Imperial College London


Faculty of MedicineDepartment of Surgery & Cancer

Clinical Senior Lecturer in Orthopaedics



a.liddle Website




Miss Colinette Hazel +44 (0)20 7594 2725




203Building E - Sir Michael UrenWhite City Campus





Publication Type

87 results found

Vella-Baldacchino M, Webb J, Selvarajah B, Chatha S, Davies A, Cobb JP, Liddle ADet al., 2023, Should we recommend patellofemoral arthroplasties to patients?, Bone Jt Open, Vol: 4, Pages: 948-956

AIMS: With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. METHODS: MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used. RESULTS: A total of nine studies were included, made up of four randomized controlled trials (domain 1) and five cohort studies (domain 2). PROMs and knee function specific scores developed for reporting TKA were unable to detect any difference between PFA and TKA. There was no significant difference in complications between PFA and TKA. PFAs were found to have a better postoperative range of motion. CONCLUSION: TKA and PFA are both viable options for patients with primary PFJ OA. Over time, we have seen an emphasis on patient satisfaction and better quality of life. Recommending sacrificing healthy medial and lateral compartments to treat patellofemoral joint arthritis should be given further thought.

Journal article

Davies A, Lloyd T, Sabharwal S, Liddle AD, Reilly Pet al., 2023, Anatomical shoulder replacements in young patients: a systematic review and meta-analysis, Shoulder & Elbow, Vol: 15, Pages: 4-14, ISSN: 1758-5732

IntroductionIncreasing numbers of young patients receive shoulder replacements. Greater information on outcomes is needed to inform implant choice. The aim of this study was to investigate the survivorship and clinical effectiveness of hemiarthroplasty and anatomical total shoulder arthroplasty (TSA) in patients younger than 65 years.MethodA systematic review was performed of MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports. The primary outcomes were implant survival and change in perioperative shoulder scores.ResultsMeta-analysis of implant survivorship was performed of six studies reporting on 416 patients. Implant survival was 86.1% (72.1,100) at 10 years for hemiarthroplasty and 82.3% (64.6,100) for TSA. 20 year survival was 80.0% for hemiarthroplasty (72.5,87.4) and 75.0% (56.9,93.1) for TSA. Ten studies were included in the meta-analysis of shoulder scores, multiple instruments were used. The standardised mean difference between pre-operative and post-operative shoulder scores was 2.15 (1.95, 2.35) for TSA at 4.2–4.9 years, and 2.72 (1.98,3.47) for hemiarthroplasty at 3.8–6 years.ConclusionOver 80% of shoulder replacements last more than 10 years, and 75% last more than 20 years. Significant improvements in shoulder scores are shown at all time points.

Journal article

Morgan C, Li L, Kasetti PR, Varma R, Liddle ADet al., 2023, Pregnancy, parenthood, and fertility in the orthopaedic surgeon, BONE & JOINT JOURNAL, Vol: 105B, Pages: 857-863, ISSN: 2049-4394

Journal article

Plumb W, Casale G, Bottle A, Liddle Aet al., 2023, Clinical pathway clustering using surrogate likelihoods and replayability validation, Winter Simulation Conference 2023, Publisher: ACM / IEEE

Modelling clinical pathways from Electronic Health Records (EHRs) can optimize resources and improvepatient care, but current methods for generating pathway models using clustering have limitations includingscalability and fidelity of the clusters. We propose a novel pathway modelling approach using MaximumLikelihood (ML) data clustering on Markov chain representations of clinical pathways. Our method iscalibrated to produce clusters with low inter-cluster variability across the pathways. We use machine learningwith Stochastic Radial Basis Functions (SRBF) kernels for surrogate optimization to handle non-convexityand propose an incremental optimization method to improve scalability. We also define a methodologybased on novel replayability scores to help analysts compare the fidelity of alternative clustering results.Results show that our ML method produces clusters that have higher fidelity in terms of replayability scoresthan k-means based clustering and in capturing queueing contention, which is important for bottleneckidentification in healthcare.

