The edition · Orthopaedics
Two to three hours of brisk walking a week, and the bone responds
A 124-trial network meta-analysis puts a dose on exercise for bone density; an eight-nerve block matched infiltration on pain but halved nothing except opioids and bed days; and the cemented-versus-cementless question in robotic knees remains unanswered.
The edition in brief
Today's orthopaedics edition opens with fixation in robotic-assisted total knee arthroplasty, where a meta-analysis of ten observational studies found every pooled estimate imprecise and every certainty rating very low — revision risk ratio 0.63 with a confidence interval from 0.09 to 4.53, and an operative-time difference of about 13 minutes whose interval crosses zero. The honest position is that the evidence does not favour either fixation. A Taiwanese joint consensus sets out how to manage osteoporosis in diabetes: screen early, expect standard fracture-risk calculators to underestimate, and choose glucose-lowering therapy with its skeletal effect in mind, since anti-osteoporosis drugs themselves work equally well in diabetes. A randomised trial in 217 knee arthroplasties found an eight-nerve block combination no better than local infiltration analgesia on the primary pain outcome at any time point, although exploratory secondary outcomes showed lower 48-hour opioid consumption — 70 against 96 mg oral morphine equivalent — and a median stay one day shorter. A single-centre trial of 66 adults reported a large advantage for high-intensity laser over therapeutic ultrasound as an exercise adjunct in knee osteoarthritis, with a WOMAC difference of 27.7 points, well above the minimum important change, though the size of the effect invites caution. The practice-changer is a hierarchical Bayesian network meta-analysis of 124 trials and 18,429 adults aged 40 and over, which finds brisk walking or jogging and combined aerobic-resistance work best for bone mineral density, with clinically meaningful benefit at around 600 metabolic equivalent minutes per week and an inverted-U dose-response.
Cement or no cement in a robotic knee: still unanswered
There is no outcome evidence favouring cementless or cemented fixation in robotic-assisted knee arthroplasty — decide on patient factors and unit practice, not on the robot.
In diabetes, the fracture risk score reads low
In a patient with long-standing diabetes, screen for osteoporosis early and treat a normal-looking bone density as insufficient reassurance — the standard risk calculation underestimates them.
Eight blocks, no better pain scores, fewer opioids
An eight-nerve block gave no better pain relief than local infiltration after knee replacement — adopt it only if lower opioid use is the goal you are pursuing, and audit it.
A large effect for laser over ultrasound in knee osteoarthritis
If your department uses a passive adjunct alongside exercise for knee osteoarthritis, high-intensity laser has better comparative evidence than therapeutic ultrasound — but the effect size needs replication.
Ask what the patient is actually doing with the crutches
Calibrate partial weight-bearing on a set of scales before the patient goes home, and ask at follow-up how much load they think they are applying.
Brisk walking, about 600 MET-minutes a week, is the bone prescription
Prescribe about two to three hours of brisk walking a week — roughly 600 metabolic equivalent minutes — with resistance work added where the spine is the concern, and do not push beyond the plateau.
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