Aims. In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. Methods. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”. Results. A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training. Conclusion. Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment. We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision

We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I. 2. = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I. 2. = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism. We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted

The Oxford hip and knee scores are used to measure the outcome after primary total hip and knee replacement. We propose a new layout for the instrument in which patients are always asked about both limbs. In addition, we have defined an alternative scoring method which accounts for missing data. Over a period of 4.5 years, 4086 (1423 patients) and 5708 (1458 patients) questionnaires were completed for hips and knees, respectively. The hip score had a pre-operative median of 70.8 (interquartile range (IQR) 58.3 to 81.2) decreasing to 20.8 (IQR 10.4 to 35.4) after one year. The knee score had a pre-operative median of 68.8 (IQR 56.2 to 79.2) decreasing to 29.2 (IQR 14.6 to 45.8). There was no further significant change in either score after one year. As a result of the data analysis, we suggest that the score percentiles can be used as a standard for auditing patients before and after operation.

All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

Aims. Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

Aims. Bacterial infection activates neutrophils to release neutrophil extracellular traps (NETs) in bacterial biofilms of periprosthetic joint infections (PJIs). The aim of this study was to evaluate the increase in NET activation and release (NETosis) and haemostasis markers in the plasma of patients with PJI, to evaluate whether such plasma induces the activation of neutrophils, to ascertain whether increased NETosis is also mediated by reduced DNaseI activity, to explore novel therapeutic interventions for NETosis in PJI in vitro, and to evaluate the potential diagnostic use of these markers. Methods. We prospectively recruited 107 patients in the preoperative period of prosthetic surgery, 71 with a suspicion of PJI and 36 who underwent arthroplasty for non-septic indications as controls, and obtained citrated plasma. PJI was confirmed in 50 patients. We measured NET markers, inflammation markers, DNaseI activity, haemostatic markers, and the thrombin generation test (TGT). We analyzed the ability of plasma from confirmed PJI and controls to induce NETosis and to degrade in vitro-generated NETs, and explored the therapeutic restoration of the impairment to degrade NETs of PJI plasma with recombinant human DNaseI. Finally, we assessed the contribution of these markers to the diagnosis of PJI. Results. Patients with confirmed PJI had significantly increased levels of NET markers (cfDNA (p < 0.001), calprotectin (p < 0.001), and neutrophil elastase (p = 0.022)) and inflammation markers (IL-6; p < 0.001) in plasma. Moreover, the plasma of patients with PJI induced significantly more neutrophil activation than the plasma of the controls (p < 0.001) independently of tumour necrosis factor alpha. Patients with PJI also had a reduced DNaseI activity in plasma (p < 0.001), leading to a significantly impaired degradation of NETs (p < 0.001). This could be therapeutically restored with recombinant human DNaseI to the level in the controls. We developed a model to improve the diagnosis of PJI with cfDNA, calprotectin, and the start tail of TGT as predictors, though cfDNA alone achieved a good prediction and is simpler to measure. Conclusion. We confirmed that patients with PJI have an increased level of NETosis in plasma. Their plasma both induced NET release and had an impaired ability to degrade NETs mediated by a reduced DNaseI activity. This can be therapeutically restored in vitro with the approved Dornase alfa, Pulmozyme, which may allow novel methods of treatment. A combination of NETs and haemostatic biomarkers could improve the diagnosis of PJI, especially those patients in whom this diagnosis is uncertain. Cite this article: Bone Joint J 2024;106-B(9):1021–1030

Aims. Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. Methods. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded. Results. A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection. Conclusion. Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay. Cite this article: Bone Jt Open 2021;2(8):655–660

Aims. The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Results. Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Conclusion. Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485–494

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This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

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The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature.

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The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

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It is well described that patients with bone and joint infections (BJIs) commonly experience significant functional impairment and disability. Published literature is lacking on the impact of BJIs on mental health. Therefore, the aim of this study was to assess health-related quality of life (HRQoL) and the impact on mental health in patients with BJIs.

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome.

Aims

The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons.

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Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation.

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The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

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Disorders of bone integrity carry a high global disease burden, frequently requiring intervention, but there is a paucity of methods capable of noninvasive real-time assessment. Here we show that miniaturized handheld near-infrared spectroscopy (NIRS) scans, operated via a smartphone, can assess structural human bone properties in under three seconds.

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Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.

Aims. We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. Methods. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire. Results. The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19. Conclusion. During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure

Aims. Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. Methods. Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. Results. TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. Conclusion. Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements. Cite this article: Bone Joint Open 2020;1-7:398–404

Aims

The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors.

