ORCID Profile
0000-0002-4515-8202
Current Organisations
University of Warwick Warwick Medical School
,
University Hospitals Coventry and Warwickshire NHS Trust
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Publisher: Springer Science and Business Media LLC
Date: 14-03-2019
Publisher: SAGE Publications
Date: 04-2021
DOI: 10.1177/23259671211000038
Abstract: A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)–injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined. To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs). Cross-sectional study Level of evidence, 3. A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot. Six factors were associated with a high-grade pivot shift: Beighton score (each additional point odds ratio [OR], 1.17 95% CI, 1.06-1.30 P = .002), male sex (OR, 2.30 95% CI, 1.28-4.13 P = .005), presence of a posterior third medial (OR, 2.55 95% CI, 1.11-5.84 P = .03) or lateral (OR, 1.76 95% CI, 1.01-3.08 P = .048) meniscal injury, tibial slope ° (OR, 2.35 95% CI, 1.09-5.07 P = .03), and chronicity months (OR, 1.70 95% CI, 1.00-2.88 P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope ° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14 P = .04) however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores. Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 03-2022
DOI: 10.1302/2633-1462.33.BJO-2021-0107
Abstract: Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article: Bone Jt Open 2022 (3):268–274.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 02-2009
DOI: 10.1302/0301-620X.91B2.21609
Abstract: As part of the government’s initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement. The Kinemax total knee replacement system was used in all cases. The cumulative survival rate at three years was 79.2% (95% confidence interval (CI) 69.2 to 86.8) using re-operation for any cause as an endpoint and 85.3% (95% CI 75.9 to 91.8) using aseptic revision as an endpoint. This is significantly worse than that recorded in the published literature. These poor results have resulted in a significant impact on our service.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 2018
Publisher: Springer Science and Business Media LLC
Date: 02-2021
DOI: 10.1007/S00167-021-06458-2
Abstract: The management of meniscal tears is a widely researched and evolving field. Previous studies reporting the incidence of meniscal tears are outdated and not representative of current practice. The aim of this study was to report the current incidence of MRI confirmed meniscal tears in patients with a symptomatic knee and the current intervention rate in a large NHS trust. Radiology reports from 13,358 consecutive magnetic resonance imaging scans between 2015 and 2017, performed at a large UK hospital serving a population of 470,000, were assessed to identify patients with meniscal tears. The hospital database was interrogated to explore the subsequent treatment undertaken by the patient. A linear regression model was used to identify if any factors predicted subsequent arthroscopy. 1737 patients with isolated meniscal tears were identified in patients undergoing an MRI for knee pain, suggesting a rate of 222 MRI confirmed tears per 100,000 of the population aged 18 to 55 years old. 47% attended outpatient appointments and 22% underwent arthroscopy. Root tears [odds ratio (95% CI) 2.24 (1.0, 4.49) p = 0.049] and bucket handle tears were significantly associated with subsequent surgery, with no difference between the other types of tears. The presence of chondral changes did not significantly affect the rate of surgery [0.81 (0.60, 1.08) n.s]. Meniscal tears were found to be more common than previously described. However, less than half present to secondary care and only 22% undergo arthroscopy. These findings should inform future study design and recruitment strategies. In agreement with previous literature, bucket handle tears and root tears were significant predictors of subsequent surgery. III.
Publisher: Elsevier BV
Date: 02-2020
DOI: 10.1016/J.INJURY.2019.11.015
Abstract: Open tibia fractures are a common cause of admission following road traffic accidents in low and middle income countries (LMICs), resulting in substantial mortality and disability. It is important to summarise the clinical course of this injury using patient reported scores in order to assess best treatment in LMICs. To summarise the disability after sustaining an open tibia fracture in LMICs METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. Studies were performed in a low or middle income country. The primary outcome was any validated patient reported outcome score reported after three months. Secondary outcomes included economic impact and complications such as infection, non-union and utation. Data was extracted and summarised. We reviewed 3,593 articles from our search. A total of 18 studies were included from 10 countries with 8 different outcome scores. The average age was 35 years old and 86% of the patients were male. Thirty-one percent were Gustilo I, 28% Gustilo II, 19% Gustilo IIIA, 17% Gustilo IIIB and 5% Gustilo IIIC. The most common complications reported were 18% infection, 15% non-union and 15% utation. Economic impact was reported in only one study with 100% patients working pre-injury and 20% post-injury at 12 months. Mean follow-up duration for outcome scores was 19.8 months. There was heterogeneity between the studies in terms of subject of the studies, outcome criteria, fracture type, surgical technique and length of follow-up. Therefore, no meta-analysis could be performed. The clinical history of open tibia fractures in low or middle income countries remains largely unknown in terms of patient reported outcomes. Further studies are required to define these outcomes in open tibia fractures before best treatments can be assessed.
Publisher: Elsevier BV
Date: 10-2008
DOI: 10.1016/J.ARTHRO.2007.05.005
Abstract: The Intrafix device (DePuy Mitek, Raynham, MA) is one of a number of recently developed products whose aim is to improve fixation of quadrupled hamstring grafts when used for anterior cruciate ligament reconstruction. We present a case of failure and intra-articular migration of the sleeve of an Intrafix device causing locking of the knee 10 weeks after anterior cruciate ligament reconstruction. We were unable to identify the cause of the failure or migration of the device. Rehabilitation had been progressing normally and without incident. The broken fragments were removed arthroscopically, and the reconstruction was found to be intact and healing well. Presumably, the device retained enough mechanical function to allow healing to progress, despite failure of the sleeve. This is, to our knowledge, the first reported case of such an event occurring with the new generation of hamstring graft fixation devices.
Publisher: Wiley
Date: 24-01-2023
Publisher: Elsevier BV
Date: 10-2018
DOI: 10.1016/J.KNEE.2018.05.007
Abstract: There is ongoing debate in the literature as to whether or not patellofemoral joint overstuffing has a clinically significant effect on postoperative outcomes following total knee arthroplasty (TKA). This study investigates the effect of patellofemoral joint overstuffing on patient-reported outcomes using novel methods of radiographic measurement. The study population consisted of a prospective cohort of 266 patients receiving a Triathlon® (Stryker, Kalamazoo, MI, USA) TKA between 2006 and 2009. Participants completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire preoperatively and at 12 months postoperatively. Pre- and postoperative radiographic measurements were taken according to a defined protocol to assess for patellofemoral overstuffing. Measurement reproducibility was assessed using inter-observer intraclass correlation coefficients. Associations between radiographic measurements and patient-reported outcomes were analysed using linear regression analysis. A total of 107 patients had adequate images and were included in the analysis for this study. Three different radiographic measurements were used to identify patellofemoral overstuffing all with good intra- and inter-observer reliability. There was no association identified between combined (patella and trochlea) patellofemoral overstuffing measurements and WOMAC scores. However, a statistically significant association was identified between an increase in anterior trochlear offset and worse knee pain and function scores (P < 0.05). There is no identifiable association between true patellofemoral overstuffing and clinical outcome however, there is a small association with the anterior trochlear offset though further studies are warranted to confirm the clinical significance of this finding.
Publisher: Wiley
Date: 21-11-2017
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 07-2017
DOI: 10.1302/0301-620X.99B7.BJJ-2016-0767.R2
Abstract: The aim of this study was to compare the effectiveness of a femoral nerve block and a periarticular infiltration in the management of early post-operative pain after total knee arthroplasty (TKA). A pragmatic, single centre, two arm parallel group, patient blinded, randomised controlled trial was undertaken. All patients due for TKA were eligible. Exclusion criteria included contraindications to the medications involved in the study and patients with a neurological abnormality of the lower limb. Patients received either a femoral nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol and 0.25 mg of adrenaline all diluted with 0.9% saline to make a volume of 150 ml. A total of 264 patients were recruited and data from 230 (88%) were available for the primary analysis. Intention-to-treat analysis of the primary outcome measure of a visual analogue score for pain on the first post-operative day, prior to physiotherapy, was similar in both groups. The mean difference was -0.7 (95% confidence interval (CI) -5.9 to 4.5 p = 0.834). The periarticular group used less morphine in the first post-operative day compared with the femoral nerve block group (74%, 95% CI 55 to 99). The femoral nerve block group reported 39 adverse events, of which 27 were serious, in 31 patients and the periarticular group reported 51 adverse events, of which 38 were serious, in 42 patients up to six weeks post-operatively. None of the adverse events were directly attributed to either of the interventions under investigation. Periarticular infiltration is a viable and safe alternative to femoral nerve block for the early post-operative relief of pain following TKA. Cite this article: Bone Joint J 2017 -B:904–11.
Publisher: Wiley
Date: 14-07-2020
Publisher: Wiley
Date: 08-12-2020
Publisher: BMJ
Date: 04-2018
Publisher: BMJ
Date: 21-10-2022
DOI: 10.1136/BMJQS-2022-015077
Abstract: Landmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects. A sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings. Changes in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online. The six surgical trials were funded and published by England’s National Institute for Health Research’s Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area. The quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data. While practice does not always change in the direction indicated by clinical trials, our results suggest that in iduals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.
Publisher: Springer Science and Business Media LLC
Date: 12-01-2022
DOI: 10.1007/S00590-021-03198-4
Abstract: To systematically review the effect of PRP on healing (vascularization, inflammation and ligamentization) and clinical outcomes (pain, knee function and stability) in patients undergoing ACL reconstruction and compare the preparation and application of PRP. Independent systematic searches of online databases (Medline, Embase and Web of Science) were conducted following PRISMA guidelines (final search 10th July 2021). Studies were screened against inclusion criteria and risk of bias assessed using Critical appraisal skills programme (CASP) Randomised controlled trial (RCT) checklist. Independent data extraction preceded narrative analysis. 13 RCTs were included. The methods of PRP collection and application were varied. Significant early increases in rate of ligamentization and vascularisation were observed alongside early decreases in inflammation. No significant results were achieved in the later stages of the healing process. Significantly improved pain and knee function was found but no consensus reached. PRP influences healing through early vascularisation, culminating in higher rates of ligamentization. Long-term effects were not demonstrated suggesting the influence of PRP is limited. No consensus was reached on the impact of PRP on pain, knee stability and resultant knee function, providing avenues for further research. Subsequent investigations could incorporate multiple doses over time, more frequent observation and comparisons of different forms of PRP. The lack of standardisation of PRP collection and application techniques makes comparison difficult. Due to considerable heterogeneity, ( I 2 50%), a formal meta-analysis was not possible highlighting the need for further high quality RCTs to assess the effectiveness of PRP. The biasing towards young males highlights the need for a more erse range of participants to make the study more applicable to the general population. CRD42021242078CRD, 15th March 2021, retrospectively registered.
