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The Bone & Joint Journal
Vol. 102-B, Issue 5 | Pages 550 - 555
1 May 2020
Birch N Todd NV

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of “failure to warn”, i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on “failure to warn” and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550–555


Bone & Joint Open
Vol. 3, Issue 6 | Pages 495 - 501
14 Jun 2022
Keohane D Sheridan GA Masterson E

Aims

Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component.

Methods

A retrospective, single-surgeon review was carried out of all of the NexGen Legacy Posterior Stabilized (LPS) TKAs performed in this institute. The specific model used for the index procedures was the NexGen Complete Knee System (Legacy Knee-Posterior Stabilized LPS-Flex Articular Surface, LPS-Flex Femoral Component Option, and Stemmed Nonaugmentable Tibial Component Option).


Bone & Joint Research
Vol. 11, Issue 8 | Pages 575 - 584
17 Aug 2022
Stoddart JC Garner A Tuncer M Cobb JP van Arkel RJ

Aims

The aim of this study was to determine the risk of tibial eminence avulsion intraoperatively for bi-unicondylar knee arthroplasty (Bi-UKA), with consideration of the effect of implant positioning, overstuffing, and sex, compared to the risk for isolated medial unicondylar knee arthroplasty (UKA-M) and bicruciate-retaining total knee arthroplasty (BCR-TKA).

Methods

Two experimentally validated finite element models of tibia were implanted with UKA-M, Bi-UKA, and BCR-TKA. Intraoperative loads were applied through the condyles, anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral collateral ligament (LCL), and the risk of fracture (ROF) was evaluated in the spine as the ratio of the 95th percentile maximum principal elastic strains over the tensile yield strain of proximal tibial bone.


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 911 - 914
1 Aug 2022
Prijs J Liao Z Ashkani-Esfahani S Olczak J Gordon M Jayakumar P Jutte PC Jaarsma RL IJpma FFA Doornberg JN

Artificial intelligence (AI) is, in essence, the concept of ‘computer thinking’, encompassing methods that train computers to perform and learn from executing certain tasks, called machine learning, and methods to build intricate computer models that both learn and adapt, called complex neural networks. Computer vision is a function of AI by which machine learning and complex neural networks can be applied to enable computers to capture, analyze, and interpret information from clinical images and visual inputs. This annotation summarizes key considerations and future perspectives concerning computer vision, questioning the need for this technology (the ‘why’), the current applications (the ‘what’), and the approach to unlocking its full potential (the ‘how’).

Cite this article: Bone Joint J 2022;104-B(8):911–914.


Bone & Joint 360
Vol. 11, Issue 3 | Pages 17 - 20
1 Jun 2022


The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1033 - 1042
1 Aug 2018
Kayani B Konan S Pietrzak JRT Huq SS Tahmassebi J Haddad FS

Aims. The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA. Patients and Methods. This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (. sd. 6.8) vs 64.1 years (. sd. 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (. sd. 2.7) vs 28.1 kg.m2 (. sd. 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications. Results. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time (p < 0.001) and surgical team confidence levels (p < 0.001). Cumulative robotic experience did not affect accuracy of implant positioning (p = 0.52), posterior condylar offset ratio (p = 0.71), posterior tibial slope (p = 0.68), native joint line preservation (p = 0.55), and postoperative limb alignment (p = 0.65). Robotic-arm assisted UKA improved accuracy of femoral (p < 0.001) and tibial (p < 0.001) implant positioning with no additional risk of postoperative complications compared to conventional jig-based UKA. Conclusion. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time and surgical team confidence levels but no learning curve for accuracy of implant positioning. Cite this article: Bone Joint J 2018;100-B:1033–42


Bone & Joint 360
Vol. 11, Issue 3 | Pages 14 - 17
1 Jun 2022


Bone & Joint 360
Vol. 11, Issue 3 | Pages 40 - 43
1 Jun 2022


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 915 - 921
1 Aug 2022
Marya S Tambe AD Millner PA Tsirikos AI

Adolescent idiopathic scoliosis (AIS), defined by an age at presentation of 11 to 18 years, has a prevalence of 0.47% and accounts for approximately 90% of all cases of idiopathic scoliosis. Despite decades of research, the exact aetiology of AIS remains unknown. It is becoming evident that it is the result of a complex interplay of genetic, internal, and environmental factors. It has been hypothesized that genetic variants act as the initial trigger that allow epigenetic factors to propagate AIS, which could also explain the wide phenotypic variation in the presentation of the disorder. A better understanding of the underlying aetiological mechanisms could help to establish the diagnosis earlier and allow a more accurate prediction of deformity progression. This, in turn, would prompt imaging and therapeutic intervention at the appropriate time, thereby achieving the best clinical outcome for this group of patients.

