Aims. The objective of this study was to compare the two-year migration and clinical outcomes of a new cementless hydroxyapatite (HA)-coated titanium acetabular shell with its previous version, which shared the same geometrical design but a different manufacturing process for applying the titanium surface. Methods. Overall, 87 patients undergoing total hip arthroplasty (THA) were randomized to either a Trident II HA or Trident HA shell, each cementless with clusterholes and HA-coating. All components were used in combination with a cemented Exeter V40 femoral stem. Implant migration was measured using radiostereometric analysis (RSA), with radiographs taken within two days of surgery (baseline), and at three, 12, and 24 months postoperatively. Proximal acetabular component migration was the primary outcome measure. Clinical scores and patient-reported outcome measures (PROMs) were collected at each follow-up. Results. Mean proximal migrations at three, 12, and 24 months were 0.08 mm (95% confidence interval (CI) 0.03 to 0.14), 0.11 mm (95% CI 0.06 to 0.16), and 0.14 mm (95% CI 0.09 to 0.20), respectively, in the Trident II HA group, versus 0.11 mm (95% CI 0.06 to 0.16), 0.12 mm (95% CI 0.07 to 0.17), and 0.14 mm (95% CI 0.09 to 0.19) in the Trident HA group (p = 0.875). No significant differences in translations or rotations between the two designs were found in any other direction. Clinical scores and PROMs were comparable between groups, except for an initially greater postoperative improvement in Hip disability and Osteoarthritis Outcome Symptoms score in the Trident HA group (p = 0.033). Conclusion. The Trident II clusterhole HA shell has comparable migration with its predecessor, the Trident hemispherical HA cluster shell, suggesting a similar risk of long-term aseptic loosening. Cite this article: Bone Joint J 2024;106-B(2):136–143

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The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair.

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

Aims. For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis. Methods. We reviewed 15 patients over a five-year period (January 2017 to December 2022) who had undergone extra-articular resection of the hip joint due to malignant tumour using a custom-made osteotomy guide and 3D-printed endoprosthesis. Each of the 15 patients had a single lesion, with six originating from the acetabulum side and nine from the proximal femur. All patients had their posterior column preserved according to the surgical plan. Results. Postoperative pathological assessment revealed a negative surgical margin was achieved in all patients. At final follow-up, 13.3% (2/15) died and no recurrence occurred. The overall survival was 81.7% at five years. None of the patients showed any signs of aseptic loosening, and no wound healing issues were observed. In total, 20% (3/15) developed complications, with two cases of early hip dislocation and one case of deep infection. The cumulative incidence of mechanical and non-mechanical failure in this series was 13.7% and 9.3%, respectively, at five years. In this cohort, the mean time to full weightbearing was 5.89 (SD 0.92) weeks and the mean Musculoskeletal Tumor Society score was 24.1 (SD 4.4). Conclusion. For patients with a hip joint tumour who met the inclusion criteria and were deemed suitable for posterior column preservation, a custom-made osteotomy guide combined with 3D-printed endoprosthesis is worth performing when treating patients who require extra-articular resection of the hip joint, as it can achieve adequate margin for local control, maximize bone preservation to maintain pelvic ring integrity, reduce the risk of complications by simplifying the surgical procedure, and allow for more precise reconstruction for better function. Cite this article: Bone Jt Open 2024;5(11):1027–1036

