The Journal of Bone and Joint Surgery published in the A and B volumes remains the premier Orthopaedic Journal of the world. Like other specialist scientific journals it is coming under increasing pressure from the move to more electronic publication on the Internet and the wider availability of freely downloadable information. The need to move to the new technology must be balanced against the needs of the majority of our subscribers, who still require the paper journal, and with the financial requirements of a charitable based not-for-profit publication. The paper will discuss how these pressures might be met and the plans for the redesign of our website to deliver a wider range of material, including the possibility of electronic pre-prints. The future of the Combined subscription CD-ROM will also be addressed together with the exciting future possibilities offered by the developments in digital information technology

Introduction

Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis.

From 1998 to July 2003 admissions for elective arthroplasty surgery in Derriford Hospital were nursed alongside other orthopaedic and general medical patients. Since August 2003 a policy of pre-operative MRSA screening and a unit reserved exclusively for MRSA-free joint replacement patients have been used. No transfers from other wards were allowed. Patients positive on screening underwent eradication and were admitted to a different ward where they received teicoplanin on induction (in addition to standard policy cephradine). All post-operative wound infections following THR & TKR were monitored (NINSS surveillance system). Infections within 3 months were recorded. A control of non-screened hip hemi-arthroplasty patients was used to ensure a departmental wide reduction in MRSA was not occurring.

1.9% MRSA carriage rate was detected over the study. Before screening, 0.59% of 3386 cases were acutely infected with MRSA. After institution of screening and a dedicated MRSA free unit, 0.10% of 1034 were acutely infected. This was a 6-fold decrease (p<0.05). The infection noted was in a patient treated outside the ringfenced unit on High Dependency. In fact the infection rate on the ringfenced unit was zero. MRSA infection in the control was statistically unchanged during this period.

Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author.

One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods.

Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era.

Since Aug‘03 pre-operative MRSA screening & a ward reserved exclusively for MRSA free joint replacement patients has been used. All postoperative wound infections within 3 months following THR & TKR were monitored.

Before screening, 0.59% of 3386 were acutely infected with MRSA. After institution of study policy, 0.10% of 1034, were infected with MRSA.. This was a 6 fold decrease (p< 0.05). The rate of MRSA infection in a control of hemiarthroplasties was unchanged during this period.

A policy of MRSA screening & an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.

The role of joint preserving surgery for Rheumatoid Forefoot is being explored. This involves a Scarf osteotomy of the first Metatarsal along with shortening osteotomy of the lesser metatarsals. This prospective study includes 49 patients (17 Bilateral; Total 66 procedures) with Rheumatoid Forefoot deformities who underwent Scarf Osteotomy of the First Metatarsal and Weil osteotomy of the lesser metatarsals. The minimum follow up was 33 months and the maximum follow up was 58 months with a mean of 43.95 months. All patients were evaluated clinically and radiologically. AOFAS score for forefoot was collected prospectively. The majority (90%) were females with mean age of 56.1 years. There was a significant improvement in the HVA, IMA and SP. The AOFAS score improved significantly from a mean of 39.8 to 88.7(p=< 0.001). Subjective improvement was also noted with In our study patients rated their outcome as excellent in 51 feet (77.27%), good in twelve feet (18.18%) and as fair in three feet (4.54%). Before surgery no patient was pain free but 44 feet (66.66%) caused severe,19 feet (28.78%) caused moderate and 3 feet (4.54%) caused mild pain. After surgery 55 feet (83.33%) were pain free, 7 feet ((10.6%) caused moderate, 4 feet (6.06%) caused mild pain. Residual deformity in terms of recurrence of lesser toes varus deformity was reported in 5 feet (7.5%). Stiffness of toes was reported in 5 feet and 11 (16.7%) had some residual pain. Forefoot joint preserving reconstructive procedure for rheumatoid forefoot is a reliable procedure and should be considered as a safe method for treating rheumatoid forefoot deformities. However in severe hallux valgus with radiological destruction of the first MTPJ we recommend a primary fusion. Therefore joint preserving surgery should be regarded as a complement to various surgical treatments of rheumatoid forefoot

