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In the era of patient centred medical practice, we are forced to regularly adapt our approach to keep up with the growing demands of an aging population while focusing on quality improvement, and reducing unwarranted variations in access to health services as well as in quality and outcomes. In a mission to address some of these challenges, the five north central London (NCL) clinical commissioning groups and five NCL National Health Service trusts currently undertaking adult elective orthopaedic surgery collaborated to propose and develop dedicated elective orthopaedic centres. The goal was to create an orthopaedic clinical network that will join together orthopaedic services under one quality improvement umbrella. We present this process, which provides an innovative model of service delivery and the genesis of an orthopaedic network. We believe this model offers essential principles with which future integrated care systems could engage: clinical leadership, early public involvement, proposal transparency, co-design through multiple trust collaboration, addressing health inequalities and establishing a system to deliver best practice care. Our ability to all come together (hospital trusts, patients and the public) is a clear example of the collaborative potential that our healthcare system has, and can be seen as a blueprint for future endeavours. We hope that the transformation of the NCL elective orthopaedic network through elective orthopaedic centres will provide a beneficial template to colleagues and public communities attempting to meet the enhancing demand on current orthopaedic services, and that this will improve the delivery of health services beyond the constraints of our locality. [ABSTRACT FROM AUTHOR]

Background: Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies.Questions/purposes: We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs.Methods: We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years).Results: Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate.Conclusions: Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA.Level Of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

We describe a software tool specifically developed to support the monitoring and reporting of the occurrence of surgical site infections (SSI) in hospitals. The tool uses data collected routinely by a London teaching hospital as part of its infection surveillance system, which includes post-discharge follow-up. Based on these data, the tool is used to generate graphs showing cumulative infections over time and variable life-adjusted display (VLAD) charts that account for the expected specialty average infection risk. The user can select, along with other options, the definition of infection used in the preparation of the graphs. Using an illustrative example of SSI monitoring in orthopaedic surgery, we demonstrate the tool and its intended use to trigger further scrutiny rather than draw firm conclusions. We show that the tool has the ability to generate departmental debate, which should ultimately lead to the increased safety of surgical patients. We recommend adopting the tool and VLAD charts wherever surgical site surveillance is continuous. [ABSTRACT FROM AUTHOR]

Total hip arthroplasty is a well-established treatment for arthritis of the hip. The choice of bearing couple used for articulation should be tailored to the patient. This article reviews the history of different bearing surfaces, and outlines the advantages and disadvantages that may influence their use. [ABSTRACT FROM AUTHOR]

Background: Successful treatment of an infected joint arthroplasty depends on correctly identifying the responsible pathogens. The value of a preoperative biopsy remains controversial.Questions/purposes: We (1) compared the sensitivity and specificity of both tests separately and in combination, and (2) asked whether the combination of tissue biopsy and aspiration would improve our diagnostic yield in the evaluation of periprosthetic joint infections.Patients and Methods: We prospectively followed 120 patients with suspected infection of a total joint arthroplasty: 64 with THAs and 56 with TKAs. All patients had aspiration with culture and biopsy.Results: The sensitivity was 83% for aspiration, 79% for biopsy, and 90% for the combination of both techniques. The specificity was 100% for aspiration and biopsy and the combination. The overall accuracy was 84%, 81%, and 90%, respectively.Conclusions: Our data suggest tissue biopsy alone offers no clear advantage over joint aspiration. However, the combination of both techniques provides improved sensitivity and accuracy. We recommend the use of tissue biopsy as an adjunct to joint aspiration in the diagnosis of total joint infection.Level Of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The thrust of meniscal surgery has now moved toward meniscal preservation. Repair is particularly indicated on the lateral side where the sequelae of resection are severe even in an older patient population.Questions/purposes: The aim of this study was to analyze the success of all-inside meniscus repairs in a carefully selected patient population.Methods: Three hundred twelve repairs were performed in 288 patients with a mean age of 32 years (range, 17-46 years). One hundred seventy-one lateral menisci and 141 medial menisci were repaired. The minimum followup was 12 months (mean, 18 months; range, 12-55 months). Medicolegal cases, major trauma, and knee dislocations were excluded. Failure was defined as persistent meniscal symptoms beyond 16 weeks, an MRI diagnosis of a nonhealed meniscal tear beyond 52 weeks, reoperation for the meniscal tear, and failure to return to the patient's previous functional level.Results: There were three painful capsular sutures that required removal, two cases of complex regional pain syndrome, and two deep venous thromboses. The repair failed in 6% of cases with associated ACL reconstruction and 14.1% of cases without ACL reconstruction. Repeat surgery was typically performed at a mean of 16 months (range, 1-44 months).Conclusions: At short-term followup, all-inside meniscus repairs have good outcomes in the majority of highly selected cases, although this was a very selected cohort with a large number of associated ACL reconstructions.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: There is limited information regarding revision total knee arthroplasty (TKA) with respect to etiology, outcome, and long-term survival comparing different implant types.Questions/purposes: We compared patient outcomes, survivorship and modes of failure and the most common etiologic factors for rerevision between different revision implant types.Methods: We retrospectively reviewed 349 cases of revision TKA in 343 patients whose mean age was 67.8 years. Three implant types were used: posterior stabilized, condylar constrained knee, and rotating hinge. The etiologies included infection (32.7%), aseptic loosening (14.9%), and polyethylene wear (12.3%). The minimum followup was 12 months (mean, 57.7 months; range, 12-120 months).Results: The mean Knee Society scores were 89 (range, 48-94), 88.9 (range, 45-95), and 84 (range, 56-94) and the mean ranges of motion were 110.0 degrees (range, 70 degrees -125 degrees ), 106.1 degrees (range, 70 degrees -120 degrees ), and 111.7 degrees (range, 85 degrees -125 degrees ) for the posterior stabilized, condylar constrained knee, and rotating hinge types, respectively. The rotating hinge group had the highest satisfaction rates (88%). Overall 10-year survivorship was 90.6% with highest survivorship seen in the rotating hinge group. The most common causes for rerevision were infection (2.9% of our cohort), instability (1.7%), and aseptic loosening (1.4%). The mean overall time to rerevision was 69.9 months (range, 11-119 months).Conclusions: In our experience periprosthetic infection is the most common cause of failure of both primary and revision TKA. Functional outcome and range of motion improve irrespective of revision implant type. The rotating hinge prosthesis provides patient satisfaction and survivorship similar to that of other implant types.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

