BACKGROUND:The objectives were to evaluate whether the EQ-5D-3L questionnaire demonstrated a ceiling effect after total hip arthroplasty (THA), identify which patients were more likely to reach the ceiling score, and determine whether this limited assessment of potential improvement, relative to baseline, in their outcomes. METHODS:A cohort of 7,871 primary THAs was identified from an institutional arthroplasty database. Patient demographics, American Society of Anesthesiologists grade, socioeconomic status, Oxford Hip Score (OHS), and EQ-5D-3L were prospectively collected preoperatively and one and two years postoperatively. Regression analyses were performed to determine which preoperative factors were independently associated with achieving a ceiling score. RESULTS:The median preoperative EQ-5D-3L was 0.516, improving significantly at one year to 0.850 (P < 0.001), with nonsignificant change at two years (median, 0.883; P = 0.075). A ceiling effect was observed in 47.5% (n = 2,961) at one year, increasing to 48.6% (n = 2,853) at two years. Women, younger age, lower socioeconomic deprivation, and higher preoperative OHS, EQ-5D, and EQ-VAS were independent predictors of achieving a ceiling EQ-5D. Receiver operating characteristic curve analyses indicated that a preoperative EQ-5D score (≥ 0.534) predicted postoperative ceiling scores at one and two years (area under the receiver operating characteristic curve, 65.6 and 64.1%, respectively; P < 0.001). Patients who reached the postoperative EQ-5D ceiling had significant improvements in OHS, EQ-5D, and EQ-VAS and were more likely to achieve minimal important change and a patient-acceptable symptom state compared with those below the ceiling. CONCLUSIONS:The EQ-5D showed moderate ceiling effects at one and two years following THA, with higher preoperative scores being associated with ceiling attainment. Patients who reached the ceiling experienced greater improvements from baseline and were more likely to achieve clinically meaningful outcomes.

Objective: Determining the effect of microRNA-544a (miR-544a) in articular chondrocytes isolated from patients affected by osteoarthritis (OA) and its role in the modulation of the Wnt signalling. Methods: Articular chondrocytes were isolated from patients undergoing joint replacement because of OA. Expression levels of miR-544a were measured by PCR and by in situ hybridization. Putative targets of miR-544a were confirmed by reporter assay and by qPCR in cells stimulated with a miR-544a mimic. The effect of miR-544a on chondrocyte metabolism was monitored by qPCR for phenotypic markers, protein expression levels of aggrecan neoepitopes/MMP-13 and modulation of alcian blue content in micromass cultures, upon stimulation with a miR-544a mimic. The expression levels of MMP-13 and Aggrecan neoepitopes in response to miR-544a stimulation was also measured in co-stimulation with Xav-939 and KN93, which are respectively β-catenin and CaMKII inhibitors. Results: Our results suggest that miR-544a enhances the activation of the Wnt-signalling in the articular chondrocytes, by downregulating the expression of components of the Wnt/β-catenin destruction complex. The expression of miR-544a is higher in chondrocytes isolated from damaged areas of the articular cartilage removed from OA patients, and can be upregulated by pro-inflammatory and pro-fibrotic cytokines. miR-544a exerts a pro-catabolic effect of articular chondrocytes, which is rescued both by the inhibition of the Wnt/β-catenin and Wnt/CaMKII signalling pathways. Conclusion: our results point to miR-544a as a new, important modulator of the Wnt signalling network within the articular cartilage suggesting a key role for microRNAs in regulating how the multiple branches of the network and their interaction modulate cartilage homeostasis. ### Competing Interest Statement The authors have declared no competing interest.

