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Callary SA, Sharma DK, D’Apollonio TM, Critchley O, Mercer G, Wilson C, Campbell DG. What is the Long-term Wear of a 5-Mrad Highly Crosslinked Polyethylene Liner? A 14-year RSA Study. Clin Orthop Relat Res 2024; 482:1789-1797. [PMID: 38546666 PMCID: PMC11419525 DOI: 10.1097/corr.0000000000003047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/27/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Lower doses of irradiation (≤ 5 Mrad) during the manufacture of highly crosslinked polyethylene acetabular liners may result in less crosslinking and an increased wear rate. Radiostereometric analysis (RSA) studies have found that wear of more highly irradiated highly crosslinked polyethylene liners (7 to 10 Mrad) decreases at longer-term follow-up compared with earlier reports of the same cohorts. Although wear of 5-Mrad irradiated liners appears to increase at midterm follow-up, it is unclear whether that remains true at longer follow-up. QUESTIONS/PURPOSES We asked: (1) In patients who underwent THA with a 5-Mrad highly crosslinked polyethylene liner, what is the wear rate evaluated with RSA during the first 14 years? (2) Does the wear rate decrease after 6 years in situ? METHODS This is a brief follow-up of prior RSA studies performed at 2 and 6 years. We prospectively reviewed the longer-term wear rate in 13 patients who underwent primary THAs with the same design of a 5-MRad irradiated crosslinked acetabular liner and a 28-mm cobalt-chromium articulation. Of the initial 30 patients who were enrolled, 13 (43%) were available at the 14-year timepoint; nine patients had died, 1 patient had withdrawn, 1 had an intraoperative fracture, 3 patients were too infirm to have radiographs, 2 had no baseline RSA radiographs, and 1 had poor-quality RSA images. Tantalum markers were inserted during surgery, and all patients had RSA radiographic examinations at 1 week, 6 months, and 1, 2, 6, and 14 years postoperatively. RESULTS The mean ± standard deviation proximal, 2D, and 3D wear rates calculated between 1 year and 14 years were 0.019 ± 0.013 mm, 0.022 ± 0.015 mm, and 0.025 ± 0.019 mm per year, respectively. No patient had proximal 2D or 3D wear rates exceeding 0.06 mm per year. An increasing wear rate over time was measured for proximal and 2D wear rates between 6 and 14 years (0.024 and 0.030 mm per year) compared with that between 1 and 6 years (0.008 and 0.010 mm per year; p = 0.03). CONCLUSION The proximal, 2D, and 3D wear of a highly crosslinked polyethylene liner produced using 5-Mrad radiation remains low in the longer-term. With the small numbers available in a long-term RSA study such as this, we confirmed that the wear rate did not decrease at longer-term follow-up, unlike previous RSA studies of more highly irradiated highly crosslinked polyethylene liners. Nevertheless, the wear rate remains very low and below the threshold typically associated with the development of osteolysis (0.1 mm/year of wear). This should provide assurance to orthopaedic surgeons monitoring patients with this 5-Mrad irradiated liner in situ, while providing useful information to manufacturers of future highly crosslinked polyethylene liners. LEVEL OF EVIDENCE Level IV therapeutic study.
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Affiliation(s)
- Stuart A. Callary
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Deepti K. Sharma
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Taisha M. D’Apollonio
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Owain Critchley
- Department of Orthopaedics and Trauma Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Graham Mercer
- Department of Orthopaedics, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - Christopher Wilson
- Department of Orthopaedics and Trauma Surgery, Flinders University, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David G. Campbell
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
- Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia
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Zitsch BP, Cahoy KM, Urban ND, Buckner BC, Garvin KL. Highly Cross-Linked Polyethylene in Patients 50 Years of Age and Younger: A 20-year Follow-Up Analysis. J Arthroplasty 2024; 39:S145-S152. [PMID: 38548239 DOI: 10.1016/j.arth.2024.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Highly cross-linked polyethylene (HXLPE) has been an excellent bearing for total hip arthroplasty (THA) due to improved wear characteristics compared to conventional materials. Patients 50 years of age or younger are at high risk for wear-related complications of their THA, and few studies have followed these patients who have HXPLE into the third decade. METHODS In a retrospective review of 88 consecutive THAs performed in 77 patients aged 50 years and younger (mean 41; range, 20 to 50), in which HXLPE was utilized, they were evaluated for their clinical and radiographic results at an average of 20-year follow-up (range, 18 to 24). The current study reports on longer-term follow-up from our previously published series at shorter follow-up times. Patients were categorized by femoral head material: cobalt chrome (n = 14), ceramic (n = 30), and oxidized zirconium (n = 22) and by femoral head size: 26 mm (n = 12), 28 mm (n = 46), and 32 mm (n = 8). Harris Hip Scores were collected preoperatively and at the most recent follow-up. Radiographs were evaluated for linear and volumetric wear, radiolucent lines, and osteolysis. RESULTS Mean Harris Hip Scores improved from 47.1 (standard deviation [SD] 8.8) preoperatively to 92.0 (SD 7.7) (P < .0001) at 20-year follow-up. There was one hip that was revised for recurrent instability, and no hip demonstrated radiographic evidence of loosening or osteolysis. The mean polyethylene linear wear rate was 0.017 (SD 0.012) mm/y, and the mean polyethylene volumetric wear rate was 3.15 (SD 2.8) mm3/year, with no significant differences based on articulation type or head size. CONCLUSIONS Total hip arthroplasty with HXLPE in patients ≤ 50 years of age continues to demonstrate excellent long-term clinical and radiographic outcomes with low wear characteristics at 20-year follow-up, regardless of femoral head material or size.
