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Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.La multimorbidité est la présence de plus d'une maladie chronique chez un individu. L'aboutissement de la multimorbidité est influencé par des facteurs sanitaires, socio-économiques, culturels et environnementaux. Aborder ces facteurs biopsychosociaux complexes et souvent interdépendants requiert donc un changement de traitement, qui consiste à s'éloigner d'un modèle axé sur les dommages physiques pour se rapprocher d'un modèle de soins intégré et centré sur la personne, allié à une meilleure implication du patient. L'éducation a un impact sur le comportement et peut être utilisée pour renforcer la capacité d'agir des patients et de leurs soignants, ce qui permettra de conférer plus de responsabilités et un meilleur contrôle de la gestion des soins aux patients. Dans ce document, nous réfléchissons à notre propre apprentissage en tant que communauté de professionnels de la santé issus de différentes disciplines. Nous reconnaissons l'importance croissante de l'implication du patient pour stimuler l'évolution des soins de santé, et imaginons un concept de centre de santé numérique et personnalisé via site Web pour la prise en charge intégrée des patients. Grâce à la collaboration entre patients, professionnels de la santé et structures pédagogiques, nous partageons nos premières expériences en matière de mise en œuvre d'un centre de santé regroupant des patients présentant des fractures de la hanche. Nous dévoilons également notre vision d'avenir pour les soins de santé, qui repose sur la cocréation de centres de santé numériques adaptés aussi bien aux besoins des patients qu'à ceux des soignants. Ce concept pourrait faire progresser l'enseignement et la pratique pour les professionnels du secteur, mais aussi améliorer leur efficacité; favoriser la participation des patients et soignants dans les soins auto-administrés; et enfin, permettre la collecte des données fournies par les patients, et nécessaires à la poursuite des recherches et améliorations dans le domaine des soins de santé.La multimorbilidad es la presencia de más de una enfermedad crónica en un individuo. Los factores medioambientales, culturales, socioeconómicos y los relacionados con la salud, así como el comportamiento de los pacientes, influyen en los resultados de la multimorbilidad. Por lo tanto, se requiere un cambio en el tratamiento desde el modelo de daño físico hacia una atención integrada y centrada en el individuo con una mayor participación del paciente para abordar estos factores biopsicosociales complejos y a menudo interactivos. La educación influye en el comportamiento y se puede utilizar para que los pacientes y sus cuidadores tengan más capacidad de acción, lo que permite una mayor responsabilidad y control sobre la gestión de la atención al paciente. En este documento reflexionamos sobre nuestro propio aprendizaje como comunidad de profesionales de la salud de diferentes disciplinas. Se describe el concepto de un centro de salud virtual personalizado para la atención integrada del paciente, al reconocer la creciente relevancia de la participación y la acción del paciente en el proceso de evolución de la atención médica. Gracias a la colaboración entre las comunidades de pacientes, de salud y de educación, compartimos nuestra experiencia inicial sobre el establecimiento de un centro de salud en torno a una cohorte de pacientes con fracturas de cadera. Asimismo, describimos una visión de la futura atención médica basada en la creación conjunta de centros de salud virtuales que se centran en las necesidades de los pacientes y de los cuidadores. El centro de salud permitiría alcanzar importantes avances y mejoras en la práctica y la educación de la fuerza de trabajo; en el compromiso de los pacientes y los cuidadores con el autocuidado de la salud; y en la recopilación de los datos sobre la salud que los pacientes comunican y que se requieren para la investigación y las mejoras continuas en la atención médica.تعدد الأمراض هو وجود أكثر من حالة مرضية مزمنة واحدة لدى الفرد. تؤثر العوامل الاجتماعية الاقتصادية، والعوامل الثقافية والبيئية، المرتبطة بالصحة، وكذلك سلوك المريض، على نتائج تعدد الأمراض. إن التعامل مع هذه العوامل البيولوجية النفسية الاجتماعية المعقدة، والمتداخلة غالباً، تتطلب تحولاً في العلاج من نموذج الضرر الجسدي إلى الرعاية المتكاملة التي تركز على الشخص، معتمكين أكبر للمريض للمشاركة وتحمل المسؤولية في العلاج. يؤثر التعليم على السلوك، ويمكن استخدامه لتمكين المرضى ومقدمي الرعاية لهم من خلال ومشاركة أكبر، وبالتالي السماح بمزيد من المسؤولية تجاه إدارة رعاية المرضى، والتحكم فيها. نركز في هذه الورقة على تعلمنا كمجتمع من الممارسين الصحيين من مختلف التخصصات. في ظل إدراك الأهمية المتزايدة لتمكين المريض في دفع تطور الرعاية الصحية، فإننا نصف مركز الصحة الرقمية الشخصي على شبكة الإنترنت للرعاية المتكاملة للمرضى. وبناءً على التعاون بين مجتمعات المرضى والصحة والتعليم، فإننا نشارك تجربتنا المبكرة في تنفيذ مركز صحي حول مجموعة من المرضى الذين يعانون من كسور الورك. كما نصف أيضاً رؤية للرعاية الصحية المستقبلية استنادًا إلى الإنشاء المشترك لمراكز الصحة الرقمية التي تركز على احتياجات المرضى ومقدمي الرعاية. يمكن أن يسمح المركز الصحي بتحقيق تطورات وكفاءات هامة في ممارسة القوى العاملة والتعليم؛ ومشاركة المريض ومقدم الرعاية في الرعاية الذاتية؛ وجمع البيانات الصحية التي قدمها المريض، والمطلوبة للبحث والتحسينات المستمرة في الرعاية الصحية.多重病症是指一个人患有一种以上的慢性疾病。与健康有关的因素，社会经济、文化和环境方面的因素以及患者行为都会影响多重病症患者的治疗结果。因此，若要解决这些复杂且经常相互作用的生物心理社会因素，需要将治疗从物理性损伤模式转换为以患者为中心的综合护理，并提高患者在其中所发挥的作用。教育影响行为并且可以用来为患者及其照顾者赋权，让他们发挥更大的作用，从而对患者护理的管理工作承担更大的责任和管控力度。在本文中，作为一支汇聚不同学科从业人员的团队，我们反思了我们总结的经验。我们意识到患者在推动医疗护理改革方面所发挥的作用日益重要，因此我们描述了一个基于网络的个人数字医疗中枢的概念，用于整合患者护理。通过患者、卫生和教育团体之间的合作互通，我们围绕一批髋部骨折患者分享了我们在医疗中枢实施方面的早期体验。我们还基于共建以患者和护理人员需求为中心的数字医疗中枢，表达了对未来医疗卫生事业的美好愿景。医疗中枢可以在人员实践和教育方面实现重要进展和效率提升；可以让患者和照顾者参与自我护理；可以收集患者自述的医疗数据，所收集的数据用于医疗护理事业的长期研究和提升。.Мультиморбидность это наличие у одного человека нескольких хронических заболеваний. Исход мультиморбидности зависит от факторов, связанных со здоровьем, социально-экономических, культурных и экологических факторов, а также поведения пациента. Таким образом, решение вопросов относительно этих сложных и часто взаимосвязанных биопсихосоциальных факторов, требует перехода в лечении от модели физического повреждения к комплексному медицинскому обслуживанию, ориентированному на человека и предоставляющему большую свободу действий пациенту. Обучение влияет на поведение и может использоваться для расширения возможностей пациентов и ухаживающих за ними лиц, предоставляя им больше ответственности и контроля за процессом лечения и ухода. В этой статье авторы рассматривают процесс собственного обучения как сообщества практикующих специалистов из разных дисциплин. Признавая растущую важность свободы воли пациентов как движущей силы эволюции здравоохранения, авторы описывают концепцию сетевого персонального цифрового центра здоровья для комплексного подхода к лечению пациентов. Опираясь на опыт сотрудничества между пациентами и сообществами здравоохранения и образования, авторы делятся первоначальным опытом в части создания центра здоровья для контингента пациентов с переломами шейки бедра. В статье также описана концепция здравоохранения будущего, основанная на совместном создании цифровых центров здоровья, сосредоточенных вокруг потребностей пациентов и лиц, осуществляющих уход. Центр здоровья может позволить добиться значительных успехов и эффективности в сфере практической деятельности и обучения медицинских работников, вовлечения пациентов и ухаживающих за ними лиц в процесс самопомощи, а также сбора предоставляемых самим пациентом данных о его здоровье, которые необходимы для текущих исследований и совершенствования системы здравоохранения.

