Abstract

Abstract

Aims

The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA).

This study aims to determine satisfaction rates after hip and knee arthroplasty in patients who did not initially respond to PROMs, characteristics of non-responders, and contact preferences to maximise response rates. We performed a prospective cohort study of 709 patients undergoing THA and 737 patients undergoing TKA in a single centre in 2018. EQ-5D health related quality of life score and Oxford Hip/knee scores (OHS/OKS) were completed preoperatively and at 1year postoperatively via post when satisfaction was also assessed. Univariate, multivariate and receiver operator curve analysis were performed.

151/709 (21.2%) hip patients were non-responders, 83 (55.0%) of whom were contactable. 108/737 (14.6%) knee patients were non-responders, 91 (84.3%) of whom were contactable. There was no difference in satisfaction after arthroplasty between initial non-responders and responders for hips (74/81 vs 476/516, p=0.847) or knees (81/93 vs 470/561, p=0.480). Initial and persistent non-response was associated with younger age, higher BMIs and significantly worse preoperative PROMS for both hip and knee patients (p=0.05). Multivariate analysis demonstrated that younger age, higher BMI and poorer pre-operative OHS were independently associated with persistent non-response to hip PROMs (p<0.05). For the entire cohort (n=1352) patients <67 years were less likely to respond to postal PROMs with OR 0.63 (0.558 to 0.711). Using a threshold of >66.4 years predicted a preference for contact by post with 65.4% sensitivity and 68.1% specificity (AUC 0.723 (0.647-0.799 95%CI, p<0.001)).

Most initial non-responders were ultimately contactable with effort. Satisfaction rates were not inferior in patients who did not initially respond to PROMs.

Aims

Golf is a popular pursuit among those requiring total hip arthroplasty (THA). The aim of this study was to determine if participating in golf is associated with greater functional outcomes, satisfaction, or improvement in quality of life (QoL) compared to non-golfers.

The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient reported outcome measures (PROMs) of the Olympia stem.

Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. PROMs were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score and patient satisfaction at mean 10-years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3 to 17.8) following THA to identify occurrence of complications or revision surgery for any cause.

Mean patient age at surgery was 68.0 years (SD 10.9, 31–93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). Stem survivorship at 10 years was 99.2% (95 % confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%–100%). The 15-year stem survival for aseptic loosening was 100%. Only one occurrence of peri-prosthetic fracture was identified, with no episodes of dislocation found. At a mean of 10 (SD 0.8, 8.7 –11.3) years follow-up, mean OHS was 39 (SD 10.3, range 7 – 48) and 94% of patients reported being very satisfied or satisfied.

The Olympia stem demonstrated excellent 10-year PROMs, very high rates of stem survivorship and negligible peri-prosthetic fracture and dislocation rate at final follow-up beyond 15 years.

Non-surgical osteoarthritis management includes analgesia escalation to oral opiates; however, tolerance can occur. This study aims to assess analgesic effects of opiate use pre-operatively and whether this influences outcome 1-year post-operatively in patients undergoing total hip/knee arthroplasty (THA/TKA).

This prospective study assessed 1487 patients undergoing primary THA (n=729) or TKA (n=758) for osteoarthritis, with 95 respectively reporting pre-operative opiate use >1 month. THA opiate users had significantly higher BMI (p=0.007) and more likely to suffer associated comorbidities. TKA opiate users were significantly younger (p<0.001), with higher BMI (p=0.019) and more likely to suffer associated comorbidities. Pre-operative quality of life (QoL) and joint specific function were significantly worse (Hip EQ-5D 0.17 vs 0.41, p<0.001, OHS 14.6 vs 21.2, p<0.001; Knee EQ-5D 0.27 vs 0.44, p<0.001, OKS 16.4 vs 21.4, p<0.001). Pre-operative pain was significantly worse in those taking opioids (Hip Pain VAS 42.73 vs 50.70, p<0.001; Knee Pain VAS 50.93 vs 53.36, p=0.30). Post-operatively the THA opiate group had significant improvement in EQ-5D (0.175, p<0.001) and OHS (6.5, p<0.001) but were significantly less improved than opiate naïve patients after adjusting for confounding (EQ-5D 0.10, p<0.001; OHS 3.2, p<0.001). TKA opiate group also had significant improvement in EQ-5D (p<0.001) and OKS (p<0.001) but were significantly less (EQ-5D 0.089, p<0.001; OKS 3.9, p<0.001) than opioid naïve patients.

Pre-operative opiate use was associated with significantly worse pre-operative QoL, joint specific function and worse subjective pain. Post-operatively, the opiate group had significantly lower improvement in their QoL and joint specific function.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

Successful return to work (RTW) is a crucial outcome after primary total knee arthroplasty (TKA) in patients under 65 years old. We aimed to determine whether TKA facilitated RTW in patients <65 years, whose intention was to return preoperatively.