We report an unusual case of femoral fracture from minimal trauma, due to the rapid disappearance of a bioabsorbable interference screw used for reconstruction of the posterolateral corner of the knee. The literature on bone tunnel fractures following knee ligament reconstruction surgery is also reviewed. [ABSTRACT FROM AUTHOR]

Total hip arthroplasty (THA) is one of the most commonly preferred orthopaedic procedures. Although the rate of deep infection after primary hip arthroplasty is relatively low, the economic burden, associated morbidity and mortality make it potentially devastating. Because of an ageing population will need an increasing number of arthroplasties, prevention, diagnosis and treatment of infection must be optimised in order to reduce both direct and indirect costs to patients and healthcare systems. [ABSTRACT FROM AUTHOR]

Numerous physical tests have been described but their diagnostic accuracy is often questioned. Karachalios et al. described the new 'Thessaly test' and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery. Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test. We examined 109 patients (80 male, 29 female; average age: 39 years; range: 16-56) who were presented with a history suggestive of a meniscal tear. Joint line tenderness, McMurray's test, and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated. Our study showed a much lower diagnostic accuracy for the Thessaly test (61% for medial meniscus and 80% for lateral meniscus). It is comparable to McMurray's test (57% for medial meniscus and 77% for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (81% for medial meniscus and 90% for lateral meniscus). However, combining the joint line tenderness test with McMurray's test or the joint line tenderness test with Thessaly test further increased the accuracy of physical diagnosis of meniscal tears. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations and especially where more than one pathology is suspected. Our study showed that the Thessaly test in isolation was not useful for the detection of meniscal tears but it helps to increase diagnostic certainty when combined with other standard tests. [ABSTRACT FROM AUTHOR]

Primary total hip arthroplasty has been one of the most successful orthopaedic procedures of the last century. Several classical surgical approaches to the hip have been described. Each approach has advantages and disadvantages. Recently, minimally invasive techniques have been developed with incisions less than 10cm. The goals of minimally invasive surgery are minimal soft tissue damage and a shorter hospital stay, faster recovery and return to work, less pain, and improved cosmetic results. The disadvantages are less visibility, longer operation time, nerve injuries, higher incidence of femoral fractures, malposition of the components and a long learning curve. The originator results with these techniques were promising. Subsequently, more controversial results have been published. Further follow-up and development is necessary to compare the results with the classical proven approaches. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) surgery is a widely used treatment and has a high success rate. Despite its success, the patello-femoral articulation has been overlooked as a contributor to the successful outcome of TKA. Patello-femoral complications remain the leading cause of failed knee replacement, accounting for up to 10% of complications. To understand the concept of patellar mal-tracking, we explore the normal anatomy and biomechanics of the patello-femoral articulation, and review the surgical factors and complications related to patellar tracking, with an aim to discussing the concepts on how to avoid such complications. Surgeons should be aware of the frequent occurrence of abnormal patellar tracking, and should pay particular attention to the patello-femoral component of knee replacement surgery. [ABSTRACT FROM AUTHOR]

