Ortho Appraised

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In this episode of Ortho Appraised, Dr Rajabifard appraises the evidence on gluteal tendinopathy (greater trochanteric pain syndrome) across three sources — the Mellor RCT in the BMJ, the Fitzpatrick platelet-rich plasma trials in the American Journal of Sports Medicine, and a stage-adjusted systematic review in Orthopaedic Journal of Sports Medicine. The clinical question: what works best over the longer term — education plus exercise, corticosteroid injection, or PRP? The trials point away from corticosteroid as a durable solution.

📄 Citation: Mellor R, et al. Education plus exercise versus corticosteroid injection versus a wait-and-see approach for gluteal tendinopathy. BMJ. 2018;361:k1662. DOI: https://doi.org/10.1136/bmj.k1662 · Fitzpatrick J, et al. PRP versus corticosteroid injection in gluteal tendinopathy. Am J Sports Med. 2018;46(4):933–9. DOI: https://doi.org/10.1177/0363546517745525 · Fitzpatrick J, et al. Leucocyte-rich PRP, 2-year follow-up. Am J Sports Med. 2019;47(5):1130–7. DOI: https://doi.org/10.1177/0363546519826969 · Ladurner A, et al. Stage-adjusted treatment recommendation. Orthop J Sports Med. 2021;9(7). DOI: https://doi.org/10.1177/23259671211016850

Key Takeaways:

* Two Australian RCTs (Mellor, n=204; Fitzpatrick, n=80) plus a stage-adjusted systematic review.

* Both trials show corticosteroid injection underperforms at longer follow-up.

* One trial favours education plus exercise; the other favours leukocyte-rich PRP — but neither compared its winner against the other's.

* Practice implication: lead with load-based exercise and education, and view corticosteroid as short-term relief rather than a durable fix.

* No head-to-head exercise-versus-PRP trial exists, and the arbitrating review was co-authored by the PRP trialists — a genuine gap in the evidence.

🔗 Full papers: https://doi.org/10.1136/bmj.k1662 · https://doi.org/10.1177/0363546517745525 · https://doi.org/10.1177/0363546519826969 · https://doi.org/10.1177/23259671211016850

Keywords: gluteal tendinopathy, greater trochanteric pain syndrome, platelet-rich plasma, corticosteroid injection, tendon exercise therapy.

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In this episode of Ortho Appraised, Dr Rajabifard appraises "Minimum 5-Year Follow-up Results: CROSSBAT" published in Foot & Ankle International. The clinical question: for a stable Weber B ankle fracture with no talar shift, does surgery beat a walking boot over five or more years? The long-term data support non-operative management for these stable injuries.

📄 Citation: O'Keefe R, Naylor JM, Symes MJ, Harris IA, Mittal R. Minimum 5-Year Follow-up Results: CROSSBAT (Combined Randomised and Observational Study of Surgery vs No Surgery for Type B Ankle Fracture Treatment). Foot Ankle Int. 2022;43(12):1517–24. DOI: https://doi.org/10.1177/10711007221128562

Key Takeaways:

* Long-term (5–8 year) follow-up of a pragmatic Australian RCT with masked outcome assessors and a pre-specified 5-point MCID.

* Surgery was not superior on either patient-reported primary outcome; the differences were small and non-significant.

* Non-operative care avoided the additional adverse events seen in the surgical arm.

* Practice implication: a walking boot is a sound first-line option for isolated Weber B fractures without talar shift.

* As with any long-term follow-up, attrition accumulates over the years, so individual figures are best read as part of a consistent overall picture.

🔗 Full paper: https://doi.org/10.1177/10711007221128562

Keywords: Weber B ankle fracture, CROSSBAT trial, non-operative ankle fracture, walking boot, foot and ankle evidence.

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In this episode of Ortho Appraised, Dr Rajabifard appraises "Surgical fixation versus non-surgical care for children with a displaced medial epicondyle fracture of the elbow (the SCIENCE study)" published in The Lancet. The clinical question: for a displaced medial epicondyle elbow fracture in a child, does surgical fixation deliver better function than non-operative care? Surgery was not shown to be superior, making non-operative care a reasonable option for most.

📄 Citation: Perry DC, Achten J, Zimmermann A, et al. Surgical fixation versus non-surgical care for children with a displaced medial epicondyle fracture of the elbow (the SCIENCE study): a multicentre, randomised controlled, superiority trial and economic evaluation. Lancet. 2026;407:577–86. DOI: https://doi.org/10.1016/S0140-6736(25)02098-7

Key Takeaways:

* Pragmatic multicentre superiority RCT (n=334) with a pre-specified, family-set MCID and a within-trial economic evaluation.

* Surgical fixation did not produce a clinically important improvement in arm function over non-operative care.

* Because the MCID was pre-specified and powered to, this reads as a genuine "no meaningful benefit" rather than an ambiguous null.

* Practice implication: non-operative management is a defensible default for most displaced medial epicondyle fractures.

