Correlation between anthropometric measurements and graft size in anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to investigate the correlation between anthropometric measurements and graft size in anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic search of Ovid MEDLINE, Embase, and Cochrane Library databases was conducted for observational studies published until March 2023 that reported the relationship between anthropometric data [height, weight, body mass index (BMI), age, gender, thigh length, and circumference] and ACL graft size. Correlation coefficients (COR) and their associated 95% confidence intervals were used as the primary effect size. This review was conducted in line with PRISMA guidelines. RESULTS: A total of 42 observational studies involving 7110 patients were included, with a mean age of 29.8 years. Statistically significant, moderately positive correlations were found between graft size and height (COR: 0.49; 95% CI: 0.41-0.57; p-value: < 0.001), weight (COR: 0.38; 95% CI: 0.31-0.44; p-value: < 0.001), thigh circumference (COR: 0.40; 95% CI: 0.19-0.58; p-value: < 0.001), and thigh length (COR: 0.35; 95% CI: 0.18-0.50; p-value: < 0.001). However, age and gender were insignificantly correlated with graft size (p-value: NS). A subanalysis based on graft type showed a significant positive correlation between height and graft diameter, which was more significant in the peroneus tendon than in hamstring grafts (COR: 0.76 vs. 0.45; p-value: 0.020). CONCLUSION: This study demonstrated a moderate positive correlation between anthropometric measurements (height, weight, thigh circumference, and length) and ACL graft size, along with a weak positive correlation with BMI. Age and gender showed no significant correlation. These findings support the predictability and selection of ACL graft size based on pre-operative patient anthropometric data. LEVEL OF EVIDENCE: Level of Evidence: IV. PROSPERO registration number: CRD42023416044.

Reliability of artificial intelligence in predicting total knee arthroplasty component sizes: a systematic review.

PURPOSE: This systematic review aimed to investigate the reliability of AI predictive models of intraoperative implant sizing in total knee arthroplasty (TKA). METHODS: Four databases were searched from inception till July 2023 for original studies that studied the reliability of AI prediction in TKA. The primary outcome was the accuracy ± 1 size. This review was conducted per PRISMA guidelines, and the risk of bias was assessed using the MINORS criteria. RESULTS: A total of four observational studies comprised of at least 34,547 patients were included in this review. A mean MINORS score of 11 out of 16 was assigned to the review. All included studies were published between 2021 and 2022, with a total of nine different AI algorithms reported. Among these AI models, the accuracy of TKA femoral component sizing prediction ranged from 88.3 to 99.7% within a deviation of one size, while tibial component sizing exhibited an accuracy ranging from 90 to 99.9% ± 1 size. CONCLUSION: This study demonstrated the potential of AI as a valuable complement for planning TKA, exhibiting a satisfactory level of reliability in predicting TKA implant sizes. This predictive accuracy is comparable to that of the manual and digital templating techniques currently documented in the literature. However, future research is imperative to assess the impact of AI on patient care and cost-effectiveness. LEVEL OF EVIDENCE III: PROSPERO registration number: CRD42023446868.

The outcomes of total hip replacement in osteonecrosis versus osteoarthritis: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to compare the outcomes of THA in patients with osteonecrosis (ON) and those with osteoarthritis (OA). METHODS: Four databases were searched from inception till December 2022 for original studies that compared the outcomes of THA in ON and OA. The primary outcome was the revision rate; the secondary outcomes were dislocation and Harris hip score. This review was conducted in line with PRISMA guidelines, and the risk of bias was assessed using the Newcastle-Ottawa scale. RESULTS: A total of 14 observational studies with 2,111,102 hips were included, with a mean age of 50.83 ± 9.32 and 55.51 ± 8.95 for ON and OA groups, respectively. The average follow-up was 7.25 ± 4.6 years. There was a statistically significant difference in revision rate between ON and OA patients in favour of OA (OR: 1.576; 95%CI: 1.24-2.00; p-value: 0.0015). However, dislocation rate (OR: 1.5004; 95%CI: 0.92-2.43; p-value: 0.0916) and Haris hip score (HHS) (SMD: - 0.0486; 95%CI: - 0.35-0.25; p-value: 0.6987) were comparable across both groups. Further sub-analysis adjusting for registry data also showed similar results between both groups. CONCLUSION: A higher revision rate, periprosthetic fracture and periprosthetic joint infection following total hip arthroplasty were associated with osteonecrosis of the femoral head compared with osteoarthritis. However, both groups had similar dislocation rates and functional outcome measures. This finding should be applied in context due to potential confounding factors, including patient's age and activity level.