Cite this article: Bone Joint J 2022;104-B(8):915–921.


The Bone & Joint Journal
Vol. 100-B, Issue 10 | Pages 1275 - 1279
1 Oct 2018
Fader RR Tao MA Gaudiani MA Turk R Nwachukwu BU Esposito CI Ranawat AS

Aims. The purpose of this study was to evaluate spinopelvic mechanics from standing and sitting positions in subjects with and without femoroacetabular impingement (FAI). We hypothesize that FAI patients will experience less flexion at the lumbar spine and more flexion at the hip whilst changing from standing to sitting positions than subjects without FAI. This increase in hip flexion may contribute to symptomatology in FAI. Patients and Methods. Male subjects were prospectively enrolled to the study (n = 20). Mean age was 31 years old (22 to 41). All underwent clinical examination, plain radiographs, and dynamic imaging using EOS. Subjects were categorized into three groups: non-FAI (no radiographic or clinical FAI or pain), asymptomatic FAI (radiographic and clinical FAI but no pain), and symptomatic FAI (patients with both pain and radiographic FAI). FAI was defined as internal rotation less than 15° and alpha angle greater than 60°. Subjects underwent standing and sitting radiographs in order to measure spine and femoroacetabular flexion. Results. Compared with non-FAI controls, symptomatic patients with FAI had less flexion at the spine (mean 22°, . sd. 12°, vs mean 35°, . sd. 8°; p = 0.04) and more at the hip (mean 72°, . sd. 6°, vs mean 62°, . sd. 8°; p = 0.047). Subjects with asymptomatic FAI had more spine flexion and similar hip flexion when compared to symptomatic FAI patients. Both FAI groups also sat with more anterior pelvic tilt than control patients. There were no differences in standing alignment among groups. Conclusion. Symptomatic patients with FAI require more flexion at the hip to achieve sitting position due to their inability to compensate through the lumbar spine. With limited spine flexion, FAI patients sit with more anterior pelvic tilt, which may lead to impingement between the acetabulum and proximal femur. Differences in spinopelvic mechanics between FAI and non-FAI patients may contribute to the progression of FAI symptoms. Cite this article: Bone Joint J 2018;100-B:1275–9


The Bone & Joint Journal
Vol. 104-B, Issue 6 | Pages 703 - 708
1 Jun 2022
Najefi A Zaidi R Chan O Hester T Kavarthapu V

Aims

Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.

Methods

We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded.


The Bone & Joint Journal
Vol. 96-B, Issue 11 | Pages 1485 - 1490
1 Nov 2014
Kim CW Seo SS Kim JH Roh SM Lee CR

The aim of this study was to find anatomical landmarks for rotational alignment of the tibial component in total knee replacement (TKR) in a CT-based study. Pre-operative CT scanning was performed on 94 South Korean patients (nine men, 85 women, 188 knees) with osteoarthritis of the knee joint prior to TKR. The tibial anteroposterior (AP) axis was defined as a line perpendicular to the femoral surgical transepicondylar axis and passing through the centre of the posterior cruciate ligament (PCL). The angles between the defined tibial AP axis and anatomical landmarks at various levels of the tibia were measured. The mean values of the angles between the defined tibial AP axis and the line connecting the anterior border of the proximal third of the tibia to the centre of the PCL was -0.2° (-17 to 14.1, . sd. 4.1). This was very close to the defined tibial axis, and remained so regardless of lower limb alignment and the degree of tibial bowing. Therefore, AP axis defined as described, is a reliable anatomical landmark for rotational alignment of tibial components. Cite this article: Bone Joint J 2014; 96-B:1485–90


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 963 - 971
1 Aug 2022
Sun Z Liu W Liu H Li J Hu Y Tu B Wang W Fan C

Aims

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Methods

This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation.