Summary Combining thematic analysis and a human–computer persuasive systems framework suggests that hip fracture recovery among older people can be enhanced through person-centered digital health hub models of care focused on behavior change education and integrated care. The findings intend to guide settings involving comorbid conditions and low- and middle-income countries in developing innovative digital health solutions. Purpose The purpose of this study was to understand stakeholders’ perspectives on the development of a digital health-enabled model of care for fragility hip fractures and to map out factors that could influence the design and implementation of such a model. Methods Qualitative in-depth interviews were conducted with stakeholders from various clinical disciplines, allied health, and computer science. A hybrid process involving thematic analysis of the raw data using inductive coding was the first step. In the second step, the tenets of a theoretical framework (health behavior change supporting systems) were deductively applied to the thematic constructs generated as part of the first step of the analysis. Results In total, 24 in-depth interviews were conducted with stakeholders. We identified 18 thematic constructs presented under the categories of context, content, and system. Context covered patient characteristics such as frailty, digital literacy, and patient or carer participation, whereas healthcare delivery aspects included the structure and culture of existing practice and the need for innovative holistic models of care. Content outlines the active ingredients and approach in developing a digital health hub, and it highlights the importance of targeted education and behavior change. The system is a complicated matrix crossing different aspects of healthcare and offering a value proposition design through personalization across modes of content delivery. This must foster trust, ensure adequate financing, and support ownership and privacy by establishing appropriate mechanisms for embedding change. Conclusion The findings from this study provide insights around potential factors related to patients, community support, and healthcare delivery influencing the design and next-stage implementation of a digital health hub model of care for fragility hip fractures. Supplementary Information The online version contains supplementary material available at 10.1007/s11657-021-01031-3.