Objective: The objective of this study was to elucidate the role of Calcium calmodulin-dependent Kinase II (CaMKII) in articular chondrocytes and its involvement in osteoarthritis (OA) pathogenesis. By performing gain and loss of function experiments, the research aimed to determine how CaMKII modulates chondrocyte metabolism, anabolic and catabolic processes, hypertrophic differentiation, and autophagy within the articular cartilage. Design: Articular cartilage was harvested from patients undergoing joint replacement surgery for OA, and adult human articular chondrocytes (AHACs) were isolated and cultured. Recombinant adenoviruses were used to overexpress a constitutively active form of CaMKIIγ (AdCaMKII) or inhibit CaMKII activity (AdAIP). Various assays, including RT-PCR analysis, alcian blue staining of Micromass cultures, immunofluorescence, and Western blotting, were performed to assess the effects of CaMKII modulation on chondrocyte function. Results: Overexpression of activated CaMKIIγ promoted anabolism, evidenced by increased expression of SOX9, COL2A1, and ACAN, and decreased MMP-13 levels. It also enhanced proteoglycan content in AHAC micromass cultures. Furthermore, CaMKII counteracted the catabolic effects of IL-1β and preserved proteoglycan content. We also observed decreased chondrocyte proliferation and increased synthesis of hypertrophic marker Type X Collagen. CaMKII activation was found to induce autophagy, as indicated by increased phosphorylation of Beclin1 and decreased p62 expression. The anabolic effects of CaMKII were dependent on autophagy, as inhibition of autophagy with Bafilomycin prevented the CaMKII-induced increase in glycosaminoglycan content. Conclusions: CaMKII plays a significant role in modulating chondrocyte metabolism and maintaining cartilage homeostasis. It promotes anabolic processes, counteracts catabolic stimuli, and induces autophagy in articular chondrocytes. However, it also promotes hypertrophic differentiation, highlighting the complexity of CaMKII-mediated signalling in cartilage. Understanding these pathways could lead to new therapeutic strategies that leverage CaMKII's anabolic potential while mitigating its pro-degenerative effects. ### Competing Interest Statement The authors have declared no competing interest.

Using data from two ED. departments of 773 patients admitted with SARS-CoV-2, ICD-10 codes derived from the General Practitioner - Summary Care Record (GP-SCR) and Emergency Department (ED.) records were analysed for code discrepancies and whether this related to increased mortality. The average number of ICD-10 codes in both GP-SCR and ED. records was higher for patients who died than patients who survived (all p < .0001). Pre-existing GP digital data provides a better prediction of mortality than data collected manually during admission clerking in the ED. Up to 78.47% of GP-SCR codes were missed in the ED. records and up to 45.49% of the ED. record codes were not in the GP-SCR. A subset of missed ICD-10 codes were identified as being able to predict outcome; a trend towards increasing death rate as the proportion of missed codes increases. Initiatives to make the GP-SCR available to the wider healthcare community should improve patient care and reduce bias during development of machine learning based algorithms.

BACKGROUND:As the population ages, the proportion of elderly patients requiring total hip arthroplasty (THA) increases, but it is not clear whether older age independently influences outcome. The aim was to assess function, quality of life, and satisfaction after THA in patients ≥ 80 years compared with those aged between 65 and 75 years when adjusting for confounding factors. METHODS:A single-center retrospective cohort study was performed between 2010 and 2019. A total 2,367 THAs were performed on patients ≥ 80 years and 5,113 on patients aged 65 to 75 years. The demographic data and length of stay (LOS) were recorded. Preoperative and 2-year postoperative Oxford Hip Scores (OHS), EuroQol (EQ-5D), and satisfaction scores were collected. Clinically meaningful difference was defined as 5 points in OHS and utility of 0.085 in EQ-5D. Regression analyses were performed to adjust for confounding factors. RESULTS:Patients in ≥ 80-years group were more likely women (P < .001), have higher American Society of Anesthesiolgists grade (P < .001), worse preoperative OHS (mean difference [MD] 2.3, P < .001), and EQ-5D (MD 0.087, P < .001). Both age groups achieved clinically meaningful and statistically significant (P < .001) improvement in OHS and EQ-5D utility at 2 years. When adjusting for confounding variables, the ≥ 80-year-old group had significantly (P < .001) lower improvement in OHS (MD -1.9 points) and EQ-5D (MD -0.055 utility), but these differences were not clinically meaningful. There was no difference (P = .813) in satisfaction between the groups. When adjusting for confounding variables, ≥ 80-year-old group had increased risk of longer LOS (odds ratio 1.27, P < .001). CONCLUSIONS:There were no clinically meaningful differences in hip-specific outcome or health-related quality of life according to age group, and both were equally satisfied with their outcome. The older age group did, however, have longer LOS. LEVEL OF EVIDENCE:Level III retrospective cohort study.

