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Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

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The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model.

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To assess the cost-effectiveness of a two-layer compression bandage versus a standard wool and crepe bandage following total knee arthroplasty, using patient-level data from the Knee Replacement Bandage Study (KReBS).

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The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

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Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

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To identify the responsiveness, minimal clinically important difference (MCID), minimal clinical important change (MIC), and patient-acceptable symptom state (PASS) thresholds in the 36-item Short Form Health Survey questionnaire (SF-36) (v2) for each of the eight dimensions and the total score following total knee arthroplasty (TKA).

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To compare the cost-utility of removable brace compared with cast in the management of adult patients with ankle fracture.

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The cemented Oxford unicompartmental knee arthroplasty (OUKA) features two variants: single and twin peg OUKA. The purpose of this study was to assess the stability of both variants in a worst-case scenario of bone defects and suboptimal cementation.

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Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error.

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The aim of this study was to assess medium-term improvements following total hip arthroplasty (THA), and to evaluate what effect different preoperative Oxford Hip Score (OHS) thresholds for treatment may have on patients’ access to THA and outcomes.

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An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise.

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Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC.

Little guidance exists in the current literature regarding which patient recorded outcome measures (PROMs) are most clinically appropriate following anterior cruciate ligament reconstruction (ACL) surgery, and what results surgeons should expect or accept. Many PROMs have been validated, but their “ideal” results have not been published, limiting a surgeon's ability to compare their patients’ outcomes with those of their colleagues. We undertook a systematic review of PROMs for ACL to look at common usage and outcomes. After appropriate paper selection, we then undertook a pragmatic meta-analysis (i.e., including all papers that fulfilled the selection criteria, regardless of CONSORT status) and calculated weighted mean outcome scores and standard deviations for the most commonly used PROMs. A comprehensive literature search of all English articles of PubMed and other sources including search terms (‘Patient related outcome measure’ or ‘PROM’) AND ‘anterior cruciate ligament’ (limited to abstract/title) yielded 722 articles. Title review narrowed this to 268, and abstracts review to 151, of which 88 were included in our meta-analysis. Weighted mean and standard deviations were calculated for IKDC, KOOS, Lysholm, Teneger and “VAS Pain” PROMs as the most commonly reported. We identified significant, novel findings relating to selected PROMs and (i) demographics including age, gender and body mass index, (ii) surgical factors including bundle count, strand count, and graft type, and (iii) post operative complications. We clarified the most commonly used PROMs for ACL, and their weighted means and standard deviations. This will allow surgeons to compare results with colleagues, ensuring they meet international levels of quality in PROMs. We have also updated which patient and operative factors have an impact on PROMs scoring to allow for population variance

Patients may be able to return to higher level activities following hip arthroplasty with modern techniques and prostheses, but the Oxford hip score, the standard PROM used by the NJS exhibits severe skew and kurtosis. The commonest score is 48/48. Most patients score above 40 preventing any discrimination between approaches or prostheses. We therefore sought both subjective and objective metrics which were relevant and valid without skew or high kurtosis in postoperative patients. The Metabolic Equivalent of Task (MET) reports energy usage in kcal/min burnt across a range of activities, condensed into a score of 0–25. A MET over 8 is considered ‘conditioning exercise’ tethered to life expectancy. A 2 point difference in average MET is considered a clinically relevant difference. Walking speed is a simple valid metric tethered to life expectancy, with a 0.1m/sec difference in walking speed equates to a clinically important difference. Oxford Hip Score (OHS), and the MET were prospectively recorded in 221 primary hip arthroplasty procedures pre-operatively and at 1-year using a web based application. Pre and postoperative Gait analysis was undertaken on a subgroup of 34 patients, in comparison with age and sex matched controls. Post-operatively, the OHS demonstrated significant skewed distributions with ceiling effects of 41% scoring 48/48. The MET was normally distributed around a mean of 10.3, with a standard deviation of 3.8 and no ceiling effect. Walking speed was normally distributed around a mean of 1.8m/sec, with a standard deviation was 0.15 m/sec. The MET is a simple patient reported score, which is normally distributed in patients following hip arthroplasty, around a mean of 10.3 with a standard deviation of 3.8. This valid activity metric correlates well with fast walking speed. This is also normally distributed with a standard deviation of over 0.1m/sec confirming low kurtosis. These simple measures have face validity: undertaking less active pastimes and being unable to keep up with other walkers are obviously inadvisable. The normal kurtosis of these metrics suggest that they may able to detect clinically relevant differences in outcome which are undetectable with commonly used PROMs. For surgeons developing less invasive approaches or using novel stems, these measures may detect clinically important improvements undetectable by the Oxford Hip Score