Conference paper

Patel A, Edwards T, Jones G, Liddle A, Cobb J, Garner Aet al., 2023, Metabolic equivalent of task (MET) scores avoid the ceiling effect observed with conventional patient reported outcome scores following knee arthroplasty, Bone & Joint Open, Vol: 4, Pages: 129-137, ISSN: 2633-1462

Aims : The metabolic equivalent of task (MET) score examines patient performance in relation toenergy expenditure before and after knee arthroplasty. This study assesses it’s use in a kneearthroplasty population in comparison with the widely used Oxford Knee Score (OKS) and EuroQol5d Index (EQ-5D) which are reported to be limited by ceiling effects.Method: One-hundred and sixteen patients with OKS, EQ-5D and MET scores before, and at least sixmonths following unilateral primary knee arthroplasty were identified from a database. Procedureswere performed by a single surgeon between 2014 & 2019 consecutively. Scores were analysed fornormality, skewness, kurtosis and the presence of ceiling/floor effects. Concurrent validity betweenthe MET score, OKS and EQ-5D was assessed using Spearman’s rank.Results: Post-operatively the OKS and EQ-5D demonstrated negative skews in distribution, with highkurtosis at six months and one year. The OKS demonstrated a ceiling effect at one year (15.7%) postoperatively. The EQ-5D demonstrated a ceiling effect at six months (30.2%) and one year (39.8%)post-operatively. The MET score did not demonstrate a skewed distribution or ceiling effect either atsix months or one year post-operatively. Weak-moderate correlations were noted between the METscore and conventional scores at six-months and one-year post-operatively.Conclusion: In contrast to the OKS and EQ-5D, the MET score was normally distributed postoperatively with no ceiling effect. It is worth consideration as an arthroplasty outcome measure,particularly for patients with high expectations.

Journal article

Bottle A, Liddle A, 2022, Hip fracture in the COVID-19 era: what can we say about care and patient outcomes?, BMJ Quality & Safety, Vol: 32, Pages: 244-246, ISSN: 2044-5423

Journal article

Munford M, 2022, Biomimetic Orthopaedic Implants: Harnessing Bone’s Remodelling Response with Additive Manufacturing

The long-term healing of bone is inherently coupled with the strain it experiences, as described by numerous laws governing bone’s mechanobiology and natural remodelling process. Bone regeneration can therefore be accelerated by the use of porous structures in orthopaedics which have a mechanical modulus akin to the bone being replaced. Following design and regulatory requirements, a further consideration is that yield strength and fatigue strength must be suitable for the implants applications. Conventional orthopaedic implants are solid metal so therefore have excessive strength and stiffness. This means that theycause regions of bone to be underloaded, leading to bone resorption which complicates surgery. This PhD explored optimising additively manufactured (AM) porous structures for application as bone growth stimulating orthopaedic implants. The mechanical modulus, strength and anisotropy of bone and AM structures was characterised in a workflow which uses manufacturing and imaging methods commonly used in industry. Following this, individual AM structures were designed and manufactured based on computed tomography (CT) scans of bone to control the strain experienced. Orthopaedic implants were then manufactured which replicated the loading and strain environment experienced in healthy bone. Mechanical mappings of bone and AM structures were shown to predict properties to within 5.6% and 2%, while custom AM implants could control bone strain from -15% to +15% of homeostasis (corresponding to an extension of -4500 µm to 4500 µm). Conventional solid counter parts underloaded up to 70% of peri-prosphethic bone, whereas AM implants closely replicated the loaded experienced by bone prior to implantation (achieving mechanical environments which were 68-78% similar). This thesis has emphasis on understanding bone’s mechanical properties and the effect of implants on mechanical stimulus, which will allow for more accurate testing of the mechanica

Thesis dissertation

Edwards T, Guest B, Garner A, Logishetty K, Liddle A, Cobb Jet al., 2022, The metabolic equivalent of task score: a useful metric for comparing high functioning hip arthroplasty patients, Bone & Joint Research, Vol: 11, Pages: 1-10, ISSN: 2046-3758