Background Difficulty kneeling following total knee arthroplasty (TKA) remains highly prevalent, and has cultural, social, and occupational implications. With no clear evidence of superiority, whether or not to resurface the patella remains debatable. This systematic review examined whether resurfacing the patella (PR) or not (NPR) influences kneeling ability following TKA. Methods This systematic review was conducted by following PRISMA guidelines. Three electronic databases were searched utilizing a search strategy developed with the aid of a department librarian. Study quality was assessed using MINROS criteria. Article screening, methodological quality assessment and data extraction were performed by two independent authors, and a third senior author was consulted if consensus was not reached. Results A total of 459 records were identified, with eight studies included in the final analysis, and all deemed to be level III evidence. The average MINORS score was 16.5 for comparative studies and 10.5 for non-comparative studies. The total number of patients was 24,342, with a mean age of 67.6 years. Kneeling ability was predominantly measured as a patient-reported outcome measure (PROM), with two studies also including an objective assessment. Two studies demonstrated a statistically significant link between PR and kneeling, with one demonstrating improved kneeling ability with PR and the other reporting the opposite. Other potential factors associated with kneeling included gender, postoperative flexion, and body mass index (BMI). Re-operation rates were significantly higher in the NPR cohort whereas PR cohorts had higher Feller scores, patient-reported limp and patellar apprehension. Conclusion Despite its importance to patients, kneeling remains not only under-reported but also ill-defined in the literature, with no clear consensus regarding the optimum outcome assessment tool. Conflicting evidence remains as to whether PR influences kneeling ability, and to clarify the situation, large prospective randomized studies are required.

The true incidence of periprosthetic femoral fracture (PFF) around cemented polished taper-slip implants remains largely unknown. Registries usually only capture PFFs that result in revision, missing those managed non-operatively or treated by open reduction and internal fixation (ORIF). This study reports the long-term rate of PFF with the original triple-tapered C-stem femoral implant. A prospective review of a consecutive series of 500 primary total hip arthroplasties (THAs) performed at a single centre between March 2000 and December 2005, with average follow-up of 15 years (12–19 years). There were 500 consecutive THAs in 455 patients. Seven PFFs (1.4%) occurred in seven patients at an average of 7.9 years (range 2–11.5) from the primary arthroplasty. Five PFFs were managed by ORIF, one Vancouver B3 fracture was revised for a loose implant and one patient was treated non-operatively. Average age at primary operation was 74 years (67–87) and BMI averaged 27.3 (22–31). There was no typical fracture pattern and no statistically significant associations with patient demographics (age, gender, BMI, diagnosis) or prosthetic details (size, offset, alignment, cement mantle, subsidence). Survivorship to the occurrence of PFF was 99% (97.3–99.6%) at 10 years and 97.8% (95.5–99.0%) at 15. A PFF rate of 1.4% at an average follow-up of 15 years represents the true incidence of PFF with the use of the original triple-tapered C-Stem femoral implant, similar to that of published Exeter series (1.85%) but lower than the CPT (3.3%).

PurposePatients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results.MethodsA systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients.ResultsTen studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%).ConclusionThe use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.

Over 8000 total hip arthroplasties (THA) in the UK were revised in 2019, half for aseptic loosening. It is believed that Artificial Intelligence (AI) could identify or predict failing THA and result in early recognition of poorly performing implants and reduce patient suffering. The aim of this study is to investigate whether Artificial Intelligence based machine learning (ML) / Deep Learning (DL) techniques can train an algorithm to identify and/or predict failing uncemented THA. Consent was sought from patients followed up in a single design, uncemented THA implant surveillance study (2010–2021). Oxford hip scores and radiographs were collected at yearly intervals. Radiographs were analysed by 3 observers for presence of markers of implant loosening/failure: periprosthetic lucency, cortical hypertrophy, and pedestal formation. DL using the RGB ResNet 18 model, with images entered chronologically, was trained according to revision status and radiographic features. Data augmentation and cross validation were used to increase the available training data, reduce bias, and improve verification of results. 184 patients consented to inclusion. 6 (3.2%) patients were revised for aseptic loosening. 2097 radiographs were analysed: 21 (11.4%) patients had three radiographic features of failure. 166 patients were used for ML algorithm testing of 3 scenarios to detect those who were revised. 1) The use of revision as an end point was associated with increased variability in accuracy. The area under the curve (AUC) was 23–97%. 2) Using 2/3 radiographic features associated with failure was associated with improved results, AUC: 75–100%. 3) Using 3/3 radiographic features, had less variability, reduced AUC of 73%, but 5/6 patients who had been revised were identified (total 66 identified). The best algorithm identified the greatest number of revised hips (5/6), predicting failure 2–8 years before revision, before all radiographic features were visible and before a significant fall in the Oxford Hip score. True-Positive: 0.77, False Positive: 0.29. ML algorithms can identify failing THA before visible features on radiographs or before PROM scores deteriorate. This is an important finding that could identify failing THA early.

