Periprosthetic joint infection (PJI) is one of the most dreaded complications after arthroplasty surgery; thus numerous approaches have been undertaken to equip metal surfaces with antibacterial properties. Due to its antimicrobial effects, silver is a promising coating for metallic surfaces, and several types of silver-coated arthroplasty implants are in clinical use today. However, silver can also exert toxic effects on eukaryotic cells both in the immediate vicinity of the coated implants and systemically. In most clinically-used implants, silver coatings are applied on bulk components that are not in direct contact with bone, such as in partial or total long bone arthroplasties used in tumour or complex revision surgery. These implants differ considerably in the coating method, total silver content, and silver release rates. Safety issues, such as the occurrence of argyria, have been a cause for concern, and the efficacy of silver coatings in terms of preventing PJI is also controversial. The application of silver coatings is uncommon on parts of implants intended for cementless fixation in host bone, but this option might be highly desirable since the modification of implant surfaces in order to improve osteoconductivity can also increase bacterial adhesion. Therefore, an optimal silver content that inhibits bacterial colonization while maintaining osteoconductivity is crucial if silver were to be applied as a coating on parts intended for bone contact. This review summarizes the different methods used to apply silver coatings to arthroplasty components, with a focus on the amount and duration of silver release from the different coatings; the available experience with silver-coated implants that are in clinical use today; and future strategies to balance the effects of silver on bacteria and eukaryotic cells, and to develop silver-coated titanium components suitable for bone ingrowth.

Cite this article: Bone Joint J 2021;103-B(3):423–429.

Over the past 30 years there have been many improvements in implant fixation, correction of deformity, improved polyethylene wear, and survival after knee replacement. The work over the last decade has focused on less invasive surgical techniques, multimodal pain management protocols, more rapid functional recovery and reduced length of stay, aiming to minimise the side effects of treatment while maintaining function and implant durability. When combined and standardised these pre-, intra- and post-operative factors have now facilitated outpatient knee replacement procedures for unicompartmental replacement, patella femoral arthroplasty and total knee replacement (TKR).

We have found liposomal bupivacaine, with potential for longer therapeutic action, to be a helpful adjunct and describe our current pain management program. The next step in our multimodal program is to improve the duration of patient satisfaction and reduce cost and length of stay after TKR.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):7–9.

A modular femoral head–neck junction has practical advantages in total hip replacement. Taper fretting and corrosion have so far been an infrequent cause of revision. The role of design and manufacturing variables continues to be debated. Over the past decade several changes in technology and clinical practice might result in an increase in clinically significant taper fretting and corrosion. Those factors include an increased usage of large diameter (36 mm) heads, reduced femoral neck and taper dimensions, greater variability in taper assembly with smaller incision surgery, and higher taper stresses due to increased patient weight and/or physical activity. Additional studies are needed to determine the role of taper assembly compared with design, manufacturing and other implant variables.

Cite this article: Bone Joint J 2013;95-B, Supple A:3–6.

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an ‘acceptable’ radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world.

Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage.

Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.

The survivorship of contemporary resurfacing arthroplasty of the hip using metal-on-metal bearings is better than that of first generation designs, but short-term failures still occur. The most common reasons for failure are fracture of the femoral neck, loosening of the component, osteonecrosis of the femoral head, reaction to metal debris and malpositioning of the component. In 2008 the Australian National Joint Registry reported an inverse relationship between the size of the head component and the risk of revision in resurfacing hip arthroplasty. Hips with a femoral component size of ≤ 44 mm have a fivefold increased risk of revision than those with femoral components of ≥ 55 mm irrespective of gender. We have reviewed the literature to explore this observation and to identify possible reasons including the design of the implant, loading of the femoral neck, the orientation of the component, the production of wear debris and the effects of metal ions, penetration of cement and vascularity of the femoral head. Our conclusion is that although multifactorial, the most important contributors to failure in resurfacing arthroplasty of the hip are likely to be the design and geometry of the component and the orientation of the acetabular component.

We have reviewed the literature to establish the role of lateral retinacular release in the management of disorders of the extensor apparatus of the knee. The scientific evidence for intervention is explored and reports on outcome are discussed.

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet α granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-β, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches.

The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function.

Articular cartilage repair remains a challenge to surgeons and basic scientists. The field of tissue engineering allows the simultaneous use of material scaffolds, cells and signalling molecules to attempt to modulate the regenerative tissue. This review summarises the research that has been undertaken to date using this approach, with a particular emphasis on those techniques that have been introduced into clinical practice, via in vitro and preclinical studies.

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

The mammalian growth plate is a complex structure which is essential for the elongation of long bones. However, an understanding of how the growth plate functions at the cellular level is lacking. This review, summarises the factors involved in growth-plate regulation, its failure and the consequence of injury. We also describe some of the cellular mechanisms which underpin the increase in volume of the growth-plate chondrocyte which is the major determinant of the rate and extent of bone lengthening. We show how living in situ chondrocytes can be imaged using 2-photon laser scanning microscopy to provide a quantitative analysis of their volume. This approach should give better understanding of the cellular control of bone growth in both healthy and failed growth plates.

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 pathophysiology of intervertebral disc degeneration has been extensively studied. Various factors have been suggested as influencing its aetiology, including mechanical factors, such as compressive loading, shear stress and vibration, as well as ageing, genetic, systemic and toxic factors, which can lead to degeneration of the disc through biochemical reactions. How are these factors linked? What is their individual importance? There is no clear evidence indicating whether ageing in the presence of repetitive injury or repetitive injury in the absence of ageing plays a greater role in the degenerative process. Mechanical factors can trigger biochemical reactions which, in turn, may promote the normal biological changes of ageing, which can also be accelerated by genetic factors. Degradation of the molecular structure of the disc during ageing renders it more susceptible to superimposed mechanical injuries.

This review supports the theory that degeneration of the disc has a complex multifactorial aetiology. Which factors initiate the events in the degenerative cascade is a question that remains unanswered, but most evidence points to an age-related process influenced primarily by mechanical and genetic factors.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.