Impact of age on unicompartmental knee arthroplasty outcomes: a systematic review and meta-analysis.

PURPOSE: Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. METHODS: The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. Five databases were searched in December 2021 for original comparative studies with a minimum of 1-year follow-up. No restrictions were placed on the type of UKA prosthesis. RESULTS: A total of 11 observational studies with 6130 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64 years, with average follow-up of 7.5 ± 2.98 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. CONCLUSION: Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that age alone is not a contraindication to UKA, but the surgical choice must be based on several elements, and this finding should be applied in context, given the binary division and heterogeneity of patients. LEVEL OF EVIDENCE: III.

The environmental impact of orthopaedic surgery: assessing strategies for change.

Climate change poses one of the most critical threats to humanity. Surgical care needs to be considered in relation to the impending climate emergency. Little thought appears to have been given to the role of operating departments as a high-yield target for environmental change. This article evaluates the environmental impact of orthopaedic surgery, focusing on anaesthesia, waste management and surgical hardware. Developing 'green' operating protocols should be the minimum expectation of orthopaedic departments. Just as the management of complex surgical pathology requires a multidisciplinary approach, mitigating the environmental impact of surgical endeavour requires collective action and buy-in.

Assessing the attitude of surgical trainees towards virtual reality simulation: A national cross-sectional questionnaire study.

BACKGROUND: We performed a cross sectional study to determine the attitudes of surgical trainees and medical students towards virtual reality (VR) simulation in surgical training. A survey was devised through an iterative process before distribution to surgical trainees, foundation year doctors and medical students through online platforms. METHODS: The survey was disseminated within the United Kingdom through social media and email correspondence, in co-operation with national surgical organisations. 91 trainees responded from a variety of clinical specialities. RESULTS: VR technology in surgical training was viewed positively, with 91.3% of trainees agreeing that VR should be both an adjunct in surgical training as well as a competency-based assessment tool. Barriers to access were present, with access notably more challenging for senior surgeons. CONCLUSION: Virtual reality surgical simulation in surgical training is beginning to emerge as a genuine high-fidelity, low-risk solution to the lack of surgical case volume trainees are currently experiencing.

The role of hydroxyapatite coating in joint replacement surgery - Key considerations.

The use of a porous hydroxyapatite (HA) coating has definitively increased the durability and biocompatibility of joint replacement prostheses (JRP) since its introduction. This article will contextualise the properties of porous HA and relate these characteristics to its clinical function. Novel strategies to encourage osseointegration will also be explored, alongside their clinical relevance. All major literature databases were scrutinised for literature relevant to the scope of our review. The role of Hydroxyapatite was evaluated, alongside further strategies to augment bone ingrowth. HA coatings remain the most optimal coating for widespread clinical use. Advantages are conferred due to the method of application, the tribology and the biocompatibility of the material. Further strategies are available to augment bone ingrowth, pertaining to biological modifications and implantation of external factors. An evaluation of the literature has described the relative long term performance of the HA coated JRPs both in isolation and when compared with cemented prosthesis. Metanalyses have shown HA coated JRPs to perform as well as cemented prosthesis in terms of survivability over both short and long term follow ups. Concerning strategies to augment osseointegration, consideration should be given to form and function of the coating surface, as this provides the basis for cell adherence, proliferation, and differentiation.

A quality improvement project: Reducing the number of unnecessary plain abdominal radiographs performed in the emergency department of a London district general hospital.

Background: Inappropriate completion of abdominal radiographs results in unnecessary exposure to ionizing radiation. This quality improvement project aimed to reduce the number of inappropriate abdominal radiographs performed in the emergency department. Materials and methods: Abdominal radiograph request forms were analyzed with reference to the Royal College of Radiologists (RCR) iRefer guidance. A teaching session was then delivered to ED clinicians and posters were disseminated within the department. Post-intervention data collection followed. Results: Following the intervention, there was an increase in the proportion of abdominal radiographs meeting iRefer guidance, which was accompanied by an increased diagnostic yield of these investigations. There was a reduction in the number of requests post-intervention. Conclusions: Our interventions helped increase awareness of both the guidelines and radiation dose associated with each study. Routine education of the iRefer guidelines will help reduce inappropriate requests. This in turn will reduce unnecessary radiation exposure, whilst also reducing the financial burden.

Preventing Venous Thromboembolism after elective total hip arthroplasty surgery - are the current guidelines appropriate? Venous thromboembolism prophylaxis in elective total hip arthroplasty surgery.

