Aims. To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF). Patients and Methods. We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups. Results. We identified 1624 patients who underwent initial arthroplasty for PHF, and 98 patients who underwent secondary arthroplasty following failed ORIF. In total, 72 patients (4.4%) in the primary arthroplasty group had a reoperation within two years following arthroplasty, compared with 19 patients (19.4%) in the revision arthroplasty group. This difference was significantly different (p < 0.001) after covariable adjustment. Conclusion. The number of reoperations following arthroplasty for failed ORIF of PHF is significantly higher compared with primary arthroplasty. This suggests that primary arthroplasty may be a better choice for patients whose prognostic factors suggest a high reoperation rate following ORIF. Prospective clinical studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B:1272–1279

Objectives. The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls. Methods. Patients over 70 years old who visited an outpatient clinic for back pain treatment and underwent a standing whole-body radiograph were enrolled. Falls were prospectively assessed for 12 months using a monthly fall diary, and patients were divided into fallers and non-fallers according to the history of falls. Radiological parameters from whole-body radiographs and clinical data were compared between the two groups. Results. A total of 144 patients (120 female patients and 24 male patients) completed a 12-month follow-up for assessing falls. A total of 31 patients (21.5%) reported at least one fall within the 12-month follow-up. In univariate logistic regression analysis, the risk of falls was significantly increased in older patients and those with more medical comorbidities, decreased lumbar lordosis, increased sagittal vertical axis, and increased horizontal distance between the C7 plumb line and the centre of the ankle (C7A). Increased C7A was significantly associated with increased risk of falls even after multivariate adjustment. Conclusion. Whole body sagittal balance, measured by the horizontal distance between the C7 plumb line and the centre of the ankle, was significantly associated with risk of falls among elderly patients with back pain. Cite this article: J. Kim, J. Y. Hwang, J. K. Oh, M. S. Park, S. W. Kim, H. Chang, T-H. Kim. The association between whole body sagittal balance and risk of falls among elderly patients seeking treatment for back pain. Bone Joint Res 2017;6:–344. DOI: 10.1302/2046-3758.65.BJR-2016-0271.R2

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10. −6. ) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known

Concerns have been reported to the United Kingdom National Patient Safety Agency, warning that cementing the femoral component during hip replacement surgery for fracture of the proximal femur may increase peri-operative mortality. . The National Hip Fracture Database collects demographic and outcome data about patients with a fracture of the proximal femur from over 100 participating hospitals in the United Kingdom. We conducted a mixed effects logistic regression analysis of this dataset to determine whether peri-operative mortality was increased in patients who had undergone either hemiarthroplasty or total hip replacement using a cemented femoral component. A total of 16 496 patients from 129 hospitals were included in the analysis, which showed a small but significant adjusted survival benefit associated with cementing (odds ratio 0.83, 95% confidence interval 0.72 to 0.96). Other statistically significant variables in predicting death at discharge, listed in order of magnitude of effect, were gender, American Society of Anesthesiologists grade, age, walking accompanied outdoors and arthroplasty. Interaction terms between cementing and these other variables were sequentially added to, but did not improve, the model. . This study has not shown an increase in peri-operative mortality as a result of cementing the femoral component in patients requiring hip replacement following fracture of the proximal femur

There has been extensive discussion about the effect of delay to surgery on mortality in patients sustaining a fracture of the hip. Despite the low level of evidence provided by many studies, a consensus has been accepted that delay of > 48 hours is detrimental to survival. The aim of this prospective observational study was to determine if early surgery confers a survival benefit at 30 days. Between 1989 and 2013, data were prospectively collected on patients sustaining a fracture of the hip at Peterborough City Hospital. They were divided into groups according to the time interval between admission and surgery. These thresholds ranged from <  6 hours to between 49 and 72 hours. The outcome which was assessed was the 30-day mortality. Adjustment for confounders was performed using multivariate binary logistic regression analysis. In all, 6638 patients aged > 60 years were included. . Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p <  0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality. . Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality. Cite this article: Bone Joint J 2015;97-B:104–8

We reviewed 87 patients who had undergone expansive cervical laminoplasty between 1999 and 2005. These were divided into two groups: those who had diabetes mellitus and those who did not. There were 31 patients in the diabetes group and 56 in the control group. Although a significant improvement in the Japanese Orthopaedic Association score was seen in both groups, the post-operative recovery rate in the control group was better than that of the diabetic group. The patients’ age and symptom duration adversely affected the rate of recovery in the diabetic group only. Smoking did not affect the outcome in either group. A logistic regression analysis found diabetes and signal changes in the spinal cord on MRI to be significant risk factors for a poor outcome (odds ratio 2.86, 3.02, respectively). Furthermore, the interaction of diabetes with smoking and/or age increased this risk. We conclude that diabetes mellitus, or the interaction of this with old age, can adversely affect outcome after cervical laminoplasty. However, smoking alone cannot be regarded as a risk factor

The anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student’s two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test. . The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100 000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001). . The rates of use of TSA/100 000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p <  0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p <  0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001). In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes. . Cite this article: Bone Joint J 2015;97-B:1385–9