Publisher: Royal College of Surgeons of England
Date: 05-2008
Publisher: BMJ
Date: 10-2023
Publisher: BMJ
Date: 06-2022
DOI: 10.1136/BMJOPEN-2022-062721
Abstract: Knee replacement (KR) is a clinically proven procedure typically offered to patients with severe knee osteoarthritis (OA) to relieve pain and improve quality of life. However, artificial joints fail over time, requiring revision associated with higher mortality and inferior outcomes. With more young people presenting with knee OA and increasing life expectancy, there is an unmet need to postpone time to first KR. Knee joint distraction (KJD), the practice of using external fixators to open up knee joint space, is proposed as potentially effective to preserve the joint following initial studies in the Netherlands, however, has not been researched within an NHS setting. The KARDS trial will investigate whether KJD is non-inferior to KR in terms of patient-reported postoperative pain 12 months post-surgery. KARDS is a phase III, multicentre, pragmatic, open-label, in idually randomised controlled non-inferiority trial comparing KJD with KR in patients with severe knee OA, employing a hybrid-expertise design, with internal pilot phase and process evaluation. 344 participants will be randomised (1:1) to KJD or KR. The primary outcome measure is the Knee Injury and Osteoarthritis Outcomes Score (KOOS) pain domain score at 12 months post-operation. Secondary outcome measures include patient-reported overall KOOS, Pain Visual Analogue Scale and Oxford Knee Scores, knee function assessments, joint space width, complications and further interventions over 24 months post-operation. Per patient cost difference between KR and KJD and cost per quality-adjusted life year (QALY) gained over 24 months will be estimated within trial, and incremental cost per QALY gained over 20 years by KJD relative to KR predicted using decision analytic modelling. Ethics approval was obtained from the Research Ethics Committee (REC) and Health Research Authority (HRA). Trial results will be disseminated at clinical conferences, through relevant patient groups and published in peer-reviewed journals. NCT14879004 recruitment opened April 2021.
Publisher: Elsevier BV
Date: 04-2010
DOI: 10.1016/J.INJURY.2009.10.006
Abstract: Systems for collecting information about patient care are increasingly common in orthopaedic practice. Databases can allow various comparisons to be made over time. Significant decisions regarding service delivery and clinical practice may be made based on their results. We set out to determine the number of cases needed for comparison of 30-day mortality, inpatient wound infection rates and mean hospital length of stay, with a power of 80% for the demonstration of an effect at a significance level of p<0.05. We analysed 2 years of prospectively collected data on 1050 hip fracture patients admitted to a city teaching hospital. Detection of a 10% difference in 30-day mortality would require 14,065 patients in each arm of any comparison, demonstration of a 50% difference would require 643 patients in each arm for wound infections, demonstration of a 10% difference in incidence would require 23,921 patients in each arm and 1127 patients for demonstration of a 50% difference for length of stay, a difference of 10% would require 1479 patients and 6660 patients for a 50% difference. This study demonstrates the importance of considering the population sizes before comparisons are made on the basis of basic hip fracture outcome data. Our data also help illustrate the impact of s le size considerations when interpreting the results of performance monitoring. Many researchers will be used to the fact that rare outcomes such as inpatient mortality or wound infection require large s le sizes before differences can be reliably demonstrated between populations. This study gives actual figures that researchers could use when planning studies. Statistically meaningful analyses will only be possible with major multi-centre collaborations, as will be possible if hospital Trusts participate in the National Hip Fracture Database.
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.GAITPOST.2012.04.018
Abstract: Knee osteoarthritis is common and patients frequently complain that they are 'overloading' the joints of the opposite leg when they walk. However, it is unknown whether moments or co-contractions are abnormal in the unaffected joints of patients with single joint knee osteoarthritis, or how they change following treatment of the affected knee. Twenty patients with single joint medial compartment knee osteoarthritis were compared to 20 asymptomatic control subjects. Gait analysis was performed for normal level gait and surface EMG recordings of the medial and lateral quadriceps and hamstrings were used to investigate co-contraction. Patients were followed up 12 months post-operatively and the analysis was repeated. Results are presented for the first 14 patients who have attended follow-up. Pre-operatively, adduction moment impulses were elevated at both knees and the contra-lateral hip compared to controls. Co-contraction of hamstrings and quadriceps was elevated bilaterally. Post-operatively, moment waveforms returned to near-normal levels at the affected knee and co-contraction fell in the majority of patients. However, abnormalities persisted in the contra-lateral limb with partial or no recovery of both moment waveforms and co-contraction in the majority. Patients with knee osteoarthritis do experience abnormal loads of their major weight bearing joints bilaterally, and abnormalities persist despite treatment of the affected limb. Further treatment may be required if we are to protect the other major joints following joint arthroplasty.
Publisher: Springer Science and Business Media LLC
Date: 21-08-2021
DOI: 10.1186/S43019-021-00110-6
Abstract: The purpose of this study was to investigate the outcomes of management of mucoid degeneration of the anterior cruciate ligament (MDACL) by performing a systematic review of methods of treatment that have been reported. A systematic literature search in the databases MEDLINE, Embase, Google Scholar, Cochrane, ISI web of science and Scopus was performed through July 2020 by three independent reviewers. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42018087782). Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A total of nine studies were eligible for review. All nine studies assessed the outcome of arthroscopic debridement of MDACL. A total of 313 knees in 292 patients were included. The mean follow up ranged from 13 to 72 months. There was strong association between MDACL and chondral lesions (82%) and between MDACL and meniscal tears (69%). The rate of simultaneous meniscectomy ranged from 13 to 44%. Postoperative pain relief ranged from 53.8 to 95%. There was an improvement in postoperative range of motion and outcome scores (Lysholm and International Knee Documentation Committee scores and the Knee Injury and Osteoarthritis Outcome Score). Postoperative Lachman test was positive in 40% of patients, and 6% of patients had symptomatic instability. The mean MINORS score was 9.5 out of 16 (4–12). Arthroscopic debridement of the anterior cruciate ligament (ACL) results in satisfactory pain relief and improvement in knee outcome scores. Postoperative ACL laxity is common after arthroscopic ACL debridement, however, symptomatic instability is not. The need for delayed ACL reconstruction should be discussed preoperatively, especially if complete resection of the ACL is to be performed. IV
Publisher: Springer Science and Business Media LLC
Date: 10-2022
DOI: 10.1186/S12874-022-01734-2
Abstract: Assessing the long term effects of many surgical interventions tested in pragmatic RCTs may require extended periods of participant follow-up to assess effectiveness and use patient-reported outcomes that require large s le sizes. Consequently the RCTs are often perceived as being expensive and time-consuming, particularly if the results show the test intervention is not effective. Adaptive, and particularly group sequential, designs have great potential to improve the efficiency and cost of testing new and existing surgical interventions. As a means to assess the potential utility of group sequential designs, we re-analyse data from a number of recent high-profile RCTs and assess whether using such a design would have caused the trial to stop early. Many pragmatic RCTs monitor participants at a number of occasions (e.g. at 6, 12 and 24 months after surgery) during follow-up as a means to assess recovery and also to keep participants engaged with the trial process. Conventionally one of the outcomes is selected as the primary (final) outcome, for clinical reasons, with others designated as either early or late outcomes. In such settings, novel group sequential designs that use data from not only the final outcome but also from early outcomes at interim analyses can be used to inform stopping decisions. We describe data from seven recent surgical RCTs (WAT, DRAFFT, WOLLF, FASHION, CSAW, FIXDT, TOPKAT), and outline possible group sequential designs that could plausibly have been proposed at the design stage. We then simulate how these group sequential designs could have proceeded, by using the observed data and dates to replicate how information could have accumulated and decisions been made for each RCT. The results of the simulated group sequential designs showed that for two of the RCTs it was highly likely that they would have stopped for futility at interim analyses, potentially saving considerable time (15 and 23 months) and costs and avoiding patients being exposed to interventions that were either ineffective or no better than standard care. We discuss the characteristics of RCTs that are important in order to use the methodology we describe, particularly the value of early outcomes and the window of opportunity when early stopping decisions can be made and how it is related to the length of recruitment period and follow-up. The results for five of the RCTs tested showed that group sequential designs using early outcome data would have been feasible and likely to provide designs that were at least as efficient, and possibly more efficient, than the original fixed s le size designs. In general, the amount of information provided by the early outcomes was surprisingly large, due to the strength of correlations with the primary outcome. This suggests that the methods described here are likely to provide benefits more generally across the range of surgical trials and more widely in other application areas where trial designs, outcomes and follow-up patterns are structured and behave similarly.
Publisher: Elsevier BV
Date: 08-2022
Publisher: BMJ
Date: 06-2021
DOI: 10.1136/BMJOPEN-2020-045353
Abstract: Tourniquet use in total knee replacement (TKR) is believed to improve the bone-cement interface by reducing bleeding, potentially prolonging implant survival. This study aimed to compare the risk of revision for primary cemented TKR performed with or without a tourniquet. We analysed data from the National Joint Registry (NJR) for all primary cemented TKRs performed in England and Wales between April 2003 and December 2003. Kaplan-Meier plots and Cox regression were used to assess the influence of tourniquet use, age at time of surgery, sex and American Society of Anaesthesiologists (ASA) classification on risk of revision for all-causes. Data were available for 16 974 cases of primary cemented TKR, of which 16 132 had surgery with a tourniquet and 842 had surgery without a tourniquet. At 10 years, 3.8% had undergone revision (95% CI 2.6% to 5.5%) in the no-tourniquet group and 3.1% in the tourniquet group (95% CI 2.8% to 3.4%). After adjusting for age at primary surgery, gender and primary ASA score, the HR for all-cause revision for cemented TKR without a tourniquet was 0.82 (95% CI 0.57 to 1.18). We did not find evidence that using a tourniquet for primary cemented TKR offers a clinically important or statistically significant reduction in the risk of all-cause revision up to 13 years after surgery. Surgeons should consider this evidence when deciding whether to use a tourniquet for cemented TKR.
