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The Journal of Bone & Joint Surgery (British Volume) had a long and justified reputation for delivering the latest musculoskeletal research in a well-written and easily digestible format. Readers want and deserve clear and concise reporting of research findings and, in particular, how these will

Introduction Osteoporotic hip fractures present a significant global challenge to patients, clinicians and healthcare systems. It is estimated that hip fracture accounts for 1.4% of total social and healthcare costs in the established market economies. Methods and analysis The World Hip Trauma Evaluation (WHiTE) was set up to measure outcome in a comprehensive cohort of UK patients with hip fracture. All patients in the cohort are treated under a single comprehensive treatment pathway. A core outcome set, including health-related quality of life, is collected on all the patients. This protocol describes the current multicentre project that will be used as a vehicle to deliver a series of embedded observational studies. Ethics and dissemination Research Ethics Committee approval was granted (Rec reference 11/LO/0927, approved 18/8/2011) and each hospital trust provided National Health Service (NHS) approvals. Trial registration number The study is registered with National Institute of Health Research Portfolio (UKCRN ID 12351) and the ISRCTN registry ([ISRCTN63982700][1]). [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN63982700

Background There is strong evidence that severely injured patients are optimally treated within inclusive trauma networks. One feature of such networks is prehospital triage of the most injured patients to designated trauma hospitals. In April, 2012, major trauma services across England were reconfigured into regional trauma networks based around designated major trauma centres (MTCs). This study explored the early effects of the regionalisation of major trauma services in England. Methods The Trauma & Audit Research Network (TARN) identified severely injured patients treated in the 9 months before and after each MTC became fully operational. Outcomes included quality indicators (eg, time to CT scanning for head injured patients) and clinical outcomes (eg, in-hospital mortality). Completeness of the TARN dataset was quantified with Hospital Episode Statistics. Death registrations were used to identify any change in the overall number of traumatic deaths in England. Findings The number of severely injured patients treated in MTCs increased from 7705 to 12 476. All care quality indicators improved: treatment by a consultant (30·4% before MTC vs 54·3 after MTC, p vs 58·5, p=0·006), and time to CT scanning for head injured patients (49·2 min vs 31·2, p vs 25·9, p vs 64·5, p Interpretation There is early evidence of improved care associated with trauma service regionalisation, including some process measures, enhanced case reporting for national audit, and reduced need for secondary transfer of patients between hospitals. However, in this early post-implementation analysis, significant reductions in patient mortality were not observed. Funding Royal College of Surgeons of England Fulbright Scholarship.

Objective: To report on the relative cost-effectiveness of total hip arthroplasty and resurfacing arthroplasty (replacement of articular surface of femoral head only) in patients with severe arthritis suitable for hip joint resurfacing arthroplasty. \ud \ud \ud Design: Cost-effectiveness analysis on an intention-to-treat basis of a single-centre, single-blind randomised controlled trial of 126 adult patients within 12 months of treatment. Missing data were imputed using multiple imputations with differences in baseline quality of life and gender adjusted using regression techniques. \ud \ud \ud Setting: A large teaching hospital trust in the UK. \ud \ud \ud Participants: A total of 126 adult patients with severe arthritis of the hip joint suitable for a resurfacing arthroplasty of the hip. \ud \ud \ud Results: Data were received for 126 patients, 4 of whom did not provide any resource use data. For the remainder, data were imputed for costs or quality of life in at least one time point (baseline, 3, 6 months and 1 year) for 18 patients. Patients in the resurfacing arm had higher quality of life at 12 months (0.795 vs 0.727) and received 0.032 more QALYs within the first 12 months postoperation. At an additional cost of £564, resurfacing arthroplasty offers benefits at £17 451 per QALY within the first 12 months of treatment. When covariates are considered, the health economic case is stronger in men than in women. \ud \ud \ud Conclusions: Resurfacing arthroplasty appears to offer very short-term efficiency benefits over total hip arthroplasty within a selected patient group. The short-term follow-up in this trial should be noted, particularly in light of the concerns raised regarding adverse reactions to metal debris from metal-on-metal bearing surfaces in the longer term. Longer-term follow-up of resurfacing arthroplasty patients and decision analytic modelling is also advised. \ud \ud \ud Trial registration Current controlled Trials: ISRCTN33354155. UKCRN 4093.\ud

Proximal femur fractures carry significant levels of morbidity and mortality. Surgical delay is one factor that adversely affects outcome in these patients. In 2010, hospital-income from patients with proximal femur fractures was linked to the surgery being undertaken within 36 h of admission. Can we deliver this target?Data from the 2009 National Hip Fracture Database was interrogated and appropriate patients were identified. Patient records were reviewed to identify the reasons for surgical delay. Mortality rates were compared within 36 h and after.Five-hundred and thirty-two patients were admitted in 2009, 118 (22 %) of them were delayed more than 36 h. Surgery was delayed for a variety of identified reasons. Median time to surgery was 24 h (1-273). Ninety-day mortality for patients treated within 36 h was 12.4 %, but 25 % (P = 0.047) in patients delayed for medical problems.Not all patients with a fracture of the proximal femur can have surgery within 36 h of their injury. However, we have identified and describe four specific areas that could increase the number of patients who meet this target.

