Trends in incidence and average waiting time for arthroplasty from 1998-2021: an observational study of 282,367 patients from the Scottish arthroplasty project.

BACKGROUND: Current waiting times for arthroplasty are reported as being the worst on record. This is a combination of increasing demand, the COVID-19 pandemic and longer standing shortage of capacity. The Scottish Arthroplasty Project (SAP) is a National Audit that analyses all joint replacements undertaken in the Scottish NHS and Independent Sector. The aim of this study was to investigate the long-term trend in provision and waiting time for lower limb joint replacement surgery. METHODS: All total hip replacements (THR) and total knee replacements (TKR) undertaken in NHS Scotland from 1998 to 2021 were identified. Waiting times data were analysed each year to determine the minimum, maximum, median, mean and standard deviation. RESULTS: In 1998, there were 4,224 THR and 2,898 TKR with mean (range, SD) waiting time of 159.5 days (1-1,685, 119.8) and 182.9 days (1-1,946, 130.1). The minimum waiting times were both in 2013 for 7,612 THR - 78.8 days (0-539, 46) and 7,146 TKR - 79.1 days (0-489, 43.7). The maximum waiting times recorded were in 2021 with 4,070 THR waiting 283.7 days (0-945, 215) and 3,153 TKR waiting 316.8 days (4-1,064, 217). CONCLUSIONS: This is the first robust large-scale national dataset showing trends in incidence and waiting time for THR and TKR over two decades. There was an expansion of activity with a reduction in waiting time, which peaked in 2013, followed by an increase in waiting time with a plateau and modest decline in the number of procedures.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation.

PURPOSE: The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. METHODS: Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. RESULTS: 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001). CONCLUSIONS: This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. LEVEL OF EVIDENCE: III (cohort study).

Hand-arm vibration and outcomes of surgery for Dupuytren's contracture.

BACKGROUND: Dupuytren's contracture was recently designated a prescribed occupational disease when it occurs in patients with previous hand-arm vibration (HAV) exposure. AIMS: The aims of this study were to describe the impact of self-reported HAV exposure on upper limb function and satisfaction following surgery for Dupuytren's contracture. METHODS: Paired pre- and postoperative Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient satisfaction questionnaires were prospectively collected from all patients undergoing surgery for Dupuytren's contracture over a 6-year period. Patients self-reported HAV exposure duration. RESULTS: Results were available for 425 hands (65%) at mean 13 months postoperatively. There were 111 patients (26%) that reported HAV exposure. The prevalence of HAV exposure was significantly greater in male compared with female patients (32% versus 4%; P < 0.001). A statistically significant difference in preoperative (difference 7.47; 95% confidence interval 4.78-10.17; P < 0.001) and postoperative QuickDASH score (difference 6.78; 95% confidence interval 2.69-10.88; P < 0.001) was observed between the two groups, but difference in QuickDASH improvement was not significantly different (difference 1.76; 95% confidence interval -1.58 to 5.10; P > 0.05). No significant difference in satisfaction rate or return to work was observed between the two groups. CONCLUSIONS: Previous HAV exposure influenced the pre and postoperative function in patients undergoing surgery for Dupuytren's contracture, but had no effect on satisfaction or return to work. Further prospective research will be required to determine whether the introduction of a compensatory framework will have a more profound effect on the functional outcomes of surgery.

Comorbid status influences quality of life following carpal tunnel decompression.

