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

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.

Cite this article: Bone Joint J 2023;105-B(4):356–360.

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The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

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This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

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This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

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The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius.

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The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD.

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Conflicting clinical results are reported for the ATTUNE Total Knee Arthroplasty (TKA). This randomized controlled trial (RCT) evaluated five-year follow-up results comparing cemented ATTUNE and PFC-Sigma cruciate retaining TKAs, analyzing component migration as measured by radiostereometric analysis (RSA), clinical outcomes, patient-reported outcome measures (PROMs), and radiological outcomes.

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The aim of this study was to assess medium-term improvements following total hip arthroplasty (THA), and to evaluate what effect different preoperative Oxford Hip Score (OHS) thresholds for treatment may have on patients’ access to THA and outcomes.

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To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score.

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The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC.

Introduction. Rising incidence of fracture neck of femur (NOF) are associated with rising geriatric population. Majority of patients are suffering from comorbid factors. Impaired renal function is a common comorbid factor and most of the time it is attributed to an acute renal impairment following the fracture and surgery. Objective of this study was to identify the effect of renal comorbid factors and their probable relative risk for a fracture and compare the results with Asian and European data. Specific objective was to identify a possibility of presence of pretraumatic subclinical chronic renal failure among fractured Sri Lankans. Methodology. Data were collected from fractured patients (N=200) and non-fracture sample for a period of one year. Variables studied were, serum calcium, serum phosphate, blood hemoglobin level, blood urea and serum creatinine. Data were analyzed using binary logistic and multiple regressions, principal component statistical technique using STATA software. Results. The logistic regression of renal co morbid factors with fracture showed that relative risk of occurrence of higher blood urea (> 8.2 mmol/L) in a NOF patient is 3.35 times higher(p value 0.012), relative risks of occurrence of high serum creatinine (> 120 µmol/L) is 3.17 times higher(P value-0.027), risk of low hemoglobin (Hb < 12) is 2.58(p value 0.005) times higher than a non-fracture patient even after adjustments for blood loss following fracture. Results were compared with the Asian and European data. Conclusions. Pretraumatic high blood urea, serum creatinine and low hemoglobin are associated with NOF Sri Lankan patients. Comparative Asian data shows higher figures in Sri Lanka. Studies in Nordic countries and Europe shows higher incidence of renal impairment in fracture neck of femur patients. Further studies are required to assess the presence of pretraumatic sub clinical chronic renal insufficiency in Sri Lanka and in European countries

Introduction. Spinal aBMD only explains 50–80% of vertebral strength, and the application of aBMD measurements in isolation cannot accurately identify individuals who are likely to eventually experience bone fracture, due to the low sensitivity of the test. For appropriate treatment intervention, a more sensitive test of bone strength is needed. Such a test should include not only bone mineral density, but also bone quality. Quantitative computed tomography-based finite element methods (QCT/FEM) may allow structural analyses taking these factors into consideration to accurately predict bone strength (PBS). To date, however, basic data have not been reported regarding the prediction of bone strength by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PBS in a normal population as a preliminary trial. With these data, parameters that affect PBS were also analyzed. Methods. Participants in this study comprised individuals who participated in a health checkup program with CT at our hospital in 2009. Participants included 217 men and 120 women (age range, 40–89 years). Exclusion criteria were provided. Scan data of the second lumber vertebra (L2) were isolated and taken from overall CT data for each participant obtained with simultaneous scans of a calibration phantom containing hydroxyapatite rods. A FE model was constructed from the isolated data using Mechanical Finder software. For each of the FE models, A uniaxial compressive load with a uniform distribution and uniform load increment was applied. For each participant, height and weight were measured, BMI was calculated. Simple linear regression analysis was used to estimate correlations between age and PBS as analyzed by QCT/FEM. Changes in PBS with age were also evaluated by grouping participants into 5-year age brackets. One-way analysis of variance was used to compare average PBS for participants in each age range. Mean PBS in the 40–44 year age range was taken as the young adult mean (YAM). The ratio of mean PBS in each age group to YAM was calculated as a percentage. A multivariate statistical technique was used to determine how PBS was affected by age, height, weight, and BMI. Result/Discussion. Mean PBS was lower in women than in men for all age ranges. PBS in men and women significantly decreased with age. Simple linear regression between age and PBS showed the annual rate of decline in PBS was 55 N/year in men and 164 N/year in women. Mean PBS in the 75–79 year age range was 77% of YAM in men and in women, that in the 70–79 year age range was 47% of YAM. PBS was strongly dependent on age, while physical status had less effect

The statistical quality of 103 original articles published in The Journal of Bone and Joint Surgery (British Volume) in 1984 was assessed. Some papers were found to be deficient: thus, it was not always clear how series were selected and sometimes neither the data nor the results were clearly presented. Sample sizes were frequently inadequate for the conclusions reached and statistical techniques should have been used more frequently. A majority of papers were descriptions of case series for which no comparative data were made available. It is suggested that collaborative research would best advance knowledge about the relative benefits of various managements, and that statistical advice could make a substantial contribution

