with readmission with odds ratio between 1.5 and 1.9 under various model assumptions. A RRAT score of 3 or higher resulted in higher odds of readmission. Discussion and Conclusion. Population health management, cost-effective care and optimization of outcomes to maximize value are the new maxims for healthcare delivery in the United States. The RRAT has a significant association with readmission following joint arthroplasty and could potentially be a clinically meaningfully tool for risk mitigation

Aim

There is an ongoing controversy whether the observed benefit of infection risk reduction by ALBC outweighs the risk of possible antimicrobial resistance development.

Objectives: The view that patients low back pain presenting with ‘abnormal’ psychometric and poor DRAM scores predict an unsatisfactory surgical outcome is considered controversial. This prospective study was designed to identify if DRAM Scores (Scores of Distress Risk Assessment Method) is a predictive determinant or a reactive instrument in regard to the outcome of Endoscopic Foraminoplasty. Design: Pre- and postoperative assessment of disability and DRAM at two years. Subjects: One hundred and eighty-five patients (86 males and 99 females) underwent an Endoscopic Laser Foraminoplasty between April 1997 and November 1998. Outcome measures: Oswestry Disability Scale, and the Visual Analogue Pain Scale and the DRAM scores. Patients were categorised by their pre-op DRAM score. Kruskal-Wallis analysis of variance and a regression analysis were performed. Results: There was significant improvement in disability and pain scores at two years. (p< 0.05). A significant difference in median DRAM between the preoperative and postoperative score at two years was noted. Conclusion: The DRAM score highlights individuals in distress who may need psychological support and physical treatment for optimum benefit from endoscopic spinal intervention. While the DRAM score predicted the patients’ disability and pain it failed to predict percentage benefit gain in outcome

The view that patients low back pain presenting with ‘abnormal’ psychometric and poor DRAM scores predict an unsatisfactory surgical outcome is considered controversial. This prospective study was designed to identify if DRAM Scores (Scores of Distress Risk Assessment Method) is a predictive determinant or a reactive instrument in regard to the outcome of Endoscopic Foraminoplasty. One hundred and eighty-five patients (86 males and 99 females) underwent an Endoscopic Laser Foraminoplasty between April 1997 and November 1998. Pre- and postoperative assessment at 2 years was made using the Oswestry Disability Scale, and the Visual Analogue Pain Scale and the DRAM scores. Patients were categorised by their pre-op DRAM score. A Kruskal-Wallis analysis of variance and a regression analysis were performed. There was significant improvement in disability and pain scores at two years. (p< 0.05). A significant difference in median DRAM between the preoperative and postoperative score at two years was noted. While the DRAM score predicted the patients’ disability and pain it failed to predict the change in outcome. The DRAM score highlights individuals in distress who may need psychological support and physical treatment for optimum benefit from endoscopic spinal intervention and not be used to deny a surgical intervention

We invited 1604 randomly selected women, all 75 years of age, to participate in a study on the risk factors for fracture. The women were divided into three groups consisting of 1044 (65%) who attended the complete study, 308 (19%) respondents to the study questionnaire only and 252 (16%) who did not respond. The occurrence of the life-time fracture was ascertained from radiological records in all groups and by questionnaires from the attendees and respondents.

According to the radiological records, fewer of the questionnaire respondents (88 of 308, 28.6%) and non-respondents (68 of 252, 27%) had sustained at least one fracture when compared with the attendees (435 of 1044, 41.7%; chi-squared test, p < 0.001). According to the questionnaire, fewer of the respondents (96 of 308, 31.1%) had sustained at least one previous fracture when compared with the attendees (457 of 1044, 43.7%; chi-squared test, p < 0.001).

Any study concerning the risk of fracture may attract those with experience of a fracture which explains the higher previous life-time incidence among the attendees. This factor may cause bias in epidemiological studies.

Background and objectives

The prevention of osteoporotic fractures is a global problem. Key to this strategy is efficient identification of ‘at risk’ patients in order to address the osteoporosis pandemic, including the identification of previously sustained fractures. GP practices are now integrating touch screens as a method of registering patients' attendance for an appointment, so all ages of patients are becoming familiar with this channel of communication. Our touch screen patient administered questionnaire system intends to provide an effective solution.

Aims: The purpose of the study is to evaluate the risk of fractures in long bones with metastases based on intact cortical bone index (ICBI) and functional assessment. Methods: We evaluate radiograms of 36 (25 fractures) and 86 patients (56 fractures) with the upper and lower extremity metastases, respectively. We measured on radiograms intact cortical bone index (ICBI) using the schedule K-G/K-J x100%, where is K-shaft diameter, G-size of destruction, J-bone marrow diameter above or below the metastases. We asses the extremity function by the ability to elevate and abduct it straight. Results: We found that fracture occurs if the ICBI is lower than 46% and 40% in upper and lower extremity, respectively. 7 (5,7%) patients develop fracture despite higher ICBI. If the metastases are located in upper part of the femur and humerus and he/she can not elevate or abduct the extremity the fracture inevitably occurs. Conclusions: Counting the ICBI and simple functional assessment allows to predict fracture in 94,3% of patients with long bone metastases.