AIM:There are 12 signs of the zodiac, each attributed with its own specific personality traits, desires and attitudes. The aim of the study was to evaluate the effect of zodiac sign on patient-reported outcome measures (PROMS) following primary total knee arthroplasty (TKA). METHOD:Patients undergoing primary TKA during a 2-year period (January 2019 to December 2020) were identified retrospectively. Patient demographics, Oxford Knee Score (OKS), EuroQol 5-dimension (EQ-5D) (baseline, 1 and 2 years) and patient satisfaction scores (1 and 2 years) were collected. Each patient's zodiac sign was assigned from their date of birth. RESULTS:There were 509 patients (228 males [44.8%] and 281 females [55.2%]) with a mean age of 70.9 years and a mean BMI of 30.3. There were no significant differences in gender (p=0.712), age (p=0.088), BMI (p=0.660), or pre-operative OKS (p=0.539). Aries and Gemini (0.366) had the worst and Pisces the best (0.595) pre-operative EQ-5D scores (p=0.038). When adjusting for confounding, Aries (p=0.031) had a greater improvement in EQ-5D at 1 year, although this was not maintained at 2 years. When adjusting for confounding, Pisceans had significantly less of an improvement in OKS at both 1 (p=0.022) and 2 years (p=0.042) and also had a significantly lower risk of satisfaction at 2 years (odds ratio 0.41, p=0.043). CONCLUSION:Zodiac sign was associated with outcome following TKA. Pisceans had the best pre-operative EQ-5D scores, but the least improvement in the post-operative joint specific score (OKS) and were less likely to be satisfied, despite achieving an equal improvement in their health-related quality of life (EQ-5D). Aries started with the lowest pre-operative EQ-5D scores but achieved the best scores at 1 year. Our study shows that an individual's zodiac sign may serve as a useful predictive factor for functional outcomes and satisfaction following TKA. However, our findings are the result of multiple testing in a large dataset following a data trawl, and correlation does not necessarily equal causation even in a real-world registry.

Degradation of the articular cartilage is a hallmark of osteoarthritis, a progressive and chronic musculoskeletal condition, affecting millions of people worldwide. The activation of several signalling cascades is altered during disease development: among them, the Wnt signalling plays a pivotal role in the maintenance of tissue homeostasis. Increasing evidence is showing that its activation needs to be maintained within a certain range to avoid the triggering of degenerative mechanisms. In this review, we summarise our current knowledge about how a balanced activation of the Wnt signalling is maintained in the articular cartilage, with a particular focus on receptor-mediated mechanisms.

BACKGROUND:Surgical waiting lists have risen dramatically across the UK as a result of the COVID-19 pandemic. The effective use of operating theatres by optimal scheduling could help mitigate this, but this requires accurate case duration predictions. Current standards for predicting the duration of surgery are inaccurate. Artificial intelligence (AI) offers the potential for greater accuracy in predicting surgical case duration. This study aimed to investigate whether there is evidence to support that AI is more accurate than current industry standards at predicting surgical case duration, with a secondary aim of analysing whether the implementation of the models used produced efficiency savings. METHOD:PubMed, Embase, and MEDLINE libraries were searched through to July 2023 to identify appropriate articles. PRISMA extension for scoping reviews and the Arksey and O'Malley framework were followed. Study quality was assessed using a modified version of the reporting guidelines for surgical AI papers by Farrow et al. Algorithm performance was reported using evaluation metrics. RESULTS:The search identified 2593 articles: 14 were suitable for inclusion and 13 reported on the accuracy of AI algorithms against industry standards, with seven demonstrating a statistically significant improvement in prediction accuracy (P < 0.05). The larger studies demonstrated the superiority of neural networks over other machine learning techniques. Efficiency savings were identified in a RCT. Significant methodological limitations were identified across most studies. CONCLUSION:The studies suggest that machine learning and deep learning models are more accurate at predicting the duration of surgery; however, further research is required to determine the best way to implement this technology.

