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

Introduction and aims

Robotic Assisted Arthroplasty (RAA) is increasingly proliferative in the international orthopaedic environment. Traditional bibliometric methods poorly assess the impact of surgical innovations such as robotic technology. Progressive Scholarly Acceptance (PSA) is a new model of bibliographic analysis which quantitatively evaluates the impact of robotic technology in the orthopaedic scientific community.

The inquisitive and skeptical nature of humans drives research. Questions continue to be raised from a basic, applied and clinical perspective related to our areas of interest—be it molecular biology, biomaterials, biomechanics or clinical. The future of research will only be realised by understanding the past and the planning a pathway for the future. Translating advances in the laboratory to the patient are key to improving clinical outcomes. The future holds great promise, as long as we continue to challenge ourselves and ask those fundamental questions of ‘why’ and ‘how’ things happen.

Aims. The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature. Methods. A bibliometric search of journals’ online archives and multiple databases was undertaken in March 2024, to identify articles using qualitative research methods in the top 12 trauma and orthopaedic journals based on the 2023 impact factor and SCImago rating. The bibliometric search was conducted and reported in accordance with the preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO). Results. Of the 7,201 papers reviewed, 136 included qualitative methods (0.1%). There was no significant difference between the journals, apart from Bone & Joint Open, which included 21 studies using qualitative methods, equalling 4% of its published articles. Conclusion. This study demonstrates that there is a very low number of qualitative research papers published within trauma and orthopaedic journals. Given the increasing focus on patient outcomes and improving the patient experience, it may be argued that there is a requirement to support both quantitative and qualitative approaches to orthopaedic research. Combining qualitative and quantitative methods may effectively address the complex and personal aspects of patients’ care, ensuring that outcomes align with patient values and enhance overall care quality

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

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts

Aims. COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic. Methods. An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers. Results. In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an ambulatory surgery centre (ASC). Of the strategies to address departmental financial deficits, 85% of providers (n = 72) were willing to work extra hours without a pay cut. Conclusion. Most orthopaedic providers are willing to help with patient care backlogs and revenue recovery by working extended hours instead of having their pay reduced. These findings provide insights that can be incorporated into COVID-19 recovery strategies. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(7):562–568

Aims. The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances. Methods. An orthopaedic research consortium at an academic medical system developed a survey examining provider perspectives regarding orthopaedic virtual care. Survey items were scored on a 1 to 5 Likert scale (1 = “strongly disagree”, 5 = “strongly agree”) and compared using nonparametric Mann-Whitney U test. Results. Providers with less experience were more likely to recommend virtual care for follow-up visits (3.61 on the Likert scale (SD 0.95) vs 2.90 (SD 1.23); p = 0.006) and feel that virtual care was essential to patient wellbeing (3.98 (SD 0.95) vs 3.00 (SD 1.16); p < 0.001) during the pandemic. Less experienced providers also viewed virtual visits as providing a similar level of care as in-person visits (2.41 (SD 1.02) vs 1.76 (SD 0.87); p = 0.006) and more time-efficient than in-person visits (3.07 (SD 1.19) vs 2.34 (SD 1.14); p = 0.012) in non-pandemic circumstances. During the pandemic, most providers viewed virtual care as effective in providing essential care (83.6%, n = 51) and wanted to schedule patients for virtual care follow-up (82.2%, n = 50); only 10.9% (n = 8) of providers preferred virtual visits in non-pandemic circumstances. Conclusion. Orthopaedic providers with less clinical experience seem to favourably view virtual care both during the pandemic and under non-pandemic circumstances. Providers in general appear to view virtual care positively during the pandemic but are less accommodating towards it in non-pandemic circumstances. Cite this article: Bone Jt Open 2021;2(6):405–410

