Since the universal failure of first generation smooth threaded cups in primary total hip arthroplasty (THA), the screw-in concept of cementless acetabular cup fixation has been largely abandoned. We hypothesised that grit-blasted titanium conical cement free threaded cup shows stable long-term fixation. 198 Alloclassic total hip arthroplasties were performed in 179 patients, mean age 66 years old (22–85). 193 hips were analyzed after a mean follow-up of 10 years (1–25 years). Results were excellent or good in 184 hips (95%). Postel-Merle d'Aubigne score increased from 10.3 (range 1 to 15) pre-operatively to 16.7 (12 to 18) points and 151 hips (78%) were pain free at last FU. Radiographic signs indicating successful cup osseointegration were noted in 92% of hips. Polyethylene wear > 0.1mm/year was observed in 6 hips (3%). The main cause of re-operation/revision surgery was recurrent dislocation (9/17cases, 53%). 2 threaded cups were revised for any reason and the revision per cent observed acetabular component years was 0.10 at 10 years average FU. 20 year-survival of the metal back was 98.8% (77.2–99.9%) and 100% (79.6–100%) for revision for any reason and revision for aseptic loosening, respectively. Despite minimum PE thickness of 6.5mm and use of alumina ceramic 28mm heads, conventional polyethylene liner wear was the weak link of the acetabular reconstruction;. This study shows excellent long-lasting bone anchorage through bone on-grown of grit-blasted titanium threaded cup. Despite universal outstanding longevity in the worldwide literature, CSF threaded cups were retrieved from the European market in March 2017 due to insufficient sales, indicating that evidence base medicine may not be the major criteria influencing surgeons' choice

Objective. To investigate the effectiveness of applying fast track surgery concept in primary total hip arthroplasty. Methods. The data of patients with primary total hip arthroplasty in our department from January 1, 2013 to October 1, 2015 were retrospectively analyzed. The patients were divided into traditional recovery group, enhanced recoverygroup and update enhanced recovery group according to different interventions. The blood loss, transfusion rate, complications rate, postoperative function, length of stay, hospitalization expense and readmission rate were compared between three groups. Results. A total of 435 cases were included. Compared with traditional recovery group, the average blood loss, length of stay and total cases of complication in update enhanced recovery group were reduced 91.44 ml, 1.34 days and 14.05%, respectively, and the differences showed statistical significance. From 2013 to 2015 the hip flexion and abduction degree increased annually, the differences also showed statistical significance. The blood transfusion rate, other complications and hospitalization expense were all reduced, but there were no statistical significance. Conclusions. The emphasis of fast track surgery concept in primary total hip arthroplasty was the management in perioperative period. Through continuous optimization of intervention measures under the guidance of evidence based medicine, it can effectively accelerate recovery, diminish complications and reduce the length of hospital stay

The contemporary practice of orthopaedic surgery requires an evidence-based approach to support all medical and surgical interventions. In this essay, the author expresses a forthright, personal and somewhat prejudiced appeal to retain the legitimacy of clinical decision making in conditions that are rare, contain multiple variables, have a solution that generally works or has an unpredictable course.

Cite this article: Bone Joint J 2014;96-B:1002–4.

The August 2014 Research Roundup³⁶⁰ looks at: Antibiotic loaded ceramic of use in osteomyelitis; fibronectin implicated in cartilage degeneration; Zinc Chloride accelerates fracture healing in rats; advertisements and false claims; Net Promoter Score: substance or rhetoric?; aspirin for venous thromboembolism prophylaxis and dissection, stress and the soul.

Introduction. Classification systems are used throughout Trauma and Orthopaedic (T&O) surgery, designed to be used for communication, planning treatment options, predicting outcomes and research purposes. As a result the majority of T&O knowledge is based upon such systems with most of the published literature using classifications. Therefore we wanted to investigate the basis for the classification culture in our specialty by reviewing Orthopaedic classifications and the literature to assess whether the classifications had been independently validated. Methods. 185 published classification systems within T&O were selected. The original publication for each classification system was reviewed to assess whether any validation process had been performed. Each paper was reviewed to see if any intra-observer or inter-observer error was reported. A PubMed search was then conducted for each classification system to assess whether any independent validation had been performed. Any measurement of validation and error was recorded. Results. Four of the 185 classifications (2.1%) had a validation process described in the initial paper that introduced that classification to the literature. 54 (29.1%) of the classifications had a related study that independently assessed the classification for validity. Of these 54, only 10 (18.5%) demonstrated either an intra-observer or inter-observer error that is described as excellent (kappa score >0.8). Only 2 classification systems of the 54 (3.7%) were shown to have both intra-observer and inter-observer errors as excellent, meaning only 2 of the 185 classification systems reviewed (1.1%) have been shown to be highly reproducible. Conclusion. Over 70% of classification systems in T&O have never been independently validated and assessed for intra-observer and inter-observer error. Of those that have, only 2 are excellent. Such a finding raises questions about the use of classification systems within T&O and queries the use of classification systems in the literature as part of evidence based medicine

