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Ian Wilson, Eric Bohm, Anne Lübbeke, Stephen Lyman, Søren Overgaard, Ola Rolfson, Annette W-Dahl, Mark Wilkinson, and Michael Dunbar

  • Total joint arthroplasty is performed to decreased pain, restore function and productivity and improve quality of life.

  • One-year implant survivorship following surgery is nearly 100%; however, self-reported satisfaction is 80% after total knee arthroplasty and 90% after total hip arthroplasty.

  • Patient-reported outcomes (PROs) are produced by patients reporting on their own health status directly without interpretation from a surgeon or other medical professional; a PRO measure (PROM) is a tool, often a questionnaire, that measures different aspects of patient-related outcomes.

  • Generic PROs are related to a patient’s general health and quality of life, whereas a specific PRO is focused on a particular disease, symptom or anatomical region.

  • While revision surgery is the traditional endpoint of registries, it is blunt and likely insufficient as a measure of success; PROMs address this shortcoming by expanding beyond survival and measuring outcomes that are relevant to patients – relief of pain, restoration of function and improvement in quality of life.

  • PROMs are increasing in use in many national and regional orthopaedic arthroplasty registries.

  • PROMs data can provide important information on value-based care, support quality assurance and improvement initiatives, help refine surgical indications and may improve shared decision-making and surgical timing.

  • There are several practical considerations that need to be considered when implementing PROMs collection, as the undertaking itself may be expensive, a burden to the patient, as well as being time and labour intensive.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180080

Anne Lübbeke, Andrew J Carr, and Pierre Hoffmeyer

  • Clinical registries are health information systems, which have the mission to collect multidimensional real-world data over the long term, and to generate relevant information and actionable knowledge to address current serious healthcare problems.

  • This article provides an overview of clinical registries and their relevant stakeholders, focussing on registry structure and functioning, each stakeholder’s specific interests, and on their involvement in the registry’s information input and output.

  • Stakeholders of clinical registries include the patients, healthcare providers (professionals and facilities), financiers (government, insurance companies), public health and regulatory agencies, industry, the research community and the media.

  • The article discusses (1) challenges in stakeholder interaction and how to strengthen the central role of the patient, (2) the importance of adding cost reporting to enable informed value choices, and (3) the need for proof of clinical and public health utility of registries.

  • In its best form, a registry is a mission-driven, independent stakeholder–registry team collaboration that enables rapid, transparent and open-access knowledge generation and dissemination.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180077

Simon Donell

  • Subchondral bone remodelling is an integral part of osteoarthritis and involves the development of subchondral sclerosis seen on plain imaging, along with osteophyte formation.

  • The development of these changes is due to persistent abnormal mechanical stresses which create a cellular and biomolecular response to microfractures in the subchondral bone and osteochondral junction.

  • An early sign is bone marrow lesions seen on MRI scanning. Healing can occur at this stage by correcting the abnormal loads. Persistence leads to what is thought to be a delayed union or nonunion response by the bone.

  • Microfractures of the osteochondral junction, coupled with articular cartilage fissuring and loss, allows synovial fluid to penetrate the subchondral bone along with cytokines and other molecules reacting with the bone cells to increase the pathological effects.

  • This review gives an overview of the current thoughts on subchondral bone remodelling in osteoarthritis that is aimed at orthopaedic surgeons to help in the understanding of the pathogenesis of osteoarthritis and the role of surgical management.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180102

Claus Varnum, Alma Bečić Pedersen, Per Hviid Gundtoft, and Søren Overgaard

  • Establishment of orthopaedic registers started in 1975 and many registers have been initiated since. The main purpose of registers is to collect information on patients, implants and procedures in order to monitor and improve the outcome of the specific procedure.

  • Data validity reflects the quality of the registered data and consists of four major aspects: coverage of the register, registration completeness of procedures/patients, registration completeness of variables included in the register and accuracy of registered variables.

  • Survival analysis is often used in register studies to estimate the incidence of an outcome. The most commonly used survival analysis is the Kaplan–Meier survival curves, which present the proportion of patients who have not experienced the defined event (e.g. death or revision of a prosthesis) in relation to the time. Depending on the research question, competing events can be taken into account by using the cumulative incidence function. Cox regression analysis is used to compare survival data for different groups taking differences between groups into account.

  • When interpreting the results from observational register-based studies a number of factors including selection bias, information bias, chance and confounding have to be taken into account. In observational register-based studies selection bias is related to, for example, absence of complete follow-up of the patients, whereas information bias is related to, for example, misclassification of exposure (e.g. risk factor of interest) or/and outcome.

  • The REporting of studies Conducted using Observational Routinely-collected Data guidelines should be used for studies based on routinely-collected health data including orthopaedic registers.

  • Linkage between orthopaedic registers, other clinical quality databases and administrative health registers may be of value when performing orthopaedic register-based research.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180097

Andrew Carr

  • The increasing use of regional and national registries of surgical implants has raised concerns that the cost and consequences of these initiatives will adversely influence innovation. The opposite appears to be true, with no evidence of a reduction in overall innovation and an association of increased innovation in countries with more evaluation using registries.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180065

James R. Berstock and Michael R. Whitehouse

  • Use the PICO framework to formulate a specific clinical question.

  • Formulate a search strategy.

  • Prospectively register the review protocol.

  • Execute the literature search.

  • Apply eligibility criteria to exclude irrelevant studies.

  • Extract data and appraise each study for risk of bias and external validity.

  • Provide a narrative review.

  • If appropriate data are available, perform a meta-analysis.

  • Report the review findings in the context of the risk of bias assessment, any sensitivity analyses and the analysis of risk of publication bias.