BACKGROUND Atrial fibrillation (AF) and hip fractures are both prevalent in the elderly population. The aim of this study was to systematically review the literature regarding the association between AF and hip fractures, and the impact of AF on hip fracture prognosis. METHODS The literature search was performed using PubMed, MEDLINE, Embase and Scopus. Inclusion was based upon the application of eligibility criteria in duplicate prior to data extraction with a standardized form. RESULTS A total of 42 studies met the inclusion criteria. AF prevalence was found to vary between 6.5% and 35% in cohorts. Large studies with broad inclusion criteria found the prevalence of AF in hip fracture patients to be approximately 12-15%. There were conflicting results as to whether patients with AF have an increased rate of hip fractures, as compared to patients without AF. Several studies demonstrated that hip fracture patients with AF have increased rates of mortality, both as an inpatient and following discharge, and increased readmission rates. CONCLUSION AF and hip fractures frequently coexist, and there is evidence to suggest AF is associated with increased readmission and mortality rates in hip fracture patients. Elements of the relationship between AF and hip fractures remain uncertain and further prospective studies on AF and hip fracture cohorts may clarify this relationship. Interventional studies targeting hip fracture patients with AF may be beneficial.

Relationship between perioperative anaemia and outcomes in older people with hip fractures: A systematic review and meta-analysis protocol

Rheumatic and musculoskeletal diseases (RMDs) encompass a spectrum of degenerative, inflammatory conditions predominantly affecting the joints. They are a leading cause of disability worldwide and an enormous socioeconomic burden. However, worldwide deficiencies in adult and paediatric RMD knowledge among medical school graduates and primary care physicians (PCPs) persist. In October 2017, the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD), an international think tank of RMD and related experts, met to discuss key challenges and opportunities in undergraduate RMD education. Topics included needs analysis, curriculum content, interprofessional education, teaching and learning methods, implementation, assessment and course evaluation and professional formation/career development, which formed a framework for this white paper. We highlight a need for all medical graduates to attain a basic level of RMD knowledge and competency to enable them to confidently diagnose, treat/manage or refer patients. The importance of attracting more medical students to a career in rheumatology, and the indisputable value of integrated, multidisciplinary and multiprofessional care are also discussed. We conclude that RMD teaching for the future will need to address what is being taught, but also where, why and to whom, to ensure that healthcare providers deliver the best patient care possible in their local setting.

Objective: Well-designed evidence-based resources that reflect participant experiences and priorities are imperative for informed consumer health decision-making and to combat the pervasive health misinformation existing today. Qualitative research data can inform the development of such resources, but the process of reconciling qualitative research data with other sources of evidence through co-design processes is not well described in the literature. In response to the need for such evidence-based materials and corresponding methodological guidance, we co-designed a series of video resources through transdisciplinary and community partnership. In this manuscript, we provide methodological insight into the process of collaborative co-design to improve the utilization of qualitative research evidence into evidence-based resources for the public. Methods: Following from a large qualitative research study, we engaged in a collaborative and creative co-design process involving a multi-stakeholder advisory group guided by Boyd’s co-design framework. We explicate this process, drawing from a case exemplar of transdisciplinary frailty research. Results: We utilized thematic qualitative data to co-produce: (i) an animation, (ii) a documentary-style video, (iii) a video vignette with key messages embedded in narratives of older adults, and (iv) a key-message video delivered by academic health researchers and clinicians. Discussion: The integration of experiential evidence of health care consumers with other sources of research evidence through co-design is an epistemological and procedural challenge with potential to improve public awareness, knowledge, and to support evidence-based decision making.

Background Provision of quality care can help to reduce adverse health outcomes following hip fracture. While surgical management by either a consultant or junior surgeon has shown inconclusive differences in patient outcomes, consultant presence is often recommended, yet little is known about the factors that influence whether a consultant surgeon is present during hip fracture surgery. The aim of this study is to examine patient, surgical and hospital factors associated with having a consultant surgeon present during hip fracture surgery. Methods An examination of hip fracture surgeries of adults aged ≥ 50 years admitted to hospitals in Australia and New Zealand between 1 January 2015 and 31 December 2018 using data from the Australia and New Zealand Hip Fracture Registry was conducted. Multivariable logistic regression was used to examine factors associated with the presence of a consultant surgeon during hip fracture surgery. Results There were 29 530 hip fracture surgeries 58.1% had a consultant surgeon present (range 8.5-100% by hospital). Patients were more likely to have a consultant surgeon present during surgery if they had private health insurance, were operated on after hours, required total hip replacements or were operated on in hospitals that conducted ≤150 surgeries per year. Conclusion There is variation in the presence of consultant surgeons within Australia and New Zealand during hip fracture surgery, potentially associated with the complexity of surgery and hospital factors. However, further research is needed to determine the optimum level of supervision required based on patient factors and surgical complexity.

