Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes.

This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test.

The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis.

The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable.

Minimally displaced paediatric proximal humerus fractures (PHFs) can be reliably managed non-operatively, however there is considerable debate regarding the appropriate management of severely displaced PHFs, particularly in older children and adolescents with limited remodelling potential. The purpose of this study was to perform a systematic review to answer the questions: “What are the functional and quality-of-life outcomes of paediatric PHFs?” and “What factors have been associated with a poorer outcome?”. A review of Medline and EMBASE was performed on 4. th. July 2021 using search terms relevant to PHFs, surgery, non-operative management, paediatrics and outcomes. Studies including ≥10 paediatric patients with PHFs, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes. Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favourable outcome scores were found for patients with minimally displaced fractures, and for children aged less than ten years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score. An excellent functional outcome can be expected following non-operative management for minimally displaced paediatric PHFs. Prospective trials are required to establish a guideline for the management of severely displaced PHFs in children and adolescents according to fracture displacement and the degree of skeletal maturity

Surgical biopsies are still considered the gold standard in obtaining tumor tissue samples. In this study, we will analyze the core needle biopsy in the evaluation of musculoskeletal tumors focusing on the accuracy, effectiveness, and safety of this technique in comparison to an open biopsy procedure. This is a retrospective case series at King Abdulaziz Medical City (KAMC). All medical records from all patients who had a core needle biopsy (CNB) for a musculoskeletal mass and eventually underwent excisional biopsy between January 2010 and December 2016 at KAMC were included. Besides patient demographic data, the data extracted included the locations of the suspected mass, type of tissue acquired (bone or soft tissue), number of biopsies, complications reported during the procedure, histopathological report of core needle biopsy. A total of 262 patients who were suspected to have a musculoskeletal tumor were identified. Female to male ratio was (1:1.4) and paediatrics (of 93.1%. The AUC of CNB in comparison to excisional biopsy was 0.86. The most common site of tumor extraction was in lower extremities (47.3%), followed by upper extremities (23.7%), pelvis and gluteal area (19.5%) and spine (9.5%). In conclusion, CNB is cost-effective, safe and minimally invasive in bony and soft tissue lesions in comparison to an open biopsy procedure. Therefore, initiatives are required to implement this procedure to the majority of health care centers

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and . sd. s were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes

Technology within medicine has great potential to bring about more accessible, efficient, and a higher quality delivery of care. Paediatric supracondylar fractures are the most common elbow fracture in children and at our institution often have high rates of unnecessary long term clinical follow-up, leading to an inefficient use of healthcare and patient resources. This study aims to evaluate patient and clinical factors that significantly predict necessity for further clinical visits following closed reduction and percutaneous pinning. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics, perioperative course, goniometric measurements, functional outcome measures, clinical assessment and decision making for further follow up were assessed. Categorical and continuous variables were analyzed and screened for significance via bivariate regression. Significant covariates were used to develop a predictive model through multivariate logistical regression. A probability cut-off was determined on the Receiver Operator Characteristic (ROC) curve using the Youden index to maximize sensitivity and specificity. The regression model performance was then prospectively tested against 22 patients in a blind comparison to evaluate accuracy. 246 paediatrics patients were collected, with 29 cases requiring further follow up past the three month visit. Significant predictive factors for follow up were residual nerve palsy (p < 0 .001) and maximum active flexion angle of injured elbow (p < 0 .001). Insignificant factors included other goniometric measures, subjective evaluations, and functional outcomes scores. The probability of requiring further clinical follow up at the 3 month post-op point can be estimated with the equation: logit(follow-up) = 11.319 + 5.518(nerve palsy) − 0.108(maximum active flexion). Goodness of fit of the model was verified with Nagelkerke R2 = 0.574 and Hosmer & Lemeshow chi-square (p = 0.739). Area Under Curve of the ROC curve was C = 0.919 (SE = 0.035, 95% CI 0.850 – 0.988). Using Youden's Index, a cut-off for probability of follow up was set at 0.094 with the overall sensitivity and specificity maximized to 86.2% and 88% respectively. Using this model and cohort, 194 three month clinic visits would have been deemed medically unnecessary. Preliminary blind prospective testing against the 22 patient cohort demonstrates a model sensitivity and specificity at 100% and 75% respectively, correctly deeming 15 visits unnecessary. Virtual clinics and automated clinical decision making can improve healthcare inefficiencies, unclog clinic wait times, and ultimately enhance quality of care delivery. Our regression model is highly accurate in determining medical necessity for physician examination at the three month visit following supracondylar fracture closed reduction and percutaneous pinning. When applied correctly, there is potential for significant reductions in health care expenditures and in the economic burden on patient families by removing unnecessary visits. In light of positive patient and family receptiveness toward technology, our promising findings and predictive model may pave the way for remote health care delivery, virtual clinics, and automated clinical decision making

