Musculoskeletal diseases

Computed tomography (CT) of the knee has traditionally had a limited role in routine practice. Recent Medicare data show a rapid increase in CT knee utilisation in Australia, far exceeding growth in other imaging modalities. This divergence is unlikely to reflect clinical need and instead suggests a shift in practice, potentially driven by expansion into non-evidence-based CT-guided procedures. This raises concerns regarding unnecessary radiation exposure, procedure-related harm and escalating costs driven by volume rather than value. The absence of clear differentiation between diagnostic and procedural CT imaging within current Medicare Benefits Schedule item structures limits oversight. Imaging stewardship and policy reform are required to ensure appropriate, evidence-based use.

Hanwen Chen, Rachelle Buchbinder, Sean Docking, Ian A Harris

Objectives To characterise osteoporosis medicine prescribing patterns following low-trauma fractures and identify predictors of early treatment initiation.Study TypeRetrospective population-based cohort study.SettingNew South Wales, Australia, using statewide linked administrative health data.ParticipantsAdults aged ≥ 50 years with an incident low-trauma fracture between January 2011 and June 2019.Main Outcome MeasuresPrimary outcomes were osteoporosis treatment prescribing patterns and timing of initiation after incident fracture over 3 years, categorised as early (within 12 months), late (within 1–3 years) or no initiation. Secondary analyses examined predictors of time to treatment initiation within 12 months using Fine–Gray competing-risk regression.ResultsAmong 132,268 individuals with incident fractures, 63.7% (84,222) were female. Overall, 29,802 (22.5%) initiated osteoporosis medicine, whereas 102,466 (77.5%) remained untreated. Among females (mean [standard deviation] age, 77.7 [10.1] years), 20.1% initiated therapy within 12 months, 7.0% within 1–3 years, and 72.9% remained untreated. Among males (mean [standard deviation] age, 77.2 [10.0] years), the corresponding proportions were 10.8%, 3.7% and 85.6%. After accounting for the competing risk of death, treatment initiation was more likely with non-distal fractures, older age, polypharmacy, prior steroid use, prior dual-energy x-ray absorptiometry and later fracture year, and less likely with greater comorbidity, rural or regional residence and prior hospitalisation for falls. The strongest associations were for hip or vertebral fracture (subdistribution hazard ratio range, 1.90–3.03) and high comorbidity burden (subdistribution hazard ratio range, 0.72–0.75). Almost one in four late initiators had a refracture before starting treatment. Denosumab rapidly replaced oral bisphosphonates as the dominant therapy over time.ConclusionMore than three-quarters of individuals remain untreated after fracture, highlighting persistent and substantial gaps in secondary fracture prevention. Treatment initiation is strongly associated with fracture site and multimorbidity burden, and initiation rates are lower in males. Increasing reliance on denosumab underscores the need for careful long-term treatment planning and strategies.

Mike Lin, Huy Nguyen, Thach Tran, Robert D. Blank, Dana Bliuc, Jacqueline R. Center

Follow-up surgical interventions are frequent in people with spinal cord stimulators, and they are very expensive

Caitlin MP Jones · Christopher G Maher · Rachelle Buchbinder · Ian A Harris · Chung‐Wei Christine Lin · Christopher Hayes · Alexandra Gorelik

Evidence-based profiling could identify people most likely to benefit from interventions for reducing the risk of hospitalisation

Yuqi Zhang · Susanna M Cramb · Steven M McPhail · Rosana Pacella · Jaap J Netten · Ewan M Kinnear · Peter A Lazzarini

Increasing bone health awareness by a co-created Community education program was valued by Indigenous people

Troy Walker (Yorta Yorta) · Karan P Singh · Vanessa Gan · Brooke Conley (Ngiyampaa) · Jessica Bravo · Nigel Smith (Weilwan) · April Clarke (Eastern Maar, Kirrae Whurrung, Djap Wurrung) · Jackson Baker · Louise J Maple‐Brown · Robin M Daly · Jennifer Browne · Jesse Zanker · Cat Shore‐Lorenti · David Scott · Peter R Ebeling · Ayse Zengin

