Referral patterns in spine clinic of young patients with suspected scoliosis is suboptimal with 19% of late referrals and 42% of inappropriate referrals. Patients' triage and prioritisation in spine clinic is a strategy to ensure that health care allocation is done according to the level of health needs, favoring effective management and efficient use of health care resources use. The objective of the study is to elaborate a model for triage and prioritisation of young patients in spine clinic based on expert consensus and literature on best practices. This projects was structured in three parts: 1)We documented best evidence. We conducted a review of empirical studies evaluating triage and prioritisation initiatives in order to identify key components for intervention success. 2)We elaborate a model of health care delivery with the professionals of a local paediatric spine clinic. In this model, the triage and prioritisation algorithm was developed from list of potential factors (demographics, signs and perceived symptoms, provisional diagnoses and known co-morbidities, results of preliminary physical examination and radiological findings) that was submitted to five paediatric orthopaedic surgeons for rating according to their potential relevance to orient prioritisation decisions. 3) We compared the professionals' model of health care delivery to the literature synthesis in order to propose the best model. Seven key components of triage and prioritisation systems were identified: centralised review of referral requests, list of consensual objectives criteria for triage, fast track evaluation of urgent cases, selection of cases for management at point of triage, cases prioritisation to main consultant, multidisciplinary evaluation and alternatives pathways. The consensual decision algorithm confirmed that cases who should be seen in priority are immature patients presenting with a significant trunk deformity. In addition, presence of persisting neurological symptoms, severe incapacitating pain or night pain, as well as abnormal scan or MRI findings were considered as urgent/PI priority. Cases characteristics for evaluation by nurse practitioners as well as alternative pathways of management were defined. Acceptability, compatibility, clinical relevance and discriminant capacity of the new model of health care delivery were satisfactorily demonstrated. Consensus was easily reached between the five respondents on factors supporting decisions to prioritise patients in spine clinic for suspected spinal deformity. Refinements to the initially proposed model according the identified key features from the literature, led to a final model of health care delivery that is evidence-base, feasible and coherent with the local context. Future implementation of this model should facilitate timely and appropriate health care delivery and best use of health care resources according to patients' needs

Long waiting times and a growing demand on services for joint replacement surgery (JRS) prompted the Victorian Department of Human Services to fund a University of Melbourne/Melbourne Health partnership to develop and implement an osteoarthritis (OA) hip and knee service delivery and prioritisation system for those who may require JRS. The service delivery model consists of a multidisciplinary team providing, comprehensive early assessment, evidence-based interventions, including support for patient self-management, continuity of care processes, and prioritisation for both surgical assessment and JRS. Prioritisation occurs via clinical assessment and the Hip and Knee Multi-Attribute Prioritisation Tool (MAPT), a patient, clinician, or proxy-administered 11-item questionnaire, resulting in a 100-point scale ranking of need for surgery. The Hip and Knee MAPT was developed using intensive consultation with surgeons, state-of-the-art clinimetrics and with input from patients, hospital management groups. Ninety-six surgeons contributed to the developing the final scoring system. Over 4000 patients per year are entering the system across 14 hospitals in Victoria. Under the supervision of the orthopaedics unit, musculoskeletal coordinator (MSC), typically an experienced physiotherapist or nurse, as part of the multidisciplinary team, undertakes early comprehensive assessment, referral and prioritisation of patients with hip or knee OA referred to orthopaedic outpatient clinics. In addition, the MSC coordinates the monitoring and management of patients on the orthopaedic surgery waiting list. The processes enable patients who are most needy (via higher MAPT score and clinical assessment) to be fast-tracked to orthopaedic surgery; conversely those patients with lower scores receive prompt conservative management. Time to first assessment and waiting times to see a surgeon for many patients have reduced from 12+ months to weeks. Patients seen by surgeons are more likely to be ready for surgery and have had more comprehensive non-operative optimisation. Patients placed on the surgical waiting list receive quarterly reassessments and evidence of deterioration is used as a basis for fast-tracking to surgery. The OWL system is a whole of system(tm) approach informed by patients needs and surgeons needs. Clinicians have developed confidence in the clinical relevance of the MAPT scores. Uptake of the OWL model of care has been very high because it facilitates better care and better patient outcomes

