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The primary aim assessed whether preoperative anemia was associated with a worse knee-specific functional outcome after total knee arthroplasty (TKA). The secondary aims assessed the association of preoperative anemia with generic health and patient satisfaction.A retrospective cohort study was undertaken to compare patients who did and did not have anemia (Hb13.0 g/dL for men and Hb11.5 g/dL for women). During a 1-year period, 497 patients underwent a total knee arthroplasty with complete preoperative and postoperative data, including 215 (43.3%) men and 282 (56.7%) women, who had a mean age of 70 years (range 45-93). Patient demographics, comorbidities, preoperative and postoperative (1 year) Oxford Knee Score (OKS), EuroQol 5 dimension (EQ-5D), postoperative Forgotten Joint Score (FJS), and patient satisfaction were collected. Regression analyses were used to adjust for confounding factors between the groups.The 56 (11.3%) patients who had anemia were older (4.6 years, P.001) and more likely to have chronic obstructive pulmonary disease (P = .004), connective tissue (P = .047), or kidney disease (P = .011) compared to those who did not have anemia. There were no differences in the preoperative OKS (P = .752) or EQ-5D (P = .762) scores between the groups. When adjusting for confounding differences, there was a significantly lower postoperative OKS (-3.0 points, P = .035) and FJS (-11.6 points, P = .011) associated with the anemia group. There were no significant differences in the EQ-5D (P = .118) or patient satisfaction between groups (odds ratio 0.84, P = .976).Preoperative anemia is associated with a lower postoperative joint-specific functional outcome. It is not clear if these differences are clinically meaningful. No difference in patient satisfaction was observed.Level III, diagnostic study.

Background The aim of this study was to determine if radiographic severity, extent or pattern of knee osteoarthritis was associated with pain and function before total knee arthroplasty (TKA) or improvement therein one year after TKA. Methods A prospective study of 259 patients undergoing unilateral TKA for Kellgren-Lawrence (KL) grade ≥ 3 knee osteoarthritis was conducted: mean age 69.8 ± 9.7 (44–91); mean BMI 31.0 ± 5.8 (17–52); 152/259 (58.7%) female. Preoperative radiographs were assessed using the KL and Ahlback systems. Preoperatively and 1 year postoperatively patients completed Oxford Knee Scores, VAS-Pain and EQ-5D scores. Full thickness cartilage loss was recorded intraoperatively. Results Median radiographic severity was Ahlback 2, KL 4: 51/259 (19.7%) hypertrophic; 23/259 (8.8%) atrophic. Neither Ahlback nor Kellgren-Lawrence OA grade was associated with OKS, VAS Pain or EQ-5D prior to TKA (p > 0.05). The extent and pattern of cartilage loss did not affect preoperative PROMs. Radiographic OA severity, compartment involvement, and pattern of cartilage loss were not significantly associated with PROMs or improvements therein following TKA (p > 0.05). Hypertrophic OA was associated with less pain before TKA (difference 6.8, 0.23–13.9 95%CI, p = 0.044), and worse improvement in OKS following TKA (difference −3.41, −6.8 to −0.05 95%CI, p = 0.047). Better preoperative OKS and hypertrophic OA were independently associated with poorer improvement in OKS 1 year following TKA (R2 = 0.208). Conclusion Provided at least one compartment has KL grade ≥ 3 changes, further radiographic severity, pattern or extent of cartilage loss did not affect PROMs before or after TKA: multicompartmental was no worse than unicompartmental disease.

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).

Purpose To describe patients’ self-reported hand normality before and after surgery for Dupuytren contracture and to determine whether this metric could be used as an adjunct to determine the success of surgery. Methods Preoperative and 1-year postoperative Quick–Disabilities of the Arm, Shoulder, and Hand and EuroQol 5-Dimensions 5-level scores were collected prospectively over 5 years. Patients were asked “How normal is your hand?” Scores were recorded on a 100-point visual analog scale. Outcomes were available for 296 patients (77%). Results Median hand normality score improved significantly from 50 to 86 after surgery. Effect size of the change in normality was 1.2 SDs. The change in normality score correlated significantly with the Quick–Disabilities of the Arm, Shoulder, and Hand score. No significant floor or ceiling effects were observed. Conclusions This study introduced the concept of self-perceived hand normality in Dupuytren disease. Hand normality improved after surgery for Dupuytren disease, and this score performed favorably compared with preexisting outcome measures, which suggests it may be a useful adjunct to gauge the success of surgery. Clinical relevance This study introduces the concept of self-perceived hand normality in patients undergoing surgery for Dupuytren disease and quantifies improvement observed after surgery.

