Andrew D. Duckworth

Purpose: The aim was to assess mapping models to predict the EQ-5D-3L utility from the Oxford hip score (OHS) and validate these before and after total hip arthroplasty (THA). Methods: Separate retrospective cohorts of patients who had undergone THA in different centres were used to create (n = 3981) and validate (n = 7168) the prediction models. Patient demographics, body mass index (BMI), OHS and EQ-5D were collected preoperatively and one year postoperatively. Predictive models were formulated using generalised linear regression. Results: In the modelling cohort, mean OHS improved from 20.8 preoperatively to 39.6 postoperatively; the mean EQ-5D improved from 0.391 preoperatively to 0.788 postoperatively. Significant (p < 0.001) correlations were observed between OHS and EQ-5D preoperatively (r = 0.690) and postoperatively (r = 0.777) and for change (r = 0.611) and combined scores (r = 0.812). Four models predicting EQ-5D from OHS explained 38.5% to 65.9% of the variance. Age and BMI did not improve model fit. Predicted mean EQ-5D utilities differed statistically from observed values for most models, but all differences were below the minimal clinical important difference (MCID). Including individual OHS items marginally improved performance (<2%). External validation showed good agreement at the cohort level but lower accuracy for individual-level prediction (27.7% for change to 65.0% for postoperative scores to be within the MCID). Conclusions: The EQ-5D-3L utility index, on a cohort level, may be reliably estimated from the OHS. Predicted individual patient utility error beyond the MCID varied from one-third to more than two-thirds depending on the data assessed and so should not be employed for this purpose on a patient level.

Background: Patient-reported outcome measures (PROMs) are important after hip fracture but can impose respondent burden. A simple global measure may provide complementary information about a patient’s overall perception of hip normality. The Normal Hip Score (NHS) is a single-item 0–100 measure of perceived hip normality. This study evaluated preliminary evidence of construct validity for the NHS following hip fracture surgery. Methods: This was a prospective observational study with cross-sectional validation analyses based on a single postoperative PROM assessment. Paired NHS–OHS and NHS–EQ-5D-5L data were available for 80 participants. The mean age was 79.3 years (SD 10.8), and 46 (57.5%) of these participants were female. Assessment occurred at a mean of 3.47 months (SD 0.75; range 2–7 months) following fracture surgery. The NHS was assessed in relation to the OHS and EQ-5D-5L index and dimensions. Convergent validity was assessed using Pearson and Spearman correlations, with exploratory analyses of individual OHS items and EQ-5D-5L dimensions. Known-groups validity was examined across OHS quartiles, and multivariable linear regression was performed. Results: The mean NHS was 60.4 (SD 25.4). NHS demonstrated a moderate correlation with OHS (Pearson r = 0.657, 95% CI 0.511–0.766; p < 0.001) and with the EQ-5D-5L index (r = 0.541, 95% CI 0.365–0.680; p < 0.001). All 12 OHS items and all five EQ-5D-5L dimensions were significantly associated with NHS. The strongest OHS item associations were pain when rising from a chair, pain, work/housework interference, limping, and washing/bathing. Mobility showed the strongest EQ-5D-5L dimension association. NHSs increased across OHS quartiles (Kruskal–Wallis H = 35.77; p < 0.001). In multivariable analysis, OHS remained associated with NHS (β = 1.54, 95% CI 0.80–2.28; p < 0.001). Conclusions: The NHS demonstrated preliminary evidence of cross-sectional construct and known-groups validity following hip fracture surgery. The findings support the NHS as a potentially useful complementary global measure of perceived hip normality, but do not establish test–retest reliability, responsiveness, clinically meaningful change, or suitability for standalone clinical use.

Aims: Necrotizing fasciitis (NF) is a rapidly progressive surgical emergency. The effects of time from hospital presentation to theatre on short- and long-term outcomes, as well as specific modifiable aspects of the care pathway that would enable early surgery, remain poorly defined. Methods: A retrospective cohort study of all suspected cases of limb NF presenting across a large health board region over ten years (January 2015 to April 2025) was undertaken. Early surgery was defined as ≤ six hours from presentation (triage time) to theatre (operation start time). The independent associations between surgical timing and 30-day mortality or amputation were assessed. A timeline analysis identified areas where delays occurred. Survivors completed the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and Toronto Extremity Salvage Score (TESS) outcome assessments. Results: Of 359 referrals, four patients died prior to surgery and 80 patients underwent emergency surgery due to surgeon suspicion of NF. For cases of intraoperatively confirmed NF (n = 63/80), early surgery was associated with a five-fold reduction in 30-day mortality rate (overall rate 22% (n = 14/63); adjusted hazard ratio 0.19, 95% CI 0.04 to 0.87, p = 0.032; absolute risk difference 25%). Additionally, early surgery was associated with reduced rates of 30-day amputation (overall rate 30% (n = 19/63); adjusted hazard ratio 0.19, 95% CI 0.05 to 0.66, p = 0.009; absolute risk difference 32%). At a median of 27 months’ follow-up (IQR 16 to 48), only 35 patients (56%) were alive. Survivors having early surgery reported significantly better patient-reported outcomes (EQ-5D: 0.785 vs 0.133, p = 0.003; TESS combined: 64.9 vs 28.7, p = 0.007). Conclusion: Early surgery for patients with NF was associated with a lower risk of mortality, amputation, and severe long-term disability. Early recognition and transfer to theatre represent modifiable targets for improving survival and outcomes. Cite this article: Bone Jt Open 2026;7(9):1126–1136.

