Musculoskeletal diseases are having a growing impact worldwide. It is therefore crucial to have an evidence base to most effectively and efficiently implement future health services across different healthcare systems. International trials are an opportunity to address these challenges and have many potential benefits. They are, however, complex to set up and deliver, which may impact on the efficient and timely delivery of a project. There are a number of models of how international trials are currently being delivered across a range of orthopaedic patient populations, which are discussed here. The examples given highlight that the key to overcoming these challenges is the development of trusted and equal partnerships with collaborators in each country. International trials have the potential to address a global burden of disease, and in turn optimize the benefit to patients in the collaborating countries and those with similar health services and care systems. Cite this article: Bone Joint J 2023;105-B(7):719–722

Aims. The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care. Methods. We compared all ten established national hip fracture registries: England, Wales, and Northern Ireland; Scotland; Australia and New Zealand; Republic of Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; and Spain. We tabulated all questions included in each registry, and cross-referenced them against the 32 questions of the MCD dataset. Having identified those questions consistently used in the majority of national audits, and which additional fields were used less commonly, we then used consensus methods to establish a revised MCD. Results. A total of 215 unique questions were used across the ten registries. Only 72 (34%) were used in more than one national audit, and only 32 (15%) by more than half of audits. Only one registry used all 32 questions from the 2014 MCD, and five questions were only collected by a single registry. Only 21 of the 32 questions in the MCD were used in the majority of national audits. Only three fields (anaesthetic grade, operation, and date/time of surgery) were used by all ten established audits. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from expert clinicians from different countries. A draft revision of the MCD was then presented to all 95 nations represented at the Global FFN conference in September 2021, with online feedback again used to finalize the revised MCD. Conclusion. The revised MCD will help aspirant nations establish new registry programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services. Cite this article: Bone Joint J 2022;104-B(6):721–728

Introduction. LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study. Materials & Methods. A mixed method multiphase approach was used to develop LIMB-Q Kids. In phase one, a systematic review was conducted to identify concepts from existing PROMs used in research with children with LLDs. A preliminary conceptual framework derived from the systematic review informed an international qualitative study. The data from qualitative interviews were used to form the LIMB-Q Kids, which was further refined through multiple rounds of cognitive debriefing interviews with children. Input was obtained from parents and healthcare professionals from Australia, Canada, Ethiopia, India, UK, and the USA. LIMB-Q Kids was translated and culturally adapted into multiple languages. Results. The final field-test version consists of 11 scales (159 items) that measure appearance, physical function, symptoms (hip, knee, ankle, foot, and leg), leg-related distress, and school, social and psychological function. This version was rigorously translated into Danish and German. Translations that are in progress include Arabic, Finnish, Hindi, Swahili, Portuguese, Spanish, and Luganda. An international field-test study is underway in nine countries (15 sites with a target recruitment of 150 participants per country). At the time of abstract submission, 190 patients from seven sites have completed LIMB-Q Kids. The UK collaborative has worked on language adaption for the UK and is currently validating the score across five paediatric limb reconstruction units. Conclusions. No internationally applicable PROM exists for children with LLDs. We present the current progress in developing and validating such a score. Data from the international field-test study will be used to reduce items and perform psychometric testing of LIMB-Q Kids. The rigorous translation and cultural adaption process will provide versions of LIMB-Q Kids in different languages. Once completed, the LIMB-Q Kids will provide a common metric for outcome assessment for children with lower limb differences internationally

The 2020 London International Hamstring Consensus meeting was convened to improve our understanding and treatment of hamstring injuries. The multidisciplinary consensus panel included 14 International specialists on the management of hamstring injuries. The Delphi consensus process consisted of two rounds of surveys which were completed by 19 surgeons from a total of 106 participants. Consensus on individual statements was regarded as over 70% agreement between panel members. The consensus group agreed that the indications for operative intervention included the following: gapping at the zone of injury (86.9%); high functional demands of the patient (86.7%); symptomatic displaced bony avulsions (74.7%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (71.4%). Panel members agreed that surgical intervention had the capacity to restore anatomy and function, while reducing the risk of injury recurrence (86.7%). The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help to further standardise the treatment of hamstring injuries and facilitate decision-making in the surgical treatment of these injuries