Purpose This study describes the impact of self-reported hand–arm vibration (HAV) exposure on patient-reported outcomes, health-related quality of life, and satisfaction after carpal tunnel release. Methods We prospectively collected data from Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH), patient satisfaction, and 5-level EuroQol-5D questionnaires before and after surgery. Patient-reported outcomes were available for 475 patients (78% follow-up at a mean of 14 months). Fifteen patients were excluded, giving a final cohort of 460 patients. Results A total of 119 patients reported HAV exposure (26%). Median postoperative QuickDASH and QuickDASH improvement were significantly worse in the HAV-exposed group, although both groups improved after surgery. Multivariable linear regression revealed a significantly worse postoperative score and change in QuickDASH in HAV-exposed patients. There was no difference in satisfaction, but after surgery, the 5-level EuroQol-5D score was significantly worse in HAV-exposed patients. Conclusions Carpal tunnel release in HAV-exposed patients results in a significantly lower improvement in self-reported disability compared with patients without HAV exposure. This study provides important prognostic information for patients with previous HAV exposure undergoing carpal tunnel release. Type of study/level of evidence Prognostic III.

Background The aim of this study was to assess the reliability of the Oxford Knee Score (OKS) collected verbally compared with the validated written score, using a population of patients who underwent total knee arthroplasty (TKR). Methods Ninety patients (mean age 70.6; (43–92), 56.7% female) undergoing TKR were prospectively assessed. One group (n = 45) completed written (standard) and verbal (over the telephone) OKS preoperatively, half (n = 23) performed the written questionnaire first followed by the verbal questionnaire, and the other half (n = 22) performed this in reverse. A separate group (n = 45) completed the same regime one year postoperatively. Results A mean difference of 0.63 (95% CI − 0.985–2.23) points between verbal and written OKS was observed preoperatively, and of 1.36 (95% CI − 0.942–3.65) points was observed at one year postoperatively. Excellent reliability was observed using ‘average measures’ intra-class coefficient for the OKS preoperatively (r = 0.848) and at one year postoperatively (r = 0.970) in both groups who had written scores performed first, and those who had verbal scores performed first (preoperative r = 0.780, one year r = 892). Bland and Altman plots demonstrated consistent correlation between patients reporting their preoperative score and one-year postoperative score verbally and written. There was no significant variation between groups who had written scores performed prior to verbal, compared with those who reported verbal scores prior to written. Conclusions Prospective written collection of OKS remains the benchmark. However, verbal recording of OKS is not clinically different to written score, and may be a useful alternative to OKS in patients who are unable to attend or complete written questionnaires.

The primary aim of this study is to identify independent preoperative predictors of outcome and patient satisfaction for the second total knee arthroplasty (TKA).A retrospective cohort of 454 patients undergoing an asynchronous (6 weeks or more apart) bilateral primary TKA were identified from an arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Short Form-12 scores were collected preoperatively and 1 year postoperatively. Overall patient satisfaction was assessed at 1 year.The 1 year WOMAC pain score (P = .01), and improvement in WOMAC pain (P.001) and functional (P = .002) scores were significantly lower for the second TKA. Worse preoperative WOMAC pain, function, and stiffness scores were demonstrated to be independent predictors of improvement in the WOMAC pain, function, and stiffness scores, respectively, for both the first and second TKA. The overall rate of satisfaction with the first TKA was 94.0% and 94.7% for the second TKA (P = .67). The rate of satisfaction for the second TKA was 77.8% for patients that were dissatisfied with their first TKA, which was an independent predictor of dissatisfaction (P = .02).Improvement in pain and function is less with the second TKA, but the satisfaction rate remains similar. There are common independent predictors for change in the WOMAC score for the first and second TKA; however, the predictors of satisfaction were different with no common factors. Patients that were dissatisfied with their first TKA were more likely to be dissatisfied with their second TKA.Prognostic retrospective cohort study.