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Affiliation(s)
- Bradford P Zitsch
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kevin M Cahoy
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nathanael D Urban
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Brandt C Buckner
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kevin L Garvin
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Wright BH, Hadley ML, Harmer JR, Fruth KM, Sierra RJ, Couch CG. No Revisions Attributable to Wear of Highly Cross-Linked Polyethylene Liners: A Long-Term Follow-Up Study. J Arthroplasty 2024; 39:S347-S352. [PMID: 38964487 DOI: 10.1016/j.arth.2024.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND There is a paucity of data beyond 15 years on the survivorship of total hip arthroplasty since the introduction of highly cross-linked polyethylene (HXLPE) liners. Our aim was to evaluate implant survivorship, liner wear rates, and clinical outcomes after primary total hip arthroplasty using HXLPE liners implanted between 1999 and 2002. METHODS Between 1999 and 2002, 690 primary total hip arthroplasties utilizing 28-mm femoral heads and HXLPE liners of a single design were identified using our institutional total joint registry. Femoral heads were made of metal in 96% of cases and ceramic in 4%. The mean age was 56 years, 48% were women, and the mean body mass index was 30. Survivorship analyses were performed for the outcomes of implant revision, reoperation, and complications for the entire cohort. Linear HXLPE liner wear rates were determined on 197 hips with radiographs with more than 18.5 years of follow-up. RESULTS At 20 years, survivorship free of revision was 94%, free of reoperation was 92%, and free of any complication was 81%. There were no documented wear-related revisions. The linear wear rate at a mean of 20.3 years postoperatively was 0.02 mm/y. There was no statistically significant difference in measured wear observed between the first available postoperative radiographs and those taken at the final follow-up. The use of elevated liners, patient body mass index, age, preoperative diagnosis, acetabular component inclination, and anteversion angles were not associated with increased wear rates. Mean Harris hip scores improved from 52 preoperatively to 90 at greater than 18.5 years CONCLUSIONS: Primary total hip arthroplasties using a single first-generation HXLPE liner demonstrated excellent survivorship and clinical outcomes at long-term follow-up with no wear-related revisions. Wear rates of HXLPE liners at 20 years are exceedingly low and are not significantly impacted by acetabular component position or patient-dependent variables such as BMI. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Breydan H Wright
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Hadley
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joshua R Harmer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kristin M Fruth
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cory G Couch
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Migliorini F, Maffulli N, Pilone M, Bell A, Hildebrand F, Konrads C. Risk factors for liner wear and head migration in total hip arthroplasty: a systematic review. Sci Rep 2023; 13:15612. [PMID: 37730762 PMCID: PMC10511625 DOI: 10.1038/s41598-023-42809-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023] Open
Abstract
Total hip arthroplasty (THA) is a successful orthopaedic surgical procedure, and its longevity depends on bearing components and implant fixation. Optimizing polyethylene and ceramics has led to improved wear parameters and contributed to improved long-term outcomes. The present systematic review investigated whether time span from implantation, patient characteristics and performance status exert an influence on liner wear and head migration in THA. This study was conducted in conformity to the 2020 PRISMA guidelines. All the clinical investigations which reported quantitative data on the amount of liner wear and head migration in THA were considered. Only studies which reported quantitative data at least on one of the following patient characteristics were suitable: mean age, mean BMI (kg/m2), sex, side, time span between the index THA and the last follow-up (months) were eligible. A multiple linear model regression analysis was employed to verify the association between patient characteristics and the amount of liner wear and/or head migration. The Pearson Product-Moment Correlation Coefficient was used to assess the association between variables. Data from 12,629 patients were considered. The mean length of the follow-up was 90.5 ± 50.9 months. The mean age of patients at surgery was 58.4 ± 9.4 years, and the mean BMI was 27.2 ± 2.5 kg/m2. 57% (7199 of 12,629 patients) were women, and in 44% (5557 of 12,629 patients) THAs were performed on the left. The mean pre-operative Harris hip score was 46.5 ± 6.0 points. There was evidence of a moderate positive association between the amount of liner wear and the time elapsed between the index surgery to the follow-up (P = 0.02). There was evidence of a moderate positive association between the amount of head migration and the time elapsed between the index surgery to the follow-up (P = 0.01). No further statistically significant association was found. The time elapsed between the index surgery to the follow-up was the most important factor which influence the head migration and liner wear in THA. Patients' characteristics and preoperative physical activity did not influence the amount of head migration and liner wear.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano, Teaching Hospital of Paracelsus Medical University (PMU), 39100, Bolzano, Italy.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, Simmerath, Germany.