Aims. There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome. Patients and Methods. We retrospectively reviewed 29 patients (17 women, 12 men) from our total joint registry who had undergone 31 cemented TKAs after a DFO between 2000 and 2012. Their mean age at TKA was 51 years (22 to 76) and their mean body mass index 32 kg/m. 2. (20 to 45). The mean time between DFO and TKA was ten years (2 to 20). The mean follow-up from TKA was ten years (2 to 16). The prostheses were posterior-stabilized in 77%, varus-valgus constraint (VVC) in 13%, and cruciate-retaining in 10%. While no patient had metaphyseal fixation (e.g. cones or sleeves), 16% needed a femoral stem. Results. The ten-year survivorship was 95% with aseptic loosening as the endpoint, 88% with revision for any reason as the endpoint, and 81% with re-operation for any reason as the endpoint. Three TKAs were revised for instability (n = 2) and aseptic tibial loosening (n = 1). No femoral component was revised for aseptic loosening. Patients under the age of 50 years were at greater risk of revision for any reason (hazard ratio 7; p = 0.03). There were two additional re-operations (6%) and four complications (13%), including three manipulations under anaesthetic (MUA; 10%). The Knee Society scores improved from a mean of 50 preoperatively (32 to 68) to a mean of 93 postoperatively (76 to 100; p < 0.001). Conclusion. A cemented posterior-stabilized TKA has an 88% ten-year survivorship with revision for any reason as the endpoint. No femoral component was revised for aseptic loosening. Patients under the age of 50 years have a greater risk of revision. The clinical outcome was significantly improved but balancing the knee was challenging in 13% of TKAs requiring VVC. Overall, 10% of TKAs needed an MUA, and 6% of TKAs were revised for instability. Cite this article: Bone Joint J 2019;101-B:660–666

Aims. The purpose of this multicentre observational study was to investigate the association between intraoperative component positioning and soft-tissue balancing on short-term clinical outcomes in patients undergoing robotic-arm assisted unicompartmental knee arthroplasty (UKA). Patients and Methods. Between 2013 and 2016, 363 patients (395 knees) underwent robotic-arm assisted UKAs at two centres. Pre- and postoperatively, patients were administered Knee Injury and Osteoarthritis Score (KOOS) and Forgotten Joint Score-12 (FJS-12). Results were stratified as “good” and “bad” if KOOS/FJS-12 were more than or equal to 80. Intraoperative, post-implantation robotic data relative to CT-based components placement were collected and classified. Postoperative complications were recorded. Results. Following exclusions and losses to follow-up, 334 medial robotic-arm assisted UKAs were assessed at a mean follow-up of 30.0 months (8.0 to 54.9). None of the measured parameters were associated with overall KOOS outcome. Correlations were described between specific KOOS subscales and intraoperative, post-implantation robotic data, and between FJS-12 and femoral component sagittal alignment. Three UKAs were revised, resulting in 99.0% survival at two years (95% confidence interval (CI) 97.9 to 100.0). Conclusion. Although little correlation was found between intraoperative robotic data and overall clinical outcome, surgeons should consider information regarding 3D component placement and soft-tissue balancing to improve patient satisfaction. Reproducible and precise placement of components has been confirmed as essential for satisfactory clinical outcome. Cite this article: Bone Joint J 2019;101-B:435–442

Aims. The aim of this study was to assess the influence of obesity on the clinical outcomes and survivorship ten years postoperatively in patients who underwent a fixed-bearing unicompartmental knee arthroplasty (UKA). Patients and Methods. We prospectively followed 184 patients who underwent UKA between 2003 and 2007 for a minimum of ten years. A total of 142 patients with preoperative body mass index (BMI) of < 30 kg/m. 2. were in the control group (32 male, 110 female) and 42 patients with BMI of ≥ 30 kg/m. 2. were in the obese group (five male, 37 female). Pre- and postoperative range of movement (ROM), Knee Society Score (KSS), Oxford Knee Score (OKS), 36-Item Short-Form Health Survey (SF-36), and survivorship were analyzed. Results. Patients in the obese group underwent UKA at a significantly younger mean age (56.5 years (. sd. 6.4)) than those in the control group (62.4 years (. sd. 7.8); p < 0.001). There was no significant difference in preoperative functional scores. However, those in the obese group had a significantly lower ROM (116° (. sd. 15°) vs 123° (. sd. 17°); p = 0.003). Both groups achieved significant improvement in outcome scores regardless of BMI, ten years postoperatively. All patients achieved the minimal clinically important difference (MCID) for OKS and KSS. Both groups also had high rates of satisfaction (96.3% in the control group and 97.5% in the obese group) and the fulfilment of expectations (94.9% in the control group and 95.0% in the obese group). Multiple linear regression showed a clear association between obesity and a lower OKS two years postoperatively and Knee Society Function Score (KSFS) ten years postoperatively. After applying propensity matching, obese patients had a significantly lower KSFS, OKS, and physical component score (PCS) ten years postoperatively. Seven patients underwent revision to total knee arthroplasty (TKA), two in the control group and five in the obese group, resulting in a mean rate of survival at ten years of 98.6% and 88.1%, respectively (p = 0.012). Conclusion. Both groups had significant improvements in functional and quality-of-life scores postoperatively. However, obesity was a significant predictor of poorer improvement in clinical outcome and an increased rate of revision ten years postoperatively

