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Risk & Prognosis

Risk factors for residual back pain and new vertebral compression fractures following percutaneous vertebral augmentation, focusing on patient, radiological, and surgical predictors.

Overview

Risk stratification is essential for identifying individuals at high risk of recurrent instability following first-time patellar dislocation, as not all patients achieve favorable outcomes with conservative treatment [1]. A multivariable model based on individual risk factors can effectively identify patients at high risk for recurrent lateral patellar dislocation, designating these individuals as good candidates for early operative treatment [7]. Valid prognosis studies require representative patient samples and sufficient homogeneity regarding prognostic risk to ensure reliability [2].

Specific patient factors significantly influence outcomes across various orthopaedic procedures. In the elderly, attention to specific prognostic factors may reduce complications after proximal humerus fracture surgery [5], while increasing age, male sex, and higher comorbidity are associated with numerous complications and worse recovery after hip fracture [13]. Conversely, obesity is a poor predictor of complications in total joint arthroplasty, and no specific BMI cutoff should be recommended as an absolute contraindication [10]. Despite higher risks of revision and complications, morbidly obese patients derive functional benefits from total knee arthroplasty that surpass these risks [20].

Surgeons must also account for specific comorbidities and anatomical variables to optimize planning. Hypothyroidism increases the risk of periprosthetic joint infection, necessitating heightened awareness during risk stratification [34]. For anterior cervical corpectomy and fusion, lower C2 slope and milder uncovertebral joint degeneration are risk factors for pseudarthrosis that should be considered in surgical planning [21]. Proper patient selection and technical attention remain critical to reducing high complication rates in reverse total shoulder arthroplasty [11], while optimizing bone health is vital for minimizing periprosthetic fracture risks following total hip arthroplasty [12]. Reported adverse outcome rates for pulmonary embolism prophylaxis in total knee arthroplasty are now far lower than historically reported [9].

Anatomy & Pathophysiology

Osseous

Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis [43], while facet tropism may play a more important role in the pathogenesis of chronic low back pain [68]. Age and bone mineral density (BMD) are major risk factors for vertebral fracture risk [78], with reduced cortical bone density in vertebral bodies serving as a specific risk for osteoporotic fractures [74]. The T12 vertebral body has the highest likelihood of experiencing an osteoporotic fracture [74]. Cervical kyphosis is associated with health-related quality of life [72], and the spinal morphological characteristics of thoracolumbar kyphosis must be taken into account during surgical planning to prevent placing the upper instrumented vertebra (UIV) within the kyphotic region [51]. Measurement of thoracic kyphosis (TK) with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6° [76]. Evaluation of fall risk factors contributes to identifying patients with bone risk factors at highest immediate risk of subsequent non-vertebral fracture despite guideline-based treatment [22].

Ligamentous & Joint

The posterior and posterior superior labral (PPS) injury produces alterations in glenohumeral kinematics with implications for glenohumeral joint instability, increased glenohumeral joint loading, and potential joint damage [64].

Kinematics & Biomechanics

Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [77]. Improved physical performance, including walking and balancing, after decompression lumbar spinal surgery reduces the future risk of falling [30]. A personalized risk calculator was developed to assess the risk of proximal junctional kyphosis after adult spinal deformity surgery based on novel and modifiable clinical features [66]. Lumbosacral fixation should be considered for patients with specific risk factors for L5 radiculopathy following lumbar floating fusion surgery even if they have few symptoms from the L5-S1 junction [79]. Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year [32]. There is a lack of evidence regarding neuromuscular and biomechanical risk factors for ACL injury in male athletes [57].

Classification

Risk Stratification: Risk stratification identifies individuals at high risk of recurrent instability following first-time patellar dislocation [1], though not all such patients do well with conservative treatment [1]. Prognosis studies, defined as investigations examining possible outcomes and their probabilities, require representative samples and patient homogeneity regarding prognostic risk to ensure validity [2].

Musculoskeletal Oncology: Classification in musculoskeletal oncology, which involves the diagnosis and management of benign tumors, sarcomas, and metastatic carcinoma, is based on histomorphology to yield insight into behavior and prognosis [24]. The revised Tokuhashi, Tomita, and modified Bauer scoring systems demonstrate equal overall prognostic performance [3].

Joint Arthroplasty & Comorbidities: The American Society of Anesthesiologists (ASA) classification is the most commonly used comorbidity measure in orthopaedic surgery and is systematically recorded by the majority of national arthroplasty registries [49]. For elective total hip arthroplasty, 30-day mortality risk is highest in patients aged 80–89, of ASA class IV, with a Charlson Comorbidity Index (CCI) score of 4, or with a non-OA diagnosis [31]. Multiple HbA1c strata can be incorporated into preoperative risk-stratification models for total hip arthroplasty [45]. Demographic variables including advanced age, low family income, and multiple medical conditions significantly affect scores for total knee arthroplasty [53].

