Aims. Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233

Background. This survey was conducted to gain information about how surgeons use scientific literature and how this is influenced by their knowledge of evidence-based medicine. The results were compared to a survey conducted 10 years previously. Where appropriate, the same questions as in the 2003 survey were used. Methods. We administered a voluntary questionnaire to participants at the AO Foundation courses in Davos, Switzerland, in December 2013. We surveyed, amongst other topics, the surgeons’ levels of education in Evidence-Based Medicine (EBM), how they implement EBM in daily practice and their publication record. Results. A total of 330 surgeons completed the 27 question survey. 49% (159/322) had learned about EBM in medical school. However, 69% (110/159) of those with EBM education had taken only one semester or less on the subject. 54% of participants (170/317) correctly identified a definition of EBM in surgery. This compares to 45% in the 2003 survey (130/288 respondents) of a subset who said they have previously heard of evidence-based orthopaedic surgery. When it came to applying EBM in their daily work, 45% of respondents (143/320) claim to always practice it (2003 figure: 28%, 113/404), while 26% (84/320) only use EBM for difficult or controversial cases (2003 figure: 26%, 104/404). 27% (88/323) have never published a manuscript as an author or co-author (2003 figure: 14%, 121/453), 53% (170/323) have been involved in 1–10 publications (2003 figure: 59%, 269/453), and 20% (65/323) have published more than 10 times (2003 figure: 27%, 63/453). Conclusions. While at face value there appears to be a greater understanding and utilisation of EBM among AO course participants who completed the 2013 survey compared to the 2003 study, several outcomes do not show any great variation in the intervening decade. Level of Evidence. professional survey

Artificial bone models (ABMs) are commonly used in traumatology and orthopedics for training, education, research and development purposes. The aim of this study was to develop the first evidence-based generic Asian pelvic bone model and compare it to an existing pelvic model. A hundred clinical CT scans of intact adult pelvises (54.8±16.4 years, 161.3±8.3 cm) were acquired. They represented evenly distributed female and male patients of Malay (n=33), Chinese (n=34) and Indian (n=33) descent. The CTs were segmented and defined landmarks were placed. By this means, 100 individual three-dimensional models were calculated using thin plate spline transformation. Following, three statistical mean pelvic models (male, female, unisex) were generated. Anatomical variations were analyzed using principal component analysis (PCA). To quantify length variations, the distances between the anterior superior iliac spines (ASIS), the anterior inferior iliac spines (AIIS), the promontory and symphysis (conjugate vera) as well as the ischial spines (diameter transversa) were measured for the three mean models and the existing ABM. PCA demonstrated large variability regarding pelvic surface and size. Principal component one (PC 1) contributed to 24% of the total anatomical variation and predominantly displayed a size variation pattern. PC 2 (17.7% of variation) mainly exhibited anatomical variations originating from differences in shape. Female and male models were similar in ASIS (225±20 mm; 227±13 mm) and AIIS (185±11 mm; 187±10 mm), whereas differed in conjugate vera (116±10 mm; 105±10 mm) and diameter transversa (105±7 mm; 88±8 mm). Comparing the Asian unisex model to the existing ABM, the external pelvic measurements ASIS (22.6 cm; 27.5 cm) and AIIS (186 mm; 209 mm) differed notably. Conjugate vera (111 mm; 105 mm) and diameter transversa (97 mm; 95 mm) were similar in both models. Low variability of mean distances (3.78±1.7 mm) was found beyond a sample number of 30 CTs. Our analysis revealed notable anatomical variations regarding size dominating over shape and gender-specific variability. Dimensions of the generated mean models were comparatively smaller compared to the existing ABM. This highlights the necessity for generation of Asian ABMs by evidence-based modeling techniques