Publisher: Springer Science and Business Media LLC
Date: 16-11-2020
DOI: 10.1186/S12891-020-03761-W
Abstract: Planned lower limb surgery is common, with over 90,000 hip replacements, 95,000 knee replacements and 15,000 anterior cruciate ligament reconstructions performed in the UK each year. These procedures are primarily indicated to treat osteoarthritis, sporting injuries and trauma. Patient satisfaction is an important element of healthcare provision, which is usually measured by functional outcomes but influenced by other factors. Few studies have assessed patients’ views on the information given to them pertaining surgery and patients are infrequently consulted when designing leaflets and information packs, which can lead to confusion during the recovery period and poor long-term outcomes. Furthermore, previous studies have not directly asked patients what resources they would prefer, or which format would suit them best. This project aimed to assess if patients were satisfied with the information they received around their operations and to identify potential improvements. Set in a National Health Service (NHS) run major trauma centre in the West Midlands, a multiple choice and free-text answer survey was administered to patients who used the orthopaedic service over the course of 1 month. Surveys were designed in Qualtrics and administered face-to-face on paper. Thematic content analysis was performed on the results. Eighty patients completed the survey, of which 88.8% of patients were satisfied with the information they received. Discussions with surgeons were the most useful resource and 53% of patients requested more internet resources. Post-operative patients were statistically more likely to be dissatisfied with information provision than pre-operative patients. Over 20% of the study population requested more information on post-operative pain and recovery timelines. Although patients were satisfied in general, areas for change were identified. Suggested resources took the form of webpages and mobile platforms. These resources could contain educational videos, patient experience blogs or interactive recovery timelines, to be of benefit to patients. These suggestions may enable NHS Trusts to “get into the digital age”, however, more research on patient satisfaction around information provision and the impact it has on recovery and decision making is needed.
Publisher: Springer Science and Business Media LLC
Date: 02-10-2022
DOI: 10.1186/S42836-022-00143-6
Abstract: Debate continues as to the optimal orientation of the acetabular component in total hip arthroplasty (THA) and how to reliably achieve this. The primary objective of this study was to compare functional CT-based planning and patient-specific instruments with conventional THA using 2D templating. A pragmatic single-center, patient-assessor blinded, randomized control trial of patients undergoing THA was performed. 54 patients (aged 18–70) were recruited to either Corin Optimized Positioning System (OPS) or conventional THA. All patients received a cementless acetabular component. All patients underwent pre- and postoperative CT scans, and four functional X-rays. Patients in the OPS group had a 3D surgical plan and bespoke guides made. Patients in the conventional group had a surgical plan based on 2D templating X-rays. The primary outcome measure was the mean error in acetabular anteversion as determined by postoperative CT scan. There was no statistically significant difference in the mean error in angle of acetabular anteversion when comparing OPS and conventional THA. In the OPS group, the achieved acetabular anteversion was within 10° of the planned anteversion in 96% of cases, compared with only 76% in the conventional group. The clinical outcomes were comparable between the groups. Large errors in acetabular orientation appear to be reduced when CT-based planning and patient-specific instruments are used compared to the standard technique but no significant differences were seen in the mean error.
Publisher: Springer Science and Business Media LLC
Date: 14-05-2019
Publisher: Springer Science and Business Media LLC
Date: 04-2021
DOI: 10.1007/S00590-021-02957-7
Abstract: Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following lower limb fracture surgery performed with or without tourniquet. We searched databases for RCTs comparing lower limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid–base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310. Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI −10.12 to −1.87 p 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI −1.25–27.02 p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI −0.00–0.12 p = 0.070), 0.05 (95% CI −0.02–0.11 p = 0.150) and 0.03 (95% CI -0.03–0.09 p = 0.340). Tourniquet use was associated with a reduced length of procedure. It is possible that tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.
Publisher: Springer Science and Business Media LLC
Date: 14-11-2018
DOI: 10.1007/S40273-018-0737-Z
Abstract: Chondrosphere (Spherox) is a form of autologous chondrocyte implantation (ACI). It is licensed for repair of symptomatic articular cartilage defects of the femoral condyle and the patella of the knee with defect sizes up to 10 cm
Publisher: F1000 Research Ltd
Date: 13-09-2021
DOI: 10.12688/WELLCOMEOPENRES.17145.1
Abstract: Background : Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines. Methods : This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period. Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines. Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.
Publisher: SAGE Publications
Date: 08-07-2020
Abstract: Ankle fractures are the third most common fracture in the elderly. Patients over 60 years are more severely affected by these injuries than their younger counterparts and have a higher rate of complications regardless of the management strategy. Traditional management strategies for unstable ankle fractures include plaster immobilisation and open reduction and internal fixation, with newer modalities such as intramedullary fixation becoming increasingly popular. The aim of this review is to establish the best current evidence for or against different treatment strategies. A systematic review and meta-analysis of randomised controlled trials comparing treatment options for unstable ankle fractures in adults over 55 was conducted, with the primary outcome being functional assessment score at 6–12 months (Olerud and Molander Ankle Score). Secondary outcomes were adverse events including infection and re-operation. The search strategies identified 426 articles. After screening and full text review, four papers met the inclusion and exclusion criteria, providing data on 754 ankle fractures. Alternative treatment groups were tibio-talo-calcaneal nail, fibular nail and casting and were compared to open reduction and internal fixation. Meta-analysis of the data showed no difference in Olerud and Molander Ankle Score between treatment modalities at 6–12 months. There was, however, a significant reduction in the incidence of adverse events (OR 0.59 (0.44, 0.81)) and wound infection (0.13 (0.05, 0.31)) in the alternative treatment groups compared to open reduction and internal fixation. The current evidence shows no significant difference between treatment modalities for ankle fractures in older adults in terms of functional outcome. Open reduction and internal fixation has a higher rate of adverse events and wound infection when compared to alternative treatments. Therefore, surgery should be carefully considered and if undertaken, in a select patient cohort other treatment modalities, such as intramedullary fixation should be considered.
Publisher: Springer Science and Business Media LLC
Date: 12-2019
DOI: 10.1186/S13063-019-3708-6
Abstract: There is widespread concern across the clinical and research communities that clinical trials, powered for patient-reported outcomes, testing new surgical procedures are often expensive and time-consuming, particularly when the new intervention is shown to be no better than the standard. Conventional (non-adaptive) randomised controlled trials (RCTs) are perceived as being particularly inefficient in this setting. Therefore, we have developed an adaptive group sequential design that allows early endpoints to inform decision making and show, through simulations and a worked ex le, that these designs are feasible and often preferable to conventional non-adaptive designs. The methodology is motivated by an ongoing clinical trial investigating a saline-filled balloon, inserted above the main joint of the shoulder at the end of arthroscopic debridement, for treatment of tears of rotor cuff tendons. This research question and setting is typical of many studies undertaken to assess new surgical procedures. Test statistics are presented based on the setting of two early outcomes, and methods for estimation of sequential stopping boundaries are described. A framework for the implementation of simulations to evaluate design characteristics is also described. Simulations show that designs with one, two and three early looks are feasible and, with appropriately chosen futility stopping boundaries, have appealing design characteristics. A number of possible design options are described that have good power and a high probability of stopping for futility if there is no evidence of a treatment effect at early looks. A worked ex le, with code in R, provides a practical demonstration of how the design might work in a real study. In summary, we show that adaptive designs are feasible and could work in practice. We describe the operating characteristics of the designs and provide guidelines for appropriate values for the stopping boundaries for the START:REACTS (Sub-acromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery) study. ISRCTN Registry, ISRCTN17825590. Registered on 5 March 2018.
Publisher: Elsevier BV
Date: 10-2011
DOI: 10.1016/J.INJURY.2011.03.019
Abstract: Previous studies have demonstrated the need for accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. A computed tomography (CT) scan allows better visualisation of the transverse relationship between the fibula and incisura fibularis. The difference ('G' a term we coined for ease of description) between the fibula and the anterior and posterior facets of the incisura fibularis was compared between normal and injured ankles following syndesmotic fixation in 19 patients. The mean diastasis (MD) was also calculated, representing the average measurement between the fibula and the anterior and posterior incisura. When compared with the normal side, eight out of 19 (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis. However, if a standard value of G (2mm) was used for the injured leg only, all of the 19 cases would have abnormal values of 'G' following reduction. Our study has clearly demonstrated the need for in idualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of 'G' of 2mm as the normal limit cannot be applied universally, as apparent from the data presented in this study.
Publisher: SAGE Publications
Date: 19-10-2022
DOI: 10.1177/03635465221128581
Abstract: Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. Cohort study Level of evidence, 2. Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)—namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. Of the 618 patients randomized in the STABILITY study, 399 (228 male 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors—namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19 95% CI, 0.77-1.84 P = .42) or graft failure (OR, 1.13 95% CI, 0.51-2.50 P = .76). There was no significant difference between the groups in Lachman ( P = .46) and pivot-shift ( P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL ( P = .67) and IKDC ( P = .83) scores between the 2 subgroups. At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.
Publisher: SAGE Publications
Date: 02-07-2018
Abstract: Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known. To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials. Systematic review and meta-analysis. Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores. A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms. Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.
Publisher: Elsevier BV
Date: 2005
DOI: 10.1016/J.CLINBIOMECH.2004.09.003
Abstract: Although clear differences in fracture site displacement have previously been demonstrated between transverse and oblique fracture models stabilised by an asymmetrical method, the direction of the obliquity has not been examined biomechanically. Eight Sawbones tibiae were cut to represent oblique fractures: four ran from antero-inferior to postero-superior and four from antero-superior to postero-inferior. These were fixed with a Sheffield Ring Fixator and cyclically loaded in axial and off-axis compression. Direct measurements were taken of inter-fragmentary displacement. Significant differences were detected between the fracture directions (P < 0.01) and inter-fragmentary displacements were generally reduced in antero-superior to postero-inferior fractures compared with antero-inferio to postero-superior fractures. Fixation asymmetries need to be tailored to specific fracture orientation to improve fracture site mechanics.