Poor bone health is highly treatable with appropriate widely available lifestyle and dietary measures and pharmacological agents; the updated guideline is an evidence-based pragmatic tool to assist general practitioners in the day-to-day care of such patients in partnership with bone specialists

Peter Wong · Weiwen Chen · Dan Ewald · Christian Girgis · Morton Rawlin · John Tsingos · Justine Waters

Phased introduction of an injury prevention program, supported by a national ACL registry, would facilitate best practice

Chris Schilling · Siddharth Rele

Investing in a national, evidence-based program for averting ACL injuries in amateur footballers is economically justifiable

Andrew Ross · Joosup Kim · Marnee McKay · Evangelos Pappas · Natalie Hardaker · Matt Whalan · Kerry Peek

A national approach to reducing waiting time for public elective joint replacements is urgently needed

Christopher J Wall · Christopher J Vertullo · David RJ Gill · Richard S Page · Carl Holder · Paul N Smith

Changing key FLS operational characteristics would only moderately reduce minimal trauma fractures among people aged 50 years or more

Alicia R Jones · Danielle Currie · Cindy Peng · Peter R Ebeling · Jackie R Center · Gustavo Duque · Sean Lybrand · Greg Lyubomirsky · Rebecca J Mitchell · Sallie Pearson · Markus J Seibel · Jo‐An Occhipinti

Prosthetic joint infection diagnostic criteria have been progressively refined in recent decades, and novel approaches are emerging

Joshua S Davis · David Dewar · Laurens Manning

A 53-year-old Indigenous male farmer presented with several weeks of fluctuating lumbar back pain while physically supporting an older family member

Michael D Riceman · Caitlyn Sun · John Pierides · Jennifer Catford · Renjy Nelson · Anushia Ashokan

Despite the large national DFD burden, Australian regions implementing guideline-based care have demonstrated large reductions in their regional DFD burdens and costs

Peter A Lazzarini · Anita Raspovic · Jenny Prentice · Robert J Commons · Robert A Fitridge · James Charles · Jane Cheney · Nytasha Purcell · Stephen M Twigg

We need to get serious about collecting data, using robust definitions of diagnoses, surgical indications, and patient-important outcomes

Susan Liew

Differences in procedure rates suggest that too many private or too few publicly funded spinal procedures are undertaken

Duong Thuy Tran · Adriane M Lewin · Louisa Jorm · Ian A Harris

Lack of clinician knowledge, poor access to services, negative attitudes, and lagging research have led to substandard menopause-related health care

Susan R Davis · Karen Magraith

A new clinical care standard provides evidence-based guidance to help clinicians deliver best care for people with low back pain

Christopher G Maher · Aline Archambeau · Rachelle Buchbinder · Simon D French · Julie Morphet · Michael K Nicholas · Peter O'Sullivan · Marie Pirotta · Michael J Yelland · Leo Zeller · Nivene Saad · Elizabeth Marles · Alice L Bhasale · Christina Lane

A 78-year-old man with hypertension, dyslipidaemia, hypothyroidism and gout presented with two weeks of migratory polyarthritis and fever

Hannah Poole · Amy Crowe · John Daffy

Health care professionals caring for men with prostate cancer starting ADT should ensure that their bone health is routinely assessed

Mariya F Hamid · Amy Hayden · Tania Moujaber · Sandra Turner · Howard Gurney · Mathis Grossmann · Peter Wong

The role of spinal surgery in the management of degenerative low back pain is not supported by the studies currently available

Lachlan Evans · Thomas O’Donohoe · Andrew Morokoff · Katharine Drummond

A 41-year-old man presented with right knee pain for 3 months

Te‐Feng A Chou · Ching‐Hua Hsiao

A 21-year-old man presented to the emergency department with a 2-week history of thoracic back pain

Royston Ponraj · Jenna Langfield · Louise Wong · Ian Kerridge · William S Stevenson

Translating guidelines into practice is required to maintain the balance between practitioner autonomy and accountability

Peter FM Choong