The treatment of patients with osteoarthritis of the knee and associated extra-articular deformity of the leg is challenging. Current teaching recognises two possible approaches: (1) a total knee replacement (TKR) with intra-articular bone resections to correct the malalignment or (2) an extra-articular osteotomy to correct the malalignment together with a TKR (either simultaneously or staged). However, a number of these patients only have unicompartmental knee osteoarthritis and, in the absence of an extra-articular deformity would be ideal candidates for joint preserving surgery such as unicompartmental knee replacement (UKR) given its superior functional outcome and lower cost relative to a TKR [1). We report four cases of medial unicondylar knee replacement, with a simultaneous extra-articular osteotomy to correct deformity, using novel 3D printed patient-specific guides (Embody, UK) (see Figure 1). The procedure was successful in all four patients, and there were no complications. A mean increase in the Oxford knee score of 9.5, and in the EQ5D VAS of 15 was observed. To our knowledge this is the first report of combined osteotomy and unicompartmental knee replacement for the treatment of extra-articular deformity and knee osteoarthritis. This technically challenging procedure is made possible by a novel 3D printed patient-specific guide which controls osteotomy position, degree of deformity correction (multi-plane if required), and orientates the saw-cuts for the unicompartmental prosthesis according to the corrected leg alignment. Using 3D printed surgical guides to perform operations not previously possible represents a paradigm shift in knee surgery. We suggest that this joint preserving approach should be considered the preferred treatment option for suitable patients

Introduction: The majority of patients with extremity osteo-sarcoma undergo limb salvage surgery. The most common location is about the knee, where at least one half of the knee joint is usually removed. A select group of patients with proximal tibial osteosarcomas had preservation of the entire articular surface following reconstruction. Method: Since 1993, 67 patients with osteosarcoma have been treated. Sixteen patients had tibial tumors. The original MRI of five patients showed part of the condyle appeared uninvolved. These five underwent joint sparing surgery. A portion of the proximal tibial condyle was resected, leaving the articular surface intact. The tibial defect was reconstructed with autograft bone from the iliac crest and a vascularised fibula. A gastrocnemius muscle flap was rotated to cover the grafts. Four patients had continuation of high dose chemotherapy following surgery and one patient had acute liver failure in the post-operative period requiring the cessation of further chemotherapy. Results: There are three males and two females aged 10 to 18 years. The length of resection was 6.5cm to 12cm and the distance from the articular surface of the tibia to the proximal resection margin ranged from 3mm to 8mm. One patient had reattachment of the tibial tendon because the tibial tubercle had to be resected with the tumor. Pathologic examination showed greater than 90% necrosis in all patients. One patient required two additional procedures because of fracture of the vascularised fibular graft. Her leg is solidly united at 70 months follow-up. Another patient had delayed wound healing with spontaneous resolution. Two patients had contralateral epiphyseodesis to prevent a progressive limb length discrepancy. Follow-up is 13, 46, 55, 70 and 81 months since surgery. The patients are continuously disease-free. The knees in four patients are stable to medial and lateral stress; one patient has slight medial opening, and no patients exhibit anteroposterior laxity. The range of motion of all knees is complete and there is no joint narrowing. Four patients have resumed sports and two wear a brace for these activities. Conclusion: This surgical approach resulted in excellent outcomes in a selected group of patients. Since this is a biologic reconstruction, the patient is allowed unrestricted athletic activities. There is no sign of joint deterioration after short follow-up. Further investigations are required to determine the safety of the procedure and define surgical indications

Aim

The purpose of this single center study was to analyze the robustness and thoroughness of debridement and irrigation in first stage procedures for periprosthetic joint infections in which the latter had been confirmed by fulfilling the PJI criteria produced by the musculoskeletal infection society.

Hip impingement is a diagnosis that has been increasingly recognized among young patients with hip pain.

Two different types of impingement have been described. Over coverage impingement, or a “pincer” effect, occurs between the anterior wall or labrum of the acetabulum and the femoral head. This is typically due to a decrease in anteversion of the acetabulum or over-coverage of the femoral head (coxa profunda or protrusio). A so-called cam-effect impingement occurs when the femoral head-neck junction has an abnormally large radius resulting in insufficient offset. Widening of the femoral neck reduces its concavity, creating an impingement over the acetabular rim. Thus, the anterolateral junction is forced under the acetabular rim, resulting in labral injury and deterioration of the cartilage.