Pathological Fracture & Transfusion: The Katagiri-New score identifies patients with intermediate-to-high risk for impending pathological fractures at the proximal femur; these patients have a lower mortality rate than those undergoing surgery for established pathological fractures [46]. The OARA score reliably identifies patients at risk for postoperative blood transfusion, whereas the ASA grade does not [60].

Other Considerations: Clinical classification systems established for post-tuberculosis kyphosis facilitate precise risk stratification, enable targeted preoperative interventions to mitigate surgical risks, and enhance surgical outcomes [18]. A risk score for osteonecrosis of the femoral head demonstrates satisfactory discrimination, calibration, and clinical utility with good internal validity [8]. In studies of septic arthritis risk factors, the subset of patients with active malignancy was small and varied widely, preventing statistical conclusions when further dividing patients into groups [59]. The current risk stratification method based on DRG code, geography, and the presence of a fracture is helpful for Medicare's "Comprehensive Care for Joint Replacement" bundled payments, though substantial room for improvement remains by adjusting based on demographics, comorbidities, and procedure type [61].

Clinical Presentation

Risk stratification is essential for identifying individuals at high risk of recurrent instability following first-time patellar dislocation [1]. While conservative management is standard, not all patients with first-time patellar dislocation do well with this approach [1]. A multivariable model based on individual risk factors can effectively identify patients at high risk for recurrent lateral patellar dislocation; those identified as high risk are good candidates for early operative treatment [7].

Prognosis studies examine the possible outcomes of a disease or operative procedure and the probability with which they can be expected to occur [2]. Validity assessment requires determining if there was a representative sample of patients and if patients were sufficiently homogeneous with respect to prognostic risk [2]. Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation [4].

Risk Factors: * Total Hip Arthroplasty: Patients and physicians must be aware of the relationship between patient-reported allergies and poor outcomes, and should identify and optimize other risk factors for poor outcome [6]. Dependent functional status is a risk factor for perioperative and postoperative complications, aiding patient counseling and risk stratification [14]. * Hip Fracture: Increasing age, male sex, and higher comorbidity are associated with a higher number of complications and may explain the higher mortality and worse recovery seen in these groups [13]. * Thromboembolism: Patients should be carefully evaluated for risk factors associated with thromboembolic complications given the increased mortality associated with pulmonary embolism [15]. * Total Joint Arthroplasty: Obesity is a poor predictor of complications, and a specific BMI cutoff cannot be recommended as an absolute contraindication [10]. * Osteoporosis: The identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies [23].

Specific Clinical Scenarios: * Proximal Humerus Fractures: Paying attention to specific prognostic factors may help to reduce the complication rate after surgical treatment in the elderly [5]. * Low Back Pain: Risk factors for pain severity in non-specific low back pain should be considered for early interventions to improve outcomes [16]. * Vertebral Augmentation: Early identification and targeted management of high-risk patients may help reduce residual back pain incidence after vertebral augmentation in osteoporotic vertebral compression fracture patients [19]. * Anterior Cervical Corpectomy and Fusion: Lower C2 slope and milder uncovertebral joint degeneration are risk factors for pseudarthrosis; these characteristics should be further considered in surgical planning to identify high-risk patients [21]. * Post-Tuberculosis Kyphosis: Clinical classification systems facilitate precise risk stratification for postoperative neurological complications and enable targeted preoperative interventions to mitigate surgical risks and enhance outcomes [18].

Scoring Systems and Oncology: The revised Tokuhashi, Tomita, and modified Bauer scoring systems are equally good in terms of overall prognostic performance [3]. A risk score for osteonecrosis of the femoral head demonstrated satisfactory discrimination and calibration performance with clinical utility and good internal validity [8]. Musculoskeletal oncology involves the diagnosis and management of neoplastic conditions affecting the musculoskeletal system, including benign tumors, sarcomas, and metastatic carcinoma [24]. Classification of these conditions based on histomorphology yields insight into behavior and prognosis [24].

Pediatric and Tumor-Specific Risks: While each risk factor for growth retardation in children with juvenile idiopathic arthritis demonstrates moderate predictive value individually, their combined consideration significantly improves predictive accuracy [25]. There is an increased risk of pulmonary metastasis of giant cell tumor of bone in patients who are younger, present with Enneking stage-3 disease, develop local recurrence, or present with axial disease [26].

