EDITORIAL
Fundamental questions in need of answers
F. S. Haddad From The British Editorial Society of Bone and Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B5. 36261 $2.00 Bone Joint J 2015;97-B:577.
VOL. 97-B, No. 5, MAY 2015
I have just had the privilege of attending the American Academy of Orthopaedic Surgeon’s meeting in Las Vegas. This confirmed that there are still many areas where high-level evidence is desperately needed. This month’s Bone & Joint Journal includes several thought-provoking papers that will generate further research. Henrik Malchau’s update1 on patient-reported outcome measures (PROMs) is particularly important. He has been a leader in this field for over 20 years and played a key role in the success of the Swedish Arthroplasty register, and in educating the orthopaedic community about the stepwise introduction of innovation. The move in the assessment of outcome away from objective measures and towards patient-reported tools has been a very successful one. There is a place for both for research purposes,2 but the linkage of PROMs to observational datasets is clearly on the rise. It is critical, in this era of value based healthcare, that PROMS are embedded in our practice in order for us to understand the real effects of our interventions, and also to apply or prioritise them according to the benefits that they provide.3,4 However, there are, of course, dangers in the interpretation of such data, particularly if it is recorded at the wrong time, is incompletely available, or is not case-mix adjusted. One of the challenges that will face us, both in research and in general trauma and orthopaedic practice over the next decade, is the appropriate stratification of our patients and procedures so that we can truly begin to understand the differences in outcome that are seen in various settings. Our instructional reviews this month highlight areas where there has been far too little progress over the last three decades. The prevention and management of periprosthetic infection has not progressed as we would have wished. The review by Brennan et al5 on silver nanoparticles presents one possible solution, although the translation from the laboratory to widespread clinical practice may well prove difficult. Tim Spalding’s update on meniscal allograft transplantation6 also illustrates the importance of biological interventions in the prevention and management of early osteoarthritis, another area where there is a big unmet need. I would like to commend the EndoKlinic paper on single-stage knee arthrodesis after failed total knee arthroplasty.7 This is an important piece of work at several levels, most particularly in relation to the devastating effects that infection has on
patients. Their data suggest that patients were happy with their arthrodesis, perhaps reflecting the disability most patients suffered pre-operatively. It also highlights the increasing success rate of single-stage interventions in appropriate centres with evidence-based protocols dealing with the local delivery of antibiotics. The authors also hint that they have now started using hinged implants with external adjustment of flexion – this is a solution that has been applied in several centres. Outcome studies are awaited with interest. I am also pleased to see two prospective randomised studies in this issue of the journal.8,9 It is critical that we start to enter more patients into such studies as we undoubtedly lag behind other specialties in this area. There is also some evidence that patients in studies have better outcomes than those who are not.10 I would like to highlight the very wide international spread of papers in BJJ. Whilst we appreciate that some parts of the world struggle with research funding, there is still a great deal that all of us can learn from the experiences of others.
References 1. Rolfson O, Malchau H. The use of patient-reported outcomes after routine arthroplasty: beyond the whys and ifs. Bone Joint J 2015;97B:578–581. 2. Konan S, Hossain F, Patel S, Haddad FS. Measuring function after hip and knee surgery: the evidence to support performancebased functional outcome tasks. Bone Joint J 2014;96-B:1431–1435. 3. Keurentjes JC, Van Tol FR, Fiocco M, et al. Patient acceptable symptom states after total hip or knee replacement at mid-term follow-up: thresholds of the Oxford hip and knee scores. Bone Joint Res 2014;3:7–13. 4. Harris KK, Price AJ, Beard DJ, et al. Can pain and function be distinguished in the Oxford Hip Score in a meaningful way?: an exploratory and confirmatory factor analysis. Bone Joint Res 2014;3:305–309. 5. Brennan SA, Ní Fhoghlú C, Devitt BM, et al. Silver nanoparticles and their orthopaedic applications. Bone Joint J 2015;97B:582–589. 6. Smith NA, Costa ML, Spalding T. Meniscal allograft transplantation. Bone Joint J 2015;97-B:590–594. 7. Hawi N, Kendoff D, Citak M, Gehrke T, Haasper C. Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail. Bone Joint J 2015;97-B:649–653. 8. Domeij-Arverud E, Labruto F, Latifi A, et al. Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation. Bone Joint J 2015;97B:675–680. 9. McCalden RW, Korczak A, Somerville L, Yuan X, Naudie DD. A randomised trial comparing a short and standard-length metaphyseal engaging cementless femoral stem using radiostereometric analysis. Bone Joint J 2015;97-B:595–602. 10. Krzyzanowska MK, Kaplan R, Sullivan R. How may clinical research improve healthcare outcomes? Ann Oncol 2011;22(Suppl 7):10–15. 577
Fundamental questions in need of answers
F. S. Haddad From The British Editorial Society of Bone and Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B5. 36261 $2.00 Bone Joint J 2015;97-B:577.