The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research

Background. Author credibility and creativity is often gauged by the number of scientific papers published, with the frequency of citations for particular articles reflecting the impact of published data on the area of practice. Aims. The objective of this study was to identify and analyse the qualities of the top one hundred cited articles in Orthopaedic surgery. Methods. We used the database of the Science Citation Index of the Institute for Scientific Information (1945-1995) in addition to Scopus, Medline and Pubmed search engines. Results. 1490 articles were cited in excess of 100 times with the top 100 being subjected for further analysis. The 100 articles discussed were published between 1945 and 2005. The mean number of citations per articles was 446.5 (range 334 - 1786). The majority of published articles originated in the United States (68) with the United Kingdom and Canada closely behind (12 and 5 respectively). The 100 articles were published in 7 Orthopaedic journals led by the Journal of Bone and Joint Surgery American edition (JBJS Am) (n=55) followed by Spine (n=16), Clinical Orthopaedic Related Research (n=14), JBJS Britain (n=7), Journal of Orthopaedic Research (n=5), Acta Orthopaedica Scandinavia (n=2) and Foot and Ankle International (n=1). 80 of the most cited articles reported clinical experiences, 7 were clinical review articles and 13 dealt with basic science. 34 persons authored greater than one top citing article. Conclusion. Analysis of the most cited Orthopaedic papers allows us a unique insight into the qualities, characteristics and clinical innovations, required for a paper to attain the ‘classic’ status. Based on these findings to be well cited such a contribution should be published in the English Language in a high impact journal and originate in North America or the United Kingdom

The management of bone loss in revision total knee replacement (TKA) remains a challenge. To accomplish the goals of revision TKA, the surgeon needs to choose the appropriate implant design to “fix the problem,” achieve proper component placement and alignment, and obtain robust short- and long-term fixation. Proper identification and classification of the extent of bone loss and deformity will aid in preoperative planning. Extensive bone loss may be due to progressive osteolysis (a mechanism of failure), or as a result of intraoperative component removal. The Anderson Orthopaedic Research Institute (AORI) is a useful classification system that individually describes femoral and tibial defects by the appearance, severity, and location of bone defects. This system provides a guideline to treatment and enables preoperative planning on radiographs. In Type 1 defects, femoral and tibial defects are characterised by minor contained deficiencies at the bone-implant interface. Metaphyseal bone is intact and the integrity of the joint line is not compromised. In this scenario, the best reconstruction option is to increase the thickness of bone resection and to fill the defect with cancellous bone graft or cement. Type 2 defects are characterised by deficient metaphyseal bone involving one or more femoral condyle(s) or tibial plateau(s). The peripheral rim of cortical bone may be intact or partially compromised, and the joint line is abnormal. Reconstruction options for a Type 2A defect include impaction bone grafting, cement, or more commonly, prosthetic augmentation (e.g. sleeves, augments or wedges). In Type 2B defects, metaphyseal bone of both femoral condyles or both tibial plateaus is deficient. The peripheral rim of cortical bone may be intact or partially compromised, and the joint line is abnormal. Options for a Type 2B defect include impaction grafting, bulk structural allograft, prosthetic augmentation, metaphyseal sleeves (in some cases), or metaphyseal cones. Finally, in the presence of a Type 3 deficiency, both metaphyseal and cortical bone is deficient and there is partial or complete disruption of the collateral ligament attachments. In this case, the most commonly used reconstruction options include hinged implants or megaprostheses with or without bulk structural allograft, prosthetic augmentation, and/or metaphyseal/diaphyseal sleeves or cones. Today, we are fortunate to have a wide variety of options available to aid in reconstruction of a revision TKA with massive bone loss. Historically, use of cement, bone grafting, or use of a tumor-type or hinged implant were considered the main options for reconstruction. The development and adoption of highly porous sleeves and cones has given the surgeon a new and potentially more durable option for reconstruction of previously difficult to treat defects. Using radiographs and computed tomography, surgeons are able to preoperatively classify bone loss and anticipate a reconstruction plan based upon the classification; however, it is always important to have several back-up options on hand during revision surgery in the event bone loss is worse than expected

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

Introduction. The bone defect reconstruction is the first step of successful primary or revision TKA in case of large bone defect. If the defect is not reconstructed adequately, we can neither preserve knee joint function nor guarantee long survival of the implant. Allogeneic bone graft is known to be the treatment of choice in large defect. However the surgical technique is demanding and incorporation failure is constant issue of the allogeneic bone graft. We propose new bone defect reconstruction technique using multiple screws and cement. Material and method. From April 2012 to April 2014, 12 patients with large defect which could not be reconstructed with metal augment were involved in this study. The bone defect type was 10 cases of 2A and 2 cases of 2B according to AORI (Anderson Orthopedic Research Institute) classification. The defect was reconstructed with multiple screws and cementing technique by single surgeon (WS Cho). Average follow-up period was 15 months. (24 ∼ 1 month). Result. We analyzed 6 patients whose follow-up periods were more than 12 months. Average ROM was 107' and clinical scores were 86 by HSS, 93 by KS and 11 by WOMAC respectively. No complications such as infection and loosening were developed. Mean surgical time was 1 hour and 57 minutes. Conclusion. In short term follow-up, cementing technique using multiple screws can be a solution for large bone defect reconstruction