Investigations

Plain radiography: Preoperative assessment of spinopelvic risk factors, particularly abnormal standing pelvic tilt, is critical as patients with two or more factors demonstrate significantly lower postoperative HOOS-JR scores after total hip arthroplasty [47]. In the context of posterior lumbar fusion, preoperative CT examination identifying disc bulge is related to the occurrence of symptomatic adjacent segment degeneration surgery [50]. Additionally, preoperative MRI findings of adjacent disc degeneration are similarly related to subsequent symptomatic adjacent segment degeneration surgery [50].

MRI: Detailed and specific information regarding prognosis is critical in the management of a first-time anterior shoulder dislocation [4]. For juvenile discoid lateral meniscus, an anterocentral shift on preoperative MRI serves as a risk factor for degenerative changes and smaller residual meniscal width following arthroscopic reshaping [40]. In rotator cuff pathology, specific radiological parameters on imaging are associated with outcomes after retear; an increased AP retear size and a decreased anterior humeral distance (AHD) are both linked to poor clinical outcomes [67].

CT: As noted in plain radiography, preoperative CT examination findings of disc bulge are related to the occurrence of symptomatic adjacent segment degeneration surgery after posterior lumbar fusion [50].

Bone scan: F-18-FDG PET/CT is indicated for septic shoulder arthritis, as a negative result excludes the diagnosis with high probability [63].

Other Considerations: Risk stratification tools are essential for identifying individuals at high risk of recurrent instability following first-time patellar dislocation, as not all such patients do well with conservative treatment [1]. A multivariable model based on individual risk factors can identify patients at high risk for recurrent lateral patellar dislocation, who are subsequently good candidates for early operative treatment [7]. In spinal metastases, the revised Tokuhashi, Tomita, and modified Bauer scoring systems demonstrate equal overall prognostic performance [3]. For osteonecrosis of the femoral head, a specific risk score has demonstrated satisfactory discrimination and calibration performance with good internal validity [8]. In total joint arthroplasty, patient-reported allergies are a risk factor for poor outcomes in both total hip and total knee procedures [6], while prior fragility fractures increase the risk of periprosthetic fracture following total hip arthroplasty [12]. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize periprosthetic fracture complications [12]. Prior total joint replacement (TJR) is a risk factor for subsequent TJR in the contralateral joint [17]. Proper patient selection and attention to technical details are required to reduce the high complication rate associated with reverse total shoulder arthroplasty [11]. In pediatric populations, while individual risk factors for growth retardation in juvenile idiopathic arthritis show moderate predictive value, their combined consideration significantly improves predictive accuracy [25]. For giant cell tumor of bone, increased risk of pulmonary metastasis is associated with younger age, Enneking stage-3 disease, local recurrence, and axial disease presentation [26]. Regarding lumbar fusion, overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting fusion status at one year [32]. Symptomatic adjacent segment degeneration surgery after posterior lumbar fusion is also related to BMI [50]. A proper understanding of cardiac diagnoses before surgical intervention provides insight into potential risks for patients undergoing elective spine fusion [70]. Finally, patient demographic characteristics, alignment, and radiographic arthritic changes did not differ between nonextruded and extruded lateral meniscal allograft transplant cases [71].

Treatment

Risk stratification is essential across orthopaedic practice to identify individuals at high risk for recurrent instability following first-time patellar dislocation [1] and to guide management decisions, as not all patients with first-time patellar dislocation do well with conservative treatment [1]. Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation [4], while a multivariable model based on individual risk factors can identify patients at high risk for recurrent lateral patellar dislocation who are good candidates for early operative treatment [7].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [42]. In hip arthroscopy, unreasonable expectations by the patient will doom the operation, and subjective contraindications often take precedence over objective ones [33]. For osteoporotic vertebral compression fractures, early identification and targeted management of high-risk patients may help reduce residual back pain incidence after vertebral augmentation [19].

Surgical Approach / Technique: Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [35]. Paying attention to specific prognostic factors may help to reduce the complication rate after surgical treatment of proximal humerus fractures in the elderly [5].

Implant Selection: Patients and physicians should identify and optimize other risk factors for poor outcomes when patient-reported allergies are present in total hip and knee arthroplasty [6].

Alignment / Balancing Strategy: There was no correlation between treatment outcome and the Instability Severity Index Score (ISIS) measure in recurrent anterior shoulder instability, suggesting the measure may need to be redesigned [36].

Pain Management: Risk factors for pain severity in non-specific low back pain should be considered for early interventions to improve outcomes [16].

Adjuncts: Treatment of a fracture and increased operative time were risk factors for all adverse events following total elbow arthroplasty, while outpatient status was protective [58].

Setting of Care: Outpatient status was protective against adverse events following total elbow arthroplasty [58].