We prospectively assessed 106 TKA patients under 65 years over a 1 year period both preoperatively and at 1 year following surgery. Patient demographics were collected including Oxford knee score, Oxford-APQ, VAS pain/health scores and EQ-5D. A novel questionnaire was distributed to delineate pre-operative employment status and post-operative intentions. This included questions on nature of pre and post-operative occupation, whether joint disease affected their ability to work and details of retirement plans and how this was affected by their knee.

69 patients intended to return to work following their TKA. Following arthroplasty, 57/69 patients (82.6%) returned to work at a mean of 16.4 weeks (SD 16.6). Univariate analysis showed significant factors facilitating RTW included, pre-operative oxford knee score, pre-operative Oxford-APQ score and pre-operative EQ-5D score. These were not predictive on multivariate analysis.

This study finds that TKA facilitates return to work in 83% of those who intend to return to work following their surgery. This could have significant positive and health and financial cost implications for the individual, health system and society.

To evaluate if clinical recovery following midshaft clavicle fracture is associated with nonunion and determine if this has superior predictive value compared to estimation at time of injury.

A prospective study of all patients (≥16 years) who sustained a displaced midshaft clavicle fracture was performed. We assessed patient demographics, injury factors, functional scores and radiographic predictors with a standardized protocol at six-weeks. Conditional-stepwise regression was used to assess which factors independently predicted nonunion at six-months post-injury determined by CT. The nonunion predictor six-week model (NUP6) was compared against a previously validated model based on factors available at time of injury (NUP0-smoking, comminution and fracture displacement).

200 patients completed follow-up at six months. The nonunion rate was 14% (27/200). Of the functional scores, the QuickDASH had the highest accuracy on receiver-operator-characteristic (ROC) curve analysis with a 39.8 threshold, above which was associated with nonunion (Area Under Curve (AUC) 76.8%, p<0.001).

On regression modelling QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort (n=80/200). Conversely if two or more were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%.

The NUP6 model appeared to have superior accuracy when compared to the NUP0 model on ROC curve analysis (AUC 87.3% vs 64.8% respectively).

Delayed assessment at six-weeks following displaced clavicle fracture enables a more accurate prediction of fracture healing.

The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches.

95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort.

53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds.

We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach.

Anterior knee pain (AKP) is the commonest complication of total knee arthroplasty (TKA). This study aims to assess whether sagittal femoral component position is an independent predictor of AKP after cruciate retaining single radius TKA without primary patellofemoral resurfacing.

From a prospective cohort of 297 consecutive TKAs, 73 (25%) patients reported AKP and 89 (30%) reported no pain at 10 years. Patients were assessed pre-operatively and at 1, 5 and 10 years using the short form 12 and Oxford Knee Score (OKS). Variables assessed included demographic data, indication, reoperation, patella resurfacing, and radiographic criteria.

Patients with AKP (mean age 67.0 (38–82), 48 (66%) female) had mean Visual Analogue Scale (VAS) Pain scores of 34.3 (range 5–100). VAS scores were 0 in patients with no pain (mean age 66.5 (41–82), 60 (67%) female). Femoral component flexion (FCF), anterior femoral offset ratio, and medial proximal tibial angle all differed significantly between patients with AKP and no pain (p<0.001), p=0.007, p=0.009, respectively). All PROMs were worse in the AKP group at 10 years (p<0.05). OKSs were worse from 1 year (p<0.05). Multivariate analysis confirmed FCF and Insall ratio <0.8 as independent predictors of AKP (R² = 0.263). Extension of ≥0.5° predicted AKP with 87% sensitivity.

AKP affects 25% of patients following single radius cruciate retaining TKA, resulting in inferior patient-reported outcome measures at 10 years. Sagittal plane positioning and alignment of the femoral component are important determinants of long-term AKP with femoral component extension being a major risk factor.

The primary aim of this study was to compare the knee specific functional outcome of partial compared with total knee replacement (TKR) for the management of patellofemoral osteoarthritis.

Fifty-four consecutive Avon patellofemoral replacements were identified and propensity score matched to a group of 54 patients undergoing a TKR with patella resurfacing for patellofemoral osteoarthritis. The Oxford knee score (OKS), the Short Form (SF-) 12 and patient satisfaction were collected (mean follow up 9.2 years). Survival was defined by revision or intention to revise.

There was no significant difference in the OKS (p>0.60) or SF-12 (p>0.28) between the groups. The TKR group was significantly less likely to be satisfied with their knee (95.1% versus 78.3%, OR 0.18, p=0.03). Length of stay was significantly (p=0.008) shorter for the Avon group (difference 1.8 days, 95% CI 0.4 to 3.2). The 10 year survival for the Avon group was 92.3% (95% CI 87.1 to 97.5) and for the TKR group was 100% (95% CI 93.8 to 100). There was no statistical difference in the survival rate (Log Rank p=0.10).