Aims. Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Methods. The study included 42 consecutive hips in 42 patients (three male and 39 female) who underwent PAO from May 2016 to July 2018. We prospectively evaluated the incidence of LFCN injury at ten days, three months, six months, and one year postoperatively. We also evaluated the clinical scores, including the HHS, SF-36, and JHEQ scores, at one year postoperatively. Results. LFCN injury was observed in 31 of 42 (74%) patients at ten days, of which 11 resolved completely by one year. Incidence decreased gradually, to 25 of 42 (60%) patients at three months, 24 of 42 patients (57%) at six months, and 20 of 42 (48%) patients at one year postoperatively. There was no significant difference in the HHS between patients with and without LFCN injury at one year postoperatively. Regarding the SF-36 and JHEQ, a significant difference in the mental score was recognized between patients with and without LFCN injury, but there were no significant differences in the other clinical scores. Conclusion. The incidence of LFCN injury was 74% at ten days after PAO, and subsequently decreased to 48% at one year. LFCN injury did not influence the hip function as assessed by the HHS, but had a negative impact on mental health at one year. Cite this article: Bone Joint J 2021;103-B(4):659–664

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The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

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Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

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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.

We have investigated whether shape of the knee can predict the clinical outcome of patients after an anterior cruciate ligament rupture. We used statistical shape modelling to measure the shape of the knee joint of 182 prospectively followed patients on lateral and Rosenberg view radiographs of the knee after a rupture of the anterior cruciate ligament. Subsequently, we associated knee shape with the International Knee Documentation Committee subjective score at two years follow-up. The mean age of patients was 31 years (21 to 51), the majority were male (n = 121) and treated operatively (n = 135). We found two modes (shape variations) that were significantly associated with the subjective score at two years: one for the operatively treated group (p = 0.002) and one for the non-operatively treated group (p = 0.003). Operatively treated patients who had higher subjective scores had a smaller intercondylar notch and a smaller width of the intercondylar eminence. Non-operatively treated patients who scored higher on the subjective score had a more pyramidal intercondylar notch as opposed to one that was more dome-shaped. We conclude that the shape of the femoral notch and the intercondylar eminence is predictive of clinical outcome two years after a rupture of the anterior cruciate ligament. Cite this article: Bone Joint J 2014;96-B:737–42

Aims. Responsiveness and ceiling effects are key properties of an outcome score. No such data have been reported for the original English version of the International Hip Outcome Tool 12 (iHOT-12) at a follow-up of more than four months. The aim of this study was to identify the responsiveness and ceiling effects of the English version iHOT-12 in a series of patients undergoing hip arthroscopy for intra-articular hip pathology at a minimum of one year postoperatively. Methods. A total of 171 consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement (FAI) under the care of a single surgeon between January 2013 and March 2017 were included. iHOT-12 and EuroQol 5D-5L (EQ-5D-5L) scores were available pre- and postoperatively. Effect size and ceiling effects for the iHOT-12 were calculated with subgroup analysis. Results. A total of 122 patients (71.3%) completed postoperative PROMs scores with median follow-up of 24.3 months (interquartile range (IQR) 17.2 to 33.5). The median total cohort iHOT-12 score improved significantly from 31.0 (IQR 20 to 58) preoperatively to 72.5 (IQR 47 to 90) postoperatively (p < 0.001). The effect size (Cohen’s d) was 1.59. In all, 33 patients (27%) scored within ten points (10%) of the maximum score and 38 patients (31.1%) scored within the previously reported minimal clinically important difference (MCID) of the maximum score. Furthermore, nine (47%) male patients aged < 30 years scored within 10% of the maximum score and ten (53%) scored within the previously reported MCID of the maximum score. Conclusion. There is a previously unreported ceiling effect of the iHOT-12 at a minimum one-year follow-up which is particularly marked in young, male patients following hip arthroscopy for FAI. This tool may not have the maximum measurement required to capture the true outcome following this procedure. Cite this article: Bone Joint J 2020;102-B(8):1010–1015

