Aims

This study examined windswept deformity (WSD) of the knee, comparing prevalence and contributing factors in healthy and osteoarthritic (OA) cohorts.

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

The April 2023 Spine Roundup³⁶⁰ looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

Aims

The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone.

There is a lack of evidence as to the best way to deliver rehabilitation following TKA. Previous work has suggested that postoperative physiotherapy applied to all patients is not effective at improving one-year post-surgical outcomes. The aim of this study was to target physiotherapy to those at risk of poor outcome following TKA, and to determine if a therapist-led intervention offered superior results compared to a home-exercise based protocol in this ‘at risk’ group. The Targeted Rehabilitation to Improve Outcomes (TRIO) study was a prospective randomised controlled trial run at 15-centres in the UK. Patients were identified as ‘potential poor outcome’ based on an Oxford Knee Score (OKS) classification at 6-weeks post-surgery and randomised to either therapist-led or home-exercise based protocols. Patients were reviewed by a physiotherapist and commenced 18-exercise sessions over 6-weeks. The therapist-led group undertook a progressive functional protocol (modified weekly in 1-1 contact sessions) in contrast to the static home-exercise based regime. Evaluation took place following rehabilitation intervention, then at 6-months and 1-year post-surgery. Primary outcome was comparative group OKS at 1-year. Secondary outcomes included, ‘worst’ and ‘average’ pain scores, OXS and EQ-5D, and satisfaction questionnaire. Health economic (cost-utility) analysis was undertaken from NHS perspective up to 1-year post-surgery. Incremental cost per Quality Adjusted Life Years (QALYs) were calculated from intervention costs, patient reported primary and secondary care usage, and EQ-5D data. 4264 patients were screened, 1296 were eligible, 334 patients were randomised, 8 were lost to follow-up, therapy compliance was >85%. Clinically meaningful improvement in OKS (between baseline and 1-year) was seen in both arms (p < 0 .001). Between group difference in 1-year OKS was 1.91 (95%CI, −0.17–3.99) points favouring the therapist-led arm (p=0.07). Incorporating all time point data, between group difference in OKS was 2.25 points (95%CI, 0.61–3.90, p=0.008). Small, non-significant reductions (< 5 %) in both worst and average pain scores were observed favouring the therapist-led group. Enhanced satisfaction with pain relief (OR 1.65, p < 0 .02), ability to perform daily functional tasks (OR 1.66, p < 0 .02), and perform heavy functional tasks (OR 1.6, p=0.04) was reported in the therapist-led group. There was a small non-significant difference of 0.02 points (95%CI −0.02–0.06) between groups in EQ-5D, resulting in a £12,125 cost per QALY of delivering the therapist led intervention with a 57% chance of being cost-effective at the standard UK policy threshold of £20,000 per QALY. TRIO is the largest randomised trial of physiotherapy following TKA, and the first to target rehabilitation to patients at risk of poor outcomes. Both therapist-led and home-exercise based rehabilitation groups made clinically meaningful improvements in outcome by 1-year. We observed a modest difference in OKS in favour of therapist-led rehabilitation compared to the home-exercises which was not statistically significant. The relatively tight confidence intervals suggests that any difference which might exist is too small to be clinically relevant. Patient satisfaction with outcome was however higher in those that received greater physiotherapist contact. While cost per QALY estimates were below UK policy threshold, this result is uncertain and insufficient to make accept-decline recommendations