BACKGROUND The morbidity and socioeconomic costs associated with long bone healing are considerable. Platelet-rich therapies are autologous blood products with a greater concentration of platelets than physiological whole blood. Despite promising results from a number of in-vitro animal studies, clinical evidence to support the use of platelet-rich therapy in long bone healing is unclear. OBJECTIVES To assess the effects (benefits or harms) of platelet-rich therapies for treating long bone osteotomies, acute fractures, un-united fractures and defects in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (8 November 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 4), MEDLINE (1948 to November Week 1 2011) and EMBASE (1980 to Week 44 2011). Trial registers and reference lists of articles were also searched. SELECTION CRITERIA Randomised and quasi-randomised controlled clinical trials evaluating any type of platelet-rich therapy compared with either no additional treatment or a placebo in the management of long bone osteotomies, acute fractures, un-united fractures and defects in adults. Studies including participants over 18 years of age; reporting functional outcomes, time to union, non-union, secondary procedures such as for fixation failure or delayed or non-union, adverse effects, pain or costs were included. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies for inclusion in the review. Studies were assessed for the risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Treatment effects for dichotomous outcomes were expressed with risk ratios (RR) and continuous measures with mean differences, together with 95% confidence intervals (CI). MAIN RESULTS Only one eligible study, involving 21 participants, was included. The study compared platelet-rich therapy and allogenic bone graft with allogenic bone graft alone in patients undergoing corrective osteotomy for medial compartment osteoarthrosis of the knee. The risk of bias associated with this study was substantial. There was no significant difference in patient-reported or clinician-assessed functional outcome scores between groups at one year. There was a statistically significant benefit from platelet-rich therapy in the proportion of bones that were united at one year (8/9 versus 3/9; RR 2.67; 95% CI 1.03 to 6.91). This benefit, however, was not maintained when assuming poor outcomes for participants who were lost to follow-up (8/11 versus 3/10; RR 2.42; 95% CI 0.88 to 6.68). One adverse event was reported in a participant receiving platelet-rich therapy.One other eligible study involving hip fracture patients is currently underway. AUTHORS' CONCLUSIONS While a potential benefit of platelet-rich therapies to augment long bone healing in adults cannot be ruled out, the currently available evidence from a single trial is insufficient to support the routine use of this intervention in clinical practice. Future trials should focus on reporting patient-reported functional outcomes from all trial participants for a minimum follow-up of one year.

The net production of NO by the muscle microvascular endothelium is a key regulator of muscle microvascular blood flow. Here, we describe the development of a method to quantify the protein content and phosphorylation of endothelial NO synthase (eNOS content and eNOS ser(1177) phosphorylation) and NAD(P)H oxidase expression.Human muscle cryosections were stained using antibodies targeting eNOS, p-eNOS ser(1177) and NOX2 in combination with markers of the endothelium and the sarcolemma. Quantitation was achieved by analyzing fluorescence intensity within the area stained positive for the microvascular endothelium. Analysis was performed in duplicate and repeated five times to investigate CV. In addition, eight healthy males (age 21 ± 1 year, BMI 24.4 ± 1.0 kg/m(2)) completed one hour of cycling exercise at ~65%VO(2max) . Muscle biopsies were taken from the m. vastus lateralis before and immediately after exercise and analyzed using the new methods.The CV of all methods was between 6.5 and 9.5%. Acute exercise increased eNOS serine(1177) phosphorylation (fold change 1.29 ± 0.05, p0.05).These novel methodologies will allow direct investigations of the molecular mechanisms underpinning the microvascular responses to insulin and exercise, the impairments that occur in sedentary, obese and elderly individuals and the effect of lifestyle interventions.

Objectives To study the vascularity and bone metabolism of the femoral head/neck following hip resurfacing arthroplasty, and to use these results to compare the posterior and the trochanteric-flip approaches. Methods In our previous work, we reported changes to intra-operative blood flow during hip resurfacing arthroplasty comparing two surgical approaches. In this study, we report the vascularity and the metabolic bone function in the proximal femur in these same patients at one year after the surgery. Vascularity and bone function was assessed using scintigraphic techniques. Of the 13 patients who agreed to take part, eight had their arthroplasty through a posterior approach and five through a trochanteric-flip approach. Results One year after surgery, we found no difference in the vascularity (vascular phase) and metabolic bone function (delayed phase) at the junction of the femoral head/neck between the two groups of patients. Higher radiopharmaceutical uptake was found in the region of the greater trochanter in the trochanteric-flip group, related to the healing osteotomy. Conclusions Our findings using scintigraphic techniques suggest that the greater intra-operative reduction in blood flow to the junction of the femoral head/neck, which is seen with the posterior approach compared with trochanteric flip, does not result in any difference in vascularity or metabolic bone function one year after surgery.

