Aims. This Delphi study assessed the challenges of diagnosing soft-tissue knee injuries (STKIs) in acute settings among orthopaedic healthcare stakeholders. Methods. This modified e-Delphi study consisted of three rounds and involved 32 orthopaedic healthcare stakeholders, including physiotherapists, emergency nurse practitioners, sports medicine physicians, radiologists, orthopaedic registrars, and orthopaedic consultants. The perceived importance of diagnostic components relevant to STKIs included patient and external risk factors, clinical signs and symptoms, special clinical tests, and diagnostic imaging methods. Each round required scoring and ranking various items on a ten-point Likert scale. The items were refined as each round progressed. The study produced rankings of perceived importance across the various diagnostic components. Results. In Round 1, the study revealed widespread variability in stakeholder opinions on diagnostic components of STKIs. Round 2 identified patterns in the perceived importance of specific items within each diagnostic component. Round 3 produced rankings of perceived item importance within each diagnostic component. Noteworthy findings include the challenges associated with accurate and readily available diagnostic methods in acute care settings, the consistent acknowledgment of the importance of adopting a patient-centred approach to diagnosis, and the transition from divergent to convergent opinions between Rounds 2 and 3. Conclusion. This study highlights the potential for a paradigm shift in acute STKI diagnosis, where variability in the understanding of STKI diagnostic components may be addressed by establishing a uniform, evidence-based framework for evaluating these injuries. Cite this article: Bone Jt Open 2024;5(11):984–991

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A review of the literature on elbow replacement found no consistency in the clinical outcome measures which are used to assess the effectiveness of interventions. The aim of this study was to define core outcome domains for elbow replacement.

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The Single Assessment Numerical Evalution (SANE) score is a pragmatic alternative to longer patient-reported outcome measures (PROMs). The purpose of this study was to investigate the concurrent validity of the SANE and hip-specific PROMs in a generalized population of patients with hip pain at a single timepoint upon initial visit with an orthopaedic surgeon who is a hip preservation specialist. We hypothesized that SANE would have a strong correlation with the 12-question International Hip Outcome Tool (iHOT)-12, the Hip Outcome Score (HOS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), providing evidence for concurrent validity of the SANE and hip-specific outcome measures in patients with hip pain.

Aims. To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design. Methods. Healthcare professionals, clinicians, and/or researchers (HCP/Rs) were surveyed, and the data were presented at a congress workshop. A second and related survey was then developed for people with joint damage caused by knee injury and/or osteoarthritis (PJDs), who were approached by a UK Charity newsletter or Oxford involvement registry. Anonymized data were collected and analyzed in Qualtrics. Results. Survey responses (n = 19 HCP/Rs, 39 PJDs) supported studies testing pharmacological agents preventing PTOA. All HCP/Rs and 30/31 (97%) PJDs supported the development of new treatments that improved or delayed knee symptoms and damage to knee structure. PJDs thought that improving structural knee damage was more important than knee symptoms. Both groups found studies more acceptable as expected future benefit and risk of PTOA increased. All drug delivery routes were acceptable. Workshop participants (around n = 60) reflected survey views. Discussions suggested that stratifying using molecular testing for likely drug response appeared to be more acceptable than using characteristics such as sex, age, and BMI. Conclusion. Our findings supported PTOA drug intervention studies, including situations where there is low risk of disease, no expected benefit of treatment, and frequent treatment administration. PJDs appeared less risk-averse than HCP/Rs. This work reinforces the benefits of consensus and involvement work in the co-creation of PTOA drug trial design. Involvement of key stakeholders, such as PJDs with different risks of OA and regulatory representatives, are critical for trial design success. Cite this article: Bone Joint Res 2024;13(9):513–524

Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

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Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