The authors entered patients into a randomised trial to compare the results of the use of cemented and cementless acetabular prostheses between 1993 and 1995. The results of mid-term wear studies at average follow up of eight years were reported in the journal in 2004. We now present long-term results to show the eventual fate of the hip replacements under study. The initial study group of 162 patients was randomly assigned to a modular titanium cup with a polyethylene liner or an all polyethylene cemented cup. All patients received a cemented stem with a 26 mm head and a standardised surgical technique. The polyethylene wear was estimated via head penetration measurement and the mid-term results showed a significantly higher wear rate in the cementless cups compared to the cemented cups (0.15mm/yr vs. 0.07mm/yr p<0.0001). The prediction was that this would lead to a higher rate of aseptic loosening in the cementless group. Patients have now been re-examined at an average of 15 years with the main emphasis on prosthesis survival. Wear studies were also performed. There were exclusions from the initial study because of death and reoperation for reasons other than aseptic loosening. The number of patients in this longer-term study had decreased as a result of death and loss to follow up. Revisions for aseptic loosening did not follow the path as suggested by the mid term wear studies. There were five cup revisions in the cemented group and one cup revision in the cementless group for aseptic loosening. No femoral stem was revised for aseptic loosening. Details of the long-term wear studies will be presented and osteolysis rates and extent documented. Despite the statistically significant difference in wear rates at the mid term, an incorrect prediction of eventual loosening rates was made. The authors believe that there are many factors other than wear rates involved in longevity of fixation. We also believe there are many weaknesses in long term prospective, randomised trials in joint replacement and question whether they are, in fact, level 1 evidence in the age of evidence based medicine

Introduction: Since the first meeting in 1875, and the subsequent introduction of the concept of evidence based medicine in the 1990s, the journal club has become an integral part of keeping abreast with current literature. There is no study assessing orthopaedic journal clubs amongst training programs across the UK. This study had two aims: the first was to determine whether journal clubs still play an important part in orthopaedic training programs, the second was to evaluate the frequency, format and goals of journal clubs conducted in orthopaedic training programs in the UK. Method: We surveyed fifty seven hospitals across the UK. This included hospitals from all the orthopaedic teaching regions of which twelve were teaching hospitals and forty five district general hospitals. Results: A total of 57 hospitals were surveyed. Of these hospitals 28/57(49%) had a journal club programme in place. On average journals clubs were undertaken once a month and lasted about 1 hour. Most occurred during the working day and were chaired by a consultant. Specialist registrars presented the vast majority of papers (average of 1.9 each per session), with the JBJS Br being the most widely used journal (100% of journal clubs). Of the twelve teaching hospitals questioned, five (42%) had journal clubs, and twenty three of the forty five (51%) district general hospitals had journal clubs. The average number of articles critically appraised by trainees who attended journal clubs was 5 (0–15) compared to 3 (0–18) in those not attending a journal club. When asked whether there was any alternative way in which a trainee might otherwise learn how to critically appraise an article, fourteen suggested online journal forums and eighteen suggested self-directed learning or personal study. Although only 49% of hospital had journal clubs, 88% of trainees believed that it formed a valuable part of training and 56% thought it should be compulsory. Discussion: This study shows that journal clubs occur in around half of the orthopaedic departments surveyed across the country. This is despite the importance trainees’ associate with journal clubs being part of their training. In contrast, studies from North America show that a regular journal club occurs in 99% of residency programs. It may therefore be suggested that for those trainees who do not attend a journal club, an alternative method to learning the skills of critical appraisement may have to be sort. One suggested modality is through on-line journal clubs or forums within regions which trainees may be encouraged to undertake from their regional directors

Clinical follow-up of hip and knee arthroplasty is not related to objective functional parameters while this is one of the main goal of evidence based medicine. Therefore a functional test was defined in order to correlate clinical and biomechanical data. The experimental set-up has been presented [1] as well as the test protocol [2]. Three parameters have been analyzed: reaction time (Tr), flight time (Tf) and maximum force (Fmax). The data refer to 21 subjects with hip joint replacement (HRG) and 22 subjects with knee joint replacement (KRG). Tests, were performed before surgery and after one, three and six months. The results were compared with values obtained from a control group of 402 normal subjects. One months after surgery the performance is lower respect to normal data, both for HRG and KRG. Three months later, there is a partial recover expecially for HRG. At six months follow-up, also the KRG reach better performance. While the performance starting point is higher in the HRG, the percentage recovery is equal in both the groups. During the follow-up also the non operated leg, both for HRG and KRG, shows a progressive changing in its performances, which can increase or decrease, but always it brings at the same level of ability for both legs. The data suggest that there are different performance and time recover related to the replaced joint (hip or knee) while the total amount of recover is not joint related and there are no differences for laterality. Experimental data correlate with clinical observation; therefore the proposed protocoll seems to be usefull for objective evaluation of joint replacement follow-up. The re-equilibration of the kinematic abilities between the limbs, which cannot be detected by clinical observation, requires further investigation and could be related to neurological integration and less algia limitation