As there is currently no evidenced-based and systematic way of prioritising people requiring JRS we aimed to develop a clinically relevant system to improve prioritisation of people who may require JRS. An important challenge in this area is to accurately assign a queue position and improve list management. To identify priority criteria areas eight workshops were held with surgeons and patients. Domains derived were pain, activity limitations, psychosocial wellbeing, economic impact and deterioration. Draft questions were developed and refined through structured interviews with patients and consultation with consultants. 38 items survived critical appraisal and were mailed to 600 patients. Eleven items survived clinimetric and statistical item reduction. Validation then included co-administration with standardised questionnaires (960 patients), verification of patient MAPT scores through clinical interview, examination of concordance with surgeon global ratings and test-retest. Ninety-six Victorian surgeons weighted items using Discrete Choice Experiments (DCEs). The DCE scaling generated a scale, which clearly ranked patients across the disease continuum. The MAPT differentiated people on or not on waiting lists (p<0.001), and was highly correlated with other questionnaires, e.g., unweighted-MAPT vs WOMAC (r=0.78), Oxford Hip/Knee (r=0.86/0.75), Quality of Life (r=0.78), Depression (r=0.64), Anxiety (r=0.60), p<0.001 for all. Test-retest was excellent (ICC=0.89, n=90). Cronbachs reliability was also high 0.85. The MAPT is now routinely administered across all Victorian hospitals undertaking arthroplasty where the response rate is generally above 90%. In the hands of clinicians the MAPT has been used to facilitate fast-tracking of patients with the greatest need, monitoring for deterioration in those waiting for surgery or having a trial of non-operative treatment and deferment of surgery for those that may benefit from further non-operative treatments. The MAPT is short, easy to complete and clinically relevant. It is a specific measure of severity of hip/knee arthritis and assigns priority for surgery. It has excellent psychometric and clinimetric properties evidenced by concordance with standard disease-specific and generic scales and widespread use and endorsement across health services

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria.

We sought to measure the rate of progress of Dupuytren's contracture.

All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively.

Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits.

Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers.

This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk.

The New Zealand Joint Registry (NZJR) was established in 1999. However, ethnicity data was not recorded by prioritisation in line with Ministry of Health (MoH) recommendations. Recently, cross-referencing with MoH updated ethnicity data for all 326,150 entries in the NZJR database. The objective of this national level, population study was to identify any ethnic disparities in access and outcome for Māori for primary total hip (THA) and knee arthroplasty (TKA) for Osteoarthritis. The utilisation rate for THA and TKAs were calculated for the Māori and NZ European population from all data in the NZJR and Census data in 2001, 2006, 2013 and 2018. Utilisation rate was reported separately for four age groups (<55, 55-64, 65-74, >75) over four time periods (1999-2004, 2005-2009, 2010-2014, 2015-2020). Revision rate, 6 months and 5-year Oxford scores were adjusted for age, sex and BMI, then compared between groups. In every age group and at all but one time point, significant under-utilisation of TKA was observed in Māori. For THAs, Māori had similar utilisation rates in the <55 and 55-64 age groups, but significantly lower utilisation rates in all other age groups. When adjusted for age, sex and BMI, no significant differences in revision rates were observed between Māori and NZ Europeans for THAs (HR 0.939, P 0.417) or TKAs (HR 1.129, P 0.149). Adjusted 6 months and 5-year Oxford scores were significantly higher in NZ Europeans, however, the maximum difference was less than 3 points and is unlikely to be clinically significant. Despite the same risk of being diagnosed with osteoarthritis, Māori are less likely to undergo THA and TKA. There are no clinically significant differences in outcomes post arthroplasty between Māori and NZ Europeans. Further research is required to investigate causes for lower utilisation in Māori