Background Most older people after a hip fracture injury never return to their prefracture status, and some are admitted to residential aged care facilities. Advancement of digital technology has helped in optimizing health care including self-management and telerehabilitation. Objective This study aims to understand the perspectives of older patients with hip fracture and their family members and residential aged caregivers on the feasibility of developing a model of care using a personalized digital health hub. Methods We conducted a mixed methods study in South Australia involving patients aged 50 years and older, their family members, and residential aged caregivers. Quantitative data analysis included basic demographic characteristics, and access to digital devices was analyzed using descriptive statistics. Spearman rank-order correlation was used to examine correlations between the perceived role of a personalized digital health hub in improving health and the likelihood of subsequent use. Findings from qualitative analysis were interpreted using constructs of capability, opportunity, and motivation to help understand the factors influencing the likelihood of potential personalized digital health hub use. Results This study recruited 100 participants—55 patients, 13 family members, and 32 residential aged caregivers. The mean age of the patients was 76.4 (SD 8.4, range 54-88) years, and 60% (33/55) of the patients were female. Approximately 50% (34/68) of the patients and their family members had access to digital devices, despite less than one-third using computers as part of their occupation. Approximately 72% (72/100) of the respondents thought that personalized digital health hub could improve health outcomes in patients. However, a moderate negative correlation existed with increasing age and likelihood of personalized digital health hub use (Spearman ρ=–0.50; P Conclusions This study emphasized the complex relationship between capabilities, motivation, and opportunities for patients, their family members, and formal caregivers as a patient networked unit. The next stage of research will continue to involve a cocreation approach followed by iterative processes and understand the factors influencing the development and successful integration of complex digital health care interventions in real-world scenarios.

BACKGROUND Most older people after a hip fracture injury never return to their prefracture status, and some are admitted to residential aged care facilities. Advancement of digital technology has helped in optimizing health care including self-management and telerehabilitation. OBJECTIVE This study aims to understand the perspectives of older patients with hip fracture and their family members and residential aged caregivers on the feasibility of developing a model of care using a personalized digital health hub. METHODS We conducted a mixed methods study in South Australia involving patients aged 50 years and older, their family members, and residential aged caregivers. Quantitative data analysis included basic demographic characteristics, and access to digital devices was analyzed using descriptive statistics. Spearman rank-order correlation was used to examine correlations between the perceived role of a personalized digital health hub in improving health and the likelihood of subsequent use. Findings from qualitative analysis were interpreted using constructs of capability, opportunity, and motivation to help understand the factors influencing the likelihood of potential personalized digital health hub use. RESULTS This study recruited 100 participants—55 patients, 13 family members, and 32 residential aged caregivers. The mean age of the patients was 76.4 (SD 8.4, range 54-88) years, and 60% (33/55) of the patients were female. Approximately 50% (34/68) of the patients and their family members had access to digital devices, despite less than one-third using computers as part of their occupation. Approximately 72% (72/100) of the respondents thought that personalized digital health hub could improve health outcomes in patients. However, a moderate negative correlation existed with increasing age and likelihood of personalized digital health hub use (Spearman ρ=–0.50; PPP CONCLUSIONS This study emphasized the complex relationship between capabilities, motivation, and opportunities for patients, their family members, and formal caregivers as a patient networked unit. The next stage of research will continue to involve a cocreation approach followed by iterative processes and understand the factors influencing the development and successful integration of complex digital health care interventions in real-world scenarios.

Objective to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care. Design parallel randomised controlled trial with integrated health economic study. Setting NCFs, in Adelaide South Australia. Subjects people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture. Measurements primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months. Results participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056). Conclusions the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective. Trial registration ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980.

Objective: To investigate the reliability of a clinically applicable method of dynamometry to assess and monitor hip abductor muscle strength in older persons. Design: Bilateral isometric hip abductor muscle strength measured with a handheld dynamometer, patients supine with the contralateral hip positioned directly against a wall for stabilization. Reliability determined by comparing intra-assessor and inter-assessor results and comparison to a criterion standard (stabilized dynamometer with patients in the standing position). Setting: UniSA Nutritional Physiology Research Centre. Participants: Twenty-one patients older than 65 years were recruited from the Royal Adelaide Hospital. Main Outcome Measures: Intraclass correlation coefficients (ICCs), bias, and limits of agreement calculated to determine reliability. Results: Intra-assessor and inter-assessor ICCs were high (0.94 and 0.92-0.94, respectively). There was no intra-assessor bias and narrow limits of agreement (±2.4%). There was a small inter-assessor bias but narrow limits of agreement (0.6%-0.9% and ± 2.3%, respectively). There was a wide variation comparing results to the criterion standard (±5.0%-5.2% limits of agreement), highlighting problems attributed to difficulties that the test population had with the standing position used in the criterion standard test. Conclusions: Testing older persons’ hip abductor muscle strength while in the supine position with optimal pelvic stabilization using a handheld dynamometer is highly reliable. While further studies must be done to assess patients with specific pathologies, this test has potential application to monitor and evaluate the effects of surgical interventions and/or rehabilitation protocols for a variety of conditions affecting hip abductor function such as hip fractures and arthritis.

