The effect of vitamin D supplementation on outcomes following total hip or knee arthroplasty surgery: a rapid systematic review of current evidence.

Purpose: Vitamin D deficiency has been linked to poorer outcomes following hip (THR) and knee (TKR) replacement. We review the effect of peri-operative supplementation on clinical and patient-reported outcomes following THR/TKR. Methods: This study was registered with PROSPERO (CRD42021238086). Searches of electronic databases were performed from inception to March 2021. All randomised, cohort, or case-controlled studies reported in English of adults undergoing THR/TKR where vitamin D supplementation was given peri-operatively and at least one outcome was reported were included. Studies reporting on vitamin D in relation to osteoporosis and hip fracture were excluded, as were conference abstracts and those involving preclinical models. Risks of bias were performed using the RoB-2 and ROBINS-I tools. Results: Three studies comprising 413 TKR patients were identified; two were randomised controlled trials and one was a prospective cohort study. No studies meeting the inclusion criteria reported on the outcomes following THR. Supplementation was associated with a statistically significant reduction in the IL6:IL10 ratio at 24- and 48h following surgery, but no effect was noted on Western Ontario and McMaster Universities Osteoarthritis Index scores or the rates of falls. All studies were judged to be limited by bias, with heterogeneity in the supplementation dose and timing of administration, as well as the reported outcome measures used. Discussion: Further adequately powered randomised-controlled trials using vitamin D supplementation and a specific clinically relevant or patient-reported outcome measure are required to assess if pre-operative vitamin D insufficiency is a modifiable risk factor to improve outcomes following THR/TKR.

The effect of triclosan-coated sutures on the rate of surgical site infection after hip and knee arthroplasty: a double-blind randomized controlled trial of 2546 patients.

Aims: Surgical site infection (SSI) is a common complication of surgery with an incidence of about 1% in the United Kingdom. Sutures can lead to the development of a SSI, as micro-organisms can colonize the suture as it is implanted. Triclosan-coated sutures, being antimicrobical, were developed to reduce the rate of SSI. Our aim was to assess whether triclosan-coated sutures cause a reduction in SSIs following arthroplasty of the hip and knee. Patients and Methods: This two-arm, parallel, double-blinded study involved 2546 patients undergoing elective total hip (THA) and total knee arthroplasty (TKA) at three hospitals. A total of 1323 were quasi-randomized to a standard suture group, and 1223 being quasi-randomized to the triclosan-coated suture group. The primary endpoint was the rate of SSI at 30 days postoperatively. Results: The baseline characteristics of age, gender and comorbidities were well matched in the two groups. The rates of superficial SSI were 0.8% in the control group and 0.7% in the intervention group (p = 0.651), and when deep and superficial SSIs were combined the rates were 2.5% and 1.8 (p = 0.266). The length of stay in hospital and the rates of medical complications did not differ significantly between the groups (p = 1.000). Conclusion: This trial provided no evidence that the use of triclosan-coated sutures at THA and TKA leads to a reduction in the rate of SSI. Cite this article: Bone Joint J 2018;100-B:296-302.

A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip: the WHiTE 3: HEMI Trial.

Aims: This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures. Patients and Methods: This was a pragmatic, multicentre, multisurgeon, two-arm, parallel group, randomized standard-of-care controlled trial. It was embedded within the WHiTE Comprehensive Cohort Study. The sample size was 964 patients. The setting was five National Health Service Trauma Hospitals in England. A total of 964 patients over 60 years of age who required hemiarthroplasty of the hip between February 2015 and March 2016 were included. A standardized measure of health outcome, the EuroQol (EQ-5D-5L) questionnaire, was carried out on admission and at four months following the operation. Results: Of the 964 patients enrolled, 482 died or were lost to follow-up (50%). No significant differences were noted in EQ-5D between groups, with a mean difference at four months of 0.037 in favour of the Exeter/Unitrax implant (95% confidence interval (CI) 0.014 to 0.087, p = 0.156), rising to 0.045 (95% CI 0.007 to 0.098, p = 0.09) when patients who died were excluded. The minimum clinically important difference for EQ-5D-5L used in this study is 0.08, therefore any benefit between implants is unlikely to be noticeable to the patient. There was no difference in mortality or mobility score. Conclusion: Allowing for the high rate of loss to follow-up, the use of the traditional Thompson hemiarthroplasty in the treatment of the displaced intracapsular hip fracture shows no difference in health outcome when compared with a modern cemented hemiarthroplasty. Cite this article: Bone Joint J 2018;100-B:352-60.

Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose.

OBJECTIVES: We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. METHODS: We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. RESULTS: A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. CONCLUSION: We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design.Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499-505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1.

Thompson hemiarthroplasty versus modular unipolar implants for patients requiring hemiarthroplasty of the hip: A systematic review of the evidence.