The Bone & Joint Journal
Vol. 104-B, Issue 7 | Pages 765 - 766
1 Jul 2022
Haddad FS Malchau H


Bone & Joint Research
Vol. 11, Issue 7 | Pages 494 - 502
20 Jul 2022
Kwon HM Lee J Koh Y Park KK Kang K

Aims

A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes.

Methods

ACL- or PCL-deficient models with posterior tibial slopes of 1°, 3°, 5°, 7°, and 9° were developed and compared to intact models. The kinematics and contact stresses on the tibiofemoral joint were evaluated under gait cycle loading conditions.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 8 | Pages 1021 - 1026
1 Aug 2011
Kalteis T Sendtner E Beverland D Archbold PA Hube R Schuster T Renkawitz T Grifka J

Orientation of the native acetabular plane as defined by the transverse acetabular ligament (TAL) and the posterior labrum was measured intra-operatively using computer-assisted navigation in 39 hips. In order to assess the influence of alignment on impingement, the range of movement was calculated for that defined by the TAL and the posterior labrum and compared with a standard acetabular component position (abduction 45°/anteversion 15°). With respect to the registration of the plane defined by the TAL and the posterior labrum, there was moderate interobserver agreement (r = 0.64, p < 0.001) and intra-observer reproducibility (r = 0.73, p < 0.001). The mean acetabular component orientation achieved was abduction of 41° (32° to 51°) and anteversion of 18° (−1° to 36°). With respect to the Lewinnek safe zone (abduction 40° ±10°, anteversion 15° ±10°), 35 of the 39 acetabular components were within this zone. However, there was no improvement in the range of movement (p = 0.94) and no significant difference in impingement (p = 0.085). Alignment of the acetabular component with the TAL and the posterior labrum might reduce the variability of acetabular component placement in total hip replacement. However, there is only a moderate interobserver agreement and intra-observer reliability in the alignment of the acetabular component using the TAL and the posterior labrum. No reduction in impingement was found when the acetabular component was aligned with the TAL and the posterior labrum, compared with a standard acetabular component position


Bone & Joint Research
Vol. 11, Issue 3 | Pages 180 - 188
1 Mar 2022
Rajpura A Asle SG Ait Si Selmi T Board T

Aims

Hip arthroplasty aims to accurately recreate joint biomechanics. Considerable attention has been paid to vertical and horizontal offset, but femoral head centre in the anteroposterior (AP) plane has received little attention. This study investigates the accuracy of restoration of joint centre of rotation in the AP plane.

Methods

Postoperative CT scans of 40 patients who underwent unilateral uncemented total hip arthroplasty were analyzed. Anteroposterior offset (APO) and femoral anteversion were measured on both the operated and non-operated sides. Sagittal tilt of the femoral stem was also measured. APO measured on axial slices was defined as the perpendicular distance between a line drawn from the anterior most point of the proximal femur (anterior reference line) to the centre of the femoral head. The anterior reference line was made parallel to the posterior condylar axis of the knee to correct for rotation.


The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 34 - 44
1 Jan 2022
Beckers L Dandois F Ooms D Berger P Van Laere K Scheys L Vandenneucker H

Aims

Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs.

Methods

In total, 34 patients (13 female, 21 male; mean age 62 years (41 to 79); BMI 29.7 kg/m2 (23.6 to 42.1)) with 38 medial Oxford partial UKAs (20 left, 18 right; 19 cementless, 14 cemented, and five hybrid) were prospectively followed with sequential 99mTc-hydroxymethane diphosphonate single photon emission CT (SPECT)/CT preoperatively, and at one and two years postoperatively. Changes in mean osteoblastic activity were investigated using a tracer localization scheme with volumes of interest (VOIs), reported by normalized mean tracer values. A SPECT/CT registration platform additionally explored cortical tracer evolution in zones of interest identified by previous experimental research.


Bone & Joint 360
Vol. 11, Issue 2 | Pages 3 - 4
1 Apr 2022
Ollivere B


Bone & Joint Open
Vol. 3, Issue 7 | Pages 515 - 528
1 Jul 2022
van der Heijden L Bindt S Scorianz M Ng C Gibbons MCLH van de Sande MAJ Campanacci DA

Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

Methods

We included 76 patients with distal radius GCTB in three sarcoma centres (1990 to 2019). Median follow-up was 8.8 years (2 to 23). Seven patients underwent curettage, 38 curettage with adjuvants, and 31 resection; 20 had denosumab.