Harvinder Pal Singh

Aims: It is known that survival of primary total shoulder arthroplasty at 10 years is excellent; however, evidence beyond this time-point is limited. We aimed to evaluate the long-term survival of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) implants, at ≥13 years follow-up, using case series and international joint registry data. Methods: CENTRAL, Embase, and MEDLINE databases were searched for studies reporting TSA survival data at ≥13 years follow-up. National joint registries were contacted for implant data. Pooled survival at 13, 15, and 20 years was calculated for case series and registry data using a random-effects model. Results: Data from four national joint registries and seven studies were analysed. Pooled aTSA registry data showed survival of 91.50% (89.36–93.64) at 13-years and 90.82% (88.25–93.38) at 15-years. Pooled rTSA registry data showed survival of 93.19% (91.78–94.60) at 13-years and 90.74% (85.73–95.74) at 15-years. Data from case series gave pooled aTSA survival estimates of 88.69% (76.97–100.42), 90.23% (85.87–94.58) and 82.08% (70.30–93.88) at 13, 15 and 20 years, respectively. Conclusion: Our analysis suggests approximately 90% of shoulder replacements last up to 15 years without revision. Variation between individual implants highlights the need for granular implant-level data to guide patient and clinician decision making.

Design: A qualitative study using uni-professional focus groups, forming the first stage of a multi-phase co-design project to develop a model of care for early sling removal after conservatively managed proximal humerus fracture. Setting: Focus groups were conducted online via Microsoft Teams with participants from a wide geographical spread across multiple United Kingdom National Health Service Trusts. Participants: Healthcare professionals ( n = 23), including orthopaedic surgeons, therapists (physio and occupational), and nurses, recruited through purposive sampling. Intervention: Three focus groups explored healthcare professionals’ perspectives on early sling removal in the non-operative management of proximal humerus fractures. Patient and public involvement and engagement work informed study design, identifying the need to first understand professionals’ viewpoints before engaging patients and progressing to consensus co-design. Main measures: Data were collected through focus groups supported by pre-session forms and analysed thematically following Braun and Clarke's framework using NVivo software. Results: Three overarching themes were identified: Navigating pain and fear , clinician confidence , and early engagement . Fear of patient harm and high pain levels in the early weeks were barriers to early sling removal. Confidence was influenced by experience, fracture severity and limited evidence, with hierarchical decision-making by surgeons. Participants considered enablers to be consistent messaging, early education, and reassurance to support both clinicians and patients. Conclusions: Whilst healthcare professionals recognise benefits of earlier sling removal, implementation is limited by pain, uncertainty, and hierarchical decision-making. These findings highlight the need for multidisciplinary, co-designed pathways. There is a need next to explore patient perspectives to inform future co-designed pathways.

Background: Despite reverse shoulder replacement (RSR) being the predominant form of shoulder arthroplasty in the United Kingdom, substantial variation exists in implant selection and surgical technique. This study aims to capture current RSR practice among members of the British Elbow and Shoulder Society (BESS). Methods: A 24-question online survey was sent to BESS surgeon members in December 2024, assessing routine practice in both trauma and elective RSR. Descriptive statistical analysis was performed. Results: In total, 127 surgeons responded. Over half performed at least 20 RSRs annually (54.3%). The most common glenosphere sizes were 42 mm and 36 mm for male and female patients, respectively. Glenoid onlay components were used by 87.9% of respondents, and humeral inlay components by 55.6%. Most surgeons used symmetric liners (69.2%), a standard (50.0%) or short (48.4%) humeral stem, 10°–20° of humeral version (56.7%), and 135° (45.4%) or 145° neck-shaft angles (36.1%). Intraoperatively, 79.5% of surgeons routinely repaired the subscapularis, and metallic augments (70.9%) were the most used method of building offset. Preoperative planning was used by 67.7% of surgeons, while 7.9% used computer navigation. Discussion: This survey highlights variation in implant selection, operative technique, and technology use among UK surgeons, underscoring the need for evidence-based standardisation.

Background: Large language models are a type of artificial intelligence that can understand language and generate responses to text inputs. This presents potential within healthcare to improve triage of common conditions with established care pathways, such as lateral elbow tendinopathy (LET). However, its application to clinical scenarios requires evaluation. Methods: Four questions regarding LET investigation and management were posed to ChatGPT-3.5, which was asked to provide five evidence sources. Five clinical scenarios were posed to the model, simulating consultations with typical and red-flag features. Responses were evaluated by three upper-limb Consultants using the DISCERN tool. Results: Overall quality was unanimously rated as moderate for both questions and scenario responses, representing potentially important but not serious shortcomings. The model correctly identified the diagnosis and red-flag features and sign-posted accordingly. References cited were found to not exist in 40% of cases. Where references were correctly cited, issues identified included erroneous terminology; exclusion of recent evidence; and misinterpretation of findings. Conclusions: While this technology's ability to identify diagnosis and red-flag features when presented with clinical scenarios shows promise, application in the clinical setting is not yet justified due to limitations in evidence basis of recommendations and lack of real-time access to evidence.