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

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The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld.

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The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery.

Aims. The aim of this paper was to present the clinical features of patients with musculoskeletal sources of methicillin-sensitive Staphylococcus aureus (MSSA) septicaemia. Patients and Methods. A total of 137 patients presented with MSSA septicaemia between 2012 and 2015. The primary source of infection was musculoskeletal in 48 patients (35%). Musculoskeletal infection was considered the primary source of septicaemia when endocarditis and other obvious sources were excluded. All patients with an arthroplasty at the time were evaluated for any prosthetic involvement. . Results. The most common site of infection was the spine, which occurred in 28 patients (58%), and was associated with abscess formation in 16. Back pain was the presenting symptom in these patients, with a positive predictive value of 100%. A total of 24 patients had a total of 42 arthroplasties of the hip or knee in situ. Prosthetic joint infection occurred in six of these patients (25%). In five patients, the infection originated outside the musculoskeletal system. Three patients (6%) with MSSA septicaemia from a musculoskeletal sources died. . Conclusion. Amongst the musculoskeletal sources of MSSA septicaemia, the spine was the most commonly involved. We recommend an MRI scan of the whole spine and pelvis in patients with MSSA septicaemia with back pain, when the primary source of infection has not been identified or clinical examination is unreliable. Cite this article: Bone Joint J 2017;99-B:1545–51

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Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

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Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence.

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Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems.

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The COVID-19 pandemic drastically affected elective orthopaedic services globally as routine orthopaedic activity was largely halted to combat this global threat. Our institution (University College London Hospital, UK) previously showed that during the first peak, a large proportion of patients were hesitant to be listed for their elective lower limb procedure. The aim of this study is to assess if there is a patient perception change towards having elective surgery now that we have passed the peak of the second wave of the pandemic.

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COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic.

Aims

Due to widespread cancellations in elective orthopaedic procedures, the number of patients on waiting list for surgery is rising. We aim to determine and quantify if disparities exist between inpatient and day-case orthopaedic waiting list numbers; we also aim to determine if there is a ‘hidden burden’ that already exists due to reductions in elective secondary care referrals.

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COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.

An extensive review of the spinal and arthroplasty literature was undertaken to evaluate the effectiveness of local antibiotic irrigation during surgery. The efficacy of antibiotic irrigation for the prevention of acute post-operative infection after total joint arthroplasty was evaluated retrospectively in 2293 arthroplasties (1990 patients) between January 2004 and December 2013. The mean follow-up was 73 months (20 to 139). One surgeon performed all the procedures with minimal post-operative infection. . The intra-operative protocol included an irrigation solution of normal saline with vancomycin 1000 mg/l and polymyxin 250 000 units/l at the rate of 2 l per hour. No patient required re-admission for primary infection or further antibiotic treatment. Two morbidly obese patients (two total hip arthroplasties) developed subcutaneous fat necrosis requiring debridement and one was revised because the deep capsular sutures were contaminated by the draining subcutaneous haematoma. One patient who had undergone total knee arthroplasty had unrecognised damage to the lateral superior geniculate artery and developed a haematoma that became infected secondarily four months after the surgery and underwent revision. . The use of antibiotic irrigation during arthroplasty surgery has been highly effective for the prevention of infection in the author’s practice. However, it should be understood that any routine prophylactic use of antibiotics may result in resistant organisms, and the wise stewardship of the use of antibiotics is an important part of surgical practice. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):23–6

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

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The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers.

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

Aims

This study presents patient-reported quality of life (QoL) over the first year following surgical debridement of long bone osteomyelitis. It assesses the bone involvement, antimicrobial options, coverage of soft tissues, and host status (BACH) classification as a prognostic tool and its ability to stratify cases into ‘uncomplicated’ or ‘complex’.

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This study aimed to identify patients receiving total hip arthroplasty (THA) for trauma during the peak of the COVID-19 pandemic in the UK and quantify the risks of contracting SARS-CoV-2 virus, the proportion of patients requiring treatment in an intensive care unit (ICU), and rate of complications including mortality.

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.

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The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.

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The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting.

Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Aims

The use of technology to assess balance and alignment during total knee surgery can provide an overload of numerical data to the surgeon. Meanwhile, this quantification holds the potential to clarify and guide the surgeon through the surgical decision process when selecting the appropriate bone recut or soft tissue adjustment when balancing a total knee. Therefore, this paper evaluates the potential of deploying supervised machine learning (ML) models to select a surgical correction based on patient-specific intra-operative assessments.