Background. Work disability due to low back pain (LBP) is a global concern, resulting in significant healthcare costs and welfare payments. In recognition of this, recent UK policy calls for healthcare to become more ‘work-focused’. However, an ‘evidence-policy’ gap has been identified, resulting in uncertainty about how this is to be achieved. Clear, evidence-based recommendations relevant to both policy-makers and healthcare practitioners are required. Methods. A policy theory approach combining scientific evidence with governance principles in a pragmatic manner was undertaken. This entailed extracting evidence from a recent review of the system influences on work disability due to LBP* (focused specifically on the healthcare system) and appraising it alongside the most recent review evidence on the implementation of clinical guidance, and policy material aimed at developing work-focused healthcare. Results. It was found that further resources are needed to assist healthcare professionals (HCPs) to engage in work discussions with LBP patients, which can often be complex and challenging. HCPs themselves often have misconceptions about the work-health relationship and the related evidence-based guidance. System-level barriers that reduce access to suitable healthcare at the right time, and those that increase conflict with other key stakeholders (e.g. the workplace and welfare/compensatory systems) were found to be significant obstacles. Supportive policy and legislation that (a) embeds work as a health outcome, and (b) enables all key stakeholders to collaborate would be a major vehicle to facilitate work-focused healthcare for LBP. Conclusions. Accepting that work-focused healthcare for LBP is required does not diminish the challenge it presents. Evidence-based recommendations relevant for both policy and practice would enable a better understanding of what works for whom, and at what cost. *A full description and results of the evidence synthesis were presented at the Society's Annual Meeting 2016 and will be presented at the 15th International Forum for Back and Neck Pain Research in Primary Care 2017. These results also form part of a chapter in ISSLS Online Textbook 2017. Conflicts of interest; None. Sources of funding: None

Background: The Journal of Bone and Joint Surgery, American Edition (the Journal) recently initiated a section called “Evidence-Based Orthopaedics”. Furthermore, a Levels of Evidence rating is now used in the Journal to help readers in clinical decision-making. Little is known if this recent emphasis of Evidence-based Medicine (EBM) influenced surgeons’ perceptions about and competence in evidence-based medicine. Therefore, we examined perceptions and competence in evidence-based medicine among Dutch orthopaedic surgeons. Methods: Members of the Dutch Orthopaedic Association were surveyed to examine surgeons’ attitudes towards evidence-based medicine and competence in evidence-based medicine. We evaluated perceptions using a newly developed instrument tailored to surgical practice. Univariate analysis, and a multivariable analysis using Generalized Estimating Equations were performed to model the competence instrument. Results: 367 Surgeons responded (60%). Orthopaedic surgeons welcomed evidence-based medicine. Practical evidence-based medicine resources were perceived as the best methods to move from eminence-based to evidence-based practice. Four variables were significantly and positively associated with the competence instrument:. 1) younger age, particularly age between 36 and 45 years,. 2) experience of less than 10 years,. 3) having a PhD degree, and. 4) working in an academic or teaching setting. The majority of the respondents (65%) were aware of the Journal’s evidence-based medicine section, and 20% used the Journal’s evidence-based medicine abstracts in clinical decision-making. This increased awareness in evidence-based medicine was also reflected in a frequent use of Cochrane reviews in clinical decision-making (27%). Surgeons who used the Journal’s evidence-based medicine abstracts and Cochrane reviews had significantly higher competence scores. Conclusions: Evidence-based medicine is welcomed by Dutch orthopaedic surgeons. Recent emphasis of evidence-based medicine is reflected in an increased awareness about the Journal’s evidence-based medicine section, Levels of Evidence, and the largest evidence-based medicine resource: Cochrane reviews. Younger orthopaedic surgeons had better knowledge about evidence-based medicine. Development and use of evidence-based resources as well as pre-appraised summaries like the Journal’s evidence-based medicine abstracts and Cochrane reviews were perceived as the best way to move from eminence based- to evidence-based orthopaedic practice

Introduction: Evidence-based medicine is a form of practice in which the physician accesses relevant, state-of-the-art research findings to guide the care of the individual patient (Gordon and Cameron, 2000). Therefore, evidence-based medicine should influence the decision making process when developing a treatment algorithm for early stage osteonecrosis. It was the purpose of this project to explore the literature concerning surgical options that are used currently to treat early stage osteonecrosis. Materials and Methods: Literature searches were conducted using PubMed (National Library of Medicine, USA) to identify journal articles pertaining to the treatment of pre-arthrosis osteonecrosis during the past decade. The articles were screened to include only those with greater than 5 patients and greater than two year follow-up. Results: Published reports in medical journals included: core decompression with and without nonvascular grafting (18); core decompression augmented with BMP or bone marrow cells (2); bone cement (1); vascularized graft – fibular or iliac (10); osteotomy (26); osteotomy and vascularized grafts (3); trap-door procedure (2); and hemiarthroplasty/resurfacing arthroplasty (9). There was one review of nonoperative treatment, but no clinical studies. There were only a few case reports concerning osteochondral graft/osteochondroplasty; which did not meet the inclusion criteria. Several classification systems were used: Ficat and Arlet (55%); University of Pennsylvania / Steinberg (21%); Japanese Investigational Committee (13%); Marcus (2%); Myers (3%); ARCO (5%), and other (1%). A majority of reports included follow-up of 5 years or greater (91%). Most studies (91%) were not randomized, control-matched, or prospective. Discussion: Several surgical options are available for the treatment of pre-arthrosis osteonecrosis. However, it is not possible to apply evidence-based medicine practices to the research relating to the treatment of osteonecrosis as most of the research is not controlled and not comparative. This represents a substantial void in our knowledge base concerning osteonecrosis which remains to be filled

