Ian Andrew Harris

Background: Rotator cuff-related shoulder pain accounts for up to 85% of shoulder pain. Guidelines recommend 6 months of non-surgical care before considering surgery, yet many are referred to a surgeon before trying it. High referral rates to public hospital shoulder surgery clinics in Australia mean many patients wait 1-2 years to see a surgeon, during which symptoms may become more complex and costly to manage. A promising solution is the VIRtual physiotherapist-led Triage of referrals to shoUlder surgEons (VIRTUE) model of care, in which physiotherapists screen new referrals and determine suitability for non-surgical care or surgical review. However, no such model has been co-designed to incorporate virtual care nor evaluated in a randomised controlled trial. Aims: The broad aim of this study is to co-design the VIRTUE model of care ready for evaluation in a randomised controlled trial conducted in public hospital shoulder surgery clinics in Australia. Specifically, this study has two aims (two stages): i) explore stakeholders perceptions of the feasibility, acceptability and implementation of the VIRTUE model of care for adults with rotator cuff-related shoulder pain who are referred to public hospital shoulder surgery clinics; and ii) co-design the VIRTUE model of care so that it is user-centred and acceptable to patients, clinicians and key stakeholders. Methods: Stage 1 is a qualitative descriptive study using semi-structured online interviews with patients, clinicians and key stakeholders, recruited using purposive, maximum variation sampling. Interviews will explore experiences of current care, perceptions of the proposed model, and barriers and facilitators to implementation, guided by the Theoretical Framework for Acceptability and Consolidated Framework for Implementation Research. Stage 2 will use Experience-Based Co-Design methodology and involves three online workshops: separate workshops for patients, and for clinicians and key stakeholders, then a combined workshop. Workshops will explore Stage 1 findings, perceptions of the proposed model, and refinements needed to finalise it, with data mapped to the Framework for Reporting Adaptations and Modifications-Expanded. Conclusion: Co-designing VIRTUE with patients, clinicians and key stakeholders will ensure it is user-centred, acceptable and feasible within Australian public health services, ready for evaluation in a randomised controlled trial. By facilitating timely and equitable access to evidence-based care, VIRTUE could improve outcomes for patients, ensure specialist services are available for those most in need, and improve health system performance.

Objective: Persistent pain affects around 20% of Australians after total knee replacement (TKR), yet no dedicated Australian model of care exists to address this unmet need. The Early Pain Intervention after Knee replacement (EPIK) model is being developed, informed by the effective and cost‐effective UK Support and Treatment After Replacement care pathway and extensive multistakeholder engagement. Before evaluating the EPIK model of care in a randomized controlled trial, it must be adapted for the Australian context. This qualitative study aimed to explore stakeholders’ perspectives to inform this adaptation. Methods: This qualitative descriptive study, guided by a subtle realist ontologic stance and a pragmatic epistemology, used semistructured interviews with key stakeholders across Australia. A preinterview screening questionnaire captured demographic, clinical, and professional characteristics which informed purposive sampling to ensure diverse views. Interviews were audio‐recorded, transcribed verbatim, and analyzed using inductive analysis. Results: Sixty‐one participants were interviewed (9 patients, 20 physiotherapists, 15 orthopedic surgeons, 14 general practitioners, 1 nurse, and 2 health fund managers) across all six states and the Australian Capital Territory, with 75% residing in metropolitan areas. We identified four key themes: (1) living with pain after TKR, (2) acceptability and value of EPIK, (3) defining the scope of the EPIK care coordinator, and (4) infrastructure and system‐level challenges. Conclusion: The EPIK model was well accepted by stakeholders as the first approach designed to improve care coordination for Australians with persistent pain after TKR, with potential to support a more efficient and patient‐centered health care system. These insights will inform the EPIK model, which will be tested in a registry‐nested randomized controlled trial.

Endobronchial valves (EBVs) are one-way valves used for targeted lung volume reduction in patients with severe emphysematous chronic obstructive pulmonary disease (COPD) [1]. Following several rand...