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To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Aims

As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve.

Cite this article: Bone Joint Open 2020;1-6:272–280.

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

Aims

This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google.

The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA. We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA. We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA

Aims

The worldwide COVID-19 pandemic is directly impacting the field of orthopaedic surgery and traumatology with postponed operations, changed status of planned elective surgeries and acute emergencies in patients with unknown infection status. To this point, Germany's COVID-19 infection numbers and death rate have been lower than those of many other nations.

Aims

Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA.

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.

The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review. Cite this article: Bone Joint J 2015;97-B:1162–9

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.

Introduction

Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia.

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again

The most frequent cause of failure after total hip replacement in all reported arthroplasty registries is peri-prosthetic osteolysis. Osteolysis is an active biological process initiated in response to wear debris. The eventual response to this process is the activation of macrophages and loss of bone. Activation of macrophages initiates a complex biological cascade resulting in the final common pathway of an increase in osteolytic activity. The biological initiators, mechanisms for and regulation of this process are beginning to be understood. This article explores current concepts in the causes of, and underlying biological mechanism resulting in peri-prosthetic osteolysis, reviewing the current basic science and clinical literature surrounding the topic

We have studied prospectively the outcome of wound discharge in patients after arthroplasty of the hip and knee. Over a period of 3.5 years 530 primary arthroplasties were carried out in one hospital. Postoperative wound infections developed in 82. At a mean follow-up of two years a comparison was made between these patients and 82 with healthy wounds, in terms of symptoms and signs of deep infection. There was an incidence of 1.1% of early deep infection, within six weeks in all cases. The rate of ‘superficial’ infection was 17.3% in the hips, 10.5% in the knees and 14.3% in total. At a mean follow-up of 26 months, there were no significant differences between the patients with infected wounds and a matched group of patients with healthy wounds in terms of the ESR, level of C-reactive protein, white cell count and radiological scores, but clinical scores were significantly worse in the patients with infected knees (p < 0.05). The length of stay was also significantly longer in this group (mean 14.6 days in the healthy wound group, 19 days in the problem group; p < 0.005). There was, however, no convincing evidence that these wound infections led to deep infection and early revision in the early to medium follow-up period. A larger and longer prospective trial would be necessary to shed more light on this potential problem

Treatment for osteoarthritis (OA) has traditionally focused on joint replacement for end-stage disease. An increasing number of surgical and pharmaceutical strategies for disease prevention have now been proposed. However, these require the ability to identify OA at a stage when it is potentially reversible, and detect small changes in cartilage structure and function to enable treatment efficacy to be evaluated within an acceptable timeframe. This has not been possible using conventional imaging techniques but recent advances in musculoskeletal imaging have been significant. In this review we discuss the role of different imaging modalities in the diagnosis of the earliest changes of OA. The increasing number of MRI sequences that are able to non-invasively detect biochemical changes in cartilage that precede structural damage may offer a great advance in the diagnosis and treatment of this debilitating condition. Cite this article: Bone Joint J 2013;95-B:738–46

The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001. There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents. Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study. These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital

Aims

The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

The risk of venous thromboembolism in patients following arthroplasty may be reduced by continuing chemical thromboprophylaxis for up to 35 days post-operatively. This prospective cohort study investigated the compliance of 40 consecutive consenting patients undergoing lower limb arthroplasty with self-administration of a recommended subcutaneous chemotherapeutic agent for six weeks after surgery. Compliance was assessed by examination of the patient for signs of injection, number of syringes used, and a self-report diary at the end of the six-week period. A total of 40 patients, 15 men and 25 women, were recruited. One woman was excluded because immediate post-operative complications prevented her participation. Self-administration was considered feasible in 87% of patients (95% confidence interval (CI) 76 to 98) at the time of discharge. Among this group of 34 patients, 29 (85%) were compliant (95% CI 73 to 97). Patients can learn to self-administer subcutaneous injections of thromboprophylaxis, and compliance with extended prophylaxis to six weeks is good

We have investigated in a prospective, randomised placebo-controlled study the effect of high-dose aprotinin on blood loss in patients admitted for major surgery (revision arthroplasty of the hip or knee, or for resection of a soft-tissue sarcoma). The mean intraoperative blood loss was reduced from 1957 ml in the control group to 736 ml in the aprotinin group (p = 0.002). The mean requirement for intraoperative homologous blood transfusion in the aprotinin group was 1.4 units (95% CI 0.2 to 2.7) and 3.1 units (95% CI 1.7 to 4.6) in the control group (p = 0.033). The mean length of hospital stay was reduced from 27.8 days in the control group to 17.6 days in the aprotinin group which was not statistically significant. The intraoperative use of aprotinin in major orthopaedic operations significantly reduced blood loss and the required amount of packed cells. It may result in a decrease in the length of hospital stay and costs