Utility score is a preference-based measure of general health state – where 0 is equal to death, and 1 is equal to perfect health. To understand a patient's smallest perceptible change in utility score, the minimal clinically important difference (MCID) can be calculated. However, there are multiple methods to calculate MCID with no consensus about which method is most appropriate. The aim of this study is to calculate MCID values for the Veterans-RAND 12 (VR12) utility score using varying methods. Our hypothesis is that different methods will yield different MCID values. A tertiary institutional registry (SMART) was used as the study cohort. Patients who underwent unilateral TKA for osteoarthritis from January 2012 to January 2020 were included. Utility score was calculated from VR12 responses using the standardised Brazier's method. Distribution and anchor methods were used for the MCID calculation. For distribution methods, 0.5 standard deviations of the baseline and change scores were used. For anchor methods, the physical and emotional anchor questions in the VR12 survey were used to benchmark utility score outcomes. Anchor methods included mean difference in change score, mean difference in 12 month score, and receiver operating characteristics (ROC) analysis with the Youden index. Complete case analysis of 1735 out of 1809 eligible patients was performed. Significant variation in the MCID estimates for VR12 utility score were reported dependent on the calculation method used. The MCID estimate from 0.5 standard deviations of the change score was 0.083. The MCID estimate from the ROC analysis method using physical or emotional anchor question improvement was 0.115 (CI95 0.08-0.14; AUC 0.656). Different MCID calculation methods yielded different MCID values. Our results suggest that MCID is not an umbrella concept but rather many distinct concepts. A general consensus is required to standardise how MCID is defined, calculated, and applied in clinical practice

Successful estimation of postoperative PROMs prior to a joint replacement surgery is important in deciding the best treatment option for a patient. However, estimation of the outcome is associated with substantial noise around individual prediction. Here, we test whether a classifier neural network can be used to simultaneously estimate postoperative PROMs and uncertainty better than current methods. We perform Oxford hip score (OHS) estimation using data collected by the NJR from 249,634 hip replacement surgeries performed from 2009 to 2018. The root mean square error (RMSE) of the various methods are compared to the standard deviation of outcome change distribution to measure the proportion of the total outcome variability that the model can capture. The area under the curve (AUC) for the probability of the change score being above a certain threshold was also plotted. The proposed classifier NN had a better or equivalent RMSE than all other currently used models. The standard deviation for the change score for the entire population was 9.93, which can be interpreted as the RMSE that would be achieved for a model that gives the same estimation for all patients regardless of the covariates. However, most of the variation in the postoperative OHS/OKS change score is not captured by the models, confirming the importance of accurate uncertainty estimation. The threshold AUC shows similar results for all methods close to a change score of 20 but demonstrates better accuracy of the classifier neural network close to 0 change and greater than 30 change, showing that the full probability distribution performed by the classifier neural network resulted in a significant improvement in estimating the upper and lower quantiles of the change score probability distribution. Consequently, probabilistic estimation as performed by the classifier NN is the most adequate approach to this problem, since the final score has an important component of uncertainty. This study shows the importance of uncertainty estimation to accompany postoperative PROMs prediction and presents a clinically-meaningful method for personalised outcome that includes such uncertainty estimation