Background The aim of this study was to identify minimal clinically important difference (MCID), minimal important change (MIC) and minimal detectable change (MDC) for the Short Form (SF-) 12 physical and mental component summary (PCS, MCS) scores after total knee arthroplasty (TKA) using an anchor based methodology. Methods During a 10-year period, 2589 TKA were performed. SF-12 PCS and MCS scores were recorded preoperatively and at one year postoperatively. At one year, patients were asked “How much did the knee replacement surgery improve the quality of your life?” Their response was recorded as: a great improvement, moderate improvement, little improvement, no improvement at all, or the quality of my life is worse. Patients recording a little (n = 211) and no (n = 115) were used to calculate the MCID and the MIC. The MDC90 was calculated using distribution based methods for the whole cohort. Results The MCID was 1.8 (p = 0.04) for the PCS and 1.5 (p = 0.33) for the MCS score. The MIC was 2.7 (p = 0.04) for the PCS and − 1.4 (p = 0.17) for the MCS score. The MDC90 was 8.9 for the PCS and 13.8 for the MCS score. Conclusion The MCID for the PCS can be used to compare the outcomes between groups, and the MIC can be used to ensure that a clinical difference has been observed for a cohort of patients. The values for the MDC90 can be used to assess whether or not an individual patient has experienced a change.

To describe the ceiling effect for the components of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and identify preoperative independent predictors for patients who achieve maximal scores (ceiling effect) after total knee arthroplasty (TKA).A retrospective cohort of 2589 patients undergoing a primary TKA were identified from an established arthroplasty database. Patient demographics, WOMAC and Short Form 12 (SF-12) scores were collected preoperatively and 1 year postoperatively. Logistic regression analysis was used to identify independent preoperative predictors of patients achieving ceiling scores.The ceiling effect was 26.8% (n = 695) for the pain score, 6.4% (n = 165) for the function score, and 21.2% (n = 548) for the stiffness score. Lower body mass index (P = .001), absence of gastric ulceration (P = .04), absence of anemia (P = .02), absence of depression (P = .004), and absence of back pain (P.001) and better preoperative WOMAC pain and SF-12 physical (P = .01) and mental (P.001) scores were associated with a ceiling WOMAC pain score. Male gender (P = .03), lower body mass index (P = .040), absence of gastric ulceration (P = .004), and absence of back pain (P.001) and better preoperative SF-12 physical (P = .02) scores were associated with a ceiling WOMAC function score. Male gender (P = .001), absence of back pain (P.001), and better preoperative WOMAC stiffness score (P = .005) and SF-12 mental (P = .001) scores were associated with a ceiling WOMAC stiffness score.The WOMAC pain and stiffness components demonstrated a high ceiling effect but in contrast the functional score had a low ceiling effect. The absence of back pain was a common predictive factor for all 3 components and had the greatest impact upon the likelihood of achieving a ceiling score.

Background The primary aim was to assess survival of opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early conversion to total knee arthroplasty (TKA). Methods During the 18-year period (1994–2011) 111 opening wedge HTO were performed at the study centre. Mean age was 45 years (range 18–68) and the majority male (84%). Mean follow-up was 12 (range six to 21) years. Failure was defined as conversion to TKA. Kaplan–Meier, Cox regression and receiver operating curve (ROC) analyses were performed. Results Forty (36.0%) HTO failed at a mean of 6.3 years (range one to 15). By Kaplan–Meier analysis, the five-year survival rate was 84% (95% confidence interval (CI) 82.6–85.4), 10-year rate 65% (95% CI 63.5–66.5) and 15-year rate 55% (95% CI 53.3–56.7). Cox regression analysis identified older age (hazard ratio (HR) 1.07 for each additional year, 95% CI 1.03–1.11, p b 0.001) and female gender (HR 2.37, 95% CI 1.06–5.33, p = 0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62–0.81, p b 0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26–4.91, p = 0.01) risk of failure in patients aged 47 years old or more. Conclusion The risk of early conversion to TKA is significantly increased in females and those older than 47. These risk factors should be considered pre-operatively when planning intervention for isolated medial compartment osteoarthritis.