Other Considerations: A risk score for osteonecrosis of the femoral head demonstrated satisfactory discrimination, calibration performance, and clinical utility with good internal validity [8]. Reported adverse outcome rates for pulmonary embolism prophylaxis in total knee arthroplasty are far lower than historically reported regardless of the chosen regimen [9]. Obesity is a poor predictor of complications in total joint arthroplasty, and a specific BMI cutoff cannot be recommended as an absolute contraindication [10]. Identification of high-risk patients with prior fragility fractures and emphasis on preoperative and postoperative bone health optimization may help minimize periprosthetic fracture risk following total hip arthroplasty [12]. Patients should be carefully evaluated for risk factors associated with thromboembolic complications after total hip arthroplasty and managed with an appropriate chemoprophylactic regimen given the increased mortality associated with pulmonary embolism [15]. The risk of 30-day mortality after elective total hip arthroplasty was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis [31]. Evaluation of fall risk factors contributes to identifying patients with bone risk factors at highest immediate risk of subsequent non-vertebral fracture despite guideline-based treatment [22]. Identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies [23]. Improved physical performance, including walking and balancing, after decompression lumbar spinal surgery reduces the future risk of falling in patients with lumbar spinal stenosis [30]. Patients with a low-risk RIPSS score without ABR+R may not benefit from remplissage augmentation, whereas patients with a high- or extreme-risk RIPSS score would likely benefit from remplissage supplementation [37]. The decision on whether to offer surgery to patients with carpal tunnel syndrome may be influenced by nonclinical factors, and treatment recommendations from the health-care provider can be an important contributing factor to disparities [55].

Complications

Instability: Risk stratification tools can identify individuals at high risk of recurrent instability following a first-time patellar dislocation [1], though not all patients with this injury achieve satisfactory outcomes with conservative treatment alone [1].

Thromboembolism: Increased mortality is associated with pulmonary embolism following total hip arthroplasty [15]. Reported adverse outcome rates for pulmonary embolism prophylaxis in total knee arthroplasty are significantly lower than historically reported, regardless of the specific prophylactic regimen chosen [9].

Infection (PJI): The greatest risk factors for infection after reverse shoulder arthroplasty include a history of prior failed arthroplasty and age younger than 65 years [65]. Greater comorbidity is associated with increased odds of a complication after total hip arthroplasty for hip osteoarthritis [41].

Wound complications: Dependent functional status is a risk factor for perioperative and postoperative complications after total hip arthroplasty [14]. Patient-related factors such as increasing age, male sex, and higher comorbidity are associated with a number of complications after hip fracture [13]. Risk estimates from the American College of Surgeons Risk Calculator were significantly associated with complications in categories of any complication, cardiac complication, pneumonia, and discharge to a skilled nursing facility [39], although the predictability of complication occurrence was poor for all complications assessed by this calculator [39].

Other Considerations: Prognosis studies examine possible outcomes and their probabilities, with validity primarily guided by sample representativeness and patient homogeneity regarding prognostic risk [2]. Revised Tokuhashi, Tomita, and modified Bauer scoring systems demonstrated equal overall prognostic performance [3]. Paying attention to specific prognostic factors may help reduce complication rates after surgical treatment of proximal humerus fractures in the elderly [5]. Patient-reported allergies are a risk factor for poor outcomes in total hip and total knee arthroplasty [6]. Higher comorbidity, increasing age, and male sex may explain the higher mortality and worse recovery seen in patients with hip fracture [13]. Prior total joint replacement is a risk factor for subsequent total joint replacement in the contralateral joint [17]. Frailty is associated with longer hospitalizations, more major complications, and non-home discharge after total elbow arthroplasty [28]. A prognostic model can accurately predict a 1-year survival rate for patients with fragile hip fractures [29]. Greater comorbidity was independently associated with slightly worse patient-rated outcomes 12 months after total hip arthroplasty for hip osteoarthritis [41]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [73]. Patients aged over 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing a subsequent fracture within the next 2 years [75]. Further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [27]. Adverse outcomes from intra-articular hip corticosteroid injections occur in patients without pre-existing osteoarthritis, despite most available literature reporting such outcomes in patients with pre-existing osteoarthritis [38].

Recovery

Risk Stratification & Prognostic Indicators: Risk stratification tools can identify individuals at high risk of recurrent instability following first-time patellar dislocation [1], while detailed and specific information regarding prognosis is critical in the management of a first-time anterior shoulder dislocation [4]. Specific patient factors significantly influence outcomes: dependent functional status is a risk factor for perioperative and postoperative complications after total hip arthroplasty [14], and frailty is associated with longer hospitalizations, more major complications, and non-home discharge after total elbow arthroplasty [28]. Prior total joint replacement (TJR) serves as a risk factor for subsequent TJR in the contralateral joint [17], and a maternal age of twenty-seven years or more indicates a risk factor for greater progression of the curve in idiopathic scoliosis and a potential need for arthrodesis [83]. A prognostic model can accurately predict a 1-year survival rate for patients with fragile hip fractures [29].