Introduction: There is a general trend and even demand of using evidence-based methods in the practice of medicine. Especially in orthopedic surgery, which is a specialty traditionally employing treatments with obvious effectiveness, evidence-based clinical decision-making has become a strong trend. Yet all evidence-based decisions are only as sound as the evidence they are based on. In other studies, we could show that only 1 in 3 controlled orthopaedic trial accounts for confounding, and that there is even conflict in the results of meta-analyses, which are supposed to produce the highest level of evidence. This study asked how high the quality of evidence in orthopaedic research really is, and, thus, whether it would be applicable in “evidence”-based orthopaedics. Method: All 2006 controlled trials from orthopedic journals with high impact-factor are analyzed in a cross-sectional study. A score based on the CONSORT statement was used to assess study quality. This score assesses power analyses, prospectiveness, randomization, allocation concealment and observer blinding, intention-to-treat, and how losses during follow-up were addressed. We also assessed whether there was an association between the test score and variables such as area of research and participation of a researcher with methodological training. Finally we tested the inter-observer reliability of our test between an investigator with postgraduate training in biostatistics and epidemiology and an orthopaedic resident with no specific methodological training beyond medical school. Results: The overall quality of 126 studies was moderate to high, with an average score of 3.4 ± 1.7. The most neglected parameters were power analysis, intention-to-treat, and concealment. There were significant differences in results by area of research (p=0.022). The highest values were seen in oncology (4.6 ± 1.4) and osteoarthritis (4.4 ± 1.8), the lowest in traumatology (2.9 ± 1.3). The participation of a methodologically trained investigator increases study quality significantly (p=0.002). There is no difference in study quality whether there is statistically significant result or not (p=0.497). There was a 81.2% agreement, suggesting that study quality can be judged regardless of “specific training”. Conclusion: We found good to high values for orthopaedic evidence on our scale, suggest high validity and applciability. We also saw that this instrument can be used without methodological training. However, there seems to be neglect of some important study features like power analyses, intention-to-treat, and concealment. Heightened awareness of this problem will help to increase the quality of orthopaedic evidence, and thus the clinical applicability of evidence-based orthopaedics

Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR. Four interconnected work packages have recently been completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from four national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty. We will present the following Recommendations:. For ODEP10A∗ minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review. For ODEP10A∗ minimum implants in complex cases, or non-ODEP10A∗ minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years. At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation. After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment; ongoing rapid access to orthopaedic review is still required. Overarching statements. These recommendations apply to post primary hip and knee replacement follow-up. The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years. The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure

The prospective evaluation of two hundred and seven symptomatic total knee arthroplasties presenting for revision total knee arthroplasty is reported. On univariate analysis patients who had infection differed significantly (p< .001) from those without infection with regards to: elevated ESR, CRP, positive aspiration, and history of; revision procedure less than two years since last surgery, early wound problems, ongoing pain since index procedure, and discharging wound. On multivariate analysis elevated ESR or CRP, positive aspiration, pain since index procedure and early wound complications were significant predictors of infection (p< .05). These variables were then used to formulate an evidence-based multivariate predictive algorithm to assist the clinician in decision making prior to surgery. Differentiating septic from aseptic failure of total knee arthroplasty on the basis of clinical features and diagnostic tests can be troublesome for the clinician. The purpose of this paper is to describe significant differences between cases of septic and aseptic failure of total knee arthroplasty. The incorporation of these variables into a practical multivariate clinical prediction algorithm can provide assistance in establishing the diagnosis of infection prior to revision knee arthroplasty. A simple clinical prediction algorithm can assist in the diagnosis of infection in patients with painful total knee arthroplasty. Patients with five of five criteria have a 99% probability of infection whereas patients with zero of five criteria have a 1% probability of infection. This is the first multivariate evidence-based clinical prediction algorithm presented for use in decision making prior to revision total knee arthroplasty. The surgeon can use the information derived from clinical and laboratory assessment to compute an approximate pre-operative probability of infection prior to surgery (see table). On multivariate analysis elevated ESR or CRP, positive aspiration, pain since index procedure and early wound complications were significant predictors of infection (p< .05). These variables were then used to formulate an evidence-based multivariate predictive algorithm to assist in clinical decision making. Prospective data was collected on two hundred and seven symptomatic knee arthroplasties presenting for revision arthroplasty. A multivariate logistic regression model was used to determine the probability of infection using five significant variables. Combinations of these five variables can provide the clinician with an estimate of the probability of infection prior to revision knee arthroplasty. Please contact author for tables and/or charts