The Avon patellofemoral replacement have a shorter length of stay with a functional outcome and satisfaction rate that is equal to that of TKR. The benefits of the Avon need to be balanced against the increased rate of revision when compared with TKR.

The optimal approach for total hip arthroplasty (THA) remains controversial. We present the results of the Direct Superior Approach (DSA), an improved variation of the posterior approach with high levels of stability, patient-reported functional outcomes, and satisfaction.

This is a single-surgeon prospective series. All patients undergoing THA between 2010 and 2015 via the DSA were included. Complication data was collected by interrogation of the Scottish Arthroplasty Project national joint registry. Pre and one-year post-operative Oxford Hip Score (OHS), Euroqol-5D (EQ-5D), and patient satisfaction questionnaires were collected.

659 patients received a THA via the DSA during the study period. Average age was 61.8 years (range 16.4–93.3). Analysis of registry data revealed no cases of dislocation, 5 cases of venous thromboembolism (0.75%), and 5 cases of deep infection (0.75%). 586 patients (88.9%) underwent their surgery in the National Health Service, and post-operative outcomes were available for 337 of these patients (57.5% follow-up) at one year. Average improvement in OHS and EQ-5D was 20 (range −14 – 48) and 0.39 (−0.697–1.2) respectively. 311 patients (92.3%) were satisfied.

This description of the DSA is accessible to all surgeons, confers excellent stability with no dislocations, and is associated with excellent post-operative functional outcomes and patient satisfaction.

Objectives

The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient’s recollection of their own preoperative OHS and OKS one year following surgery.

Aim

To evaluate the association of BMI and improvement in patient-reported outcomes after TKA.

Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision.

Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery.

Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort.

Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome.

In the UK, the posterior approach (PA) and direct lateral approach (DLA) are the most common total hip arthroplasty (THA) procedures. Few studies however, have compared the subsequent functional outcomes. This exploratory study aimed to examine the effect of PA and DLA approaches on post-operative hip kinematics, strength and hip muscle cross-sectional area (CSA), compared to healthy controls.

Participants comprised of 15 cases in the DLA group, > 12 month post-operatively, (ten male, age 68.9+/-5.5 years, BMI 26.9+/-3.0), 13 cases in the PA group (six male; age 72.9+/-6.9 years, BMI 27.1+/-3.6) and 11 age/BMI-matched healthy control participants. All participants underwent 3D kinematic (Vicon, Oxford, UK) and kinetic (AMTI, USA) analysis whist performing self-selected and fast walking as well as sit-to-stand and stand-to-sit. Isometric dynamometry was performed (Biodex Medical systems, USA) for all major muscle groups around the operated hip, and a subset of five participants (three DLA v two PA) underwent “slice encoding for metal artefact correction” (SEMAC) MRI imaging to measure muscle CSA. Patient-reported outcome measures were collected.

Both post-operative surgical groups exhibited altered gait, particularly in limited hip extension, compared to the control participants. The DLA group demonstrated forced hip extension matching controls only under fast walking conditions while the PA group did not achieve hip extension. Both surgical approaches achieved high PROMs scores.

The PA group were weaker for all strength activities tested, whereas the DLA cases demonstrated similar hip strength to controls. SEMAC imaging revealed reduced CSA for those muscles dissected during surgery, compared to the contralateral side.

This exploratory study demonstrated small but measurable differences between surgical approaches for muscle CSA, hip strength of major hip muscle groups and a number of gait variables, although both approaches produce satisfactory functional outcomes for patients after surgery.

Background

Hip arthroplasties are associated with high postoperative pain scores. In some reports, moderate to severe pain was 58% on the first day postoperatively in total hip replacements (THRs). Several techniques are currently used at our institution to tackle acute pain following THRs. These include: 1) Spinal anaesthetic (SA) with Diamorphine only; 2) General anaesthetic (GA) only; 3) SA with local infiltration anaesthetic mixture 1 (LIA1,). Mixture 1 consisted of ropivacaine, adrenaline, and ketorolac; 4) SA with LIA mixture 2 (LIA2). Mixture 2 consisted of bupivacaine and adrenaline; 5) SA with LIA1 and PainKwell pump system. In this study we report on the techniques of acute pain control following THR at our regional centre for elective primary THRs.

Introduction

Total knee arthroplasty (TKA) is a successful procedure for end stage arthritis of the knee that is being performed on an exponential basis year after year. Most surgeons agree that soft tissue balancing of the TKA is a paramount to provide a successful TKA. We utilized a set of retrieved lower extremities with an existing TKA to measure the laxity of the knee in all three planes to see if wear scores of the implants correlated to the laxity measured. This data has never been reported in the literature.