AbstractIntroduction30-day emergency readmission is an indicator of treatment related complication once discharged, resulting in readmission. A board-approved quality improvement pathway was introduced to reduce elective re-admissions.MethodThe pathway involved telephone and email contact details provision to patients for any non-life threatening medical assistance, allowing for initial nurse led management of all issues. A new clinic room available 7 days, and same day ultrasound scanning for DVT studies were introduced. A capability, opportunity and behavior model of change was implemented.Readmission rates before and six months after implementation were collected from Model Hospital. A database used to document patient communications was interrogated for patient outcomes.ResultsPrior to implementation, readmission rates following elective primary total knee replacement (TKR) at the 1st business quarter of 2021 (April – June 2021), was 8.7%, (benchmark 3.8%). Following implementation, readmission rates decreased to 4.1% (October – December 2021). 54% of patients making contact were managed with telephone advice. 15% of patients required face-to-face clinic. 32% of those required a same day scan to exclude DVT (1/4).20 out of 684 TKRs performed following protocol introduction were re-admitted within 30 days. Readmissions were 41% surgical, 29% medical. 52% were unaware of the newly implemented protocol. Further improvements have been made to the protocol based on these findings.Implementation of a suitable pathway can significantly reduce re-admission rates in our center and could be used to reduce readmission rates in other national elective treatment centers.

Background: There is a trend towards minimising length of stay (LOS) after total knee arthroplasty (TKA), as greater LOS is associated with poorer outcomes and higher costs. Patient factors known to influence LOS post-TKA include age and ASA grade. Evidence regarding the effect of body mass index (BMI) in particular is conflicting, with some studies finding that increased BMI predicts increased LOS, while others have found no relationship. Few previous studies, which have mostly been conducted outside the UK, have examined the effect of living alone or socioeconomic deprivation, which may be confounders.Methods: We conducted a retrospective cohort study of 1031 consecutive primary TKAs performed between 1 April 2021 and 31 December 2021 in a single high-volume arthro-plasty centre. A multivariable negative binomial regression model was performed for the 860 patients with complete data, using pre-operative (BMI, age, gender, ASA grade, smok-ing, ethnicity, socioeconomic deprivation, living arrangement, EQ5D quality of life score, and indication for surgery) and peri-operative variables (surgeon, surgical approach, tourniquet use, a.m./p.m operation, operation side, duration, and day of the week).Results: Mean LOS was 2.6 days. BMI and socioeconomic deprivation had no effect on LOS (P > 0.05). Increased LOS was associated with living alone, lower EQ5D, age and ASA grade (all P < 0.001), p.m. operation (P < 0.01), female gender and duration of surgery (P < 0.05).Conclusion: BMI and socioeconomic status were not correlated with LOS after TKA. Living alone, which has not been previously reported and lower pre-operative EQ5D status were significant risk factors, which merit consideration in pre-operative planning and counselling.(c) 2023 Elsevier B.V. All rights reserved.

End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count. A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan–Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV. Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94

There are advocates of both two-dimensional (2D) and three-dimensional (3D) templating methods for planning total hip replacement. The aim of this study was to compare the accuracy of implant size prediction when using 2D and 3D templating methods for total hip arthroplasty, as well as to compare the inter- and intra-observer reliability in order to determine whether currently available methods are sufficiently reliable and reproducible. Medline, EMBASE and PubMed were searched to identify studies that compared the accuracy of 2D and 3D templating for total hip replacement. Results were screened using the PRISMA flowchart and included studies were assessed for their level of evidence using the Oxford CEBM criteria. Non-randomized trials were critically appraised using the MINORS tool, whilst randomized trials were assessed using the CASP RCT checklist. A series of meta-analyses of the data for accuracy were also conducted. Ten studies reported that 3D templating is an accurate and reliable method of templating for total hip replacement. Six studies compared 3D templating with 2D templating, all of which concluded that 3D templating was more accurate, with three finding a statistically significant difference. The meta-analyses showed that 3D CT templating is the most accurate method. This review supports the hypothesis that 3D templating is an accurate and reliable method of preoperative planning, which is more accurate than 2D templating for predicting implant size. However, further research is needed to ascertain the significance of this improved accuracy and whether it will yield any clinical benefit.