Surgical Selection & Outcome Trade-offs: Proper patient selection and attention to technical details are needed to reduce the currently high complication rate associated with reverse total shoulder arthroplasty [11]. While current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [54], the incidence of complications and revision surgery does not differ significantly between current smokers, former smokers, and nonsmokers [54]. Beyond the first year, the infection risk after primary total joint arthroplasty is similar to never smokers for those who smoke [82]. For morbidly obese patients undergoing total knee arthroplasty, the gained benefit in functional outcome surpasses the increase in risk of revision and complications [20]. Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy for osteonecrosis of the femoral head, though physical recovery requires an extended duration [48]. If adequately treated, avulsion fractures of the tibial spine show a good long-term prognosis [52].

Complication Rates & Prophylaxis: No matter what prophylactic regimen is chosen for pulmonary embolism, the reported adverse outcome rates in total knee arthroplasty patients are far lower than historically reported [9]. Early reimplantation (abbreviated two-stage) for infection provides similar outcomes to traditional two-stage exchange, though optimal timing and selection criteria remain undefined [80]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [27].

Functional Assessment & Prognostic Models: The three scoring systems (revised Tokuhashi, Tomita, and modified Bauer) were equally good in terms of overall prognostic performance for the Oswestry Risk Index [3]. The Musculoskeletal Function Assessment Questionnaire was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [56]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [81]. Not all patients with first-time patellar dislocation do well with conservative treatment [1].

