Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

The Bone & Joint Journal has published several consensus statements in recent years, many of which have positively influenced clinical practice and policy.^1-13 However, even the most valued consensus statements have limitations, and all ultimately represent Level V evidence. Consensus studies add greatest value where higher-order evidence to aid decision making is ambiguous or lacking. In all settings, care must be taken to critically appraise standards of methodology, with particular attention to potential biases that may influence the conclusions which are drawn.

Cite this article: Bone Joint J 2023;105-B(4):343–346.

As advancements in total knee arthroplasty progress at an exciting pace, two areas are of special interest, as they directly impact implant design and surgical decision making. Knee morphometry considers the three-dimensional shape of the articulating surfaces within the knee joint, and knee phenotyping provides the ability to categorize alignment into practical groupings that can be used in both clinical and research settings. This annotation discusses the details of these concepts, and the ways in which they are helping us better understand the individual subtleties of each patient’s knee.

Cite this article: Bone Joint J 2024;106-B(12):1363–1368.

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

Cite this article: Bone Joint J 2024;106-B(4):312–318.

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care.

Cite this article: Bone Joint J 2024;106-B(11):1206–1215.

Aims. The purpose of this article was to review the current literature pertaining to the use of mobile compression devices (MCDs) for venous thromboembolism (VTE) following total joint arthroplasty (TJA), and to discuss the results of data from our institution. Patients and Methods. Previous studies have illustrated higher rates of post-operative wound complications, re-operation and re-admission with the use of more aggressive anticoagulation regimens, such as warfarin and factor Xa inhibitors. This highlights the importance of the safety, as well as efficacy, of the chemoprophylactic regimen. Results. Studies have shown a symptomatic VTE rate of 0.92% with use of MCDs for prophylaxis, which is comparable with rates seen with more aggressive anticoagulation protocols. A prior prospective study found that use of a pre-operative risk stratification protocol based on personal history of deep vein thrombosis, family history of VTE, active cancer, or a hypercoaguable state allowed for the avoidance of aggressive prophylactic anticoagulation in over 70% of patients while maintaining a low incidence of symptomatic VTE. Conclusion. Further investigation is needed into the role of aspirin in VTE prophylaxis as well as the efficacy of MCDs as stand-alone prophylactic treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):8–13

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients’ performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.

Cite this article: Bone Joint J 2022;104-B(10):1104–1109.

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI.

Cite this article: Bone Joint J 2022;104-B(5):532–540.

Artificial intelligence and machine-learning analytics have gained extensive popularity in recent years due to their clinically relevant applications. A wide range of proof-of-concept studies have demonstrated the ability of these analyses to personalize risk prediction, detect implant specifics from imaging, and monitor and assess patient movement and recovery. Though these applications are exciting and could potentially influence practice, it is imperative to understand when these analyses are indicated and where the data are derived from, prior to investing resources and confidence into the results and conclusions. In this article, we review the current benefits and potential limitations of machine-learning for the orthopaedic surgeon with a specific emphasis on data quality.

There is increasing popularity in the use of artificial intelligence and machine-learning techniques to provide diagnostic and prognostic models for various aspects of Trauma & Orthopaedic surgery. However, correct interpretation of these models is difficult for those without specific knowledge of computing or health data science methodology. Lack of current reporting standards leads to the potential for significant heterogeneity in the design and quality of published studies. We provide an overview of machine-learning techniques for the lay individual, including key terminology and best practice reporting guidelines.

Cite this article: Bone Joint J 2021;103-B(12):1754–1758.

There are three basic concepts that are important to the biomechanics of pedicle screw-based instrumentation. First, the outer diameter of the screw determines pullout strength, while the inner diameter determines fatigue strength. Secondly, when inserting a pedicle screw, the dorsal cortex of the spine should not be violated and the screws on each side should converge and be of good length. Thirdly, fixation can be augmented in cases of severe osteoporosis or revision.

A trajectory parallel or caudal to the superior endplate can minimise breakage of the screw from repeated axial loading. Straight insertion of the pedicle screw in the mid-sagittal plane provides the strongest stability.

Rotational stability can be improved by adding transverse connectors. The indications for their use include anterior column instability, and the correction of rotational deformity.

Modern principles for the treatment of open fractures include stabilisation of the bone and management of the soft tissues. Wound debridement and irrigation is thought to be the mainstay in reducing the incidence of infection. Although numerous studies on animals and humans have focused on the type of irrigation performed, little is known of the factors which influence irrigation. This paper evaluates the evidence, particularly with regard to additives and the mode of delivery of irrigation fluid.

Normal saline should be used and although many antiseptics and antibiotics have been employed, no consensus has been reached as to the ideal additive. Despite the advocates of high-pressure methods highlighting the improved dilutional ability of such techniques, the results are inconclusive and these irrigation systems are not without complications.

New systems for debridement are currently being investigated, and an ideal method has yet to be determined.

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised.

Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.

National registers compare implants by their revision rates, but the validity of the method has never been assessed. The New Zealand Joint Registry publishes clinical outcomes (Oxford knee scores, OKS) alongside revision rates, allowing comparison of the two measurements. In the two types of knee replacement, unicompartmental (UKR) had a better knee score than total replacement (TKR), but the revision rate of the former was nearly three times higher than that of the latter. This was because the sensitivity of the revision rate to clinical failure was different for the two implants. For example, of knees with a very poor outcome (OKS < 20 points), only about 12% of TKRs were revised compared with about 63% of UKRs with similar scores.

Revision therefore is not an objective measurement and should not be used to compare these two types of implant. Furthermore, revision is much less sensitive than the OKS to clinical failure in both types and therefore exaggerates the success of knee replacements, particularly of TKR.

In a systematic review, reports from national registers and clinical studies were identified and analysed with respect to revision rates after joint replacement, which were calculated as revisions per 100 observed component years.

After primary hip replacement, a mean of 1.29 revisions per 100 observed component years was seen. The results after primary total knee replacement are 1.26 revisions per 100 observed component years, and 1.53 after medial unicompartmental replacement. After total ankle replacement a mean of 3.29 revisions per 100 observed component years was seen.

The outcomes of total hip and knee replacement are almost identical. Revision rates of about 6% after five years and 12% after ten years are to be expected.

This article considers some of the problems of the interpretation of information from other national arthroplasty registers when setting up a new register. In order for the most useful information to be available from registers much international co-operation is required between all those responsible for the design of registers as well as those who gather, assess and publish the data.

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.