The pathogenesis of knee osteoarthritis is complex and involves many correlated factors that can be measured with gait analysis. Important biomechanical factors may lie in the interrelationships between variables. This study demonstrated the use of a multidimensional gait data analysis technique that simultaneously considered multiple time varying and constant measures. The gait patterns of normal and knee osteoarthritic subjects were successfully separated with a misclassification error rate of < 6%. One of the most discriminatory features identified an important knee osteoarthritis difference during the loading response phase of the gait cycle. The objective of this study was to detect biomechanical factors of knee osteoarthritis with a multidimensional gait data analysis technique. A multidimensional gait data analysis technique detected a very discriminatory feature that described a knee osteoarthritis difference during the loading response phase of the gait cycle. The combination of variables involved in the loading response feature may be important to the onset and development of knee osteoarthritis. Discriminatory gait features associated with knee osteoarthritis were identified with a misclassification error rate of < 6%. In a very discriminatory feature, the loading response phase of the gait cycle was completely isolated as important. Body mass index (BMI) was the greatest contributing factor to the loading response feature. Three-dimensional gait analysis was performed on fifty elderly patients with severe knee osteoarthritis and sixty-three elderly asymptomatic subjects. Three components of knee joint angles, moments and forces were calculated. Body mass index (BMI), radiographic measures and stride characteristics were also measured. A multivariate statistical technique extracted important features from the data and a discrimination procedure defined the optimal separation between the two groups. The importance of loading response had been hypothesized previously, and this study quantitatively identified a very discriminatory gait pattern difference during loading response. The difference described was multidimensional. Although BMI was the largest contributing factor, there was no univariate difference in BMI between the two groups. Funding: NSERC

Background: The osteolysis in revision total knee arthroplasty was observed. The purpose of this study was to compare the prevalence and characteristics of osteolysis recognized in revision total knee arthroplasties between the failed mobile bearing and fixed bearing knees. Methods: Eighty revision total knee arthroplasties were done between 1995 and 1998. The primary prosthesis that failed included thirty-four mobile bearing (Low Contact Stress) knees and forty-six fixed bearing knees of vary prostheses. At the time of revision surgery, all the interfaces between bone and prosthesis or cement were routinely checked and recorded for evidence of osteolytic resorption of bone. Preoperative radiographs were assessed independently by two authors for evidence of focal or severe periprosthetic osteolysis. The presence of the lesion was recorded. The demographic data included age and body weight was reviewed. The interval between the primary and revision surgery was recorded. The revision technique was reviewed. A statistical technique of chi-square test was applied in this study. Results: Osteolysis was recognized in sixteen of thirty-four mobile bearing knees (47 per cent) with thirteen knees involved distal femur and in six of forty- six fixed bearing knees (13 per cent) with four knees involved distal femur. The incidence of osteolysis was statistically significant difference between the mobile bearing and fixed bearing knees (p< 0.05). An overall 28 per cent (twenty-two knees) incidence of osteolysis was identified intraoperatively. The overall incidence of osteolysis in distal femur was 21 per cent (seventeen knees). The average time interval from the primary surgery to revision was 108 months. All the knees were affected by osteoarthritis. The most common site of osteolytic bone resorption was the posterior femoral condyle. Conclusions: Comparing to the fixed bearing knees, the mobile bearing (Low Contact Stress) knees were at increased risk for osteolysis in our series. Osteolysis occurred predominantly on the femoral side, especially adjacent to the prostheses in posterior condyle. Radiographic evaluation of osteolysis in distal femur is unreliable

Introduction: Proximal humeral fractures are common in the elderly osteoporotic population. Surgical management of such fractures with traditional internal fixation techniques is often challenging due to poor bone quality. Fixation with intramedullary devices theoretically offers better fixation, but with increased risk of shoulder pain and decreased range of motion. We undertook a study to compare outcome following fixation of such fractures with either an intramedullary nail (Polarus), standard Clover Leaf plate (AO), or Philos Locking plate (AO). Method: All patients admitted for surgical management of a proximal humeral fracture were entered into the study. 10 patients were treated using a Philos plate (Group 1), 5 with a Clover Leaf plate (Group 2), and 10 with a Polarus nail (Group 3). Post-operative assessment included radiological evaluation, clinical assessment of range of motion compared to the non-injured arm, assessment of pain severity (visual analogue scale), and functional assessment (DASH score). Non-parametric statistical techniques were used to analyse results. Results: There was no significant difference in age or sex distribution between the three groups. (Mean ages: Group 1: 54.6 yrs, Group 2: 45.2 yrs, Group 3: 59.7 yrs) Mean patient follow-up was 22 months (range 5–52 months). All patients in Group 1 and 2 went on to satisfactory radiological and clinical union. A higher complication rate was noted in the Polarus nail group, with 3 patients requiring removal of metal due to soft tissue or subacromial impingement. In addition one patient developed a non-union and required Philos plate fixation. All groups demonstrated a significant decrease in shoulder range of motion following injury, however this was less marked in Group 1 (Philos plate). In addition, patients in group 1 (Philos plate) demonstrated a more rapid recovery in terms of severity of pain, functional impairment and range of motion in the early postoperative phase. However, no significant long-term difference was noted in terms of post-operative pain or functional deficit between group 1 and 2. The poor outcome in group 3 was associated with a high incidence of shoulder pain and secondary procedures. Conclusion: Intramedullary fixation of proximal humeral fractures resulted in a high level of complications requiring secondary procedures in many cases. Our study supports the safety and efficacy of plate fixation techniques in the operative management of proximal humeral fractures