BACKGROUND. High-volume surgeons and hospital systems have been shown to deliver higher value care in several studies. However, no evidence-based volume thresholds for cost currently exist in total hip arthroplasty (THA). The objective of this study was to establish clinically meaningful volume thresholds based on cost for surgeons and hospitals performing THA. A secondary objective was to analyze the relative market share of THAs among the newly defined surgeon and hospital volume strata. METHODS. Using 136,501 patients from the New York State Department of Health's SPARCS database undergoing total hip arthroplasty, we used stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate volume thresholds predictive of increased costs for both surgeons and hospitals. Additionally, we examined the relative proportion of annual THA cases performed by each of these surgeon and hospital volume strata we had established. RESULTS. SSLR analysis of cost by annual surgeon THA volume produced stratifications at: 0–73 (low), 74–123 (medium), and 124 or more (high) (Figure 1). Analysis by annual hospital THA volume produced stratifications at: 0–121 (low), 122–309 (medium), and 310 or more (high) (Figure 2). Hospital costs decreased significantly (P < .05) in progressively higher volume stratifications. The largest proportion of THA cases are performed at high-volume hospitals (48.6%); however, low-volume surgeons perform the greatest share of these cases (44.6%) (Figure 3). CONCLUSIONS. Our study establishes economies of scale in total hip arthroplasty by demonstrating a direct relationship between volume and cost reduction. High volume hospitals are performing the greatest proportion of total hip arthroplasties; however, low volume, surgeons perform the largest share of these cases, which highlights a potential area for enhanced value in the care of patients undergoing total hip arthroplasty

Background and aims. The EU-funded Back-UP project aims to develop a cloud computer platform to guide the treatment of low back and neck pain (LBNP) in first contact care and early rehabilitation. In order to identify evidence-based treatment options that can be recommended and are accessible to people with LBNP across Europe, we conducted a systematic review of recently published guidelines. Methods. Electronic databases, including Medline, Embase, CINAHL, PsycINFO, HMIC, Epistemonikos, PEDro, TRIP, NICE, SIGN, WHO, Guidelines International Network (G-I-N) and DynaMed Plus were searched. We searched for guidelines published by European health professional or guideline development organisations since 2013, focusing on the primary care management of adult patients presenting with back or neck pain (including whiplash associated symptoms, radicular pain, and pregnancy-related LBP). The AGREE-II tool was used to assess the quality of guideline development and reporting. Results. Searches generated 3098 unique citations that were screened for eligibility. A total of 189 full-texts were retrieved, and 18 guidelines were included in the review (from the UK, Germany, France, Italy, Denmark, Poland, Belgium, and the Netherlands). Data extraction showed considerable variation in guideline development processes, especially regarding the methods used for identifying, appraising, and synthesising evidence, and for formulating, agreeing, and grading recommendations. Conclusions. Recommendations for the management of LBNP cover a wide range of treatment options, with self-management advice, analgesics, and exercise proposed as core treatments by most guidelines. A narrative synthesis, taking into account consistency, strength, and quality of guideline recommendations, will be presented. No conflicts of interest. Funding: This abstract presents independent research within the Back-UP project, which has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 777090. This document reflects only the views of the authors, and the European Commission is not liable for any use that may be made of its contents. The information in this document is provided “as is”, without warranty of any kind, and accept no liability for loss or damage suffered by any person using this information

Aims

To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty.