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating preoperative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Porous metal cones or sleeves 7) Massive structural allograft-prosthetic composites; 8) Custom implants. Of these, use of uncemented highly porous metal metaphyseal cones in combination with an initial cemented or partially cemented implant has been shown to provide versatile and highly durable results for a range of bone defects including those previously requiring structural bone graft. The hybrid fixation combination of both cement and cementless fixation of an individual tibial or femoral component has emerged as a frequent and often preferred technique. Initial secure and motionless interfaces are provided by the cemented portions of the construct, while subsequent bone ingrowth to the cementless porous metal portions is the key to long term stable fixation. As bone grows into the porous portions there is off loading and protection of the cemented interfaces from mechanical stresses. While maximizing support on intact host bone has been a longstanding fundamental principle of revision arthroplasty, this is facilitated by the use of metaphyseal cones or sleeves in combination with initial fixation into the adjacent diaphysis. Preoperative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the preoperative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intraoperative findings such as occult fracture through deficient periprosthetic bone. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions, the degree of revision implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus, some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects, especially of the cavitary sort, may be well managed with minimal constraint

Introduction. Bone loss in the distal femur and proximal tibia is frequently encountered with both complex primary and revision knee replacement surgery. Metaphyseal sleeves provide a good option for enhanced fixation in managing such defects on both the tibia and femur. We present our results in 48 patients (50 knees) with a minimum 12 month follow up (range 12 to 45). Methods. 48 patients (50 knees) who had revision knee arthroplasty for either septic or aseptic loosening. All were graded Type II or III using the Anderson Orthopaedic Research Institute (AORI) grading system of both femoral and tibial defects. A large portion of aseptic loosening revisions were for extreme osteolysis of a bicondylar knee prosthesis. Results. 52% had tibial sleeves only, 38% had both tibial and femoral sleeves and the remainder had only femoral sleeves inserted. All knee radiographs at final follow-up showed well-fixed osteointegrated components without component migration or clinically significant osteolysis. Two knees were treated with multiple arthroscopic washouts for infection. Two knees subsequently underwent manipulation under anaesthesia with good improvement in range of movement. One subsequently developed Complex Regional Pain Syndrome. No femoral or tibial components were revised. The average pre-operative Oxford Knee Score was 22 (12 to 38) and subsequently improved to 38 (12 to 45) post-operatively. Discussion and conclusions. Our early results show encouraging signs that porous titanium sleeves are a good option when managing large metaphyseal bone loss in both femur and tibia especially in revision arthroplasty. Post operative complications were low and functional outcome scores were comparable with more traditional knee revision arthroplasty techniques in the presence of bone loss

Aim. One of the most challenging problems in total knee arthroplasty (TKA) is periprosthetic infection. A major problem that arises in septic revision TKA (RTKA) are extended bone defects. In case of extended bone defects revision prostheses with metaphyseal sleeves are used. Only a few studies have been published on the use of metaphyseal sleeves in RTKA - none were septic exclusive. The aim of our study was to determine the implant survival, achieved osseointegration as well as the radiological mid-term outcomes of metaphyseal sleeve fixation in septic two-stage knee revision surgery. Method. Clinical and radiological follow-up examinations were performed in 49 patients (25 male and 24 female). All patients were treated with a two-stage procedure, using a temporary non-articulating bone cement spacer. The spacer was explanted after a median of 12 weeks (SD 5, min. 1 – max. 31) and reimplantation was performed, using metaphyseal sleeves in combination with stem fixation. Bone defects were classified on preoperative radiographs using the Anderson Orthopaedic Research Institute (AORI) classification. During follow-up postoperative range of motion (ROM) was measured and radiographs were performed to analyse: (i) osseointegration (radiolucent lines and spot welds), (ii) leg alignment, (iii) patella tilt and shift. Results. All types of bone defects were found on the tibial (4× type 1, 7× type 2a, 26× type 2b, 9× type 3) as well as on the femoral side (1× type 1, 4× type 2a, 20× type 2b, 6× type 3). Mean follow-up time was 4.7 years (minimum 1 year). In total 12 knees (24.5%) had to be re-revised, all due to re-infection. We did not encounter any case of aseptic loosening. In 3 patients (6.8%) we detected an insufficient osseointegration, but no patient had to be re-revised due to only minimal or to the absence of symptoms and no clinical signs of loosening. The ROM (mean 93°, SD 20.6, min. 25° max. 125°) has shown very satisfying results at the time of follow-up. Malalignment was detected in 4 patients (10.3%), a patella tilt in 7 (19.4%) and a patella shift in 14 (48.3%). Conclusions. Metaphyseal Sleeves have shown very promising mid-term results regarding osseointegration and aseptic implant survival in RTKA with compromised metaphyseal bone stock. Our results indicate that they are a reliable fixation option in septic RTKA patients

