The edition · Orthopaedics
Who holds the drill explains dual-mobility use better than who is on the table
A 238,000-hip registry analysis finds surgeon and institution account for more than half the variation in dual-mobility implant choice while patient factors explain a tenth; a network meta-analysis ranks five fixation strategies for distal tibial fractures; and psychiatric comorbidity quadruples failure a decade after hip arthroscopy.
The edition in brief
A network meta-analysis of 11 randomised trials and 18 cohorts covering 2145 distal tibial fractures compared open reduction and internal fixation, minimally invasive plate osteosynthesis, external fixation with limited open reduction, and two intramedullary nailing routes. No strategy was consistently best. Minimally invasive plating carried a higher malunion risk than external fixation with limited open reduction (RR 3.26, 95% CI 1.08 to 9.80) and than suprapatellar nailing (RR 4.03, 1.30 to 12.48), while open reduction beat plating on malunion (RR 0.30, 0.11 to 0.82) but carried more infection. Delayed union and nonunion did not differ. In 238,455 primary total hip arthroplasties in the National Joint Registry for England, surgeon-level factors explained 32.4 per cent of variation in dual-mobility use and institutional factors 22.9 per cent, against about 10 per cent for patient characteristics. A meta-analysis of vertebral body sliding osteotomy against anterior cervical corpectomy and fusion found lower rates of subsidence, pseudarthrosis, revision and neurological deterioration with the newer technique, but all four included cohorts came from one institution with the same first author, findings were fragile on leave-one-out analysis, and GRADE certainty was very low throughout. Extended reality for knee osteoarthritis showed low-certainty benefit for interactive digital rehabilitation on pain-related functioning (pooled SMD -0.59, 95 per cent CI -1.11 to -0.06) with a prediction interval crossing zero, and no meaningful effect on pain after knee replacement. Ten years after hip arthroscopy for femoroacetabular impingement, failure occurred in 23.3 per cent of patients with psychiatric comorbidity against 5.3 per cent without, with failure-free survivorship of 11.49 against 13.68 years.
Distal tibial fractures: no winner, but plating trades malunion against infection
Across 2145 distal tibial fractures no fixation strategy was consistently superior; minimally invasive plating had more malunion than nailing or external fixation, while open reduction and plating both carried more infection.
Dual-mobility choice is a property of the surgeon, not of the patient
Surgeon and institution explained 55 per cent of the variation in dual-mobility implant use in 238,455 English hip replacements against about 10 per cent for patient factors, which makes local rate an auditable question worth asking.
Vertebral body sliding osteotomy looks better than corpectomy, from four cohorts and one surgeon
Vertebral body sliding osteotomy showed large advantages over corpectomy on subsidence, pseudarthrosis and revision, but every study came from one centre and one senior author with very low GRADE certainty, so this is hypothesis-generating rather than practice-changing.
Digital rehabilitation helps knee osteoarthritis; after knee replacement it does not yet
Interactive digital rehabilitation is worth offering as an adjunct in knee osteoarthritis on low-certainty evidence of better pain-related functioning, but it did not reduce pain after knee replacement and immersive virtual reality remains unproven for both.
In a swollen distal tibia, the skin sets the operating date
Do not fix a distal tibial fracture definitively until the skin wrinkles - span it, elevate it, CT it in the frame, and accept the delay, because infection over the subcutaneous tibia is far harder to undo than malalignment.
Psychiatric comorbidity quadruples failure ten years after hip arthroscopy
Ask every hip arthroscopy candidate about anxiety, depression and psychotropic use, and consent those who screen positive to a ten-year failure risk of about 23 per cent rather than the 5 per cent quoted to everyone else.
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