Aims. Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children. Methods. In this retrospective cohort study, ultrasound and radiograph examinations were performed every two weeks in 30 paediatric patients undergoing limb lengthening. Ultrasound was used to monitor new bone formation. The number of vertical vessels and the blood flow resistance index were compared with those from plain radiographs. Results. We categorized the new bone formation into three stages: stage I (early lengthening), in which there was no obvious callus formation on radiographs and ultrasound; stage II (lengthening), in which radiographs showed low-density callus formation with uneven distribution and three sub-stages could be identified on ultrasound: in Ia punctate callus was visible; in IIb there was linear callus formation which was not yet connected and in IIc there was continuous linear callus. In stage III (healing), the bone ends had united, the periosteum was intact, and the callus had disappeared, as confirmed on radiographs, indicating healed bone. A progressive increase in the number of vertical vessels was noted in the early stages, peaking during stages IIb and IIc, followed by a gradual decline (p < 0.001). Delayed healing involved patients with a prolonged stage IIa or those who regressed to stage IIa from stages IIb or IIc during lengthening. Conclusion. We found that the formation of new bone in paediatric patients undergoing limb lengthening could be reliably evaluated using ultrasound when combined with the radiological findings. This combination enabled an improved assessment of the prognosis, and adjustments to the lengthening protocol. While SMI offered additional insights into angiogenesis within the new bone, its role primarily contributed to the understanding of the microvascular environment rather than directly informing adjustments of treatment. Cite this article: Bone Joint J 2024;106-B(7):751–758

Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Aims. The aim of this study was to explore differences in operative autonomy by trainee gender during orthopaedic training in Ireland and the UK, and to explore differences in operative autonomy by trainee gender with regard to training year, case complexity, index procedures, and speciality area. Methods. This retrospective cohort study examined all operations recorded by orthopaedic trainees in Ireland and the UK between July 2012 and July 2022. The primary outcome was operative autonomy, which was defined as the trainee performing the case without the supervising trainer scrubbed. Results. A total of 3,533,223 operations were included for analysis. Overall, male trainees performed 5% more operations with autonomy than female trainees (30.5% vs 25.5%; 95% CI 4.85 to 5.09). Female trainees assisted for 3% more operations (35% vs 32%; 95% CI 2.91 to 3.17) and performed 2% more operations with a supervising trainer scrubbed (39% vs 37%; 95% CI 1.79 to 2.06). Male trainees performed more operations with autonomy than female trainees in every year of training, in each category of case complexity, for each orthopaedic speciality area, and for every index procedure except nerve decompression. When adjusting for year, training level, case complexity, speciality area, and urgency, male trainees had 145% (95% CI 2.18 to 2.76) increased odds of performing an operation with autonomy and 35% (95% CI 1.25 to 1.45) increased odds of performing an operation under trainer supervision, than assisting, compared to female trainees. Conclusion. Male trainees perform more operations with autonomy during orthopaedic training than female trainees. Female orthopaedic trainees assist for a greater proportion of cases than their male counterparts. A comprehensive review of trauma and orthopaedic training is needed to identify any additional differences in training opportunities between female and male trainees, particularly with regard to progression through training. Cite this article: Bone Jt Open 2025;6(1):62–73

Aims. Paediatric pelvic ring fractures are rare but severe injuries, presenting significant treatment challenges. This study aimed to analyze patient characteristics and explore trends in incidence, treatment methods, and mortality associated with these injuries. Methods. This multicentre, retrospective cohort study analyzed paediatric patients (aged ≤ 18 years) with pelvic ring fractures treated between 2001 and 2021 at two level 1 trauma centres. Data on patient demographics, injury characteristics, treatment approaches, and outcomes were collected, and visual trend analysis was conducted to identify patterns. Results. A total of 157 patients with pelvic ring fractures were included. The median age was 15 years (IQR 12 to 17), with 52% (n = 81) being female. Traffic accidents were the leading cause of injury, accounting for 68% of cases (n = 106). Concomitant injuries were observed in 83% of patients (n = 131). The one-year mortality rate was 11.5%, with 76% of deaths occurring within 48 hours of admission, primarily due to traumatic brain injury (53%). Most patients (60%) were treated nonoperatively, while 48% of surgically treated patients underwent internal fixation without prior external fixation. Visual trend analysis revealed an increase in the absolute number of paediatric pelvic ring fractures over time, though no significant shift towards surgical treatment was observed. Among surgically treated patients, there was a trend towards open reduction and internal fixation rather than external fixation as definitive treatment. Nonoperative treatment was more common in children (69%) than in adolescents (55%). For surgical cases, external fixation was preferred in children (44%), while ORIF was more common in adolescents (53%). Conclusion. The incidence of paediatric pelvic ring fractures has increased over time, with a high mortality rate largely attributable to severe neurotrauma. There has been a shift towards surgical treatment without prior external fixation, with differences noted in the treatment approaches between children and adolescents, particularly in surgical fixation methods. Cite this article: Bone Jt Open 2025;6(3):254–263