Publisher: BMJ
Date: 2021
DOI: 10.1136/BMJOPEN-2020-043564
Abstract: Tourniquets are routinely used during total knee replacement (TKR) surgery. They could increase the risk of thromboembolic events including cerebral emboli, cognitive decline, pain and other adverse events (AEs). A randomised controlled trial to assess whether tourniquet use might safely be avoided is therefore warranted but it is unclear whether such a trial would be feasible. In a single-site feasibility study and pilot randomised controlled trial, adults having a TKR were randomised to surgery with an inflated tourniquet versus a non-inflated tourniquet. Participants underwent brain MRI preoperatively and within 2 days postoperatively. We assessed cognition using the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Oxford Cognitive Screen (OCS) and thigh pain using a Visual Analogue Scale at baseline and days 1 and 2, and 1 week postsurgery. AEs related to surgery were recorded up to 12 months. We randomised 53 participants (27 tourniquet inflated and 26 tourniquet not inflated). Fifty-one participants received care per-protocol (96%) and 48 (91%) were followed up at 12 months. One new ischaemic brain lesion was detected. Of the cognitive tests, MoCA was easy to summarise, sensitive to change with lower ceiling effects compared with OCS and MMSE. There was a trend towards more thigh pain (mean 49.6 SD 30.4 vs 36.2 SD 28 at day 1) and more AEs related to surgery (21 vs 9) in participants with an inflated tourniquet compared with those with a tourniquet not inflated. A full trial is feasible, but using MRI as a primary outcome is unlikely to be appropriate or feasible. Suitable primary outcomes would be cognition measured using MoCA, pain and AEs, all of which warrant investigation in a large multicentre trial. ISRCTN20873088 .
Publisher: BMJ
Date: 11-2021
DOI: 10.1136/BMJOPEN-2021-050830
Abstract: Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis. Prospective, international, multicentre, observational cohort study. Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative). 30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality. This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p .001), age years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787). Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with in idualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups. NCT04323644
Publisher: Elsevier BV
Date: 11-2020
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 06-2022
DOI: 10.1302/0301-620X.104B6.BJJ-2021-0944.R2
Abstract: Meniscal allograft transplantation (MAT) for patients with symptomatic meniscal loss has demonstrated good clinical results and survivorship. Factors that affect both functional outcome and survivorship have been reported in the literature. These are typically single-centre case series with relatively small numbers and conflicting results. Our aim was to describe an international, two-centre case series, and identify factors that affect both functional outcome and survival. We report factors that affect outcome on 526 patients undergoing MAT across two sites (one in the UK and one in Italy). Outcomes of interest were the Knee injury and Osteoarthritis Outcome Score four (KOOS4) at two years and failure rates. We performed multiple regression analysis to examine for factors affecting KOOS, and Cox proportional hazards models for survivorship. Our results indicate that baseline KOOS4 score affects functional outcome at two years, but no other included factors were significantly related to functional outcome. The only factor that affected failure rate was the presence of cartilage lesions down to bone on both the femur and tibia, decreasing the five-year survivorship from 95% (95% confidence interval (CI) 91 to 99) to 84% (95% CI 74 to 94). To our knowledge, this is the largest international cohort reporting on MAT. Our results indicate that factors such as age, BMI, and cartilage lesions down to bone on both the femur and tibia of the affected compartment should not present barriers to offering MAT. Baseline KOOS4 score and the presence of bone-on-bone arthritis can be used to help counsel patients regarding the expected risks and rewards of surgery. Cite this article: Bone Joint J 2022 -B(6):657–662.
Publisher: Springer Science and Business Media LLC
Date: 22-03-2019
Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.KNEE.2016.03.004
Abstract: The Journey patellofemoral joint arthroplasty (PFA) was designed to improve patient outcomes following surgical management of patellofemoral joint osteoarthritis. It is based on the asymmetric trochlear geometry of the Genesis II total knee arthroplasty, with Oxinium components, to provide a reliable treatment option in an often young, high demand group of patients. We report the minimum five year functional outcome and survivorship of the Journey PFA performed at our institution between October 2005 and September 2009. A total of 101 Journey PFAs were implanted in 83 patients, and we have complete outcomes for 90 implants (89%). There were 80 implants in female patients, and the mean age at time of surgery was 60years (26 to 86). The median Oxford Knee Score (0 to 48) improved from 18 to 30, and median Western Ontario and McMaster University Osteoarthritis Short Form Index (0 to 60) improved from 22 to 35. There were a total of 12 revisions, with mean time to revision 50months (10 to 99). The Journey PFA gives a good medium-term functional outcome with 88% survivorship at a mean of seven years. This is the largest study of Journey PFA in the literature, and it provides a reliable option for patients with isolated patellofemoral joint osteoarthritis when arthroplasty is considered.
Publisher: Elsevier BV
Date: 10-2011
DOI: 10.1016/J.INJURY.2010.11.062
Abstract: In the emergency management of patients with pelvic fractures, there is ongoing debate about the roles of angiography and open pelvic packing. It is agreed that some form of haemorrhage control is required for patients who are haemo-dynamically unstable despite resuscitation. We set out to determine whether on-call general and orthopaedic surgeons would feel able to perform emergency surgical procedures for these patients and whether vascular radiology was available to them. Surveys were sent to all 221 general and orthopaedic surgeons in Wales. Questions included: sub-speciality interest, geographical region, whether there is a pelvic binder in their hospital, availability of interventional radiology, and whether surgeons would perform a range of procedures to control haemorrhage in the emergency setting. There were 141 responses to the survey, giving a 64% response rate. Only 18% reported that their unit had a formal rota for interventional radiology out of hours. 16% did not know. 96% of orthopaedic surgeons would perform external fixation, although only 49% would use a C-cl . 90% of general surgeons would be able to pack the pelvis from within the abdominal compartment and 84% would be prepared to cross-cl the aorta if the situation required. Despite being widely recommended in the literature as a method of haemorrhage control, our survey revealed only 45% would perform extra(pre)-peritoneal packing of the pelvis (58% of general surgeons 34% of orthopaedic surgeons) and only 12% had received formal training in this procedure. With appropriately targeted training it is likely that the care of patients with pelvic fractures can be significantly improved.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 05-2021
Publisher: Springer Science and Business Media LLC
Date: 22-08-2012
Publisher: Elsevier BV
Date: 08-2016
DOI: 10.1016/J.KNEE.2016.04.009
Abstract: There is a lack of information about the association between patellofemoral osteoarthritis (PFOA) and both adolescent anterior knee pain (AKP) and previous patellar dislocations. This case-control study involved 222 participants from our knee arthroplasty database answering a questionnaire. One hundred and eleven patients suffering from PFOA were 1:1 matched by gender with a unicompartmental tibiofemoral arthritis control group. Multivariate correlation and binary logistic regression analysis were performed, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. An in idual is 7.5 times more likely to develop PFOA if they have suffered from adolescent AKP (OR 7.5, 95% CIs 1.51 to 36.94). Additionally, experiencing a patellar dislocation increases the likelihood of development of PFOA, with an adjusted odds ratio of 3.2 (95% CIs 1.25 to 8.18). A 44-year difference in median age of first dislocation was also observed between the groups. This should bring into question the traditional belief that adolescent anterior knee pain is a benign pathology. Patellar dislocation is also a significant risk factor. These patients merit investigation, we encourage clinical acknowledgement of the potential consequences when encountering patients suffering from anterior knee pain or patellar dislocation.
Publisher: BMJ
Date: 06-2023
DOI: 10.1136/BMJOPEN-2022-068255
Abstract: Robotic-assisted knee replacement systems have been introduced to healthcare services worldwide in an effort to improve clinical outcomes for people, although high-quality evidence that they are clinically, or cost-effective remains sparse. Robotic-arm systems may improve surgical accuracy and could contribute to reduced pain, improved function and lower overall cost of total knee replacement (TKR) surgery. However, TKR with conventional instruments may be just as effective and may be quicker and cheaper. There is a need for a robust evaluation of this technology, including cost-effectiveness analyses using both within-trial and modelling approaches. This trial will compare robotic-assisted against conventional TKR to provide high-quality evidence on whether robotic-assisted knee replacement is beneficial to patients and cost-effective for healthcare systems. The Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial-Knee is a multicentre, participant-assessor blinded, randomised controlled trial to evaluate the clinical and cost-effectiveness of robotic-assisted TKR compared with TKR using conventional instruments. A total of 332 participants will be randomised (1:1) to provide 90% power for a 12-point difference in the primary outcome measure the Forgotten Joint Score at 12 months postrandomisation. Allocation concealment will be achieved using computer-based randomisation performed on the day of surgery and methods for blinding will include sham incisions for marker clusters and blinded operation notes. The primary analysis will adhere to the intention-to-treat principle. Results will be reported in line with the Consolidated Standards of Reporting Trials statement. A parallel study will collect data on the learning effects associated with robotic-arm systems. The trial has been approved by an ethics committee for patient participation (East Midlands—Nottingham 2 Research Ethics Committee, 29 July 2020. NRES number: 20/EM/0159). All results from the study will be disseminated using peer-reviewed publications, presentations at international conferences, lay summaries and social media as appropriate. ISRCTN27624068 .
Publisher: SAGE Publications
Date: 20-01-2022
DOI: 10.1177/03635465211061150
Abstract: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active in iduals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates however, indications for this procedure have yet to be clearly defined. The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. Case-control study Level of evidence, 3. Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40 95% CI, 0.18-0.91) and older age (OR, 0.83 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.
