Aims. Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

Aims. The Oxford Shoulder Score (OSS) is a 12-item measure commonly used for the assessment of shoulder surgeries. This study explores whether computerized adaptive testing (CAT) provides a shortened, individually tailored questionnaire while maintaining test accuracy. Methods. A total of 16,238 preoperative OSS were available in the National Joint Registry (NJR) for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey dataset (April 2012 to April 2022). Prior to CAT, the foundational item response theory (IRT) assumptions of unidimensionality, monotonicity, and local independence were established. CAT compared sequential item selection with stopping criteria set at standard error (SE) < 0.32 and SE < 0.45 (equivalent to reliability coefficients of 0.90 and 0.80) to full-length patient-reported outcome measure (PROM) precision. Results. Confirmatory factor analysis (CFA) for unidimensionality exhibited satisfactory fit with root mean square standardized residual (RSMSR) of 0.06 (cut-off ≤ 0.08) but not with comparative fit index (CFI) of 0.85 or Tucker-Lewis index (TLI) of 0.82 (cut-off > 0.90). Monotonicity, measured by H value, yielded 0.482, signifying good monotonic trends. Local independence was generally met, with Yen’s Q3 statistic > 0.2 for most items. The median item count for completing the CAT simulation with a SE of 0.32 was 3 (IQR 3 to 12), while for a SE of 0.45 it was 2 (IQR 2 to 6). This constituted only 25% and 16%, respectively, when compared to the 12-item full-length questionnaire. Conclusion. Calibrating IRT for the OSS has resulted in the development of an efficient and shortened CAT while maintaining accuracy and reliability. Through the reduction of redundant items and implementation of a standardized measurement scale, our study highlights a promising approach to alleviate time burden and potentially enhance compliance with these widely used outcome measures. Cite this article: Bone Joint Res 2024;13(8):392–400

The August 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data.

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The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery.

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In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.

Introduction. This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales. Methods. Patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Foot Ankle Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 261 (51.9%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 31 (6.2%) COFAS 3 and 89 (17.7%) COFAS type 4. 38 patients (7.6%) presented with inflammatory arthritis. 99 (19.7%) implantations utilised patient specific instrumentation. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results. The mean follow up was 34.2 months (range 24–64). 15 patients have died, 8 withdrawn and 3 lost to follow up. 8 implants (1.6%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%. There have been an additional 13 non revision re-operations (2.6%) at the latest follow up. There was a significant (p < 0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Discussion and conclusion. This large cohort has shown a low early revision rate and high functional outcomes with a low-profile fixed bearing prosthesis

Introduction. Despite the increasing numbers of ankle replacements that are being performed there are still limited studies on the survival of ankle replacements and comparisons between different implants. The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements. Secondary outcomes include analysis risk factors for failure, patient demographics and outcomes of individual prosthesis. Methods. A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device inserted during ankle replacement surgery. Life tables and Kaplan Meier survival charts demonstrated survivorship. Cox proportional hazards regression models with the Breslow method used for ties were fitted to compare failure rates. Results. 5,562 primary ankle replacement were recorded on the NJR. The 1-year survivorship was 98.8% (95% CI 98.4%–99.0%), 5-year survival in 2725 patients was 90.2% (95% CI 89.2%–91.1%), and 10-year survival in 199 patients was 86.2% (95% CI 84.6%–87.6%). When using a Cox regression model for all implants with over 100 implantations using the Infinity as the reference, only the Star (Hazard ratio 1.60 95% CI 0.87–2.96) and Inbone (HR 0.38 95% CI 0.05–2.84) did not produce significantly worse survivorship. Conclusion. Ankle replacements have increased in numbers over the past decade, and the currently used implants have lower failure rates than older prosthesis. It is expected that in the future the outcomes of ankle replacements will continue to improve

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During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon’s decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.

The June 2024 Shoulder & Elbow Roundup. 360. looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

The June 2024 Knee Roundup³⁶⁰ looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants.