Aims. Osseous invasion exhibited in soft-tissue sarcoma (STS) is recognized as a prognostic risk factor. Achieving a wide margin is the default surgical approach for local control. However, for STSs where the tumour is in contact with the adjacent cortex but without clear evidence of osseous invasion, such as medullary invasion, the question of whether bone resection can provide better local control or survival than more conservative sub-periosteal excision remains controversial. The aim of this study was to assess whether bone resection for thigh STS with cortical contact of the adjacent bone results in better local control and survival compared to sub-periosteal dissection, and to investigate the prognostic factors for clinical outcomes in STS. Methods. A retrospective cohort study was conducted on 142 patients with thigh STS exhibiting cortical contact but without medullary invasion, from May 2000 to May 2020. Patients underwent either composite bone resection or sub-periosteal excision. Demographics, clinical outcomes, and functional outcomes were compared between the two groups. Additionally, Cox regression analysis was used to analyze risk factors for local recurrence. Results. The five-year overall survival, local recurrence-free survival, and metastasis-free survival among patients with bone resection was 74.0%, 65.9%, and 74.1%, respectively, compared to 72.9%, 68.3%, and 72.0%, respectively, among patients with sub-periosteal excision. The cumulative incidence of recurrence was 33.1% for patients who underwent bone and 36.4% for those with sub-periosteal excision (p = 0.681). In multivariate analysis, STS with high Fédération Nationale des Centres de Lutte Contre Le Cancer (FNCLCC) grade, invasion involving posterior intermuscular septum, medial intermuscular septum, and adductor brevis were found to be associated with poorer prognosis. The mean Musculoskeletal Tumor Society (MSTS) score in the bone resection group was 24.7, significantly lower than the 28.3 in the sub-periosteal group (p < 0.001). Conclusion. Routine bone resection failed to improve local control or survival in STS patients with cortical bone contact, but resulted in significantly impaired postoperative function. A more conservative sub-periosteal excision approach may be preferable for these cases. Cite this article: Bone Jt Open 2025;6(2):215–226

Aims. This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods. This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m. 2. (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results. Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion. Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists. Cite this article: Bone Joint J 2024;106-B(9):942–948

Aims. The aim of this study was to evaluate the diagnostic accuracy of the absolute synovial polymorphonuclear neutrophil cell (PMN) count for the diagnosis or exclusion of periprosthetic joint infection (PJI) after total hip (THA) or knee arthroplasty (TKA). Methods. In this retrospective cohort study, 147 consecutive patients with acute or chronic complaints following THA and TKA were included. Diagnosis of PJI was established based on the 2018 International Consensus Meeting criteria. A total of 39 patients diagnosed with PJI (32 chronic and seven acute) and 108 patients with aseptic complications were surgically revised. Results. Using receiver operating characteristic curves and calculating the area under the curve (AUC), an optimal synovial cut-off value of 2,000 PMN/µl was determined (AUC 0.978 (95% confidence interval (CI) 0.946 to 1)). Using this cut-off, sensitivity and specificity of absolute synovial PMN count for PJI were 97.4% (95% CI 91.2 to 100) and 93.5% (95% CI 88.9 to 98.1), respectively. Positive and negative predictive value were 84.4% (95% CI 72.7 to 93.9) and 99.0% (95% CI 96.7 to 100), respectively. Exclusion of 20 patients with acute complications improved specificity to 97.9% (95% CI 94.6 to 100). Different cut-off values for THA (< 3,600 PMN/µl) and TKA (< 2,000 PMN/µl) were identified. Absolute synovial PMN count correlated strongly with synovial alpha-defensin (AD) (r = 0.759; p < 0.001). With a positive AD result, no additional PJI could be identified in any case. Conclusion. Absolute synovial PMN count is a widely available, rapid, cost-effective, and accurate marker in PJI diagnostics, whereas synovial AD appears to be a surrogate parameter of absolute synovial PMN count. Despite limitations in the early postoperative phase, wear, and rheumatic diseases in confirming PJI, an absolute synovial PMN count below 2,000/µl is highly suitable for ruling out PJI, with specific cut-off values for THA and TKA. Cite this article: Bone Joint J 2023;105-B(4):373–381