Publisher: National Institute for Health and Care Research
Date: 02-2017
DOI: 10.3310/HTA21060
Abstract: The surfaces of the bones in the knee are covered with articular cartilage, a rubber-like substance that is very smooth, allowing frictionless movement in the joint and acting as a shock absorber. The cells that form the cartilage are called chondrocytes. Natural cartilage is called hyaline cartilage. Articular cartilage has very little capacity for self-repair, so damage may be permanent. Various methods have been used to try to repair cartilage. Autologous chondrocyte implantation (ACI) involves laboratory culture of cartilage-producing cells from the knee and then implanting them into the chondral defect. To assess the clinical effectiveness and cost-effectiveness of ACI in chondral defects in the knee, compared with microfracture (MF). A broad search was done in MEDLINE, EMBASE, The Cochrane Library, NHS Economic Evaluation Database and Web of Science, for studies published since the last Health Technology Assessment review. Systematic review of recent reviews, trials, long-term observational studies and economic evaluations of the use of ACI and MF for repairing symptomatic articular cartilage defects of the knee. A new economic model was constructed. Submissions from two manufacturers and the ACTIVE (Autologous Chondrocyte Transplantation/Implantation Versus Existing Treatment) trial group were reviewed. Survival analysis was based on long-term observational studies. Four randomised controlled trials (RCTs) published since the last appraisal provided evidence on the efficacy of ACI. The SUMMIT (Superiority of Matrix-induced autologous chondrocyte implant versus Microfracture for Treatment of symptomatic articular cartilage defects) trial compared matrix-applied chondrocyte implantation (MACI ® ) against MF. The TIG/ACT/01/2000 (TIG/ACT) trial compared ACI with characterised chondrocytes against MF. The ACTIVE trial compared several forms of ACI against standard treatments, mainly MF. In the SUMMIT trial, improvements in knee injury and osteoarthritis outcome scores (KOOSs), and the proportion of responders, were greater in the MACI group than in the MF group. In the TIG/ACT trial there was improvement in the KOOS at 60 months, but no difference between ACI and MF overall. Patients with onset of symptoms 3 years’ duration did better with ACI. Results from ACTIVE have not yet been published. Survival analysis suggests that long-term results are better with ACI than with MF. Economic modelling suggested that ACI was cost-effective compared with MF across a range of scenarios. The main limitation is the lack of RCT data beyond 5 years of follow-up. A second is that the techniques of ACI are evolving, so long-term data come from trials using forms of ACI that are now superseded. In the modelling, we therefore assumed that durability of cartilage repair as seen in studies of older forms of ACI could be applied in modelling of newer forms. A third is that the high list prices of chondrocytes are reduced by confidential discounting. The main research needs are for longer-term follow-up and for trials of the next generation of ACI. The evidence base for ACI has improved since the last appraisal by the National Institute for Health and Care Excellence. In most analyses, the incremental cost-effectiveness ratios for ACI compared with MF appear to be within a range usually considered acceptable. Research is needed into long-term results of new forms of ACI. This study is registered as PROSPERO CRD42014013083. The National Institute for Health Research Health Technology Assessment programme.
Publisher: Elsevier BV
Date: 02-2003
DOI: 10.1016/S0020-1383(02)00192-4
Abstract: Clinical experience and published studies suggest that oblique fractures of the tibia are associated with delayed healing and non-union. Experimental studies have attributed this to increased shear at the fracture site. We have adopted the practice of using supplementary olive wires to reduce shear when using circular fixation for these fractures. A complete cohort of 54 oblique tibial fractures treated with the Sheffield Ring Fixator (Orthofix, Verona) was reviewed to elucidate the effect of using additional olive wires on fracture healing/treatment times. Fifty patients were studied in the final analysis. With low-energy injuries, the use of olive wires reduced treatment times significantly (no olives: 37 weeks, olives: 22 weeks, P<0.05), although this was not seen with higher energy injuries (no olives: 44 weeks, olives: 39 weeks, P=NS). There was no evidence of additional complications related to their use. We recommend the use of additional olive wires in the circular fixation of these difficult fractures.
Publisher: Elsevier BV
Date: 03-2021
Publisher: National Institute for Health and Care Research
Date: 08-2023
DOI: 10.3310/TKJY2101
Publisher: Elsevier BV
Date: 12-2019
DOI: 10.1016/J.KNEE.2019.08.010
Abstract: Total knee replacement (TKR) is the commonest joint arthroplasty procedure worldwide. Despite excellent outcomes, some studies have reported dissatisfaction in up to 20% of patients. There is evidence of an association between the biochemical stress response to surgery and outcomes. The objective of this study is to describe the stress biomarker profile for TKR, and correlate this with patient outcomes. A prospective cohort study of 50 patients undergoing primary TKR was conducted. Serum IL-6, TNF-α, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were measured immediately pre- and post-operatively, and on Days 1 and 3. Follow-up questionnaires including the Oxford Knee Score (OKS) and EuroQol five dimensions (EQ-5D) were completed at 12-months. Univariate analysis was completed using a linear regression model (p < 0.05). Serum IL-6, NLR, and PLR all increased to Day 1 post-operatively, and decreased by Day 3. TNF-α values increased across all time points. Statistical analysis found a significant negative correlation (r = -0.414 p = 0.005) between pre-operative IL-6 and 12-month OKS. There was a significant positive correlation between pre-operative NLR and 12 month OKS (r = 0.272 p = 0.039) and 12 month EQ5D (r = 0.268 p = 0.043). This is the first study to describe the biochemical stress response to TKR. The results raise the potential for a pre-operative risk stratification tool for patients based on IL-6 and NLR measurements. Further research should be conducted to explore the underlying mechanisms involved, and investigate interventions to reduce pre-operative physiological stress with a view to improving post-operative outcomes.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.CLINBIOMECH.2017.02.009
Abstract: Gait adaptations, including toe out gait, have been proposed as treatments for knee osteoarthritis. The clinical application of toe out gait, however, is unclear. This study aims to identify the changes in Knee adduction moment in varus knee deformity assessing toe out gait as an alternative to high tibial osteotomy, and if any change in dynamic loading persists post operatively, when anatomical alignment is restored. Three-dimensional motion analysis was performed on 17 patients with medial compartment knee osteoarthritis and varus deformity prior to undergoing high tibial osteotomy, 13 patients were assessed post-operatively, and results compared to 13 healthy controls. Pre-operatively, there was no significant difference between natural and toe out gait for measures of knee adduction moment. Post high tibial osteotomy, first (2.70 to 1.51% BW·h) and second peak (2.28 to 1.21% BW·h) knee adduction moment were significantly reduced, as was knee adduction angular impulse (1.00 to 0.52% BW·h·s), to a healthy level. Adopting toe out gait post-operatively reduced the second peak further to a level below that of healthy controls. Increasing the foot progression angle from 20° (natural) to 30° in isolation did not significantly alter the knee adduction moment or angular impulse. This suggests that adopting a toe out gait, in isolation, in an already high natural foot progression angle, is not of benefit. Adopting toe out gait post-operatively, however, resulted in a further reduction in the second peak to below that of the healthy control cohort, however, this may increase lateral compartment load.
Publisher: Elsevier BV
Date: 11-2022
Publisher: F1000 Research Ltd
Date: 09-08-2022
DOI: 10.12688/WELLCOMEOPENRES.18063.1
Abstract: Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients’ experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in in iduals’ societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.
Publisher: Springer Science and Business Media LLC
Date: 05-08-2019
Publisher: Public Library of Science (PLoS)
Date: 25-01-2019
Publisher: Springer Science and Business Media LLC
Date: 20-05-2019
Publisher: BMJ
Date: 05-2020
DOI: 10.1136/BMJOPEN-2020-036829
Abstract: Shoulder pain due to irreparable rotator cuff tears can cause substantial disability, but treatment options are limited. A balloon spacer is a relatively simple addition to a standard arthroscopic debridement procedure, but it is costly and there is no current randomised trial evidence to support its use. This trial will evaluate the clinical and cost-effectiveness of a subacromial balloon spacer for in iduals undergoing arthroscopic debridement for irreparable rotator cuff tears. New surgical procedures can provide substantial benefit to patients. Good quality randomised controlled trials (RCTs) are needed, but trials in surgery are typically long and expensive, exposing patients to risk and the healthcare system to substantial costs. One way to improve the efficiency of trials is with an adaptive s le size. Such methods are well established in drug trials but have rarely, if ever, been used in surgical trials. Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS) is a participant and assessor blinded, adaptive, multicentre RCT comparing arthroscopic debridement with the InSpace balloon (Stryker, USA) to arthroscopic debridement alone for people with a symptomatic irreparable rotator cuff tear. It uses a group sequential adaptive design where interim analyses are performed using all of the 3, 6 and 12-month data that are available at each time point. A maximum of 221 participants will be randomised (1:1 ratio), this will provide 90% power (at the 5% level) for a 6 point difference in the primary outcome the Oxford Shoulder Score at 12 months. A substudy will use deltoid-active MRI scans in 56 participants to assess the function of the balloon. Analysis will be on an intention-to-treat basis and reported according to principles established in the Consolidated Standards of Reporting Trials statement. NRES number 18/WM/0025. The results will be disseminated via peer-reviewed publications, presentations at conferences, lay summaries and social media. ISRCTN17825590
Publisher: Springer Science and Business Media LLC
Date: 13-09-2022
DOI: 10.1007/S00167-022-07085-1
Abstract: Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than satisfactory outcome in some patients. It was hypothesized that certain factors can be identified on radiological review that correlate with poor patient reported outcomes following PFA. A retrospective cohort review of 369 patients undergoing PFA at our institution between 2005 and 2018 identified 43 “poor outcome” patients with an Oxford Knee Score (OKS) of less than 20 at 2 years follow up. These cases were matched by sex and age with 43 “good outcome” patients who had an OKS above 40 at 2 years post-op. Multiple radiological measurements were performed including anterior trochlea offset ratio (ATOR), component flexion/extension, component varus/valgus, component to bone width ratio and retinacular index. The OKS PROM was the primary outcome of the study. Stepwise logistic regression was performed to analyze the differences in radiological indices between the two groups. Intraclass correlation coefficients for inter-observer and intra-observer reliability were 0.90–0.98 for all indices measured. The only index demonstrating statistical significance between the groups was the ATOR ( p = 0.003). The good outcome group had a mean ATOR of 0.19 whereas the poor outcome group had a mean ATOR of 0.24. Lower ATOR on radiological review was strongly associated with improved outcomes following PFA. The surgeon should therefore take particular care to prevent increasing the anterior offset of the trochlea component when performing PFA. Retrospective cohort study, Level III.
