Aims. The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons. Methods. Semi-structured in-depth interviews were carried out on a sample of 12 orthopaedic surgeons. Inductive thematic analysis was used to identify key themes. Results. The four intersecting themes identified were: 1) validity in traditional research, 2) confusion around the definition of AI, 3) an inability to validate AI research, and 4) cautious optimism about AI research. Underpinning these themes is the notion of a validity heuristic that is strongly rooted in traditional research teaching and embedded in medical and surgical training. Conclusion. Research involving AI sometimes challenges the accepted traditional evidence-based framework. This can give rise to confusion among orthopaedic surgeons, who may be unable to confidently validate findings. In our study, the impact of this was mediated by cautious optimism based on an ingrained validity heuristic that orthopaedic surgeons develop through their medical training. Adding to this, the integration of AI into everyday life works to reduce suspicion and aid acceptance. Cite this article: Bone Jt Open 2023;4(9):696–703

Aims

The aim of this study was to investigate surgeons’ reported change of treatment preference in response to the results and conclusion from a randomized contolled trial (RCT) and to study patterns of change between subspecialties and nationalities.

Introduction and aims. The International Orthopaedic community is eagerly adopting Robotic Assisted Arthroplasty (RAA) technology. However, the evidence for the benefits of this technology are unproven and at best equivocal. This study is a comprehensive bibliometric analysis of all published research in the field of RAA. Methods. A systematic literature search was conducted to retrieve all peer-reviewed, English language, publications studying robot- assisted hip and knee arthroplasty between 1992 and 2017. Review articles were excluded. Articles were classified by type of study and level of evidence according to the Oxford Centre for Evidence-based Medicine (OCEBM) Levels of Evidence System. The number of citations, authorship, year of publication, journal of publication, and country and institution of origin were also recorded for each publication. Results. We identified 73 original studies published since 1992 in the field of RAA. The procedures reported were total hip and total knee replacement, and uni-compartmental knee replacement. Publications originated from 17 countries and 117 organisations. Fifty percent of studies identified were published in the last 5 years at an average of 7 publications per year, compared to an average of 2.7 publications per year from 1992 to 2012. Thirty-six percent of original studies were of level 5 evidence or below, with a preponderance of biomechanical and cadaveric studies. The most cited paper was Bargar, Bauer and Borner's original RCT proving efficacy and safety of the Robodoc system for total hip replacement. Most publications originated in the US (36.9%) and more than 15% were published in the Journal of Arthroplasty. Conclusions. Analysis of publication patterns in robotic orthopaedic surgery allow us a unique insight into the qualities, characteristics, clinical innovations and advances in the evolution of RAA research

Aging of Population – Baby Boomers, Millennials, Generation X. Burden of TJR in USA – Estimated ∼ 4 million US adults currently live with TKR (4.2% of the population aged 50 or older) – Females (4.8%); Males (3.4%). Prevalence increased with increasing age. Estimated lifetime risk of primary TKR – 7.0% for males, 9.5% for females. Changes in Resident Education – Resident Work Hour Restrictions. Changes in Fellowship Education – Presumed shortage of fellowship trained arthroplasty surgeons, BWH Data. Changes in Healthcare Paradigm – Hospital – Margin/Mission, Efficiency, Contribution Margin, Ambulatory Centers. Academic/Community Practice – Revenue Driven, Diminished Education/Research Incentive. Arthroplasty Education – Time Restraints, Surgical Volume, Exposure to Options – CR/CS TKR, Revision TKR/THR, Femoral Cementing in THR. “Mind's EYE”. CME Training/Evidence-Based Medicine. Learn Basic Principles of Arthroplasty. “Be Neither the First nor Last to Embrace a New Technology”. “Always Act in the Best Interests of Your Patient”

The World Health Organisation (WHO) has recently identified musculoskeletal care as a major global health issue in the developing world. However, little is known about the quality and trends of orthopaedic research in resource-poor settings. The purpose of this study was to perform a systematic review of orthopaedic research in low-income countries (LIC). The primary objective was to determine the quality and publication parameters of studies performed in LIC. Secondary objectives sought to provide recommendations for successful strategies to implement research endeavors in LIC. A systematic review of the literature was performed by searching MEDLINE (1966-November 2014), EMBASE and the Cochrane Library to identify peer-reviewed orthopaedic research conducted in LICs. The PRISMA guidelines for performing a systematic review were followed. LIC were defined by the WHO and by the World Bank as countries with gross national income per capita equal or less than 1045US$. Inclusion criteria were (1) studies performed in a LIC, (2) conducted on patients afflicted by an orthopaedic condition, and (3) evaluated either an orthopaedic intervention or outcome. The Oxford Centre for Evidence-Based Medicine Levels of Evidence, and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to objectively rate the overall methodological quality of each study. Additional data collected from these studies included the publication year, journal demographics, orthopaedic subspecialty and authors' country of origin. A total of 1,809 articles were screened and 277 studies met our inclusion criteria. Eighty-eight percent of studies conducted in LIC were of lower quality evidence according to the GRADE score and consisted mostly of small case series or case reports. Bangladesh and Nepal were the only two LIC with national journals and produced the highest level of research evidence. Foreign researchers produced over 70% of the studies with no collaboration with local LIC researchers. The most common subspecialties were trauma (42%) and paediatrics (14%). The 3 most frequent countries where the research originated were the United States (42%), United Kingdom (11%), and Canada (8%). The 3 most common locations where research was conducted were Haiti (18%), Afghanistan (14%), and Malawi (7%). The majority of orthopaedic studies conducted in LIC were of lower quality and performed by foreign researchers with little local collaboration. In order to promote the development of global orthopaedic surgery and research in LIC, we recommend (1) improving the collaboration between researchers in developed and LIC, (2) promoting the teaching of higher-quality and more rigorous research methodology through shared partnerships, (3) improving the capacity of orthopaedic research in developing nations through national peer-reviewed journals, and (4) dedicated subsections in international orthopaedic journals to global healthcare research