Purpose. Patient expectations of total knee arthroplasty (TKA) can be managed through education. E-learning is the application of information technology to education. Providing information to patients at the place and time of their choosing, e-learning has the potential to broaden the reach of existing services for patients. This study evaluated whether an e-learning tool could affect whether patients felt their expectations were met and whether they were satisfied with surgery one year following primary TKA. Method. We recruited consecutive patients with osteoarthritis and randomized them to either standard patient education (n=207), or to our standard patient education plus a new e-learning tool (n=209). Preoperative measures were completed following the patients’ Pre-Admission clinic (PAC) visit and prior to accessing the e-learning tool. Postoperative patient reported outcome measures (PROMs) were completed at six weeks, three months and one year after TKA. We used the Postoperative Expectation Questionnaire to measure the degree to which patient expectations had been met and the Patient Acceptable Symptom State (PASS) question to measure patient satisfaction at one year postoperative. We collected several PROMs for descriptive purposes including: new Knee Society Knee Scoring System (KSS); (Pre-Op and Post-Op versions), Knee injury and Osteoarthritis Outcome Score (KOOS), the Medical Outcomes Study 12-Item Short Form Health Survey, version 2 (SF-12), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), University of California at Los Angeles (UCLA) Activity Score, and the Social Role Participation Questionnaire (SRPQ). Results. Both groups were similar with respect to their preoperative PROMs. Preoperative patient satisfaction was low, with few patients satisfied with their present state prior to TKA and similar between groups (14% intervention group, 11% control group). At one year postoperatively, the risk that expectations of patients were not met was 21.8% in the control group and 21.4% in the intervention group for a risk difference of 1.3% (95% CI −7.8% to 10.4%, p = 0.78). The proportion of patients satisfied with their TKA at one year postoperative was similar in the intervention group 78.6% and the control group 78.2%, and the risk difference 0.6% (95% CI −8.4% to 9.6%) was not statistically significant (p = 0.78). At one year postoperative we found significant postoperative between-group differences in favour of the control group for the new KSS symptoms score and the functional activities score. We also found that control patients had less anxiety, lower scores for rumination, magnification, and helplessness than intervention patients on the PCS. Conclusion. Patients randomized to the e-learning tool had significantly better KSS symptom scores and functional activities scores as well as lower anxiety and helplessness scores but they did not have a reduced risk of expectations not being met or an improved overall satisfaction with their TKA

Introduction

Cementless tapered wedge stems have shown excellent results over the last decade. Distal potting with inadequate proximal fit, as well as failure to achieve biologic fixation has led to thigh pain, loosening and implant failure. To support a variety of patient morphologies a novel tapered wedge stem was designed with reduced distal morphology, maximizing the proximal contact of the grit blasted surface. The objective of the study was to analyze the clinical outcomes of this stem design.

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour.

The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195).

In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients.

In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%).

VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated.

Cite this article: Bone Joint J 2015;97-B:853–61.

Satisfaction with care is important to both patients and to those who pay for it. The Net Promoter Score (NPS), widely used in the service industries, has been introduced into the NHS as the ‘friends and family test’; an overarching measure of patient satisfaction. It assesses the likelihood of the patient recommending the healthcare received to another, and is seen as a discriminator of healthcare performance. We prospectively assessed 6186 individuals undergoing primary lower limb joint replacement at a single university hospital to determine the Net Promoter Score for joint replacements and to evaluate which factors contributed to the response.

Achieving pain relief (odds ratio (OR) 2.13, confidence interval (CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR 2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI 2.03 to 2.68) are the domains that explain whether a patient would recommend joint replacement services. These three factors, combined with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17), drove a predictive model that was able to explain 95% of the variation in the patient’s recommendation response. Though intuitively similar, this ‘recommendation’ metric was found to be materially different to satisfaction responses. The difference between THR (NPS 71) and TKR (NPS 49) suggests that no overarching score for a department should be used without an adjustment for case mix. However, the Net Promoter Score does measure a further important dimension to our existing metrics: the patient experience of healthcare delivery.

Cite this article: Bone Joint J 2014;96-B:622–8.

The December 2012 Research Roundup³⁶⁰ looks at: whether the rheumatoid factor is just a ‘quick test’; osteonecrosis in smokers; pasteurisation effect on bone reconstruction; venous thromboembolism risk in rheumatoids; whether stem cells reverse age-related osteopenia; the effect of running on rat knees; rapid fracture healing in rats with ultrasound; magnetic stem cells; and the safety of surgery.