Purpose and background. Nearly 70% of UK physiotherapists experience work-related musculoskeletal disorders (WRMSDs) during their career, with a significant proportion occurring in the back and being attributed to patient handling tasks. Evidence suggests that manual handling training alone is ineffective and interventions among nurses indicate that a tailored approach, including targeted exercise (TE), can reduce WRMSD rates. This study aimed to explore physiotherapists’ perspectives of WRMSDs, patient handling, and the role of TE in reducing WRMSDs among physiotherapists. Methods and Results. Key informant interviews were conducted with 4 physiotherapy operational leads and 1 manual handling trainer from NHS Grampian. Interviews were transcribed and Framework Analysis was utilised to identify key themes, including challenges, barriers, and facilitators. Following this, two online focus groups were conducted with 7 qualified NHS physiotherapists across the UK. Views of manual handling training varied across specialities, with some finding it comprehensive and adaptable, and others finding it less applicable to patients in their speciality or community setting. Physiotherapist views on fitness for work varied, with some highlighting the necessity of TE to ensure workforce health whilst others considered exercise to be a personal matter. Facilitators to implementation identified by participants were having support from management and a strong justification for the exercise content. Varied work schedules and facilities were identified as barriers to implementation of a work-based TE intervention. Conclusion. Varying perspectives on TE interventions and barriers to implementation were identified. This work will inform future research to develop TE interventions in consultation with key stakeholders. Conflicts of Interest. No conflicts of interest. Source of Funding. NHS Endowment Research Grant 22/001

Background. A local authority approached us, for a cost-beneficial solution to their increasing low back pain referrals. We proposed developing a student-led clinic – an intervention delivered by students but supervised by clinicians. We then conducted scoping reviews on student-led clinics in the management of health conditions and on the self-management of back pain. The findings suggested that student-led self-management interventions for low back health should be feasible. The next step was to co-construct the intervention with key stakeholders. Co-Construction. A hybrid of Action Research and Design Science methodology was used to co-construct the intervention with five key stakeholder groups (council staff, managers and human resources, employee healthcare, students, and lecturers). Three rounds of focus groups explored the ‘problem’, the possible solutions, the process, and the content. Themes were taken from each of these focus groups and the similarities and differences were analysed. This analysis and subsequent synthesis with the evidence base created potential intervention models, which were discussed and refined with the stakeholder groups. Intervention. The proposed intervention is focused on providing evidence informed biopsychosocial support for work-relevant back pain, based on identifying obstacles and solutions to improve coping with back health at work. An onboarding workshop challenges positively their thinking around back pain and work. This is followed by up to three 1:1 sessions that support the individual to identify work-relevant back health goals and agree a plan to achieve them using techniques to facilitate behaviour change. Conclusion. The intervention is evidence informed and aims to address the prioritised needs of the stakeholders. Conflicts of interest. No conflicts of interest. Sources of funding. National Health Service Education

Background. Chronic pain is a significant burden and represents a major issue for world healthcare systems. Interventions include medication, surgery, pain management programmes, and social support through peer support groups. These groups are often informal, providing informational, emotional, and social support to members. The aim of this project is to co-produce guidance on how to establish a peer support programme for people living with chronic, non-cancer pain that is informed by evidence, theory, and stakeholder experience. Methods. This project is using Steps 1–4 of the Intervention Mapping (IM) approach to inform the research. Online workshops consisting of people living with chronic pain, third sector representatives, healthcare professionals, and researchers are being used to co-produce the guidance. Results. To date, 2 of the 4 planned workshops have been conducted. These have identified the needs of people living with chronic pain, goals for the peer support programme, and expectations of how a peer support programme should be executed. Topics for inclusion in the programme and their content have been identified, with further workshops to refine this planned. The final stage of this project will identify methods of delivery, specific resources that should be developed, and the training to be provided to peer support volunteers. Conclusion. The project has identified the diverse needs of people living with chronic pain and how these may be addressed by a peer support programme. It has identified flexible options that can be recommended to those who want to set up a programme and a variety content that may be included. Conflicts of Interest. None. Sources of Funding. Robert Gordon University