It is estimated that a quarter to half of all hospital waste is produced in the operating room. Recycling of surgical waste in the perioperative setting is largely underutilized, despite the fact that many of the materials being discarded can be potentially recycled safely and easily. Given this mounting waste production, recycling programs have become increasingly popular. Therefore, the primary objective of this study is assess the effect of these recent eco-friendly polices by determining the amount of waste and recycling produced in the pre-operative and operative time period for several orthopaedic subspecialties. Surgical cases were prospectively chosen and assigned to an orthopaedic subspecialty category, which included trauma, arthroplasty, sports, foot and ankle, upper extremity, and paediatrics. The preoperative phase began with the opening of the surgical case carts and concluded with the end of skin preparation. The intraoperative period began after skin preparation was complete, and concluded after the operating room was cleaned. At the end of the preoperative period all surgical waste was weighed and divided into recyclables and non-recyclables. Following the intraoperative period, surgical waste was divided into recyclables, non-recyclables, linens, and biohazardous waste streams. All bags were weighed in a standardized fashion using a portable hand held scale. The primary outcome of interest was the amount of recyclable waste produced per case. Secondary outcomes included the amount of nonrecyclable, biohazardous and total waste produced during the same time intervals. Statistical analysis was then completed using (ANOVA) to detect differences between specialties. This study included 55 procedures collected over a 1-month period at two hospitals from October 2017 to November 2017. A total of 341 kg of waste was collected with a mean mass of 6.2 kg per case. In terms of primary outcomes, arthroplasty surgery produced a significantly greater amount of recyclable waste per case in the preoperative (2327.9 g)and intraoperative (938.6 g)period. It also produced the greatest amount of total recyclable waste per case, resulting in a significantly greater ratio of waste recycling per case then nearly all other specialties in the preoperative (86.2%) and intraoperative period (14.5%). In terms of secondary outcomes, arthroplasty surgery similarly produced a significantly greater amount of nonrecyclable waste per case then all other specialties (5823.6 g), the majority of which was produced during the intraoperative period (5512.9 g). Arthroplasty surgery also produced a significantly greater amount of biohazardous waste then all other specialties (409.3 g). The majority of surgical waste was produced in the intraoperative period compared to the preoperative period. In the preoperative period an average of 74.4% of waste was recyclable, compared to 7.6% of waste produced during the intraoperative period. In total, the average amount of waste recycled per case was 25.6%. Biohazardous waste only constituted 1.8% of the total waste mass. Orthopaedic surgery is a significant source of waste production in our hospital system. Among orthopaedic subspecialties, arthroplasty is one of the largest waste producers, but also has the highest potential for recycling of materials. Effective OR recycling programs can significantly reduce our ecological footprint by diverting waste from landfills. In particular, the preoperative period has significant potential for landfill diversion as our study showed that nearly three quarters of all waste in this period can be effectively recycled