The aim of this study was to characterize the change in health-related quality of life following carpal tunnel decompression. Pre- and postoperative Euroqol 5 Dimensions scores were collected prospectively over three years. Outcomes were available for 435 of 563 patients (77%); mean age was 62 years. Comorbid status was described using the Charlson Comorbidity Index. Change in Euroqol 5 Dimensions scores declined with increasing age and Charlson Comorbidity Index: the greatest improvement in quality of life occurred in the youngest group (+0.07 vs. -0.07 in the oldest group; p < 0.001) and patients with the lowest Comorbidity Index (+0.05 vs. -0.07 in the highest comorbidity group; p < 0.001). Charlson Comorbidity Index was an independent predictor of worse change in Euroqol 5 Dimensions scores on regression analysis. Carpal tunnel decompression results in significant improvement in health-related quality of life in younger patients with minimal comorbidities, but not in older patients with more comorbidities. We advise interpreting the Euroqol 5 Dimensions scores with caution in this patient cohort. LEVEL OF EVIDENCE: III (cohort study).

Occupation classification predicts return to work after carpal tunnel decompression.

BACKGROUND: The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear. AIMS: To investigate predictors of RTW following CTD. METHODS: We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010. RESULTS: Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2-6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P < 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9-6.5) and non-manual workers (6.2; 95% CI 4.8-7.6) (P > 0.05). Median pre-operative (difference 15.9; 95% CI 4.5-25) and post-operative (difference 43.2; 95% CI 13.6-43.2) hand function scores were significantly worse in patients who did not RTW (P < 0.05). CONCLUSIONS: Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.

Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction.

UNLABELLED: We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies. LEVEL OF EVIDENCE IV: Prognosis, observational cohort study.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

OBJECTIVES: Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. DESIGN: A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. SETTING: An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. PARTICIPANTS: 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. OUTCOME MEASURES: Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. RESULTS: Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. CONCLUSIONS: This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

A comparison of the use of uncemented hydroxyapatite-coated bipolar and cemented femoral stems in the treatment of femoral neck fractures: a case-control study.

We performed a case-control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.

Variability in local pressures under digital tourniquets.

The UK National Patient Safety Agency issued a rapid response report in 2009 following reports of complications related to digital tourniquet use and inadvertent retention. In their guidance, they recommend the use of CE marked digital tourniquets and advise against the use of surgical gloves. There are a number of different commercially available non-pneumatic digital tourniquets, but little clear data relating to their comparable physical properties, clinical efficacy or safety. The aim of this study was to investigate the variability of pressures exerted by non-pneumatic digital tourniquets. A Tekscan FlexiForce(®) force sensor was used to measure applied force and to calculate the surface pressures under: the Toe-niquet™; T-Ring™ and surgical glove 'roll down' tourniquets in finger models. The lowest mean pressures were produced by the larger glove sizes (size 8) (25 mmHg), while the highest pressures were produced by the Toe-niquet (1560 mmHg). There was a significant overall difference in pressures exerted under tourniquets when comparing tourniquet type (p<0.001) and finger size (p<0.001) with these techniques. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Safe limits for application time and surface pressures are difficult to define. Further work is required to model the pressure effects of commercially available digital tourniquets and to identify which are most effective but safe.

Total knee replacement in patients with haemophilia: the Scottish experience.

INTRODUCTION: Patients with haemophilia commonly develop arthropathy secondary to recurrent haemarthroses. Although modern treatment with replacement coagulation factors has reduced the prevalence of end-stage arthropathy, total joint replacement is still required in a small group of patients. These patients may be at higher risk of complications and the outcome of surgery may not be comparable to reports of outcomes of total joint replacement in the general population. The purpose of this study was to describe the change in function in patients undergoing total knee replacement for haemophilic arthropathy. PATIENTS AND METHODS: Patients undergoing total knee arthroplasty in a tertiary centre had prospective evaluations of patient reported outcome measures and range of movement. Their post-operative function was evaluated in a combined orthopaedic-haematology clinic. Eight male patients underwent 13 total knee replacements from 1999 to 2007 and were followed up for a median of 78 months (range 17-116). RESULTS: The median Oxford knee score improved from 45.5 pre-operatively to 28 (p = 0.049). There was a similar improvement in SF-12 physical (p = 0.017) and Knee Society scores (objective p = 0.001; function p = 0.002). Four total knee replacements were performed in patients with inhibitor antibodies and were treated with recombinant activated factor VIIa. These patients had reduced range of movement (p = 0.047). No patients suffered deep infection. CONCLUSIONS: Total knee replacement in patients with haemophiliac arthropathy resulted in improvement in range of movement and function. The presence of factor VIII inhibitors resulted in reduced range of movement, but similar patient reported outcome measures.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.

