Aims

The aim of the LightFix Trial was to evaluate the clinical outcomes for one year after the treatment of impending and completed pathological fractures of the humerus using the IlluminOss System (IS), and to analyze the performance of this device.

Aims. This study aimed to determine clinical outcomes; relationships between postoperative anterior, lateral, and posterior acetabular coverage and joint survival; and prognostic factors for joint survival after transposition osteotomy of the acetabulum (TOA). Methods. Data from 616 patients (800 hips) with hip dysplasia who underwent TOA between November 1998 and December 2019 were reviewed. The median follow-up period was 8.9 years (IQR 5 to 14). A medical notes review was conducted to collect demographic data, complications, and modified Harris Hip Score (mHHS). Radiological indicators of acetabular coverage included lateral centre-edge angle (LCEA), anterior wall index (AWI), and posterior wall index (PWI). The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors for failure. Results. Median mHHS improved from 68 preoperatively to 96 at the latest follow-up (p < 0.001). The overall joint survival rate was 97% at ten years and 70% at 20 years. For the postoperative LCEA subgroups, survival in the deficient group was lower than that in the excessive (p = 0.006) and normal (p = 0.007) groups. For the postoperative AWI subgroups, survival in the deficient group was lower than that in the excessive (p = 0.015) and normal (p < 0.001) groups. Multivariate analysis identified age (p = 0.010), Tönnis grade 2 (p < 0.001), roundness index (p = 0.003), fair joint congruity (p = 0.004), and postoperative AWI (p = 0.002) as independent risk factors. Conclusion. Deficient postoperative AWI adversely affected joint survival after TOA, underscoring the importance of sufficient anterior acetabular coverage, along with precise surgical indications, to ensure successful hip joint preservation in the treatment of hip dysplasia. Cite this article: Bone Joint J 2024;106-B(12):1399–1407

Aims. Surgeon and patient reluctance to participate are potential significant barriers to conducting placebo-controlled trials of orthopaedic surgery. Understanding the preferences of orthopaedic surgeons and patients regarding the design of randomized placebo-controlled trials (RCT-Ps) of knee procedures can help to identify what RCT-P features will lead to the greatest participation. This information could inform future trial designs and feasibility assessments. Methods. This study used two discrete choice experiments (DCEs) to determine which features of RCT-Ps of knee procedures influence surgeon and patient participation. A mixed-methods approach informed the DCE development. The DCEs were analyzed with a baseline category multinomial logit model. Results. The proportion of respondents (surgeons n = 103; patients n = 140) who would not participate in any of the DCE choice sets (surgeons = 31%; patients = 40%), and the proportion who would participate in all (surgeons = 18%; patients = 30%), indicated strong views regarding the conduct of RCT-Ps. There were three main findings: for both surgeons and patients, studies which involved an arthroscopic procedure were more likely to result in participation than those with a total knee arthroplasty; as the age (for patients) and years of experience (for surgeons) increased, the overall likelihood of participation decreased; and, for surgeons, offering authorship and input into the RCT-P design was preferred for less experienced surgeons, while only completing the procedure was preferred by more experienced surgeons. Conclusion. Patients and surgeons have strong views regarding participation in RCT-Ps. However, understanding their preferences can inform future trial designs and feasibility assessments with regard to recruitment rates. Cite this article: Bone Joint J 2024;106-B(12):1408–1415

Aims

Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR).

In the UK, multidisciplinary teamwork for patients with hip fracture has been shown to reduce mortality and improves health-related quality of life for patients, while also reducing hospital bed days and associated healthcare costs. However, despite rapidly increasing numbers of fragility fractures, multidisciplinary shared care is rare in low- and middle-income countries around the world. The HIPCARE trial will test the introduction of multidisciplinary care pathways in five low- and middle-income countries in South and Southeast Asia, with the aim to improve patients’ quality of life and reduce healthcare costs.

Cite this article: Bone Joint J 2024;106-B(12):1369–1371.

Aims. Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee. Methods. Patients with C. acnes PJI between January 2005 and December 2018 were retrospectively reviewed utilizing the institutional total joint registry. Patients with monomicrobial PJI and two or more positive cultures were considered to have true C. acnes PJI. Patients with polymicrobial infection or with only one positive culture were excluded. This resulted in 35 PJIs (21 hips and 14 knees); the patients’ mean age was 63 years (35 to 84) and 15 (43%) were female. Mean follow-up was five years (1 to 14). Results. The median time to positive culture was five days (IQR 5 to 6) and median synovial fluid cell count was 22,583 cells (IQR 15,200 to 53,231). The median ESR was 25 mm/hr (IQR 7 to 37), and CRP was 15 mg/l (IQR 3 to 29). Of the 35 PJIs, 18 (51%) were treated with chronic antibiotic suppression without surgical intervention, and the remainder were treated with two-stage exchange arthroplasty. The two-year survival free of any revision was 94%. Four patients failed treatment due to symptomatic infection, with three treated with two-stage exchange and one treated with irrigation and debridement with modular component exchange for a survival rate of 89% and 83% at two and five years, respectively. Conclusion. Laboratory evidence of C. acnes PJI in this cohort was typical compared to more conventional organisms. Cultures grew more quickly than previously thought in patients with C. acnes PJI. Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up. Cite this article: Bone Joint J 2024;106-B(12):1426–1430