OBJECTIVES: The objective of this study was to assess all evidence comparing the Thompson monoblock hemiarthroplasty with modular unipolar implants for patients requiring hemiarthroplasty of the hip with respect to mortality and complications. METHODS: A literature search was performed to identify all relevant literature. The population consisted of patients undergoing hemiarthroplasty of the hip for fracture. The intervention was hemiarthroplasty of the hip with a comparison between Thompson and modular unipolar prostheses.Pubmed, Embase, CINAHL, Web of Science, PROSPERO and the Cochrane Central Register of Controlled Trials.The study designs included were randomised controlled trials (RCTs), well designed case control studies and retrospective or prospective cohort studies. Studies available in any language, published at any time until September 2015 were considered. Studies were included if they contained mortality or complications. RESULTS: The initial literature search identified 4757 items for examination. Four papers were included in the final review. The pooled odds ratio for mortality was 1.3 (95% confidence Interval 0.78 to 2.46) favouring modular designs. The pooled odds ratio for post-operative complications was 1.1 (95% CI 0.79 to 1.55) favouring modular designs. Outcomes were reported at 12 or six months. These papers all contained potential sources of bias and significant clinical heterogeneity. CONCLUSION: The current evidence comparing monoblock versus modular implants in patients undergoing hemiarthroplasty is weak. Confidence intervals around the pooled odds ratios are broad and incorporate a value of one. Direct comparison of outcomes from these papers is fraught with difficulty and, as such, may well be misleading. A well designed randomised controlled trial would be helpful to inform evidence-based implant selection.Cite this article: A. L. Sims, A. J. Farrier, M. R. Reed, T. A. Sheldon. Thompson hemiarthroplasty versus modular unipolar implants for patients requiring hemiarthroplasty of the hip: A systematic review of the evidence. Bone Joint Res 2017;6:-513. DOI: 10.1302/2046-3758.68.BJR-2016-0256.R1.

STICKS study - Short-sTretch Inelastic Compression bandage in Knee Swelling following total knee arthroplasty - a feasibility study.

BACKGROUND: Postoperative knee swelling is common and impairs early postoperative function following total knee arthroplasty. It was hypothesised that the use of a short-stretch, inelastic compression bandage would reduce knee swelling and improve pain and early function. The aim of this study was to provide preliminary data and test feasibility with a view to informing a larger, future trial. METHODS: Fifty consecutive patients selected for primary total knee arthroplasty underwent distance randomisation to receive a short-stretch, inelastic compression bandage or a standard wool and crepe bandage for the first 24 h postoperatively. Study feasibility including recruitment rates, retention rates and complications were analysed. The Oxford Knee Score, the EQ-5D-3L index score, knee swelling, knee range of motion, visual analogue pain score and length of stay were compared between groups. Analysis of covariance (ANCOVA) was performed adjusting for the preoperative measurement. RESULTS: Sixty-eight percent of eligible patients were recruited into the trial. The retention rate was 88%. There were no complications regarding compression bandage use. There was a greater mean but non-significant improvement in Oxford Knee Score (p = 0.580; point estimate = 2.1; 95% CI -3.288 to 7.449) and EQ-5D-3L index score (p = 0.057; point estimate = 0.147; 95% CI -0.328 to 0.005) in the compression bandage group at 6 months. There was no significant difference between groups regarding knee swelling, knee range of motion, visual analogue pain score, complications and length of stay. CONCLUSION: Preliminary data suggests that the use of an inelastic, short-stretch compression bandage following total knee arthroplasty is a safe technique that is acceptable to patients. A larger, multicentre trial is required to determine its effect postoperatively. TRIAL REGISTRATION: The study was registered with Current Controlled Trials, identifier: ISRCTN86903140 . Registered on 30 May 2013.

The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: The Fractured Hip Infection trial.

AIMS: A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection. PATIENTS AND METHODS: A quasi-randomised study of 848 patients with an intracapsular fracture of the hip was conducted in one large teaching hospital on two sites. All were treated with a hemiarthroplasty. A total of 448 patients received low dose single-antibiotic impregnated cement (control group) and 400 patients received high dose dual-antibiotic impregnated cement (intervention group). The primary outcome measure was deep SSI at one year after surgery. RESULTS: The rate of deep SSI was 3.5% in the control group and 1.1% in the intervention group (p = 0.041; logistic regression adjusting for age and gender). The overall rate of non-infective surgical complications did not differ between the two groups (unadjusted chi-squared test; p > 0.999). CONCLUSION: The use of high dose dual-antibiotic impregnated cement in these patients significantly reduces the rate of SSI compared with standard low dose single antibiotic loaded bone cement. Cite this article: Bone Joint J 2016;98-B:1534-1541.