VOL. 97-B, No. 5, MAY 2015
I have just had the privilege of attending the American Academy of Orthopaedic Surgeon’s meeting in Las Vegas. This confirmed that there are still many areas where high-level evidence is desperately needed. This month’s Bone & Joint Journal includes several thought-provoking papers that will generate further research. Henrik Malchau’s update1 on patient-reported outcome measures (PROMs) is particularly important. He has been a leader in this field for over 20 years and played a key role in the success of the Swedish Arthroplasty register, and in educating the orthopaedic community about the stepwise introduction of innovation. The move in the assessment of outcome away from objective measures and towards patient-reported tools has been a very successful one. There is a place for both for research purposes,2 but the linkage of PROMs to observational datasets is clearly on the rise. It is critical, in this era of value based healthcare, that PROMS are embedded in our practice in order for us to understand the real effects of our interventions, and also to apply or prioritise them according to the benefits that they provide.3,4 However, there are, of course, dangers in the interpretation of such data, particularly if it is recorded at the wrong time, is incompletely available, or is not case-mix adjusted. One of the challenges that will face us, both in research and in general trauma and orthopaedic practice over the next decade, is the appropriate stratification of our patients and procedures so that we can truly begin to understand the differences in outcome that are seen in various settings. Our instructional reviews this month highlight areas where there has been far too little progress over the last three decades. The prevention and management of periprosthetic infection has not progressed as we would have wished. The review by Brennan et al5 on silver nanoparticles presents one possible solution, although the translation from the laboratory to widespread clinical practice may well prove difficult. Tim Spalding’s update on meniscal allograft transplantation6 also illustrates the importance of biological interventions in the prevention and management of early osteoarthritis, another area where there is a big unmet need. I would like to commend the EndoKlinic paper on single-stage knee arthrodesis after failed total knee arthroplasty.7 This is an important piece of work at several levels, most particularly in relation to the devastating effects that infection has on
patients. Their data suggest that patients were happy with their arthrodesis, perhaps reflecting the disability most patients suffered pre-operatively. It also highlights the increasing success rate of single-stage interventions in appropriate centres with evidence-based protocols dealing with the local delivery of antibiotics. The authors also hint that they have now started using hinged implants with external adjustment of flexion – this is a solution that has been applied in several centres. Outcome studies are awaited with interest. I am also pleased to see two prospective randomised studies in this issue of the journal.8,9 It is critical that we start to enter more patients into such studies as we undoubtedly lag behind other specialties in this area. There is also some evidence that patients in studies have better outcomes than those who are not.10 I would like to highlight the very wide international spread of papers in BJJ. Whilst we appreciate that some parts of the world struggle with research funding, there is still a great deal that all of us can learn from the experiences of others.
References 1. Rolfson O, Malchau H. The use of patient-reported outcomes after routine arthroplasty: beyond the whys and ifs. Bone Joint J 2015;97B:578–581. 2. Konan S, Hossain F, Patel S, Haddad FS. Measuring function after hip and knee surgery: the evidence to support performancebased functional outcome tasks. Bone Joint J 2014;96-B:1431–1435. 3. Keurentjes JC, Van Tol FR, Fiocco M, et al. Patient acceptable symptom states after total hip or knee replacement at mid-term follow-up: thresholds of the Oxford hip and knee scores. Bone Joint Res 2014;3:7–13. 4. Harris KK, Price AJ, Beard DJ, et al. Can pain and function be distinguished in the Oxford Hip Score in a meaningful way?: an exploratory and confirmatory factor analysis. Bone Joint Res 2014;3:305–309. 5. Brennan SA, Ní Fhoghlú C, Devitt BM, et al. Silver nanoparticles and their orthopaedic applications. Bone Joint J 2015;97B:582–589. 6. Smith NA, Costa ML, Spalding T. Meniscal allograft transplantation. Bone Joint J 2015;97-B:590–594. 7. Hawi N, Kendoff D, Citak M, Gehrke T, Haasper C. Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail. Bone Joint J 2015;97-B:649–653. 8. Domeij-Arverud E, Labruto F, Latifi A, et al. Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation. Bone Joint J 2015;97B:675–680. 9. McCalden RW, Korczak A, Somerville L, Yuan X, Naudie DD. A randomised trial comparing a short and standard-length metaphyseal engaging cementless femoral stem using radiostereometric analysis. Bone Joint J 2015;97-B:595–602. 10. Krzyzanowska MK, Kaplan R, Sullivan R. How may clinical research improve healthcare outcomes? Ann Oncol 2011;22(Suppl 7):10–15. 577