Increased collection of patient-reported outcome measures (PROM) in registries enables international comparison of patient-centered outcomes after knee and hip replacement. We aimed to investigate 1) variations in PROM improvement, 2) the possible confounding factor of BMI, and 3) differences in comorbidity distributions between registries. Registries affiliated with the International Society of Arthroplasty Registries (ISAR) or OECD membership countries were invited to report aggregate EQ-5D, OKS, OHS, HOOS-PS and KOOS-PS values. Eligible patients underwent primary total, unilateral knee or hip replacement for osteoarthritis within three years and had completed PROMs preoperatively and either 6 or 12 months postoperatively, excluding patients with subsequent revisions. For each PROM cohort, Chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (male/female, age 20-64/65-74/>75, high or low preoperative PROM scores). Comorbidity distributions were reported for available comorbidity indexes. Thirteen registries from 9 countries contributed data, n~130000 knee (range 140 to 79848) and n~113000 hip (range 137 to 85281). Mean EQ-5D index values (10 registries) ranged from 0.53 to 0.71 (knee) and 0.50 to 0.70 (hips) preoperatively and 0.78 to 0.85 (knee) and 0.83 to 0.87 (hip) postoperatively. Mean OKS (6 registries) ranged from 19.3 to 23.6 preoperatively and 36.2 to 41.2 postoperatively. Mean OHS (7 registries) ranged from 18.0 to 23.2 preoperatively and 39.8 to 44.2 postoperatively. Four registries reported KOOS-PS and three reported HOOS-PS. Proportions of patients with BMI >30 ranged from 35 to 62% (10 knee registries) and 16 to 43% (11 hip registries). For both knee and hip registries, distributions of patients across six BMI categories differed significantly among registries (p30 were for patients in the youngest age groups (20 to 64 and 65 to 74 years) with the lowest baseline scores. Additionally, females with lowest preoperative PROM scores had highest BMI. These findings were echoed for the OHS and OKS cohorts. Proportions of patients with ASA scores ≥3 ranged from 7 to 42% (9 knee registries) and 6 to 35% (8 hip registries). PROM-score improvement varies between international registries, which may be partially explained by differences in age, sex and preoperative scores. BMI and comorbidity may be relevant to adjust for

Abstract. Introduction. There is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children. Methodology. An international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus. Results. A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study. Surgeons from the UK, Europe, USA and South America took part. 34 statements were identified exploring 4 main domains – clinical diagnosis, investigation, management and specialist tears. Following round 1 consensus was reached on 17 (50%) statements, subsequently after completion of round 2 consensus was reached on 28 (82%) statements, leaving 6 (18%) with no consensus. Conclusions. This is the first modified delphi consensus which provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. Further studies are required to provide evidence for the areas where no consensus was reached

Given the low prevalence of sarcoma, international cooperation is necessary to recruit sufficient numbers of patients for surgical trials. The PARITY (Prophylactic Antibiotic Regimens in Tumour Surgery) trial is the first international multicentre trial in orthopedic oncology and successfully achieved target enrollment of 600 patients across 12 countries. It is important to reflect upon the challenges encountered and experiences gained to inform future trials. The objective of this study is to describe recruitment patterns and examine the differences in enrollment across different PARITY sites and identify variables associated with varying levels of recruitment. Data from this study was obtained from the PARITY trial Methods Centre and correspondence data. We performed descriptive statistics to demonstrate the recruitment patterns over time. We compared recruitment, time to set up, and time to enroll the first patient between North American and international sites, and sites that had dedicated research personnel. Two-tailed non-paired t-tests were performed to compare average monthly recruitment rates between groups with significance being set at alpha=0.05. A total of 600 patients from 48 clinical sites and 12 countries were recruited from January 2013 through to October 2019. Average monthly enrollment increased every year of the study. There were 36 North American and 12 international sites. North American sites were able to set up significantly faster than international sites (19.3 vs. 28.3 months p=0.037). However, international sites had a significantly higher recruitment rate per month once active (0.2/month vs. 0.62/month, p=0.018). Of active sites, 40 (83%) had research support personnel and 8 (17%) sites did not. Sites with research personnel were able to reach ‘enrolment ready’ status significantly faster than sites without research support (19.6 vs. 30.7 months, p=0.032). However, there was no significant difference in recruitment rate per month once the sites began enrolling (0.28/month vs. 0.2/month, p=0.63). Trial sites that took longer than 1 year to recruit their first patient had 3x lower average recruitment rate compared to sites that were able to recruit their first patient within a year of being enrolment ready. The PARITY trial is the first multicentre RCT in orthopaedic oncology. The PARITY investigators were able to increase the recruitment levels throughout the trial and generally avoid trial fatigue. This was a North American based trial which may explain the longer start up times internationally given the different regulatory bodies associated with drug-related trials. However, international sites should be considered critical as they were able to recruit significantly more patients per month once active. The absence of research support personnel should not preclude a site from inclusion. These sites took longer to setup but had no difference in monthly recruitment once active. This study will create a framework for identifying and targeting high yield sites for future randomized control trials within orthopaedic oncology to maximum recruitment and resource allocation. Data quality is another consideration that will be addressed in future analyses of the PARITY trial