Background. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardisation of care on short-term post-operative outcomes and resource utilisation in lower-extremity total joint arthroplasty. Methods. An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first 30 days after discharge. Hierarchical models were used to estimate effects of hospital and surgeon procedure volume and standardisation on individual and combined surgical outcomes and length of stay. Results. After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality and lower risk of readmission and higher likelihood of being discharged home. The impact of process standardisation was substantial; maximising adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusion. Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardisation is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established. However, our findings suggest that process standardisation could help providers optimise quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume

Purpose and Background: The introduction of clinical governance made NHS organisations accountable for the monitoring and continuous improvement of the quality of patient care at all levels, across all services. Implementation of evidence-based practice and provision of an adequate infrastructure to support it is a major component and at local level, clinicians in all NHS organisations are required to participate fully in audit. The following describes the second phase. *. of a study investigating the dissemination and utilisation of an audit toolkit for the UK acute low back pain guideline through clinical governance routes. *. Phase I Results Were Previously Reported At SBPR. Methods: structured telephone interviews were conducted with 50 clinical governance leads and 22 clinical audit leads in 72 primary care trusts (pcts). the qualitative data were analysed using a framework approach involving identification of issues, concepts and themes and the construction of a theoretical perspective for the main categories. these were cross-validated by the original interviewer checking for dissonance. Results: Six categories were identified: priorities; capacity and resources; loss of quality support groups; organisational issues; local environment and lack of audit strategies. the results suggest that low back pain is still a considerable problem but has lost its priority status at both government and local levels, largely due to the introduction of national service frameworks (nsfs) and to inadequate resourcing. primary care has a huge agenda that is seen as being grossly under-resourced with respondents reporting difficulty in meeting nsf requirements. many localities had not generated or finalised audit strategies while gp autonomy and poor communication between the gps and pcts were identified as barriers to the implementation of audit processes in primary care. Conclusion: Presently, implementation of evidence-based healthcare for non-priority areas seems not to be feasible through clinical governance routes. without nsf status, the likelihood of seeing clinical audit used to assure evidence-based primary care for low back pain seems remote

Introduction. This study aimed to: (1) compare published follow-up guidelines for metal-on-metal (MoM) hip patients and analyse protocols in relation to current evidence, and (2) assess the financial implications of these guidelines. Methods. Follow-up guidance for MoM hips from five national authorities (MHRA in the UK; EFORT; United States FDA; Therapeutic Goods Administration of Australia; Health Canada) were contrasted and critically appraised. Using National Joint Registry (NJR) data (67,363 MoM hips implanted) the cost of annual surveillance for all MoM hips recorded in the NJR was calculated for each protocol. Results. Significant differences existed between recommended guidance, with protocols not reflecting the best available evidence. These include not stratifying patients according to implant type (total hip replacement (THR) or hip resurfacing (HR)) or adverse reaction to metal debris (ARMD) risk factors, using symptoms to decide patient follow-up, and using suboptimal blood metal ion thresholds to identify poorly performing hips. Patients with asymptomatic ARMD lesions, especially HR patients with no ARMD risk factors, would not be identified by most protocols. Vast cost differences exist between protocols when considering annual surveillance of the NJR population. The MHRA guidance was cheapest for annual follow-up (£8,264,064/10,423,296 Euro/$13,717,440). The most expensive protocols were those recommended by the FDA (£22,321,020/28,134,526 Euro/$37,029,889) and EFORT (£22,708,226/28,590,554 Euro/$37,671,431), both approaching three-times the MHRA costs. The FDA protocol was most costly for surveillance of all symptomatic patients (£18,210,816/22,947,840 Euro/$30,228,480), and EFORTs was most costly for asymptomatic HR patients (£8,283,010 / 10,428,250 Euro / $13,735,495). Discussion. Current MoM hip follow-up guidance is not evidence-based. Most protocols lack the sensitivity to detect asymptomatic ARMD lesions. It is also clear that these protocols are not financially sustainable in the long-term. Conclusions. Further work is required to ensure future guidance published by authorities is more unified as well as both clinically and cost effective

