Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and 15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons.
A number of postoperative complications of navigated total knee arthroplasty have been discussed in the literature, including tracker pin site infection and fracture. In this paper we discuss the low postoperative complication rate in a series of 3100 navigated total knee arthroplasties and the overall complication rate in a systematic analysis of the literature. 3100 consecutive patients with navigated total knee arthroplasties from 2001 to 2016 were retrospectively evaluated for complications specific to navigation. We discuss the two cases of postoperative fracture through tracker pin sites that we experienced and compare this systematically to the literature.Abstract
Methods
Implementation fidelity (IF) is the extent to which an intervention is implemented as intended by its developers, and increases confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. The aim of this study was to evaluate the IF within a behaviour-change self-management intervention for people with chronic low back pain and/or osteoarthritis, consisting of six weekly sessions (SOLAS ISRCTN49875385). In a sample of data, the intervention was delivered by physiotherapists (n=9) in seven sites. IF was assessed using self-report (by physiotherapists) of all sessions (n=60), direct observations (by the research team) of 40% of the sessions (n=24) and audio-recorded observations (by the research team) of all sessions (n=60) using checklists. Data were analysed in SPSSv20 to assess % agreement between methods and fidelity scores.Purpose and background:
Methods:
Unicompartmental Knee Arthroplasty (UKA) has been offered as a tissue sparing alternative to total knee arthroplasty (TKA) for treatment of early to mid-stage osteoarthritis (OA). While the spared tissue and retention of cruciate ligaments may result in faster recovery, smaller incision, less bone resection, decreased pain and blood loss and more normal kinematics and function, UKA has shown unpredictable results in practice, which may be due to variations in surgical techniques1. Recently a robotic-assisted technique has been introduced as a means to provide more consistent and reproducible surgical results. In this study, the early return to function was measured to determine proposed benefits between UKA and TKA. Patients requiring either UKA or TKA were prospectively enrolled in this IRB approved study. Each patient received pre-operative education regarding their expected physical therapy (PT) regimen, which was uniform for all patients. PT was determined to be concluded when each patient reached an achievable functional endpoint with each of the following 5 criteria: range of motion from 5 to 115 degrees, recovery of flexion and extension strength to 4/5 of pre-operative strength, gait with minimal limp and without an assistive device for 250 feet and ability to ascend and descend a flight of stairs with step over gait and good control. The number of PT visits to reach each functional goal was recorded.Introduction
Methods
Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA. A two phase search strategy of electronic databases was used to identify systematic reviews and studies relevant to this area. Articles were coded independently for their use of behaviour change theory, and the number of behaviour change techniques (BCTs) was identified using a 93 item taxonomy, Taxonomy (v1).Background
Methods
Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important in increasing confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. Growing demands on healthcare services mean that multiple condition interventions involving highly prevalent musculoskeletal pain conditions such as chronic low back pain (CLBP) and/or osteoarthritis (OA) are of increasing clinical interest. This is the first in-depth review of implementation fidelity within self-management interventions for any musculoskeletal pain condition. Structured self-management interventions delivered by health-care professionals (including at least one physiotherapist) in a group format involving adults with OA of the lumbar spine, hip or knee and/or CLBP were eligible for inclusion. The National Institutes of Health Behaviour Change Consortium Treatment Fidelity checklist was used by two independent reviewers to assess fidelity.Background
Methods
Osteoarthritis (OA) and chronic low back pain (CLBP > 12 weeks duration) are two of the most common and costly chronic musculoskeletal conditions globally. Healthcare service demands mean that group-based multiple condition interventions are of increasing clinical interest and a priority for research, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions concurrently. Rapid review methodologies are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions. The electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Register of Controlled Trials were searched from the earliest date possible to August 26th 2013. Structured group-based interventions that aimed to promote self-management and that were delivered by health-care professionals (including at least one physiotherapist) involving adults with OA and/or CLBP were eligible for inclusion. The screening and selection of studies, data extraction and risk of bias assessment were conducted independently by two reviewers.Background
Methods
The CONNECT trial evaluated a theory-based intervention to increase low back pain patients' adherence to treatment recommendations through physiotherapists' communication behaviour. Bridging the gap between evidence and evidence-based practice, we aimed to develop an implementation intervention to support physiotherapists in translating the CONNECT communication training into practice. A systematic approach was used to develop this intervention. 1. Focus groups underpinned by the Theoretical Domains Framework were conducted to assess CONNECT trained physiotherapists' (n = 9) perceptions of the barriers and enablers to implementing these strategies in practice; the results of which yielded four main domains; two related to factors outside the individual (i.e. social influences and environmental resources), and two related to individuals' motivation and capabilities (i.e. self –efficacy and behavioural regulation). 2. Intervention components (i.e., behavior change techniques (BCT) and mode of delivery) were chosen. BCTs were mapped to the identified domains (e.g., the BCT of self-monitoring mapped to the self-efficacy domain) and audit and feedback focused coaching was selected as the main mode of delivery based on empirical evidence and feasibility. 3. Outcome measures were selected to evaluate the proposed changes in physiotherapist practice (i.e., Health Care Climate Questionnaire). This intervention was trialed with physiotherapists (n = 2) using a case-study design. Results from patient consultation audio-recordings and follow-up interviews revealed this intervention supported the translation of evidence-based training into practice and is considered feasible and acceptable to physiotherapists.Purpose of the study and background