Background Accompanying the unprecedented growth in the older adult population worldwide is an increase in the prevalence of frailty, an age-related clinical state of increased vulnerability to stressor events. This increased vulnerability results in lower social engagement and quality of life, increased dependency, and higher rates of morbidity, health service utilization and mortality. Early identification of frailty is necessary to guide implementation of interventions to prevent associated functional decline. Consensus is lacking on how to clinically recognize and manage frailty. It is unknown how healthcare providers and healthcare consumers understand and perceive frailty, whether or not they regard frailty as a public health concern; and information on the indirect and direct experiences of consumer and healthcare provider groups towards frailty are markedly limited. Methods We will conduct a qualitative study of consumer, practice nurse, general practitioner, emergency department physician, and orthopedic surgeons’ perspectives of frailty and frailty screening in metropolitan and non-metropolitan South Australia. We will use tailored combinations of semi-structured interviews and arts-based data collection methods depending on each stakeholder group, followed by inductive and iterative analysis of data using qualitative description. Discussion Using stakeholder driven approaches to understanding and addressing frailty and frailty screening in context is critical as the prevalence and burden of frailty is likely to increase worldwide. We will use the findings from the Perceptions of Frailty and Frailty Screening study to inform a context-driven identification, implementation and evaluation of a frailty-screening tool; drive awareness, knowledge, and skills development strategies across stakeholder groups; and guide future efforts to embed emerging knowledge about frailty and its management across diverse South Australian contexts using a collaborative knowledge translation approach. Study findings will help achieve a coordinated frailty and healthy ageing strategy with relevance to other jurisdictions in Australia and abroad, and application of the stakeholder driven approach will help illuminate how its applicability to other jurisdictions.

The objective of this review is to evaluate the effectiveness of digital health supported targeted patient communication versus usual provision of health information, on the recovery of fragility fractures. The review considered studies including older people, aged 50 and above, with a fragility fracture. The primary outcome was prevention of secondary fractures by diagnosis and treatment of osteoporosis, and its adherence. This review considered both experimental and quasi-experimental study designs. A comprehensive search strategy was built to identify key terms including Medical subject headings (MeSH) and applied to the multiple electronic databases. An intention to treat analysis was applied to those studies included in the meta-analysis and odds ratio was calculated with random effects. Altogether, 15 studies were considered in the final stage for this systematic review. Out of these, 10 studies were Randomised controlled trials (RCT) and five were quasi experimental studies, published between the years 2003 and 2016 with a total of 5037 participants. Five Randomised control trails were included in the meta-analysis suggesting that digital health supported interventions were overall, twice as effective when compared with the usual standard care (OR 2.13, 95% CI 1.30&ndash, 3.48), despite the population sample not being homogeneous. Findings from the remaining studies were narratively interpreted.

BackgroundOver the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts.MethodsWe used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation.ResultsOrthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used.ConclusionsThere is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Innovation is a form of realising a new way of doing something, often ignoring traditional wisdom, in order to meet new challenges. Globally, particularly in emerging economies, the high burden of musculoskeletal conditions and their contribution to multimorbidity continue to rise, as does the gap for services to deliver essential care. There is a growing need to find solutions to this challenge and deliver person-centred and integrated care, wherein empowering patients with the capacity for self-management is critical. Whilst there is an abundance of information available online to support consumer education, the number of sources for credible medical information is diluted by uninformed anecdotal social media solutions. Even with the provision of high-quality information, behavioural change does not necessarily follow, and more robust educational approaches are required. In this chapter, we examine innovation, its management and the strategic directions required to improve musculoskeletal healthcare at macro (policy), meso (service delivery) and micro (clinical practice) levels. We discuss the critical role of consumer agency (patients and their families/carers) in driving innovation and the need to leverage this through empowerment by education. We provide a snapshot of real-world examples of innovative practices including capacity building in consumer and interprofessional musculoskeletal education and practice; recommendations to transform the access and delivery of integrated, person-centred care; and initiatives in musculoskeletal care and implementation of models of care, enabled by digital health solutions including telehealth, remote monitoring, artificial intelligence, blockchain technology and big data. We provide emerging evidence for how innovation can support systems' strengthening and build capacity to support improved access to 'right' musculoskeletal care, and explore some of the ways to best manage innovations. We conclude with recommended systematic steps to establish required leadership, collaboration, research, networking, dissemination, implementation and evaluation of future innovations in musculoskeletal health and care.

Sedentary behaviour and falls are important interrelated health issues in older people. One in three people aged 65 years and above fall at least once a year and sedentary behaviour has been identified as one of the risk factors for falls. Studies have shown that the duration of sedentary time increases with age. These dual problems need to be addressed effectively as the ageing population grows. Accelerometers enable accurate measurement of sedentary time. This study aims to establish the feasibility and effect of an individualized goal-setting health coaching intervention using feedback initially from an accelerometer and then pedometer over a period of 12 weeks (intervention) compared with providing a one-off advice through a brochure (control), on sedentary time in older people with a recent fall or at risk of one. A single-blinded randomized controlled feasibility trial involving 80 community-dwelling people aged 65 years and above will be conducted with 40 randomized to the intervention and another 40 to control. Primary outcomes will be the feasibility of the intervention and change in total sedentary time at 12 and 24 weeks. Secondary outcomes include a change in fear of falling based on the falls efficacy scale, gait speed, self-reported sedentary time, the proportion of fallers and number of falls. Four focus groups (two from each arm) will be conducted at the end of the study to evaluate the feasibility and effectiveness of this intervention. Feasibility findings will be primarily descriptive. Mean group differences will be examined using independent samples t test for normally distributed data and nonparametric tests (Kruskal-Wallis and Mann-Whitney U) for non-normally distributed data. Differences in frequency of variables will be compared using chi-square test. Analysis of variance (ANOVA) will be used to test the post-intervention difference between the two groups at 12 and 24 weeks. The trial will address a key gap in evidence about sedentary behaviour and falls amongst older people and will evaluate the feasibility of an intervention that could be implemented within the primary health care settings. Australian New Zealand Clinical Trials Registry 12617001186347 , Registered 11 August 2017.