The purpose of this study was to investigate the clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM). We reviewed a consecutive series of 248 patients (71 women and 177 men) with CSM who had undergone surgery at our institution between January 2000 and October 2010. Their mean age was 59.0 years (16 to 86). Medical records, office notes, and operative reports were reviewed for data collection. Special attention was focused on pre-operative duration and severity as well as post-operative persistence of myelopathic symptoms. Disease severity was graded according to the Nurick classification. Our multivariate logistic regression model indicated that Nurick grade 2 CSM patients have the highest chance of complete symptom resolution (p < 0.001) and improvement to normal gait (p = 0.004) following surgery. Patients who did not improve after surgery had longer duration of myelopathic symptoms than those who did improve post-operatively (17.85 months (1 to 101) vs 11.21 months (1 to 69); p = 0.002). More advanced Nurick grades were not associated with a longer duration of symptoms (p = 0.906). Our data suggest that patients with Nurick grade 2 CSM are most likely to improve from surgery. The duration of myelopathic symptoms does not have an association with disease severity but is an independent prognostic indicator of surgical outcome. Cite this article: Bone Joint J 2013;95-B:966–71

Aims. The aim of the study was to develop a quantitative scoring system to predict whether a large-to-massive rotator cuff tear was arthroscopically reparable prior to surgery. Patients and Methods. We conducted a retrospective review of the pre-operative MR imaging and surgical records of 87 patients (87 shoulders) who underwent arthroscopic repair of a large-to-massive rotator cuff tear. Patients were divided into two groups, based on the surgical outcome of the repair. Of the 87 patients, 53 underwent complete repair (Group I) and 34 an incomplete repair (Group II). Pre-operative MR images were reviewed to quantify several variables. Between-group differences were evaluated and multiple logistic regression analysis was used to calculate the predictive value of significant variables. The reparability index (RI) was constructed using the odds ratios of significant variables and a receiver operating characteristic curve analysis performed to identify the optimal RI cutoff to differentiate between the two groups. Results. The following variables were identified as independent predictors of arthroscopic reparability: the size of the defect with medial-lateral diameter (cutoff, 4.2 cm) and anterior-posterior diameter (cutoff, 3.7cm); Patte’s grade of muscle atrophy (cutoff, grade 3) and Goutallier grade of fatty degeneration (cutoff, grade 3). An RI cutoff value of 2.5 provided the highest differentiation between groups I and II, with an area under the curve of 0.964, and a sensitivity of 73.5% and specificity of 96.2%. Conclusion. The RI developed in our study may prove to be an efficient clinical scoring system to predict whether a large-to-massive rotator cuff tear is arthroscopically reparable. Cite this article: Bone Joint J 2016;98-B:1656–61

The patellar clunk syndrome describes painful catching, grinding or jumping of the patella when the knee moves from a flexed to an extended position after total knee replacement (TKR). The posterior stabilised TKR had been noted to have a higher incidence of this problem. Mobile-bearing posteriorly stabilised TKRs have been introduced to improve patellar tracking and related problems by a mechanism of self-alignment. We evaluated the patellar clunk syndrome in 113 knees in 93 patients with such a TKR at a mean follow-up of 2.3 years (2.0 to 3.2). The syndrome was identified in 15 knees (13.3%). Logistic regression analysis showed that the absolute value of the post-operative angle of patellar tilt was significantly associated with the occurrence of patellar clunk (p = 0.025). Patellar tracking should be carefully checked during surgery

The aim of this study was to evaluate the risk factors for dislocation of the bearing after a mobile-bearing Oxford medial unicompartmental knee replacement (UKR) and to test the hypothesis that surgical factors, as measured from post-operative radiographs, are associated with its dislocation. From a total of 480 UKRs performed between 2001 and 2012, in 391 patients with a mean age of 66.5 years (45 to 82) (316 female, 75 male), we identified 17 UKRs where bearing dislocation occurred. The post-operative radiological measurements of the 17 UKRs and 51 matched controls were analysed using conditional logistic regression analysis. The post-operative radiological measurements included post-operative change in limb alignment, the position of the femoral and tibial components, the resection depth of the proximal tibia, and the femoral component-posterior condyle classification. We concluded that a post-operative decrease in the posterior tibial slope relative to the pre-operative value was the only significant determinant of dislocation of the bearing after medial Oxford UKR (odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative posterior tibial slope < 8.45° and a difference between the pre-operative and post-operative posterior tibial slope of > 2.19° may increase the risk of dislocation. Cite this article: Bone Joint J 2014; 96-B:914–22

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique). Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions

We examined differences in the rate of open reduction, operating time, length of hospital stay and outcome between two groups of children with displaced supracondylar fractures of the humerus who underwent surgery either within 12 hours of the injury or later. There were 77 children with type-3 supracondylar fractures. Of these, in 43 the fracture was reduced and pinned within 12 hours and in 34 more than 12 hours after injury. Both groups were similar in regard to gender, age and length of follow-up. Bivariate and logistical regression analysis showed no statistical difference between the groups. The number of peri-operative complications was low and did not affect the outcome regardless of the timing of treatment. Our study confirmed that the treatment of uncomplicated displaced supracondylar fractures of the humerus can be early or delayed. In these circumstances operations at night can be avoided

