Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace

Ankle replacements have improved significantly since the first reported attempt at resurfacing of the talar dome in 1962. We are now at a stage where ankle replacement offers a viable option in the treatment of end-stage ankle arthritis. As the procedure becomes more successful, it is important to reflect and review the current surgical outcomes. This allows us to guide our patients in the treatment of end-stage ankle arthritis. What is the better surgical treatment – arthrodesis or replacement?

Patient-centred medicine is an approach to medical care that emphasises the patient experience. Treatment outcome measures reflect this experience, and outcomes are measured by obtaining patient feedback. Central to this type of care is the patient-physician relationship. Communication, physician empathy, and shared decision making are key components of this relationship. Patient-centred care is correlated with better patient outcomes across medical specialties and higher patient perceived quality of care. Payors are now using patient-centred quality measures in their physician reimbursement schedules

This article provides an overview of the role of genomics in sarcomas and describes how new methods of analysis and comparative screening have provided the potential to progress understanding and treatment of sarcoma. This article reviews genomic techniques, the evolution of the use of genomics in cancer, the current state of genomic analysis, and also provides an overview of the medical, social and economic implications of recent genomic advances

Arthroscopy has become a routine surgical procedure, used as a diagnostic and therapeutic tool for the treatment of joint problems. This article discusses its origins and looks at how it is currently used

We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity.

The global economy has been facing a financial crisis. Healthcare costs are spiraling, and there is a projected £30 billion health funding gap by 2020 in the UK.¹ This has prompted a drive for efficiency in healthcare provision in the UK, and in 2012, the Health and Social Care Act was introduced, heralding a fundamental change to the structure of the National Health Service, especially in the way that healthcare is funded in England.²

What is happening in the UK is a reflection of a global problem. Rationing of healthcare is a topic of much discussion; as unless spending is capped, providing healthcare will become unsustainable. Who decides how money is spent, and which services should be rationed?

In this article we aim to discuss the impact that rationing may have on orthopaedic surgery, and we will discuss our own experiences of attempts to ration local services.³ We also seek to inform and educate the general orthopaedic community on this topic.

This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury.

Clinical studies evaluating the effects of vitamin D alone or in combination with calcium on physical function, falls and fractures have been inconsistent. Vitamin D has, however, been the focus of much orthopaedic, trauma and endocrine research. Playing a central role in muscle and bone metabolism, some studies on Vitamin D therapies offer the tantalising suggestion of a reduction in falls and fractures simply with vitamin D supplementation. We review the background and evidence behind vitamin D.

Obesity is a global epidemic of 2.1 billion people and a well known cause of osteoarthritis. Joint replacement in the obese attracts more complications, poorer outcomes and higher revision rates. It is a reversible condition and the fundamental principles of dealing with reversible medical conditions prior to elective total joint replacement should apply to obesity. The dilemma for orthopaedic surgeons is when to offer surgery in the face of a reversible condition, which if treated may obviate joint replacement and reduce the risk and severity of obesity related disease in both the medical arena and the field of orthopaedics.

This review examines the future of total hip arthroplasty, aiming to avoid past mistakes

There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents.

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

Not all questions can be answered by prospective randomised controlled trials. Registries were introduced as a way of collecting information on joint replacements at a population level. They have helped to identify failing implants and the data have also been used to monitor the performance of individual surgeons. This review aims to look at some of the less well known registries that are currently being used worldwide, including those kept on knee ligaments, ankle arthroplasty, fractures and trauma.

In the UK we have many surgeon inventors – surgeons who innovate and create new ways of doing things, who invent operations, who design new instruments to facilitate surgery or design new implants for using in patients. However truly successful surgeon inventors are a rare breed and they need to develop additional knowledge and skills during their career in order to push forward their devices and innovations. This article reviews my own experiences as a surgeon inventor and the highs and lows over the whole of my surgical career.