Although most uncomplicated paediatric fractures do not require routine long-term follow-up with an orthopaedic surgeon, practitioners with limited experience dealing with paediatrics fractures will often defer to a strategy of unnecessary frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway may help reduce unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. A retrospective analysis including patients who presented to SickKids hospital between October 2009 and October 2014 for management of clavicle fractures was performed. Patients with previous clavicle fractures, perinatal injury, multiple fractures, non-accidental injury, underlying bone disease, sternoclavicular dislocations, fractures of the medial clavicular physis and fractures that were managed at external hospitals were excluded from the analysis. Variables including age, gender, previous injury, fracture laterality, mechanism of injury, polytrauma, surgical intervention and complications and number of clinic visits were recorded for all patients. Radiographs were analysed to determine the fracture location (medial, middle or lateral), type (simple or comminuted), displacement and shortening. 339 patients (226 males, 113 females) with an average age of 8.1 (range 0.1–17.8) were reviewed. Diagnoses of open fractures, skin tenting or neurovascular injury were rare, 0.6%, 4.1%, and 0%, respectively. 6 (1.8%) patients underwent surgical management. All decisions for surgery were made on the first consultation with the orthopaedic surgeon. For patients managed non-operatively, the mean number of clinic visits including initial consultation in the emergency department was 2.0 (±1.2). The mean number of radiology department appointments was 4.1 (± 1.0) where patients received a mean number of 4.2 (±2.9) radiographs. Complications in the non-operative group were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Development of a paediatric clavicle fracture pathway may reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients' families without jeopardising patient outcomes

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

Aims

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

Surgery for DDH is one of the common paediatric orthopaedics procedures in a tertiary care paediatrics hospital. There are no uniformly agreed guidelines about the pre-operative work up related to blood transfusion in DDH surgery. This leads to lack of uniformity in practice, sometimes causes cancellations of operations on the day of surgery (due to no cross matched blood available) and on other occasions wastage of the cross matched blood. The aims of our study were to know the incidence of perioperative blood transfusion in a series of DDH operations and to determine what types of operations/kids have more chances of needing a blood transfusion peri-operatively. We included all children who had surgery for DDH between April 2009 and October 2012 in our institution. We found out which of these children had blood transfusion peri-operatively and reviewed their notes to determine any trends in transfusion requirements. 165 children had operations for DDH during the study period. This included operations ranging from hip open reduction to Ganz osteotomy. 6 out of 165 (4%) were transfused blood. Children needing blood transfusion tended to be older and had multiple hip operations previously. Only 3 (2 during Ganz and 1 during bilateral hip reconstruction) of these 6 children needed intra-operative blood transfusion. None of the under 4 years old children needed intra-operative blood transfusion. We conclude that children for unilateral primary hip operations for DDH do not need pre operative blood cross match. A group and save is enough in these cases

Aims

Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice.

Introduction. Through the paediatric LCP Hip plating system, the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to paediatrics. The purpose of this study was to review the outcome of the paediatric LCP Hip plate use in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications. Materials and methods. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Hip Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Results. Forty-three Paediatric LCP hip plates were used in forty patients for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, DDH, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of SUFE. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p = 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. There were no implant related complications. Conclusion. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric hip conditions in children with and without neuromuscular disease

The goals of evidence-based clinical practice guidelines in medicine are to promote best practices and reduce variations. Ideally they should improve physician performance and patient outcomes. Although controversy exists about the definition of a high quality guideline and how guidelines will be used in our health care system, there is a call for their use to help improve quality patient care. Guidelines related to musculoskeletal topics should be developed by national orthopaedic organisations and subspecialty societies using the best available clinical evidence. The American Academy of Orthopaedic Surgeons has, since 2007, developed nine evidence-based guidelines in the areas of hand, sports, foot/ankle, shoulder, paediatrics and total joint replacement. The keys to successful guideline development include an expert methodologist, an experienced evidence analysis staff, strict adherence to established rules to minimise bias, and strong communication with relevant subspecialty societies. The AAOS process allows any individual or group to submit a potential topic for consideration. A physician workgroup of 5-8 members is selected after wide advertisement of the topic. Workgroup members must have no relevant financial conflicts of interest to the topic and are required to fill out an enhanced disclosure form. The workgroup is comprised of orthopaedic surgeons and other specialists with expertise in the topic. There are two in-person meetings between which the staff finds and analyses the data to support the specific initial questions. The final document is 300-350 pages. There is a period of peer review by relevant societies as well as a period of public commentary followed by the formal committee and Board approval. The final guideline is disseminated widely via press releases, subspecialty societies, AAOS meetings, webinars, JBJS, JAAOS, and related questions on resident and member national examinations. These guidelines now form the basis for future AAOS quality initiatives

Aims

Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Aim. To review the evolution of the orthopaedic surgical care offered at a small rural hospital in western Nepal. The United Missions Hospital of Tansen (UMHT) was established in 1954 and has progressed substantially over the past 55 years. Located in the hills 300 km west of Kathmandu, it services not only Palpa District but also the surrounding nine districts and Indian patients from across the nearby border. The hospital has progressed from a simple medical clinic to a 165-bed hospital with four operating theatres, a new emergency department and multiple outpatient clinics. Orthopaedics in particular has come a long way from solely non-operative care such as plasters, splints and traction, to plating and intra-medullary nailing with intra-operative imaging facilities. This talk will review the progression of services in the region and highlight how western intervention has drastically improved the health care and lives of people in and around Tansen. Methods. UMHT is a 165-bed hospital with medical staff covering paediatrics, general medicine, general surgery and orthopaedics. Exact specialty coverage can vary depending on expatriate cover and locally trained staff expertise. There are around 315 Nepali employees, and eight mission appointees, mainly from the UK, USA, Australia and Sweden. There are six resident medical officers who are post internship and usually completing GP training schemes. The hospital is accredited to train 10 interns per year and frequently takes local and international medical students on rotation. Surgical facilities include daily outpatient surgical clinics of 30–60 patients, two minor operation theatres and two operating theatres. Generally, these are run as one orthopaedic and one general surgical theatre. This review is based on the experiences of Dr John Bosanquet, Dr Sandy Bosanquet and Dr Lachlan Host in their outreach trips to this hospital and in particular will focus on the progression over the last 10 years of the orthopaedic services available. Major advances have been in the provision of x-ray and CT facilities, improved supply of sterile equipment, introduction of IM nailing using the SIGN nail, and the training of local staff to continue the work. Conclusions. UMHT is a work in progress and is only made possible by the contributions of the many doctors, nurses, teachers and other professionals who willingly offer their services to help those less fortunate. Even more importantly is the funding provided from multiple organisations to sustain this outreach. The challenge remains, as in any outreach offered, of providing a service that is sustainable long-term. To date, UMHT has stood the test of time and there is much to be learnt from its example in the establishment of similar outreach projects. Future challenges for Tansen include the need for improved sterile facilities, the challenges of introducing elective surgery, particularly arthroplasty, provision of spine and neurosurgical facilities, and retention of skilled personal in what can be an isolating environment

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective.

Cite this article: Bone Jt Open 2021;2-10:893–899.

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.

Aims

The ongoing COVID-19 pandemic has disrupted and delayed medical and surgical examinations where attendance is required in person. Our article aims to outline the validity of online assessment, the range of benefits to both candidate and assessor, and the challenges to its implementation. In addition, we propose pragmatic suggestions for its introduction into medical assessment.

Introduction

Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia.

We evaluated the top 13 journals in trauma and orthopaedics by impact factor and looked at the longer-term effect regarding citations of their papers.

All 4951 papers published in these journals during 2007 and 2008 were reviewed and categorised by their type, subspecialty and super-specialty. All citations indexed through Google Scholar were reviewed to establish the rate of citation per paper at two, four and five years post-publication. The top five journals published a total of 1986 papers. Only three (0.15%) were on operative orthopaedic surgery and none were on trauma. Most (n = 1084, 54.5%) were about experimental basic science. Surgical papers had a lower rate of citation (2.18) at two years than basic science or clinical medical papers (4.68). However, by four years the rates were similar (26.57 for surgery, 30.35 for basic science/medical), which suggests that there is a considerable time lag before clinical surgical research has an impact.

We conclude that high impact journals do not address clinical research in surgery and when they do, there is a delay before such papers are cited. We suggest that a rate of citation at five years post-publication might be a more appropriate indicator of importance for papers in our specialty.

Cite this article: Bone Joint J 2014;96-B:414–19.