INTRODUCTION: Venous Thromboembolism after elective Total Hip Arthroplasty surgery is a well-recognised complication, resulting in fatal pulmonary embolism, post thrombotic syndrome and recurrent thrombotic episodes. Guidelines developed by clinical organisations attempt to provide evidence-based recommendations to clinicians. METHODS: This narrative review evaluated the current available literature in relation to the available guidelines, to evaluate whether the current major guidelines reflect the evidence base. All major clinical guidelines were collated through database searching, alongside the relevant clinical studies. PRINCIPAL FINDINGS: The promotion of a multi-modal approach, combining mechanical and chemical prophylaxis, does appear to be well validated, with mechanical prophylaxis offering positive clinical effects with little negative clinical consequence. Within the current guidelines surrounding VTE prevention in the elective-THA patient, there does appear to be a lack of prescription in relation to risk stratification and adopting personalised approaches for specific patient subsets. CONCLUSION: We suggest moving away from protocolisation of VTE prevention, given the evidence base is not fully developed to allow a 'one-size-fits-all' approach.

Updates in postoperative imaging modalities following musculoskeletal surgery.

Postoperative imaging following orthopaedic surgeries is essential in assessing complications post-surgery and also helps plan further treatment. Combining a high degree of clinical insight with appropriate imaging can guide the treating clinician to the correct diagnosis. Imaging is quite challenging because of surgery-related soft tissue changes, especially in the early postoperative period and the presence of metal implants resulting in image scatter and metal artifacts. Newer modalities and advances in imaging have helped overcome shortcomings and assess better, especially in procedures that involve implants. Collaborative decision-making involving radiologists and clinicians has shown to be beneficial and is the way forward. This narrative review discusses the utility of imaging in evaluating postoperative complications following musculoskeletal surgeries with specific relation to trauma, arthroplasty, and tumour by discussing commonly encountered clinical scenarios.

The role of specialist nurses in delivering effective care in a tertiary sarcoma referral service.

Musculoskeletal sarcomas are rare cancers with an incidence of less than 1% of all cancers. Management of these tumors requires multidisciplinary care comprising of numerous specialists. Critical decisions following collaborative discussion among treating specialists followed by timely communication and starting prompt treatment are vital in delivering care in such rare sarcomas. While musculoskeletal surgeons, radiologists, and clinical oncologists are well known, the role of specialist nurses has been less described. They form a vital pillar in any tertiary sarcoma service by assisting in collaborative care, having consultations in nurse-led clinics, offering psychological support, imparting details of treatment to patient and helping in palliative care. This narrative review focuses on the role of trained specialist nurses in a tertiary sarcoma service and gives insight into their vital role in delivering timely, coordinated, effective care.

Stem Cell Therapy in the Management of Fracture Non-Union - Evaluating Cellular Mechanisms and Clinical Progress.

Bone, as a physiological and anatomical construct, displays remarkable intrinsic healing capacity. The overwhelming majority of fractures will heal satisfactorily, if aligned anatomically, compressed and immobilised appropriately. Of the 10% of fractures that do not heal, even under ideal mechanical and biological conditions, further consideration must be given to augment bone healing. Management strategies for non-union pose a significant clinical challenge to the practicing orthopaedic surgeon. Stem cell therapy is beginning to demonstrate significant potential for augmented bone repair in the context of non-union. This review attempts to contextualise the function of stem cells within this clinical setting, reviewing the relevant cellular mechanisms and clinical applications. From evaluating the literature base, there is a lack of high-quality evidence examining the role of mesenchymal stem cells (MSCs) within this research focus. Appropriately designed randomised controlled trials are required to evaluate this research area further, with a view to guiding future treatment options for the practicing orthopaedic surgeon.

Use of Wide-Awake Local Anaesthetic No Tourniquet (WALANT) in upper limb and hand surgery: A systematic review protocol.

INTRODUCTION: Wide Awake Local Anaesthetic No Tourniquet (WALANT) technique has been developed to eliminate tourniquet pain during upper limb and hand surgery whilst also improving utilisation of operating theatre time and inpatient stay, however inconclusive data still limits the techniques uptake. Here presents a protocol for a systematic review to collate findings to produce conclusive data on efficacy of WALANT. METHODS: This systematic review will be registered a priori. All study designs defined by the Oxford Centre for Evidence-Based Medicine will be included in the search. "WALANT" in "upper limb" and "hand" surgery will be investigated as per the devised search strategy. 18 electronic databases will be searched, including PubMed, Medline and Embase in addition to a Grey literature search. Two independent teams of 3 researchers will screen all relevant titles, abstracts and subsequent full texts for suitability. Data will be extrapolated and entered into a preformatted database for analysis. ETHICS AND DISSEMINATION: This systematic review will be published in a peer-reviewed journal and presented at both national and international conferences within the field of plastic and orthopaedic surgery. This review aims to inform surgical practice and policy.