We describe our medium-term results for the management of chronic osteomyelitis in long bones using the Lautenbach procedure. Seventeen consecutive patients (18 segments) were treated prospectively. Osteomyelitis had been present for a mean of 12.5 years (1 to 31). A discharging sinus was present in all cases. Nine of the associated fractures had failed to unite and a further two needed correction of malunion. The Lautenbach procedure involves debridement, intramedullary reaming and the insertion of double-lumen tubes to establish both a local antibiotic delivery system and cavity analysis for volume and culture. The end-point of treatment is when the irrigate produces three consecutive clear cultures with improvement in the blood indices and obliteration of the cavity volume. The mean length of treatment was 27 days (14 to 48). One patient required a second procedure and another local debridement for recurrence of the infection. Two patients had Papineau grafting because of cortical defects. All the patients have subsequently remained free from infection. After treatment 11 had internal or external fixation for treatment of non- or malunion or a joint replacement, including two successful limb-lengthening procedures. Two further patients, while cured of infection, underwent amputation for other reasons. The mean length of follow-up was 75 months. This procedure allows precise control over the osteomyelitis until objective assessment suggests that infection has been cleared and the cavity obliterated. We recommend this procedure for long-standing complex cases in which basic techniques using debridement and antibiotics have failed

Aims

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects.

Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages.

We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):27–30.

Bactericidal levels of antibiotics are difficult to achieve in infected total joint arthroplasty when intravenous antibiotics or antibiotic-loaded cement spacers are used, but intra-articular (IA) delivery of antibiotics has been effective in several studies. This paper describes a protocol for IA delivery of antibiotics in infected knee arthroplasty, and summarises the results of a pharmacokinetic study and two clinical follow-up studies of especially difficult groups: methicillin-resistant Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 μg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 μg/mL (mean, 12.3 μg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):31–6.

Construction of a functional skeleton is accomplished through co-ordination of the developmental processes of chondrogenesis, osteogenesis, and synovial joint formation. Infants whose movement in utero is reduced or restricted and who subsequently suffer from joint dysplasia (including joint contractures) and thin hypo-mineralised bones, demonstrate that embryonic movement is crucial for appropriate skeletogenesis. This has been confirmed in mouse, chick, and zebrafish animal models, where reduced or eliminated movement consistently yields similar malformations and which provide the possibility of experimentation to uncover the precise disturbances and the mechanisms by which movement impacts molecular regulation. Molecular genetic studies have shown the important roles played by cell communication signalling pathways, namely Wnt, Hedgehog, and transforming growth factor-beta/bone morphogenetic protein. These pathways regulate cell behaviours such as proliferation and differentiation to control maturation of the skeletal elements, and are affected when movement is altered. Cell contacts to the extra-cellular matrix as well as the cytoskeleton offer a means of mechanotransduction which could integrate mechanical cues with genetic regulation. Indeed, expression of cytoskeletal genes has been shown to be affected by immobilisation. In addition to furthering our understanding of a fundamental aspect of cell control and differentiation during development, research in this area is applicable to the engineering of stable skeletal tissues from stem cells, which relies on an understanding of developmental mechanisms including genetic and physical criteria. A deeper understanding of how movement affects skeletogenesis therefore has broader implications for regenerative therapeutics for injury or disease, as well as for optimisation of physical therapy regimes for individuals affected by skeletal abnormalities.

Cite this article: Bone Joint Res 2015;4:105–116

The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):18–22.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.

Plots are an elegant and effective way to represent data. At their best they encourage the reader and promote comprehension. A graphical representation can give a far more intuitive feel to the pattern of results in the study than a list of numerical data, or the result of a statistical calculation.

The temptation to exaggerate differences or relationships between variables by using broken axes, overlaid axes, or inconsistent scaling between plots should be avoided.

A plot should be self-explanatory and not complicated. It should make good use of the available space. The axes should be scaled appropriately and labelled with an appropriate dimension.

Plots are recognised statistical methods of presenting data and usually require specialised statistical software to create them. The statistical analysis and methods to generate the plots are as important as the methodology of the study itself. The software, including dates and version numbers, as well as statistical tests should be appropriately referenced.