Objectives To compare the clinical and cost effectiveness of total hip arthroplasty with resurfacing arthroplasty in patients with severe arthritis of the hip. Design Single centre, two arm, parallel group, assessor blinded, randomised controlled trial with 1:1 treatment allocation. Setting One large teaching hospital in the United Kingdom. Participants 126 patients older than 18 years with severe arthritis of the hip joint, suitable for resurfacing arthroplasty of the hip. Patients were excluded if they were considered to be unable to adhere to trial procedures or complete questionnaires. Interventions Total hip arthroplasty (replacement of entire femoral head and neck); hip resurfacing arthroplasty (replacement of the articular surface of femoral head only, femoral neck remains intact). Both procedures replaced the articular surface of the acetabulum. Main outcome measures Hip function at 12 months after surgery, assessed using the Oxford hip score and Harris hip score. Secondary outcomes were quality of life, disability rating, physical activity level, complications, and cost effectiveness. Results 60 patients were randomly assigned to hip resurfacing arthroplasty and 66 to total hip arthroplasty. Intention to treat analysis showed no evidence for a difference in hip function between treatment groups at 12 months (t test, P=0.242 and P=0.070 for Oxford hip score and Harris hip score, respectively); 95% of follow-up data was available for analysis. Mean Oxford hip score was 40.4 (95% confidence interval 37.9 to 42.9) in the resurfacing group and 38.2 (35.3 to 41.0) in the total arthroplasty group (estimated treatment effect size 2.23 (−1.52 to 5.98)). Mean Harris hip score was 88.4 (84.4 to 92.4) in the resurfacing group and 82.3 (77.2 to 87.5) in the total arthroplasty group (6.04 (−0.51 to 12.58)). Although we saw no evidence of a difference, we cannot definitively exclude clinically meaningful differences in hip function in the short term. Overall complication rates did not differ between treatment groups (P=0.291). However, we saw more wound complications in the total arthroplasty group (P=0.056) and more thromboembolic events in the resurfacing group (P=0.049). Conclusions No evidence of a difference in hip function was seen in patients with severe arthritis of the hip, one year after receiving a total hip arthroplasty versus resurfacing arthroplasty. The long term effects of these interventions remain uncertain. Trial registration Current Controlled Trials ISRCTN33354155, UKCRN 4093.

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure. We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation.

Background: The application of statistics in reported research in trauma and orthopaedic surgery has become ever more important and complex. Despite the extensive use of statistical analysis, it is still a subject which is often not conceptually well understood, resulting in clear methodological flaws and inadequate reporting in many papers. Methods: A detailed statistical survey sampled 100 representative orthopaedic papers using a validated questionnaire that assessed the quality of the trial design and statistical analysis methods. Results: The survey found evidence of failings in study design, statistical methodology and presentation of the results. Overall, in 17% (95% confidence interval; 10–26%) of the studies investigated the conclusions were not clearly justified by the results, in 39% (30–49%) of studies a different analysis should have been undertaken and in 17% (10–26%) a different analysis could have made a difference to the overall conclusions. Conclusion: It is only by an improved dialogue between statistician, clinician, reviewer and journal editor that the failings in design methodology and analysis highlighted by this survey can be addressed. Background Statistics is an essential component of medical research from design initiation to project reporting, and it influences all aspects of the research process from data collection and management to analysis and interpretation. The application of statistics to medical sciences, and particularly in our area of interest, trauma and orthopaedic surgery, has become more widespread and complex. However, there is considerable evidence, both anecdotal and in the literature [1], of poor reporting and use of statistical methods in orthopaedics papers. Although our experience providing statistical support more widely in medicine leads us to suspect that similar opinions, about the quality of both design and statistical analysis, exists within many other medical disciplines. So our selection of general orthopaedic journals is not solely to highlight particularly bad practice in this discipline, as we suspect much of what we report here is generally applicable to research across all disciplines, and as such orthopaedic publications simply provide an exemplar of this larger population. In an attempt to quantify the extent of poor reporting and use of statistical methods, Parsons et al. [2] undertook a large survey of the orthopaedic literature to assess both the quality of reporting and the appropriate and correct use of statistical methods. The first part of this study found major deficiencies in reporting, with 59% (95% confidence interval; 56–62%) and 58% (56–60%) compliance with CONSORT [3] and STROBE [4] guidelines, and commented on differences between journals and paper types [2]. In the second part of the study, the quality of statistical analysis methods was assessed using a detailed questionnaire which was completed for a random sample of orthopaedics papers by two experienced statisticians. The results of this survey are discussed in detail here. Methods A random sample of 100 papers from the general orthopaedic literature was obtained and included 27

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

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. The National Hip Fracture Audit currently provides a framework for service evaluation. This evaluation is based upon the assessment of process rather than assessment of patient-centred outcome and therefore it fails to provide meaningful data regarding the clinical effectiveness of treatments. This study aims to capture data from the cohort of patients who present with a fracture of the proximal femur at a single United Kingdom Major Trauma Centre. Patient-centred outcomes will be recorded and provide a baseline cohort within which to test the clinical effectiveness of experimental interventions.

INTRODUCTION The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool. METHODS An electronic literature search was performed, restricted to the English language, of MEDLINE®, Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session. RESULTS Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training. CONCLUSIONS Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.