Background Like other procedural skills, the ability to relocate a joint is an important aspect of junior doctor education. Changes in the approach to teaching and learning from the traditional apprenticeship-style model have made the teaching of practical skills more difficult logistically. Workshops utilising cadaveric specimens offer a solution to this problem. Methods One hundred forty-six fourth year medical students were randomly divided into 5 groups. Each group received a different teaching intervention based on ankle, patella and hip relocation. The interventions consisted of online learning modules, instructional cards and workshops using skeleton models and cadaveric dislocation models. Following the intervention students were given a test containing multiple choice and true/false style questions. A 13-item 5-point Likert scale questionnaire was also delivered before and after the intervention. The data was analysed using one-way analysis of variance (ANOVA) and the Bonferroni post-hoc test. Results Compared to the instructional cards group, the other 4 groups showed a 10.8–19.2% improvement in total test score (p

Background: It is unclear whether people living in nursing homes benefit from post acute rehabilitation and few trials are done with this group who often suffer dementia. In a group of nursing home residents who were managing to walk (independently, with aids or with assistance) prior to fracture, our aim was to determine whether post-operative rehabilitation (which included a comprehensive geriatric assessment and interdisciplinary rehabilitation program) delivered in nursing homes would improve mobility compared to receiving usual nursing home care.

To review the literature on epidemiology and postoperative outcomes particularly surgical, functional and quality of life of atypical femoral fractures (AFFs) in the older population (aged ≥65 years) using the first and second American Society of Bone Mineral Research (ASBMR) Task Force consensus definition. Electronic search for articles on AFFs and bisphosphonates published in English was performed. Eligible studies were reviewed systematically in relation to (a) the epidemiology of AFFs in older people and (b) postoperative outcomes of AFFs. Twenty-three studies on AFFs were included: 14 on epidemiology and 11 on treatment outcomes (two articles reported on both aspects). The epidemiological studies showed that the incidence of AFFs is low (3.0-9.8 per 100,000 person-years) but relative risk increased with longer duration of bisphosphonates use, especially after more than three years. Most cases of AFFs occurred in older people aged 65 years and above. However, in six studies, the mean age of patients with bisphosphonate-related AFFs is younger than those with typical proximal femoral fractures (mean age range of 66–75 years versus 75-89 years respectively). Varying postoperative and functional outcomes have been reported but differences in study population, management approaches and endpoints may account for these variations. For incomplete AFFs, prophylactic surgical intervention is potentially beneficial. The benefits of bisphosphonates in reducing osteoporotic fractures still outweigh the risk of AFFs in view of its low absolute risk, when the ASBMR Task Force criteria for this type of fracture were applied. The risk of AFFs in different age groups is not well defined but tends to affect the younger patients more (aged

Introduction Atypical femoral fractures (AFFs) are rare but a serious complication associated with prolonged use of bisphosphonates. However little is known about clinical outcomes of AFFs. The aim of this study is to compare the characteristics and postoperative outcomes between older patients with AFFs and typical femoral fractures (TFFs). Methods A retrospective matched cohort study (each AFF was age- and sex-matched with three TFFs) of patients aged 65 years or older who were admitted to The Queen Elizabeth Hospital, South Australia between January 2011 and December 2013 was undertaken. Baseline characteristics of both groups were compared. The primary outcomes evaluated were level of independence in mobility at discharge and 3 months after surgery. Secondary outcomes included length of hospital stay, post-operative complications, rate of surgical revision, discharge destination (after acute hospital stay or rehabilitation), 28-day hospital readmission and 12-month mortality. Results Ten patients (mean age: 78.1 years) with AFFs were compared with 30 matched TFFs. Patients with AFFs were predominantly female (90%) and 80% had been taking oral bisphosphonate. Nine of the AFFs had their fractures fixed with an intramedullary (IM) nail. The level of independent mobility at discharge (OR 0.31; 95%CI: 0.06–1.71; p =0.26) and at 3 months (OR 0.51; 95%CI: 0.10–2.53; p =0.47) were comparable between the two groups. Only one AFF patient treated with plate and screws required surgical revision, compared with none in the TFF group. Secondary outcomes were not significantly different between the two groups. Conclusion Recovery of mobility and reoperation rates after surgery of patients with AFFs were favourable and did not differ significantly from TFFs. Further consideration should be given to using IM fixation in the management of AFFs in older people.