Purpose Cell-based therapies using lipoaspirate are gaining popularity in orthopaedics due to their hypothesised regenerative potential. Several ‘point-of-care’ lipoaspirate-processing devices/systems have become available to isolate cells for therapeutic use, with published evidence reporting their clinical relevance. However, few studies have analysed the composition of their ‘minimally-manipulated’ cellular products in parallel, information that is vital to understand the mechanisms by which these therapies may be efficacious. This scoping review aimed to identify devices/systems using mechanical-only processing of lipoaspirate, the constituents of their cell-based therapies and where available, clinical outcomes. Methods PRISMA extension for scoping reviews guidelines were followed. MEDLINE, Embase and PubMed databases were systematically searched to identify relevant articles until 21 st April 2022. Information relating to cellular composition and clinical outcomes for devices/systems was extracted. Further information was also obtained by individually searching the devices/systems in the PubMed database, Google search engine and contacting manufacturers. Results 2895 studies were screened and a total of 15 articles (11 = Level 5 evidence) fulfilled the inclusion criteria. 13 unique devices/systems were identified from included studies. All the studies reported cell concentration (cell number regardless of phenotype per millilitre of lipoaspirate) for their devices/systems (range 0.005–21 × 10 6 ). Ten reported cell viability (the measure of live cells- range 60–98%), 11 performed immuno-phenotypic analysis of the cell-subtypes and four investigated clinical outcomes of their cellular products. Only two studies reported all four of these parameters. Conclusion When focussing on cell concentration, cell viability and MSC immuno-phenotypic analysis alone, the most effective manual devices/systems were ones using filtration and cutting/mincing. However, it was unclear whether high performance in these categories would translate to improved clinical outcomes. Due to the lack of standardisation and heterogeneity of the data, it was also not possible to draw any reliable conclusions and determine the role of these devices/systems in clinical practice at present. Level of Evidence Level V Therapeutic.

Peri-prosthetic fractures (PPFs) are a serious complication of total hip arthroplasty (THA) associated with significant morbidity, mortality and re-operation similar to the rates seen following femoral neck fractures. When exploring the PPF rates around cemented stems, many studies combine the results of composite beam and taper-slip stems despite their different philosophies. This review looks specifically at PPFs with the use of cemented stems of the taper-slip philosophy to evaluate the demographics, PPF rate and fracture patterns in this patient cohort. A systematic search of Embase, Medline and CINAHL databases was performed to seek studies involving the use of cemented, polished, taper-slip stems, reporting on a rate of post-operative PPF and not involving patient cohorts that were exclusively hip fracture or revision arthroplasty. 27 studies reported on 505 PPFs with an average time from primary operation to PPF of 71.2 months (2–301 months). The average age of patients who sustained PPFs was 70.6 years (53.5–82 years) and the majority were female (64.2%). The Vancouver B2 fracture type was most common (39.5%). Open reduction and internal fixation represented the management of choice in 61.2% of PPFs. There was a re-operation rate of 11.4%. This review suggests an association with being older and female, and a greater risk of PPFs secondary to low energy falls in cemented polished taper-slip stems.

Purpose Rapidly progressive osteoarthritis of the hip is an uncommon and poorly understood condition. No universal definition of RPOH exists, however, a loss of joint space of 2 mm or more per year or 50% or more in one year with no other cause can be classed as RPOH. Due to the rapid loss of joint space and associated bone loss, total hip arthroplasty is the only viable treatment option. The aim of this systematic review is to assess the outcomes of THA in RPOH. Methods A systematic search of Embase, Medline and CINAHL databases was performed for studies reporting on the outcomes of patients with RPOH as their primary diagnosis for undergoing THA. Patient demographics, surgical techniques, implant selection, blood loss, morbidity and mortality, length of stay and patient-reported outcomes were amongst the data collected. Results Eight studies were found to be eligible, reporting on the outcomes of 270 patients with a mean age of 71. The majority of patients (88.1%) were female and the mean Body Mass Index was 27.6 kg/m 2 . Six of the eight studies reported on the need for additional reconstructive devices and procedures including the use of acetabular roof augmentation, acetabular reinforcement devices and revision acetabular components. Two studies reported increased blood loss in RPOH patients compared with non-RPOH patients (945 ml vs. 578 ml and 473.9 g vs. 353.9 g, respectively). Conclusion RPOH leads to significant pre-operative morbidity and THA for RPOH has been shown to result in greater blood loss, prolonged operative time and increased complexity of the procedure all of which result in increased cost. There is a paucity of data on the long-term outcomes for these patients and more well-constructed studies are therefore required.

AIMS:There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019. METHODS:A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019. RESULTS:A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery. CONCLUSION:Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery. Level of evidence: III Cite this article: Bone Jt Open 2022;3(1):42-53.