Introduction. Single-stage resection and reimplantation for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is of recent interest, yet outcomes may be skewed by selected populations with healthier patients and less virulent organisms. This study quantified the effectiveness of a contemporary, evidence-based and standardized two-stage treatment protocol in patients with THA PJI including chronically infected, poor hosts. Methods. Sixty-one consecutive two-stage resection and reimplantation THAs for PJI between 2011 and 2017 were retrospectively reviewed in a prospectively collected registry database. Patients were categorized with McPherson's Staging System and infection was defined by MSIS criteria. Contemporary standardized protocols were adhered to including implant resection and meticulous surgical debridement, six-week intravenous antibiotics with a high-dose antibiotic spacer, a two-week drug holiday, and laboratory assessment of infection eradication prior to reimplantation. Extended antibiotics after reimplantation were not routinely used. Successful treatment was defined as reimplantation with component retention at minimum two-year follow-up. Results. After exclusions for confounds, 43 of 47 patients had obtained minimum two-year follow-up (mean 50.9 months). 54% were male with an average BMI of 31 kg/m2. 56% were chronically infected poor hosts (Stage III-B/C). Three patients required repeat debridement and/or spacer exchange prior to final reimplantation. Treatment success rate was 95% at two-year follow-up. Success did not vary based on patient sex, age, BMI, or multi-organism PJI (p ≥ 0.117). There were no failures in the early postoperative PJI group (stage I), and both failures occurred in the late chronic PJI group (stage III). Conclusion. Our success rate with the two-stage procedure equals or exceeds that of single-stage treatment, even in an unselected cohort of chronically infected poor hosts. More rigorous scientific comparative studies are warranted prior to indiscriminate adoption of the single-stage treatment approach for PJI in THA

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Background & Objectives: The physical therapy professions (musculoskeletal physiotherapy, osteopathy and chiropractic) are involved in the management of low back pain (LBP) in approximately 15–20% of all cases in the UK. LBP accounts for between 50% and 67% of the workload of this group. Initiatives to implement evidence-based practice (EBP) in the UK have included the development of national multidisciplinary guidelines for acute LBP, the target audience of which include all three physical therapy professions. The objective of this study was to explore and identify perceptions, attitudes and beliefs held by practitioners from these three professional groups about their approaches to the care of LBP patients. Methods & Results: An exploratory study was used to investigate beliefs and attitudes of practitioners, concerning factors that potentially influence practice. Particular attention was given to practitioners’ thoughts on the opportunities and threats of taking an EBP approach to LBP management, and identifying other factors that influence their clinical behaviour with LBP patients. Following ethical approval and informed consent, five focus groups were conducted with members of the physical therapy professions. Audio recordings of each focus group were made, and subsequently transcribed verbatim. Transcript data were analysed in line with a grounded theory approach to produce relevant themes. Preliminary categories of themes that emerged were: Evidence; Perceived Knowledge; Personality Characteristics; Professional Identity; The Patient; and Motivation. Of particular interest, practitioners seem to have mixed opinions with regard to basing their practice on evidence from external research. Conclusions: Practitioners’ views of EBP in LBP management are diverse and it cannot be presumed that all practitioners view EBP as desirable. They seem to have mixed opinions with regard to basing their practice on evidence from external research. Practitioner behaviour, and thus the implementation of EBP may relate to practitioners’ beliefs and attitudes

‘Safety’ is at the centre of surgical practice with the aim of minimising the risks of complications and adverse events. Much evidence, based on either retrospective case series or prospective cohorts, concerns the frequency of adverse events. There may be a temptation to describe a procedure as ‘safe’ if no – or few – serious adverse events (the numerator) have occurred out of a number of procedures performed (the denominator). In 1983, Hanley and Lippman-Hand described a simple algorithm to calculate the 95% upper Confidence Interval for data sets in which the numerator is zero (ie series in which there no adverse events). Paediatric orthopaedics suffers from small datasets which may make its researchers especially prone to the erroneous attribution of procedures being ‘safe’. The aim of the current study was to formally assess the evidence on which paediatric orthopaedic surgical procedures are described as ‘safe’. In particular, the objective was to ascertain the proportion of studies describing a procedure as ‘safe’ which achieved a 95% upper limit Confidence Interval of risk of 5% for major adverse events.

We examined all papers published by the Journal of Paediatric Orthopaedics in the previous 5 years searching for the single term ‘safe’. 84 papers were returned and 71 were considered appropriate for analysis. Of these 60 papers positively identified their intervention as ‘safe’. These papers were read in full and the number of interventions was recorded along with the rate of complication. 66 data sets were created and the 95% upper confidence interval was calculated for complication rates. Only 16 out of 66 data sets could safely predict a major complication rate of under 5%.

Our work would tend to suggest that a failure to apply proper statistical tools is leading to procedures being erroneously classified as safe in the published literature.