Options for treatment of impingement include non-operative management, arthroscopic débridement, trimming of the anterior aspect of the acetabular rim after surgical dislocation of the hip, periacetabular osteotomy when impingement is secondary to an acetabular torsion abnormality, and surgical resection of a femoral neck bump and/or part of the anterolateral aspect of the neck when the primary anatomic abnormality is secondary to insufficient head-neck offset. Resection of a portion of the anterolateral aspect of the femoral head-neck junction improves the femoral head-neck ratio, increasing the range of motion before impingement occurs.

Recently, surgical dislocation has been used for achieving full access to the femoral head and the acetabulum. Surgical dislocation and resection osteochondroplasty were performed in 22 hips from January 2001 to Decem-ber 2004 because of anterior impingement resulting from an idiopathic nonspherical femoral head, mild slipped capital femoral epiphysis, or poor offset at the head-neck junction. Osteonecrosis was not observed in the hips treated with this method. Pain and function markedly improved after the index operation. Two patients required hardware removal. Treatment goals in young patients with hip impingement should be pain relief and, prevention of further damage to the cartilage and subsequent osteoarthritis. Surgeons using this technique need to know the amount of bone that can be removed safely before catastrophic weakening of the femoral neck occurs.

To elaborate upon the complex variety of successful reconstructive techniques for limb salvage surgery for the management of aggressive juxta-articular and peri-acetabular bone tumors. Limb sparing surgery, while complex, continues to gain wider acceptance among an increasing number of highly specialised musculoskeletal oncology surgeons. The collective experience of the Musculoskeletal Sarcoma Group at The University of Calgary has utilised a variety of limb and joint salvage techniques in its armamentarium for reconstruction of such cases. Whether malignant or benign, aggressive lesions occur at or near the joint resulting in marked subchondral bone destruction or pathologic fractures. comprehensive stepwise plan can result in a stable, pain free and functional joint with limb sparing. The author has utilised local tumor removal and cementation with polymethylmethacrylate with and without secondary internal fixation. ome cases have been amenable to massive osteoarticular allografts, and more recently, tumor endoprostheses. The North American experience with massive oncology prostheses is growing, resulting in increased opportunities for limb and joint salvage surgery with decreased morbidity and complications. his presentation will review the experience of the principal author’s work in limb and joint-sparing bone tumor surgery over the past 18 years

It has been proposed that scoring systems could be nationally used, initially on a secondary care level as a method of prioritising patients on waiting lists for hip and knee arthroplasty. If this were to be successful, scoring systems could be used as a way of tackling the ever increasing waiting list times for surgery which currently stand at around 15 months on the NHS.

I studied and compared the New Zealand and Oxford Hip and Knee Scores, collecting data from 79 patients over a period of seven weeks.

I found that generally, patients who scored highly were recommended for surgery; however I also found that in the group of patients recommended for surgery there was a wide range of scores obtained. There was also a great deal of overlap between the scores obtained by those who were recommended for surgery and those who were not. This means that it would be very difficult to predict a decision for an individual patient based purely on their scores. In addition, many confounding variables can affect the wide range of scores obtained.

I concluded that there was too much variation between the scores obtained by patients undergoing surgery to be able to consistently and fairly prioritise them. In order to implement the use of scoring systems in this country, nationally approved criteria and priority banding categories need to be established. Scoring systems need to be modified to be clearer and to cover more variables. Larger studies need to be conducted with more patients and over a longer period of time; and further work could be done into the proposal that GP’s could use these systems as a tool for referral to consultant out-patient clinics.

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic.

Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate.

Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic.

Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups.

Introduction

Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011.

Total joint replacement (TJR) was one of the most revolutionary breakthroughs in joint surgery. The majority studies had shown that most implants could last about 25 years, anyway, there is still variation in the longevity of implants. In US, for all the hip revisions from 2012 to 2017 in the United States, 12.0% of the patients were diagnosed as aseptic loosening. Variable studies have showed that any factor that could cause a systemic or partial bone loss, might be the risk of periprosthetic osteolysis and aseptic loosening. Breast cancer is the most frequent malignancy in women, more than 2.1 million women were newly diagnosed with breast cancer, 626,679 women with breast cancer died in 2018. It's been reported that the mean incidence of THA was 0.29% for medicare population with breast cancer in USA, of which the incidence was 3.46% in Norwegian. However, the effects of breast cancer chemotherapy and hormonotherapy, such as aromatase inhibitors (AI), significantly increased the risk of osteoporosis, and had been proved to become a great threat to hip implants survival. In this case, a 46-year-old female undertook chemotherapy and hormonotherapy of breast cancer 3 years after her primary THA, was diagnosed with aseptic loosening of the hip prosthesis. Her treatment was summarized and analyzed. Breast cancer chemotherapy and hormonotherapy might be a threat to the stability of THA prosthesis. More attention should be paid when a THA paitent occurred with breast cancer. More studies about the effect of breast cancer treatments on skeleton are required