| | - Nicola Maffulli
- Department of Orthopaedic and Trauma Surgery, Hospital Sant'Andrea, University of Rome La Sapienza, Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, E1 4DG, England
| | - Marco Pilone
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20122, Milan, Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Christian Konrads
- Department of Orthopaedics and Traumatology, Helios Hanseatic Hospital Stralsund, 18435, Stralsund, Germany
- Medical Faculty, University of Tübingen, 72076, Tübingen, Germany
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Fransen BL, Howard LC, MacDonell T, Bengoa F, Sheridan GA, Garbuz DS, Neufeld ME. Highly crosslinked polyethylene liner thickness does not influence survival in primary total hip arthroplasty after mean follow-up of 13 years: a study of 2,565 hips with a single design liner. J Arthroplasty 2023:S0883-5403(23)00260-7. [PMID: 36931361 DOI: 10.1016/j.arth.2023.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Concerns remain that thinner highly crosslinked polyethylene (HXLPE) liners in modern total hip arthroplasty (THA) may lead to premature liner-related failures or revision. The aim of this study was to evaluate the effect of liner-thickness on survival and revision rates of HXLPE in primary THA after more than 10 years. METHODS We retrospectively identified 2,565 primary THA using HXLPE with a mean follow-up of 13 years (range, 11 to 19). Patients were grouped for each millimeter (mm) of polyethylene thickness. Liner thickness varied from 4.9 to 12.7 mm, with one third measuring less than 6 mm. Primary outcomes were reoperation, all-cause revision, and liner-related revision. RESULTS The reoperation rate was 7.3%, the all-cause revision rate was 5.6%, and the liner-related revision rate was 0.04%. There was no significant difference in all-cause revision when stratified by liner thickness (P=0.286) and liner thickness was not associated with liner-related revision (n=1). There was a statistically, but not clinically significant difference in mean liner thickness for the cohort that underwent reoperation (7.09 vs 6.89 mm, P=0.01) and all-cause revision (7.16 vs 6.89 mm, P=0.031). CONCLUSION In our cohort, liner thickness was not associated with all-cause revision-free survival and there was no clinically significant difference in liner thickness between those patients who did require a reoperation or all-cause revision, and those who did not. There was only 1 liner related failure in the entire cohort. Our results indicate that using thinner HXPE liners to maximize femoral head size in THA is a safe practice that does not lead to increased revision rates or liner failure at a mean 13 years follow-up.
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Affiliation(s)
- B L Fransen
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada.
| | - L C Howard
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
| | - T MacDonell
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
| | - F Bengoa
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
| | - G A Sheridan
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
| | - D S Garbuz
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
| | - M E Neufeld
- Department of Orthopaedics, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada
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Fransen BL, Bengoa FJ, Neufeld ME, Sheridan GA, Garbuz DS, Howard LC. Thin highly cross-linked polyethylene liners combined with large femoral heads in primary total hip arthroplasty show excellent survival and low wear rates at a mean follow-up of 12.8 years. Bone Joint J 2023; 105-B:29-34. [PMID: 36587249 DOI: 10.1302/0301-620x.105b1.bjj-2022-0812.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIMS Several short- and mid-term studies have shown minimal liner wear of highly cross-linked polyethylene (HXLPE) in total hip arthroplasty (THA), but the safety of using thinner HXLPE liners to maximize femoral head size remains uncertain. The objective of this study was to analyze clinical survival and radiological wear rates of patients with HXLPE liners, a 36 mm femoral head, and a small acetabular component with a minimum of ten years' follow-up. METHODS We retrospectively identified 55 patients who underwent primary THA performed at a single centre, using HXLPE liners with 36 mm cobalt-chrome heads in acetabular components with an outer diameter of 52 mm or smaller. Patient demographic details, implant details, death, and all-cause revisions were recorded. Cox regression and Kaplan-Meier survival was used to determine all-cause and liner-specific revision. Of these 55 patients, 22 had a minimum radiological follow-up of seven years and were assessed radiologically for linear and volumetric wear. RESULTS Overall survival rate for all-cause revision was 94.5% (95% confidence interval (CI) 81.7% to 97.2%) at a mean follow-up of 12.8 years (10.9 to 18.7). Three patients were revised, none for liner wear, fracture, or dissociation. A total of 22 patients were included in the radiological analysis (mean follow-up 9.9 years (7.5 to 13.7)). Mean linear liner wear was 0.085 mm (95% CI -0.086 to 0.257) and the volumetric wear rate was 11.097 mm3/year (95% CI -6.5 to 28.7). CONCLUSION Using HXLPE liners with 36 mm heads in 52 mm acetabular components or smaller is safe, with excellent survival and low rates of linear and volumetric wear at medium-term follow-up. Patients did not require revision surgery for liner complications such as fracture, dissociation, or wear. Our results suggest that the advantages of using larger heads outweigh the potential risks of using thin HXLPE liners.Cite this article: Bone Joint J 2023;105-B(1):29-34.