We aimed to document the pre-operative expectations in Korean patients undergoing total knee replacement using an established survey form and to determine whether expectations were influenced by sociodemographic factors or pre-operative functional status. Expectations regarding 17 items in the Knee Replacement Expectation Survey form were investigated in 454 patients scheduled for total knee replacement. The levels and distribution patterns of summated expectation and of five expectation categories (relief from pain, baseline activity, high flexion activity, social activity and psychological well-being) constructed from the 17 items were assessed. Univariate analyses and multivariate logistic regression were performed to examine the associations of expectations with the sociodemographic factors and the functional status. The top three expectations were relief from pain, restoration of walking ability, and psychological well-being. Of the five expectation categories, relief from pain was ranked the highest, followed by psychological well-being, restoration of baseline activity, ability to perform high flexion activities and ability to participate in social activities. An age of < 65 years, being employed, a high Western Ontario and McMaster Universities osteoarthritis index function score and a low Short-form 36 social score were found to be significantly associated with higher overall expectations

Redisplacement is the most common complication of immobilisation in a cast for the treatment of diaphyseal fractures of the forearm in children. We have previously shown that the three-point index (TPI) can accurately predict redisplacement of fractures of the distal radius. In this prospective study we applied this index to assessment of diaphyseal fractures of the forearm in children and compared it with other cast-related indices that might predict redisplacement. A total of 76 children were included. Their ages, initial displacement, quality of reduction, site and level of the fractures and quality of the casting according to the TPI, Canterbury index and padding index were analysed. Logistic regression analysis was used to investigate risk factors for redisplacement. A total of 18 fractures (24%) redisplaced in the cast. A TPI value of > 0.8 was the only significant risk factor for redisplacement (odds ratio 238.5 (95% confidence interval 7.063 to 8054.86); p < 0.001). The TPI was far superior to other radiological indices, with a sensitivity of 84% and a specificity of 97% in successfully predicting redisplacement. We recommend it for routine use in the management of these fractures in children. Cite this article: Bone Joint J 2013;95-B:563–7

Objectives. Preservation of posterior condylar offset (PCO) has been shown to correlate with improved functional results after primary total knee arthroplasty (TKA). Whether this is also the case for revision TKA, remains unknown. The aim of this study was to assess the independent effect of PCO on early functional outcome after revision TKA. Methods. A total of 107 consecutive aseptic revision TKAs were performed by a single surgeon during an eight-year period. The mean age was 69.4 years (39 to 85) and there were 59 female patients and 48 male patients. The Oxford Knee Score (OKS) and Short-form (SF)-12 score were assessed pre-operatively and one year post-operatively. Patient satisfaction was also assessed at one year. Joint line and PCO were assessed radiographically at one year. Results. There was a significant improvement in the OKS (10.6 points, 95% confidence interval (CI) 8.8 to 12.3) and the SF-12 physical component score (5.9, 95% CI 4.1 to 7.8). PCO directly correlated with change in OKS (p < 0.001). Linear regression analysis confirmed the independent effect of PCO on the OKS (p < 0.001) and the SF-12 physical score (p = 0.02). The overall rate of satisfaction was 85% and on logistic regression analysis improvement in the OKS (p = 0.002) was a significant predictor of patient satisfaction, which is related to PCO; although this was not independently associated with satisfaction. Conclusion. Preservation of PCO should be a major consideration when undertaking revision TKA. The option of increasing PCO to balance the flexion gap while maintaining the joint line should be assessed intra-operatively. Cite this article: N. D. Clement, D. J. MacDonald, D. F. Hamilton, R. Burnett. Posterior condylar offset is an independent predictor of functional outcome after revision total knee arthroplasty. Bone Joint Res 2017;6:172–178. DOI: 10.1302/2046-3758.63.BJR-2015-0021.R1

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores. While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours

Pre-operative variables are increasingly being used to determine eligibility for total knee replacement (TKR). This study was undertaken to evaluate the relationships, interactions and predictive capacity of variables available pre- and post-operatively on patient satisfaction following TKR. Using nationally collected patient reported outcome measures and data from the National Joint Registry for England and Wales, we identified 22 798 patients who underwent TKR for osteoarthritis between August 2008 and September 2010. The ability of specific covariates to predict satisfaction was assessed using ordinal logistic regression and structural equational modelling. Only 4959 (22%) of 22 278 patients rated the results of their TKR as ‘excellent’, despite the majority (71%, n = 15 882) perceiving their knee symptoms to be much improved. The strongest predictors of satisfaction were post-operative variables. Satisfaction was significantly and positively related to the perception of symptom improvement (operative success) and the post-operative EuroQol-5D score. While also significant within the models pre-operative variables were less important and had a minimal influence upon post-operative satisfaction. The most robust predictions of satisfaction occurred only when both pre- and post-operative variables were considered together. These findings question the appropriateness of restricting access to care based on arbitrary pre-operative thresholds as these factors have little bearing on post-operative satisfaction. Cite this article: Bone Joint J 2013;95-B:1359–65