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OR1.6 | Recent Advances in Orthopaedic Management — SDL Guide (Part 3)
Self-Assessment: Evaluating Orthopaedic Advances
The following self-assessment exercises are designed to test your ability to integrate the content of this module — not to recall isolated facts, but to apply the critical appraisal framework to specific clinical situations. Work through each scenario before reading the guidance.
Scenario 1 — Trauma: A 45-year-old polytrauma patient with a closed femoral shaft fracture and a GCS of 12 (head injury) arrives at a level 1 trauma centre 2 hours after a road traffic collision. The surgeon proposes immediate intramedullary nailing. A colleague suggests applying an external fixator first and delaying definitive fixation. Which approach is more consistent with modern evidence-based practice, and what is the physiological rationale for the staged approach?
Scenario 2 — Sports: A 32-year-old recreational footballer is told by a private orthopaedic surgeon that he needs PRP injections for his patellar tendinopathy at a cost of Rs 15,000 per session, with three sessions recommended. What questions would you ask to critically appraise this recommendation? What does current evidence show for PRP in patellar tendinopathy versus lateral epicondylitis?
Scenario 3 — Arthroplasty: A 65-year-old woman with end-stage medial compartment knee osteoarthritis is offered a total knee replacement. She asks whether the newer 'metal-on-metal' hip designs she has read about would apply to her knee. How would you explain the difference between hip and knee bearing surfaces, and why metal-on-metal has been largely abandoned for hips?
Scenario 4 — Spine: A 40-year-old with single-level C5-6 disc prolapse and radiculopathy is told by a neurosurgeon that he needs ACDF. He has read about cervical disc replacement on the internet and asks whether it is a better option for him. Summarise what cervical TDR offers, its contraindications, and what the RCT evidence shows versus ACDF.
After completing these scenarios, identify the advance in each domain that you think has the strongest evidence for adoption and the one with the weakest evidence. This exercise in evidence hierarchy will serve you throughout your career as orthopaedics continues to evolve.
CLINICAL PEARL
The 'metal-on-metal cautionary tale' is the most important lesson from orthopaedic advances of the past 20 years. Metal-on-metal hip arthroplasty (particularly large-head metal-on-metal bearings and hip resurfacing) was adopted widely based on excellent short-term wear data and theoretical advantages. Millions of implants were inserted. Then the long-term data arrived: elevated cobalt-chromium ion levels, pseudotumour formation (Adverse Local Tissue Reaction, ALTR), and pain from metal sensitivity — affecting 5–10% of patients. Major recalls followed. The lesson is not 'never adopt new techniques' — it is that the adoption of a new implant or technique should be proportionate to the strength of the evidence, and short-term data never adequately predicts long-term outcomes in a device that will be in a patient for 20 years. Always ask: 'What is the longest follow-up data available, and who funded the study?'