Publisher: Springer Science and Business Media LLC
Date: 13-04-2019
Publisher: Springer Science and Business Media LLC
Date: 15-05-2019
Publisher: Springer Science and Business Media LLC
Date: 24-02-2016
Publisher: BMJ
Date: 20-03-2012
DOI: 10.1136/EMERMED-2011-200782
Abstract: To examine variations and consistencies in the emergency management of distal radial fractures across England and Wales. A survey was conducted of emergency departments (ED) in England and Wales regarding the acute management of patients with distal radius fractures. The study investigated the use of anaesthesia, the person performing both the anaesthetic and the manipulation, the use of resuscitation facilities and monitoring, the cast applied, the follow-up and the management of complex injuries or those in younger patients. Surveys were conducted in 105 units, giving a response rate of 91% of ED in England and Wales. The most frequent anaesthetic types were haematoma block (50%), intravenous benzodiazepines (20%), Bier's block (17%) and a small minority using other techniques such as brachial plexus blocks (2%). Basic cardiorespiratory monitoring was variable, and 10% of trusts did not routinely monitor patients undergoing Bier's blocks or manipulation with sedatives. Only 50% of ED would manipulate comminuted fractures or fractures in young adult patients. There are significant regional variations. The use of monitoring is highly variable and there are no consistent standards when administering potentially potent anaesthetic medications. The low percentage of units attempting reduction of complex fractures or fractures in young patients will disadvantage training in ED as well as patients. Guidelines are required to improve care, which is highly inconsistent at present.
Publisher: Elsevier BV
Date: 06-2021
Publisher: Cold Spring Harbor Laboratory
Date: 23-08-2018
DOI: 10.1101/398743
Abstract: Gait analysis can be used to measure variations in joint function in patients with knee osteoarthritis (OA), and is useful when observing longitudinal biomechanical changes following Total Knee Replacement (TKR) surgery. The Cardiff Classifier is an objective classification tool applied previously to examine the extent of biomechanical recovery following TKR. In this study, it is further developed to reveal the salient features that contribute to recovery towards healthy function. Gait analysis was performed on 30 patients before and after TKR surgery, and 30 healthy controls. Median TKR follow-up time was 13 months. The combined application of principal component analysis (PCA) and the Cardiff Classifier defined 18 biomechanical features that discriminated OA from healthy gait. Statistical analysis tested whether these features were affected by TKR surgery and, if so, whether they recovered to values found for the controls. The Cardiff Classifier successfully discriminated between OA and healthy gait in all 60 cases. Of the 18 discriminatory features, only six (33%) were significantly affected by surgery, including features in all three planes of the ground reaction force (p .001), ankle dorsiflexion moment (p .001), hip adduction moment (p=0.003), and transverse hip angle (p=0.007). All but two (89%) of these features remained significantly different to those of the control group after surgery. This approach was able to discriminate gait biomechanics associated with knee OA. The ground reaction force provided the strongest discriminatory features. Despite increased gait velocity and improvements in self-reported pain and function, which would normally be clinical indicators of recovery, the majority of features were not affected by TKR surgery. This TKR cohort retained pre-operative gait patterns reduced sagittal hip and knee moments, decreased knee flexion, increased hip flexion, and reduced hip adduction. The changes that were associated with surgery were predominantly found at the ankle and hip, rather than at the knee.
Publisher: BMJ
Date: 07-2020
DOI: 10.1136/BMJOPEN-2020-038681
Abstract: This study is designed to explore the baseline characteristics of patients under 55 years of age with a meniscal tear, and to describe the relationship between the baseline characteristics and patient-reported outcome measures (PROMs) over 12 months. Research has highlighted the need for a trial to investigate the effectiveness of arthroscopic meniscectomy in younger patients. Before this trial, we need to understand the patient population in greater detail. This is a multicentre prospective cohort study. Participants aged between 18 and 55 years with an MRI confirmed meniscal tear are eligible for inclusion. Baseline characteristics including age, body mass index, gender, PROMs duration of symptoms and MRI will be collected. The primary outcome measure is the Western Ontario Meniscal Evaluation Tool at 12 months. Secondary outcome measures will include PROMs such as EQ5D, Knee Injury and Osteoarthritis Outcome Score and patient global impression of change score at 3, 6 and 12 months. The study obtained approval from the National Research Ethics Committee West Midlands—Black Country research ethics committee (19/WM/0079) on 12 April 2019. The study is sponsored by the University of Warwick. The results will be disseminated via peer-reviewed publication. UHCW R& D Reference: IA428119. University of Warwick Sponsor ID: SC.08/18–19
Publisher: Elsevier BV
Date: 06-2015
Publisher: Elsevier BV
Date: 05-2022
Publisher: SAGE Publications
Date: 06-2018
Abstract: The first-line treatment for patellar dislocations is often nonoperative and consists of physical therapy and immobilization techniques, with various adjuncts employed. However, the outcomes of nonoperative therapy are poorly described, and there is a lack of quality evidence to define the optimal intervention. To perform a comprehensive review of the literature and assess the quality of studies presenting patient outcomes from nonoperative interventions for patellar dislocations. Systematic review Level of evidence, 4. The MEDLINE, AMED, Embase, CINAHL, Cochrane Library, PEDro, and SPORTDiscus electronic databases were searched through July 2017 by 3 independent reviewers. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Study quality was assessed using the CONSORT (Consolidated Standards for Reporting Trials) criteria for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies and case series. A total of 25 studies met our inclusion criteria, including 12 randomized controlled trials, 7 cohort studies, and 6 case series, consisting of 1066 patients. Studies were grouped according to 4 broad categories of nonoperative interventions based on immobilization, weightbearing status, quadriceps exercise type, and alternative therapies. The most commonly used outcome measure was the Kujala score, and the pooled redislocation rate was 31%. This systematic review found that patient-reported outcomes consistently improved after all methods of treatment but did not return to normal. Redislocation rates were high and close to the redislocation rates reported in natural history studies. There is a lack of quality evidence to advocate the use of any particular nonoperative technique for the treatment of patellar dislocations.
Publisher: SAGE Publications
Date: 15-01-2020
Abstract: Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active in iduals. Randomized controlled trial Level of evidence, 1. This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk ivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. A total of 618 patients (297 males 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38 95% CI, 0.21-0.52 P .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67 95% CI, 0.36-0.83 P .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 ( P = .003) and KOOS ( P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months ( P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale ( P = .11). The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. NCT02018354 ( ClinicalTrials.gov identifier)
Publisher: Springer Science and Business Media LLC
Date: 08-05-2023
Publisher: Oxford University Press (OUP)
Date: 02-05-2018
DOI: 10.1093/SLEEP/ZSY085
Abstract: In this systematic review and meta-analysis, we aimed to examine the relationship between obstructive sleep apnea (OSA) and metabolic abnormalities in women with polycystic ovary syndrome (PCOS). Electronic databases (Medline, Embase, Cinahl, PsycInfo, Scopus, Web of Science, Opengrey, and CENTRAL), conference abstracts, and reference lists of relevant articles were searched. No restriction was applied for language or publication status. Six studies involving 252 participants were included. Women with PCOS and OSA had significantly higher body mass index (mean difference [MD]: 6.01 kg/m2, 95% confidence intervals [CI]: 4.69-7.33), waist circumference (MD: 10.93 cm, 95% CI: 8.03-13.83), insulin resistance, systolic and diastolic blood pressure, and worse lipids' profile and impaired glucose regulation compared with women with PCOS without OSA. Most studies did not adjust for weight in their between-groups analysis. Total and free testosterone levels were not significantly different between the two groups. The majority of studies were found to be at high risk of selection bias, did not account for important confounders, were conducted in one country (United States), and used different methodologies to assess testosterone levels (preventing a meta-analysis for this specific outcome). OSA is associated with obesity and worse metabolic profiles in women with PCOS. However, whether the effects of OSA are independent of obesity remain unclear. As OSA is a treatable condition, research focused on the independent effects of OSA on key clinical outcomes in women with PCOS, including fertility, psychological health, type 2 diabetes, and cardiovascular risk, is lacking and needed. PROSPERO registration number: CRD42016048587.
Publisher: Elsevier BV
Date: 03-2021
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 2018
DOI: 10.1302/0301-620X.100B1.BJJ-2017-0918.R1
Abstract: Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months. A single-centre assessor-blinded, comprehensive cohort study, incorporating a pilot randomized controlled trial (RCT) was performed on patients with a symptomatic compartment of the knee in which a (sub)total meniscectomy had previously been performed. They were randomized to be treated either with a meniscal allograft transplantation or personalized physiotherapy, and stratified for malalignment of the limb. They entered the preference groups if they were not willing to be randomized. The Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Lysholm score and complications were collected at baseline and at four, eight and 12 months following the interventions. A total of 36 patients entered the study 21 were randomized and 15 chose their treatments. Their mean age was 28 years (range 17 to 46). The outcomes were similar in the randomized and preference groups, allowing pooling of data. At 12 months, the KOOS 4 composite score (mean difference 12, p = 0.03) and KOOS subscales of pain (mean difference 15, p = 0.02) and activities of daily living (mean difference 18, p = 0.005) were significantly superior in the meniscal transplantation group. Other PROMs also favoured this group without reaching statistical significance. There were five complications in the meniscal transplantation and one in the physiotherapy groups. This is the first study to compare meniscal allograft transplantation to non-operative treatment. The results provide the best quality evidence to date of the symptomatic benefits of meniscal allograft transplantation in the short term, but a multicentre RCT is required to investigate this question further. Cite this article: Bone Joint J 2018 -B:56–63.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 04-2012
DOI: 10.1302/0301-620X.94B4.27978
Abstract: As part of the national initiative to reduce waiting times for joint replacement surgery in Wales, the Cardiff and Vale NHS Trust referred 224 patients to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement (TKR). A total of 258 Kinemax TKRs were performed between November 2004 and August 2006. Of these, a total of 199 patients (232 TKRs, 90%) have been followed up for five years. This cohort was compared with 258 consecutive TKRs in 250 patients, performed at Cardiff and Vale Orthopaedic Centre (CAVOC) over a similar time period. The five year cumulative survival rate was 80.6% (95% confidence interval (CI) 74.0 to 86.0) in the Weston-Super-Mare cohort and 95.0% (95% CI 90.2 to 98.2) in the CAVOC cohort with revision for any reason as the endpoint. The relative risk for revision at Weston-Super-Mare compared with CAVOC was 3.88 (p 0.001). For implants surviving five years, the mean Oxford knee scores (OKS) and mean EuroQol (EQ-5D) scores were similar (OKS: Weston-Super-Mare 29 (2 to 47) vs CAVOC 29.8 (3 to 48), p = 0.61 EQ-5D: Weston-Super-Mare 0.53 (-0.38 to 1.00) vs CAVOC 0.55 (-0.32 to 1.00), p = 0.79). Patients with revised TKRs had significantly lower Oxford knee and EQ-5D scores (p 0.001). The results show a higher revision rate for patients operated at Weston-Super-Mare Treatment Centre, with a reduction in functional outcome and quality of life after revision. This further confirms that patients moved from one area to another for joint replacement surgery fare poorly.