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The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

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This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

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The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

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The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques.

Introduction. A key outcome measured by national joint registries are revision events. This informs best practice and identifies poor-performing surgical devices. Although registry data often record reasons for revision arthroplasty, interpretation is limited by lack of standardised definitions of revision reasons and objective assessment of radiologic and laboratory parameters. Our study aim was to compare reasons for unicompartmental knee arthroplasty (UKA) revision reported to the New Zealand Joint Registry (NZJR) with reasons identified by independent clinical review. Methods. A total of 2,272 patients undergoing primary medial and lateral UKA at four large tertiary hospitals between 2000 and 2017 were included. A total of 158 patients underwent subsequent revision with mean follow-up of 8 years. A systematic review of clinical findings, radiographs and operative data was performed to identify revision cases and to determine the reasons for revision using a standardised protocol. These were compared to reasons reported to the NZJR using Chi-squared and Fisher exact tests. Results. Osteoarthritis progression was the most common reason for revision on systematic clinical review (30%), however this was underreported to the registry (4%, p<0.001). A larger proportion of revisions reported to the registry were for ‘unexplained pain’ (30% of cases vs. 4% on clinical review, p<0.001). A reason for revision was not reported to the registry for 24 (15%) of cases. Discussion and Conclusion. We found significant inaccuracies in registry-reported reasons for revision following UKA. These included over-reporting of ‘unexplained pain’, under-reporting of osteoarthritis progression, and failure to identify a reason for revision. Efforts to improve registry capture of revision reasons for UKA should focus on increasing accuracy in these three areas. This could be addressed through standardised recording methods and tailored revision reason options for UKA for surgeons to select when recording the reasons

Current advice regarding implant choice is based on estimates of cost-benefit derived from implant survival to an endpoint of revision. Current estimates do not account for many implant failures which are treated with non-revision surgery and may not be accurate. The aim of this study was to estimate survival of major stem implant design groups to an endpoint of reoperation. Primary total hip replacement and linked revision form the National Joint Registry (NJR) and Hospital Episode Statistics (HES) data linked by unique identifier were used. Survival of femoral implant groups (cemented stainless steel polished taper [PTSS], cemented cobalt chrome polished taper [PTCC], cemented composite beam [CB], collarless cementless [NCOL] and collared cementless [COL]) was estimated using Kaplan-Meier method. 809,832 patients with valid NJR and HES data from England, were included. Cumulative failure at ten years for PTSS increased overall from 2.9% (95%CI 2.8–2.9) to 3.6% (95%CI 3.6–3.7) after inclusion of reoperations. Cumulative failure at ten years for PTSS increased from 2.5% (95%CI 2.5–2.6) to 3.3% (95%CI 3.2–3.4), for PTCC increased from 3.8% (95%CI 3.5–4.0) to 5.4% (95%CI 5.1–5.6), for CB increased from 3.1% (95%CI 2.9–3.3) to 4.1% (95%CI 3.8–4.3), for NCOL increased from 3.4% (95%CI 3.3–3.5) to 3.9% (95%CI 3.8–4.0), and for COL increased from 2.5% (95%CI 2.4–2.6) to 3.1% (95%CI 2.9–3.2), after inclusion of reoperations. Re-operation for internal fixation is as significant life event for the patient as revision. When a more inclusive metric is used, the patient and clinician's perspective on what constitutes a GIRFT implant may not be the same. Further work is required to update implant selection guidance in view of the change in implant performance

Hip bearing surfaces materials are typically broadly reported in national registry (metal-on-polyethylene, ceramic-on-ceramic etc). We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by detailed types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with detailed head and shell/liner bearing material combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 were included in the primary analysis (Monobloc cups: n=378,979 and Modular cups: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the overall risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the overall risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The overall and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is reduced for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup in reference to THRs with a cobalt chrome head and HCLPE liner/cup