Purpose

Introduce an Integrated Approach for Orthopedic-Sports Medicine Practice and Patient Care Management that

Is built around effective and efficient surgical techniques, and patient care management processes

Integrates Operations and Service Excellence best practices with patient care management processes

Integrates orthopedic care delivery between outpatient clinic, pre-surgery, surgery, inpatient, (acute care) and post acute care settings

Delivers exceptional clinical, patient satisfaction and financial outcomes as validated by independent national healthcare benchmarking organization

Helps position Ortho-Sports medicine services for strategic growth

Is replicable to develop Ortho-Sports Medicine Centers of Excellence

Presentation illustrates the ‘Ten Elements’ approach to implement the Ortho-Sports Medicine Centers of Excellence and demonstrate the effectiveness of the approach with an outcomes study from over 1000 total knee arthroplasty (TKA) procedures. During the presentation, the speakers would share the key clinical, patient satisfaction, and financial outcomes achieved by the implementation of the best practices defined in our ‘Ten Elements’ approach. All performance data elements are collected, validated and analyzed by an independent third party, national healthcare benchmarking company.

During the presentation Dr. Bramlett would elaborate on the surgical protocol, and the key differentiating steps in procedure technique from traditional approach that significantly enhances procedure effectiveness, efficiency and lowers the patient complication rate as demonstrated by benchmarking data. Speakers would further present the key elements of Total Knee Arthoplasty procedure that focus on patient education, patient participation in pre-surgical weight loss and pre-habilitation program, anesthesia approach, avoiding tourniquet use and deep veen thrombosis (DVT) risk reduction, early post operative patient ambulation and weight bearing, and post operative patient management approach. On average the ortho-sports medicine clinical of Alabama TKA patients are disharged from the hospital in 2.6 days, and experience 65 percent less complications than expected for a similar patient population and assume early control of their independent functionality.

Introduction. The objective of this study was to verify the long-term outcome of transtrochanteric anterior rotational osteotomy (ARO) for osteonecrosis of the femoral head (ONFH) in young patients with systemic lupus erythematosus (SLE). Methods. Consecutive series of 21 symptomatic ONFH patients with SLE (33 hips), aged 20 to 40 years, underwent ARO between 1980 and 1988. We reviewed the cases of 16 patients (25 hips), which represents a 76% rate of follow-up. Patients included 4 men and 12 women who had a mean age of 29 years at the time of surgery. A Kaplan-Meier curve was used for the survivorship analysis of ARO. Patients with surviving hips were evaluated by the modified Oxford hip score and the Medical Outcomes Study Short Form 36 (SF-36). Results. Twelve hips in 8 patients survived at the final follow-up. The average length of surviving was 25 years (range, 20 to 27 years). Three patients (6 hips) had died of unrelated causes without any conversion at the mean time of 9 years after ARO. Based on Kaplan-Meier analysis with the end point defined as any conversion, the survival rate at 25 years was 73.7% (95% confidence interval, 53.9 to 93.5%). Based on the classification of the modified Oxford hip score, 5 hips were classified as excellent, 2 hips were good, and the remaining 5 hips were fair. The average SF-36 physical component summary score was 34 points and the average mental component summary score was 46 points. The physical component summary scores of 3 patients (53.0, 56.6, 57.1) exceeded the level of the Japanese population norm. Conclusion. In ONFH patients with SLE, ARO achieved a 73.7% survival rate at 25 years