Background Severe arthritis of the knee is a disabling condition, with over 50,000 knee replacements performed each year in the UK. Isolated patellofemoral joint arthritis occurs in over 10% of these patients with the treatment options being patellofemoral arthroplasty or total knee arthroplasty. Whilst many surgeons believe total knee arthroplasty is the 'gold standard' treatment for severe knee arthritis, patellofemoral arthroplasty has certain potential advantages. Primarily, because this operation allows the patient to keep the majority of their own knee joint; preserving bone-stock and the patients' own ligaments. Patellofemoral arthroplasty has also been recognised as a less 'invasive' operation than primary total knee arthroplasty, facilitating a more rapid recovery. There are currently no published results of randomised clinical trials comparing the two arthroplasty techniques. The primary objective of the current study is to assess whether there is a difference in functional knee scores and quality of life outcome assessments at one year post-operation between patellofemoral arthroplasty and total knee arthroplasty. The secondary objective is to assess the complication rates for both procedures. Methods/design Patients who are deemed suitable, by an Orthopaedic Consultant, for patellofemoral arthroplasty and medically fit for surgery are eligible to take part in this trial. The consenting patients will be randomised in a 1:1 allocation to a total knee or patellofemoral arthroplasty. The randomisation sequence will be computer generated and administered by a central independent randomisation service. Following consent, all participants will have their knee function, quality of life and physical activity level assessed through questionnaires. The assigned surgery will then be performed using the preferred technique and implant of the operating surgeon. The first post-operative assessments will take place at six weeks, followed by further assessments at 3, 6 and 12 months. At each assessment time point all complications will be recorded. In addition, community and social care services usage will be collected using a patient questionnaire at 3, 6 & 12 months. The patients will then be sent an annual postal questionnaire. The questionnaire will ask about any problems, knee pain and function following their knee arthroplasty to monitor long-term function and failure rates. Discussion This trial is expected to deliver results in early 2013. Trial Registration ISRCTN: ISRCTN34863373 UKCRN portfolio ID 6847

The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research.

Background Fractures of the distal radius are extremely common injuries in adults. However, the optimal management remains controversial. In general, fractures of the distal radius are treated non-operatively if the bone fragments can be held in anatomical alignment by a plaster cast or orthotic. However, if this is not possible, then operative fixation is required. There are several operative options but the two most common in the UK, are Kirschner-wire fixation (K-wires) and volar plate fixation using fixed-angle screws (locking-plates). The primary aim of this trial is to determine if there is a difference in the Patient-Reported Wrist Evaluation one year following K-wire fixation versus locking-plate fixation for adult patients with a dorsally-displaced fracture of the distal radius. Methods/design All adult patients with an acute, dorsally-displaced fracture of the distal radius, requiring operative fixation are potentially eligible to take part in this study. A total of 390 consenting patients will be randomly allocated to either K-wire fixation or locking-plate fixation. The surgery will be performed in trauma units across the UK using the preferred technique of the treating surgeon. Data regarding wrist function, quality of life, complications and costs will be collected at six weeks and three, six and twelve months following the injury. The primary outcome measure will be wrist function with a parallel economic analysis. Discussion This pragmatic, multi-centre trial is due to deliver results in December 2013. Trial registration Current Controlled Trials ISRCTN31379280 UKCRN portfolio ID 8956

Delayed union and non-union of fractures are a considerable cause of morbidity to patients. Laboratory studies have shown that electromagnetic fields can stimulate the formation of new bone, indicating a potential role for electromagnetic stimulation in the treatment of fractures that have failed to heal.To assess the effects of electromagnetic stimulation for treating delayed union or non-union of long bone fractures in adults.We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2010), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010) and EMBASE (1980 to 2010 Week 20), trial registers and reference lists of articles.Randomised controlled trials evaluating electromagnetic field stimulation for the treatment of delayed union or non-union of long bones in adults.Two authors independently selected studies and performed data extraction and risk of bias assessment. Treatment effects were assessed using risk ratios and, where appropriate, data were pooled using a random-effects model.Four studies, involving 125 participants, were included. Three studies evaluated the effects of pulsed electromagnetic fields and one study, capacitive coupled electric fields. Participants with delayed union and non-union of the long bones were included, but most data related to non-union of the tibia. Although all studies were blinded randomised placebo-controlled trials, each study had limitations.The primary measure of the clinical effectiveness of electromagnetic field stimulation was the proportion of participants whose fractures had united at a fixed time point. The overall pooled effect size was small and not statistically significant (risk ratio 1.96; 95% confidence interval 0.86 to 4.48; 4 trials). There was substantial clinical and statistical heterogeneity in this pooled analysis (I(2) = 58%). A sensitivity analysis conducted to determine the effect of multiple follow-up time-points on the heterogeneity amongst the studies showed that the effect size remained non-significant at 24 weeks (risk ratio 1.61; 95% confidence interval 0.74 to 3.54; 3 trials), with similar heterogeneity (I(2) = 57%).There was no reduction in pain found in two trials. No study reported functional outcome measures. One trial reported two minor complications resulting from treatment.Though the available evidence suggests that electromagnetic field stimulation may offer some benefit in the treatment of delayed union and non-union of long bone fractures, it is inconclusive and insufficient to inform current practice. More definitive conclusions on treatment effect await further well-conducted randomised controlled trials.