BACKGROUND: There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment. METHODS: In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed. RESULTS: The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001). CONCLUSIONS: Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

Coronary artery calcification correlates with the presence and severity of valve calcification.

AIM: To investigate the prevalence of coronary artery calcification (CAC) in symptomatic individuals with CT evidence for left heart valve calcification, aortic valve (AVC), mitral valve (MAC) or both. METHODS: This is a retrospective study of 282 consecutive patients with calcification in either the aortic valve or mitral annulus. Calcium scoring of the coronary artery, aortic and mitral valve was measured using the Agatston score. RESULTS: AVC was more prevalent than MAC (64% vs. 2.5%, p < 0.001), with 34% having both. Absence of CAC was noted in 12.7% of the study population. AVC + CAC were observed in 53.5%, MAC and CAC in 2.1%, and combined AVC, MAC and CAC in 31.6%. The median CAC score was higher in individuals with combined AVC+MAC, followed by those with AVC and lowest was in the MAC group. The majority (40%) of individuals with AVC had CAC score >400, and only in 16% had CAC = 0. The same pattern was more evident in individuals with AVC + MAC, where 70% had CAC score >400 and only 6% had CAC score of 0. These results were irrespective of gender. There was no correlation between AVC and MAC but there was modest correlation between CAC score and AVC score (r = 0.28, p = 0.0001), MAC (r = 0.36, p = 0.0001) and with combined AVC + MAC (r = 0.5, p = 0.0001). AVC score of 262 had a sensitivity of 78% and specificity of 92% for the prediction of presence of CAC. CONCLUSION: The presence and extent of calcification in the aortic valve or/and mitral valves are associated with severe coronary artery calcification.

Progression of coronary artery calcification in asymptomatic individuals with pre-existing calcium score.

AIM: Coronary artery calcification (CAC) has been introduced as a reliable, non-invasive marker of atherosclerosis. In this retrospective study, we investigated the progression of CAC using electron beam computed tomography. METHODS: The study enrolled 598 individuals (521 males; mean age: 59.3±8.3 years) with initial CAC score (CACS) ≥10. The mean interscan period was 2.4±1.35 years (range: 1-7 years). The mean CACS, for the entire cohort, was 262.4±423.9 at baseline scan and 380.3±547.6 at follow-up. The mean annualized progression in CACS was 57.7±123.7; 47.4±66.5 in females and 58.3±128.1 in males (P=0.46). The mean annualized progression in CACS was 39.6±61.3 in individuals <60 years and 75.7±161.5 in individuals >60 years (P=0.0003). In multivariate analysis, only baseline CACS (P<0.0001) and smoking (P=0.002) were independently associated with the annual change in CACS.

Socioeconomic status affects the Oxford knee score and short-form 12 score following total knee replacement.

We assessed the effect of social deprivation upon the Oxford knee score (OKS), the Short-Form 12 (SF-12) and patient satisfaction after total knee replacement (TKR). An analysis of 966 patients undergoing primary TKR for symptomatic osteoarthritis (OA) was performed. Social deprivation was assessed using the Scottish Index of Multiple Deprivation. Those patients that were most deprived underwent surgery at an earlier age (p = 0.018), were more likely to be female (p = 0.046), to endure more comorbidities (p = 0.04) and to suffer worse pain and function according to the OKS (p < 0.001). In addition, deprivation was also associated with poor mental health (p = 0.002), which was assessed using the mental component (MCS) of the SF-12 score. Multivariable analysis was used to identify independent predictors of outcome at one year. Pre-operative OKS, SF-12 MCS, back pain, and four or more comorbidities were independent predictors of improvement in the OKS (all p < 0.001). Pre-operative OKS and improvement in the OKS were independent predictors of dissatisfaction (p = 0.003 and p < 0.001, respectively). Although improvement in the OKS and dissatisfaction after TKR were not significantly associated with social deprivation per se, factors more prevalent within the most deprived groups significantly diminished their improvement in OKS and increased their rate of dissatisfaction following TKR.

Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis.

The aim of this study was to perform a cost-utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health-utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Carpal tunnel syndrome: the association with occupation at a population level.

The aim of this study was to examine the association of occupation and gender with the incidence and severity of carpal tunnel syndrome (CTS). We examined 884 patients of working age, diagnosed with CTS, in a specialist hand clinic that was the only provider of hand services to a health board area. We categorized occupation using the Standard Occupational Classification 2010 (SOC2010) and used local census data to calculate the incidence in each of the nine major occupational groups. The greatest incidence was in caring and leisure occupations (197 per 100 000 population per year), while the lowest incidence was in the associate professional group (37 per 100 000). Professional occupations had a high incidence of CTS, along with skilled trades and elementary occupations. Women had a higher incidence of CTS than men in managerial, professional, skilled trades, and elementary occupations (OR 2.9-3.6). The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score varied across occupational groups (p < 0.001) and was worst in the caring and leisure group. As traditional heavy industry associated with previously described occupational risks declines, new patterns of occupational association may emerge. We recommend ongoing observational research of potential occupational risk factors to identify these new trends.

Ten-year survival of cemented total knee replacement in patients aged less than 55 years.

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years. These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age.

The outcome of carpal tunnel decompression in patients with diabetes mellitus.

Diabetes mellitus is recognised as a risk factor for carpal tunnel syndrome. The response to treatment is unclear, and may be poorer than in non-diabetic patients. Previous randomised studies of interventions for carpal tunnel syndrome have specifically excluded diabetic patients. The aim of this study was to investigate the epidemiology of carpal tunnel syndrome in diabetic patients, and compare the outcome of carpal tunnel decompression with non-diabetic patients. The primary endpoint was improvement in the QuickDASH score. The prevalence of diabetes mellitus was 11.3% (176 of 1564). Diabetic patients were more likely to have severe neurophysiological findings at presentation. Patients with diabetes had poorer QuickDASH scores at one year post-operatively (p = 0.028), although the mean difference was lower than the minimal clinically important difference for this score. After controlling for underlying differences in age and gender, there was no difference between groups in the magnitude of improvement after decompression (p = 0.481). Patients with diabetes mellitus can therefore be expected to enjoy a similar improvement in function.

Predictors of mortality after total knee replacement: a ten-year survivorship analysis.

We report the general mortality rate after total knee replacement and identify independent predictors of survival. We studied 2428 patients: there were 1127 men (46%) and 1301 (54%) women with a mean age of 69.3 years (28 to 94). Patients were allocated a predicted life expectancy based on their age and gender. There were 223 deaths during the study period. This represented an overall survivorship of 99% (95% confidence interval (CI) 98 to 99) at one year, 90% (95% CI 89 to 92) at five years, and 84% (95% CI 82 to 86) at ten years. There was no difference in survival by gender. A greater mortality rate was associated with increasing age (p < 0.001), American Society of Anesthesiologists (ASA) grade (p < 0.001), smoking (p < 0.001), body mass index (BMI) < 20 kg/m(2) (p < 0.001) and rheumatoid arthritis (p < 0.001). Multivariate modelling confirmed the independent effect of age, ASA grade, BMI, and rheumatoid disease on mortality. Based on the predicted average mortality, 114 patients were predicted to have died, whereas 217 actually died. This resulted in an overall excess standardised mortality ratio of 1.90. Patient mortality after TKR is predicted by their demographics: these could be used to assign an individual mortality risk after surgery.