* Outcomes were family-reported and unmasked, with slightly more missing data in the cast arm; the result agrees with a smaller Finnish RCT.

🔗 Full paper: https://doi.org/10.1016/S0140-6736(25)02098-7

Keywords: paediatric elbow fracture, medial epicondyle fracture, SCIENCE trial, surgery versus conservative, children's orthopaedic trauma.

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In this episode of Ortho Appraised, Dr Rajabifard appraises the FASHIoN body of work — the UK FASHIoN RCT in The Lancet, the Personalised Hip Therapy protocol paper in the British Journal of Sports Medicine, and the Australian FASHIoN trial in BMC Musculoskeletal Disorders. The clinical question: for femoroacetabular impingement in young adults, does hip arthroscopy beat a structured physiotherapy programme — and why? The answer is nuanced: a real symptom benefit, but no demonstrated disease modification.

📄 Citation: Griffin DR, et al. Hip arthroscopy versus best conservative care for FAI syndrome (UK FASHIoN). Lancet. 2018;391:2225–35. DOI: https://doi.org/10.1016/S0140-6736(18)31202-9 · Wall PDH, et al. Personalised Hip Therapy: development of a non-operative protocol. Br J Sports Med. 2016;50:1217–23. DOI: https://doi.org/10.1136/bjsports-2016-096368 · Hunter DJ, Bennell KL, et al. Australian FASHIoN trial (hip cartilage metabolism). BMC Musculoskelet Disord. 2021;22:697. DOI: https://doi.org/10.1186/s12891-021-04576-z

Key Takeaways:

* Three linked papers: the UK FASHIoN RCT (n=348), the comparator-protocol paper, and the Australian FASHIoN trial (n=99) using hip cartilage metabolism as its primary outcome.

* Hip arthroscopy improved symptoms over conservative care in both trials.

* The Australian trial found no benefit to hip cartilage metabolism — the disease-modification rationale was not supported.

* Practice implication: offer surgery for symptom relief rather than to alter the joint's natural history; well-delivered physiotherapy is a legitimate comparator.

* The magnitude of the symptom benefit is modest and depends on how well the conservative arm is delivered.

🔗 Full papers: https://doi.org/10.1016/S0140-6736(18)31202-9 · https://doi.org/10.1136/bjsports-2016-096368 · https://doi.org/10.1186/s12891-021-04576-z

Keywords: femoroacetabular impingement, hip arthroscopy, FASHIoN trial, personalised hip therapy, hip preservation.

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In this episode of Ortho Appraised, Dr Rajabifard appraises "Arthroscopic meniscal surgery vs non-operative treatment for degenerative tears with mechanical symptoms: 5-year outcomes" published in the Journal of Orthopaedic Reports. The clinical question: for a degenerative meniscal tear with mechanical symptoms, does arthroscopic surgery beat non-operative care at five years? The evidence reinforces a non-operative-first approach.

📄 Citation: Zilani N, Tan J, Raj S, Maris A, Vasiliadis AV, Patel A. Arthroscopic meniscal surgery vs non-operative treatment for degenerative tears with mechanical symptoms: 5-year outcomes systematic review and meta-analysis of RCTs. J Orthop Rep. 2025;100809. DOI: https://doi.org/10.1016/j.jorep.2025.100809

Key Takeaways:

* Systematic review and meta-analysis of 6 RCTs (n=1,157) reporting 5-year outcomes — a Level I evidence synthesis.

* No clinically meaningful patient-reported outcome benefit from arthroscopic meniscal surgery over physiotherapy-led care.

* Even the "mechanical symptoms" subgroup — the usual justification for operating — showed no durable advantage.

* Risk of osteoarthritis was roughly doubled after surgery (OR 2.09, 95% CI 1.49–2.93).

* Practice implication: structured exercise-based care is a sound first line, interpreting the pooled estimates alongside the usual between-trial heterogeneity.

🔗 Full paper: https://doi.org/10.1016/j.jorep.2025.100809

Keywords: degenerative meniscal tear, knee arthroscopy, mechanical symptoms, meniscectomy versus physiotherapy, evidence-based knee surgery.

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## Episode 3: Early vs Delayed Weight-Bearing After Ankle Fracture Surgery (Dehghan + WAX)

In this episode of Ortho Appraised, Dr Rajabifard appraises two randomised trials on weight-bearing after ankle fracture fixation — Dehghan et al. in the Journal of Orthopaedic Trauma and the large multicentre WAX trial in The Lancet. The clinical question: after fixation of an unstable ankle fracture, is it safe to bear weight early rather than staying non-weightbearing for six weeks? Both support letting selected patients walk sooner.

📄 Citation: Dehghan N, McKee MD, Jenkinson RJ, et al. Early weightbearing and range of motion versus non-weightbearing and immobilization after ORIF of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016;30(7):345–352. DOI: https://doi.org/10.1097/BOT.0000000000000572 — and Bretherton CP, Achten J, Jogarah V, et al. Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial. Lancet. 2024;403:2787–97. DOI: https://doi.org/10.1016/S0140-6736(24)00710-4

Key Takeaways:

* Two RCTs paired: Dehghan (2016, ~100 patients) and the large multicentre WAX trial (2024).