Background. The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. Methods. All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. Results. A total of 379 articles were analysed from a total of 42 different countries. The kappa value for the inter-observer reliability showed very good agreement between the reviewers for types of evidence (κ = 0.785 (P< 0.01)) and excellent agreement for levels of evidence (κ = 0.846 (P< 0.01)). Between 2000 and 2010 the percentage of high level evidence (Levels I and II) increased (5.2% to 10.3%), and low level evidence (levels III, IV and V) decreased (94.8% to 89.7%) (p=0.09). The most frequent type of study was Therapeutic. The JBJS A produced the highest proportion of high-level evidence. The USA and UK were the highest producer of articles. The number of rest-of-world articles (non USA or UK) increased from 40.5% to 46.4% between 2000 and 2010. Conclusion. There has been a trend towards higher levels of evidence in foot and ankle surgery over a decade but the differences did not reach statistical significance

INTRODUCTION. There is a growing interest in surgical variables that are controlled by the orthopaedic surgeon, including lower leg alignment and soft tissue balancing. Since more tight control over these factors is associated with improved outcomes of total knee arthroplasty (TKA), several computer navigation systems have been developed. Many meta-analyses showed that mechanical axis accuracy and component positioning are improved using computer navigation and one may therefore expect better outcomes with computer navigation but studies showing this are lacking. Therefore, a systematic review with meta-analysis was performed on studies comparing functional outcomes of computer-navigated and conventional TKA. Goals of this study were to (I) assess outcomes of computer-navigated versus conventional TKA and (II) to stratify these results by the surgical variables the systems aim to control. METHODS. A systematic search in PubMed, Embase and Cochrane Library was performed for comparative studies reporting functional outcomes of computer-navigated versus conventional TKA. Knee Society Scores (KSS) Total were most often reported and studies reporting this outcome score were included. Outcomes of computer-navigated and conventional TKA were compared (I) in all studies and (II) stratified by navigation systems that only controlled for lower leg alignment or systems that controlled for lower leg alignment and soft tissue balancing. Level of evidence was determined using the adjusted Oxford Centre for Evidence-Based Medicine tool and methodological quality was assessed using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) tool. Outcomes were reported in mean difference (MD) with 95% confidence intervals [Lower Bound 95%, Upper Bound 95%]. RESULTS. Twenty-eight studies reported KSS Total outcomes in 3,504 patients undergoing computer-navigated or conventional TKA. Fifteen studies were evidence level I, five studies level II and eight studies level III. Study quality varied between low and high with most studies having high methodological quality. Patients reported better outcomes following computer navigated TKA than conventional TKA (MD 2.86 [0.96, 4.76], p=0.003), which was both seen at short-term follow-up of six months and one year (MD 5.20 [3.41, 7.00] and MD 8.46 [0.65, 16.28], respectively) and at mid-term follow-up (≥4 years) (MD 2.65 [0.96, 4.76]) (Figure 1). In studies that used computer navigation for controlling lower leg alignment, no difference in functional outcomes was seen between computer-navigated and conventional TKA (MD 0.66 [−2.06, 3.38], p=0.63, Figure 2). However, in studies that used computer navigation for controlling lower leg alignment and soft tissue balancing, patients reported superior functional outcomes following computer-navigate over conventional TKA (MD 4.84 [1.61, 8.07], p=0.003, Figure 3). CONCLUSION. This is the first meta-analysis showing superior functional outcomes following computer-navigated over conventional TKA. Stratifying results by variables the systems control, superiority in functional outcomes following computer-navigated over conventional TKA were only seen in systems that controlled soft tissue balancing. This suggests that soft tissue balancing plays an important role in short-term outcomes of TKA. Manually controlling all these surgical variables can be difficult for the orthopaedic surgeon and findings in this study suggest that computer navigation may help managing these multiple variables and improve outcomes. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Aims

The adequate provision of personal protective equipment (PPE) for healthcare workers has come under considerable scrutiny during the COVID-19 pandemic. This study aimed to evaluate staff awareness of PPE guidance, perceptions of PPE measures, and concerns regarding PPE use while caring for COVID-19 patients. In addition, responses of doctors, nurses, and other healthcare professionals (OHCPs) were compared.

The contemporary practice of orthopaedic surgery requires an evidence-based approach to support all medical and surgical interventions. In this essay, the author expresses a forthright, personal and somewhat prejudiced appeal to retain the legitimacy of clinical decision making in conditions that are rare, contain multiple variables, have a solution that generally works or has an unpredictable course.

Cite this article: Bone Joint J 2014;96-B:1002–4.

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding.

Cite this article: Bone Joint Res 2014;3:161–8.

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club.

The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions.

It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and sds were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training.

Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.