Pacific people in New Zealand experience significant disparity in health outcomes. There is little known about the burden of arthritis within this community or difficulties accessing specialist orthopaedic care. This qualitative study evaluated the experiences of Pacific patients who underwent hip or knee arthroplasty with a goal to identify barriers to accessing arthroplasty for this community. We interviewed Pacific patients within the Bay of Plenty region who had received either elective hip or knee arthroplasty between 2013 and 2022. Interviews were centred on perceptions of arthritis severity, duration of symptoms, primary care and specialist interactions. Patients were encouraged to offer feedback on ways to improve this experience. We identified 6087 publicly funded primary joints performed in Tauranga hospital and 58 patients were of Pacific ethnicity. After exclusion criteria was applied, we successfully interviewed 20 patients eligible for our study. Pacific patients represented 2.9% of the of the BOP catchment but only received 0.43% of the publicly funded joints. Most reported reluctance to seek help from primary care until symptoms were present for at least a year. Most commonly cited reasons for not seeking help were fear of hospital services and lack of awareness in the community about osteoarthritis. We identified a lack of community awareness of osteoarthritis and arthroplasty among Pacific. This may result in delayed presentation to primary care and decreased utilisation of publicly funded joint surgery. It is reassuring that most patients of Pacific ethnicity who receive primary hip or knee arthroplasty report a positive experience. Public health initiatives together with positive feedback from Pacific patients who have undergone surgery will help to increase awareness of arthroplasty as an option to restore function and relieve pain

Background. The diagnosis of periprosthetic joint infection (PJI) remains a challenge in clinical practice and the analysis of synovial fluid (SF) is a useful diagnostic tool. Recently, two synovial biomarkers (leukocyte esterase (LE) strip test, alpha-defensin (AD)) have been introduced into the MSIS (MusculoSkeletal Infection Society) algorithm for the diagnosis of PJI. AD, although promising with high sensitivity and specificity, remains expensive. Calprotectin is another protein released upon activation of articular neutrophils. The determination of calprotectin and joint CRP is feasible in a routine laboratory practice with low cost. Purpose. Our objective was to evaluate different synovial biomarkers (calprotectin, LE, CRP) for the diagnosis of PJI. Methods. In this monocentric study, we collected SF from hip, knee, ankle and shoulder joints of 42 patients who underwent revision or puncture for diagnostic purposes. Exclusion criteria included a joint surgery in the previous 3 months and a diagnosis of a systemic inflammatory disease. PJI was diagnosed in a multidisciplinary consultation meeting (RCP) of the Reference Centers for Osteoarticular Infections of the Great West (CRIOGO). SF was analysed for LE, CRP and calprotectin. The cut-off values used were 50 mg/L for calprotectin, 8.8 mg/L for CRP and 125 WBC/µL for LE. The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for these different synovial markers. Results. Of the 42 patients included, 28 were considered as infected and 14 uninfected. The statistical parameters are presented in Table 1. Conclusion. The present study shows that the synovial calprotectin assay has an excellent sensitivity and a 100% NPV for the diagnosis of PJI, suggesting that a result < 50 mg/L could exclude PJI. This promising study suggests that calprotectin should be included with synovial CRP in a new decision algorithm for the diagnosis of PJI. For any tables or figures, please contact the authors directly