Following some of the guidance provided in this article will enhance a manuscript.

Cite this article: Bone Joint J 2015;97-B:1593–1603.

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Cite this article: Bone Joint J 2014;96-B:1561–5.

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation. The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at -78º to -68º C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up. The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon’s discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment. Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings.

Cite this article: Bone Joint J 2015;97-B:427–31.

Nanotechnology is the study, production and controlled manipulation of materials with a grain size < 100 nm. At this level, the laws of classical mechanics fall away and those of quantum mechanics take over, resulting in unique behaviour of matter in terms of melting point, conductivity and reactivity. Additionally, and likely more significant, as grain size decreases, the ratio of surface area to volume drastically increases, allowing for greater interaction between implants and the surrounding cellular environment. This favourable increase in surface area plays an important role in mesenchymal cell differentiation and ultimately bone–implant interactions.

Basic science and translational research have revealed important potential applications for nanotechnology in orthopaedic surgery, particularly with regard to improving the interaction between implants and host bone. Nanophase materials more closely match the architecture of native trabecular bone, thereby greatly improving the osseo-integration of orthopaedic implants. Nanophase-coated prostheses can also reduce bacterial adhesion more than conventionally surfaced prostheses. Nanophase selenium has shown great promise when used for tumour reconstructions, as has nanophase silver in the management of traumatic wounds. Nanophase silver may significantly improve healing of peripheral nerve injuries, and nanophase gold has powerful anti-inflammatory effects on tendon inflammation.

Considerable advances must be made in our understanding of the potential health risks of production, implantation and wear patterns of nanophase devices before they are approved for clinical use. Their potential, however, is considerable, and is likely to benefit us all in the future.

Cite this article: Bone Joint J 2014; 96-B: 569–73.

There has been an in increase in the availability of effective biological agents for the treatment of rheumatoid arthritis as well as a shift towards early diagnosis and management of the inflammatory process. This article explores the impact this may have on the place of orthopaedic surgery in the management of patients with rheumatoid arthritis.

Cite this article: Bone Joint J 2014;96-B:1287–9

In May 2012, in airports across the globe, seven orthopaedic surgeons bravely said goodbye to their loved ones, and slowly turned towards their respective aircraft. Filled with expectation and mild trepidation they stepped into the unknown… the ABC fellowship of 2012.

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding.

Cite this article: Bone Joint Res 2014;3:161–8.

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.

Cite this article: Bone Joint J 2013;95-B:4–9.

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE).

Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE.

A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3).

According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more.

One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE.

The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used.

The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients.

Cite this article: Bone Joint J 2014;96-B:426–30.

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects.

A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.

The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research.

Between November 1994 and June 1999, 35 patients referred to our Problem Fracture Service with chronic diaphyseal osteomyelitis were treated using a closed double-lumen suction irrigation system after reaming and arthroscopic debridement of the intramedullary canal. This is a modified system based on that of Lautenbach.

Between June and July 2007 the patients were reviewed by postal questionnaire and telephone and from the case notes. At a mean follow-up of 101 months (2 to 150), 26 had no evidence of recurrence and four had died from unrelated causes with no evidence of recurrent infection. One had been lost to follow-up at two months and was therefore excluded. Four had persisting problems with sinus discharge and one had his limb amputated for recurrent metaplastic change.

Our results represent a clearance of infection of 85.3% (29 of 34), with recurrence in 11.8% (4 of 34). They are comparable to the results of the Papineau and Belfast techniques, but with considerably less surgical insult to the patient.

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.

We have prospectively studied the outcome of infections associated with implants which were retained and treated using a standardised antimicrobial protocol. Over a period of four years, we studied 24 consecutive patients who had symptoms of infection for less than one year, a stable implant, no sinus tract and a known pathogen which was susceptible to recommended antimicrobial agents. The infections involved hip prostheses (14), knee prostheses (5), an internal fixation device (4), and an ankle prosthesis (1).

Twenty patients had a successful outcome at a median follow-up of 3.7 years (1.8 to 4.7); four had failure of the implant after a median follow-up of 1.2 years (0.3 to 2.5). The probability of survival without failure of treatment was 96% at one year (95% confidence interval (CI) 88 to 100), 92% at two years (95% CI 80 to 100) and 86% at three years (95% CI 72 to 100).

Patients with a short-term infection but with a stable implant, no sinus tract and a known pathogen may be successfully treated by retention of the implant and the use of a standardised regimen of antimicrobial treatment.