Summary: Periprosthetic factures around the shoulder and elbow are rare and are often difficult to treat. Treatment options depend on the stability of the prosthesis, the location of the fracture, and the bone quality. The basic principles of treatment are that loose or unstable prostheses are removed and revised to a longer prosthesis with the possible addition of cortical struts and/or plate and screws. If the prosthesis is stable, nonoperative measures may be tried initially. In cases of nonunion, surgical treatment is recommended. This article describes the current literature related to periprosthetic fractures around the shoulder and the elbow.

Introduction As the Bone and Joint Decade 2000–2010 draws to a close, it is timely to review its impact on musculoskeletal medical education, which was clearly identified by the World Health Organization as a key factor contributing to less than optimal musculoskeletal care (1). The increasing burden of musculoskeletal disorders (including chronic bone and arthritic conditions) and the uncertain quality of care provided (2,3) has meant that there is a growing imperative to ensure that optimal, evidence-based, and cost-effective treatment is being provided to people with musculoskeletal disorders by medical practitioners (4). In 2004, the Bone and Joint Decade established the International Education Task Force and Undergraduate Curriculum Development Group to develop strategies to address the issue of insufficient and/or inadequate medical education, particularly in the areas of basic and clinical science (5,6). They released global core recommendations for a musculoskeletal undergraduate medical curriculum, which were designed to enable the development of a locally applicable musculoskeletal curriculum that was able to meet national guidelines and be reflective of local needs, priorities, and opportunities (5). Despite the release of the global core recommendations for a musculoskeletal undergraduate medical curriculum, in 2007 Woolfe and Akesson identified that the poor quality of medical education and a lack of coordination between the different disciplines and professional specialties working in musculoskeletal health care have meant that people do not receive the best practice treatment (6). Furthermore, in 2007 Day et al demonstrated significant deficiencies in the knowledge of chronic arthritic conditions in graduating medical students (2). Deficiencies in undergraduate education in musculoskeletal science have also been identified by medical students and graduates in studies conducted in a number of countries (2,7–10), and there is an obvious requirement for clinically relevant, evidence-based curriculum design that integrates traditional scientific and clinical disciplines. The Australian Musculoskeletal Education Collaboration (AMSEC) project began in Australia in 2005, with the aim of developing nationally agreed musculoskeletal core competencies (based on the Bone and Joint Decade curriculum recommendations) for implementation in all Australian medical schools. Initiated by the Australian Orthopaedic Association and funded by the Australian government, this project has succeeded in bringing together all key musculoskeletal specialist and representative organizations in a national, multidisciplinary education collaboration (including orthopedics, rheumatology, general practice, rehabilitation medicine, sports medicine, endocrinology, neurology, geriatrics, radiology, pediatrics, nursing, and interested allied health professions). While the Bone and Joint Decade recommendations formed the base from which the Australian competencies were developed, it was also vital that specific Australian standards and requirements were considered. The AMSEC competencies were therefore also related directly to the Australian Medical Council standards and principles and The National Patient Safety Framework (11,12). The purpose of this article is to outline the relevance of a competency-based approach to musculoskeletal education and to describe the development of theAMSECmusculoskeletal core competencies. Furthermore, we demonstrate the significance of the AMSEC competencies and the competency education process for optimal education in musculoskeletal medicine relative to chronic rheumatic disease.

Background and purpose The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model. Methods Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models. Results The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 μm in all axes. The precision (95% confidence interval) was less than ± 16 μm in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123° and a precision of ± 0.024°. Interpretation RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our center's RSA system provides evidence to support future clinical RSA fracture studies.

The global population is increasing rapidly with older persons accounting for the greatest proportion. Associated with this rise is an increased rate of injury, including polytrauma, for which low energy falls has become the main cause. The resultant growing impact on trauma resources represents a major burden to the health system. Frailty, with its related issues of cognitive dysfunction and sarcopenia, is emerging as the unifying concept that relates both to the initial event and subsequent outcomes. Strategies to better assess and manage frailty are key to both preventing injury and improving trauma outcomes in the older population and research that links measures of frailty to trauma outcomes will be critical to informing future directions and health policy. The introduction of “Geriatric Emergency Departments” and the development of “Fracture Units” for frail older people will facilitate increased involvement of Geriatricians in trauma care and aid in the education of other health disciplines in the core principles of geriatric assessment and management. Collectively these should lead to improved care and outcomes for both survivors and those requiring end of life decisions and palliation.

Sedentary behavior, assessed by self-reporting, has been associated with increased risk of falls. Studies have shown that among the oldest old, they are more likely to be sedentary (>10 hours/day). Standardized supervised exercise interventions do not necessarily reduce the level of sedentary behavior in daily life. The aim is to evaluate an individualized coaching intervention based on accelerometer feedback to reduce sedentary behavior in older people (age ≥65 years) living in the community who had a recent fall. Participants will be randomized to either the intervention or control groups in a 12-week feasibility study. In both groups, ActivPAL® accelerometer (35x53x7mm, 15g) will be attached to the mid-thigh of the participants (dominant side) for 7-days at week 0, 6 and 12. To reduce sedentary time, the intervention group will be: (a) presented with the objective information regarding their physical activity levels based on the ActivPAL® accelerometer recordings, (b) educated about the benefits of exercise (using Choose Health: Be Active booklet), (c) face-to-face goal-setting sessions (at weeks 1 and 6) and (d) fortnightly follow-up phone calls. The intervention is based on self-determination theory, which addresses psychological needs in order to modify behavior. The control group will be given the Choose Health: Be Active booklet. Primary outcome is change in sedentary duration. Secondary outcomes assessed include gait speed, Short Physical Performance Battery and Falls Efficacy Scale. The effect of the intervention on sedentary duration and secondary outcomes will be assessed by 2-sided t-test. Primary analyses will be performed by intention-to-treat principle.