Randomised controlled trials represent the gold standard in the evaluation of outcome of treatment. They are needed because differences between treatment effects have been minimised and observational studies may give a biased estimation of the outcome. However, conducting this kind of trial is challenging. Several methodological issues, including patient or surgeon preference, blinding, surgical standardisation, as well as external validity, have to be addressed in order to lower the risk of bias. Specific tools have been developed in order to take into account the specificity of evaluation of the literature on non-pharmacological intervention. A better knowledge of methodological issues will allow the orthopaedic surgeon to conduct more appropriate studies and to better appraise the limits of his intervention.

Introduction: Now that evidence base medicine gains importance scientifically good evaluation of the results of treatment is fundamental. There exist however a large number of evaluation tools for dorsolumbar disorders. These tools measure different aspects of outcome, like pain, impairment, handicap, disability, satisfaction and health perception. These tools are not always well validated either. These problems make it difficult to select the appropriate test for different purposes. Aim of the study: To compose and evaluate a system of outcome measuring tools that covers most aspects of outcome and that is relevant to spine surgeons. Materials and Methods: The tests were selected from literature, based on their scientific validity, their relevance, the frequency of their use by others and the ease of their use. The visual analogue scale for pain (VAS-pain), the low back outcome score (LBOS), the handicap subsection of the LBOS, the finger-tip to floor test (FTFT), The Oswestry disability index (ODI) and patient satisfaction were tested in a group of “pure-dorsolumbar-disorder-patients” (selected from a trauma group) and in a group of patients with degenerative disorders, as encountered in a spine surgery practice. The prospectively gathered pre- vs. postop. differences obtained with the different tests were compared with those obtained with the Oswestry disability index, which was chosen as “golden standard”. The obtained correlations (Kendall’s rank correlation coefficients and point-biserial coefficient) are a measure for the construct-validity and responsiveness of the different tests. Results: The correlation with the ODI was: weak and not significant for VAS-pain in the degenerative group, for FTFT-distance in both groups, for FTFT-pain in the trauma group and for satisfaction in both groups. The same correlation was weak but significant for the VAS-pain in the trauma group and for the LBOS-handicap part in the trauma group. It was moderate for LBOS and the LBOS-disability part in both groups, for the LBOS-handicap part in the degenerative group and for FTFT-pain in the degenerative group. There was no correlation of satisfaction with the other tests. Correlation of FTF- pain with VAS-pain was not significant in the degenerative group and moderate and in the trauma group

Talar neck fractures are rare injuries representing only 0.14%–0.32% of all fractures, one in five of these is open. In order to investigate the hypothesis that open talar neck fractures have worse outcome than closed ones, we did a Metaanalysis of the literature. Manuscripts dealing with fractures of the talus were identified from a Pubmed search including databases from 1970 to 2004. The searches were made using the keywords talar fractures, fractures of the neck of talus, outcome of talar fractures and open talar fractures. Full articles were retrieved and methodological quality filters applied for their suitability for inclusion in a more detailed review. Data were extracted from these articles and methodology and outcome were analyzed. We analyzed the numbers of patients, numbers of open fractures, mechanism of injury, associated injuries, classification used, treatment methods, complications and outcome. Of 29 manuscripts reviewed, 22 met the inclusion criteria. These were subjected to more detailed analysis, the outcomes of 1017 patients were described. The commonest mechanism of injury was road traffic accidents (42%). The incidence of Hawkins’ types was type I 27%, type II 35%, type III 30% and type IV 8%. More than half the patients were treated by open reduction and internal fixation. Medial malleolar fracture was the most common associated injury. The overall incidence of avuscular necrosis was 30%. 23% developed ankle osteoarthritis, 34% subtalar and 7.5% both. 17 % of all patients have had one form of arthrodesis. 22% were open injuries and only few authors reported the detailed treatment and outcome of their open fractures, however infection rate was higher in open injuries and they tend to be associated more with type III and IV Hawkins’ classification. The fate of the extruded talus remains controversial. In conclusion, it appears that the current literature is poor in providing evidence based medicine in the management and outcome of open talar neck fractures. More detailed studies should be done to shed more light on the fate of these rare and disabling injuries