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Affiliation(s)
- Bas L Fransen
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
| | - Francisco J Bengoa
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
| | - Michael E Neufeld
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
| | - Gerard A Sheridan
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
| | - Lisa C Howard
- Department of Orthopaedics, The University of British Columbia, Vancouver, Canada
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García-Rey E, Cruz-Pardos A, Saldaña L. New polyethylenes in total hip arthroplasty : a 20- to 22-year follow-up study. Bone Joint J 2022; 104-B:1032-1038. [PMID: 36047028 DOI: 10.1302/0301-620x.104b9.bjj-2022-0434.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS A significant reduction in wear at five and ten years was previously reported when comparing Durasul highly cross-linked polyethylene with nitrogen-sterilized Sulene polyethylene in total hip arthroplasty (THA). We investigated whether the improvement observed at the earlier follow-up continued, resulting in decreased osteolysis and revision surgery rates over the second decade. METHODS Between January 1999 and December 2001, 90 patients underwent surgery using the same acetabular and femoral components with a 28 mm metallic femoral head and either a Durasul or Sulene liner. A total of 66 hips of this prospective randomized study were available for a minimum follow-up of 20 years. The linear femoral head penetration rate was measured at six weeks, one year, and annually thereafter, using the Dorr method on digitized radiographs with a software package. RESULTS In the Durasul group, no patients underwent revision due to loosening or showed radiological evidence of osteolysis. In the Sulene group, four patients (four hips) were revised due to femoral component loosening. The 20-year cumulative failure incidence in the presence of the competing event of death for revision surgery was 4.5% (95% confidence interval (CI) 0.8 to 13.6) in the Durasul group, and 8.9% (95% CI 2.8 to 19.5) in the Sulene group. The mean wear one year after surgery was 0.09 mm (SD 0.007) in the Durasul group and 0.24 (SD 0.015) in the Sulene group (p < 0.001). From one to 20 years after surgery, the mean total penetration was 0.32 mm (SD 0.045) in the Durasul group and 1.07 mm (SD 0.13) in the Sulene group (p < 0.001). Mean femoral head penetration at 20 years was approximately 70.0% less in the Durasul group than the Sulene group. CONCLUSION The significant reduction in femoral head penetration obtained with the Durasul compared with Sulene in uncemented THA resulted in lower osteolysis and revision rates after 20 years.Cite this article: Bone Joint J 2022;104-B(9):1032-1038.
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Affiliation(s)
- Eduardo García-Rey
- Orthopaedics Department, Hospital Universitario La Paz-Idi Paz, Madrid, Spain.,Bioengineering, Biomaterials and Nanomedicine, Biomedical Research Networking Center, Madrid, Spain
| | - Ana Cruz-Pardos
- Orthopaedics Department, Hospital Universitario La Paz-Idi Paz, Madrid, Spain
| | - Laura Saldaña
- Bioengineering, Biomaterials and Nanomedicine, Biomedical Research Networking Center, Madrid, Spain.,Bone Pathophysiology and Biomaterials Group, Hospital Universitario La Paz-Idi Paz, Madrid, Spain
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Scott CEH, Clement ND, Davis ET, Haddad FS. Modern total hip arthroplasty: peak of perfection or room for improvement? Bone Joint J 2022; 104-B:189-192. [PMID: 35094584 DOI: 10.1302/0301-620x.104b2.bjj-2022-0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Chloe E H Scott
- Royal Infirmary of Edinburgh, Edinburgh, UK.,The Bone & Joint Journal , London, UK.,Bone & Joint Research , London, UK.,University of Edinburgh, Edinburgh, UK
| | | | | | - Fares S Haddad
- The Bone & Joint Journal , London, UK.,University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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