Key Evidence

  • [L5] Risk stratification can identify individuals at high risk of recurrent instability, and while treatment remains controversial, not all patients do well with conservative treatment. (10.1016/j.arthro.2019.05.039)
  • [L5] Prognosis studies are investigations examining the possible outcomes of a disease or operative procedure and the probability with which they can be expected to occur; primary guides for assessing their validity include determining if there was a representative sample of patients and if patients were sufficiently homogeneous with respect to prognostic risk. (10.2106/00004623-200110000-00017)
  • [L2] The three scoring systems (revised Tokuhashi, Tomita, and modified Bauer) were equally good in terms of overall prognostic performance. (10.1302/0301-620x.95b2.29323)
  • [L2] Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation. (10.1016/j.jse.2010.10.037)
  • [L3] Paying attention to specific prognostic factors may help to reduce the complication rate. (10.1016/j.jse.2019.02.017)
  • [L3] This multivariable model can identify patients who are at high risk for recurrent dislocation and would be good candidates for early operative treatment. (10.2106/jbjs.20.00020)
  • [L3] The risk score had satisfactory discrimination and calibration performance and demonstrated clinical utility with good internal validity. (10.1016/j.arth.2020.07.046)
  • [L3] No matter what prophylactic regimen is chosen, the reported adverse outcome rates are far lower than historically reported. (10.1016/j.arth.2011.04.006)
  • [L3] Proper patient selection and attention to technical details are needed to reduce the currently high complication rate associated with reverse total shoulder arthroplasty. (10.5435/jaaos-d-21-01090)
  • [L3] Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications. (10.1016/j.arth.2023.02.043)
  • [L2] Patient-related factors such as increasing age, male sex, and higher comorbidity were associated with a number of complications, which may explain the higher mortality and worse recovery seen in these groups. (10.1302/0301-620x.107b9.bjj-2024-0981.r2)
  • [L3] These data may aid for patient counseling and risk stratification. (10.1016/j.arth.2018.12.037)
  • [L3] Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen. (10.5435/jaaos-d-23-01213)
  • [L4] These factors should be considered for early interventions to improve outcomes in non-specific low back pain. (10.1186/s12891-024-07828-w)
  • [L2] The observation that prior TJR is a risk factor for subsequent TJR in the contralateral joint has not been described previously. (10.1186/s12891-016-0864-7)
  • [L3] The clinical classification systems established herein facilitate precise risk stratification, enabling targeted preoperative interventions to mitigate surgical risks and enhance surgical outcomes. (10.1186/s13018-025-06112-4)
  • [L1] Early identification and targeted management of high-risk patients may help reduce RBP incidence. (10.1186/s12891-025-08945-w)
  • [L1] The gained benefit in functional outcome surpasses the increase in risk of revision and complications for the morbidly obese in TKA surgery. (10.1530/eor-21-0090)
  • [L3] These characteristics should be further considered in surgical planning to identify high-risk patients. (10.1186/s13018-025-05629-y)
  • [L2] Evaluation of fall risk factors contributes to identifying patients with bone risk factors at highest immediate risk of subsequent non-vertebral fracture despite guideline-based treatment. (10.1186/1471-2474-14-121)
  • [L4] The identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies. (10.1186/1471-2474-3-22)
  • [L3] While each of these factors demonstrates moderate predictive value individually, their combined consideration significantly improves predictive accuracy. (10.1186/s12891-024-08247-7)
  • [L4] There is an increased risk of pulmonary metastasis of GCT of bone in patients who are younger, present with Enneking stage-3 disease, develop local recurrence, and/or present with axial disease. (10.2106/jbjs.n.00678)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L3] Frailty is associated with longer hospitalizations, more major complications, and non-home discharge. (10.1177/15589447221093728)
  • [L3] This prognostic model can accurately predict a 1-year survival rate for patients with fragile hip fractures. (10.1186/s13018-021-02774-y)
  • [L2] Improved physical performance, including walking and balancing, after decompression lumbar spinal surgery reduces the future risk of falling. (10.2106/jbjs.m.00427)
  • [L3] The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. (10.1016/j.arth.2021.05.026)
  • [L2] Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year. (10.1186/s13018-025-05814-z)
  • [L5] Unreasonable expectations by the patient will doom the operation, and subjective contraindications often take precedence over objective ones. (10.1016/j.arthro.2019.02.011)
  • [L3] Surgeons should be aware of this increased risk when risk stratifying patients, and future studies should investigate whether medical optimization reduces this risk. (10.1016/j.arth.2015.10.028)
  • [L3] However, there was no correlation between treatment outcome and the ISIS measure, suggesting the ISIS measure may need to be redesigned to incorporate variables that more accurately portray the actual risk of failure. (10.1177/2325967119s00269)
  • [L3] Patients with a low-risk RIPSS score without ABR+R may not benefit from remplissage augmentation, whereas patients with a high- or extreme-risk RIPSS score would likely benefit from remplissage supplementation. (10.1177/2325967124s00011)
  • [L5] Adverse outcomes occur in patients without pre-existing osteoarthritis, but most of the available literature reports these outcomes in patients with pre-existing osteoarthritis. (10.1016/j.asmr.2025.101169)
  • [L3] An anterocentral shift on preoperative MRI was a risk factor for degenerative changes and smaller residual meniscal width. (10.1177/0363546516668623)
  • [L3] Greater comorbidity was associated with increased odds of a complication and (independently) slightly worse patient-rated outcome 12 months after THA. (10.1016/j.arth.2020.04.090)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L3] Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis. (10.1155/2020/2453503)