Aims: This study investigates the use of the Metabolic Equivalent of Task (MET) score in a young hip arthroplasty population and its ability to capture additional benefit beyond the ceiling effect of conventional patient reported outcomes.Patients & Method: Oxford Hip Score (OHS), EuroQol-5D index (EQ-5D), and the MET were recorded in 221 primary hip arthroplasty procedures pre-operatively and at 1-year. The distribution was examined reporting the presence of ceiling & floor effects. Validity was assessed correlating the MET with the other scores using Spearman’s rank and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analysed by age, sex, BMI and pre-operative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS.Results: From our electronic database of 751 hip arthroplasty procedures, 117 primary total hip and 104 hip resurfacing arthroplasty operations were included. Mean age was 59.4 ± 11.3. Post-operatively the OHS and EQ-5D demonstrate significant negatively skewed distributions with ceiling effects of 41% and 53%, respectively. The MET was normally distributed post-operatively with no ceiling effect. Weak-moderate significant correlations were found between the MET and the other two metrics. In the 48/48 subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher MET scores were demonstrated for patients aged <60 (12.7 vs 10.6, p=0.008), male patients (12.5 vs 10.8, p=0.024) and those with pre-operative MET scores >6 (12.6 vs 11.0, p=0.040). Conclusion: The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS.

Journal article

Davies A, Selmi H, Sabharwal S, Vella-Baldacchino M, Liddle AD, Reilly Pet al., 2022, Revision shoulder hemiarthroplasty and total shoulder arthroplasty a systematic review and meta-analysis., Journal of Shoulder and Elbow Arthroplasty, Vol: 6, Pages: 1-8, ISSN: 2471-5492

The number of shoulder replacements performed each year continues to increase, and the need for revision replacements has grown accordingly. The outcome of a revision replacement may influence which primary implant is selected and the timing of primary surgery, particularly in younger patients. The aim of this study was to establish the expected improvement in shoulder function and implant survival following revision of a hemiarthroplasty and revision of an anatomical total shoulder arthroplasty (TSA). A systematic review and meta-analysis were performed of all studies reporting shoulder scores or implant survival following revision hemiarthroplasty or revision TSA. MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports were searched. 15 studies were included, reporting on 593 revision anatomical shoulder replacements. There was large variation in the magnitude of improvement in shoulder scores following revision surgery. Over 80% of revision replacements last 5 years and over 70% last 10 years. There was no significant difference in shoulder scores or implant survival according to the type of primary implant. The belief that revision of a shoulder hemiarthroplasty may lead to improved outcomes compared to revision of a TSA is not supported by the current literature.

Journal article

Davies DJ, McLean PF, Kemp PR, Liddle AD, Morrell MJ, Halse O, Martin NM, Sam AHet al., 2022, Assessment of factual recall and higher-order cognitive domains in an open-book medical school examination, Advances in Health Sciences Education, Vol: 27, Pages: 147-165, ISSN: 1382-4996

Open-book examinations (OBEs) will likely become increasingly important assessment tools. We investigated how access to open-book resources affected questions testing factual recall, which might be easy to look-up, versus questions testing higher-order cognitive domains. Few studies have investigated OBEs using modern Internet resources or as summative assessments. We compared performance on an examination conducted as a traditional closed-book exam (CBE) in 2019 (N = 320) and a remote OBE with free access to Internet resources in 2020 (N = 337) due to COVID-19. This summative, end-of-year assessment focused on basic science for second-year medical students. We categorized questions by Bloom’s taxonomy (‘Remember’, versus ‘Understand/Apply’). We predicted higher performance on the OBE, driven by higher performance on ‘Remember’ questions. We used an item-centric analysis by using performance per item over all examinees as the outcome variable in logistic regression, with terms ‘Open-Book, ‘Bloom Category’ and their interaction. Performance was higher on OBE questions than CBE questions (OR 2.2, 95% CI: 2.14–2.39), and higher on ‘Remember’ than ‘Understand/Apply’ questions (OR 1.13, 95% CI: 1.09–1.19). The difference in performance between ‘Remember’ and ‘Understand/Apply’ questions was greater in the OBE than the CBE (‘Open-Book’ * ‘Bloom Category’ interaction: OR 1.2, 95% CI: 1.19–1.37). Access to open-book resources had a greater effect on performance on factual recall questions than higher-order questions, though performance was higher in the OBE overall. OBE design must consider how searching for information affects performance, particularly on questions measuring different domains of knowledge.