Background The primary aim of this study was to provide an estimate of effect size for the functional outcome of operative versus non-operative treatment for patients with an acute rupture of the Achilles tendon using accelerated rehabilitation for both groups of patients. The secondary aim was to assess the use of a comprehensive cohort research design (i.e. a parallel patient-preference group alongside a randomised group) in improving the accuracy of this estimate within an orthopaedic trauma setting. Methods Pragmatic randomised controlled trial and comprehensive cohort study within a level 1 trauma centre. Twenty randomised participants (10 operative and 10 non-operative) and 29 preference participants (3 operative and 26 non-operative). The ge range was 22-72 years and 37 of the 52 patients were men. All participants had an acute rupture of their Achilles tendon and no other injuries. All of the patients in the operative group had a simple end-to-end repair of the tendon with no augmentation. Both groups then followed the same eight-week immediate weight-bearing rehabilitation programme using an off-the-shelf orthotic. The disability rating index (DRI; primary outcome), EQ-5D, Achilles Total Rupture Score and complications were assessed ed at two weeks, six weeks, three months, six months and nine months after initial injury. Results At nine months, there was no significant difference in DRI between patients randomised to operative or non-operative management. There was no difference in DRI between the randomised group and the parallel patient preference group. The use of a comprehensive cohort of patients did not provide useful additional information as to the treatment effect size because the majority of patients chose non-operative management. Conclusions Recruitment to clinical trials that compare operative and non-operative interventions is notoriously difficult; especially within the trauma setting. Including a parallel patient preference group to create a comprehensive cohort of patients has been suggested as a way of increasing the power of such trials. In our study, the comprehensive cohort model doubled the number of patients involved in the study. However, a strong preference for non-operative treatment meant that the increased number of patients did not significantly increase the ability of the trial to detect a difference between the two interventions. Trial registration ISRCTN: ISRCTN29053307

Background In hip resurfacing arthroplasty a metal implant (prosthesis) is used to resurface the patient's native femoral head. The assessment of bone function around theimplant is important in evaluating any subsequent complications. The use of bone single photon emission computed tomography/computed tomography (SPECT/CT) imaging may enhance this evaluation. Objectives The primary objective of this study was to ascertain whether SPECT/CT imaging is feasible in the presence of the metal implant. A secondary objective wasto deduce the impact attenuation correction has on thedetected counts originating from bone covered by themetal implant. Methods A phantom was constructed to allow assessment of counts obtained from a point source (PS) imaged in thevicinity of a hip resurfacing implant. Three implant cup sizes (4, 8 and 10) were assessed and images acquired with a PS positioned adjacent to the implant pin and under the cup. Multiple acquisitions were undertaken both with and without surrounding soft tissue equivalent material. The images were analysed with and without attenuation correction and the recovered counts compared with that ofa PS imaged in free space (control). Results Attenuation-corrected counts did not vary significantly with cup size (P=0.427), PS position (P=0.999), presence of soft tissue equivalent material (P=0.193) or a combination of PS position and soft tissue(P=0.193). The attenuation-corrected counts recovered from a PS (soft tissue equivalent material present) showed an overestimation, compared with the control, both when positioned adjacent to the pin and under the cup; mean 8% (4–16%) and 4% (1–6%), respectively. Conclusion The results of the study suggest that the application of the attenuation correction technique is applicable to bone SPECT/CT images of the femoral head–neck junction acquired in the presence of a hip resurfacing implant.

The Bone & Joint Journal provides the latest evidence to guide the clinical practice of orthopaedic surgeons. The benefits of one intervention compared with another are presented using outcome measures; some may be specific to a limb or joint and some are more general health-related quality of life measures. Readers will be familiar with many of these outcome measures and will be able to judge the relative benefits of different interventions when measured using the same outcome tool; for example, different treatments for pain in the knee measured using a particular knee score. But, how should readers compare outcomes between different clinical areas using different outcome measures? This article explores the use of standardised effect sizes. Cite this article: Bone Joint J 2014;96-B:853–4.

Background: Fractures of the distal radius are common. As the population of the western world ages, their incidence is set to increase further. There are various methods of treating these fractures, but optimal management remains controversial. In the United Kingdom, the most common surgical treatment of closed distal radius fractures is by Kirschner-wires (K-wires) or volar locking plate. In this study, we compared long-term functional outcomes of volar locking plates with those of K-wires. Methods: A retrospective comparative study of 71 patients with dorsally displaced distal radius fractures treated contemporaneously in two independent hospitals was performed. One group was treated with a volar locking plate (n = 36) and the other group with manipulation and K-wire fixation (n = 35). There was no difference between the two groups in terms of demographics or grade of fracture. Outcome was measured 15 months to 27 months post surgery using the Disabilities of the Arm, Shoulder and Hand score and the Patient-Rated Wrist Evaluation score. Results: We found no statistical difference between the two groups in the Patient-Rated Wrist Evaluation score or Disabilities of the Arm, Shoulder and Hand score at 1 year to 2 years postsurgery. Conclusion: We have been unable to demonstrate a clinically relevant advantage of using volar locking plates over K-wires at 1 year to 2 years postoperatively.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of any ultrasound therapy used as part of the treatment of acute fractures in adults. We will make the following comparisons: Low intensity pulsed ultrasound (LIPUS) versus control (sham ultrasound or none). High intensity focused ultrasound (HIFUS) versus control (sham ultrasound or none) Extracorporeal shockwave therapy (ECSW) versus control (sham ultrasound or none) All patients would receive a standard-of-care treatment which is the definitive treatment routinely used in clinical practice for treating the fracture. For example, including but not limited to, non-surgical treatment, such as plaster cast immobilisation, and surgical treatment such as external or internal fixation, using various devices such as intramedullary nailing.