  • [L3] Our results support the use of multiple HbA1c strata that can be incorporated into preoperative risk-stratification models. (10.1016/j.arth.2023.10.024)
  • [L3] Patients with intermediate-to-high risk IF based on the Katagiri-New score had a lower mortality rate than those who underwent surgery for pathological fractures. (10.1186/s12891-024-07838-8)
  • [L3] While preoperative spinopelvic risk factors did not universally result in inferior functional outcomes, patients with multiple risk factors (two or more), particularly those with abnormal standing pelvic tilt, showed significantly lower postoperative HOOS-JR scores. (10.1302/0301-620x.107b8.bjj-2024-1441.r1)
  • [L3] Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy, though physical recovery requires an extended duration. (10.1016/j.arth.2025.06.066)
  • [L5] Currently, the ASA classification is the most commonly used comorbidity measure and is systematically recorded by the majority of national arthroplasty registries. (10.1302/2058-5241.6.200124)
  • [L3] The occurrence of a symptomatic adjacent segment degeneration surgery is most likely multifactorial and is related to BMI, preoperative adjacent disc degeneration on MRI, and disc bulge in preoperative CT examination. (10.1186/s13018-014-0097-0)
  • [L3] The spinal morphological characteristics of thoracolumbar kyphosis must be taken into account during surgical planning to prevent placing the UIV within the kyphotic region. (10.1186/s13018-025-05458-z)
  • [L4] If adequately treated, avulsion fractures of the tibial spine show a good long-term prognosis. (10.1007/s00167-003-0387-2)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L3] Current smokers may have poorer functional outcomes after rTSA compared to former smokers and nonsmokers, despite the incidence of complications and revision surgery not differing significantly between cohorts. (10.1016/j.jse.2024.07.052)
  • [L5] The decision on whether to offer surgery to patients with CTS may be influenced by nonclinical factors, and treatment recommendations from the health-care provider can be an important contributing factor to disparities. (10.2106/jbjs.23.00637)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L4] There is a lack of evidence regarding neuromuscular and biomechanical risk factors for ACL injury in male athletes. (10.1007/s00167-013-2725-3)
  • [L3] Treatment of a fracture and increased operative time were risk factors for all patients, while outpatient status was protective. (10.1186/s13018-024-05214-9)
  • [Letter] The subset of patients with active malignancy was small and varied widely, preventing statistical conclusions when further dividing patients into groups. (10.5435/jaaos-d-22-01044)
  • [L3] The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. (10.1302/0301-620x.103b1.bjj-2019-1555.r3)
  • [L3] The current risk stratification method based on DRG code, geography, and the presence of a fracture is helpful but there remains substantial room for improvement, particularly by adjusting based on demographics, comorbidities, and procedure type. (10.1016/j.arth.2018.04.006)
  • [L3] A negative F-18-FDG PET/CT excludes septic shoulder arthritis with high probability. (10.1016/j.jse.2025.01.047)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L3] The greatest risk factors for infection after RSA were history of a prior failed arthroplasty and age younger than 65 years. (10.1016/j.jse.2014.05.020)
  • [L3] The study developed a personalized risk calculator to assess the risk of proximal junctional kyphosis after adult spinal deformity surgery based on novel and modifiable clinical features, facilitating individualized risk factor assessment and guiding perioperative management. (10.1302/0301-620x.107b8.bjj-2024-1474.r2)
  • [L3] An increased AP retear size and decreased AHD were radiological parameters that were associated with poor clinical outcomes after a retear. (10.1177/03635465221128232)
  • [L3] Facet tropism (FT) may play a more important role in the pathogenesis of chronic low back pain. (10.1186/s13018-020-01706-6)
  • [L3] Before surgical intervention, a proper understanding of cardiac diagnoses could give insight into the potential risks for each patient based on their heart condition and preventive measures showing benefit in minimizing perioperative complications after elective spine fusion. (10.5435/jaaos-d-21-00850)
  • [L4] Patient demographic characteristics, alignment, and radiographic arthritic changes did not differ between nonextruded and extruded MAT cases. (10.1016/j.arthro.2014.10.016)
  • [L3] Cervical kyphosis is associated with health-related quality of life. (10.1186/s13018-019-1351-2)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L3] Additionally, the T12 vertebral body has the highest likelihood of experiencing an osteoporotic fracture. (10.1186/s13018-024-04896-5)
  • [L3] This cohort of Canadian patients aged > 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing subsequent fracture within the next 2 years and should be proactively assessed and treated. (10.1186/s12891-021-04051-9)
  • [L3] Measurement of TK with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6°. (10.1186/s12891-021-04786-5)
  • [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
  • [L3] These data confirm that age and BMD are major risk factors for vertebral fracture risk. (10.1186/1471-2474-13-163)
  • [L3] These findings indicate that lumbosacral fixation should be considered for patients with these risk factors even if they have few symptoms from the L5-S1 junction. (10.1186/s13018-015-0307-4)
  • [L1] Early reimplation (abbreviated two-stage) provides similar outcomes to traditional two-stage exchange, though optimal timing and selection criteria remain undefined. (10.1016/j.arth.2025.10.075)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L2] Beyond the first year, the infection risk was similar to never smokers. (10.1016/j.arth.2018.02.069)
  • [L3] A maternal age of twenty-seven years or more is a risk factor for greater progression of the curve and indicates a potential need for arthrodesis. (10.2106/00004623-199072060-00018)