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

Hip fractures pose a major global health challenge, leading to high rates of morbidity and mortality, particularly among the elderly. With an ageing population, the incidence of these injuries is rising, exerting significant pressure on healthcare systems worldwide. Despite substantial research aimed at establishing best practice, several key areas remain the subject of ongoing debate. This article examines the latest evidence on the place of arthroplasty in the surgical treatment of hip fractures, with a particular focus on the choice of implant, the use of cemented versus uncemented fixation, and advances in perioperative care. Cite this article: Bone Joint J 2024;106-B(12):1372–1376

Aims

Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery.

Aims. A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness. Methods. Clinical data from a multicentre database identified patients who underwent primary aTSA from November 2004 to January 2023. A total of 390 patients (mean follow-up 48.1 months (SD 42.0)) were included: 97 (24.9%) were classified as appropriate, 218 (55.9%) inconclusive, and 75 (19.2%) inappropriate. Patients were classified as “appropriate”, “inconclusive”, or “inappropriate”, using a modified version of an appropriateness algorithm, which accounted for age, rotator cuff status, mobility, symptomatology, and Walch classification. Multiple pre- and postoperative scores were analyzed using Pearson’s chi-squared test and one-way analysis of variance (ANOVA). Postoperative complications were also analyzed. Results. All groups achieved significant improvement in mean PROM scores postoperatively. “Appropriate” patients experienced significantly greater improvement in visual analogue scale (VAS) and American Shoulder and Elbow Surgeons (ASES) score compared to “inconclusive” and “inappropriate”. The appropriate group had a significantly greater proportion of patients who achieved minimal clinically important difference (MCID) (95.8%; n = 93) and substantial clinical benefit (SCB) (92.6%; n = 89). Overall, 13 patients had postoperative complications. No significant differences in postoperative complications among classifications were found. Conclusion. Our data clinically validate the RAND/UCLA aTSA appropriateness criteria algorithm, allowing for more rapid and reliable determination of aTSA candidacy. “Appropriate” patients were more likely to achieve MCID and SCB for ASES scores compared to “inappropriate” patients. Among “appropriate” patients who did not achieve SCB, 50% (n = 4) had a postoperative complication. There was a significantly higher proportion of postoperative complications among those who did not achieve SCB across all three groups. Only 7.1% (n = 1) of patients who did not achieve SCB in the inappropriate group had a postoperative complication. Thus, it can be inferred that the failure to reach SCB in the appropriate group was likely to be due to a postoperative complication, whereas for patients deemed “inappropriate”, failure to reach SCB may be secondary to factors accounted for within our algorithm. Cite this article: Bone Joint J 2024;106-B(12):1451–1460

Aims

Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.

As advancements in total knee arthroplasty progress at an exciting pace, two areas are of special interest, as they directly impact implant design and surgical decision making. Knee morphometry considers the three-dimensional shape of the articulating surfaces within the knee joint, and knee phenotyping provides the ability to categorize alignment into practical groupings that can be used in both clinical and research settings. This annotation discusses the details of these concepts, and the ways in which they are helping us better understand the individual subtleties of each patient’s knee.

Cite this article: Bone Joint J 2024;106-B(12):1363–1368.

Aims. There has been limited literature regarding outcomes of acetabular rim syndrome (ARS) with persistent acetabular os in the setting of acetabular dysplasia. The purpose of this study was to characterize a cohort of adolescent and young adult patients with ARS with persistent os and compare their radiological and clinical outcomes to patients with acetabular dysplasia without an os. Methods. We reviewed a prospective database of patients undergoing periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia between January 1999 and December 2021 to identify hips with preoperative os acetabuli, defined as a closed triradiate cartilage but persistence of a superolateral os acetabulum. A total of 14 hips in 12 patients with persistent os acetabuli (ARS cohort) were compared to 50 randomly selected ‘control’ hips without persistent os acetabuli. Preoperative and postoperative radiographs were measured for markers of dysplasia: lateral centre-edge angle, anterior centre-edge angle, acetabular inclination, and migration index. Union of the os was determined in patients with ≥ six months’ follow-up. Patient-reported outcome measures (PROMs) included the University of California, Los Angeles (UCLA) activity score and modified Harris Hip Score (mHHS, maximum score 80) completed at one year postoperatively. Results. There was no significant difference between the ARS and control cohorts with regard to sex distribution (p = 0.270), age at surgery (p = 0.186), or BMI (p = 0.442). Preoperatively, the ARS cohort had more severe dysplasia, including lower lateral centre-edge angle (-9.3° (SD 12.5°) vs 7.6° (SD 10.7°); p < 0.001) and greater acetabular inclination (33.9° (SD 8.2°) vs 21.8° (SD 8.7°); p < 0.001). Postoperatively, 6/13 (46%) hips with ≥ six months of radiological follow up demonstrated union of the os. There was no difference between the ARS and control cohorts at one year in UCLA score (9.1 (SD 1.5) vs 8.2 (SD 1.9); p = 0.167) or mHHS (73.4 (SD 9.5) vs 69.9 (SD 8.8); p = 0.312). Conclusion. ARS with persistent acetabular os may occur in more severe dysplasia. Union occurs in 50% cases following corrective PAO. Cite this article: Bone Joint J 2024;106-B(12):1393–1398