Introduction Trauma remains a major cause of mortality and morbidity, particularly among young adults. A major trauma (whole-body) CT protocol based upon mechanism of injury was investigated in a busy emergency department. Methods Trauma patients presenting in two 3-month periods before and after the introduction of a major trauma CT protocol were identified. The mechanism of injury, Injury Severity Score, radiological imaging performed and injuries detected were recorded. Results More eligible patients received major trauma CT scanning post-protocol than pre-protocol (87/114 (76%) vs 44/94 (47%)). There were no adverse effects attributable to major trauma CT. Seventeen injuries were detected post-protocol that would not have been detected had imaging been conducted based on clinical suspicion rather than mechanism of injury. In three cases an immediate intervention was required. Conclusion Our major trauma CT protocol, based on mechanism of injury, resulted in substantial changes in clinical management in a small number of patients without any increase in adverse events. However, it is not a substitute for clinical acumen in the initial assessment of trauma patients.

Rupture of the lateral collateral ligamentous complex of the elbow is a serious injury. If direct repair of the ligamentous complex is not possible, then an alternative method must be found to stabilise the elbow. We describe a novel method of maintaining stability while allowing early movement in a severe injury to the elbow. This technique is a viable alternative to hinged external fixation in patients with severe lateral instability of the elbow joint.

Background Hip replacement (arthroplasty) surgery is a highly successful treatment for patients with severe symptomatic arthritis of the hip joint. For older patients, several designs of Total Hip Arthroplasty have shown excellent results in terms of both function and value for money. However, in younger more active patients, there is approximately a 50% failure rate at 25 years for traditional implants. Hip resurfacing is a relatively new arthroplasty technique. In a recent review of the literature on resurfacing arthroplasty it was concluded that the short-term functional results appear promising but some potential early disadvantages were identified, including the risk of femoral neck fracture and collapse of the head of the femur.The aim of the current study is to assess whether there is a difference in functional hip scores at one year post-operation between Total Hip Arthroplasty and Resurfacing Arthroplasty. Secondary aims include assessment of complication rates for both procedures as well cost effectiveness. Methods/design All patients medically fit for surgery and deemed suitable for a resurfacing arthroplasty are eligible to take part in this study. A randomisation sequence will be produced and administered independently. After consenting, all patients will be clinically reviewed and hip function, quality of life and physical activity level will be assessed through questionnaires. The allocated surgery will then be performed with the preferred technique of the surgeon. Six weeks post-operation hip function will be assessed and complications recorded. Three, six and 12 months post-operation hip function, quality of life and physical activity level will be assessed. Additional information about patients' out-of-pocket expenses will also be collected. Trial registration Current Controlled Trials ISRCTN33354155 UKCLRN portfolio ID 4093

we report the early results and complications of resurfacing arthroplasty using the 'trochanteric Flip osteotomy' approach to the hip. there are no published clinical results of this approach used for resurfacing arthroplasty. one hundred consecutive patients were assessed prospectively for a minimum follow-up of 2 years (range 2 - 5 years). the oxford Hip score fell from a median of 30 pre-operatively to 5 at two years. similar improvement was found in the UCLA activity score. there were no cases of component failure or fractures. However, nine patients had minor complications related to the osteotomy. resurfacing arthroplasty of the hip may be successfully performed through a trochanteric flip osteotomy. this surgical approach may avoid some of the complications associated with avascular necrosis of the femoral head. (Hip international 2009; 19: 131-5)

The Internet has become an important source of information for patients. Websites offering medical information are not subject to peer-review. The aim of this study was to evaluate the quality of information available on the web regarding hip resurfacing arthroplasty. The search term ‘hip resurfacing’ was entered into five commonly used general search engines. The 20 highest-ranked websites from each engine were reviewed, after eliminating duplicate and non-relevant sites. Each site was then given a quality score (maximum of 20) according to predefined general and specific criteria. Our search identified 40 unique websites. Commercial websites were the most common (n=17). Quality scores ranged from 8 to 18, indicating that the quality of information on the web varied widely. The mean score for all sites was 11.7, SD 2.6, and only four websites scored >15. Fifteen sites did not mention the disadvantages or complications specific to hip resurfacing. The quality of information on the Internet regarding hip resurfacing is variable. Only four sites out of 40 were deemed to be of high quality. Orthopaedic surgeons need to be aware of these limitations, and take the lead in educating and counselling their patients.

We used Laser Doppler flowmetry to measure the effect on the blood flow to the femoral head/neck junction of two surgical approaches during resurfacing arthroplasty. We studied 24 hips undergoing resurfacing arthroplasty for osteoarthritis. Of these, 12 had a posterior approach and 12 a trochanteric flip approach. A Laser probe was placed under radiological control in the superolateral part of the femoral head/neck junction. The Doppler flux was measured at stages of the operation and compared with the initial flux. In both groups the main fall in blood flow occurred during the initial exposure and capsulotomy of the hip joint. There was a greater reduction in blood flow with the posterior (40%) than with the trochanteric flip approach (11%).