Performance and learning curve of a surgical care practitioner in completing hip aspirations.

INTRODUCTION The roles of non-medically trained practitioners within the NHS are expanding; they are now being employed by many specialties, including surgery, to relieve pressures on healthcare teams. AIMS To investigate the learning curve and competence of an orthopaedic surgical care practitioner (SCP) in performing hip aspirations. METHODS Data were retrospectively collected on 510 orthopaedic hip aspirations, of which 360 were completed by a single SCP and 150 were completed by surgeons before the SCP took over routine aspiration. The 360 aspirations completed by an SCP were separated into groups of 30 by date, so any trend in failure rate could be analysed. Ordinal χ2 analysis was used to analyse this trend and Pearson χ2 analysis was used to analyse differences in failure rates between professionals. RESULTS The hip aspiration failure rate for the SCP was significantly lower than for the surgeons; 8.6% vs 20.7% (P<0.001). With the experience gained in completing the first 210 procedures, the failure rate of the SCP dropped to 3.3% for the remaining 150 procedures. This downward trend in hip aspiration failure rate, with advancing experience of the SCP, was shown to be statistically significant (P=0.006). DISCUSSION SCPs who complete hip aspirations on a regular basis have significantly lower failure rates than surgeons, probably as a result of the learning curve, which this study demonstrated. Other trusts should consider delegating routine hip aspiration work to a designated SCP to lower failure rates.

Resident education in orthopaedic trauma: the future role of competency-based medical education.

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees' performance in managing orthopaedic trauma patients. This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320-5.

Do large pragmatic randomised trials change clinical practice?: assessing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT).

AIMS: Our aim, using English Hospital Episode Statistics data before during and after the Distal Radius Acute Fracture Fixation Trial (DRAFFT), was to assess whether the results of the trial affected clinical practice. PATIENTS AND METHODS: Data were grouped into six month intervals from July 2005 to December 2014. All patient episodes in the National Health Service involving emergency surgery for an isolated distal radial fracture were included. RESULTS: Clinical practice in England had not changed in the five years before DRAFFT: 75% of patients were treated with plate fixation versus 12% with Kirschner (K)-wires. After the publication of the trial, the proportion of patients having K-wire fixation rose to 42% with a concurrent fall in the proportion having fixation with a plate to 48%. The proportion of 'other' procedures stayed the same. TAKE HOME MESSAGE: It appears that surgeons in the United Kingdom do change their practice in response to large, pragmatic, multicentre clinical trials in musculoskeletal trauma.

The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol.

BACKGROUND: Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of 'proven' cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes. DESIGN: This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset. DISCUSSION: Evidence on the optimum choice of prosthesis for hemiarthroplasty of the hip is lacking. National guidance is currently based on expert opinion rather than empirical evidence. The incidence of hip fracture is likely to continue to increase and providing high quality evidence on the optimumCite this article: A. L. Sims. The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol. Bone Joint Res 2016;5:18-25. doi: 10.1302/2046-3758.51.2000473.

Prophylactic antibiotics in elective hip and knee arthroplasty: an analysis of organisms reported to cause infections and National survey of clinical practice.

OBJECTIVES: We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England. METHODS: Analysis of data routinely collected by Public Health England's (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire. RESULTS: Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence. CONCLUSIONS: The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies. Cite this article: Bone Joint Res 2015;4:181-189.

Independent validation of the Nottingham Hip Fracture Score and identification of regional variation in patient risk within England.

The Nottingham Hip Fracture Score (NHFS) was developed to assess the risk of death following a fracture of the hip, based on pre-operative patient characteristics. We performed an independent validation of the NHFS, assessed the degree of geographical variation that exists between different units within the United Kingdom and attempted to define a NHFS level that is associated with high risk of mortality. The NHFS was calculated retrospectively for consecutive patients presenting with a fracture of the hip to two hospitals in England. The observed 30-day mortality for each NHFS cohort was compared with that predicted by the NHFS using the Hosmer-Lemeshow test. The distribution of NHFS in the observed group was compared with data from other hospitals in the United Kingdom. The proportion of patients identified as high risk and the mortality within the high risk group were assessed for groups defined using different thresholds for the NHFS. In all 1079 hip fractures were included in the analysis, with a mean age of 83 years (60 to 105), 284 (26%) male. Overall 30-day mortality was 7.3%. The NHFS was a significant predictor of 30-day mortality. Statistically significant differences in the distribution of the NHFS were present between different units in England (p < 0.001). A NHFS ≥ 6 appears to be an appropriate cut-point to identify patients at high risk of mortality following a fracture of the hip.

Cemented Thompson's hemiarthroplasty in patients with intracapsular neck of femur fractures: survival analysis of 1,670 procedures.