In recent literature, the fragility index (FI) has been used to evaluate the robustness of statistically significant findings of dichotomous outcomes. This metric is defined as the minimum number of outcome events to flip study conclusions from significant to nonsignificant. Orthopaedics literature is frequently found to be fragile with a median FI of 2 in 150 RCTs across spine, hand, sports medicine, trauma and orthopaedic oncology studies. While many papers discuss limitations of FI, we aimed to further characterize it by introducing the Fragility Likelihood (FL), a new metric that allows us to consider the probability of the event to occur and to calculate the likelihood of this fragility to be reached. We systematically reviewed all randomized controlled trials in the Journal of Bone and Joint Surgery (Am) over 10 years. The FL was calculated with the following formula: A x B x C x 100% (A= FI; B = probability of the event in the group with the smallest number of events; C= probability of the non-event in the group with the highest number of events). A smaller FL demonstrates more robust results and conversely, a larger FL illustrates a higher likelihood of fragility being reached and more fragile the findings. The median FI for the statistically significant outcomes was 2 (Mean: 3.8; Range 0-23). The median FL for the statistically significant outcomes was 11% (Mean: 22%, Range: 2%-73%). This means that the probability of reaching non-significance is only 11% when considering the probability of the event to occur. When comparing studies with the same FI we found the FL to range from 3% to 43%. This illustrates the large differences in robustness between trials with equal FI when the likelihood of the event was taken into consideration. As orthopaedic studies are frequently reported as fragile, we found that by calculating the FL, studies may be more robust than previously assumed based off FI alone. By using the FL in conjunction with FI and p-values will provide additional insight into the robustness of the reported outcomes. Our results indicate that by calculating the FL, study conclusions are stronger than what the FI alone predicts. Although conducting RCTs in surgery can be challenging, we must endeavor to critically evaluate our results so we can answer important orthopaedic questions with certainty

While surgeon-industry relationships in orthopaedics have a critical role in advancing techniques and patient outcomes, they also present the potential for conflict of interest (COI) and increased risk of bias in surgical education. Consequently, robust processes of disclosure and mitigation of potential COI have been adopted across educational institutions, professional societies, and specialty journals. The past years have seen marked growth in the use of online video-based surgical education platforms that are commonly used by both trainees and practicing surgeons. However, it is unclear to what extent the same COI disclosure and mitigation principles are adhered to on these platforms. Thus, the purpose of the present study was to evaluate the frequency and adequacy of potential COI disclosure on orthopaedic online video-based educational platforms. We retrospectively reviewed videos from a single, publicly-accessible online peer-to-peer orthopaedic educational video platform (VuMedi) that is used as an educational resource by a large number of orthopaedic trainees across North America. The 25 highest-viewed videos were identified for each of 6 subspecialty areas (hip reconstruction, knee reconstruction, shoulder/elbow, foot and ankle, spine and sports). A standardized case report form was developed based on the COI disclosure guidelines of the American Academy of Orthopaedic Surgery (AAOS) and the Journal of Bone and Joint Surgery. Two reviewers watched and assessed each video for presentation of any identifiable commercial products or brand names, disclosure of funding source for video, and presenter's potential conflict of interest. Additionally, presenter disclosures were cross-referenced against commercial relationships reported in the AAOS disclosure database to determine adequacy of disclosure. Any discrepancies between reviewers were resolved by consensus wherever possible, or with adjudication by a third reviewer when necessary. Out of 150 reviewed videos, only 37 (25%) included a disclosure statement of any kind. Sixty-nine (46%) videos involved the presentation of a readily identifiable commercial orthopaedic device, implant or brand. Despite this, only 13 of these (19%) included a disclosure of any kind, and only 8 were considered adequate when compared to the presenter's disclosures in the AAOS database. In contrast, 83% of the presenters of the videos included in this study reported one or more commercial relationships in the AAOS disclosure database. Videos of presentations given at conferences and/or academic meetings had significantly greater rates of disclosure as compared to those that were not (41% vs 14%; p=0.004). Similarly, disclosures associated with conference/meeting presentations had significantly greater rates of adequacy (21% vs 7%; p=0.018). Even so, less than half of the educational videos originating from a conference or meeting included a disclosure of any kind, and only about half of these were deemed adequate. No differences were seen in the rate of disclosures between orthopaedic subspecialties (p=0.791). Online orthopaedic educational videos commonly involve presentation of specific, identifiable commercial products and brands, and the large majority of presenters have existing financial relationships with potential for conflict of interest. Despite this, the overall rate of disclosure of potential conflict of interest in these educational videos is low, and many of these disclosures are incomplete or inadequate. Further work is needed to better understand the impact of this low rate of disclosure on orthopaedic education both in-training and in practice