Entrapment neuropathies are chronic local nerve lesions caused compression of anatomical structures around the nerves. The entrapment neuropathies are localized to regions where the nerves pass through anatomically narrow tunnels. The best example is carpal tunnel syndrome, which is also the most common entrapment. In literature more than 60 different entrapments have been described. Only a small number of the suggested entrapments have been reported according to standards required by evidence based medicine. Examples of these doubtful syndromes are the pronator and piriformis syndromes. The diagnosis of entrapments is based on the subjective symptoms, clinical findings and an electrodiagnostic consultation, consisting of EMG and neurography. Needle EMG can be used to demonstrate axonal lesions of motor axons. It is quite useful in moderate or severe lesions of mixed nerves. However, in purely neurapraxic lesions needle EMG is normal. Neurography across the site of entrapment is the most sensitive method. Surface electrodes can be used in the diagnosis of carpal tunnel syndrome and ulnar nerve lesions at the elbow. The nerve lesion can be localized very accurately using short segment studies. In deeply located nerves or small nerve branches, neurography must be done using needle electrodes (Morton’s metatarsalgia and meralgia paresthetica). The sensitivity and specificity of modern neurophysiological methods are high. The syndromes with consistently normal neurophysiological findings cannot be accepted as neuropathic, other etio-logic causes must be considered in these cases

We wished to see if Orthopaedic Surgeons are using the current evidence with regard to the use of drains in knee arthroplasty. A questionnaire was faxed to UK members of BASK. We had a 71. 7% response rate (160 responses out of 223). For primary TKR, 89. 5% always use a drain. 42. 1% removed their drains at between 24 and 48 hours. The commonest reason for using drains was to prevent haematoma or haemarthrosis development. The study suggests that the majority of BASK members do not practice evidence based medicine with regard to the use of knee drains

Pain management has remained a challenge for surgeons since the dawn of organised medicine. A massive influx of unproven techniques and alternative therapies has descended upon us with little regard to true efficacy and even safety. It is incumbent upon us as practitioners of medicine to finally begin to pay more attention to the tenets of evidenced based medicine while making therapeutic choices. Johns Hopkins has had a long history of dealing with pain in many of its chameleon forms ranging from the management of acute post-operative pain to the more difficult management of chronic pain. To effectively manage pain in a surgical practice requires attention to first establishing the type of pain (ie. nociceptive or neuropathic). Once the type of pain is clear, specific algorithms can be worked out based on the principles of evidenced based medicine which can be carried out by a variety of paramedical personnel (ie. Physician Assistants or Nurses) without specific surgeon input. This maximises benefit to the patient and minimises problems for the surgeon. Specific algorithms for the management of acute LBP, chronic LBP, acute postoperative pain, chronic postoperative pain, cancer pain and sociopathic pain will be discussed

Abstract: With the current shift in recommended practice towards being evidence based, we wished to see if Orthopaedic surgeons are using the current evidence with regards to the use of drains in knee arthroplasty. Method: A questionnaire was faxed to all UK members of BASK to ascertain their current practice regarding the use of drains in knee arthroplasty and the rationale for their drain policy. Results: The BASK members handbook identified 231 UK members and a questionnaire was faxed to them. 160 replies were received, of which 8 were excluded from analysis as they were either retired or non-surgeons. This gave a 68.2% response rate (1 52 results out of 223). Drain usage:. Primary TKR: Always 136(89.5%); Sometimes 13(8.5%), Never 3(2.0%). Revision TKR: Always 141(94.6%); Sometimes 3 (2.0%); Never 5(3.4%); Not applicable 3. Unicompartmental: Always 66(57.9%); Sometimes 28(24.6%); Never 20(17.5%); Not applicable 3.1. Hours drain removed at:. < 24 hours 77(50.7%); 24–48 hours 64(42.1%);. > 48 hours 4(2.6%); No answer 7(4.6%). Rationale for drain use:. Prevent wound haematoma/haemarthrosis 74; personal reasons 27; to allow retransfusion 20; evidence based 12; despite evidence 5. 29.6% of the responders are currently using cell salvage drains, and a further 7.9% are keen to start using cell salvage drains when the circumstances in their hospitals change to allow them to do so. Conclusion: The results of our questionnaire have shown that for primary TKR 89.5% always use a drain. With regard to the duration of drainage, 42.1 % of the respondents removed their drains at between 24 and 48 hours. The commonest reason given for the use of drains in total knee arthroplasty was to prevent haematorna or haemarthrosis development. However the published literature does not support these practices and beliefs. Only 12 people said that their practice was evidence based. We therefore have to conclude that the majority of practising members of BASK do not practice evidence based medicine with regard to the use of drains in knee arthroplasty