National registers compare implants by their revision rates, but the validity of the method has never been assessed. The New Zealand Joint Registry publishes clinical outcomes (Oxford knee scores, OKS) alongside revision rates, allowing comparison of the two measurements. In the two types of knee replacement, unicompartmental (UKR) had a better knee score than total replacement (TKR), but the revision rate of the former was nearly three times higher than that of the latter. This was because the sensitivity of the revision rate to clinical failure was different for the two implants. For example, of knees with a very poor outcome (OKS < 20 points), only about 12% of TKRs were revised compared with about 63% of UKRs with similar scores.

Revision therefore is not an objective measurement and should not be used to compare these two types of implant. Furthermore, revision is much less sensitive than the OKS to clinical failure in both types and therefore exaggerates the success of knee replacements, particularly of TKR.

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.

Cite this article: Bone Joint J 2024;106-B(2):114–120.

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.

Cite this article: Bone Joint J 2023;105-B(4):356–360.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Displaced fractures of the distal radius in children are usually reduced under sedation or general anaesthesia to restore anatomical alignment before the limb is immobilized. However, there is growing evidence of the ability of the distal radius to remodel rapidly, raising doubts over the benefit to these children of restoring alignment. There is now clinical equipoise concerning whether or not young children with displaced distal radial fractures benefit from reduction, as they have the greatest ability to remodel. The Children’s Radius Acute Fracture Fixation Trial (CRAFFT), funded by the National Institute for Health and Care Research, aims to definitively answer this question and determine how best to manage severely displaced distal radial fractures in children aged up to ten years.

Cite this article: Bone Joint J 2024;106-B(1):16–18.

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours.

Cite this article: Bone Joint J 2022;104-B(12):1284–1291.

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients’ performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.

Cite this article: Bone Joint J 2022;104-B(10):1104–1109.

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI.

Cite this article: Bone Joint J 2022;104-B(5):532–540.

We recently published a paper comparing the incidence of adverse outcomes after unicompartmental and total knee arthroplasty (UKA and TKA). The conclusion of this study, which was in favour of UKA, was dismissed as “biased” in a review in Bone & Joint 360. Although this study is one of the least biased comparisons of UKA and TKA, this episode highlights the biases that exist both for and against UKA. In this review, we explore the different types of bias, particularly selection, reporting and measurement. We conclude that comparisons between UKA and TKA are open to bias. These biases can be so marked, particularly in comparisons based just on national registry data, that the conclusions can be misleading. For a fair comparison, data from randomised studies or well-matched, prospective observational cohort studies, which include registry data, are required, and multiple outcome measures should be used. The data of this type that already exist suggest that if UKA is used appropriately, compared with TKA, its advantages outweigh its disadvantages. Cite this article: Bone Joint J 2017;99-B:12–15

Aims. The optimal treatment for independent patients with a displaced intracapsular fracture of the hip remains controversial. The recognised alternatives are hemiarthroplasty and total hip arthroplasty. At present there is no established standard of care, with both types of arthroplasty being used in many centres. Patients and Methods. We conducted a feasibility study comparing the clinical effectiveness of a dual mobility acetabular component compared with standard polyethylene component in total hip arthroplasty for independent patients with a displaced intracapsular fracture of the hip, for a 12-month period beginning in June 2013. The primary outcome was the risk of dislocation one year post-operatively. Secondary outcome measures were EuroQol 5 Dimensions, ICEpop CAPability measure for Older people, Oxford hip score, mortality and re-operation. Results. Only 20 patients were recruited during this time. The baseline demographics were similar in the two groups and no patient suffered a dislocation. Differences in secondary outcomes were not analysed due to the small sample. Conclusion. This feasibility study suggests that any trial investigating the effectiveness of total hip arthroplasty for fracture of the hip might not be deliverable within the constraints of current systems of care in the United Kingdom. Cite this article: Bone Joint J 2016;98-B:1431–5

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges.

Cite this article: Bone Joint J 2020;102-B(6):661–663.