Aims: Pelvic reconstruction in the setting of significant bone loss has become increasingly complex, with advancements such as custom 3D-printed prostheses now used in both large oncological resections and revision total hip arthroplasty (rTHA) with massive bone loss. Surgeons must consider how to best reconstruct the pelvis to optimize patient outcomes. The Reconstructive Pelvic Anatomy (RPA) classification system is proposed to aid in communication, reconstructive planning, and developing research cohorts suitable for modern pelvic reconstructions. This study aimed to 1) describe the development of the RPA classification as a novel classification system for pelvic reconstruction; 2) demonstrate the content and construct validity of the system; and 3) investigate its interobserver and intraobserver agreement. Methods: A group of orthopaedic surgeons and researchers, based in Sydney, Australia, developed the system’s four domains, which together form the overall classification. A total of 23 pelvic reconstruction surgeons provided an assessment of each domain’s clarity and relevance, producing an Item-Content Validity Index (I-CVI). They then applied the classification to the surgical plan and postoperative radiograph of 20 pelvic reconstructions twice, at a minimum of two weeks apart. Construct validity was assessed by agreement between observers and authors. Interobserver and intraobserver agreement was assessed using the kappa statistic. Results: A total of 23 surgeons completed the assessment of content validity, and 18 surgeons completed both surveys. Each domain demonstrated content validity for both relevance and clarity (I-CVI > 0.78). Authors and observers had moderate agreement on the classification supporting construct validity (k = 0.6) with a median agreement of 90% for individual domains. Interobserver agreement was moderate overall (k = 0.54), with individual domains having substantial or better agreement (k = 0.73 to 0.82) except for anterior fixation (k = 0.57). Intraobserver agreement of individual domains was substantial or almost perfect (k = 0.76 to 0.84) with moderate agreement for the overall classification (k = 0.6). Conclusion: This study establishes the content and construct validity of the RPA classification system as a novel classification system for pelvic reconstruction, and its reliability to support its use as a communicative tool, and in research and surgical planning. Cite this article: Bone Jt Open 2026;7(7):871–881.

Background: Approximately one in five Australians who undergo total knee replacement (TKR) experience persistent postoperative pain. There are currently no known effective and cost‐effective multidisciplinary models of care in Australia to address this. We are developing the ‘Early Pain Intervention after Knee Replacement’ (EPIK) model of care, adapted from ‘Support and Treatment After Replacement’ (STAR) care pathway. STAR was developed in the United Kingdom (UK) and shown to be effective and cost‐effective in the UK context. Extensive consumer and clinician engagement informed the development of the EPIK model of care, tailored to the Australian health system and geographical context to address this critical gap. Objective: To co‐design the ‘Early Pain Intervention after Knee replacement’ (EPIK) model of care for people with persistent pain after TKR. Methods: We used Experience‐Based Co‐Design (EBCD) methodology to co‐design EPIK, a telehealth model of care providing remote care coordination for people with persistent pain after TKR. Three online Zoom workshops were conducted with key stakeholders, including consumers with lived experience, clinicians (orthopaedic surgeons, physiotherapists, general practitioners, psychologists and a rehabilitation physician), and EPIK investigators. Workshop 1 explored consumer perspectives on the EPIK model of care assessment and follow‐up. Workshop 2 determined the feasibility and roles of clinicians in the EPIK model of care delivery. Workshop 3 brought together consumers, clinicians, and researchers to refine and finalise the EPIK model of care. Using EBCD methodology and inductive framework analysis, themes were derived iteratively. Across consumer and clinician workshops, consensus was reached through facilitated discussions where stakeholders actively contributed to prioritisation activities and iterative refinement of model components. Results: Twenty‐one individuals participated in the workshops, comprising nine consumers and 12 clinicians from the Australian Capital Territory, New South Wales, Tasmania, and Western Australia, alongside five EPIK Investigators. Workshop 1 with consumers highlighted the need for clearer definition of communication processes, patient education and coaching strategies, and the role of the EPIK care coordinator to ensure consistent information and coordinated support throughout the model of care delivery. Workshop 2 with clinicians focused on telehealth assessments, escalation of clinical pathways, referrals, and psychological support. The final workshop reached consensus on its components and delivery, emphasising the importance of patient advocacy, reassurance and continuity of personalised care. Conclusion: Through meaningful end‐user involvement, co‐design informed the development of the EPIK model of care. The effectiveness, cost‐effectiveness and safety of EPIK will be evaluated in a randomised controlled trial. Patient or Public Contribution: Two consumer co‐authors (T.G. and B.L.) guided the development of the preliminary model of care and trial protocol. Consumers with lived experience of persistent pain after TKR participated throughout the co‐design process. Trial Registration: ACTRN12625001029482p (Australian and New Zealand Clinical Trials Registry). Registered on 17 September 2025.