Background. Our current research aims to develop technologies to predict spinal loads in vivo using a combination of imaging and modelling methods. To ensure the project's success and inform future applications of the technology, we sought to understand the opinions and perspectives of patients and the public. Methods. A 90-minute public and patient involvement event was developed in collaboration with Exeter Science Centre and held on World Spine Day 2023. The event involved a brief introduction to the project goals followed by an interactive questionnaire to gauge the participants’ background knowledge and interest. The participants then discussed five topics: communication, future directions of the research, concerns about the research protocol, concerns about data, and interest in the project team and research process. A final questionnaire was used to determine their thoughts about the event. Results. Twelve adults attended the event, many motivated by their experience or interest in back pain. A thematic analysis was used to review participant comments on the research project, identifying the need to relate the research to everyday life, present risks in various ways, and be transparent about funding and data sharing. In terms of future applications, participants felt the technology should be used to understand normal spine behaviour, prevent problems, and improve treatment. Participants agreed that they had got something positive out of engaging in the event. Conclusion. Engagement with public and patient stakeholders is an essential activity that can generate vital information to inform and add value to technology development projects. Conflicts of interest. No conflicts of interest. Sources of funding. EPSRC grants EP/V036602/1 (Meakin, Holsgrove & Javadi) and EP/V032275/1 (Holt & Williams)

Aims. Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice. Methods. A consensus exercise was conducted involving all the major stakeholders in the patient journey for those with musculoskeletal injury. The consensus exercise primary aim was to seek agreement on a standardized set of terminology for weightbearing instructions. Results. A pre-meeting questionnaire was conducted. The one-day consensus meeting, including patient representatives, identified three agreed terms only to be used in defining the weightbearing status of the patient: 1) non-weightbearing; 2) limited weightbearing; and 3) unrestricted weightbearing. Conclusion. This study represents the first and only exercise in standardizing rehabilitation terminology in orthopaedics, as agreed by all major stakeholders in the patient pathway and the patients themselves. The standardization of language allows for higher-quality and more accurate research to be conducted, and is one small part of the bigger picture in increasing the mobility of patients after orthopaedic injury or surgery. Cite this article: Bone Joint J 2024;106-B(9):1016–1020

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Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

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Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures.

Introduction. Individuals with significant hip and knee trauma receive total knee (TKA) and total hip arthroplasty (THA) as definitive end-stage procedures. In Aotearoa, injury-related costs, including workers compensation, may be funded by ACC. With a steady increase of arthroplasty procedures in Aotearoa, we aim to understand the magnitude and characteristics of such procedures to inform future healthcare strategies. Method. This is a longitudinal collaborative study from 1st January 2000 to 31st December 2020, using ACC and New Zealand Joint Registry databases. Total cost was subcategorised into social and medical cost for analysis. Results. ACC funded 10179 TKA and 5611 THA, amounting to 918 million New Zealand Dollars. Most clients were between 55 and 65 years of age at time of surgery, with greater representation by Male sex and European prioritised ethnicity. Māori and Pacific peoples represent less than 10% of the study population. ACC identified requiring more than 182 days of workers’ compensation as a significant marker for needing additional supports. Risk of this was 21% for TKA and 11% for THA, with risk factors being younger age (RR 0.96), Male sex (TKA RR 1.12, THA RR 1.23), and heavy work-types (TKA RR 1.50, THA RR 1.57). Discussion. Supporting individuals with post-traumatic lower limb arthroplasty is costly. Workers’ compensation contributes to a significant proportion of social expenditure. Risk factors for increased cost utilisation can be used to highlight vulnerable clients and target interventions. Conclusions. This is one of few nationwide studies investigating the healthcare cost of post-traumatic lower limb arthroplasty. We need to focus on injury prevention, targeted treatment, and rehabilitation protocols to improve recovery and reduce time off work. These findings would be of interest to multiple stakeholders

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process. Cite this article: Bone Joint J 2024;106-B(5):422–424

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The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

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Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.