X-Linked Hypophosphataemia (XLH) is a rare, progressive, hereditary phosphate-wasting disorder characterised by excessive activity of fibroblast growth factor 23. The International XLH Registry was established to provide information on the natural history of XLH and impact of treatment on patient outcomes. The cross-sectional orthopaedic data presented are from the first interim analysis. The XLH Registry (NCT03193476) was initiated in August 2017, aims to recruit 1,200 children and adults with XLH, and will run for 10 years. At the time of analysis (Last Patient In: 30/11/2020; Database Lock: 29/03/2021) 579 subjects diagnosed with XLH were enrolled from 81 hospital sites in 16 countries (360 (62.2%) children, 217 (37.5%) adults, and 2 subjects of unknown age). Of subjects with retrospective clinical data available, skeletal deficits were the most frequently self-reported clinical problems for children (223/239, 93.3%) and adults (79/110, 71.8%). Retrospective fracture data were available for 183 subjects (72 children, 111 adults); 50 had a fracture (9 children, 41 adults). In children, fractures tended to occur in tibia/fibula and/or wrist; only adults reported large bone fractures. Joint conditions were noted for 46 subjects (6 children, 40 adults). For adults reporting osteoarthritis, knees (60%), hips (42.5%), and shoulders (22.5%) were the most frequently affected joints. Retrospective orthopaedic surgery data were collected for 151 subjects (52 children, 99 adults). Osteotomy was the most frequent surgery reported (n=108); joint replacements were recorded for adults only. This is the largest set of orthopaedic data from XLH subjects collected to date. Longitudinal information collected during the 10-year Registry duration will generate real-world evidence which will help to inform clinical practice. Authors acknowledge the contribution of all International XLH Registry Steering Committee members

The Canadian Institute for Health Information (CIHI) and the Organisation for Economic Co-operation and Development (OECD) have partnered to advance international patient-reported outcome measures (PROMs) collection and reporting standards for hip and knee arthroplasty. This project is part of the OECD's Patient-Reported Indicator Survey (PaRIS) initiative, which aims to address the need for internationally comparable patient-reported outcome and experience measures in order to better monitor health system performance and drive continuous improvement. PROMs are in varying stages of implementation across OECD health systems, with differences in collection and reporting practices across existing programs. CIHI and the OECD are leading an international working group for PROMs in hip and knee replacement surgery in order to build consensus on PROMs data collection standards and develop indicators for international reporting. Working group members include patient representatives, clinicians, national arthroplasty registries, the International Society of Arthroplasty Registries (ISAR), experts in PROMs measurement, and government representatives of several OECD member countries. Activities of the working group focus on two main priorities: 1) Use existing PROMs programs to maximize pilot comparable reporting in OECD's Health at a Glance 2019 report, and 2) Advance new PROMs standards and data collection to maximize comparable reporting beyond Health at a Glance 2019. An environmental scan of PROMs in hip and knee arthroplasty found that a number of countries are collecting this data, however, there are variations in survey instruments as well as administration and reporting methods within and across countries. As part of priority 1, the working group has achieved consensus on a number of aspects around pilot reporting. The project is compiling data from existing PROMs programs in order to report results in the Health at a Glance 2019 publication. For priority 2, the most notable challenge is establishing an agreement across countries on common survey tools, as well as a minimum data set that works for all, given the disparities of existing collection across countries. Many international programs lack the flexibility to change PROMs tools or collections methods, and have concerns regarding the break in trend for PROMs data within their own countries if they were to change methods. The project is exploring the use of crosswalks and other opportunities for comparable reporting, such as the use of single-item anchor questions. To date, the working group continues to develop consensus on international standards for PROMs collection and reporting. Results of the international consensus building and work to date will be shared. PROMs incorporate the patient's perspective into the delivery of treatments and care – such as hip and knee arthroplasty – that aim to improve a patient's quality of life. Alignment of standards in PROMs collection across countries will make comparable data available for reporting, in order to inform quality improvement initiatives within health systems to provide better care for patients. CIHI and the OECD will continue to work with member countries to develop international data collection and reporting standards for PROMs, and encourage the adoption of common approaches across countries

Aim. Deep infection following endoprosthetic replacement (EPR) of long bones is a devastating complication occurring in 15% of musculoskeletal tumour patients. The recently published PARITY Trial demonstrated that extending antibiotic prophylaxis from 24 hours to 5 days does not reduce infection rates. However, questions remain about the optimal antibiotic choice and dose. Method. A 23-question multiple-choice questionnaire was designed and piloted through an iterative feedback process until the final version was agreed by all authors. Open and closed-ended questions were used to gather information on practice and Likert-type scale responses were used to grade responses to ascertain surgeon perceptions and preferences. The online survey was sent to all surgeon delegates of the 34th Annual Meeting of the European Musculo-Skeletal Oncology Society in London in October 2022. Results. Amongst 61 respondents, 43 were based in Europe and 18 outside of Europe. The majority (48/61) had been in clinical practice over 11 years. Antibiotic choice. 1st or 2nd generation cephalosporins were the first line choice practiced among 49 (80.3%) of respondents. Of these, 39 responded had a 2nd line protocol for beta-lactam allergy which was most commonly clindamycin (18), vancomycin (11) or a combination of a glycopeptide or clindamycin plus gentamicin (4). Respondents changed their first line regimen for radiotherapy in 6/61, chemotherapy in 8/61 and tumour site in 20/61. Re-dosing. Intraoperative re-dosing intervals of 1st and 2nd generation cephalosporins ranged from 2 to 8 hourly. Re-dosing for blood loss ranged from never to when 2 litres was lost. Of the 47 respondents, 24 said intraoperative re-dosing is always reliably administered. Duration. Six (10%) of 61 respondent routinely cover the intraoperative period only, whereas 30 (49%) give 24 hours, 16 (give 48 hours or longer and 8 continue until surgical drains are removed. 31 of 61 change duration depending on clinical situation. The most common reasons for changing were patient risk factors, soft tissue status and previous radiotherapy. 57/61 surgeons were aware of the PARITY Trial. When these respondents were asked whether they had changed practice based on PARITY, 12 said yes, 24 said no and 21 said they always give 24 hours anyway. Conclusions. Amongst an international cohort of orthopaedic oncology surgeons there was a wide variation in practice. Further research should focus on the optimum choice and re-dosing strategy, which have not been defined

Excessive postoperative opioid prescribing is a significant contributor to the opioid crisis. Prescribing in orthopaedic surgery is often further complicated by high use of opioid-based preoperative analgesia. ‘Opioid PrEscRiptions and usage After Surgery’ (OPERAS) is an international multicentre prospective student- and trainee-led collaborative study which aims to quantify the amount of opioids prescribed at discharge after common orthopaedic surgeries against what is consumed by patients at 7-days, and assess the impact of opioids on patient-reported outcomes. Data is being collected over 6 14-day periods on consecutive adult patients undergoing shoulder arthroplasty, rotator cuff repair, shoulder labral repair, anterior cruciate ligament repair, hip arthroplasty, and knee arthroplasty, with follow-up via telephone call at 7-days after discharge. The primary outcome is the proportion of oral morphine equivalents (OME) of prescribed opioids versus consumed opioids at 7-days post-discharge. This ongoing study is actively recruiting in over 20 countries. Globally, 65 centres are collecting orthopaedic, including 10 New Zealand centres and 17 Australian centres. To date, 284 orthopaedic patients have been prospectively enrolled with complete data (mean age 59.6 ± 16.7 years; 51.6% female). Overall, 77% and 89% of patients were prescribed opioids on discharge in New Zealand and Australia respectively. On average, 60% of prescribed opioids were consumed at 7-days post-discharge globally (150 OME (75-500) vs. 90 OME (15-200); p<0.01). In New Zealand and Australia, 42.1% (285 OME (150-584) vs. 120 OME (6-210); p<0.01) and 63.3% (150 OME (86-503) vs. 95 OME (28-221); p<0.01) of prescribed opioids were consumed at 7-days, respectively. OPERAS will provide the first high-quality global data on opioid prescription and consumption patterns with patient perspectives. These data can inform prescribing practice and inform guidelines. The growing interest in New Zealand and Australia in student- and trainee-led orthopaedic collaborative research, as evidenced by this study should be actively encouraged and fostered

Aim. Suppressive antimicrobial therapy (SAT) is used worldwide for patients with a prosthetic joint infection (PJI but clear definitions or guidelines regarding the indications, antimicrobial strategy or treatment duration are currently lacking in the literature. The aim of this study was to identify the global differences in the clinical practice of SAT for PJI. Method. An online survey was designed to investigate the current opinion on indication and treatment goals, preferred antimicrobial drugs, dosing and treatment duration and follow-up of patients with PJI on suppression. The survey was distributed using e-mail lists of several international bone and joint infection societies and study groups. Recipients were asked to share the survey with colleagues who were not a member of one of the societies but who were involved in PJI care. Results. The questionnaire was fully completed by 330 physicians from 43 different countries on six continents (Europe, n=134, 41%; Oceania n=112, 34%; North America, n=51, 16%; other, n=33, 10%; total response rate 14%). Antimicrobial treatment for PJI was discussed in a multidisciplinary team in Europe (90%), Oceania (42%) and North America (12%). In six of eight (75%) different clinical scenarios, respondents from North America would most often place a patient on SAT. In seven of eight (88%) scenarios, SAT was started least often by European respondents. The presence of a fistula was considered a contra-indication for suppression by 74 respondents (22%). First choices of SAT for staphylococcal PJI were: oral cephalosporins (39%) and tetracyclines (31%) in North America; anti-staphylococcal penicillins (55%) and oral cephalosporins (24%) in Oceania; tetracyclines (27%) and anti-staphylococcal penicillins (22%) in Europe. For streptococcal PJI, most clinicians preferred penicillins (91% in Oceania, 67% in Europe, and 53% in North America). Preferred SAT for gram negative PJI was: fluoroquinolones and a penicillin/betalactamase inhibitor in North America (26% and 18%, respectively) and Oceania (23% and 27%, respectively); fluoroquinolones (31%) and Cotrimoxazole (28%) in Europe. The dosage of SAT was never lowered (n=126, 38%), standardly lowered for all antibiotics (n=79, 24%) or only lowered for specific antibiotics (n=125, 38%). SAT was prescribed for an indefinite duration (n=43, 13%), as fixed duration between six months and three years (n=104, 32%) or for an undetermined prespecified duration (n=154, 47%). Conclusions. Substantial variation in the practice of SAT for PJI exists between physicians worldwide and throughout the different continents. This reflects the paucity of data regarding the indication and treatment of PJI with SAT

Introduction: With a life of over five years, Spine Tango can be considered the first truly International Spine Registry. The Swedish Spine Registry has already shown the feasibility of a registry on a national level. But, there is a need for an international spine registry allowing a benchmarking on an international level. Here we demonstrate the genesis of questionnaire development, the constantly increasing activity, and limitations of the International Spine Registry Spine Tango. Methods: From 2002 until 2007 about 9000 datasets were submitted by 28 hospitals in nine countries worldwide. Three different generations of Spine Tango questionnaires were used for documentation. Results: To cope with varying international administrative issues and legal requirements of data anonymisation, national Spine Tango modules are necessary. Four national Spine Tango modules are in operation to date, another three modules are in the process of roll-out. Considering all these participants, Spine Tango will soon expand to include data from 52 hospitals in 18 countries. One-fourth of these hospitals are University Hospitals, which are destined to take the lead in the Spine Tango registry as opinion leading hospitals. Although the number of participants is steadily growing, no country is yet represented with a sufficient number of hospitals. Indisputably, a marketing concept is needed. An acquisition of new centres via national spine societies seems an obvious strategic approach. Further limitations of Spine Tango include the low number and short duration of follow-ups and the lack of sufficiently detailed patient based data on subgroup level. Discussion: Spine Tango has achieved a firm position as international spine registry and with its increasing acceptance it is also gaining importance. The strengths of Spine Tango include a potentially very large network, the participation of a specialized international society and an academic partner with expertise and extensive experience in registry implementation. Data analysis from Spine Tango is possible but complicated by the incompatibility of generations one and two with the more recent generation three. Consequently findings cannot yet be generalized to any specific country or patient population. Nevertheless, the potential benefits of the project for the whole spine community become increasingly visible. In the near future, the established Spine Tango version three with standardised patient based data will make outcome evaluations possible. In parallel to the International Spine Registry Spine Tango, a National Spine Registry in Australia could be set up – comparable to AOA’s National Joint Replacement Registry

Aims. There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries. . Methods. Six international tertiary referral orthopaedic centres were invited to participate by organising a multi-disciplinary team (MDT) meeting, consisting of two or more revision hip arthroplasty surgeons and a musculoskeletal radiologist. A full clinical dataset including history, blood tests and imaging for ten patients was sent to each unit, for discussion and treatment planning. Differences in the interpretation of findings, management decisions and rationale for decisions were compared using quantitative and qualitative methods. Results. Overall agreement between the orthopaedic centres and the recommended treatment plans for the ten patients with MOM hip implants was moderate (kappa = 0.6). Full agreement was seen in a third of cases, however split decisions were also seen in a third of cases. Units differed in their interpretation of the significance of the investigation findings and put varying emphasis on serial changes, in the presence of symptoms. Discussion. In conclusion, the management of raised or rising blood metal ions, cystic pseudotumours and peri-acetabular osteolysis led to inconsistency in the agreement between centres. Coordinated international guidance and MDT panel discussions are recommended to improve consensus in decision making. Take home message: A lack of evidence and the subsequent variation in regulator guidance leads to differences in opinions, the clinical impact of which can be reduced through a multi-disciplinary team approach to managing patients with MOM hip implants. Cite this article: Bone Joint J 2016;98-B:179–86

Hip fractures have increased in most western countries during the end of the last century. This increase will continue mainly because of an increasing number of elderly persons and also due to an increase in the risk of hip fractures in the oldest. This constitutes a threat to resources for medical care. Practise differs concerning choice of operation method and principles for rehabilitation throughout the world. A national registration of the outcome after hip fractures in the elderly started in 1988 in Sweden to compare different methods of surgery, mobilization and rehabilitation. This project has attracted great international interest and several centres have participated with prospective registration. With support from the European Commission a project was started in 1995 called Standardised Audit of Hip Fracture in Europe (SAHFE). The project aims to encourage centres in Europe to participate in a hip fracture audit with a defined data set consisting of a core of 34 questions which includes outcome measures at 4 months from operation. Printed forms are distributed to the participants as well as a computer program designed for the project. In addition there is a large number of optional questions. Each participating centres collects its own data and registers for own analysis. The data are then sent to the project centre in Lund. Hospitals wishing to participate in these international comparisons are welcome. The SAHFE project will promote comparisons of demographic features, surgical technique and rehabilitation methods to facilitate the dissemination of the best practise of hip fracture surgery and rehabilitation throughout Europe. Further international participation will widen the spectrum and facilitate improvements of the hip fracture treatment of benefit both to the patients and the society which has to provide health care to the increasing number of elderly

Aims. The aim of this consensus was to develop a definition of post-operative fibrosis of the knee. Patients and Methods. An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds. Results. Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed. Conclusion. The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479–88

Introduction. Uncertainties in the management of patients with MOM hip implants continue to be a problem for all surgeons. Guidelines vary and do not fully define or quantify thresholds. We aimed to assess the differences in decision-making amongst an international community of six specialist orthopaedic institutions. Methods. Five international tertiary referral orthopaedic units (one UK, two USA, and two European) were invited to participate. Each unit organised an MDT panel consisting of 2 or more hip surgeons and a musculoskeletal radiologist. All units discussed the same 10 patients. A full clinical dataset was provided including blood test and all imaging. Differences in the interpretation of findings, management decision and rationale for decisions were compared between institutions. Results. Asymptomatic patients with metal ions below 7ppb and intra-articular synovitis were collectively treated with monitoring and repeat ion measurement. Symptomatic patients with similar findings were recommended revision surgery by all units. Raised metal ions and a cystic pseudotumour on imaging that is palpable clinically was also consistently recommended revision surgery. Moderate symptoms (OHS 30), 2B pseudotumour, and moderate metal ions (cobalt 5.5ppb) were seen as an indication for revision in 5 units, however the reverse is seen if the patient had several co-morbidities. Further to this, rising blood metal ions (6 to 7.5ppb) was recommended surgery by 4 units, and watchful waiting in 2 units. Rising blood metal ion levels (6ppb to 10ppb) and a small fluid collection on MRI in asymptomatic patients was recommended clinical review and repeat metal ions by 3 units, repeat MRI by 1 unit and revision for suboptimal implant position by the remaining 2 units. Conclusion. Moderate symptoms, blood metal ions and cystic pseudotumours led to inconsistent agreement between institutions. Coordinated international guidance and MDT panel discussions are recommended to improve consensus in decision-making