Introduction It is accepted that the incidence of fractures in patients aged ≥ 65 years is increasing but little is known about which fractures are becoming more common in this group of patients. Virtually all research has concentrated on the classic fragility fractures of the proximal femur, proximal humerus, pelvis, spine and distal radius but it is likely that other fractures are becoming more common. Methods We have examined two prospectively collected databases 10 years apart to see which fractures are becoming more common in ≥ 65 year old patients. We compared the fractures to look for epidemiological differences over the 10-year period and we compared the epidemiology of the fractures that had increased in incidence with equivalent fractures in the Results Analysis shows that in older female patients fractures of the clavicle, finger phalanges, ankle and metatarsus are increasing in incidence. In males there is an increasing incidence of fractures of the proximal humerus, distal humerus, metacarpus, pelvis, femoral diaphysis, distal tibia and ankle. In females the basic epidemiology of fractures in the ≥ 65 year old population was very similar to the fractures seen in younger females and we believe that the increasing incidence of fractures in the future will mainly be low velocity fractures following falls. In older males however, it is apparent that there is a much wider variation in the causes of fracture. Discussion We believe that the changes in fracture epidemiology in older patients relate to improved health and longevity and analysis of our population during the study period shows significant social changes which are associated with increased longevity and improved health. It is probable that fractures in older patients will continue to increase in incidence and that other fractures that are now commonly seen in middle-aged patients will be seen in older patients. Surgeons will have to treat more complex fractures in older males than in older females and it is likely that there will be a higher incidence of open and multiple fractures. Appropriate management techniques will need to be established.

Purpose This study aimed to evaluate the mobility and excursion of the patella achieved by two different techniques for increasing exposure to the knee joint: the quadriceps snip and the extensile medial parapatellar approach. Method Six matched intact fresh frozen cadaveric knees were used in this study. A standard medial parapatellar approach was undertaken and the patella excursion with a constant force of 5 kg was measured based on two fixed points at 0, 45 and 90 °s of knee flexion. The left knee in the matched pair was made extensile with a quadriceps snip and the right with an extensile medial parapatellar approach. The distance and change in distance as a percentage were then recorded at 0, 45 and 90 °s of knee flexion. Results Both techniques increased the mobility of the patella and its excursion. Quadriceps snip was found to give an average increase in excursion of 7 mm (12% increase in excursion), while the extensile medial parapatellar approach increased the patella distance from a fixed point by 10 mm (15% increase in excursion). Maximum displacement of the patella was consistently found to occur at 5 kg. The angle of knee flexion at which the maximum excursion was achieved was variable. Conclusion The quadriceps snip and extensile medial parapatellar approach both provide increased mobility of the patella in the cadaveric knee. When exploring the options to increase exposure to the knee, the operating surgeon may wish to employ either the extensile medial parapatellar approach or the quadriceps snip. There may be clinical advantage in developing the plane between vastus medialis and rectus femoris, as opposed to cutting across the quadriceps tendon.

There has been very little analysis of the epidemiology of adult fall-related fractures outwith the osteoporotic population. We have analysed all in-patient and out-patient fall-related fractures in a one-year period in a defined population and documented their epidemiology. The overall prevalence of non-spinal fall-related fractures is 63.1% with 40.7% and 82.7% occurring in males and females respectively. In females aged 20-29 years >50% of fractures follow falls, the equivalent age range in males being 50-59 years. Analysis of fall-related fractures in two one-year periods in 2000 and 2010/11 shows a significant increase in almost all age ranges up to 60-69 years with a decreased incidence in 90+ patients. In males there is a significant increase in 30-39year males but also in males >80years. In females the greatest increase in incidence is in 16-19year females but all age ranges show a significant increase up to 60-69 years. There is a decreased incidence in 90+ females. The reasons for the increase in the incidence of fall-related are multifactorial but they are probably contributed to by the inherently weaker bone of younger females and by the increased incidence of conditions such as obesity and diabetes.