Robotic-assisted arthroplasty paradox: the disconnect between precision and patient-perceived outcomes

The number of fractures of the distal humerus in older adults is rising due to an ageing population and an increasing incidence of fragility fractures. The management is based on the patient’s preference, the pattern of the fracture, the quality of the bone and soft-tissue, the patient’s comorbidities and potential for rehabilitation, as well as balancing the risk of complications such as infection, nonunion, instability, or loosening. Nonoperative treatment remains appropriate for a few low-demand or medically unfit patients. Open reduction and internal fixation (ORIF) or arthroplasty, either hemiarthroplasty (HA) of the elbow or total elbow arthroplasty (TEA), provide good outcomes when appropriately selected. An increase in the use of arthroplasty for trauma is shown in registry data, although the indications and survival remain controversial with few robust comparative and long-term data. Similar short- to mid-term functional outcomes between ORIF and TEA have been reported in recent comparative studies, with a trend towards an increased reoperation rate after ORIF, but the evidence is derived largely from small retrospective observational studies. HA of the elbow may be a viable alternative for active older patients, particularly when stable fixation is not achievable, although instability and conversion to TEA may be required. The aim of this review was to synthesize the current evidence dealing with the indications, techniques, and outcomes for nonoperative management, ORIF and arthroplasty in older patients with a distal humeral fracture. Cite this article: Bone Joint J 2026;108-B(7):859–870.

The prolonged waiting times for hip and knee arthroplasty have resulted in numerous negative effects for patients being reported, with none more important than increasing opioid reliance due to chronic musculoskeletal pain. Opioid use prior to surgery is a factor associated with prolonged use postoperatively, and while opioids remain a valuable resource in the management of acute surgical pain, ongoing use carries substantial clinical, psychological, and societal risks. Recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance and the 2024 UK consensus statement have resulted in a shift for perioperative pain management, moving away from routine modified release opioid use towards individualized care. To address these issues and changes, interventions need to be focused both preoperatively and postoperatively using improved risk stratification, patient education, and community engagement. This annotation discusses these issues and emphasizes the importance of opioid stewardship as a unifying framework to embed principles across the arthroplasty pathway, with the aims of reducing harm, improving outcomes, and supporting safer sustainable care. Cite this article: Bone Joint J 2026;108-B(7):853–858.

Purpose: To define the ‘patient acceptable symptom state’ (PASS) and ‘minimum important change’ (MIC) for the Oxford Hip Score (OHS) following aseptic revision total hip arthroplasty (rTHA), and identify factors associated with their achievement. Methods: A prospective cohort of 135 patients (138 hips) undergoing aseptic rTHA at a single centre were followed up at one and two years postoperatively. Demographics, health-related quality of life (HRQoL; EQ-5D) and OHS were recorded at each timepoint. Anchor techniques were used to define the MIC and PASS. Regression models identified factors associated with PASS and MIC achievement. Results: The OHS PASS was 31.5 and 33.5 at one and two years postoperatively, respectively. The MIC was 8.5 at both timepoints. A greater preoperative EQ-5D was independently associated with PASS achievement at both timepoints. One-year MIC achievement was independently associated with lower BMI ( p = 0.042) and lower preoperative OHS ( p = 0.007), whilst lower preoperative OHS ( p = 0.016) alone was independently associated with two year MIC achievement ( p = 0.016). Lower preoperative EQ-5D and ASA grade 3 were associated with failure to achieve either PASS or MIC at one year ( p = 0.030) and two years ( p = 0.013) postoperatively, respectively. Conclusion: The PASS and MIC thresholds for the OHS following aseptic rTHA contextualise the score and can inform study design. Greater preoperative HRQoL was independently associated with PASS achievement, whilst worse preoperative function was independently associated with MIC achievement. These thresholds should be considered in conjunction when assessing outcomes following aseptic rTHA.

The ‘terrible triad’ injury of the elbow is defined as a dislocation of the elbow with concomitant fractures of the radial head and coronoid process. The term was based on reports of poor outcomes following this pattern of injury. However, the ‘terrible triad’ concept has meant that some very complex elbow fracture-dislocations are considered alongside more benign injuries, leading to problems with our understanding and interpretation of the literature. This annotation explores how our knowledge of elbow stability has evolved, and how the importance of the coronoid to this is becoming increasingly clear. It suggests how we best define, classify, and manage fractures of the coronoid as part of these complex injuries. Cite this article: Bone Joint J 2026;108-B(4):442–446.