Introduction: Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups.\ud \ud Methods and analysis: Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05.\ud \ud Ethics and dissemination: NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations.\ud \ud Trial registration numbers: ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.

Objectives. To determine the expression of mRNA encoding the proteoglycans aggrecan, versican, biglycan and decorin in mid-tendon samples of chronic painful Achilles tendinopathy and ruptured Achilles tendons, compared with normal tendons. Methods. Total RNA isolated from frozen tendon samples (14 normal, 13 painful, 14 ruptured) was assayed by relative quantitative reverse transcription polymerase chain reaction for aggrecan, versican, biglycan and decorin mRNA, normalized using 18S rRNA. Differences between sample groups were tested by univariate analysis of variance with age as co-variate. Results. In normal tendon samples expression of each of the proteoglycan mRNA decreased with increasing age. Decorin mRNA was the most highly-expressed of the proteoglycan mRNA, while versican mRNA expression was higher (3.8-fold) than that of aggrecan. In painful tendinopathy both aggrecan and biglycan mRNA expression increased (more than 10-fold and 5-fold, respectively) compared with normal tendon samples, but levels of versican and decorin mRNA were not significantly changed. In ruptured tendons the levels of aggrecan, biglycan and versican mRNA were not changed compared with normal tendon samples, but decorin mRNA decreased markedly. Conclusions. Increased aggrecan and biglycan mRNA expression in painful tendinopathy resembles the pattern in fibrocartilaginous regions of tendon, and may reflect an altered mechanical environment at the site of the lesion. Increased aggrecan mRNA expression may underlie the increase in glycosaminoglycan observed in painful tendinopathy.

A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes. The purpose of this prospective randomised single blind pilot study was to investigate their potential effectiveness compared with therapeutic ultrasound in subjects with relatively sedentary lifestyles in an NHS hospital setting. Eleven men and five women (mean age 53+/-21 years) with Achilles tendon pain of minimum duration 4 months were randomised to one of two treatment groups; either eccentric loading or ultrasound. Administration of ultrasound and regular supervision of exercises occurred over a period of 6 weeks, with unsupervised exercises continuing for another 6 weeks. Outcome measurements were taken prior to and after 2, 4, 6 and 12 weeks after commencing treatment. They included: pain on a visual analogue scale, functional index of the leg and lower limb, and the five question EuroQol generalised health questionnaire. The difference in mean score was calculated together with 95% confidence intervals assuming a normal distribution. There were no statistically significant differences between groups or clear trends over time. In addition there was considerable overlap between the confidence intervals. This is not unexpected given the small sample size. Both interventions proved acceptable to the patients with no adverse effects. On this basis we intend conducting a full multi-centred study.

The quality and public perception of research has never been under greater scrutiny, whether by formal mechanisms such as the Research Excellence Framework[1][1] or via the media. The scale and intent of a recent high-profile case of research fraud,[2][2] amongst a host of others too numerous to

Objectives. Versican is the principal large proteoglycan expressed in mid-tendon, but its role in tendon pathology is unknown. Our objective was to define the expression of versican isoform splice variant messenger ribonucleic acid (mRNA) in normal Achilles tendons, in chronic painful tendinopathy and in ruptured tendons. Methods. Total RNA isolated from frozen tendon samples (normal n ¼ 14; chronic painful tendinopathy n ¼ 10; ruptured n ¼ 8) was assayed by relative quantitative reverse transcriptase polymerase chain reaction (RT-PCR) for total versican, versican variants V0, V1, V2, V3 and type I collagen � 1 mRNA, normalized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Differences between sample groups were tested by Wilcoxon statistics. Results. Painful and ruptured tendons showed a significant decrease (median 2-fold) in the expression of versican mRNA, in contrast to an increased expression (median 8-fold) of type I collagen � 1 mRNA in painful tendons. Versican splice variants V0 and V1 mRNA were readily detected in normal samples, V3 levels were substantially lower, and V2 levels were more variable. Each of V1, V2 and V3 mRNA showed significant decreases in expression in painful and ruptured tendons, but V0 was not significantly changed. Conclusions. Changes in versican expression relative to that of collagen, and alterations in the balance of versican splice variants, may contribute to changes in matrix structure and function in tendinopathies.

Recent experimental and clinical evidence suggests that early loading and mobilisation for Achilles tendon ruptures may improve functional outcomes. This paper presents the results of a pilot study designed to assess the safety of immediate weight-bearing mobilisation. Twenty-eight operatively repaired patients were randomised to either immediate loading in an orthosis or traditional serial plaster casting. An independent observer, blinded to treatment, assessed the results. Improved clinical, anthropometric, and functional outcomes were noted in the immediate loading group. Ultrasound assessment confirmed no deleterious effects upon the tenodesis. There was one re-rupture of the tendon at a minimum follow-up of 1 year.