* Dehghan's return-to-work primary was null (51.2 vs 47.8 days, p=0.72), while functional recovery was faster with early motion.

* WAX found early weight-bearing clinically non-inferior and highly likely to be cost-effective.

* Practice implication: early protected weight-bearing is safe in appropriately stable fixed ankle fractures.

* Both excluded the least stable patterns, so they offer least reassurance for those; a baseline return-to-work imbalance affected Dehghan's primary outcome.

🔗 Full papers: https://doi.org/10.1097/BOT.0000000000000572 · https://doi.org/10.1016/S0140-6736(24)00710-4

Keywords: ankle fracture rehabilitation, early weight-bearing, ORIF, WAX trial, orthopaedic trauma evidence.

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In this episode of Ortho Appraised, Dr Rajabifard appraises "Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study)" published in The Lancet. The clinical question: in children with a badly displaced distal radius fracture, is a cast alone — no manipulation — as good as surgical reduction? The findings support offering a cast first for most children.

📄 Citation: Perry DC, Zimmermann A, Achten J, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet. 2026;407:1538–48. DOI: https://doi.org/10.1016/S0140-6736(26)00409-5

Key Takeaways:

* Well-conducted multicentre non-inferiority RCT — 750 children across 49 UK hospitals, with modern mixed-model missing-data handling.

* Function at 3 months only trivially favoured surgery (ITT −1.64; per-protocol −2.07 on PROMIS), and the arms were level by 6 months.

* Formally, non-inferiority of casting was "not demonstrated" against the −2.5 margin — but the difference is clinically negligible.

* Practice implication: a cast without manipulation is a reasonable first-line choice for most, sparing anaesthetic and theatre time.

* Outcomes are parent-reported and, unavoidably, unmasked; the completely off-ended subgroup is where casting is least certain.

🔗 Full paper: https://doi.org/10.1016/S0140-6736(26)00409-5

Keywords: paediatric distal radius fracture, CRAFFT trial, cast versus surgery, children's wrist fracture, non-inferiority RCT.

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In this episode of Ortho Appraised, Dr Rajabifard appraises "Effect of prior rotator cuff repair technique and timing on clinical outcomes of reverse shoulder arthroplasty" published in The Bone & Joint Journal. The clinical question: when a shoulder eventually needs a reverse shoulder replacement, does it matter whether the earlier rotator cuff repair was done open or arthroscopically, and how long ago? The findings are useful for counselling but are unlikely to change surgical decisions.

📄 Citation: Holt KE, Hao KA, Bindi VE, et al. Effect of prior rotator cuff repair technique and timing on clinical outcomes of reverse shoulder arthroplasty. Bone Joint J. 2026;108-B(7):928–935. DOI: https://doi.org/10.1302/0301-620X.108B7.BJJ-2025-1393.R1

Key Takeaways:

* Retrospective single-centre cohort of 104 shoulders (Level III) — outcomes prospectively collected, exposure determined by chart review.

* Prior arthroscopic repair was associated with a higher post-operative ASES score (+13.1) and range of motion than prior open repair.

* The effect sits at or below the minimal clinically important difference, with a wide confidence interval — so clinical importance is uncertain.

* Best used for prognostic counselling rather than to change how or when a cuff is repaired, or the timing of conversion to reverse replacement.

* Confounded by surgical era and tear severity — arthroscopic repairs were, on average, more recent.

🔗 Full paper: https://doi.org/10.1302/0301-620X.108B7.BJJ-2025-1393.R1

Keywords: reverse shoulder arthroplasty, prior rotator cuff repair, ASES outcomes, shoulder replacement, orthopaedic critical appraisal.

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Ortho Appraised is a weekly orthopaedic evidence podcast hosted by Dr Rajabifard, an orthopaedic registrar. Each episode takes a recently published journal article and breaks it down in plain terms: what was the research question, was the methodology sound, and — most importantly — should it change your practice?

Every episode runs just ten to fifteen minutes, built for clinicians who are short on time: registrars preparing for exams, consultants staying current between theatre lists, and allied health professionals working in musculoskeletal care. The goal is to get you to the clinical takeaway fast — without skipping the methodological detail that decides whether a paper can actually be trusted.

A note on how the show is made: the appraisal of the research is curated by me, an orthopaedic registrar from Melbourne in Australia, but the voice you’re hearing is A-I text to speech, used for consistency and efficiency.

Evidence in brief. Practice in focus.

New episodes every Sunday. Subscribe now wherever you get your podcasts, and you'll be ready when the first episodes land.

Keywords: orthopaedic podcast, evidence-based orthopaedics, orthopaedic literature review, critical appraisal, journal club, orthopaedic registrar exam prep, musculoskeletal medicine.