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients. Methods and analysis This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial. Ethics and dissemination CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies. Registration CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).

The frequency of chronic musculoskeletal (MSK) related disease and traumatic injury is increasing, with a major consequence being an elevated burden on medical and allied medical health resources w...

Tophaceous gout complicated by septic arthritis presents a management dilemma which can often require multiple surgical debridements. There is little published in the literature regarding treatment of these concomitant conditions. We postulate that biofilm may play a role increasing the difficulty of sterilising a tophaceous joint. The use of topical negative pressure therapy that targets biofilm has been well established for a range of wounds. A new device that incorporates both intermittent negative pressure therapy and wound irrigation was introduced in 2012. This case report describes the use of this topical negative device with the instillation option in the management of severe septic arthritis with concomitant gout and suggests directions for further research.

Background: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. Materials and Methods: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients’ notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. Results: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. Conclusions: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. Level of Evidence: Level III, retrospective comparative series.

Background. Hallux val- gus and hallux rigidus are common conditions for which numerous opera- tive interventions have been described in the literature. Various clinical and radiological measurements have been used to help grade severity and to guide treatment. Materials and methods. A survey was e-mailed to all members of the Australian Orthopaedic Association. Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 sepa- rate cases of hallux valgus and hallux rigidus of varying severity. They were specifically asked about type of defor- mity correction and type of fixation. The responses were collected and statis- tically analyzed. Results. The authors collected the answers of 454 respon- dents with a response rate of 36%. There was a disproportionately large percentage of respondents who were members of the Australian Orthopaedic Foot and Ankle Society. Preferred treat- ments were different for the 3 differ- ent cases. Older surgeons were more likely to use Chevron osteotomies, and Australian Orthopaedic Foot and Ankle Society members were more likely to use a scarf. Scarf osteotomy was pre- ferred by more than 50% for the cases of moderate and severe hallux valgus, whereas first metatarso- phalangeal joint fusion was preferred for the case with significant arthritic changes. Conclusions. There are significant associations between the surgeons' age and exper- tise and their training and their preferred oper- ative intervention. Considerable differ- ences were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. Despite the large number of surgical options avail- able for hallux valgus, only a small number were preferred by the major- ity of surgeons. Although anecdotally aware that lesser deformity is treated with distal osteotomies and more severe deformity with a proximal osteotomy, the authors are unaware of any cur- rent literature that verifies this.

We report a new technique for pelvic external fixation that we have developed as an alternative to the anterosuperior (Slatis) and the anteroinferior (supra-acetabular) type pelvic external fixator configurations. The method principally differs from the other techniques by virtue of the subcristal positioning of the pins and offers advantages in terms of easier pin placement, less skin irritation, less pin tract infection and loosening, and less interference with hip flexion, while allowing dressing, sitting, and walking. Between 1992 and 2006, we successfully used subcristal pelvic external fixators as the definitive fixation device for 20 patients with pelvic ring disruptions. The only complications encountered were superficial pin tract infections in 4 patients (20%) who were successfully treated with wound care and antibiotics.

Pelvic external fixators have a high rate of reported complications, most of which relate to pin placement. In this descriptive study, we analyzed the morphology of the ilium in cadaveric specimens and compared these with the measures obtained from normal human pelvic computer tomograph scans, and how these related to each of the three basic configurations of pin positioning for the external fixation of a pelvis: anterosuperior (Slatis type), anteroinferior (supra-acetabular), and subcristal. The irregular shape and size of the iliac wing and the abdominal wall overlying the pin's insertion site could hinder accurate placement of anterosuperior pins. Potential disadvantages of the use of anteroinferior pins was found related to the deep location of the anterior inferior iliac spine, interference with the hip flexion area, risk of hip joint penetration, and the variable obliquity of the ilium. As subcristal pins are positioned between two superficial bony landmarks of the iliac crest, our findings suggest that they are more likely to have a correct placement and avoid complications.

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.

The following 10 papers have been chosen to represent recent highlights of Australian orthopaedics. With so many quality papers to choose from, the decisions were difficult and arbitrary. The papers selected are not intended to represent the top 10, although all are excellent, but to present a breadth of material. Notably absent from the publication list, but a definite highlight of Australian orthopaedics, is the Australian Orthopaedic Association National Joint Replacement Registry (www.aoa.org.au/jointregistry.asp). The registry began collecting data in September 1999. As of December 2006, data have been collected for 332,700 hip or knee arthroplasties performed in 271,188 patients. The information from this registry undoubtedly will provide invaluable information regarding the effectiveness of different types of joint replacement prostheses and surgical techniques.