Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered. Cite this article:
The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Cite this article:
Robotic-assisted total knee arthroplasty (TKA) has proven higher accuracy, fewer alignment outliers, and improved short-term clinical outcomes when compared to conventional TKA. However, evidence of cost-effectiveness and individual superiority of one system over another is the subject of further research. Despite its growing adoption rate, published results are still limited and comparative studies are scarce. This review compares characteristics and performance of five currently available systems, focusing on the information and feedback each system provides to the surgeon, what the systems allow the surgeon to modify during the operation, and how each system then aids execution of the surgical plan. Cite this article: Abstract
Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes. Cite this article:
In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article:
Evaluating musculoskeletal conditions of the lower limb and understanding the pathophysiology of complex bone kinematics is challenging. Static images do not take into account the dynamic component of relative bone motion and muscle activation. Fluoroscopy and dynamic MRI have important limitations. Dynamic CT (4D-CT) is an emerging alternative that combines high spatial and temporal resolution, with an increased availability in clinical practice. 4D-CT allows simultaneous visualization of bone morphology and joint kinematics. This unique combination makes it an ideal tool to evaluate functional disorders of the musculoskeletal system. In the lower limb, 4D-CT has been used to diagnose femoroacetabular impingement, patellofemoral, ankle and subtalar joint instability, or reduced range of motion. 4D-CT has also been used to demonstrate the effect of surgery, mainly on patellar instability. 4D-CT will need further research and validation before it can be widely used in clinical practice. We believe, however, it is here to stay, and will become a reference in the diagnosis of lower limb conditions and the evaluation of treatment options. Cite this article:
Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article:
Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article:
Aims. In 2013, we introduced a specialized, centralized, and interdisciplinary team in our institution that applied a standardized diagnostic and treatment algorithm for the management of prosthetic joint infections (PJIs). The hypothesis for this study was that the outcome of treatment would be improved using this approach. Patients and Methods. In a retrospective
Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article:
Aims. Instability remains a challenging problem in both primary and
revision total hip arthroplasty (THA). Dual mobility components
confer increased stability, but there are concerns about the unique
complications associated with these designs, as well as the long-term
survivorship. Materials and Methods. We performed a systematic review of all English language articles
dealing with dual mobility THAs published between 2007 and 2016
in the MEDLINE and Embase electronic databases. A total of 54 articles
met inclusion criteria for the final
The wrist is a complex joint involving many small bones and complicated kinematics. It has, therefore, been traditionally difficult to image and ascertain information about kinematics when making a diagnosis. Although MRI and fluoroscopy have been used, they both have limitations. Recently, there has been interest in the use of 4D-CT in imaging the wrist. This review examines the literature regarding the use of 4D-CT in imaging the wrist to assess kinematics and its ability to diagnose pathology. Some questions remain about the description of normal ranges, the most appropriate method of measuring intercarpal stability, the accuracy compared with established standards, and the place of 4D-CT in postoperative assessment. Cite this article:
The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Abstract
Stem cells are defined by their potential for self-renewal and the ability to differentiate into numerous cell types, including cartilage and bone cells. Although basic laboratory studies demonstrate that cell therapies have strong potential for improvement in tissue healing and regeneration, there is little evidence in the scientific literature for many of the available cell formulations that are currently offered to patients. Numerous commercial entities and ‘regenerative medicine centres’ have aggressively marketed unproven cell therapies for a wide range of medical conditions, leading to sometimes indiscriminate use of these treatments, which has added to the confusion and unpredictable outcomes. The significant variability and heterogeneity in cell formulations between different individuals makes it difficult to draw conclusions about efficacy. The ‘minimally manipulated’ preparations derived from bone marrow and adipose tissue that are currently used differ substantially from cells that are processed and prepared under defined laboratory protocols. The term ‘stem cells’ should be reserved for laboratory-purified, culture-expanded cells. The number of cells in uncultured preparations that meet these defined criteria is estimated to be approximately one in 10 000 to 20 000 (0.005% to 0.01%) in native