British Editorial Society of Bone & Joint Surgery

Robotic-assisted systems are being increasingly integrated into orthopaedic surgery, offering potential improvements in precision, reproducibility, and patient-reported outcome measures (PROMs) for unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), and total hip arthroplasty (THA). A review and summary of the early value assessment (EVA) undertaken by the National Institute for Health and Care Excellence (NICE) to evaluate the clinical effectiveness, cost-effectiveness, and implementation considerations of these technologies is presented. The EVA includes a review of the literature, an evidence gap analysis, and an evidence generation plan. Evidence from 28 studies and two registries suggested that robotic-assisted surgery was noninferior to conventional approaches in key outcomes, including PROMs, complications, hospital stay, and revisions, but it was associated with enhanced implant alignment. Short-term PROMs showed modest improvements, although most differences fell below currently defined clinically meaningful thresholds. Revision data were limited in follow-up, and ergonomic benefits for surgeons were uncertain. Economic evaluations suggested potential cost-effectiveness, particularly for THA, but assumptions regarding utilities, resource use, procedure volume, and implant costs introduced substantial uncertainty. The EVA highlighted the importance of training, equitable access, and national coordination for implementation. Evidence gaps were identified in long-term revision rates, health-related quality of life outcomes, productivity, sub-group effects, surgical team benefits, and learning curves. NICE recommended conditional adoption of six robotic platforms (ApolloKnee (Corin, UK), CORI (Smith & Nephew, UK), Mako (Stryker, USA), ROSA (Zimmer Biomet, USA), SkyWalker (MicroPort, China), and VELYS (DePuy Synthes, USA)) over a three-year evidence generation period, requiring annual reporting and adherence to regulatory standards. While robotic-assisted arthroplasty offers technical advantages, definitive clinical and economic benefits remain unproven. Surgeons, healthcare systems, and industry partners will need to work collaboratively to provide the required evidence in the next three years. A UK robotic registry could help address the evidence gaps more rapidly than individual centres by capturing large-scale national data.

With the increasing use of cementless implants for primary total knee arthroplasty (TKA), the aim of this systematic review and meta-analysis was to evaluate the clinical and radiological outcomes of contemporary cementless designs of TKA compared with cemented TKA. Adhering to the PRISMA guidelines, a review of medical databases including Cochrane Registry, MEDLINE, Embase, Web of Science, and grey literature was conducted. The search included studies published since 2010 and encompassed only the current generation of cementless implants. Quality assessment was performed using the ROB-2/ROBIN-I risk of bias tools. The search yielded 23 randomized controlled trials and 45 observational studies which met the inclusion criteria. A total of 31 outcome metrics, including clinical and functional outcomes, were analyzed. Subgroup analysis was based on the patient's age. Meta-analysis of all-cause and aseptic survival at specific timepoints between one and 19 years postopertaively showed no significant difference between the groups. Subgroup analysis for individual patients aged < 60 years showed significant differences favouring cementless implants up to 14 years. Overall migration, measured at one and five years, was significantly higher for cementless implants (p < 0.001), with comparable migration at ten years (p = 0.43). Meta-analysis of most clinical outcomes showed equivalence up to 20 years, though some metrics favoured cementless implants. Subscales of Knee Society Score function/pain revealed significant differences at two (p = 0.003) and five years (all p < 0.05) favouring cementless implants. Cementless groups also had significantly shorter operating times (p < 0.001) and lengths of stay in hospital (p = 0.003). Surgical complications were significantly more frequent in the cemented group (p < 0.001), as was the incidence of deep venous thrombosis (p = 0.002). This meta-analysis highlighted considerable variations in outcomes between cemented and cementless TKA, suggesting that newer designs of cementless implants may offer improved survival in patients aged < 60 years. There was early migration of cementless TKA with stabilization in the longer term and improvement in several clinical and functional outcomes favouring cementless over cemented implants.

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.

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.

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Orthopaedic surgeons are currently faced with an overwhelming number of choices surrounding total knee arthroplasty (TKA), not only with the latest technologies and prostheses, but also fundamental decisions on alignment philosophies. From 'mechanical' to 'adjusted mechanical' to 'restricted kinematic' to 'unrestricted kinematic' - and how constitutional alignment relates to these - there is potential for ambiguity when thinking about and discussing such concepts. This annotation summarizes the various alignment strategies currently employed in TKA. It provides a clear framework and consistent language that will assist surgeons to compare confidently and contrast the concepts, while also discussing the latest opinions about alignment in TKA. Finally, it provides suggestions for applying consistent nomenclature to future research, especially as we explore the implications of 3D alignment patterns on patient outcomes.Cite this article: Bone Joint J2023;105-B(2):102-108.

AimsThe aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).MethodsWe performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale.ResultsWe enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001).ConclusionFunctional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected.Cite this article: Bone Jt Open 2023;4(1):46–52.