Introduction. Different subclinical neurological dysfunction has been reported in adolescent idiopathic scoliosis (AIS), including poor postural control and asymmetric otolith vestibulo-ocular responses when compared with normal controls. The objective of this pilot study is to establish whether abnormal MRI morphoanatomical changes arise in the CNS (brain and vestibular system), among left-thoracic versus right-thoracic AIS when compared with normal adolescent controls, with use of advanced computerised statistical morphometry techniques. Methods. We compared nine girls with left-thoracic AIS (mean age 14 years; mean Cobb angle 19°) with 11 matched controls, and 20 girls with right-thoracic AIS (mean age 15 years, mean Cobb angle 33·8°) with 17 matched controls. The statistical brain analysis was done with validated automatic segmentation and voxel-based morphometry (VBM). The T2W-MRI data for shape analysis of the vestibular system were obtained from 20 patients with right-thoracic AIS and 20 matched controls. A best-fit plane and a best-fit circle were calculated to approximate each semicircular canal. The shape of vestibular system was measured by: (1) the angle between each pair of best-fit planes; (2) the length; and (3) angle formed between the corresponding lines connecting the centres of each pair of circles. Statistical analysis was done with one-way ANOVA. Results. Patients with left-thoracic AIS had significantly lower white matter density in corpus callosum, left internal capsule, and white matter underlying orbitofrontal cortex of left hemisphere, which were not observed in patients with right-thoracic AIS. In the right-thoracic AIS group, the distance between centres of lateral and superior canals (p=0·0264) and the angle with vertex at the centre of posterior canal (p=0·02) of left-side vestibular system were significantly smaller than in the control group (figure). For vestibular analysis, there were no data for left-thoracic AIS. Conclusions. Findings from this pilot study have shown significant MRI morphoanatomical difference in CNS between patients with AIS and controls. In the brain analysis, corpus callosum (the principle commissural fibre bundle connecting left and right cerebral hemispheres, which might affect the coordination of left and right sides of the body), differed between left-thoracic and right-thoracic AIS. In the vestibular analysis, geometric morphological difference was detected on the left-side semicircular canals between right-thoracic AIS and healthy controls. These morphological changes are likely to be related to the subclinical postural, vestibular, and proprioceptive dysfunctions. Further association studies and longitudinal studies could help to further define the link between morphological and functional dysfunction, which might have important predictive and prognostic effect on curve development and progression

Purpose. To characterize the knee kinematic profiles of total knee arthroplasty patient knees intraoperatively, before implant insertion, using principal component analysis. Method. Ninety-two patientsreceived Stryker Triathlon total knee arthroplasty (TKA) implants. The Stryker surgical navigation system was used for all surgeries. The system was used to define rigid bodies representing the femur and tibia, and to track the three-dimensional movement of the knee joint during surgery. Each knee was moved through a passive range of knee flexion/extension before and after implantation of the arthroplasty components. The frontal plane (medial-lateral) movement of the knee joint through a range of 10 to 120 degrees of flexion before implantation was calculated for each knee using the joint coordinate system (referred to as the pre-implant knee kinematic curve). Visual inspection of these patterns indicated three predominant curve types: a backward S shape, a backward C shape and a valgus to varus shape. Each curve was subjectively categorized into one of these three categories. Principal component analysis (PCA), a multivariate statistical analysis technique, was applied to the pre-implant knee kinematic pattern data to objectively extract the major patterns of curve types within the 92 knees. Analysis of variance was used to compare the mean differences in PC scores between the curve shape groups to confirm visual categorization. Results. Of the 92 patient curves, 13 had a backwards S shape, 14 had a backwards C shape and 20 had a valgus to varus shape. Forty of the knee were categorized as ‘other’. The first 3 principal components extracted from the knee kinematics curves cumulatively explained 99.7% of the variability in the original data, confirming 3 predominant curve types. The first PC captured an overall measure of varus/valgus throughout the flexion range. The second PC captured an S-shape pattern, and the third PC captured a C-shape pattern. Analysis of variance showed statistically significant differences between the four groups of knees for each PC (p < 0.0001, p <0.0001, p = 0.04 for PC1, 2 and 3 respectively), indicating significant differences between the groups based on the S and C shape patterns. Conclusion. Visual inspection of pre-implant knee kinematic curves indicates that the knees of patients with severe arthritis have different patterns, the predominant patterns being S and C shape patterns. Principal component analysis was used to confirm these patterns quantitatively and to quantitatively show the differences between patient curve types. Principal component analysis is therefore a potentially powerful tool for a computerized characterization of the dynamic pattern of patient knee joints prior to total knee arthroplasty. Ongoing and future work will be used to link these curve types to outcome metrics, joint morphology and surgical technique. This will provide valuable subject-specific knee dynamic information for surgical planning and design

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To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.