Journal article

Carlos Rodriguez-Merchan E, Encinas-Ullan CA, Liddle AD, 2022, Osteochondral Allografts for Large Osteochondral Lesions of the Knee Joint: Indications, Surgical Techniques and Results, ARCHIVES OF BONE AND JOINT SURGERY-ABJS, Vol: 10, Pages: 245-251, ISSN: 2345-4644

Journal article

Munford M, Liddle A, Stoddart J, Cobb J, Jeffers Jet al., 2022, Total and partial knee replacement implants that maintain native load transfer in the Tibia, Bone and Joint Research, Vol: 11, Pages: 1-3, ISSN: 2046-3758

Aims:Unicompartmental and total knee arthroplasty (UKA and TKA) are successful treatments for osteoarthritis, but the solid metal implants disrupt the natural distribution of stress and strain which can lead to bone loss over time. This generates problems if the implant needs to be revised. This study investigates whether titanium lattice UKA and TKA implants can maintain natural load transfer in the proximal tibia. Methods:In a cadaveric model, UKA and TKA procedures were performed on 8 fresh-frozen knee specimens, using conventional (solid) and titanium lattice tibial implants. Stress at the bone-implant interfaces were measured and compared to the native knee.Results:Titanium lattice implants were able to restore the mechanical environment of the native tibia for both UKA and TKA designs. Maximum stress at the bone-implant interface ranged from 1.2-3.3 MPa compared to 1.3-2.7 MPa for the native tibia. The conventional solid UKA and TKA implants reduced the maximum stress in the bone by a factor of 10 and caused >70% of bone surface area to be underloaded compared to the native tibia. Conclusions:Titanium lattice implants maintained the natural mechanical loading in the proximal tibia after UKA and TKA, but conventional solid implants did not. This is an exciting first step towards implants that maintain bone health, but such implants also have to meet fatigue and micromotion criteria to be clinically viable.

Journal article

Logishetty K, Edwards T, Ponniah HS, Ahmed M, Liddle AD, Cobb J, Clark Cet al., 2022, How to prioritise patients and redesign care to safely resume planned surgery during the COVID-19 pandemic. A clinical validation study, Bone & Joint Open, Vol: 2, Pages: 134-140, ISSN: 2633-1462

Background and Purpose: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. Patients and Methods: A multidisciplinary Surgical Prioritisation Committee developed the SPAG, incorporating procedural urgency, shared decision making, patient safety and biopsychosocial factors; and applied it to 1142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites – including one with access to a High Dependency Unit (HDU) or Intensive Care Unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. Results: 1142 patients were included, 47 declined surgery. 110 were deemed high-risk or requiring specialist resources. In the 10-week study period, 28 high-risk patients underwent surgery, during which 68% of Priority 2 (P2, surgery within 1 month) patients underwent surgery, and 15% of P3 (<3 months) and 16% of P4 (>3 months) groups. Of the 1032 low-risk patients, 322 patients underwent surgery. Twenty-one P3 and P4 patients were expedited to ‘Urgent’ based on biopsychosocial factors identified by the SPAG. During the study period, 91% of the Urgent group, 52% of P2, 36% of P3, and 26% of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. Interpretation: Our widely generalisable model enabled the restart of planned surgery during the CO

Journal article

Rodriguez-Merchan EC, Davidson DJ, Liddle AD, 2021, Recent Strategies to Combat Infections from Biofilm-Forming Bacteria on Orthopaedic Implants, INTERNATIONAL JOURNAL OF MOLECULAR SCIENCES, Vol: 22

Journal article

Garner AJ, Edwards TC, Liddle AD, Jones GG, Cobb JPet al., 2021, The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty., Bone & Joint Open, Vol: 2, Pages: 638-645, ISSN: 2633-1462

AIMS: Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. METHODS: Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system. RESULTS: Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001). CONCLUSION: The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It h

Journal article

Edwards TC, Patel A, Szyszka B, Coombs AW, Liddle AD, Kucheria R, Cobb JP, Logishetty Ket al., 2021, Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty., Archives of Orthopaedic and Trauma Surgery, Vol: 141, ISSN: 0344-8444

INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and r

Journal article

Logishetty K, Edwards TC, Subbiah Ponniah H, Ahmed M, Liddle AD, Cobb J, Clark Cet al., 2021, How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic., Bone & Joint Open, Vol: 2, Pages: 134-140, ISSN: 2633-1462

AIMS: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. METHODS: A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. RESULTS: A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P2, surgery within one month) patients underwent surgery, and 15% (3/20) of P3 (< three months) and 16% (11/71) of P4 (> three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P3 and P4 patients were expedited to 'Urgent' based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P2, 36% (70/196) of P3, and 26% (184/720) of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. CONCLUSION: Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P2 w

Journal article

Raymond AC, Liddle AD, Alvand A, Donaldson JR, Carrington RWJ, Miles Jet al., 2021, Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties, JOURNAL OF ARTHROPLASTY, Vol: 36, Pages: 664-669, ISSN: 0883-5403

Journal article

Popat R, Liddle AD, 2021, Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty, Controversies in Orthopaedic Surgery of the Lower Limb, Pages: 121-126, ISBN: 9783030806941

Unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are established treatment options for end-stage osteoarthritis of the knee. A vast amount of evidence is available on the relative risks and benefits of UKA and TKA. Proponents of TKA argue that the revision rate of UKA is much higher than that of TKA. Supporters of UKA point to data suggesting that the threshold for revision of a UKA is lower than that applied to TKA, potentially because revising a UKA is an easier operation. Additionally, UKA is associated with numerous other benefits over TKA, including better functional outcomes, shorter hospital stays and lower morbidity/mortality. In this chapter, a clear summary of the relevant evidence regarding UKA and TKA is presented to enable informed decision-making.

Book chapter

Rodríguez-Merchán EC, Liddle AD, 2021, Total Knee Arthroplasty in Patients with a History of Metal Allergy: Conventional Implant or Hypoallergenic Implant?, Controversies in Orthopaedic Surgery of the Lower Limb, Pages: 151-159, ISBN: 9783030806941

20–25% of patients experiencing TKA acquire hypersensitivity to metals, but solely less than 1% present symptoms (dermatitis, continuous painful synovitis of the knee or aseptic loosening of the implant). Currently, skin patch test (SPT), leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being habitually utilized to evaluate metal hypersensitivity. However, these tests are not fully dependable and most patients are diagnosed on the basis of self-reported reactions. Most patients with metal allergy patients tolerate the conventional implants without complications. Given the current controversy over whether or not to use a conventional primary implant in patients who report having a metal allergy, the logical decision is to use a “hypoallergenic” primary prosthesis. There are two “hypoallergenic” options: (1) equivalent design but with different materials (oxidized zirconium, ceramic or titanium-based alloys); (2) equivalent designs but with coatings, normally titanium niobium or titanium nitride.

Book chapter

Matthews E, Sinha I, Liddle AD, 2021, Management of Distal Femoral Periprosthetic Fractures: Plate, Intramedullary Nail or Arthroplasty?, Controversies in Orthopaedic Surgery of the Lower Limb, Pages: 143-150, ISBN: 9783030806941

Whilst fractures around a knee replacement are uncommon, their incidence can be expected to increase in line with the increase in primary knee arthroplasty procedures being performed. These patients are often elderly and these injuries represent fragility fractures. The challenges of treating this patient and injury are significant. There is no consensus on which modality of treatment is best for treating the periprosthetic distal femoral fracture. Most fractures present with displacement but without loosening or compromise of the implant, these are amenable to fixation. Modalities of fixation have improved with an increase in understanding of fracture biology and improvements in technology, and locking plates, intramedullary nails, and combinations of both are being used. Fractures with poor or inadequate bone stock or a loose prosthesis may necessitate treatment with an endoprosthetic replacement.