Background Societal and financial impacts of osteoarthritis of the hip are considerable. Weight loss, pain relief and exercise help, but total hip replacement (THR) or resurfacing (RS) are frequently necessary. In the UK 80,000 of these operations are undertaken annually costing £65m. In an ageing population, costs will escalate especially as some fail and need revision. Manufacturers market more than 100 different devices and some have recently attracted controversy. We used a new method to compare clinical and cost effectiveness of different types of THR and RS for NICE. Methods We undertook a systematic review of randomised controlled trials (RCTs) of effectiveness supplemented with data from the National Joint Registry (NJR) for >240,000 patients, from the patient reported outcomes measures (PROMs) database and from the NHS Supply chain. We derived five frequently-used categories of THR, differing by bearing surface (ceramic, metal, polyethylene) and fixation (cemented/cementless). Probabilistic Markov modelling was used to compare lifetime cost effectiveness of THR and RS for men and women of various ages. Model outputs were mean costs and mean quality adjusted life years (QALYs) gained. Results The systematic review yielded 37 studies indicating that outcomes differed little between interventions. RCTs were small, short and of restricted relevance. Accurate estimates of quality of life and costs were difficult to obtain. Almost all revision rates were lower than 5% at ten years (the current national benchmark is 10%). Revision rates were higher for RS than for THR, and for THR were higher for men than women. Cemented THRs with polyethylene/ceramic bearing surfaces had the lowest revision rates. Life time QALYs varied between 6.8 and 12.6 and costs between £10,781 and £28,677 according to age, gender and intervention. Overall, RS delivered fewer QALYs at higher cost. Cemented prostheses with polyethylene/metal or polyethylene/ceramic bearing surfaces were most cost effective depending on age and gender. Conclusion RCT evidence in this field is unhelpful. Based on observational registry data, RS is not cost effective relative to THR. Cemented THR devices are more cost effective than uncemented ones. Surprisingly for such common, important operations in the NHS, accurate costs and quality of life data are not readily available. Confidential purchasing arrangements by manufacturers and hospitals hamper research. Differences in the cost effectiveness of frequently used THR types are small but important for the NHS for a large active, ageing population. The national revision rate benchmark for devices should be reduced to 5% at ten years.

Two BMJ observational studies report increased survival of patients after metal-on-metal resurfacing versus cemented or uncemented total hip replacement.1 2 We considered the potential usefulness of these new estimates for lifetime cost effectiveness models, which necessitate extrapolation beyond observed data.3 Cost effectiveness models have assumed similar mortality irrespective of implanted device.4 5 6 McMinn and colleagues examined men under 55 years who received Birmingham hip resurfacing or cemented or uncemented hip replacements (mean age ~48 years).1 Kendal and …

It is not uncommon for a pharmaceutical company to develop several new drugs simultaneously for the same indication. In a small population it may be infeasible to try all new drugs concurrently. A practical approach is to consider one at a time and if the drug is recommended for a phase III trial to temporarily suspend development of other drugs. We propose a development plan that encompasses phase II and III trials, considering a series of sequential phase II trials with interim decision-making. At each stage of a phase II trial, a decision is made whether to continue with participant recruitment to the current trial, stop the current trial and recommend the drug to be tried in a phase III trial, stop the current trial and initiate a new phase II trial with a different drug or stop the current trial and abandon the development. The unknown treatment effect for each drug is assumed to follow a prior distribution. In addition, as drugs are intended for the same population it is not unrealistic to consider treatment effects to be correlated, so that the prior distribution will reflect this. As data are observed from preceding and current trials, prior densities for subsequent drugs are updated, informing us of the performance of the groups of drugs under evaluation. The application of the design is illustrated in the setting of severe arthritis of the hip trials.

We present the case of a 28-year-old competitive runner with iliotibial band (ITB) friction syndrome associated with a synovial cyst. Magnetic resonance imaging (MRI) did not demonstrate a fluid collection. However, open exploration revealed a large cyst beneath the ITB arising from the capsule of the knee proximal to the lateral meniscus. The cyst disappeared on extension. The pre-operative MRI scan may have revealed the cyst, if it had been taken with the knee flexed.

Serious and continuing concerns have been raised about the safety of metal-on-metal total hip replacements.1 2 These concerns have also prompted wider debate about the introduction and regulation of new devices in general.3 So what have the surgeons who introduce new devices to patients been doing to deal with these concerns? The British Orthopaedic Association and the Medicines and Healthcare Products Regulatory Agency have developed a joint initiative called “Beyond Compliance,”4 which is designed to provide a framework for the safe introduction of new implants. It has three key objectives. The first is: “to improve the rigor of processes around CE marking before an implant is sold, by offering good quality advice.” The second is: “to provide guidance and support for the safe and agreed introduction of innovations.” And the last is: “to provide high quality surveillance and a decision making process to identify failures at the earliest point and suggest appropriate actions.” This all sounds sensible, but can these objectives be delivered, and will they help …

Oussedik and colleagues make some interesting points about our trial and the place of hip resurfacing in treating patients with severe arthritis.1 The trial involved many surgeons using several different approaches and implants. This was a deliberate policy: a “pragmatic” trial reflects the variety of surgeons, approaches, and implants encountered across the NHS. Radiographic outcomes and data on metal ions are important factors related …