Methods and results
Circumferential pelvic binders have been developed to allow rapid closure of the pelvic ring in unstable fracture patterns. Despite evidence to support the use of pelvic binders, there is a paucity of clinical data regarding the effect of binder position on symphyseal diastasis reduction. All patients presenting to the UK's military hospital in Afghanistan who survived and underwent pelvic radiography were reviewed. Cases were identified by retrospective assessment of all digital plain pelvic radiographs performed between January 2008 and July 2010. All radiographs and CT images were assessed to identify the presence of any pelvic fracture. Patients were grouped into three categories according to the vertical level of the buckle: superior to the trochanters (high), inferior to the trochanters (low) and at the level of the trochanters (troch). Diastasis reduction was measured in patients with Anterior-Posterior Compression (APC) grades II and III, or Combined Mechanical Injuries(CMI). Comparison of diastasis reduction between the high and troch groups was assessed by an independent samples Student's t-test. We identified 172 radiographs where the metallic springs in the buckle of a SAM Pelvic Sling™ were clearly visible. The binders were positioned at the trochanteric level in 50% of radiographs. A high position was the commonest site of inaccurate placement (37%). In the patients with fractures and an open diastasis, the mean pelvic diastasis gap was 2.75 times greater in the high group compared to the trochanteric level (mean difference 22 mm) (p < 0.01). Application of pelvic binders superior to the greater trochanters is commonplace and associated with inadequate fracture reduction, which is likely to delay cardiovascular recovery in these significantly injured casualties.
Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations. Between 2003 and 2008 twenty one patients underwent EPR following referral to the Oxford Sarcoma Service following lower limb trauma. The average age was 71 years (44–87). The average number of previous surgical procedures was 3 (range 0–11). The mean Harris Hip Score was 89.5 (range 64–85). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout. EPR is an effective salvage procedure for failed trauma fixation and periprosthetic fractures. Immediate weight bearing and a good functional outcome can be expected in this difficult group of patients.
The infrapatellar (Hoffa’s) fat pad can be affected by a variety of tumours and tumour-like conditions which can occasionally present a diagnostic and therapeutic challenge to the treating surgeon. The fat pad can be affected by diffuse or solitary disease. Solitary tumours are relatively uncommon but with widespread uptake of Magnetic Resonance Imaging Scans (MRI) an increasing number of Hoffa’s fat pad tumours (HFP) are being recognized. Between 1999 and 2008, 20 patients with HFP pathology referred to Oxford bone and soft tissue tumour service underwent resection and histological examination. Clinical records, imaging and histological findings were reviewed. Histology showed eight different diagnoses with Pigmented Villonodular Synovitis (PVNS) and ganglia being the most common pathology. In one patient, MRI identified the cause of hypophosphataemic osteomalacia as an HFP phosphaturic mesen-chyma tumour despite the lack of local symptoms. In conclusion, the majority of solitary HFP tumours are benign and maybe cystic or solid. MRI and plain radiographs are the imaging of choice. Cystic tumours maybe aspirated but the definitive treatment of both cystic and solid tumours should be open arthrotomy and excision biopsy. Arthroscopic resection is not advised, as complete excision is not always possible. None of the 20 patients in this series had a malignant tumour but this has been reported in the literature. Calcification on plain radiographs may indicate a malignant lesion. All patients in our series reported substantial improvement in symptoms following open tumour resection.
Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months). Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed. No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion. Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.
Our study looked at the short and medium-term results of a new and cost-effective method of bone surface preparation and cement introduction. Early failure and loosening of components in knee arthroplasty has been attributed to inadequate bone-cement and prosthesis- cement interfaces, established at the time of surgery. Cement pressurisation and interosseus suction have been shown to achieve effective cement penetration and interdigitation into cancellous bone. We have devised a technique of cement pressurisation using a modified 20 ml syringe, combined with interosseus suction. Retrospective evaluation of a series of 50 post-operative radiographs of total knee replacements, undertaken without the use of tourniquet, have shown that even and effective penetration of cement to a depth of 8.0 10.6 mm can be achieved consistently using this technique. Evaluation of post-operative radiographs at a minimum of 5 years follow-up showed 16 knees with minor lucent lines about the tibial component with a maximum Knee Society Total Knee Arthroplasty Roentgenographic Score of 2. In conclusion, we propose that this simple technique of bone surface preparation and cement introduction produces good results in the short and medium term. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
In the deceased patients 2 patients had undergone revision and the remaining patients had died of causes unrelated to the surgery with the prosthesis intact. There was 1 permanent ulnar nerve palsy and two deep infections one requiring debridement. Eight of the original 44 primaries required revision, 3 for fractures and 5 for loosening.
Among our patients we emphasise that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.
