Aims. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are. Methods. The Embase, MEDLINE, and PubMed libraries were systematically searched to identify relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O’Malley framework were followed. Study quality was assessed using a modified Methodological Index for Non-Randomized Studies tool. AI performance was reported using either the area under the curve (AUC) or accuracy. Results. Of the 455 studies identified, only 12 were suitable for inclusion. Nine reported implant identification and three described predicting risk of implant failure. Of the 12, three studies compared AI performance with orthopaedic surgeons. AI-based implant identification achieved AUC 0.992 to 1, and most algorithms reported an accuracy > 90%, using 550 to 320,000 training radiographs. AI prediction of dislocation risk post-THA, determined after five-year follow-up, was satisfactory (AUC 76.67; 8,500 training radiographs). Diagnosis of hip implant loosening was good (accuracy 88.3%; 420 training radiographs) and measurement of postoperative acetabular angles was comparable to humans (mean absolute difference 1.35° to 1.39°). However, 11 of the 12 studies had several methodological limitations introducing a high risk of bias. None of the studies were externally validated. Conclusion. These studies show that AI is promising. While it already has the ability to analyze images with significant precision, there is currently insufficient high-level evidence to support its widespread clinical use. Further research to design robust studies that follow standard reporting guidelines should be encouraged to develop AI models that could be easily translated into real-world conditions. Cite this article: Bone Joint J 2022;104-B(8):929–937

Cite this article: Bone Joint J 2023;105-B(6):590–592.

Aims

Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.

Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. Patients and Methods. Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. Results. A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). Conclusion. Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use. Cite this article: Bone Joint J 2019;101-B:1570–1577

Aims. A recent report from France suggested an association between the use of cobalt-chrome (CoCr) femoral heads in total hip arthroplasties (THAs) and an increased risk of dilated cardiomyopathy and heart failure. CoCr is a commonly used material in orthopaedic implants. If the reported association is causal, the consequences would be significant given the millions of joint arthroplasties and other orthopaedic procedures in which CoCr is used annually. We examined whether CoCr-containing THAs were associated with an increased risk of all-cause mortality, heart outcomes, cancer, and neurodegenerative disorders in a large national database. Methods. Data from the National Joint Registry was linked to NHS English hospital inpatient episodes for 374,359 primary THAs with up to 14.5 years' follow-up. We excluded any patients with bilateral THAs, knee arthroplasties, indications other than osteoarthritis, aged under 55 years, and diagnosis of one or more outcome of interest before THA. Implants were grouped as either containing CoCr or not containing CoCr. The association between implant construct and the risk of all-cause mortality and incident heart failure, cancer, and neurodegenerative disorders was examined. Results. There were 158,677 individuals (42.4%) with an implant containing CoCr. There were 47,963 deaths, 27,332 heart outcomes, 35,720 cancers, and 22,025 neurodegenerative disorders. There was no evidence of an association between patients with CoCr implants and higher rates of any of the outcomes. Conclusion. CoCr-containing THAs did not have an increased risk of all-cause mortality, or clinically meaningful heart outcomes, cancer, or neurodegenerative disorders into the second decade post-implantation. Our findings will help reassure clinicians and the increasing number of patients receiving primary THA worldwide that the use of CoCr-containing implants is not associated with significant adverse systemic effects. Cite this article: Bone Joint J 2022;104-B(3):359–367

Obesity is a risk factor for complications following many orthopaedic procedures. The purpose of this study was to investigate whether obesity was an independent risk factor increasing the rate of complications following periacetabular osteotomy (PAO) and to determine whether radiographic correction after PAO was affected by obesity. . We retrospectively collected demographic, clinical and radiographic data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were followed for a mean of 48 months (12 to 60) after PAO. A total of 65 patients (23.2%) were obese (body mass index (BMI) > 30 kg/m. 2. ). Univariate and multivariate analysis demonstrated that BMI was an independent risk factor associated with the severity of the complications. The average probability of a patient developing a major complication was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient The odds of a patient developing a major complication were 11 times higher (95% CI 4.71 to 17.60, p <  0.0001) for an obese compared with a non-obese patient. . Following PAO surgery, there was no difference in radiographic correction between obese and non-obese patients. PAO procedures in obese patients correct the deformity effectively but are associated with an increased rate of complications. Cite this article: Bone Joint J 2015;97-B:29–34

Radiological imaging is necessary in a wide variety of trauma and elective orthopaedic operations. The evolving orthopaedic workforce includes an increasing number of pregnant workers. Current legislation in the United Kingdom, Europe and United States allows them to choose their degree of participation, if any, with fluoroscopic procedures. For those who wish to engage in radiation-prone procedures, specific regulations apply to limit the radiation dose to the pregnant worker and unborn child. This paper considers those aspects of radiation protection, the potential effects of exposure to radiation in pregnancy and the dose of radiation from common orthopaedic procedures, which are important for safe clinical practice

Aims . Few studies have evaluated the relationship between patients’ pre-operative expectations and the outcome of orthopaedic procedures. Our aim was to determine the effect of expectations on the outcome after primary anatomical total shoulder arthroplasty (TSA). We hypothesised that patients with greater expectations would have better outcomes. . Patients and Methods. Patients undergoing primary anatomical TSA completed the Hospital for Special Surgery’s Shoulder Expectations Survey pre-operatively. The American Shoulder and Elbow Surgeons (ASES), Shoulder Activity Scale (SAS), Short-Form-36 (SF-36), and visual analogue scale (VAS) for pain, fatigue, and general health scores were also collected pre-operatively and two years post-operatively. Pearson correlations were used to assess the relationship between the number of expectations and the outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation were assessed by independent samples t-test. Multivariable linear regression analysis was used to control for potential confounding factors. Results. A total of 67 patients were evaluated two years post-operatively. Most parameters of outcome improved significantly from baseline and most patients were satisfied. A greater number of expectations was associated with a significantly greater improvement in the ASES score (p = 0.02). In the multivariable analysis, a greater number of expectations was an independent predictor of better ASES, VAS and SF-36 scores, as well as improvements in ASES and VAS pain scores (p < 0.05). Greater expectations for many specific expectation questions were significantly associated with better outcomes (p < 0.05). Conclusion. TSA is a successful procedure with significant improvements in outcome, and greater pre-operative expectations are associated with better outcomes. . Cite this article: Bone Joint J 2017;99-B:1190–6

We evaluated the safety and efficacy of total knee replacement in patients receiving continuous warfarin therapy. . We identified 24 consecutive patients receiving long-term warfarin therapy who underwent total knee replacement between 2006 and 2008 and compared them with a group of age- and gender-matched patients not on long-term anticoagulation. Primary observations were changes in haemoglobin, transfusion rates and complications. Secondary observations were fluctuations in the international normalised ratio (INR) and post-operative range of movement. . There was no significant difference between the two groups in pre- or post-operative haemoglobin, incidence of transfusion or incidence of post-operative complications. There were no surgical delays due to a high INR level. The mean change in INR during the peri-operative phase was minimal (mean 0.4; . sd. 0.7). There was no significant difference in the range of movement between the two groups after day two post-operatively. Current American College of Chest Physicians guidelines recommend bridging therapy for high-risk patients receiving oral anticoagulation and undergoing major orthopaedic procedures. We have shown that a safe alternative is to continue the steady-state warfarin peri-operatively in patients on long-term anticoagulation requiring total knee replacement

Arthroscopy of the knee is one of the most commonly performed orthopaedic procedures worldwide. Large-volume outcome data have not previously been available for English NHS patients. Prospectively collected admissions data, routinely collected on every English NHS patient, were analysed to determine the rates of complications within 30 days (including re-operation and re-admission), 90-day symptomatic venous thromboembolism and all-cause mortality. There were 301 701 operations performed between 2005 and 2010 – an annual incidence of 9.9 per 10 000 English population. Of these, 16 552 (6%) underwent ligament reconstruction and 106 793 (35%) underwent meniscal surgery. The 30-day re-admission rate was 0.64% (1662) and 30-day wound complication rate was 0.26% (677). The overall 30-day re-operation rate was 0.40% (1033) and the 90-day pulmonary embolism rate was 0.08% (230), of which six patients died. 90-day mortality was 0.02% (47). Age < 40 years, male gender and ligament reconstruction were significantly associated with an increased rate of 30-day re-admission and unplanned re-operation. In addition, a significant increase in 30-day admission rates were seen with Charlson comorbidity scores of 1 (p = 0.037) and ≥ 2 (p <  0.001) compared with scores of 0, and medium volume units compared with high volume units (p < 0.001). Complications following arthroscopy of the knee are rare. It is a safe procedure, which in the majority of cases is performed as day case surgery. These data can be used for quality benchmarking, in terms of consent, consultant re-validation and individual unit performance

Robots have been used in surgery since the late 1980s. Orthopaedic surgery began to incorporate robotic technology in 1992, with the introduction of ROBODOC, for the planning and performance of total hip replacement. The use of robotic systems has subsequently increased, with promising short-term radiological outcomes when compared with traditional orthopaedic procedures. Robotic systems can be classified into two categories: autonomous and haptic (or surgeon-guided). Passive surgery systems, which represent a third type of technology, have also been adopted recently by orthopaedic surgeons. While autonomous systems have fallen out of favour, tactile systems with technological improvements have become widely used. Specifically, the use of tactile and passive robotic systems in unicompartmental knee replacement (UKR) has addressed some of the historical mechanisms of failure of non-robotic UKR. These systems assist with increasing the accuracy of the alignment of the components and produce more consistent ligament balance. Short-term improvements in clinical and radiological outcomes have increased the popularity of robot-assisted UKR. Robot-assisted orthopaedic surgery has the potential for improving surgical outcomes. We discuss the different types of robotic systems available for use in orthopaedics and consider the indication, contraindications and limitations of these technologies

Allografts of bone from the femoral head are often used in orthopaedic procedures. Although the donated heads are thoroughly tested microscopically before release by the bone bank, some surgeons take additional cultures in the operating theatre before implantation. There is no consensus about the need to take these cultures. We retrospectively assessed the clinical significance of the implantation of positive-cultured bone allografts. The contamination rate at retrieval of the allografts was 6.4% in our bone bank. Intra-operative cultures were taken from 426 femoral head allografts before implantation; 48 (11.3%) had a positive culture. The most frequently encountered micro-organism was coagulase-negative staphylococcus. Deep infection occurred in two of the 48 patients (4.2%). In only one was it likely that the same micro-organism caused the contamination and the subsequent infection. In our study, the rate of infection in patients receiving positive-cultured allografts at implantation was not higher than the overall rate of infection in allograft surgery suggesting that the positive cultures at implantation probably represent contamination and that the taking of additional cultures is not useful

Accurate, reproducible outcome measures are essential for the evaluation of any orthopaedic procedure, in both clinical practice and research. Commonly used patient-reported outcome measures (PROMs) have drawbacks such as ‘floor’ and ‘ceiling’ effects, limitations of worldwide adaptability and an inability to distinguish pain from function. They are also unable to measure the true outcome of an intervention rather than a patient’s perception of that outcome. Performance-based functional outcome tools may address these problems. It is important that both clinicians and researchers are aware of these measures when dealing with high-demand patients, using a new intervention or implant, or testing a new rehabilitation protocol. This article provides an overview of some of the clinically-validated performance-based functional outcome tools used in the assessment of patients undergoing hip and knee surgery. Cite this article: Bone Joint J 2014;96-B:1431–5

We report a double-blind study of the effectiveness of indomethacin suppositories in the relief of postoperative pain and the reduction in demand for opiate analgesia following orthopaedic procedures

Templates are used in the preoperative planning of many orthopaedic procedures. The magnification of the bones on preoperative radiographs can vary despite using standardised radiological techniques. Templates will give misleading measurements unless this magnification is quantified. A coin may be used to calculate the magnification, with significant improvement in the accuracy of templating (p = 0.05). A group of patients undergoing uncemented arthroplasty of the hip was at high risk for intraoperative fracture of the femur because the magnification of the radiograph was larger than that of the template

We have developed a teaching programme for non-radiologists who use fluoroscopy, which includes techniques for reducing the radiation received by the patient and the surgeon during orthopaedic procedures. The techniques resolve around the radiation protection concepts of time, distance and shielding. The programme has been very successful in reducing the total fluoroscopy times of orthopaedic surgeons; in our institute, durations have been reduced to about 10% of those before the training started. We review the aims and content of our programme

Between 1980 and 1988, displacement bone-marrow transplantation was performed on 25 children with Hurler's syndrome (type-1 mucopolysaccharidosis). We describe the musculoskeletal development of 11 of the 12 surviving children and the orthopaedic procedures undertaken to treat progressive thoracolumbar kyphosis, hip subluxation and carpal tunnel syndrome. We found abnormal bone modelling, focal failures of ossification and an avascular disorder of the femoral head in every patient and offer an explanation for these phenomena. Increasing valgus deformity of the knees and progressive generalised myopathy caused loss of mobility as the children entered adolescence. The benefit of bone-marrow transplantation as a treatment for the skeletal disorders of Hurler's syndrome is limited by the poor penetration of the musculoskeletal tissues by the enzyme derived from the leucocytes

We have compared the rates of infection and resistance in an animal model of an orthopaedic procedure which was contaminated with a low-dose inoculum of Staphylococcus epidermidis. We randomised 44 Sprague-Dawley rats to have bone cement implanted subcutaneously containing either gentamicin or saline (control). The wound was inoculated with a dilute solution of gentamicin-sensitive Staphylococcus epidermidis. At two weeks the cement was retrieved and microbiologically tested. A lower overall rate of infection was seen in the gentamicin-loaded cement group, but there was a significantly higher rate of gentamicin-resistant infection in this group (Fisher’s exact test, p < 0.01). Antibiotic-impregnated cement has an optimum surface for colonisation and prolonged exposure to antibiotic allows mutational resistance to occur. Gentamicin-loaded cement may not be appropriate for revision surgery if it has been used already in previous surgery

The prevalence of HIV infection in East Africa has increased rapidly in recent years. We made a prospective study of the incidence of HIV-seropositivity in patients undergoing orthopaedic procedures in a large district hospital in Bulawayo, Zimbabwe. One of our aims was to determine whether a clinically-based screening programme, derived from the Centre for Disease Control classification of HIV infection, could identify high-risk individuals before surgery. During a 3-month period, 76 patients were tested, and 12 were HIV-positive (16%). Only two of these patients (17%) had clinical features associated with HIV infection; ten (83%) were entirely asymptomatic. Our results indicate that preoperative clinical screening is unlikely to be successful in identifying seropositive patients before routine surgery

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used. Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect. A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures

Postoperative deep-vein thrombosis (DVT) is believed to be rare in Asians. We studied 88 consecutive patients in Malaysia who had operations for fracture of the proximal femur or for total hip or knee replacement. No patient had prophylaxis against DVT; bilateral ascending venography was performed between six and ten days after operation. A total of 55 patients (62.5%) showed venographic evidence of DVT. The prevalence was greatest after total knee replacement (76.5%), less after total hip replacement (64.3%) and smallest in the fracture group (50%). One patient developed symptomatic pulmonary embolism. In contrast to other reports from Asia, we found an incidence of postoperative DVT which is similar to that reported in Western populations. This suggests that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedures should be reconsidered

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation

Previous studies of the Ilizarov procedure have concentrated on musculoskeletal assessments rather than the opinions of patients. In a prospective trial of 25 consecutive patients, we evaluated the effect of Ilizarov reconstruction of post-traumatic deformity on general health status using the SF36 and Nottingham Health Profile (NHP). The patients had very low preoperative scores, which remained low during treatment and correction, but increased postoperatively. The mean overall SF36 score improved from 36 ± 3 to 58 ± 7 (p = 0.031) and the NHP score from 39 ± 11 to 67 ± 10 (p = 0.002). The improvements in scores were not limited to the physical components and were equal or better than the improvements reported for other orthopaedic procedures, including total joint arthroplasty. Ilizarov-type reconstruction of deformity of the lower limb not only restores bony configuration, but also produces a large improvement in the general health status of patients

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients

We carried out a prospective randomised study comparing medial epicondylectomy with anterior transposition for the treatment of ulnar neuropathy at the elbow. The mean follow-up period was 4.5 years and we assessed the patients neurologically and orthopaedically. Neither procedure appeared to have a significant effect on elbow function. Our study showed better results after medial epicondylectomy; in particular patient satisfaction was higher than after ulnar nerve transposition. There were no significant differences in motor power or nerve-conduction rates and sensory fibres appeared to be more vulnerable to devascularisation

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

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We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton.

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This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

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The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years.

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The aim of this study was to understand the experience of mature patients who undergo a periacetabular osteotomy (PAO), a major hip-preserving surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to improve our understanding of how the operation affected the lives of patients and their families, with a long-term goal of improving their experience.

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Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.

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The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

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Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

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Although there is increasing legalization of the use of cannabis in the USA, few well-powered studies have evaluated the association between cannabis use disorder and outcomes following primary total hip arthroplasty (THA). Thus, the aim of this study was to determine whether patients who use cannabis and undergo primary THA have higher rates of in-hospital length of stay (LOS), medical complications, implant-related complications, and costs.

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The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway.

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Dual mobility implants in total hip arthroplasty are designed to increase the functional head size, thus decreasing the potential for dislocation. Modular dual mobility (MDM) implants incorporate a metal liner (e.g. cobalt-chromium alloy) in a metal shell (e.g. titanium alloy), raising concern for mechanically assisted crevice corrosion at the modular liner-shell connection. We sought to examine fretting and corrosion on MDM liners, to analyze the corrosion products, and to examine histologically the periprosthetic tissues.

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The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

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Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions.

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Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

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The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services.

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Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO.

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Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients.

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The purpose of this study was to develop a personalized outcome prediction tool, to be used with knee arthroplasty patients, that predicts outcomes (lengths of stay (LOS), 90 day readmission, and one-year patient-reported outcome measures (PROMs) on an individual basis and allows for dynamic modifiable risk factors.

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To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty.

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The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error.

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This study presents patient-reported quality of life (QoL) over the first year following surgical debridement of long bone osteomyelitis. It assesses the bone involvement, antimicrobial options, coverage of soft tissues, and host status (BACH) classification as a prognostic tool and its ability to stratify cases into ‘uncomplicated’ or ‘complex’.

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The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon’s cases and the total time spent in the operating theatre per day.

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The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA.

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Rates of readmission and reoperation following primary total knee arthroplasty (TKA) are under scrutiny due to new payment models, which penalize these negative outcomes. Some risk factors are more modifiable than others, and some conditions considered modifiable such as obesity may not be as modifiable in the setting of advanced arthritis as many propose. We sought to determine whether controlling for hypoalbuminaemia would mitigate the effect that prior authors had identified in patients with obesity.

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Preoperative nasal Staphylococcus aureus screening and eradication reduces surgical site infections (SSIs) but its impact on reducing early prosthetic joint infection (PJI) remains controversial. This study aims to assess the effect of preoperative nasal S. aureus screening and eradication on the incidence of early PJI in general and S. aureus-induced early PJI.

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Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning.

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Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user’s view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics.

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Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity.

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The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures.

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The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

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Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol.

Aims

Surface replacement arthroplasty (SRA), compared with traditional total hip arthroplasty (THA), is more expensive and carries unique concern related to metal ions production and hypersensitivity. Additionally, SRA is a more demanding procedure with a decreased margin for error compared with THA. To justify its use, SRA must demonstrate comparable component survival and some clinical advantages. We therefore performed a systematic literature review to investigate the differences in complication rates, patient-reported outcomes, stress shielding, and hip biomechanics between SRA and THA.

The number of arthroplasties being performed increases each year. Patients undergoing an arthroplasty are at risk of venous thromboembolism (VTE) and appropriate prophylaxis has been recommended. However, the optimal protocol and the best agent to minimise VTE under these circumstances are not known. Although many agents may be used, there is a difference in their efficacy and the risk of bleeding. Thus, the selection of a particular agent relies on the balance between the desire to minimise VTE and the attempt to reduce the risk of bleeding, with its undesirable, and occasionally fatal, consequences.

Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis following arthroplasty. Many studies have shown its efficacy in minimising VTE under these circumstances. It is inexpensive and well-tolerated, and its use does not require routine blood tests. It is also a ‘milder’ agent and unlikely to result in haematoma formation, which may increase both the risk of infection and the need for further surgery. Aspirin is also unlikely to result in persistent wound drainage, which has been shown to be associated with the use of agents such as low-molecular-weight heparin (LMWH) and other more aggressive agents.

The main objective of this review was to summarise the current evidence relating to the efficacy of aspirin as a VTE prophylaxis following arthroplasty, and to address some of the common questions about its use.

There is convincing evidence that, taking all factors into account, aspirin is an effective, inexpensive, and safe form of VTE following arthroplasty in patients without a major risk factor for VTE, such as previous VTE.

Cite this article: Bone Joint J 2017;99-B:1420–30.

Aims

The aim of the present study was to compare the 30- and 90-day re-admission rates and complication rates of outpatient and inpatient total shoulder arthroplasty (TSA).

Increasing innovation in rapid prototyping (RP) and additive manufacturing (AM), also known as 3D printing, is bringing about major changes in translational surgical research.

This review describes the current position in the use of additive manufacturing in orthopaedic surgery.

Cite this article: Bone Joint J 2018;100-B:455-60.

Aims

The aim of this study was to evaluate improvements in the quality and safety of paediatric spinal surgery following the implementation of a specialist Paediatric Spinal Surgical Team (PSST) in the operating theatre.

Aims

The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research.

Aim

The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia.

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs.

In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years).

There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029).

We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support.

Cite this article: Bone Joint J 2015;97-B:192–6.

Aims

To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.

Aims

To investigate whether elective joint arthroplasty performed at the weekend is associated with a different 30-day mortality versus that performed between Monday and Friday.

Health economic evaluations potentially provide valuable information to clinicians, health care administrators, and policy makers regarding the financial implications of decisions about the care of patients. The highest quality research should be used to inform decisions that have direct impact on the access to care and the outcome of treatment. However, economic analyses are often complex and use research methods which are relatively unfamiliar to clinicians. Furthermore, health economic data have substantial national, regional, and institutional variability, which can limit the external validity of the results of a study. Therefore, minimum guidelines that aim to standardise the quality and transparency of reporting health economic research have been developed, and instruments are available to assist in the assessment of its quality and the interpretation of results.

The purpose of this editorial is to discuss the principal types of health economic studies, to review the most common instruments for judging the quality of these studies and to describe current reporting guidelines. Recommendations for the submission of these types of studies to The Bone & Joint Journal are provided.

Cite this article: Bone Joint J 2016;98-B:147–51.

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Aims

The aim of this study was to assess the current available evidence about when patients might resume driving after elective, primary total hip (THA) or total knee arthroplasty (TKA) undertaken for osteoarthritis (OA).

Aims

Few studies dealing with chondrosarcoma of the pelvis are currently available. Different data about the overall survival and prognostic factors have been published but without a detailed analysis of surgery-related complications. We aimed to analyse the outcome of a series of pelvic chondrosarcomas treated at a single institution, with particular attention to the prognostic factors. Based on a competing risk model, our objective was to identify risk factors for the development of complications.

Aims

Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle.

Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

Aims

Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee.

Aims

Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored.

Patient specific instrumentation (PSI) uses advanced imaging of the knee (CT or MRI) to generate individualised cutting blocks aimed to make the procedure of total knee arthroplasty (TKA) more accurate and efficient. However, in this era of healthcare cost consciousness, the value of new technologies needs to be critically evaluated. There have been several comparative studies looking at PSI versus standard instrumentation. Most compare PSI with conventional instrumentation in terms of alignment in the coronal plane, operative time and surgical efficiency, cost effectiveness and short-term outcomes. Several systematic reviews and meta-analyses have also been published. PSI has not been shown to be superior compared with conventional instrumentation in its ability to restore traditional mechanical alignment in primary TKA. Most studies show comparative efficacy and no decrease in the number of outliers in either group. In terms of operative time and efficiency, PSI tended towards decreasing operative time, saving a mean of five minutes per patient (0 to 20). Furthermore, while some cost savings could be realised with less operative time and reduced instrumentation per patient, these savings were overcome by the cost of the CT/MRI and the cutting blocks. Finally, there was no evidence that PSI positively affected clinical outcomes at two days, two months, or two years. Consequently, current evidence does not support routine use of PSI in routine primary TKA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):78–80.

Aims

The long-term functional outcome of total hip arthroplasty (THA) performed by trainees is not known. A multicentre retrospective study of 879 THAs was undertaken to investigate any differences in outcome between those performed by trainee surgeons and consultants.

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.

Cite this article: Bone Joint J 2013;95-B:4–9.

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score.

A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year.

Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Cite this article: Bone Joint J 2015;97-B:997–1003.

In this study we evaluated whether pre-operative Western Ontario and McMaster Universities (WOMAC) osteoarthritis scores can predict satisfaction following total hip arthroplasty (THA). Prospective data for a cohort of patients undergoing THA from two large academic centres were collected, and pre-operative and one-year post-operative WOMAC scores and a 25-point satisfaction questionnaire were obtained for 446 patients. Satisfaction scores were dichotomised into either improvement or deterioration. Scatter plots and Spearman’s rank correlation coefficient were used to describe the association between pre-operative WOMAC and one-year post-operative WOMAC scores and patient satisfaction. Satisfaction was compared using receiver operating characteristic (ROC) analysis against pre-operative, post-operative and δ WOMAC scores.

We found no relationship between pre-operative WOMAC scores and one-year post-operative WOMAC or satisfaction scores, with Spearman’s rank correlation coefficients of 0.16 and –0.05, respectively. The ROC analysis showed areas under the curve (AUC) of 0.54 (pre-operative WOMAC), 0.67 (post-operative WOMAC) and 0.43 (δ WOMAC), respectively, for an improvement in satisfaction.

We conclude that the pre-operative WOMAC score does not predict the post-operative WOMAC score or patient satisfaction after THA, and that WOMAC scores can therefore not be used to prioritise patient care.

Cite this article: Bone Joint J 2015;97-B:150–3.

An intra-operative splash is a common occurrence in elective knee and hip replacement surgery and can potentially transmit bloodborne diseases, with devastating consequences. This study aimed to quantify the risk of a splash and to assess its correlation with body mass index, duration of surgery and the volume of lavage fluid used.

Between December 2007 and April 2008, 62 consecutive patients (38 women, 24 men) undergoing an elective total knee or total hip replacement (TKR, THR) were recruited into the study (32 TKRs and 30 THRs) after appropriate consent.

A splash occurred in all 62 cases. A THR had a slightly higher risk of a splash than a TKR, but this was not statistically significant (p = 0.27). The correlation between body mass index, duration of surgery and the amount of pulse lavage used with a splash was r = 0.013, (non-significant), r = 0.52, (significant) and r = 0.92 (highly significant), respectively.

A high number of splashes are generated during a TKR and a THR. The simple visor mask fails to protect the surgeon, the assistant or the patient from the risk of a splash and reverse splash, respectively.

There has been an in increase in the availability of effective biological agents for the treatment of rheumatoid arthritis as well as a shift towards early diagnosis and management of the inflammatory process. This article explores the impact this may have on the place of orthopaedic surgery in the management of patients with rheumatoid arthritis.

Cite this article: Bone Joint J 2014;96-B:1287–9

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation. The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at -78º to -68º C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up. The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon’s discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment. Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings.

Cite this article: Bone Joint J 2015;97-B:427–31.

Methicillin-resistant Staphylococcus aureus (MRSA) has become a ubiquitous bacterium in both the hospital and community setting. There are two major subclassifications of MRSA, community-acquired and healthcare-acquired, each with differing pathogenicity and management. MRSA is increasingly responsible for infections in otherwise healthy, active adults. Local outbreaks affect both professional and amateur athletes and there is increasing public awareness of the issue. Health-acquired MRSA has major cost and outcome implications for patients and hospitals. The increasing prevalence and severity of MRSA means that the orthopaedic community should have a basic knowledge of the bacterium, its presentation and options for treatment.

This paper examines the evolution of MRSA, analyses the spectrum of diseases produced by this bacterium and presents current prevention and treatment strategies for orthopaedic infections from MRSA.

The aim of this study was to define return to theatre (RTT) rates for elective hip and knee replacement (HR and KR), to describe the predictors and to show the variations in risk-adjusted rates by surgical team and hospital using national English hospital administrative data.

We examined information on 260 206 HRs and 315 249 KRs undertaken between April 2007 and March 2012. The 90-day RTT rates were 2.1% for HR and 1.8% for KR. Male gender, obesity, diabetes and several other comorbidities were associated with higher odds for both index procedures. For HR, hip resurfacing had half the odds of cement fixation (OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR, unicondylar KR had half the odds of total replacement (OR = 0.49, 95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23, 95% CI 1.65 to 3.01) for ages < 40 years compared with ages 60 to 69 years). There were more funnel plot outliers at three standard deviations than would be expected if variation occurred on a random basis.

Hierarchical modelling showed that three-quarters of the variation between surgeons for HR and over half the variation between surgeons for KR are not explained by the hospital they operated at or by available patient factors. We conclude that 90-day RTT rate may be a useful quality indicator for orthopaedics.

Cite this article: Bone Joint J 2014; 96-B:1663–8.

Peri-prosthetic infection is amongst the most common causes of failure following total knee replacement (TKR). In the presence of established infection, thorough joint debridement and removal of all components is necessary following which new components may be implanted. This can be performed in one or two stages; two-stage revision with placement of an interim antibiotic-loaded spacer is regarded by many to be the standard procedure for eradication of peri-prosthetic joint infection.

We present our experience of a consecutive series of 50 single-stage revision TKRs for established deep infection performed between 1979 and 2010. There were 33 women and 17 men with a mean age at revision of 66.8 years (42 to 84) and a mean follow-up of 10.5 years (2 to 24). The mean time between the primary TKR and the revision procedure was 2.05 years (1 to 8).

Only one patient required a further revision for recurrent infection, representing a success rate of 98%. Nine patients required further revision for aseptic loosening, according to microbiological testing of biopsies taken at the subsequent surgery. Three other patients developed a further septic episode but none required another revision.

These results suggest that a single-stage revision can produce comparable results to a two-stage revision. Single-stage revision offers a reduction in costs as well as less morbidity and inconvenience for patients.

Cite this article: Bone Joint J 2014;96-B:759–64.

We have investigated whether the use of laminar-flow theatres and space suits reduced the rate of revision for early deep infection after total hip (THR) and knee (TKR) replacement by reviewing the results of the New Zealand Joint Registry at ten years.

Of the 51 485 primary THRs and 36 826 primary TKRs analysed, laminar-flow theatres were used in 35.5% and space suits in 23.5%. For THR there was a significant increase in early infection in those procedures performed with the use of a space suit compared with those without (p < 0.0001), in those carried out in a laminar-flow theatre compared with a conventional theatre (p < 0.003) and in those undertaken in a laminar-flow theatre with a space suit (p < 0.001) when compared with conventional theatres without such a suit. The results were similar for TKR with the use of a space suit (p < 0.001), in laminar-flow theatres (p < 0.019) and when space suits were used in those theatres (p < 0.001). These findings were independent of age, disease and operating time and were unchanged when the surgeons and hospital were analysed individually.

The rate of revision for early deep infection has not been reduced by using laminar flow and space suits. Our results question the rationale for their increasing use in routine joint replacement, where the added cost to the health system seems to be unjustified.

In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the ‘package’ of procedures that are available and to justify their practice beyond traditional clinical preference.

In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community.

Cite this article: Bone Joint J 2013;95-B:874–6.

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.

Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

The use of platelet-rich plasma (PRP) as an adjuvant to tissue repair is gaining favour in orthopaedic surgery. Tunnel widening after anterior cruciate ligament (ACL) reconstruction is a recognised phenomenon that could compromise revision surgery. The purpose of this study was to determine whether PRP might prevent tunnel widening in ACL reconstruction.

Patients undergoing ACL reconstruction using a hamstring graft were randomly allocated either to have PRP introduced into the tunnels peri-operatively or not. CT scanning of the knees was carried out on the day after surgery and at three months post-operatively and the width of the tunnels was measured. Patients were also evaluated clinically at three months, when laxity was also measured.

Each group comprised 25 patients, and at three months post-operatively all were pain-free with stable knees, a negative Lachman test and a good range of movement. Arthrometric results had improved significantly in both groups (p < 0.001). Despite slightly less tunnel widening in the PRP group, there was no significant difference between the groups at the femoral opening or the mid-tunnel (p = 0.370 and p = 0.363, respectively) nor at the tibial opening or mid-tunnel (p = 0.333 and p = 0.177, respectively).

We conclude that PRP has no significant effect in preventing tunnel widening after ACL reconstruction.

Cite this article: Bone Joint J 2013;95-B:65–9.

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery.

Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.

Cite this article: Bone Joint J 2013;95-B:558–62.

Autologous retransfusion and no-drainage are both blood-saving measures in total hip replacement (THR). A new combined intra- and post-operative autotransfusion filter system has been developed especially for primary THR, and we conducted a randomised controlled blinded study comparing this with no-drainage.

A total of 204 THR patients were randomised to autologous blood transfusion (ABT) (n = 102) or no-drainage (n = 102). In the ABT group, a mean of 488 ml (sd 252) of blood was retransfused. The mean lowest post-operative haemoglobin level during the hospital stay was higher in the autotransfusion group (10.6 g/dl (7.8 to 13.9) vs 10.2 g/dl (7.5 to 13.3); p = 0.01). The mean haemoglobin levels for the ABT and no-drainage groups were not significantly different on the first day (11.3 g/dl (7.8 to 13.9) vs 11.0 g/dl (8.1 to 13.4); p = 0.07), the second day (11.1 g/dl (8.2 to 13.8) vs 10.8 g/dl (7.5 to 13.3); p = 0.09) or the third day (10.8 g/dl (8.0 to 13.0) vs 10.6 g/dl (7.5 to 14.1); p = 0.15). The mean total peri-operative net blood loss was 1464 ml (sd 505) in the ABT group and 1654 ml (sd 553) in the no-drainage group (p = 0.01). Homologous blood transfusions were needed in four patients (3.9%) in the ABT group and nine (8.8%) in the no-drainage group (p = 0.15). No statistically significant difference in adverse events was found between the groups.

The use of a new intra- and post-operative autologous blood transfusion filter system results in less total blood loss and a smaller maximum decrease in haemoglobin levels than no-drainage following primary THR.

Cite this article: Bone Joint J 2013;95-B:616–22.

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty.

In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105 712 cases.

Periosteum is important for bone homoeostasis through the release of bone morphogenetic proteins (BMPs) and their effect on osteoprogenitor cells. Smoking has an adverse effect on fracture healing and bone regeneration. The aim of this study was to evaluate the effect of smoking on the expression of the BMPs of human periosteum. Real-time polymerase chain reaction was performed for BMP-2,-4,-6,-7 gene expression in periosteal samples obtained from 45 fractured bones (19 smokers, 26 non-smokers) and 60 non-fractured bones (21 smokers, 39 non-smokers). A hierarchical model of BMP gene expression (BMP-2 > BMP-6 > BMP-4 > BMP-7) was demonstrated in all samples. When smokers and non-smokers were compared, a remarkable reduction in the gene expression of BMP-2, -4 and -6 was noticed in smokers. The comparison of fracture and non-fracture groups demonstrated a higher gene expression of BMP-2, -4 and -7 in the non-fracture samples. Within the subgroups (fracture and non-fracture), BMP gene expression in smokers was either lower but without statistical significance in the majority of BMPs, or similar to that in non-smokers with regard to BMP-4 in fracture and BMP-7 in non-fracture samples. In smokers, BMP gene expression of human periosteum was reduced, demonstrating the effect of smoking at the molecular level by reduction of mRNA transcription of periosteal BMPs. Among the BMPs studied, BMP-2 gene expression was significantly higher, highlighting its role in bone homoeostasis.

The aim of this study was to perform a cost–utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health–utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Cite this article: Bone Joint J 2013;95-B:115–21.

We investigated the extent to which improved balance relative to pain relief correlates with the success of total knee replacement (TKR). A total of 81 patients were recruited to the study: 16 men (19.8%) and 65 women (80.2%). Of these, 62 patients (10 men, 52 women) with a mean age of 73 (57 to 83) underwent static and dynamic assessment of balance pre-operatively and one year post-operatively. The parameters of balance were quantified using commercially available and validated equipment. Motor function and self-reported outcome were also assessed.

There was a significant improvement in dynamic balance (p < 0.001) one year after TKR, and better balance correlated with improved mobility, functional balance and increased health-related quality of life. As it seems that balance, and not only pain relief, influences the success of TKR, balance skills should be better addressed during the post-operative rehabilitation of patients who undergo TKR.