Escalating incidence of periprosthetic fractures around the knee is attributable to ever-increasing indications of total knee arthroplasties (TKAs), the growing elderly population with knee prostheses, and the increased activity of patients with TKA. Periprosthetic fractures around TKA can involve the femur, tibia, or patella. Successful treatment of periprosthetic fractures about TKA is defined as the absence of knee pain, fracture union in less than 6 months, return to functional range of motion and a normal ambulatory status. Treatment options include conservative and operative methods. [ABSTRACT FROM AUTHOR]

Female athletes in endurance sports are at risk of osteoporosis which predisposes them to femoral neck stress fractures. These require early diagnosis and treatment to avoid catastrophic consequences. [ABSTRACT FROM AUTHOR]

Acute compartment syndrome in athletes, although rare, is a limb threatening condition which warrants emergency treatment. The case of a footballer with acute compartment syndrome of the left lower leg, without any preceding direct trauma to the calf, is reported. To our knowledge this is the only description of acute atraumatic compartment syndrome secondary to rupture of one of the heads of gastrocnemius. [ABSTRACT FROM AUTHOR]

Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon's philosophy. It also helps reduce iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation., Competing Interests: A. Fontalis reports a Freemasons’ Royal Arch Fellowship with support from the Arthritis Research Trust, and was awarded the 2021/2022 Onassis Foundation Scholarship, to support his PhD studies. F. S. Haddad reports multiple research study grants from Stryker, Smith & Nephew, Corin, International Olympic Committee, NIHR, consulting fees from Stryker, royalties from Smith & Nephew, Stryker, Corin, and MatOrtho, speaker payments or honoraria from Stryker, Smith & Nephew, Zimmer, AO Recon, and Mathys, support for attending meetings and/or travel from Stryker, Mathys, AO Recon, and The Bone & Joint Journal, all of which are unrelated to this article. F. S. Haddad is also Editor-in-Chief of The Bone & Joint Journal, the incoming president of the International Hip Society, and Vice President of the European Hip Society., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Competing Interests: None declared

Aims: The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system., Methods: This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed., Results: The BOne trauma and Soft-Tissue Injury classification system in total Hip arthroplasty (BOSTI Hip) grades osseous acetabular trauma and periarticular muscle damage during THA. The classification system has an interclass correlation coefficient of 0.90 (95% CI 0.86 to 0.93) for interobserver agreement and 0.89 (95% CI 0.84 to 0.93) for intraobserver agreement. RO THA was associated with improved BOSTI Hip scores (p = 0.002) and more pristine osseous surfaces in the anterior superior (p = 0.001) and posterior superior (p < 0.001) acetabular quadrants compared with CO THA. There were no differences between the groups in relation to injury to the gluteus medius (p = 0.084), obturator internus (p = 0.241), piriformis (p = 0.081), superior gamellus (p = 0.116), inferior gamellus (p = 0.132), quadratus femoris (p = 0.208), and vastus lateralis (p = 0.135), but overall combined muscle injury was reduced in RO THA compared with CO THA (p = 0.023)., Discussion: The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. RO THA was associated with improved BOSTI Hip scores, more pristine osseous acetabular surfaces, and reduced combined periarticular muscle injury compared with CO THA. Further research is required to understand if these intraoperative findings translate to differences in clinical outcomes between the treatment groups., Competing Interests: F. S. Haddad reports board membership on The Bone & Joint Journal and membership on the British Orthopaedic Sports Trauma and Arthroscopy Association (BOSTAA) Executive Committee, and is a Trustee of the British Orthopaedic Association. F. S. Haddad also reports: multiple research study grants from Stryker, Smith & Nephew, Corin, International Olympic Committee, and National Institutes of Health and Research; royalties or licenses from Smith & Nephew, Stryker, Corin, and MatOrtho; consulting fees from Stryker; speaker payments from Stryker, Smith & Nephew, Zimmer, and AO Recon; and support for attending meetings and/or travel from Stryker, Smith & Nephew, AO Recon, and The Bone & Joint Journal., (© 2024 The British Editorial Society of Bone & Joint Surgery.)