Aims. The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population. Methods. This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models. Results. In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs. Conclusion. This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987–996

Aims. The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. Methods. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression. Results. In all, 417 fractures (77%) were managed operatively and 122 (23%) conservatively. The median time to surgery was four days (interquartile range (IQR) 2 to 7). Of those undergoing surgery, 246 (59%) underwent revision and/or fixation and 169 (41%) fixation alone. The surgical strategy used differed by Unified Classification System for PPF type, with the highest rate of revision in B2/B3 fractures (both 77%, 176/228 and 24/31, respectively) and the highest rate of fixation alone in B1- (55/78; 71%) and C-type (49/65; 75%) fractures. Cemented stem fixation (odds ratio (OR) 2.66 (95% confidence interval (CI) 1.42 to 4.99); p = 0.002) and B2/B3 fracture type (OR 7.56 (95% CI 4.14 to 13.78); p < 0.001) were predictors of operative management. The median length of stay was 15 days (IQR 9 to 23), 12-month reoperation rate was 5.6% (n = 30), and 30-day readmission rate was 8.4% (n = 45). The 30-day and 12-month mortality rates were 5.2% (n = 28) and 21.0% (n = 113). Nonoperative treatment, older age, male sex, admission from residential or nursing care, and sustaining the PPF around a revision prosthesis were significant predictors of an increased 12-month mortality. Conclusion. Femoral hip PPFs have mortality, reoperation, and readmission rates comparable with hip fracture patients. However, they have a longer wait for surgery, and surgical treatment is more complex. There is a need to create a national framework for data collection for this heterogeneous group of patients in order to understand the outcomes of different approaches to treatment. Cite this article: Bone Joint J 2022;104-B(8):997–1008

Aims. In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures. Methods. This was a retrospective cohort study of consecutive patients aged ≥ 60 years who had cannulated screws fixation for Garden I and II fractures in a teaching hospital between March 2013 and March 2016. The primary outcome was further same-side hip surgery. Descriptive statistics were used and Kaplan-Meier estimates calculated for implant survival. Results. A total of 114 operations were performed on 112 patients with a mean age of 80.2 years (SD 8.9). The 30-day and one-year mortality were 1% (n = 1) and 13% (n = 15), respectively. Median follow-up was 6.6 years (interquartile range 6.0 to 7.3). Kaplan-Meier estimates showed a survivorship of 95% at one year and 90% at five years (95% confidence interval 84% to 95%) for cannulated screws. Nine patients underwent further hip surgery: four revision to total hip arthroplasty, one revision to hemiarthroplasty, three removals of screws, and one haematoma washout. Posterior tilt was assessable in 106 patients; subsequent surgery was required in two of the six patients identified with a posterior angle > 20° (p = 0.035 vs angle < 20°). Of the 100 patients with angle < 20°, five-year survivorship was 91%, with seven patients requiring further surgery. Conclusion. This study of cannulated hip screw fixation for undisplaced fractures in patients aged ≥ 60 years reveals a construct survivorship without further operation of 90% at five years. Cannulated screws can be considered a safe reliable treatment option for Garden I and II fractures. Caution should be taken if posterior tilt angle on lateral view exceeds 20°, due to a higher failure rate and reoperation, and considered for similar management to Garden III and IV injuries. Cite this article: Bone Jt Open 2022;3(3):182–188

Aims. This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year. Methods. A single-centre retrospective cohort study was performed at an acute NHS Trust. Hip and distal femur fracture patients admitted within the first month from each of the three starting dates of each national lockdown were included and compared to a control group in March 2019. Data were collected as per the best practice tariff outcomes including additional outcomes as required. Data collection included COVID-19 status, time to theatre, 30-day mortality, presence of acute kidney injury (AKI) and pneumonia, and do not attempt cardiopulmonary resuscitation (DNACPR) status. Data were analyzed using an independent-samples t-test or chi-squared test with Fisher’s exact test where applicable. A p-value of < 0.05 was considered statistically significant. Results. A total of 95 patients during the pandemic were included and 20 were COVID-positive. Patients experienced a statistically significant increase in time to theatre in Lockdown 1 compared to 2019 (p = 0.039) with a decrease with successive lockdown periods by Lockdown 3. The 30-day mortality increased from 8.8% in 2019 to 10.0% to 14.8% in all lockdown periods. COVID-positive patient mortality was 30.0% (p = 0.063, odds ratio (OR) = 4.43 vs 2019). The rates of AKI and pneumonia experienced were higher for patients during the pandemic. The highest rates were experienced in COVID-positive patients, with 45.0% of patients with AKI versus 27.0% in 2019 (p = 0.38, OR = 1.80), and 50.0% of patients diagnosed with pneumonia versus 16.2% in 2019 (p = 0.0012, OR = 5.17). The percentage of patients with a DNACPR increased from 30.0% in 2019 to 60.7% by Lockdown 3 (p = 0.034, OR = 3.61). Conclusion. COVID-positive hip and distal femur fracture patients are at a higher risk of mortality due to AKI and pneumonia. Patient outcomes have improved with successive lockdowns to pre-pandemic levels. Cite this article: Bone Jt Open 2021;2(12):1017–1026