Introduction Tibial fractures are devastating injuries and a cause of significant morbidity. There is limited information describing the length of time it takes for these injuries to heal. The aim of this study was to define the normal distribution of healing times of a consecutive series of tibial fractures treated with intramedullary (IM) nailing by applying the Radiographic Union Scale for Tibial fractures (RUST). Methods Hundred and eighty radiographs from 217 patients were assessed with RUST. Patients requiring more than one standard deviation from the mean were defined to have a delayed union. Results Sixteen patients (7%) developed non-unions and 30 patients (14%) had delayed union. Of the 201 patients who achieved union, the mean time to healing was 18.7 (SD 6.9) weeks, with a wide range from 7 to 52 weeks. In the union group, the rate of healing was greatest in the 8- to 12-week period. In contrast, in the delayed union group there was a lower peak rate of change, which was reached at a later time point. Discussion Our data indicates that 7% of patients with tibial fractures treated with IM nailing develop non-unions and over 10% of those progressing to union will take longer than 26 weeks. The data on healing rates is important to surgeons and orthopaedic multidisciplinary staff in guiding management. It can also be of help for patients planning their finances and for giving estimates for personal injury claims. Level of evidence IV, retrospective cohort study.

This study describes functional outcomes, patient satisfaction, and health-related quality of life (HRQoL) following open revision carpal tunnel decompression (CTD) for recurrent carpal tunnel syndrome (CTS). Postoperative results were available for 16 hands in 15 patients (100% at mean follow-up at 19.9 months). This was a prospective study at a single-centre serving a population of 360,000. QuickDASH, patient satisfaction, and EQ-5D-5L questionnaires were collected pre and postoperatively for patients undergoing revision CTD over a five-year period (2013–2018). The incidence of revision CTD was 0.9 per 100,000 patients per year. Fifteen patients reported recurrent and 1 patient-reported persistent symptoms. Median time to revision was 12.5 years (interquartile range 6.7–15.7 years). Mean preoperative and postoperative quickDASH was 57.7 and 36.1, respectively. The overall mean improvement in QuickDASH was 28.1. The mean improvement in EQ-5D-5L was 0.17. Thirteen patients (81.8%) were satisfied. The Net Promoter Score was 87.5. This study confirms the widely-held view that patients with late-presenting CTS can expect to enjoy a similar improvement in function and HRQoL as patients undergoing primary CTD. Recurrent CTS presents following a long symptom-free period after primary CTD, and hand function regresses to a similar level of disability. These results can be used to counsel patients who are considering revision surgery.

This study investigated the impact of self-reported hand-arm vibration (HAV) exposure on patient-reported functional outcomes (PROMs), Health-related quality of life (HRQoL), and patient satisfaction following carpal tunnel decompression (CTD). This was a single-centre prospective study investigating postoperative PROMs in 609 patients undergoing elective CTD. QuickDASH, patient satisfaction, and EQ-5D-5L questionnaires were collected pre- and postoperatively over a three-year period. Outcomes were available for 475 patients (78% at mean 14.4 months follow-up). One hundred and twenty-eight patients (28%) reported previous HAV-exposure. Median postoperative QuickDASH was significantly (27.3 vs 15.9; P = 0.005) worse in the group exposed to HAV. Although both groups reported a postoperative improvement in QuickDASH this was significantly lower in the group exposed to HAV (−12.8 vs −19.4; P = 0.002). Multivariable linear regression revealed significantly worse preoperative, postoperative and change in QuickDASH when adjusting for covariates in patients with HAV-exposure. The most predictive variable for impact on QuickDASH was weekly vibration exposure. There was no significant difference in satisfaction between the two groups (51.2% vs 55.6%; P = 0.4), though postoperative EQ-5D-5L was significantly worse in the group exposed to HAV (0.70 vs 0.78; P = 0.007). CTD in patients with previous HAV-exposure results in improved postoperative PROMs, though the improvement was significantly lower when compared to patients without HAV-exposure. Although there was no significant difference in satisfaction rate, HRQoL was significantly lower following CTD in patients with previous HAV-exposure. Patients with previous HAV-exposure should be made aware of these results prior to CTD.

