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Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours. Cite this article:
The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. Cite this article:
Prediction tools are instruments which are commonly used to estimate the prognosis in oncology and facilitate clinical decision-making in a more personalized manner. Their popularity is shown by the increasing numbers of prediction tools, which have been described in the medical literature. Many of these tools have been shown to be useful in the field of soft-tissue sarcoma of the extremities (eSTS). In this annotation, we aim to provide an overview of the available prediction tools for eSTS, provide an approach for clinicians to evaluate the performance and usefulness of the available tools for their own patients, and discuss their possible applications in the management of patients with an eSTS. Cite this article:
There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article:
There is increasing popularity in the use of artificial intelligence and machine-learning techniques to provide diagnostic and prognostic models for various aspects of Trauma & Orthopaedic surgery. However, correct interpretation of these models is difficult for those without specific knowledge of computing or health data science methodology. Lack of current reporting standards leads to the potential for significant heterogeneity in the design and quality of published studies. We provide an overview of machine-learning techniques for the lay individual, including key terminology and best practice reporting guidelines. Cite this article:
This annotation briefly reviews the history of artificial intelligence and machine learning in health care and orthopaedics, and considers the role it will have in the future, particularly with reference to statistical analyses involving large datasets. Cite this article:
Aims. Periprosthetic joint infection (PJI) remains a challenging complication
following total hip arthroplasty (THA). It is associated with high
levels of morbidity, mortality and expense. Guidelines and protocols
exist for the management of culture-positive patients. Managing
culture-negative patients with a PJI poses a greater challenge to
surgeons and the wider multidisciplinary team as clear guidance
is lacking. Patients and Methods. We aimed to compare the outcomes of treatment for 50 consecutive
culture-negative and 50 consecutive culture-positive patients who
underwent two-stage revision THA for chronic infection with a minimum
follow-up of five years.
Aims. Treatment guidelines for atypical femoral fractures associated
with bisphosphonates have not been established. We conducted a systematic
review of the treatment of atypical femoral fractures first, to
evaluate the outcomes of surgical fixation of complete atypical fractures
and secondly, to assess whether prophylactic surgery is necessary
for incomplete atypical fractures. Materials and Methods. Case reports and series were identified from the PubMed database
and were included if they described the treatment of atypical femoral
fractures. In total, 77 publications met our inclusion criteria
and 733 patients with 834 atypical complete or incomplete femoral fractures
were identified.
Aims. The purpose of this article was to review the current literature
pertaining to the use of mobile compression devices (MCDs) for venous
thromboembolism (VTE) following total joint arthroplasty (TJA),
and to discuss the results of data from our institution. Patients and Methods. Previous studies have illustrated higher rates of post-operative
wound complications, re-operation and re-admission with the use
of more aggressive anticoagulation regimens, such as warfarin and
factor Xa inhibitors. This highlights the importance of the safety,
as well as efficacy, of the chemoprophylactic regimen.
Aims. The optimal treatment for independent patients with a displaced
intracapsular fracture of the hip remains controversial. The recognised
alternatives are hemiarthroplasty and total hip arthroplasty. At
present there is no established standard of care, with both types
of arthroplasty being used in many centres. Patients and Methods. We conducted a feasibility study comparing the clinical effectiveness
of a dual mobility acetabular component compared with standard polyethylene
component in total hip arthroplasty for independent patients with
a displaced intracapsular fracture of the hip, for a 12-month period
beginning in June 2013. The primary outcome was the risk of dislocation
one year post-operatively. Secondary outcome measures were EuroQol
5 Dimensions, ICEpop CAPability measure for Older people, Oxford
hip score, mortality and re-operation.
Our aim in this paper was to investigate the
guidelines and laws governing informed consent in the English-speaking
world. We noted a recent divergence from medical paternalism within
the United Kingdom, highlighted by the Montgomery v Lanarkshire Health
Board ruling of 2015. We investigated the situation in the United
Kingdom, Australia, New Zealand, Canada, and the United States of
America. We read the national guidance regarding obtaining consent
for surgical intervention for each country. We used the references
from this guidance to identify the laws that helped inform the guidance,
and reviewed the court documents for each case. There has been a trend towards a more patient-focused approach
in consent in each country. Surgeons should be aware of the guidance
and legal cases so that they can inform patients fully, and prevent
legal problems if outdated practices are followed. Cite this article:
Aims. To demonstrate, with concrete examples, the value of in-depth
exploration and comparison of data published in National Joint Arthroplasty
registry reports. Patients and Methods. The author reviewed published current reports of National Joint
Arthroplasty registries for findings of current significance to
current orthopaedic practice.
The development and pre-clinical evaluation of
nano-texturised, biomimetic, surfaces of titanium (Ti) implants treated
with titanium dioxide (TiO2) nanotube arrays is reviewed. Cite this article:
Despite being one of the most common orthopaedic
operations, it is still not known how many arthroscopies of the knee
must be performed during training in order to develop the skills
required to become a Consultant. A total of 54 subjects were divided
into five groups according to clinical experience: Novices (n =
10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n =
10) and Consultants (n = 6). After viewing an instructional presentation,
each subject performed a simple diagnostic arthroscopy of the knee
on a simulator with visualisation and probing of ten anatomical
landmarks. Performance was assessed using a validated global rating
scale (GRS). Comparisons were made against clinical experience measured
by the number of arthroscopies which had been undertaken, and ROC
curve analysis was used to determine the number of procedures needed
to perform at the level of the Consultants. There were marked differences between the groups. There was significant
improvement in performance with increasing experience (p <
0.05). ROC curve analysis identified that approximately 170 procedures
were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the
level of surgical skills of a Consultant should be used more widely
so that standards of training are maintained through the development
of an evidenced-based curriculum. Cite this article:
An international faculty of orthopaedic surgeons
presented their work on the current challenges in hip surgery at
the London Hip Meeting which was attended by over
400 delegates. The topics covered included femoroacetabular impingement, thromboembolic
phenomena associated with hip surgery, bearing surfaces (including metal-on-metal
articulations), outcomes of hip replacement surgery and revision
hip replacement. We present a concise report of the current opinions
on hip surgery from this meeting with appropriate references to
the current literature.
In a systematic review, reports from national registers and clinical studies were identified and analysed with respect to revision rates after joint replacement, which were calculated as revisions per 100 observed component years. After primary hip replacement, a mean of 1.29 revisions per 100 observed component years was seen. The results after primary total knee replacement are 1.26 revisions per 100 observed component years, and 1.53 after medial unicompartmental replacement. After total ankle replacement a mean of 3.29 revisions per 100 observed component years was seen. The outcomes of total hip and knee replacement are almost identical. Revision rates of about 6% after five years and 12% after ten years are to be expected.
We review the history and literature of hip resurfacing arthroplasty. Resurfacing and the science behind it continues to evolve. Recent results, particularly from the national arthroplasty registers, have spread disquiet among both surgeons and patients. A hip resurfacing arthroplasty is not a total hip replacement, but should perhaps be seen as a means of delaying it. The time when hip resurfacing is offered to a patient may be different from that for a total hip replacement. The same logic can apply to the timing of revision surgery. Consequently, the comparison of resurfacing with total hip replacement may be a false one. Nevertheless, the need for innovative solutions for young arthroplasty patients is clear. Total hip replacement can be usefully delayed in many of these patients by the use of hip resurfacing arthroplasty.