Background. In the United Kingdom, over 1 million elective surgeries were cancelled due to COVID-19, resulting in over 1.9 million people now waiting more than 4 months for their procedure – 3x the number last year. To address this backlog, the healthcare service has been asked to develop locally-designed ‘COVID-light’ facilities. In our local system, 822 patients awaited orthopaedic surgery when elective surgery was permitted to resume. The phased return of service required a careful and pragmatic prioritisation of patients, to protect resources, patients, and healthcare workers. Aims. We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to consider 1) Which type of operation and patient should be prioritised? and 2) Which patients are safe to undergo surgery? The central tenets to this were patient safety, predicted efficacy of the surgery, and delivering compassionate care by considering biopsychosocial factors. Methods. Orthopaedic surgeons were provided with details of patients on their waiting list. They prioritised patients into those for surgery within 1 month (. Urgent. : e.g. arthroplasty for rapid deterioration from avascular necrosis or infection, or in the lowest quartile of Oxford Hip/Knee/Shoulder scores), < 3 months (. Soon. : e.g. revision or second-stage arthroplasty), and > 3 months (arthroplasty for end-stage arthrosis). The surgeon-led stratification was then reviewed by a multidisciplinary surgical prioritisation team, including anaesthetists and operating theatre managers, to consider medical history, the need for additional intraoperative services (such as cardiac physiologists, or specialist equipment requiring industry ‘reps’), and the risk of postoperative deterioration requiring HDU/ICU. The MDT also reviewed what the impact of disease and further delay may have on a patient's mental health, ability to work, or ability to care for dependents. The CARES protocol created an aggregate score for efficacy, compassion, safety and surgical risk to equitably rank patients. Results. The implementation of CARES stratified the waiting list into 122 (14.8%) patients requiring urgent surgery, with high likely health-gain or biopsychosocial gain, of whom 76 were low-risk and 46 were high-risk – medically moribund or complex. There were 232 (28.2%) patients required surgery within 3 months, and 468 (57.1%) patients were deemed safe to delay for > 3months. Alongside i) staff- and patient-screening, ii) adequate personal protective equipment, and iii) increased used of regional anaesthesia, the healthcare system was reconfigured, to create two surgical pathways. ‘Green Well’ patients were scheduled for surgery at a clean site – an elective surgical centre with no on-site HDU/ICU. ‘Green High-Risk’ patients underwent surgery at the general hospital (with on-site HDU/ICU) in operating rooms (ORs) which were physically segregated from ‘Red’ ORs reserved for COVID-19+ or trauma patients. In 6 weeks, 164 patients underwent surgery with no transmission of COVID-19 between patients or staff. Conclusion. Our healthcare system safely resumed elective surgery as early as the top 2% of hospitals nationally. This was facilitated by CARES stratification (which factors safety, efficacy, and compassion), MDT-led decisions, and surgical pathway reconfiguration. This generalisable, validated approach could be widely applied to facilitate restarts globally

The significance of ring-fencing orthopaedic beds and protected elective sites have recently been highlighted by the British Orthopaedic Association & Royal College of Surgeons. During the pandemic many such elective setups were established with various degrees of success. This study aimed to compare the functioning and efficiency of a Orthopaedic Protected Elective Surgical Unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital (Pre-Pandemic ward or PPW). We retrospectively collected data of all patients who underwent elective Orthopaedic procedures in a protected elective unit during the pandemic (March 2020 – July 2020) and a similar cohort of patients operated via the routine elective service immediately prior to the pandemic (October 2019 – February 2020). Various parameters were compared and analysed. To minimise the effect of confounding factors a secondary analysis was undertaken comparing total hip replacements (THR) by a single surgeon via PESU (PESU-THR) and PPW (PPW-THR) over 5 months each from March-July 2021 and March-July 2019 respectively. A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However more than half (52%) of those listed for a surgery on PPW were cancelled and only 162 cases (48%) were actually performed. PESU had a significantly better conversion rate with only 12.5% being cancelled and 168 (87.5%) cases performed. 49% (87 out of 177) of the cases cancelled on PPW were due to a ‘bed unavailability’. A further 17% (30/177) and 16% (28/177) were cancelled due to ‘emergency case prioritisation’ and ‘patient deemed unfit’ respectively. In contrast only 3 out of the 24 patients cancelled on PESU were due to bed unavailability and the main reason for cancellation here was ‘patient deemed unfit’ (9/24). Single surgeon THR, showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The average age for these patients was 63 on PESU and 69 on PPW whereas the BMI was 33 and 30 respectively. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days in comparison to 4.8 days for those admitted to PPW. PROMS scores were comparable at 6 weeks with an average improvement of 16.4/48 in the PESU-THR cohort and of 18.8/48 in the PPW-THR cohort. There were no readmissions or revisions recorded in the PESU-THR cohort while the PPW-THR cohort had 1 readmission and revision. Our study shows how a small ring fenced Orthopaedic elective unit in a district general hospital, even during a global pandemic, can function more efficiently than a routine elective facility with many shared services