Publisher: Springer Science and Business Media LLC
Date: 03-03-2020
DOI: 10.1186/S12891-020-3125-8
Abstract: The Personalised Knee Improvement Programme (P-KIP) was developed based on previously published work, with the hypothesis that surgeons would refer patients to a well-structured conservative management intervention instead of for arthroscopy (de-implementation of arthroscopy by substitution with P-KIP). This meets NICE guidelines and international recommendations but such programmes are not widely used in the UK. Our aim was to determine whether P-KIP would reduce the number of arthroscopies performed for knee osteoarthritis. P-KIP is a conservative care pathway including a group education session followed by in idually tailored one-to-one dietician and physiotherapy sessions. Virtual clinic follow-up is conducted three to 6 months after completion of the programme. The service began in July 2015. The number of arthroscopies saved, measured from hospital level coding data, is the primary outcome measure. Interrupted time series analysis of coding data was conducted. As a quality assurance process, patient reported outcome measures (Oxford Knee Score Euroqol 5D) were collected at baseline and at follow up. Time series analysis demonstrates that the programme saved 15.4 arthroscopies a month (95% confidence interval 9–21 p 0.001), equating to 184 arthroscopies a year in a single hospital. The PROMs data demonstrated improvements in patient reported outcome scores consistent with previous published reports of conservative interventions in similar patient populations. Results suggest that P-KIP reduces the number of arthroscopies performed, and patients who took part in P-KIP had an improvement in their knee and general health outcomes. P-KIP has the potential to deliver efficiency savings and relive pressure on operative lists, however replication in other sites is required.
Publisher: Elsevier BV
Date: 12-2021
DOI: 10.1016/J.KNEE.2021.10.023
Abstract: We sought to identify which specific set of codes are used by each acute NHS trust in England to document the diagnosis and management of patellofemoral instability (PFI). All acute NHS Trusts in England were sent freedom of information (FOI) requests regarding their use of International Statistical Classification of Diseases and Related Health Problems version 10 (ICD-10) codes for the diagnoses related to PFI, and Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures 4th revision (OPCS-4) codes for surgical management of PFI. 106 of 132 (80%) relevant trusts who manage patients with PFI responded with information. Coding for diagnosis of patellar dislocation and recurrent dislocation were largely consistent with 96% of the trusts using the same code. However, coding of patellar instability varied widely with 10 different codes being used, the most common of which was being used by only 34% of trusts. Coding for operative management exhibited greater variety with the number of different codes being used by trusts for each of the eight surgical treatments ranging from 11 to 19 and the range for the most common code being used by trusts from 34% to 64%. Furthermore, a large number of trusts used multiple different codes for the same diagnosis or treatment of PFI. There is a lack of uniformity in how trusts code PFI diagnosis and treatment. Standardisation will enable further research involving focused analysis of trust databases to facilitate a better understanding of the epidemiology of this condition.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 09-2018
DOI: 10.1302/0301-620X.100B9.BJJ-2018-0174.R1
Abstract: This study reports on the medium- to long-term implant survivorship and patient-reported outcomes for the Avon patellofemoral joint (PFJ) arthroplasty. A total of 558 Avon PFJ arthroplasties in 431 patients, with minimum two-year follow-up, were identified from a prospective database. Patient-reported outcomes and implant survivorship were analyzed, with follow-up of up to 18 years. Outcomes were recorded for 483 implants (368 patients), representing an 86% follow-up rate. The median postoperative Oxford Knee Score (0 to 48 scale) was 35 (interquartile range (IQR) 25.5 to 43) and the median Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, 0 to 100 scale) was 35 (IQR 25 to 53) at two years. There were 105 revisions, 61 (58%) for progression of osteoarthritis. All documented revisions were to primary knee systems without augmentation. The implant survival rate was 77.3% (95% confidence interval (CI) 72.4 to 81.7, number at risk 204) at ten years and 67.4% (95% CI 72.4 to 81.7 number at risk 45) at 15 years. Regression analysis of explanatory data variable showed that cases performed in the last nine years had improved survival compared with the first nine years of the cohort, but the in idual operating surgeon had the strongest effect on survivorship. Satisfactory long-term results can be obtained with the Avon PFJ arthroplasty, with maintenance of patient-reported outcome measures (PROMs), satisfactory survival, and low rates of loosening and wear. Cite this article: Bone Joint J 2018 -B:1162–7.
Publisher: SAGE Publications
Date: 15-06-2022
DOI: 10.1177/26320843221106950
Abstract: To test the feasibility of undertaking a simultaneous Study Within A Trial (SWAT) to train staff who recruit participants into surgical randomised controlled trials (RCTs), by assessing key uncertainties around recruitment, randomisation, intervention delivery and data collection. Twelve surgical RCTs were eligible. Interested sites (clusters) were randomised 1:1, with recruiting staff (surgeons and nurses) offered training or no training. The primary outcome was the feasibility of recruiting sites across multiple surgical trials simultaneously. Secondary outcomes included numbers/types of staff enrolled, attendance at training, training acceptability, confidence in recruiting and participant recruitment rates six months later. Four RCTs (33%) comprising 91 sites participated. Of these, 29 sites agreed to participate (32%) and were randomised to intervention (15 sites, 29 staff) or control (14 sites, 29 staff). Research nurses attended and found the training to be acceptable no surgeons attended. In the intervention group, there was evidence of increased confidence when pre- and post- training scores were compared (mean difference in change 1.42 95% CI 0.56, 2.27 p = 0.002). There was no effect on recruitment rate. It was feasible to randomise sites across four surgical RCTs in a simultaneous SWAT design. However, as small numbers of trials and sites participated, and no surgeons attended training, strategies to improve these aspects are needed for future evaluations.
Publisher: Springer Science and Business Media LLC
Date: 12-2020
DOI: 10.1186/S13012-020-01063-2
Abstract: Clinical leadership is fundamental in facilitating service improvements in healthcare. Few studies have attempted to understand or model the different approaches to leadership which are used when promoting the uptake and implementation of evidence-based interventions. This research aims to uncover and explain how distributed clinical leadership can be developed and improved to enhance the use of evidence in practice. In doing so, this study examines implementation leadership in orthopaedic surgery to explain leadership as a collective endeavour which cannot be separated from the organisational context. A mixed-method study consisting of longitudinal and cross-sectional interviews and an embedded social network analysis will be performed in six NHS hospitals. A social network analysis will be undertaken in each hospital to uncover the organisational networks, the focal leadership actors and information flows in each organisation. This will be followed by a series of repeated semi-structured interviews, conducted over 4 years, with orthopaedic surgeons and their professional networks. These longitudinal interviews will be supplemented by cross-sectional interviews with the national established surgical leaders. All qualitative data will be analysed using a constructivist grounded theory approach and integrated with the quantitative data. The participant narratives will enrich the social network to uncover the leadership configurations which exist, and how different configurations of leadership are functioning in practice to influence implementation processes and outcomes. The study findings will facilitate understanding about how and why different configurations of leadership develop and under what organisational conditions and circumstances they are able to flourish. The study will guide the development of leadership interventions that are grounded in the data and aimed at advancing leadership for service improvement in orthopaedics. The strength of the study lies in the combination of multi-component, multi-site, multi-agent methods to examine leadership processes in surgery. The findings may be limited by the practical challenges of longitudinal qualitative data collection, such as ensuring participant retention, which need to be balanced against the theoretical and empirical insights generated through this comprehensive exploration of leadership across and within a range of healthcare organisations.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 05-2021
DOI: 10.1302/0301-620X.103B.BJJ-2020-1926.R1
Abstract: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay. We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87). TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021 -B(5):830–839.
Publisher: Elsevier BV
Date: 04-2013
DOI: 10.1016/J.ARTH.2012.07.008
Abstract: Our aim was to develop a patient reported outcome measure of satisfaction following total knee arthroplasty (TKA) and assess its correlation with Oxford knee score (OKS), Quality of life (EQ5D) and Visual analogue scale for pain (VAS). 172 patients with minimum 5year follow up post primary total knee arthroplasty completed CASI, OKS, EQ5D and VAS for pain. Receiver-operator curve analysis was performed to identify an OKS threshold of poor satisfaction defined by CASI rarely/never. The CASI showed positive correlation with the OKS, VAS for pain, and EQ5D, (Spearman's rho) 0.779 0.711 0.629. A threshold of 20 for the Oxford Knee score had 85% specificity and 85% sensitivity for poor satisfaction on CASI. The CASI is a useful measure of patient satisfaction following TKA.