According to a report by Millennium Research Group in January 2011, the US orthopaedic extremity device market will generate over $4.6 billion in revenue by 2015.¹ With an ageing demographic and increasing demand for better quality of life into old age, there is clearly a commercial drive for the orthopaedic device community to develop new and innovative solutions to bone and joint problems. Devising such solutions is one thing; protecting them, so that research investment can be rewarded, is another. How is such protection achieved? The judicious use of intellectual property rights plays a key role, and this article aims to provide some information about the use of patents to protect innovation.

Modern athletes are constantly susceptible to performance-threatening injury as they push their bodies to greater limits and endure higher physical stresses. Loss of performance and training time can adversely and permanently affect a sportsperson’s career. Now more than ever with advancing medical technology the answer may lie in biologic therapy. We have been using peripheral blood stem cells (PBSC) clinically and have been able to demonstrate that stem cells differentiate into target cells to enable regenerative repair. The potential of this technique as a regenerative agent can be seen in three broad applications: 1) articular cartilage, 2) bone and 3) soft tissue. This article highlights the successful cases, among many, in all three of these applications.

Stem cells are a key component of regenerative medicine strategies. Particular areas of musculoskeletal application include cartilage and bone regeneration in arthritis and trauma. There are several types of stem cell and this article will focus on the adult derived cells. The review includes current issues and future developments.

Ancient Egypt was a highly developed agrarian society with a massive civil engineering capability. Trauma and skeletal disease were common and vestiges of the evidence for that survive, largely in the form of hieratic images and papyri dedicated to the practice of medicine. The earliest treatise on trauma is the Edwin Smith papyrus, possibly the work of Imhotep. This study details some remarkable examples of musculoskeletal pathology including fatal open fractures, foot deformity of Tutankhamun, and the earliest recorded instances of child abuse.

A comprehensive study of osteology remains a cornerstone of current orthopaedic and traumatological education. Osteology was already established as an important part of surgical education by the 16^th century. In order to teach anatomy and osteology, the corpses of executed criminals were dissected by the praelector anatomiae of the Amsterdam Guild of Surgeons. Magnificent anatomical atlases preserve the knowledge obtained from these dissections. We present an overview of the most authoritative works of Vesalius, Bidloo, Cheselden, and Albinus authored in the 16^th, 17^th and 18^th centuries. At that time a knowledge of osteology was necessary to pass the ‘master-exam’ in order to become a surgeon, and anatomical teaching was traditionally based on the practice of dissection. In the modern era, anatomical dissection and illustrations are largely being replaced by three-dimensional imaging and computer simulations, with an unfortunate trend in current curricula away from the established teaching technique of dissection. Education through the practice of dissection, particularly for future surgeons, remains integral to the development of tissue handling techniques, understanding of anatomical variation, and furthering of spatial awareness skills. With this review, we seek to remind contemporary surgeons of the lessons we can learn from our predecessors who valued education through anatomical dissection.

The need to demonstrate probity and fair market competition has increased scrutiny of the relationships between orthopaedic surgeons and the industry that supplies them with their tools and devices. Investigations and judgements from the US Department of Justice and the introduction of the AdvaMed and Eucomed codes have defined new boundaries for interactions between these groups. This article summarises the current interplay between orthopaedic surgeons and industry, and provides recommendations for the future.

Chris Lavy is an orthopaedic surgeon in Oxford (UK) who lived and worked in Malawi for ten years. There he helped build an orthopaedic hospital and research unit. He was also one of the founders of COSECSA, the regional college of surgeons for East and Central Africa in 1999.

By and large, physicians and surgeons trust what they read, even if they take authors’ conclusions with a pinch of salt. There is a world of difference between being cautious about the implications of what you read and being defrauded by dishonest researchers. Fraud and scientific research are incompatible bedfellows and yet are an unhappy part of our research existence. All subspecialties are to blame and orthopaedics is no exception.

Amputation was once widely practised for primary bone tumours of the limbs. Yet this situation has changed with limb salvage surgery becoming increasingly popular in the last 30 years. Many different techniques are now available. These include allografts, autografts, endoprostheses and allograft-prosthesis composites. This article reviews these methods, concentrating on the functional outcomes and complications that have been reported.