Aims. Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods. This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results. In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion. Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34

Aims. Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. Methods. This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. Results. In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). Conclusion. Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized. Cite this article: Bone Jt Open 2022;3(1):35–41

Aims. The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion. Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272

The June 2024 Oncology Roundup. 360. looks at: Chondrosarcoma of the femur: is local recurrence influenced by the presence of an extraosseous component?; Diagnostic challenges in low-grade central osteosarcoma; Single osteotomy technique for frozen autograft (pedicled freezing) in patients with malignant bone tumours; Unplanned resection for small superficial soft-tissue sarcomas: disastrous or simply bad?; Inactivation and replantation of the knee joint: an infeasible surgical method; Active surveillance of diffuse-type tenosynovial giant cell tumours: a retrospective, multicentre cohort study

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

Aims. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

Aims. Type 2 diabetes mellitus (T2DM) impairs bone strength and is a significant risk factor for hip fracture, yet currently there is no reliable tool to assess this risk. Most risk stratification methods rely on bone mineral density, which is not impaired by diabetes, rendering current tests ineffective. CT-based finite element analysis (CTFEA) calculates the mechanical response of bone to load and uses the yield strain, which is reduced in T2DM patients, to measure bone strength. The purpose of this feasibility study was to examine whether CTFEA could be used to assess the hip fracture risk for T2DM patients. Methods. A retrospective cohort study was undertaken using autonomous CTFEA performed on existing abdominal or pelvic CT data comparing two groups of T2DM patients: a study group of 27 patients who had sustained a hip fracture within the year following the CT scan and a control group of 24 patients who did not have a hip fracture within one year. The main outcome of the CTFEA is a novel measure of hip bone strength termed the Hip Strength Score (HSS). Results. The HSS was significantly lower in the study group (1.76 (SD 0.46)) than in the control group (2.31 (SD 0.74); p = 0.002). A multivariate model showed the odds of having a hip fracture were 17 times greater in patients who had an HSS ≤ 2.2. The CTFEA has a sensitivity of 89%, a specificity of 76%, and an area under the curve of 0.90. Conclusion. This preliminary study demonstrates the feasibility of using a CTFEA-based bone strength parameter to assess hip fracture risk in a population of T2DM patients. Cite this article: Bone Joint J 2021;103-B(9):1497–1504

Aims. The aim of this study was to assess the clinical and radiological outcomes of an antiprotrusio acetabular cage (APC) when used in the surgical treatment of periacetabular bone metastases. Methods. This retrospective cohort study using a prospectively collected database involved 56 patients who underwent acetabular reconstruction for periacetabular bone metastases or haematological malignancy using a single APC between January 2009 and 2020. The mean follow-up was 20 months (1 to 143). The primary outcome measure was implant survival. Postoperative radiographs were analyzed for loosening and failure. Patient and implant survival were assessed using a competing risk analysis. Secondary parameters included primary malignancy, oncological treatment, surgical factors, length of stay in hospital, and postoperative complications. Results. A total of 33 patients (59%) died during the study period at a mean of 15 months postoperatively (1 to 63). No patient had radiological evidence of loosening or failure. Acetabular component survival was 100%. Three patients (5.4%) had further surgery; one (1.8%) underwent revision of the femoral component for dislocation, one required debridement with implant retention for periprosthetic joint infection, and one required closed reduction for dislocation. Using death as a competing risk, at 100 months, the probability of revision was 0.036 and the risk of death was 0.84. Conclusion. With appropriate patient selection, the antiprotrusio cage offers good implant survival, with a reasonable perioperative complication rate in this high-risk group of patients when managing metastatic disease or haematological malignancy around the acetabulum. Cite this article: Bone Joint J 2022;104-B(4):504–509

Aim. There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction. Methods. In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS). Results. The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group. Conclusion. We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155–1159