There is conflicting evidence as to whether diabetes mellitus influences the functional outcome and patient satisfaction after a total knee replacement (TKR). The aim of this study was to assess the effect of diabetes upon the Oxford knee score (OKS), short form (SF)-12, and patient satisfaction after TKR.Prospective pre- and post-operative (one year) OKS and SF-12 scores for 2389 patients undergoing primary TKR were compiled, of which 275 (12%) patients suffered with diabetes. Patient satisfaction was assessed at one year.Patients with diabetes were more likely to have a greater level of comorbidity (p0.001), and a worse pre-operative OKS and SF-12 score (p0.02), compared to those patients without diabetes. Diabetes was not a significant (p0.41) independent predictor of post-operative OKS or the SF-12 physical score on multivariable analysis. Although, factors more prevalent within the diabetic cohort (heart disease, vascular disease, liver disease, anaemia, depression, back pain, worse pre-operative OKS and SF-12 score) were found to be independent predictors of post-operative OKS and SF-12 physical score. Interestingly, diabetes was associated with a significantly greater improvement in mental wellbeing (SF-12 mental component), which was confirmed on multivariable analysis. Patient satisfaction was not influenced by a concomitant diagnosis of diabetes (p=0.57).The outcome of TKR as assessed by the OKS, SF-12, and overall patient satisfaction rates are not influenced by diabetes per se, although factors more prevalent within this population result in a worse post-operative outcome.prospective cohort study, level III.

Background Reported revision of internal fixation for undisplaced intracapsular hip fractures is between 12 and 17 % at 1 year. This risk is greater for elderly patients, for whom mortality after such a fracture is also higher. Our purpose was to identify predictors of fixation failure and mortality for elderly patients sustaining undisplaced intracapsular hip fractures, and to assess whether their socioeconomic status affected their outcome.

There is little information available about the epidemiology of open fractures. We examined 2386 open fractures over a 15-year period analysing the incidence and severity of the fractures. The majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents or falls from a height. The distribution curves of many open fractures are different to the overall fracture distribution curves with high-energy open fractures being commoner in younger males and low energy open fractures in older females. The mode of injury and the different demographic characteristics between isolated and multiple open fractures are also discussed.

Purpose The aim of this study was to define the epidemiological characteristics of proximal radial fractures. Methods Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed. Results We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13–94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity. Conclusions Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended. Type of study/level of evidence Prognostic IV.

Patients with hereditary multiple exostoses (HME) in association with palpable shoulder exostoses are more severely affected by their disease.From a prospective database of 78 families with HME identified, 172 patients were identified. Demographic details, deformity, functional scores, standing height, number of exostoses, site, exostosin genotype (EXT1 and EXT2), surgical excision, and malignant change were recorded. Nonparametric tests were used to compare patients with and without shoulder exostoses (clavicle, scapula, and humerus).There were 5361 palpable exostoses, of which 14% were of the shoulder and were present in 145 patients (84.3%). There was a younger mean age (26.8 vs 37.9 years) and a male predominance in those individuals with shoulder exostoses (P = .0005). Patients with shoulder exostoses had significantly worse disease (P.05). EXT1 mutations were more commonly observed in those with shoulder exostoses (odds ratio [OR], 20.6; 95% confidence interval [CI], 11.2-28.5; P = .001). The likelihood of surgical excision was greater in those with shoulder exostoses (OR, 2.8) and highest for scapular exostoses (OR, 3.7). Risk factors for surgical excision of shoulder exostoses were younger age (P = .03) and male gender (P.008). Seven chondrosarcomas occurred, 2 scapular and a proximal humeral. The probability of malignant change of was highest for palpable scapular exostoses relative to any other anatomic site (OR, 12.3; P = .05).Shoulder exostoses have a male predominance, and patients are more likely to have an EXT1 mutation. The presence of shoulder exostoses could serve as a tool to identify those individuals at high probability of malignant change.The existence of shoulder exostoses identifies those individuals with a high probability of having an EXT1 genotype (OR 20.6, 94.4% sensitivity, 84.8% positive predictive value), which is associated with sarcomatous change.