Introduction. Traditionally, limb reconstruction physiotherapy consisted of face to face group rehabilitation. During the COVID-19 pandemic OP physiotherapy service provision was significantly reduced and delivery methods limited due to staff redeployment, service prioritisation and restriction of footfall within the hospital. A virtual exercise group for acute limb reconstruction patients was set up to maintain contact and clinical support. Materials and Methods. A small single centre study was performed over two 4 week periods capturing the experience of 35 patients. A patient reported questionnaire was used and revised post-pandemic to gather quantitative and qualitative data about the patients experience of the Limb Reconstruction Physiotherapy Service at each point in time. The qualitative data was analysed using an inductive thematic analysis. Results. Four key themes emerged from the qualitative data: Sense of community through shared experience, support & encouragement from staff and peers, increasing confidence with the frame – fostering independence, the challenging nature of the class. Recommendation of the service, positive functional impact and overall experience remained >88% of the population (face to face & virtual). Conclusions. The results highlight the benefits of group physiotherapy (face to face & virtual) to patients recovery with improvements in confidence, mobility, function, psychosocial factors and overall QoL. Peer support is paramount in the rehabilitation and progression of limb reconstruction patients. Virtual platforms for rehabilitation are helpful in maintaining participation and should be offered where possible to facilitate ongoing inclusion, however face to face contact is preferred

Abstract. Aim. With resumption of elective spine surgery services following the first wave of COVID-19 pandemic, we conducted a multi-centre BASS collaborative study to examine the clinical outcomes of surgeries. Methods. Prospective data was collected from eight spinal centres in the first month of operating following restoration of elective spine surgery following the first wave. Primary outcomes measures were the 30-day mortality rate and postoperative Covid-19 infection rate. Secondary outcomes analysed were the surgical, medical adverse events and length of inpatient stay. Results. 257 patients (128 Male) with an age range of 2–88 years formed the study cohort. The average workload from each unit was 32(range 16–101) with 118 procedures (46%) done as category 3 prioritisation level (Procedures performed in < 3 month). 87% of patients were low-medium “risk stratification” category. 195 patients (75.8%) isolated for two weeks preoperatively and all but four patients had COVID-19 negative test prior to surgery. None of the patients were diagnosed with COVID-19 infection nor was any mortality related to COVID-19 in the 30 day follow up period, with 25 patients having been tested for symptoms. 32 patients (12%) developed a total of 34 complications with 19/34 being grade 1–2 Clavien-Dindo classification of surgical complications. Median LOS 5.2 days and 78.4 % patients stayed less than a week. Conclusions. As per our study safe and effective planned spinal surgical services can be restored avoiding viral transmission, with adherence to national guidelines and COVID-secure pathways tailored according to the resources of the individual spinal units

Transferring patient data to the care of the oncoming team is the point at which the patient is most vulnerable on their journey through the healthcare system. Effective handover is vital to protect patient safety and has become increasingly more important after introduction of shift patterns for junior doctors following the implementation of the European Working Time Directive. The aim was to assess whether the introduction of a standardised proforma and traffic light system, would improve weekend handover of patients in our orthopaedic unit. Data was collected in the form of hand written data, for 3 months, in our department. This was analysed and a standardised handover sheet and traffic light system to highlight patient priority was introduced. Following a 1 week trial, the proformas were reviewed following feedback from colleagues. A re-audit was commenced and data collected for a further 2 months. There were 108 patients handed over on weekends during the re-audit compared to the 126 in the initial audit. The handover of patient data improved across all areas, with the most improved areas in recording the patients' diagnosis (58.4% to 94.4%) and noting the results of significant or pending investigations (61.2% to 91.7%). The traffic light system improved recording the patient's condition (8.5% to 81.5%) as well as logging the urgency or frequency of patient review (25.9% to 96.8%). Standardised proformas improve patient data transferred at handover and the traffic light system allows improved prioritisation of patients, thus improving patient safety at weekends

Patients who present with a fractured neck of femur (NOF) have a significant rate of morbidity and mortality. In 2011, the National Institute for Health and Care Excellence (NICE) published clinical guidelines in order to improve these rates. Within this guideline NICE state that surgery should be performed on all NOF fractures within 36 hours. Within ABMU Health board the 1000 Lives Campaign goes a step further and aims to operate on 90% of patients within 24 hours. This study investigates the effect of an additional NOF theatre list on compliance to these national guidelines. This retrospective study was performed between October-December 2013 and December-February 2015. The first period of data collection represents a daily trauma list whilst the second period allowed an additional NOF theatre list. Data was collected using the National Hip Fracture Database and the Trauma Theatre List. The number of patients meeting the national guidelines increased with the presence of an additional theatre list (75.19% v 60%). This represents a reduction to the average time to theatre of 4 hours and 30 minutes (29:47 v 34:17). The additional theatre list improved prioritisation of patients with NOF fractures on the list (29.46% v 13.33% listed first on list) and reduced the rate of cancellations (19.38 v 29.17%). During this study Morriston Hospital did not meet national guidelines, however an additional theatre list did significantly improve average time to theatre. This study highlights the significant impact a dedicated NOF fracture theatre list can have. Winner – Best Paper Award