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. . Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects. Cite this article: Bone Joint J 2014;96-B:1478–84

This study aimed to determine the correlation between the amount of maximum flexion and the clinical outcome in 207 Koreans (333 knees) undergoing total knee replacement. The association of maximum flexion with clinical outcome was evaluated one year postoperatively using three scoring systems; the American Knee Society score, Western Ontario McMaster Universities Osteoarthritis index and the Short Form-36. The mean maximum flexion decreased post-operatively at 12 months from 140.1° (60° to 160°) to 133.0° (105° to 150°). Only the social function score of the Short Form-36 correlated significantly with maximum flexion (correlation coefficient = 0.180, p = 0.039). In comparative analyses of subgroups divided by a maximum flexion of 120°, we found no significant differences in any parameters except the social function score of the Short Form-36 (41.9 vs 47.3, p = 0.031). Knees with a maximum flexion of more than 135° had a better functional Western Ontario McMasters Universities Osteoarthritis index score than knees with maximum flexion of 135° or less (17.5 vs 14.3, p = 0.031). We found only weak correlation between the postoperative maximum flexion and the clinical parameters for pain relief, function and quality of life, even in Korean patients. Efforts to increase post-operative maximum flexion should be exercised with caution until concerns relating to high-flexion activities are sufficiently resolved

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There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Aims. Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. Methods. A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. Results. From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. Conclusion. For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160–6

We report the clinical outcome and findings at second-look arthroscopy of 216 patients (mean age 25 years (11 to 58)) who underwent anterior cruciate ligament (ACL) reconstruction or augmentation. There were 73 single-bundle ACL augmentations (44 female, 29 male), 82 double-bundle ACL reconstructions (35 female, 47 male), and 61 single-bundle ACL reconstructions (34 female, 27 male). In 94 of the 216 patients, proprioceptive function of the knee was evaluated before and 12 months after surgery using the threshold to detect passive motion test. Second-look arthroscopy showed significantly better synovial coverage of the graft in the augmentation group (good: 60 (82%), fair: 10 (14%), poor: 3 (4%)) than in the other groups (p = 0.039). The mean side-to-side difference measured with a KT-2000 arthrometer was 0.4 mm (-3.3 to 2.9) in the augmentation group, 0.9 mm (-3.2 to 3.5) in the double-bundle group, and 1.3 mm (-2.7 to 3.9) in the single-bundle group: the result differed significantly between the augmentation and single-bundle groups (p = 0 .013). No significant difference in the Lysholm score or pivot-shift test was seen between the three groups (p = 0.09 and 0.65, respectively). In patients with good synovial coverage, three of the four measurements used revealed significant improvement in proprioceptive function (p = 0.177, 0.020, 0.034, and 0.026). We conclude that ACL augmentation is a reasonable treatment option for patients with favourable ACL remnants. Cite this article: Bone Joint J 2014;96-B:1325–32

Aims. We wished to compare the clinical outcome, as assessed by questionnaires and the rate of complications, in total knee arthroplasty (TKA) undertaken with patient-matched positioning guides (PMPGs) or conventional instruments. Patients and Methods. A total of 180 patients (74 men, 106 women; mean age 67 years) were included in a multicentre, adequately powered, double-blind, randomised controlled trial. The mean follow-up was 44 months (24 to 57). Results. There were no significant or clinically relevant differences between the two groups for all outcome measures (Knee Society Score, p = 0.807; Oxford Knee Score, p = 0.304; Western Ontario and McMaster osteoarthritis index, p = 0.753; visual analogue scale for pain, p = 0.227; EuroQol-5D-3L index score, p = 0.610; EuroQol-5D-3L VAS health, p = 0.968.) There was no difference in the rate of complications (p = 0.291). . Conclusion. PMPGs are already in relatively common use and their short-term clinical results are equal to conventional instrumented TKA. Cite this article: Bone Joint J 2016;98-B:939–44

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This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA.