The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding. Cite this article: Bone Joint J 2023;105-B(8):850–856

Aims. The importance of accurate identification and reporting of surgical site infection (SSI) is well recognised but poorly defined. Public Health England (PHE) mandated collection of orthopaedic SSI data in 2004. Data submission is required in one of four categories (hip prosthesis, knee prosthesis, repair of neck of femur, reduction of long bone fracture) for one quarter per year. Trusts are encouraged to carry out post-discharge surveillance but this is not mandatory. Recent papers in the orthopaedic literature have highlighted the importance of SSI surveillance and the heterogeneity of surveillance methods. However, details of current orthopaedic SSI surveillance practice has not been described or quantified. Patients and Methods. All 147 NHS trusts in England were audited using a structured questionnaire. Data was collected in the following categories: data collection; data submission to PHE; definitions used; resource constraints; post-discharge surveillance and SSI rates in the four PHE categories. The response rate was 87.7%. Results. Variation in practice was clear in all categories in terms of methods and timings of data collection and data submission. There was little agreement on SSI definitions. At least six different definitions were used, some trusts using more than one definition. Post-discharge surveillance was carried out by 62% of respondents but there was again variation in both the methods and staff used. More than half of the respondents felt that SSI surveillance in their unit was limited by resource constraints. SSI rates ranged from 0% to 10%. Conclusion. This paper quantifies the heterogeneity of SSI surveillance in England. It highlights the importance of adequate resourcing and the unreliability of relying on voluntary data collection and submission. Conformity of definitions and methods are recommended to enable meaningful SSI data to be collated. Cite this article: Bone Joint J 2017;99-B:171–4

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article: Bone Joint J 2021;103-B(2):234–244

Stem cells are defined by their potential for self-renewal and the ability to differentiate into numerous cell types, including cartilage and bone cells. Although basic laboratory studies demonstrate that cell therapies have strong potential for improvement in tissue healing and regeneration, there is little evidence in the scientific literature for many of the available cell formulations that are currently offered to patients. Numerous commercial entities and ‘regenerative medicine centres’ have aggressively marketed unproven cell therapies for a wide range of medical conditions, leading to sometimes indiscriminate use of these treatments, which has added to the confusion and unpredictable outcomes. The significant variability and heterogeneity in cell formulations between different individuals makes it difficult to draw conclusions about efficacy. The ‘minimally manipulated’ preparations derived from bone marrow and adipose tissue that are currently used differ substantially from cells that are processed and prepared under defined laboratory protocols. The term ‘stem cells’ should be reserved for laboratory-purified, culture-expanded cells. The number of cells in uncultured preparations that meet these defined criteria is estimated to be approximately one in 10 000 to 20 000 (0.005% to 0.01%) in native bone marrow and 1 in 2000 in adipose tissue. It is clear that more refined definitions of stem cells are required, as the lumping together of widely diverse progenitor cell types under the umbrella term ‘mesenchymal stem cells’ has created confusion among scientists, clinicians, regulators, and our patients. Validated methods need to be developed to measure and characterize the ‘critical quality attributes’ and biological activity of a specific cell formulation. It is certain that ‘one size does not fit all’ – different cell formulations, dosing schedules, and culturing parameters will likely be required based on the tissue being treated and the desired biological target. As an alternative to the use of exogenous cells, in the future we may be able to stimulate the intrinsic vascular stem cell niche that is known to exist in many tissues. The tremendous potential of cell therapy will only be realized with further basic, translational, and clinical research.

Cite this article: Bone Joint J 2019;101-B:361–364.

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442–1448

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. Materials and Methods. A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results’ titles, abstracts, and references were examined for relevance. Results. A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training. Conclusion. The demonstration of ‘real-world’ benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559–65

Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient’s social and mental health. There is a limited role for medication, opioids in particular.

Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship.

Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science.

Cite this article: Bone Joint J 2020;102-B(9):1122–1127.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal.

There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced.

Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described.

The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery.

Cite this article: Bone Joint J 2020;102-B(5):568–572.

Aims

In 2013, we introduced a specialized, centralized, and interdisciplinary team in our institution that applied a standardized diagnostic and treatment algorithm for the management of prosthetic joint infections (PJIs). The hypothesis for this study was that the outcome of treatment would be improved using this approach.

Aims

The diagnosis of periprosthetic joint infection can be difficult due to the high rate of culture-negative infections. The aim of this study was to assess the use of next-generation sequencing for detecting organisms in synovial fluid.

‘Big data’ is a term for data sets that are so large or complex that traditional data processing applications are inadequate. Billions of dollars have been spent on attempts to build predictive tools from large sets of poorly controlled healthcare metadata. Companies often sell reports at a physician or facility level based on various flawed data sources, and comparative websites of ‘publicly reported data’ purport to educate the public. Physicians should be aware of concerns and pitfalls seen in such data definitions, data clarity, data relevance, data sources and data cleaning when evaluating analytic reports from metadata in health care.

Cite this article: Bone Joint J 2017;99-B:1571–6.

Episodic, or bundled payments, is a concept now familiar to most in the healthcare arena, but the models are often misunderstood. Under a traditional fee-for-service model, each provider bills separately for their services which creates financial incentives to maximise volumes. Under a bundled payment, a single entity, often referred to as a convener (maybe the hospital, the physician group, or a third party) assumes the risk through a payer contract for all services provided within a defined episode of care, and receives a single (bundled) payment for all services provided for that episode. The time frame around the intervention is variable, but defined in advance, as are included and excluded costs. Timing of the actual payment in a bundle may either be before the episode occurs (prospective payment model), or after the end of the episode through a reconciliation (retrospective payment model). In either case, the defined costs over the defined time frame are borne by the convener.

Cite this article: Bone Joint J 2017;99-B:1280–5.

The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders with clinical manifestations relevant to the orthopaedic surgeon. Our aim was to review the recent advances in their management and the implications for surgical practice.

The current literature about MPSs is summarised, emphasising orthopaedic complications and their management.

Recent advances in the diagnosis and management of MPSs include the recognition of slowly progressive, late presenting subtypes, developments in life-prolonging systemic treatment and potentially new indications for surgical treatment. The outcomes of surgery in these patients are not yet validated and some procedures have a high rate of complications which differ from those in patients who do not have a MPS.

The diagnosis of a MPS should be considered in adolescents or young adults with a previously unrecognised dysplasia of the hip. Surgeons treating patients with a MPS should report their experience and studies should include the assessment of function and quality of life to guide treatment.

Cite this article: Bone Joint J 2017;99-B:1132–9

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients.

However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively.

The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head.

Cite this article: Bone Joint J 2017;99-B:1267–79.

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids.

The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe.

Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective.

Cite this article: Bone Joint J 2017;99-B:856–64.

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees’ performance in managing orthopaedic trauma patients.

This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States.

In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma.

Cite this article: Bone Joint J 2016;98-B:1320–5.

Previous standards for assessing the reliability of a measurement tool have lacked consistency. We reviewed the most current American Society for Testing and Materials and International Organisation for Standardisation (ISO) recommendations, and propose an algorithm for orthopaedic surgeons. When assessing a measurement tool, conditions of the experimental set-up and clear formulae used to compile the results should be strictly reported. According to these recent guidelines, accuracy is a confusing word with an overly broad meaning and should therefore be abandoned. Depending on the experimental conditions, one should be referring to bias (when the study protocol involves accepted reference values), and repeatability (sr, r) or reproducibility (SR, R). In the absence of accepted reference values, only repeatability (sr, r) or reproducibility (SR, R) should be provided.

Take home message: Assessing the reliability of a measurement tool involves reporting bias, repeatability and/or reproducibility depending on the defined conditions, instead of precision or accuracy.

Cite this article: Bone Joint J 2016;98-B2:166–72.

Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following total knee arthroplasty. We provide a detailed description of our current understanding regarding the management of PJI of the knee, including diagnostic aids, pre-operative planning, surgical treatment, and outcome.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):20–9.

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects.

We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I² = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route.

In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Cite this article: Bone Joint J 2014;96-B:1005–15.

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the ‘5 moments of hand hygiene’ in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively.

We recommend caution in the universal adoption of the WHO ‘5 moments of hand hygiene’ by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.