Aim. To construct and validate a simple patient related outcome measure scheme to quantify the disability caused by Dupuytren's Disease thus enabling prioritisation of treatment, allow reliable audit of surgical outcome and support future research. Methods. The Southampton Dupuytren's Scoring System (SDSS) was developed in a staged fashion according to the recommendations of Derby Outcomes Conference. item generation from questionnaire filled in by 20 patients;. item reduction to create a 20-question proforma;. Internal consistency (Cronbach's alpha). Test-retest (3 week interval testing on 61 patients). Field management was used to assess the user friendliness of the scoring system. Sensitivity to change Standardised response mean. Construct validity: ability of the SDSS to measure what it is supposed to measure. comparing SDSS with QuickDASH (Disability of Arm, Shoulder and Hand). Results. Internal consistency. Cronbach's alpha was 0.87. (Cronbach's alpha of 0.8–0.9 indicates acceptable reliability). Test-retest reliability. The test re-test correlation coefficient was 0.79 between SDSS scores at a three-week interval (high reliability). Field-testing. The SDSS ratings were found to be higher than the QDASH ratings evaluated by the patients who answered both questionnaires. Sensitivity to change. Standardised response mean was more sensitive for SDSS compared to QuickDASH (−1.76 vs −1.19 p>0.05). Construct Validity. To assess if the SDSS is measuring what is supposed to measure, we compared the SDSS with QuickDASH. A high significant correlation (Pearson correlation-0.598) was found between the two scoring-systems. Conclusions. SDSS is a suitable disease-specific patient related outcome measure for DD. It has good internal consistency and is performs better than QuickDASH in terms of test-retest reliability and sensitivity to change. SDSS shows better field-testing attributes suggesting that it is a relatively more patient and practitioner friendly scoring-system. We propose the SDSS is a useful patient related outcome measure for DD

The Osteoarthritis Hip and Knee Service (OAHKS) was introduced in 2006 and the aim of this service was to ensure early assessment and monitoring, optimise non-operative and pre-operative management, and ensure equitable access to surgical treatment. Patients were prioritised and monitored for disease deterioration using the Multi-Attribute Arthritis Prioritisation Tool (MAPT). All patients who were referred for assessment by the OAHKS between December 2006 and April 2009 were identified. Data was collected from the OAHKS computer database, hospital patient information computer system and the Department of Health databases. Scores were identified for patients who underwent joint replacement surgery (JRS) following pre-operative MAPT. Demographic and clinical data was collected prospectively and statistically analysed. Demographic data included sex, age and ethnicity. Patient clinical data included referral source and time to initial OAHKS appointment, BMI, co-morbidities, MAPT scores, referrals to other healthcare professionals and outcome of OAHKS appointment. In total, 768 patients (296 males and 472 females) were referred to OAHKS between December 2006 and April 2009. Patients ranged in age from 20 to 94 years with a mean age of 68.22 years at initial review. Patients referred were from 20 different ethnic backgrounds. The median time to initial appointment was 80.5 days (IQR 36.5-99 days). There were 656 (85.4%) patients referred from their GP and 89 referrals were from other sources. Eighty-nine per cent of patients (n=686) were screened for co- morbidities. Of these patients, 58% had hypertension, 20.8% had diabetes mellitus, 19.3% had ischaemic heart disease, and 19.8% had a psychosocial illness. The mean body mass index (BMI) was 32.71 (median 32.01). Only 42.3% patients had some form of conservative management modality prior to attending OAHKS. A total of 1061 referrals to other healthcare professionals were made. Physiotherapy (48.6%), hydrotherapy (40%) and dietician (16.1%) were the most common referrals. Referrals to the orthopaedic surgeon accounted for 15.7% total referrals. MAPT scores increased in 229 patients, decreased in 306 patients and were unchanged in 25 patients. From December 2006–March 2009, 269 patients had MAPT scoring assessment pre-operatively. Of those patients who had surgery 52% had TKR, 40.5% THR, 5.5% UKR and 1.85% hip resurfacing. The OAHKS has enabled patients with osteoarthritis to be rapidly assessed leading to a reduction in outpatient waiting times. Patients suitable for JRS are prioritised according to clinical need and MAPT scores. Thus, patients with greatest clinical need have received surgery much sooner than previously

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Introduction

The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic.

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.