There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries. Cite this article:
Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr. Cite this article:
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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:
The transition from shutdown of elective orthopaedic services to the resumption of pre-COVID-19 activity presents many challenges. These include concerns about patient safety, staff safety, and the viability of health economies. Careful planning is necessary to allow patients to benefit from orthopaedic care in a safe and sustainable manner. Cite this article:
The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of “failure to warn”, i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on “failure to warn” and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article:
Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery. Cite this article:
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:
The posterior malleolus of the ankle is the object
of increasing attention, with considerable enthusiasm for CT scanning
and surgical fixation, as expressed in a recent annotation in Cite this article:
The posterior malleolus component of a fracture
of the ankle is important, yet often overlooked. Pre-operative CT scans
to identify and classify the pattern of the fracture are not used
enough. Posterior malleolus fractures are not difficult to fix.
After reduction and fixation of the posterior malleolus, the articular
surface of the tibia is restored; the fibula is out to length; the
syndesmosis is more stable and the patient can rehabilitate faster.
There is therefore considerable merit in fixing most posterior malleolus
fractures. An early post-operative CT scan to ensure that accurate
reduction has been achieved should also be considered. Cite this article:
Stable fractures of the ankle can be safely treated
non-operatively. It is also gradually being recognised that the integrity
of the ‘medial column’ is essential for the stability of the fracture.
It is generally thought that bi- and tri-malleolar fractures are
unstable, as are pronation external rotation injuries resulting
in an isolated high fibular fracture (Weber type-C), where the deltoid
ligament is damaged or the medial malleolus fractured. However,
how best to identify unstable, isolated, trans-syndesmotic Weber
type-B supination external rotation (SER) fractures of the lateral
malleolus remains controversial. We provide a rationale as to how to classify SER distal fibular
fractures using weight-bearing radiographs, and how this can help
guide the management of these common injuries. Cite this article:
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. 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
Materials and Methods
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. 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
Patients and Methods
The results of the DRAFFT (distal radius acute
fracture fixation trial) study, which compared volar plating with
Kirschner (K-) wire fixation for dorsally displaced fractures of
the distal radius, were published in August 2014. The use of K-wires
to treat these fractures is now increasing, with a concomitant decline
in the use of volar locking plates. We provide a critical appraisal of the DRAFFT study and question
whether surgeons have been unduly influenced by its headline conclusions. Cite this article:
Obesity is a worldwide epidemic that has both
economic and health implications of enormous consequence. The obese
patients tend to have earlier symptoms related to osteoarthritis,
more peri-operative medical problems, higher rates of infection
and more technical difficulties intra-operatively following hip
and knee arthroplasty. Nevertheless, these patients have good long-term
clinical outcomes and implant survival rates and are often some of
the most satisfied patients after joint arthroplasty. Therefore,
obese patients should not be denied surgery based on their weight
alone. Cite this article:
The continual cycle of bone formation and resorption
is carried out by osteoblasts, osteocytes, and osteoclasts under
the direction of the bone-signaling pathway. In certain situations
the host cycle of bone repair is insufficient and requires the assistance
of bone grafts and their substitutes. The fundamental properties
of a bone graft are osteoconduction, osteoinduction, osteogenesis,
and structural support. Options for bone grafting include autogenous
and allograft bone and the various isolated or combined substitutes
of calcium sulphate, calcium phosphate, tricalcium phosphate, and
coralline hydroxyapatite. Not all bone grafts will have the same
properties. As a result, understanding the requirements of the clinical
situation and specific properties of the various types of bone grafts
is necessary to identify the ideal graft. We present a review of
the bone repair process and properties of bone grafts and their
substitutes to help guide the clinician in the decision making process. Cite this article:
Recently, several high impact randomised controlled
trials have been published suggesting no greater benefit from orthopaedic
surgery over conservative treatment, or limited surgical intervention.
These studies can have profound effects on clinical practice, leading
to the abandonment of previously widely-used operations. How do surgeons who believe these operations are beneficial over
conservative treatment rationalise these findings, and justify their
use with hospital administrators and health care funders who require
evidence for the value and efficacy of surgical treatment? Cite this article:
In this paper, we critically appraise the recent
publication of the United Kingdom Heel Fracture Trial, which concluded
that when patients with an absolute indication for surgery were
excluded, there was no advantage of surgical over non-surgical treatment
in the management of calcaneal fractures. We believe that selection bias in that study did not permit the
authors to reach a firm conclusion that surgery was not justified
for most intra-articular calcaneal fractures. Cite this article:
Rupture of the tendo Achillis is a common injury
with a rising incidence. Traditionally the key question following
this injury has been whether or not to operate. However a contemporary
Cochrane review highlighted that the method of rehabilitation may
also have an important contribution to the outcome. Since this review,
various early weight-bearing rehabilitation protocols have been
described. Currently evidence points to the use of early functional
rehabilitation, regardless of