Aims. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects. Methods. A retrospective review was performed of all patients who underwent combined single-stage orthoplastic treatment of calcaneal osteomyelitis (01/2008 to 12/2022). Primary outcome measures were osteomyelitis recurrence and below-knee amputation (BKA). Secondary outcome measures included flap failure, operating time, complications, and length of stay. Results. A total of 30 patients (14 female, 16 male; mean age 53.7 years (95% CI 48.0 to 59.5)) underwent combined orthoplastic surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (IQR 11.75 to 49.25). Of these, 19 received a local flap and 11 received a free flap. The most common causes were fracture-related infection (n = 12; 40%) and ulceration (n = 10; 33%); 21 patients (70%) had already undergone at least one operation elsewhere. Osteomyelitis was eradicated in 23 patients (77%). There were seven patients who developed recurrent osteomyelitis (23%), all in the local flap group. One patient required a BKA. Univariate analysis revealed that local flap reconstruction (OR 13.5 (95% CI 0.7 to 269.7); p = 0.029) and peripheral vascular disease (OR 16.5 (95% CI 1.35 to 203.1); p = 0.008) were associated with increased risk of recurrence. Free flap reconstruction took significantly longer intraoperatively than local flaps (mean 481 minutes (408 to 554) vs mean 168 minutes (119 to 216); p < 0.001), but without significant differences in length of stay or frequency of outpatient appointments. Conclusion. In our study involving 30 patients, single-stage orthoplastic management was associated with 77% (n = 23) eradication of infection and only one amputation in this complex and comorbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. While good outcomes can be achieved, this treatment requires high levels of inpatient and outpatient care. Cite this article: Bone Joint J 2024;106-B(12):1443–1450

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

Aims

We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients.

Aims. Reconstruction after osteoarticular resection of the proximal ulna for tumours is technically difficult and little has been written about the options that are available. We report a series of four patients who underwent radial neck to humeral trochlea transposition arthroplasty following proximal ulnar osteoarticular resection. Methods. Between July 2020 and July 2022, four patients with primary bone tumours of the ulna underwent radial neck to humeral trochlea transposition arthroplasty. Their mean age was 28 years (12 to 41). The functional outcome was assessed using the range of motion (ROM) of the elbow, rotation of the forearm and stability of the elbow, the Musculoskeletal Tumor Society score (MSTS), and the nine-item abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH-9) score. Results. All patients were available for follow-up at a mean of 33 months (25 to 43) and were disease-free. The mean flexion arc was 0° to 105°. Three patients had complications. One had neuropraxia of the ulnar nerve. The symptoms resolved after three months. In one patient, the screw used for fixation of the triceps tendon became exposed and was removed, six months postoperatively. One patient with wound dehiscence required a local flap for soft-tissue cover, four months postoperatively. At a mean follow-up of 33 months (25 to 43), the mean flexion arc was 0° to 105°. All patients had full supination (85°) but none had any pronation. The mean MSTS score was 23.5 (23 to 24) and mean QuickDASH-9 score was 26.13 (16.5 to 35.75). Three patients had varus-valgus instability on examination, although only one had a sense of instability while working. Conclusion. Radial neck to humeral trochlea transposition offers a satisfactory and cost-effective biological reconstructive option after osteoarticular resection of the proximal ulna, in the short term. It provides good elbow function and, being a biological reconstruction option using native bone, is likely to provide long-term stability and durability. Cite this article: Bone Joint J 2024;106-B(11):1301–1305

Aims. Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE. Methods. This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE. Results. A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade. Conclusion. The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade. Cite this article: Bone Joint J 2024;106-B(11):1249–1256

Aims

A review of the literature on elbow replacement found no consistency in the clinical outcome measures which are used to assess the effectiveness of interventions. The aim of this study was to define core outcome domains for elbow replacement.

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.