Cemented Thompson's prostheses have been used to treat elderly patients with displaced intracapsular hip fractures at our two units for the last 15 years, amid growing support for the use of newer implant designs for hip hemiarthroplasty. This provided us with an opportunity to investigate survival of the Thompson's stem in our patients. A retrospective cohort study was set up to review previously collected data on patients who underwent Thompson's hemiarthroplasty over a 7-year period. These were linked to surgical notes, clinical letters and radiographs to record post-operative course and subsequent admissions and procedures. The identifiers were then linked to mortality data from the Office of 'National Statistics. Kaplan-Meier survival analyses were done for implants and patients. A total of 1,632 patients (mean age 82.7 years) underwent 1,670 procedures. Five-year implant survival was 95.4 %. A total of 36 stems were revised, including 14 revisions to total hip arthroplasty and 22 excision arthroplasties. Reasons for revision included infection (2.1 %), dislocation (1.1 %) and aseptic loosening (0.5 %). Symptomatic aseptic loosening and acetabular erosion occurred late (mean time 3.2 and 5.7 years, respectively following surgery). Aseptic loosening and erosion following hemiarthroplasty are relatively late complications.

Infection control hazards associated with the use of forced-air warming in operating theatres.

A review is presented of the published experimental and clinical research into the infection control hazards of using forced air-warming (FAW) in operating theatres to prevent inadvertent hypothermia. This evidence has been reviewed with emphasis on the use of ultra-clean ventilation, any interaction it has with different types of patient warming (and FAW in particular), and any related increased risk of surgical site infection (SSI). We conclude that FAW does contaminate ultra-clean air ventilation; however, there appears to be no definite link to an increased risk of SSI based on current research. Nevertheless, whereas this remains unproven, we recommend that surgeons should at least consider alternative patient-warming systems in areas where contamination of the operative field may be critical. Although this is not a systematic review of acceptable randomized controlled clinical trials, which do not exist, it does identify that there is a need for definitive research in this field.

Enhanced education and physiotherapy before knee replacement; is it worth it? A systematic review.

BACKGROUND: Around 20% of knee replacement have an unsatisfactory outcome. Pre-operative physiotherapy and education have been proposed to improve post-operative outcomes. OBJECTIVES: This systematic review evaluated whether these factors improved length of stay and patient reported outcomes after knee replacement surgery. DATA SOURCES: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO and PEDro were searched on the 1st January 2013. STUDY SELECTION OR ELIGIBILITY CRITERIA: Randomised or quasi-randomised studies assessing either pre-operative education or physiotherapy on patients undergoing a planned total or partial knee replacement were included in the review. Only studies with a control group receiving a defined standard of pre-operative care were included. RESULTS: Eleven studies met the inclusion criteria set. Two studies analysed the effect of pre-operative education, seven pre-operative treatment by a physiotherapist and two studies used both factors. No study found significant differences in validated joint specific patient reported outcome measures. The education studies found a decrease in pre-operative expectation and an improvement in knowledge, flexion and regularity of exercise. Two studies found an improvement in muscle strength in the group treated by a physiotherapist at three months. The combination of education and physiotherapy was shown to reduce patient length of stay and cost in one study. CONCLUSION: The evidence reviewed is insufficient to support the implementation of either pre-operative education or physiotherapy programmes. The combination of pre-operative education and treatment by a physiotherapist may reduce the medical costs associated with surgery.

Consultant and trainee attitudes towards supervision of operative procedures in the UK and Ireland.

The e-logbook is used to monitor progression through training and to assess training within teaching units. We document consultant and trainee opinions with regards to supervision status, and to inform guidelines for trainees and trainers using the e-logbook. A questionnaire was sent to consultants and trainees in the UK and Ireland. Eight theatre scenarios were described and respondents were asked to state what they felt was the appropriate supervision status for the trainee. Significantly more consultants in the UK use the e-logbook than those based in Ireland (58.5%:14.5%). There were differences in consensus response to the scenarios between consultants and trainees, and between Irish and UK based surgeons. We have documented the opinions of consultants and trainees from across the UK and Ireland with regards to supervision status for trainees under certain theatre situations. This information should support formal guidelines for all users of the logbook.

Evidence-base for aspirin as venous thromboembolic prophylaxis following joint replacement.

The National Institute for Health and Clinical Excellence (NICE) has thus far relied on historical data and predominantly industry-sponsored trials to provide evidence for venous thromboembolic (VTE) prophylaxis in joint replacement patients. We argue that the NICE guidelines may be reliant on assumptions that are in need of revision. Following the publication of large scale, independent observational studies showing little difference between low-molecular-weight heparins and aspirin, and recent changes to the guidance provided by other international bodies, should NICE reconsider their recommendations? Cite this article: Bone Joint Res 2014;3:146-9.