Aims. The James Lind Alliance aims to bring patients, carers, and clinicians together to identify uncertainties regarding care. A Priority Setting Partnership was established by the British Association for Surgery of the Knee in conjunction with the James Lind Alliance to identify research priorities related to the assessment, management, and rehabilitation of patients with persistent symptoms after knee arthroplasty. Methods. The project was conducted using the James Lind Alliance protocol. A steering group was convened including patients, surgeons, anaesthetists, nurses, physiotherapists, and researchers. Partner organizations were recruited. A survey was conducted on a national scale through which patients, carers, and healthcare professionals submitted key unanswered questions relating to problematic knee arthroplasties. These were analyzed, aggregated, and synthesized into summary questions and the relevant evidence was checked. After confirming that these were not answered in the current literature, 32 questions were taken forward to an interim prioritization survey. Data from this survey informed a shortlist taken to a final consensus meeting. Results. A total of 769 questions were received during the initial survey with national reach across the UK. These were refined into 32 unique questions by an independent information specialist. The interim prioritization survey was completed by 201 respondents and 25 questions were taken to a final consensus group meeting between patients, carers, and healthcare professionals. Consensus was reached for ranking the top ten questions for publication and dissemination. Conclusions. The top ten research priorities focused on pain, infection, stiffness, health service configuration, surgical and non-surgical management strategies, and outcome measures. This list will guide funders and help focus research efforts within the knee arthroplasty community. Cite this article: Bone Joint J 2020;102-B(9):1176–1182

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Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

Aims. In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Methods. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. Results. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. Conclusion. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358

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To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.

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Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Aims. The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery. Methods. This is a prospective study of 121 patients who underwent elective orthopaedic procedures through a COVID-free pathway. All patients underwent a 14-day period of self-isolation, had a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-free site. Baseline patient characteristics were recorded including age, American Society of Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type. Patients were contacted 14 days following discharge to determine if they had had a positive COVID-19 test (COVID-confirmed) or developed symptoms consistent with COVID-19 (COVID-19-presumed). Results. The study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years ± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70 patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19 test in the postoperative period. One patient (0.8%) developed anosmia postoperatively without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and self-isolated for seven days. Her symptoms resolved within a few days. Conclusion. The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. While both surgeons and patients should remain vigilant, elective surgery can be safely restarted using dedicated pathways and procedures. Cite this article: Bone Joint Open 2020;1-9:562–567

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The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR).

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The frequency of severe femoral retroversion is unclear in patients with femoroacetabular impingement (FAI). This study aimed to investigate mean femoral version (FV), the frequency of absolute femoral retroversion, and the combination of decreased FV and acetabular retroversion (AR) in symptomatic patients with FAI subtypes.

Aims. Appropriate acetabular component placement has been proposed for prevention of postoperative dislocation in total hip arthroplasty (THA). Manual placements often cause outliers in spite of attempts to insert the component within the intended safe zone; therefore, some surgeons routinely evaluate intraoperative pelvic radiographs to exclude excessive acetabular component malposition. However, their evaluation is often ambiguous in case of the tilted or rotated pelvic position. The purpose of this study was to develop the computational analysis to digitalize the acetabular component orientation regardless of the pelvic tilt or rotation. Methods. Intraoperative pelvic radiographs of 50 patients who underwent THA were collected retrospectively. The 3D pelvic bone model and the acetabular component were image-matched to the intraoperative pelvic radiograph. The radiological anteversion (RA) and radiological inclination (RI) of the acetabular component were calculated and those measurement errors from the postoperative CT data were compared relative to those of the 2D measurements. In addition, the intra- and interobserver differences of the image-matching analysis were evaluated. Results. Mean measurement errors of the image-matching analyses were significantly small (2.5° (SD 1.4°) and 0.1° (SD 0.9°) in the RA and RI, respectively) relative to those of the 2D measurements. Intra- and interobserver differences were similarly small from the clinical perspective. Conclusion. We have developed a computational analysis of acetabular component orientation using an image-matching technique with small measurement errors compared to visual evaluations regardless of the pelvic tilt or rotation. Cite this article: Bone Joint Res 2020;9(7):360–367

Aims. The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA. Methods. We developed a Markov model to estimate the expected cost and benefits of dual mobility compared with single bearing implants in patients undergoing revision THA. The rates of revision and further revision were calculated from the National Joint Registry of England and Wales, while rates of transition from one health state to another were estimated from the literature, and the data were stratified by sex and age. Implant and healthcare costs were estimated from local procurement prices and national tariffs. Quality-adjusted life-years (QALYs) were calculated using published utility estimates for patients undergoing THA. Results. At a minimum five-year follow-up, the use of dual mobility was cost-effective with an estimated incremental cost-effectiveness ratio (ICER) of between £3,006 and £18,745/QALY for patients aged < 55 years and between 64 and 75 years, respectively. For those aged > 75 years dual mobility was only cost-effective if the timeline was beyond seven years. The use of dual mobility bearings was cost-saving for patients aged < 75 years and cost-effective for those aged > 75 years if the time horizon was beyond ten years. Conclusion. The use of dual mobility bearings is cost-effective compared with single bearings in patients undergoing revision THA. The younger the patient is, the more likely it is that a dual mobility bearing can be more cost-effective and even cost-saving. The results are affected by the time horizon and cost of bearings for those aged > 75 years. For patients aged > 75 years, the surgeon must decide whether the use of a dual mobility bearing is a viable economic and clinical option. Cite this article: Bone Joint J 2020;102-B(9):1128–1135

Aims. Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community. Methods. We used data from a stand-alone hospital admitting and operating on 91 trauma patients. All patients were screened on admission and 100% of patients have been followed-up after discharge to assess outcome. Results. Overall, 87 (96%) patients remained symptom-free and recovered well following surgery. Four (4%) patients developed symptoms of COVID-19, with polymerase chain reaction ribonucleiuc acid (PCR-RNA) testing confirming infection. Conclusion. Based on our findings, we propose that if careful cohorting and screening is carried out in a stand-alone cold operating site, it is reasonable to resume elective operating, in a time of endemic but low community prevalence of SAR-Cov2. Cite this article: Bone Joint Open 2020;1-6:229–235

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Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component.

Aims. Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose. Methods. A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared. Results. The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group. Conclusion. Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I. Cite this article: Bone Joint J 2020;102-B(11):1497–1504

Aims. Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. Patients and Methods. A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. Results. A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). Conclusion. A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97–103

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19

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Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK.

Aims. Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods. This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results. Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion. Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427