See Also

References

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[2] Userʼs Guide to the Orthopaedic Literature: How to Use an Article About Prognosis. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200110000-00017

[3] The Oswestry Risk Index. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b2.29323

[4] A predictive model of shoulder instability after a first-time anterior shoulder dislocation. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.10.037

[5] Complications after surgical treatment of proximal humerus fractures in the elderly—an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.02.017

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[7] Development of a Multivariable Model Based on Individual Risk Factors for Recurrent Lateral Patellar Dislocation. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.00020

[8] A Study on the Evaluation of a Risk Score of Osteonecrosis of the Femoral Head Based on Survival Analysis. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.07.046

[9] Pulmonary Embolism Prophylaxis in More Than 30,000 Total Knee Arthroplasty Patients: Is There a Best Choice?. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.04.006

[10] Complications_of_Morbid_Obesity_in_Total_Joint_Arthroplasty_Risk_Stratification_S088354031500474X. n.d..

[11] Risk of Revision Shoulder Arthroplasty After Anatomic and Reverse Total Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01090

[12] The Association of Prior Fragility Fractures on 8-Year Periprosthetic Fracture Risk Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.02.043

[13] Risk factors associated with the development of complications after a hip fracture. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b9.bjj-2024-0981.r2

[14] Dependent Functional Status is a Risk Factor for Perioperative and Postoperative Complications After Total Hip Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.12.037

[15] Risk Factors Associated with Thromboembolic Complications After total Hip Arthroplasty: An Analysis of 1,129 Pulmonary Emboli. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01213

[16] Risk factors Associated with Pain Severity in Syrian patients with non-specific low back Pain. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07828-w

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[18] Risk stratification and clinical classification for postoperative neurological complications in post-tuberculosis kyphosis: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06112-4

[19] Risk factors of residual back pain after vertebral augmentation in osteoporotic vertebral compression fracture patients: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08945-w

[20] Mid- to long-term complications and outcome for morbidly obese patients after total knee arthroplasty: a systematic review and meta-analysis. EFORT Open Reviews. 2022. DOI: 10.1530/eor-21-0090

[21] Lower C2 slope and milder uncovertebral joint degeneration are risk factors for pseudarthrosis after single-level anterior cervical corpectomy and fusion (ACCF): retrospective study of 102 patients with minimum 2-year follow-up. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05629-y

[22] The role of the combination of bone and fall related risk factors on short-term subsequent fracture risk and mortality. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-121

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[29] Development of a prognostic model for 1-year survival after fragile hip fracture in Chinese. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02774-y

[30] Comparison of Effects of Nonoperative Treatment and Decompression Surgery on Risk of Patients with Lumbar Spinal Stenosis Falling. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00427

[31] What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.05.026

[32] 18F-fluoride PET/CT as an early predictor of bony fusion after posterior lumbar interbody fusion– a prospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05814-z

[33] Editorial Commentary: Great Expectations or “We'll See,” Said the Zen Master—Hip Arthroscopy Patient Selection. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.02.011

[34] Increased Risk of Periprosthetic Joint Infections in Patients With Hypothyroidism Undergoing Total Joint Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2015.10.028

[35] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[36] The Instability Severity Index Score Revisited: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00269

[37] To Remplissage or not to Remplissage Part 2: Recurrent Instability After Primary Stabilization Surgery (RIPSS) Risk Tool Assesses Preoperative Failure Rates in On-track Shoulders Undergoing Primary Arthroscopic Anterior Stabilization with or without Remplissage Augmentation. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00011

[38] Risks of Intra‐articular Hip Corticosteroid Injections Include Rapidly Progressive Osteoarthritis and Femoral Head Collapse in Patients With and Without Pre‐existing Osteoarthritis: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2025. DOI: 10.1016/j.asmr.2025.101169

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[45] The Creation of Data-Driven Preoperative Hemoglobin A1c and Same-Day Glucose Strata to Stratify Complication Risk Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2023.10.024

[46] Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07838-8

[47] Impact of preoperative spinopelvic risk factors on functional outcomes after total hip arthroplasty. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b8.bjj-2024-1441.r1

[48] A Five-Year Longitudinal Assessment of Quality of Life and Employment Status in Patients Who Have Osteonecrosis of the Femoral Head Undergoing Femoral Osteotomy: A Multicenter Study. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.06.066

[49] Comorbidity indices in orthopaedic surgery: a narrative review focused on hip and knee arthroplasty. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200124

[50] Risk factors for predicting symptomatic adjacent segment degeneration requiring surgery in patients after posterior lumbar fusion. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0097-0

[51] Risk factors for mechanical complications in degenerative lumbar scoliosis with concomitant thoracolumbar kyphosis: does the selection of the upper instrumented vertebra matter?. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05458-z

[52] Treatment of malunited fractures of the anterior tibial spine. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0387-2

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[55] How Do Social Factors Impact Recommendation for Surgery?. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.23.00637

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[57] Prevention of anterior cruciate ligament injuries in sports—Part I: Systematic review of risk factors in male athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2725-3

[58] Short-term adverse event rates and risk factors following total elbow arthroplasty for fracture and arthropathy: a matched analysis of nationally representative data. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05214-9

[59] Response to Letter to the Editor: A Comparison of Risk Factors for Septic Arthritis in Immunocompromised Patients: A Single Institution Study. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-01044

[60] Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b1.bjj-2019-1555.r3

[61] Are Medicare's “Comprehensive Care for Joint Replacement” Bundled Payments Stratifying Risk Adequately?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.04.006

[63] 18F-FDG PET/CT for the diagnosis of septic shoulder arthritis: metabolic uptake pattern and diagnostic performance. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.047

[64] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[65] Risk factors for periprosthetic infection after reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.05.020

[66] Novel risk factors and personalized risk calculator for predicting proximal junctional kyphosis after adult spinal deformity surgery. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b8.bjj-2024-1474.r2

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b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.