Book chapter

Rodríguez-Merchán EC, Liddle AD, 2021, Preface, Controversies in Orthopaedic Surgery of the Lower Limb

Journal article

Liddle AD, 2020, <i>CORR</i> Insights®: What Is the Survivorship After Hip Arthroscopy for Femoroacetabular Impingement? A Large-database Study, CLINICAL ORTHOPAEDICS AND RELATED RESEARCH, Vol: 478, Pages: 2274-2276, ISSN: 0009-921X

Journal article

Carlos Rodriguez-Merchan E, Liddle AD, 2020, Prevention of Periprosthetic Joint Infection in Total Knee Arthroplasty: Main Studies Reported Between November 2017 and January 2020, ARCHIVES OF BONE AND JOINT SURGERY-ABJS, Vol: 8, Pages: 465-469, ISSN: 2345-4644

Journal article

Davidson DJ, Spratt D, Liddle AD, 2019, Implant materials and prosthetic joint infection: the battle with the biofilm, EFORT Open Reviews, Vol: 4, ISSN: 2058-5241

• Prosthetic joint infection (PJI) is associated with poor clinical outcomes and is expensive to treat.• Although uncommon overall (affecting between 0.5% and 2.2% of cases), PJI is one of the most commonly encountered complications of joint replacement and its incidence is increasing, putting a significant burden on healthcare systems.• Once established, PJI is extremely difficult to eradicate as bacteria exist in biofilms which protect them from antibiotics and the host immune response.• Improved understanding of the microbial pathology in PJI has generated potential new treatment strategies for prevention and eradication of biofilm associated infection including modification of implant surfaces to prevent adhesion of bacteria.• Much research is currently ongoing looking at different implant surface coatings and modifications, and although most of this work has not translated into clinical medicine there has been some early clinical success.

Journal article

Al-Ani A, Bence M, Liddle AD, Ferris Bet al., 2019, Admission and treatment at a weekend is not associated with worse outcomes for patients admitted with fractured neck of femur, Trauma, Pages: 146040861878592-146040861878592, ISSN: 1460-4086

Journal article

Koo K, Liddle AD, Pastides PS, Rosenfeld PFet al., 2019, The Salto total ankle arthroplasty - clinical and radiological outcomes at five years, Foot and Ankle Surgery, Vol: 25, Pages: 523-528, ISSN: 1268-7731

BACKGROUND: Modern designs of total ankle arthroplasty (TAA) have the potential to treat symptomatic ankle OA without adversely affecting ankle biomechanics. We present the mid-term results of a modern, mobile-bearing TAA design. METHODS: TAA was performed in 50 consecutive patients (55 ankles) in an independent, prospective, single-centre series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of five years (range 2-10.5years). RESULTS: A total of three patients (four ankles) died and two (two ankles) were lost to follow-up. Three TAAs were revised for aseptic loosening (in two cases) or infection. Two further patients underwent reoperations, one for arthroscopic debridement of anterolateral synovitis and one for grafting of an asymptomatic tibial cyst. With all-cause revision as an endpoint, implant survival was 93.3% at five to ten years (95% CI 80.5%-97.8%). If reoperations are included this falls to 90.2% (95% CI 75.6%-96.3%) at five years. No other patient demonstrated radiographic evidence of loosening or subsidence. PROMs and satisfaction were excellent at latest follow-up. CONCLUSION: At five years, the outcomes for this design of TAA in this series were excellent, and were similar to those of previously published series from the designer centre.

Journal article

Rodríguez-Merchán EC, Liddle AD, 2019, Disorders of the Patellofemoral Joint: Diagnosis and Management, ISBN: 9783030124410

This state-of-the-art book provides a comprehensive overview of the most common patellofemoral joint problems. Utilizing the latest evidence, it guides readers through prevention, diagnosis and treatment for both adult and paediatric patients. After discussing clinical examination and diagnosis, it explores topics such as acute and recurrent dislocation of the patella, cartilage defects of the joint, patellofemoral instability and patellofemoral osteoarthritis. The book also features a chapter on conservative strategies, including physical medicine and rehabilitation. Research is moving quickly in this field, and as such there is a growing need for consensus documents: written by leading experts, this comprehensive book is a valuable resource for orthopaedic surgeons, knee specialists and sports medicine ones, and is also of great interest to physiatrists, physical therapists and all healthcare workers involved in the care of these patients.


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