  • Useful resources include the Cochrane Handbook, PROSPERO, GRADE and PRISMA.

Cite this article: EFORT Open Rev 2019;4:213-220. DOI: 10.1302/2058-5241.4.180049

E. Carlos Rodríguez-Merchán

  • The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.

  • Early continuous haematological primary prophylaxis by means of the intravenous infusion of the deficient coagulation factor (ideally from cradle to grave) is of paramount importance because the immature skeleton is very sensitive to the complications of haemophilia: severe structural deficiencies may develop quickly.

  • If primary haematological prophylaxis is not feasible due to expense or lack of venous access, joint bleeding will occur. Then, the orthopaedic surgeon must aggressively treat haemarthrosis (joint aspiration under factor coverage) to prevent progression to synovitis (that will require early radiosynovectomy or arthroscopic synovectomy), recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy).

  • Between the second and fourth decades, many haemophilic patients develop articular destruction. At this stage the main possible treatments include arthroscopic joint debridement (knee, ankle), articular fusion (ankle) and total joint arthroplasty (knee, hip, ankle, elbow).

Cite this article: EFORT Open Rev 2019;4:165-173. DOI: 10.1302/2058-5241.4.180090

Tommaso Bonanzinga, Matteo Carlo Ferrari, Piergiuseppe Tanzi, Filippo Vandenbulcke, Akos Zahar, and Maurilio Marcacci

  • Prosthetic joint infection (PJI) management is not standardized worldwide and the outcome is frequently unsatisfactory.

  • More and more arthroplasties are now being performed. An increasing number of highly virulent and antibiotic-resistant bacteria and an ageing population of patients presenting with many comorbidities make it necessary to focus on this important topic.

  • Diagnosis of PJI remains challenging because the clinical signs and symptoms and elevation of systemic biomarkers (C-reactive protein, erythrocyte sedimentation rate) may be unclear.

  • In the last few years, the clinical research has focused on synovial fluid biomarkers as a possible breakthrough in the complex scenario of PJI diagnosis.

  • Synovial biomarkers have shown encouraging results and they should be used as diagnostic adjuncts to synovial white cell count and culture bacteriology. Synovial leukocyte esterase (LE) and synovial C-reactive protein (CRP) have been evaluated as good screening measures; however, the most promising synovial fluid biomarker in terms of sensitivity and specificity for PJI seems to be alpha defensin (AD).

  • The laboratory-based alpha defensin enzyme-linked immunosorbent assay (ELISA) test demonstrated the highest ever reported accuracy for PJI diagnosis. However, an alpha defensin lateral flow test could have its place in ruling in a suspected PJI intraoperatively because of its high specificity and rapid results.

Cite this article: EFORT Open Rev 2019;4:10-13. DOI: 10.1302/2058-5241.4.180029

Jean-Charles Aurégan, Catherine Bosser, Morad Bensidhoum, Thierry Bégué, and Thierry Hoc

  • Skin and bone share similarities in terms of biochemical composition.

  • Some authors have hypothesized that their properties could evolve concomitantly with age, allowing the estimation of the parameters of one from those of the other.

  • We performed a systematic review of studies reporting the correlation between skin and bone parameters in women with postmenopausal osteoporosis.

  • Fourteen studies – including 1974 patients – were included in the review.

  • Three of these studies included two groups of participants – osteoporotic and non-osteoporotic – in order to compare skin parameters between them: two studies found a significant difference between the two groups and one did not.

  • Eleven of these studies included one population of interest and compared its skin and bone parameters in a continuous manner: eight studies compared dermal thickness to bone mineral density (seven found a significant correlation [R = 0.19–0.486] and one did not); two studies compared skin elasticity to bone mineral density (both found a significant correlation [R = 0.44–0.57); and one study compared skin collagen to bone mineral density and found a significant correlation (R = 0.587).

  • It can be assumed that the estimation of skin alterations from ageing could help in estimating concomitant bone alterations.

Cite this article: EFORT Open Rev 2018;3:449-460. DOI: 10.1302/2058-5241.3.160088

Andreas F. Mavrogenis, Vasilios G. Igoumenou, Thekla Antoniadou, Panayiotis D. Megaloikonomos, George Agrogiannis, Periklis Foukas, and Sotirios G. Papageorgiou

  • Non-Langerhans cell histiocytosis (N-LCH) summarizes a group of rare diseases with different clinical presentations, pathogenesis and morphology. These include primary cutaneous N-LCH, cutaneous N-LCH with systemic involvement, and primary extracutaneous systemic forms with occasional cutaneous involvement.

  • The juvenile (JXG) and non-juvenile xanthogranuloma (N-JXG) family of histiocytoses are N-LCH: the JXG family consisting of the JXG (cutaneous), xanthoma disseminatum (cutaneous and systemic) and Erdheim-Chester disease (ECD; systemic); and the N-JXG family consisting of the solitary reticulohistiocytoma (cutaneous), multicentric reticulohistiocytosis (cutaneous and systemic) and Rosai-Dorfman disease (RDD; systemic).

  • ECD is a clonal disorder from the JXG family of N-LCH; RDD is a reactive proliferative entity from the non-juvenile xanthogranuloma family of N-LCH.

  • ECD and RDD N-LCH are rare disorders, which are difficult to diagnose, with multi-organ involvement including bone and systemic symptoms, and which respond to therapy in an unpredictable way.

  • The key to successful therapy is accurate identification at tissue level and appropriate staging. Patients should be observed and monitored in a long-term pattern. Prognosis depends on disease extent and the organs involved; it is generally good for RDD disease and variable for ECD.

Cite this article: EFORT Open Rev 2018;3:381-390. DOI: 10.1302/2058-5241.3.170047