bone marrow and 1 in 2000 in adipose tissue. It is clear that more refined definitions of stem cells are required, as the lumping together of widely diverse progenitor cell types under the umbrella term ‘mesenchymal stem cells’ has created confusion among scientists, clinicians, regulators, and our patients. Validated methods need to be developed to measure and characterize the ‘critical quality attributes’ and biological activity of a specific cell formulation. It is certain that ‘one size does not fit all’ – different cell formulations, dosing schedules, and culturing parameters will likely be required based on the tissue being treated and the desired biological target. As an alternative to the use of exogenous cells, in the future we may be able to stimulate the intrinsic vascular stem cell niche that is known to exist in many tissues. The tremendous potential of cell therapy will only be realized with further basic, translational, and clinical research. Cite this article:
The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children. A total of 35 children were studied. There were 19 girls and 16 boys. Their mean age was 11.9 years (2 to 18) at the time of surgery. Details of the radiological examinations were recorded during gradual correction using a Taylor Spatial Frame. The dose area product for each radiograph was obtained from the Computerised Radiology Information System database. The effective dose in millisieverts (mSv) was calculated using conversion coefficients for the anatomical area. The lifetime risk of developing cancer was calculated using government-approved Health Protection Agency reports, accounting for the age and gender of the child.Aims
Patients and Methods
The aim of this study was to assess the current evidence relating
to the benefits of virtual reality (VR) simulation in orthopaedic
surgical training, and to identify areas of future research. A literature search using the MEDLINE, Embase, and Google Scholar
databases was performed. The results’ titles, abstracts, and references
were examined for relevance.Aims
Materials and Methods
The diagnosis of periprosthetic joint infection can be difficult
due to the high rate of culture-negative infections. The aim of
this study was to assess the use of next-generation sequencing for
detecting organisms in synovial fluid. In this prospective, single-blinded study, 86 anonymized samples
of synovial fluid were obtained from patients undergoing aspiration
of the hip or knee as part of the investigation of a periprosthetic
infection. A panel of synovial fluid tests, including levels of
C-reactive protein, human neutrophil elastase, total neutrophil
count, alpha-defensin, and culture were performed prior to next-generation
sequencing.Aims
Materials and Methods
‘Big data’ is a term for data sets that are so
large or complex that traditional data processing applications are
inadequate. Billions of dollars have been spent on attempts to build predictive
tools from large sets of poorly controlled healthcare metadata.
Companies often sell reports at a physician or facility level based
on various flawed data sources, and comparative websites of ‘publicly
reported data’ purport to educate the public. Physicians should
be aware of concerns and pitfalls seen in such data definitions,
data clarity, data relevance, data sources and data cleaning when
evaluating analytic reports from metadata in health care. Cite this article:
The mucopolysaccharidoses (MPS) are a group of
inherited lysosomal storage disorders with clinical manifestations relevant
to the orthopaedic surgeon. Our aim was to review the recent advances
in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising
orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include
the recognition of slowly progressive, late presenting subtypes,
developments in life-prolonging systemic treatment and potentially
new indications for surgical treatment. The outcomes of surgery
in these patients are not yet validated and some procedures have
a high rate of complications which differ from those in patients
who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or
young adults with a previously unrecognised dysplasia of the hip.
Surgeons treating patients with a MPS should report their experience
and studies should include the assessment of function and quality
of life to guide treatment. Cite this article:
The importance of accurate identification and reporting of surgical
site infection (SSI) is well recognised but poorly defined. Public
Health England (PHE) mandated collection of orthopaedic SSI data
in 2004. Data submission is required in one of four categories (hip
prosthesis, knee prosthesis, repair of neck of femur, reduction
of long bone fracture) for one quarter per year. Trusts are encouraged
to carry out post-discharge surveillance but this is not mandatory.
Recent papers in the orthopaedic literature have highlighted the
importance of SSI surveillance and the heterogeneity of surveillance
methods. However, details of current orthopaedic SSI surveillance
practice has not been described or quantified. All 147 NHS trusts in England were audited using a structured
questionnaire. Data was collected in the following categories: data
collection; data submission to PHE; definitions used; resource constraints;
post-discharge surveillance and SSI rates in the four PHE categories.
The response rate was 87.7%.Aims
Patients and Methods