Unicompartmental knee arthroplasty (UKA) has numerous advantages over total knee arthroplasty (TKA) and one disadvantage, the higher revision rate. The best way to minimize the revision rate is for surgeons to use UKA for at least 20% of their knee arthroplasties. To achieve this, they need to learn and apply the appropriate indications and techniques. This would decrease the revision rate and increase the number of UKAs which were implanted, which would save money and patients would benefit from improved outcomes over their lifetime.

Cite this article: Bone Joint J 2018;100-B:432–5.

Aims

The purpose of this article was to review the current literature pertaining to the use of mobile compression devices (MCDs) for venous thromboembolism (VTE) following total joint arthroplasty (TJA), and to discuss the results of data from our institution.

Aims

To demonstrate, with concrete examples, the value of in-depth exploration and comparison of data published in National Joint Arthroplasty registry reports.

The results of the DRAFFT (distal radius acute fracture fixation trial) study, which compared volar plating with Kirschner (K-) wire fixation for dorsally displaced fractures of the distal radius, were published in August 2014. The use of K-wires to treat these fractures is now increasing, with a concomitant decline in the use of volar locking plates.

We provide a critical appraisal of the DRAFFT study and question whether surgeons have been unduly influenced by its headline conclusions.

Cite this article: Bone Joint J 2016;98-B:298–300.

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants.

There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05).

ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant.

We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.

Cite this article: Bone Joint J 2015;97-B:1309–15.

Rupture of the tendo Achillis is a common injury with a rising incidence. Traditionally the key question following this injury has been whether or not to operate. However a contemporary Cochrane review highlighted that the method of rehabilitation may also have an important contribution to the outcome. Since this review, various early weight-bearing rehabilitation protocols have been described. Currently evidence points to the use of early functional rehabilitation, regardless of operative or non-operative management. However, there is no consensus on which exact functional rehabilitation protocol should be used. Future research should be directed towards improving our understanding of how the different rehabilitative components interact in the tendo Achillis as it heals.

An international faculty of orthopaedic surgeons presented their work on the current challenges in hip surgery at the London Hip Meeting which was attended by over 400 delegates. The topics covered included femoroacetabular impingement, thromboembolic phenomena associated with hip surgery, bearing surfaces (including metal-on-metal articulations), outcomes of hip replacement surgery and revision hip replacement. We present a concise report of the current opinions on hip surgery from this meeting with appropriate references to the current literature.

In a systematic review, reports from national registers and clinical studies were identified and analysed with respect to revision rates after joint replacement, which were calculated as revisions per 100 observed component years.

After primary hip replacement, a mean of 1.29 revisions per 100 observed component years was seen. The results after primary total knee replacement are 1.26 revisions per 100 observed component years, and 1.53 after medial unicompartmental replacement. After total ankle replacement a mean of 3.29 revisions per 100 observed component years was seen.

The outcomes of total hip and knee replacement are almost identical. Revision rates of about 6% after five years and 12% after ten years are to be expected.

Multicentre clinical trials in trauma care are gaining prominence as a means of generating good-quality evidence to inform and influence clinical practice. We believe multicentre trials have an important role to play in supporting evidence-based practice, and further investment in such trials is justified.

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

This study assessed whether undergraduate performance improved following the introduction in 2006 of a musculoskeletal teaching programme lasting for seven weeks. Different methods were used to deliver knowledge and skills in trauma and orthopaedic surgery, rheumatology and allied specialties. The programme combined four main elements: traditional firm-based teaching, weekly plenary sessions, a task-based workbook and additional specialist clinics. The block of 139 students who attended in its first year were assessed using a multiple choice question examination just before their final examinations in 2008. They showed a 6% improvement in performance over a control group of 130 students assessed in 2005 before the programme had commenced. There was no difference in performance between the students assessed in 2005 and a second group of 46 students from 2008 who did not attend the new teaching programme. Performance was improved by providing more focused musculoskeletal training using available resources, as well as increasing the length of the programme.

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.