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating pre-operative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximizing support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Pre-operative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the pre-operative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intra-operative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint

Massive bone loss on both the femur and tibia during revision total knee arthroplasty (TKA) remains a challenging problem. Multiple solutions have been proposed for small osseous defects, including morselised cancellous bone grafting, small-fragment structural allograft, thicker polyethylene inserts, and the use of modular augments attached to revision prosthetic designs. Large osseous defects can be treated with structural allografts, impaction bone-grafting with or without mesh augmentation, custom prosthetic components, and specialised hinged knee components. The metaphyseal area of the distal femur and proximal tibia is a particularly attractive option during revision TKA given that it is usually undamaged and well-vascularised. While multiple reconstructive options have been recommended, porous tantalum metaphyseal cones have the advantage of improved biologic fixation because of their high porosity (75–80%), interconnected pore space, and low modulus of elasticity (3 MPa) similar to that of cancellous bone. Such features allow tantalum cones to fill bone defects while tolerating physiological loads. Indications for porous tantalum metaphyseal cones include patients with Anderson Orthopaedic Research Institute Type 2B or greater defects. The surgical technique is simpler than structural allograft reconstructions with decreased preparation time, resulting in a possible decrease in infection rates. The modularity of porous tantalum metaphyseal cones also allows the surgeon to choose a size and position that best fits the individual defect encountered. Moreover, tantalum cones can be used with several revision systems. Short-term clinical follow up indicates that porous tantalum metaphyseal cones effectively provide structural support with the potential for long-term biologic fixation and durable reconstructions

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating pre-operative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximizing support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Pre-operative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the pre-operative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intra-operative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint. Highly porous metal augments designed to reestablish metaphyseal support and function in the manner of a prosthetic structural graft have been introduced or are under development by several manufacturers. Published reports of short term experiences have been encouraging for both the tibial side and for femoral augmentation. It remains to be seen whether these implants will provide the desired longer term durability

Purpose. Conflict of interest reporting at annual orthopaedic surgical meetings aims to ensure transparency of surgeon-industry relationships. Increasing rigor in the reporting guidelines provides a unique opportunity to understand the impact of industry relationships in the conduct of orthopaedic research. We examined self-reported conflicts by surgeons presenting original research in arthroplasty and trauma meetings. Method. We reviewed the proceedings of the 2009 Annual American Association of Hip and Knee Surgeons (AAHKS) and Orthopaedic Trauma Association (OTA). Information including the number of studies, self-reported conflicts, nature of conflicts, and direction of study results were extracted. Conflicts were compared between arthroplasty and trauma meetings. Results. A total of 85 AAHKS abstracts (45 presentations and 40 posters) and 201 OTA abstracts (88 presentations and 113 posters) were included. Abstracts presented at the AAHKS revealed significantly more conflicts than those presented at the OTA (84/85 presentations, 98.8%, versus 156/201 presentations, 77.6%, respectively, p value < 0.0001). On average, papers at the AAHKS and OTA meetings had similar numbers of conflicts per paper (9.5 versus 9.8, respectively). 213 (52.6%) of authors at the AAHKS revealed at least one conflict compared to 364 (40.6%) of authors at the OTA (p value < 0.0001). The most common conflicts included research, institutional, fellowship, and grant support (48.3%) and paid consultant, salary or staff (20.2%). Conclusion. Our findings suggest that surgeon-industry relationships are critical to the conduct of research. The high proportion of papers with self-reported conflicts of interest supports increasing transparency and rigor in reporting guidelines at orthopaedic meetings