Bone age is a radiographical assessment used in pediatric medicine due to its relative objectivity in determining biological maturity compared to chronological age and size.1 Currently, Greulich and Pyle (GP) is one of the most common methods used to determine bone age from hand radiographs.2–4 In recent years, new methods were developed to increase the efficiency in bone age analysis like the shorthand bone age (SBA) and the automated artificial intelligence algorithms. The purpose of this study is to evaluate the accuracy and reliability of these two methods and examine if the reduction in analysis time compromises their accuracy. Two hundred thirteen males and 213 females were selected. Each participant had their bone age determined by two separate raters using the GP (M1) and SBA methods (M2). Three weeks later, the two raters repeated the analysis of the radiographs. The raters timed themselves using an online stopwatch while analyzing the radiograph on a computer screen. De-identified radiographs were securely uploaded to an automated algorithm developed by a group of radiologists in Toronto. The gold standard was determined to be the radiology report attached to each radiograph, written by experienced radiologists using GP (M1). For intra-rater variability, intraclass correlation analysis between trial 1 (T1) and trial 2 (T2) for each rater and method was performed. For inter-rater variability, intraclass correlation was performed between rater 1 (R1) and rater 2 (R2) for each method and trial. Intraclass correlation between each method and the gold standard fell within the 0.8–0.9 range, highlighting significant agreement. Most of the comparisons showed a statistically significant difference between the two new methods and the gold standard; however it may not be clinically significant as it ranges between 0.25–0.5 years. A bone age is considered clinically abnormal if it falls outside 2 standard deviations of the chronological age; standard deviations are calculated and provided in GP atlas.6–8 For a 10-year old female, 2 standard deviations constitute 21.6 months which far outweighs the difference reported here between SBA, automated algorithm and the gold standard. The median time for completion using the GP method was 21.83 seconds for rater 1 and 9.30 seconds for rater 2. In comparison, SBA required a median time of 7 seconds for rater 1 and 5 seconds for rater 2. The automated method had no time restraint as bone age was determined immediately upon radiograph upload. The correlation between the two trials in each method and rater (i.e. R1M1T1 vs R1M1T2) was excellent (κ= 0.9–1) confirming the reliability of the two new methods. Similarly, the correlation between the two raters in each method and trial (i.e. R1M1T1 vs R2M1T1) fell within the 0.9–1 range. This indicates a limited variability between raters who may use these two methods. The shorthand bone age method and an artificial intelligence automated algorithm produced values that are in agreement with the gold standard Greulich and Pyle, while reducing analysis time and maintaining a high inter-rater and intra-rater reliability

The functional pelvic tilt when standing and sitting forward of 7402 cases on the OPS, Optimized Ortho, Australia Data Base were reviewed. All patients had undergone lateral radiographs when standing simulating extension of the hip, and sitting forward when the hip is near full flexion. Pelvic tilt was measured as the angle of the Anterior Pelvic Plane to the vertical Sagittal Plane, rotation anteriorly being given a positive value. Pelvises that had rotated more than 13 degrees anteriorly (+ve) when sitting forward or posteriorly (-ve) when standing were considered to place the hip at increased risk of dislocation or edge loading when flexed or extending respectively. This degree of rotation has the effect of changing the acetabular version by approximately10. 0. Most safe zones that have been described have given a range of anteversion of 20. 0. as safe. A change of 10. 0. would potentially place the acetabular orientation outside this range. Further, clinical studies have supported this concept. All lateral radiographs were reviewed to confirm that 281 had undergone instrumented spinal fusion at some level between T12 and S1. There was a large variability in the number and the levels arthrodesed. The range of pelvic mobility in the non-arthrodesed group in extension was −37. 0. to 31. 0. (mean −0.9. 0. , Standard deviation 7.49) and in flexed position was −70. 0. to 49. 0. (mean −1.9. 0. , Standard deviation 14.01). For the group with any fusion the range of pelvic tilt in extension was −31. 0. to 22. 0. (mean −4. 0. , Standard deviation 8.21) and flexed −32. 0. to 46. 0. (mean 4.4. 0. , Standard deviation 13.79). Of the 7121 cases without instrumented fusion, 15.5% were considered to be at risk when in flexion and 6.1% when extended. The risk for those with any fusion was approximately doubled in both flexion and extension. Further, those with extensive arthrodesis from T12 to S1 had a range of pelvic tilts similar to the non-fused group, although they had a significantly higher percentage of cases in the ‘at risk’ zones. The proportion of the cases in the ‘at risk’ zones decreased progressively as the arthrodesed levels moved from L5/S1 to the upper lumbar spine, and with decreasing number of levels fused. Conclusion. Spinal fusion is not just one group as there are many combinations of different levels fused. Patients with instrumented spinal fusions do have a proportionately high risk of failure of their THR than the majority of cases with no instrumentation, though the risk varies significantly with the number of levels and actual levels arthrodesed. Further approximately 21% of cases with no spinal fusion have functional pelvic movements that would potentially place them ‘at risk’ of edge loading or dislocation. For any figures or tables, please contact authors directly

Aims. Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods. This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years’ mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results. Of 202 infants who completed the protocol, 181 (90%) had two and five years’ follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years’ follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion. The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years’ follow-up. Cite this article: Bone Joint J 2024;106-B(7):744–750