Background: The COVID-19 pandemic produced a substantial reduction in arthroplasties, which could have affected patient quality of life. This study investigated quality of life in Australians undergoing elective arthroplasty before and during the COVID-19 pandemic. Methods: Using data from the Australian Orthopaedic Association National Joint Replacement Registry, quality of life was assessed in patients before and six months after primary total hip arthroplasty (THA), total knee arthroplasty (TKA) and reverse total shoulder arthroplasty (RTSA) using the EQ-5D-5L instrument. Patients with an EQ-5D Utility score less than zero were considered to have a quality of life worse than dead. Secondary outcomes included Oxford Scores, joint-specific pain, patient perceived change, responder status and patient satisfaction. Quality of life was compared before (1 July 2018–10 March 2020) and during the pandemic (11 March 2020–10 March 2023) using linear or logistic regression models. Results: The analysis included preoperative data for more than 24,000 THA patients, 20,000 TKA patients and 1,100 RTSA patients. Compared to the pre-pandemic period, preoperative and postoperative quality of life significantly reduced during the pandemic for THA and TKA, but not by a meaningful amount (adjusted mean difference ≤ 0.03 points, p < 0.001). The likelihood of having quality of life worse than dead increased during the pandemic but was only significant for preoperative THA (ORs 1.24 to 1.40, p < 0.02). For secondary outcomes, joint-specific scores deteriorated, and joint pain increased to a small degree during the pandemic for THA and TKA ( p < 0.05), but not for RTSA. The proportion of THA and TKA patients satisfied with their surgery outcome increased modestly during the pandemic by approximately five percentage points, compared to pre-pandemic. Conclusion: The COVID-19 pandemic was not associated with a clinically meaningful deterioration in pre- or post-operative quality of life, on average, for patients undergoing THA, TKA or RTSA in Australia.

Gravitational wave interferometers have studied compact object mergers and solidified our understanding of strong gravity. Their increasing precision raises the possibility of detecting new physics, especially in a neutron star binary system that may contain hidden-sector particles. In particular, a new vector force between binary constituents, giving rise to dark electromagnetic phenomena, could measurably alter the inspiral waveforms and thus be constrained by gravitational wave observations. In this work, we critically examine the mechanisms for neutron stars to acquire enough hidden-sector particles with requisite couplings to furnish a detectable signature from dark electromagnetism. In particular, we explore three plausible mechanisms for achieving a sufficient dark mass fraction, and we derive quite general limitations on the amount of charge that can be accumulated by any of these mechanisms. We demonstrate that the repulsive nature of vector forces imposes stringent constraints on any putative particle physics model or astrophysical environment which could give rise to such gravitational signatures. We argue that absent an extreme fine-tuning of parameters, such signatures are well out of reach of any current or near-future gravitational wave observatory.

Lipid nanoparticles (LNPs) are a versatile platform for in vivo delivery of biomolecules, yet systemically administered LNPs predominantly accumulate in the liver, limiting extrahepatic applications. This tropism arises from LNP adsorption of serum proteins, particularly apolipoprotein E (ApoE), which binds to LDL receptors (LDLR) on hepatocytes. Here, we overcome this tropism with two compatible strategies. First, we engineer dead ApoE mutants (dApoE) with five receptor-binding domain substitutions that selectively disrupt the ApoE-LDLR interaction but retain lipid binding. In cultured cells, pre-coating with these dApoE markedly inhibited LDLR-mediated uptake. Second, we pretreat cells with hyperactive PCSK9 (haPCSK9) to internalize surface LDLR, similarly reducing the LDLR-mediate uptake of LNPs. In vivo, both strategies substantially reduced liver LNP transduction without inducing redistribution to other major organs. To retarget LNP to new cell types we combined antibody conjugation with dApoE or haPCSK9, effectively engineering tropism to T cells, brain and lung tissues in vivo with substantially reduced hepatic background. In pilot studies, this strategy enabled specific delivery of reporter mRNAs to additional tissues, including megakaryocytes, hematopoietic progenitor cells, and cardiac tissue, and in aged T cells, to deliver miRNA cargos that produced a sustained reduction in DNA damage markers following a single systemic dose. dApoE coated CD5-targeted LNPs generated CAR+ T cells that retained cytotoxicity against CD19+ targets, while simultaneously reducing hepatocyte transduction by 90%. These findings establish a modular framework that integrates dApoE and haPCSK9-mediated detargeting with antibody-based retargeting, allowing for improvements in LNP specificity and broadening the therapeutic scope of LNPs.