A District General Hospital Trauma Service Response to COVID-19: Lessons Learnt.

OBJECTIVE: This article seeks to evaluate and outline the changes made to the trauma and orthopaedic department in a district general hospital in the United Kingdom during the COVID-19 pandemic. We detail the approach in relation to surgical management, workforce optimisation and our general reflections as a department. METHODS: We interviewed, collated and have subsequently described the adaptations implemented by our department. We have collected their shared strategy and reflections on how the COVID-19 pandemic affected our department. RESULTS: Alterations were implemented to mitigate the effects of the COVID-19 pandemic. A strategy focused on ensuring the workforce remained healthy, and patient care pathways were altered as minimally as possible. CONCLUSIONS:  As a unit, a sense of heightened vigilance needs to remain for the foreseeable future. Decisive action by departmental leadership, alongside a cohesive and open, has allowed for our trauma service to continue largely unchanged. This analysis serves as an important aide-memoire for future periods of extreme uncertainty.

Evaluating Healthcare Worker Competence in the Correct Use of Personal Protective Equipment in the COVID Era: A Quality Improvement Project.

INTRODUCTION: Throughout the coronavirus disease 2019 pandemic, personal protective equipment (PPE) guidance has rapidly evolved. Healthcare workers (HCWs) should use PPE correctly to reduce the risk of nosocomial transmission of the coronavirus. We predict a lack of training regarding correct PPE usage amongst HCWs and introduce a low-resource method of training. METHODS: HCWs from various disciplines at a District General Hospital self-rated their ability in utilising PPE using uncontrolled pre- and post-session 16-item questionnaires following a single PPE training session. Participant responses were analysed using Student's t-test for independent (unpaired) samples. RESULTS: Of 64 participants, 37 participants (59%) received any prior PPE training. Six participants (9%) previously received specific severe acute respiratory syndrome coronavirus 2 PPE training. Survey scores were higher in the post-test than the pre-test group. CONCLUSION: This study highlights the lack of formal PPE training amongst HCWs and the need for establishing PPE training as part of the mandatory training of HCWs.

Retrieval analysis of ceramic-coated metal-on-polyethylene total hip replacements.

PURPOSE: Ceramic coatings have been used in metal-on-polyethylene (MOP) hips to reduce the risk of wear and also infection; the clinical efficacy of this remains unclear. This retrieval study sought to better understand the performance of coated bearing surfaces. METHODS: Forty-three coated MOP components were analysed post-retrieval for evidence of coating loss and gross polyethylene wear. Coating loss was graded using a visual semi-quantitative protocol. Evidence of gross polyethylene wear was determined by radiographic analysis and visual inspection of the retrieved implants. RESULTS: All components with gross polyethylene wear (n = 10) were revised due to a malfunctioning acetabular component; 35 % (n = 15) of implants exhibited visible coating loss and the incidence of polyethylene wear in samples with coating loss was 54 %, significantly (p = 0.02) elevated compared to samples with intact coatings (14 %). CONCLUSIONS: In this study we found evidence of coating loss on metal femoral heads which was associated with increased wear of the corresponding polyethylene acetabular cups.

Lessons from retrievals: Retrievals help understand the reason for revision of coated hip arthroplasties.

Coatings have been applied to all surfaces of hip implants with the majority performing well in the laboratory, but there are few reports of their performance in humans. The rationale for coating the metal-on-metal bearing surfaces includes a reduction in metal ion release and risk of adverse reaction to metal debris; yet there are no reports of retrieved coated metal-on-metal hip implants despite the concern that they may delaminate. The aim of this study was to better understand the performance of coated hip implants in humans through findings of three coated metal-on-metal hip resurfacings, retrieved after failure for unexplained pain. Analysis of these implants included quantification of the amount and mechanism of coating loss which was correlated with clinical, imaging and blood data. In all cases, there were large areas of complete coating loss in which the metal substrate was exposed and found to be rougher than the coated areas. The coating loss gave rise to third body abrasive wear of the coating and the exposed metal, the latter of which led to high blood levels of cobalt and chromium. Coating of the bearing surfaces of metal-on-metal hip resurfacings, therefore, do not prevent metal ion release when implanted into humans. This is an example of a need for increased retrieval analysis of newly introduced implants and expansion of laboratory testing regulations to better reflect the clinical environment.