Objective: To date, few studies have investigated the factors associated with musculoskeletal patients’ willingness to donate biological samples and their knowledge regarding the use of such samples. We investigated the associations between these distinct knowledge factors, patients’ willingness to donate and socio-demographic factors. Design: Cross-sectional survey. Setting: Musculoskeletal outpatient clinics across four sites in England, representing varied demographic populations. Participants: A total of 469 adult patients attending musculoskeletal appointments were recruited through convenience sampling. Primary and secondary outcome measures: Ordinal regression models were employed to identify socio-demographic and clinical predictors of patients’ willingness to donate biological samples. Other outcome measures specifically in two areas of patient knowledge include: (1) knowledge of sample use and (2) knowledge of surgical waste tissue value and management. Results: Only 37% of participants were aware of the term ‘biobank’. Despite this, participants showed a high level of knowledge regarding both biological sample use and surgical waste tissue management, although their understanding varied considerably by ethnicity and education. Participants with no formal education exhibited a lower level of knowledge in both areas related to sample use and surgical waste tissue management for biomedical research ((OR 0.30, 95% CI 0.14 to 0.61; p=0.001); (OR=0.29, 95% CI 0.16 to 0.52, p<0.001), respectively). Individuals with ≥2 A-levels or equivalent (OR=0.44, 95% CI 0.24 to 0.79, p=0.006) and those identifying as Asian/Asian British (OR=0.51, 95% CI 0.29 to 0.88, p=0.016) also demonstrated a lower understanding of the value and management of surgical waste tissue. Willingness to donate was generally high but was significantly lower among non-Caucasian participants (Black (OR=0.23, 95% CI 0.08 to 0.61, p=0.004); Asian (OR=0.29, 95% CI 0.15 to 0.56, p<0.001)) and those with lower education levels (no formal education (OR=0.40, 95% CI 0.18 to 0.91, p=0.029); preferred not to disclose (OR=0.27, 95% CI 0.13 to 0.57, p<0.001)). Participants from Manchester were 2.18 times more likely to report a higher willingness (OR=2.18, 95% CI 1.09 to 4.33, p=0.027). Finally, participants who were aware of the term “biobank” had 2.16 times the odds of willingness to donate to biobanking initiatives for biomedical research (OR=2.16, 95% CI 1.23 to 3.77, p=0.007). Conclusions: Despite low awareness, musculoskeletal patients showed a high willingness to participate in biobanking. However, significant disparities by ethnicity and education persist. Targeted, inclusive engagement strategies are needed to address under-representation and foster informed, equitable participation of musculoskeletal patients in biomedical research.

Background There is strong evidence that those recruited into studies are not always representative of the population for whom the research is most relevant. Development of the study design and funding decisions are points in the research process where considerations about inclusion of under-served populations may usefully be made. Current practical guidance focuses on designing and modifying participant recruitment and retention approaches but an area that has not been addressed is recruitment site selection. Methods We present case studies of three NIHR funded trials to demonstrate how publicly available UK population datasets can be used to facilitate the identification of under-served communities for inclusion in trials. The trials have different designs, address different needs and demonstrate recruitment planning across Trauma centres, NHS Trusts and special educational settings. We describe our use of national freely available datasets, such as those provided by NHS Digital and the Office for National Statistics, to identify potential recruitment sites with consideration of health status, socio-economic status and ethnicity as well as clinical and risk factors to support inclusivity. For all three studies, we produced lists of potential recruitment sites in excess of the number anticipated as necessary to meet the recruitment targets. Discussion We reflect on the challenges to our approach and some potential future developments. The datasets used are all free to use but each has their limitations. Agreeing search parameters, acceptable proxies and identifying the appropriate datasets, then cross referencing between datasets takes considerable time and particular expertise. The case studies are trials, but the methods are generalisable for various other study types. Conclusion Through these exemplars, we aim to build on the NIHR INCLUDE project, by providing trialists with a much needed practical approach to embedding EDI into trial design at the grant application stage.

Aims: The Oxford Shoulder Score (OSS) is a 12-item measure commonly used for the assessment of shoulder surgeries. This study explores whether computerized adaptive testing (CAT) provides a shortened, individually tailored questionnaire while maintaining test accuracy.Methods: A total of 16,238 preoperative OSS were available in the National Joint Registry (NJR) for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey dataset (April 2012 to April 2022). Prior to CAT, the foundational item response theory (IRT) assumptions of unidimensionality, monotonicity, and local independence were established. CAT compared sequential item selection with stopping criteria set at standard error (SE) < 0.32 and SE < 0.45 (equivalent to reliability coefficients of 0.90 and 0.80) to full-length patient-reported outcome measure (PROM) precision.Results: Confirmatory factor analysis (CFA) for unidimensionality exhibited satisfactory fit with root mean square standardized residual (RSMSR) of 0.06 (cut-off ≤ 0.08) but not with comparative fit index (CFI) of 0.85 or Tucker-Lewis index (TLI) of 0.82 (cut-off > 0.90). Monotonicity, measured by H value, yielded 0.482, signifying good monotonic trends. Local independence was generally met, with Yen’s Q3 statistic > 0.2 for most items. The median item count for completing the CAT simulation with a SE of 0.32 was 3 (IQR 3 to 12), while for a SE of 0.45 it was 2 (IQR 2 to 6). This constituted only 25% and 16%, respectively, when compared to the 12-item full-length questionnaire.Conclusion: Calibrating IRT for the OSS has resulted in the development of an efficient and shortened CAT while maintaining accuracy and reliability. Through the reduction of redundant items and implementation of a standardized measurement scale, our study highlights a promising approach to alleviate time burden and potentially enhance compliance with these widely used outcome measures.Cite this article: Bone Joint Res 2024;13(8):392–400.