Publisher: BMJ
Date: 04-2018
Publisher: BMJ
Date: 10-2018
DOI: 10.1136/BMJOPEN-2018-021650
Abstract: Despite multiple scandals in the medical implant sector, premarket testing has been the attention of little published research. Complications related to new devices, such as the DePuy Articular Surface Replacement (ASR, DePuy Synthes, USA), have raised the issue of how designs are tested and whether engineering standards remain up to date with our understanding of implant biomechanics. Despite much work setting up national joint registries to improve implant monitoring, there have been few academic studies examining the premarket engineering standards new implants must meet. Emerging global economies mean that the markets have changed, and it is unknown to what degree engineering standards vary around the world. Governments, industry and independent regulatory bodies all produce engineering standards therefore, the comparison of surgical implants across different manufacturers and jurisdictions is difficult. In this review, we will systematically collate and compare engineering standards for trauma and orthopaedic implants around the world. This will help inform patient, hospital and surgeon choice and provide an evidence base for future research in this area. This protocol is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will conduct a systematic review of trauma and orthopaedic engineering standards from four main sources of information as identified in our preliminary scoping searches: governments, industry, independent regulatory bodies and engineering and medical publications. Any current standard relevant to trauma and orthopaedic implants will be included. We will use a predefined search strategy and follow the recommendations of the Cochrane handbook where applicable. We will undertake a narrative synthesis with qualitative evaluation of homogeneity between engineering standards. No ethics approval is required as no primary data are being collected. The results will be made available by peer-reviewed publication and reported according to PRISMA-P guidelines.
Publisher: Springer Science and Business Media LLC
Date: 30-05-2021
DOI: 10.1007/S00590-021-03019-8
Abstract: There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears. To summarise the available qualitative evidence on patients’ experiences and expectations of meniscal tears. A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes). Two studies reporting semi-structured interviews from 34 participants (24 male 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions. This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients’ experiences of meniscal tears.
Publisher: Springer Science and Business Media LLC
Date: 05-02-2019
Publisher: Springer Science and Business Media LLC
Date: 06-07-2020
DOI: 10.1186/S40814-020-00635-9
Abstract: Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care ‘Personalised Knee Therapy’ (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability. The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). www.isrctn.com/ISRCTN14950321
Publisher: Elsevier BV
Date: 12-2019
DOI: 10.1016/J.KNEE.2019.11.007
Abstract: Patellar instability is a common condition, and recurrent instability can be highly disabling. It is important to understand the patho-anatomy of patellar instability in order to treat it effectively, with the trochlear shape, patellar height and the integrity of the medial retinaculum being the most important factors in determining the risk of ongoing instability. Clinical assessment is based around correct diagnosis of instability, identification of at risk features and an assessment of neuromuscular control and factors that may affect the potential for rehabilitation before or after surgery. Radiology is important to assess features predisposing to instability and to determine the best treatment plan for each in idual. There are a range of surgical options for the treatment of patellar instability and these should be chosen based on an each patients in idual patho-anatomy. Lateral release is not recommended as a treatment for patellar instability. Medial patello-femoral ligament reconstruction, tibial tubercle distalisation, trochleoplasty or occasionally tibial or femoral osteotomies for correction of rotational or coronal plane mal-alignment may all be used either in idually or in combination. High quality physiotherapy is an essential part of post-operative management and should address the whole of the kinetic chain, working on strength and control of the lower limbs to optimise balance and movement patterns in order to achieve the best results.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 03-2017
DOI: 10.1302/0301-620X.99B3.37884
Abstract: The Bereiter trochleoplasty has been used in our unit for 12 years to manage recurrent patellar instability in patients with severe trochlea dysplasia. The aim of this study was to document the outcome of a large consecutive cohort of patients who have undergone this operation. Between June 2002 and August 2013, 214 consecutive trochleoplasties were carried out in 185 patients. There were 133 women and 52 men with a mean age of 21.3 years (14 to 38). All patients were offered yearly clinical and radiological follow-up. They completed the following patient reported outcome scores (PROMs): International Knee Documentation Committee subjective scale, the Kujala score, the Western Ontario and McMaster Universities Arthritis Index score and the short-form (SF)-12. Outcomes were available for 199 trochleoplasties in 173 patients giving a 93% follow-up rate at a mean of 4.43 years (1 to 12). There were no infections or deep vein thromboses. In total, 16 patients reported further patella dislocation, giving an 8.3% rate of recurrence. There were 27 re-operations, giving a rate of re-operation of 14%. Overall, 88% were satisfied with the operation and 90% felt that their symptoms had been improved. All PROMs improved significantly post-operatively except for the mental component score of the SF-12. Trochleoplasty performed using a flexible osteochondral flap is an effective treatment for recurrent patellar instability in patients with severe trochlea dysplasia and gives good results in the medium term. Cite this article: Bone Joint J 2017 -B:344–50.
Publisher: Springer Science and Business Media LLC
Date: 13-05-2023
DOI: 10.1186/S13012-023-01274-3
Abstract: Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why. Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory. Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together. The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership. The review protocol is registered with PROSPERO (CRD42021230709).
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 06-2005
DOI: 10.1302/0301-620X.87B6.15672
Abstract: Biomechanical studies involving all-wire and hybrid types of circular frame have shown that oblique tibial fractures remain unstable when they are loaded. We have assessed a range of techniques for enhancing the fixation of these fractures. Eight models were constructed using Sawbones tibiae and standard Sheffield ring fixators, to which six additional fixation techniques were applied sequentially. The major component of displacement was shear along the obliquity of the fracture. This was the most sensitive to any change in the method of fixation. All additional fixation systems were found to reduce shear movement significantly, the most effective being push-pull wires and arched wires with a three-hole bend. Less effective systems included an additional half pin and arched wires with a shallower arc. Angled pins were more effective at reducing shear than transverse pins. The choice of additional fixation should be made after consideration of both the amount of stability required and the practicalities of applying the method to a particular fracture.
Publisher: BMJ
Date: 08-2020
DOI: 10.1136/BMJOPEN-2019-036247
Abstract: Meniscal tears are a common knee injury with an incidence of 60 per 100 000. Management of meniscal tears can include either non-operative measures or operative procedures such as arthroscopic partial meniscectomy (APM). Despite substantial research evaluating the effectiveness of APM in the recent past, little is known about the clinical course or the experiences of patients with a meniscal tear. To summarise the short to long-term patterns of variability in outcome in patients with a meniscal tear. To summarise the evidence on patient experiences of meniscal tears. In particular, we will focus on patient experiences of treatment options, treatment pathways and their views of the outcomes used in meniscal tear research. Two search strategies will be developed to identify citations from EMBASE, MEDLINE, AMED, CENTRAL, Web of Science and Sociofile. The date of our planned search is 14 August 2020. For the quantitative review we will identify studies reporting patient-reported outcome measures in patients after a meniscal tear. The standardised mean change will be used to assess the variation in size of response and summarise the overall response to each treatment option. All studies will undergo quality assessment using either the Cochrane risk of bias or the Newcastle-Ottawa tool. A qualitative systematic review will be used to identify studies reporting views and experiences of patients with a meniscal tear. All studies will be assessed using the Critical Appraisal Skills Programme tool and if sufficient data are present a meta-synthesis will be performed to identify first, second and third-order constructs. Given the nature of this study, no formal ethical approval will be sought. Results from the review will be disseminated at national conferences and will be submitted to a peer-reviewed journal for publication. Lay summaries will be freely available via the study Twitter page. CRD42019122179.
Publisher: SAGE Publications
Date: 10-2016
Abstract: The anatomy of the anterior cruciate ligament (ACL) has become the subject of much debate. There has been extensive study into attachment points of the native ligament, especially regarding the femoral attachment. Some of these studies have suggested that fibers in the ACL are of differing functional importance. Fibers with higher functional importance would be expected to exert larger mechanical stress on the bone. According to Wolff’s law, cortical thickening would be expected in these areas. To examine cortical thickening in the region of the ACL footprint (ie, the functional footprint of the ACL). Descriptive laboratory study. Using micro–computed tomography with resolutions ranging from 71 to 91 μm, the cortical thickness of the lateral wall of the intercondylar notch in 17 cadaveric knees was examined, along with surface topography. After image processing, the relationship between the cortical thickening and surface topology was visually compared. A pattern of cortical thickening consistent with the functional footprint of the ACL was found. On average, this area was 3 times thicker than the surrounding bone and significantly thicker than the remaining lateral wall ( P .0001). This thickening was roughly elliptical in shape (with a mean centroid at 23.5 h:31 t on a Bernard and Hertel grid) and had areas higher on the wall where greater thickness was present. The relationship to previously reported osseous landmarks was variable, although the patterns were broadly consistent with those reported in previous studies describing direct and indirect fibers of the ACL. The findings of this study are consistent with those of recent studies describing fibers in the ACL of differing functional importance. The area in which the thickening was found has been defined and is likely to represent the functional footprint of the ACL. This information is of value to surgeons when determining the optimal place to position the femoral attachment site of the reconstructed ACL.
Publisher: British Editorial Society of Bone & Joint Surgery
Date: 03-2013
DOI: 10.1302/0301-620X.95B3.30850
Abstract: The aim of this study was to examine the loading of the other joints of the lower limb in patients with unilateral osteoarthritis (OA) of the knee. We recruited 20 patients with no other symptoms or deformity in the lower limbs from a consecutive cohort of patients awaiting knee replacement. Gait analysis and electromyographic recordings were performed to determine moments at both knees and hips, and contraction patterns in the medial and lateral quadriceps and hamstrings bilaterally. The speed of gait was reduced in the group with OA compared with the controls, but there were only minor differences in stance times between the limbs. Patients with OA of the knee had significant increases in adduction moment impulse at both knees and the contralateral hip (adjusted p-values: affected knee: p 0.01, unaffected knee p = 0.048, contralateral hip p = 0.03), and significantly increased muscular co-contraction bilaterally compared with controls (all comparisons for co-contraction, p 0.01). The other major weight-bearing joints are at risk from abnormal biomechanics in patients with unilateral OA of the knee. Cite this article: Bone Joint J 2013 -B:348–53.
Publisher: Elsevier BV
Date: 10-2022
DOI: 10.1016/J.KNEE.2022.07.002
Abstract: Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. 35 studies were included, 28 reported outcomes following APM four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17 95 % CI 0.04, 0.29), however, this was not clinically significant. Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications.
Location: United Kingdom of Great Britain and Northern Ireland
Location: Australia
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Andrew Metcalfe.