EDITORIAL

From needle to knife

F. S. Haddad,
A.W. McCaskie
From The British
Editorial Society of
Bone and Joint
Surgery, London,
United Kingdom

F. S. Haddad, BSc MD (Res),

FRCS (Tr&Orth), Professor of
Orthopaedic Surgery, Editor-inChief
The Bone & Joint Journal,
22 Buckingham Street, London,
WC2N 6ET, UK.
A.W. McCaskie, MMus, MD,
FRCS (Tr&Orth), Professsor of
Orthopaedic Surgery,
University of Cambridge, Box
180, Addenbrookes Hospital,
Hills Road, Cambridge, CB2
2QQ, and Arthritis Research UK
Tissue Engineering Centre, UK.
Correspondence should be sent
to Professor F. S. Haddad:
editorbjj@boneandjoint.org.uk
2015 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.97B1.
34963 $2.00
Bone Joint J
2015;97-B:12.

Trauma and Orthopaedic care has been through a rapid evolution over the past few decades.
This Editorial discusses some of the advances.
Cite this article: Bone Joint J 2015;97-B:12.

The era where non-operative interventions, such

as manipulation, plaster immobilisation and traction predominated, has in a large part of practice,
been replaced by pioneering surgical advances as
seen in joint replacement and fracture fixation.
More recently, further evolution has brought subspecialised minimally invasive high yield procedures with short inpatient episodes.1-4
In the next five to ten years, regenerative
techniques will present a further opportunity
for the evolution of trauma and orthopaedic
surgery.5 This will see the development of cell
(mesenchymal, stromal and stem) and cell free
(materials, molecules and scaffolds) therapies
targeted towards earlier stages of diseases such
as osteoarthritis, before a joint replacement is
indicated.6,7 A likely development in the shortto medium-term is a multi-modal surgical procedure which is a combination of an existing
surgical technique, such as an arthroscopic
technique, combined with the new therapy,
perhaps formulated as an injection.8-10 In so
doing, the needle, like the knife, becomes a
hugely important part of our armamentarium.
The surgical intervention is and will remain
at the heart of practice for both consultant and
trainee. We have developed supporting programmes of clinical research and audit to
address outcome and effectiveness. Moreover,
orthopaedic basic science research has been a
constant catalyst for the development of our
procedures and has characteristically combined biological and engineering sciences. This
interdisciplinary approach is as relevant to
regenerative medicine as it was, and still is, to
arthroplasty. We must continue to lead innovation in this new era and combine it with
careful and responsible translation, which
includes detailed clinical evaluation and rigorous safety and regulatory considerations.
There is a huge potential benefit for patients
who could be offered more treatment options at

VOL. 97-B, No. 1, JANUARY 2015

earlier stages of their injury or disease. This

will require an evidenced based, stratified or
even personalised approach. Given that the
future of musculoskeletal care may include
regenerative medicine, we are beholden to consider how best to define, or re-define emerging
patient pathways. Many trauma and orthopaedic clinics already see a wide variety of diseases
and stages of disease. We should continue to
embrace all those facets of musculoskeletal
care that may be useful at various stages of the
disease process. The undoubted success of the
procedure should be seen in the context of the
whole patient journey which can involve many
other types of non-surgical practitioner such as
the general practitioner, rheumatologist, pain
specialist and physiotherapist. We should lead
on implementation and work with key stakeholders to establish clear and integrated
patient pathways that will encompass the new
approaches.
There are many advances that will emerge and
allow the further evolution of bone and joint surgery, and regenerative advances are one. Whilst
we continue to provide surgical interventions for
advanced disease and acute care for musculoskeletal injury, we will also be required to
develop a range of interventional procedures that
could be applied at earlier stages of disease, making full use of the opportunities presented by the
needle to knife toolkit.
At The Bone & Joint Journal we will continue to encourage both research and publication in all facets of the musculoskeletal
pathway, both surgical and non-surgical, as
long as they pertain to the patient journey and
will influence future care.

References
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of secondary pathology after anterior cruciate ligament rupture in
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F. S. HADDAD, A.W. MCCASKIE

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the Reamer-Irrigator-Aspirator system and in bone graft from the iliac crest. Bone
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