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

Background and purpose. The musculoskeletal system is a common, but often overlooked, cause of chest pain. Little is known about the efficacy of spinal manipulation for this condition. The purpose of the present study is to evaluate the relative effectiveness of two conservative treatment approaches for acute musculoskeletal chest pain, 1) a spinal manipulation-based therapy as a typical example of chiropractic treatment and 2) self-management as an example of minimal intervention. Methods and results. In a non-blinded, randomised controlled trial set at an emergency cardiology department and four outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to four weeks of chiropractic treatment or self-management, with post-treatment questionnaire follow-up four and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale). Secondary measures included Medical Outcomes Study Short Form 36 (SF-36) scores, change in pain intensity (chest, thoracic spine, neck and shoulder/arm), and self-perceived change in general health. Preliminary results will be available at the time of presentation. Conclusions. This is the first randomised controlled trial assessing chiropractic treatment versus a minimal intervention in patients with musculoskeletal chest pain. Results will indicate whether chiropractic treatment is a useful option for patients with musculoskeletal chest pain, but the design does not allow for standardisation of treatment or identification of potentially active ingredients of care

Purpose: The treatment of extension type II pediatric supracondylar humerus fractures remains controversial. Some argue that closed reduction and cast immobilization is sufficient to treat these fractures, while others advocate closed reduction and pinning. The purpose of this radiographic outcomes study was to determine whether closed reduction and cast immobilization could successfully obtain and maintain appropriate position of extension type II supracondylar humerus fractures.

Method: The radiographs of 1017 pediatric patients treated for supracondylar fractures between 1987 and 2007 were retrospectively reviewed. Pre-reduction, immediate post-reduction, and final radiographs of 155 extension type II fractures were measured in order to assess the position and alignment of the fracture fragments. Measurements included the anterior humeral line, humeral-capitellar angle, Baumann’s angle, the Gordon index, and the Griffet index. The latter two indices calculate the rotational instability of the fracture, which can be predictive of reduction loss. Patients were excluded if insufficient radiographs failed to allow complete assessment of the measurement parameters, or if open reduction was required.

Results: The average age of the subjects was 5.3 years (range 1–13 years) and had a mean follow-up of 5.3 months. Analysis of the final radiographs demonstrated that in 80% of subjects, the anterior humeral line remained anterior to the mid third segment of the capitellum (radiographic extension deformity), the mean humeral-capitellar angle was 23.8° (range – 11°–50°), the mean Baumann’s angle was 79.4° (range 62°–97°), the mean Gordon index was 4.59%, and 44% of subjects had a Griffet index between 1–3 (potentially indicative of unstable reduction due to malrotation of the fragments, which can allow the development of a cubitus varus deformity).

Conclusion: From this radiographic review, a significant proportion of fractures treated with closed reduction and cast immobilization failed to achieve anatomic position and alignment on final x-rays. However, the clinical significance of these results and the potential for long-term re-modeling of these fractures remains unknown.

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world.

Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage.

Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.

The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip and knee arthroplasty in improving patients’ self-reported quality of life. An age, sex and time of surgery matched cohort of patients who had undergone elective primary one-two level spinal decompression (n=90) with (n=26 /90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip (n=90) and knee (n = 90) arthroplasty for osteoarthritis were compared. The primary outcome measure was the preoperative and two year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire. There was no significant difference in the mean pre-operative Physical Component Summary (PCS) / Mental Component Summary between groups [Spine −32/43; Hip − 30/45; Knee 31/46 (p > 0.5)]. With the exception of the knee MCS (p=0.2), postoperative scores were significantly improved for all groups [Spine −40/53; Hip − 43/51; Knee 39/48 (p < 0.001)]. Overall the hip surgery had the great impact on PCS and the spine surgery on MCS. Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total joint arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis has a similar positive effect at two year follow up. This study provides data that supports the need advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip or knee

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches. Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS. AIM: To find out the affect of surgical approach on oxford hip score. Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem AND were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS. Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively. CONCLUSION: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches. Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS. Aim: To find out the affect of surgical approach on oxford hip score. Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem and were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS. Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively. Conclusion: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients

Background: The phenomenon of heterotopic ossification (HO) is a well-known complication of joint replacement surgery. However, the clinical associations and effects of HO in cervical arthroplasty are unclear. This study investigates the incidence of HO in cervical disc replacement, identifies potential associated risk factors, and assesses the relationship of HO with clinical outcomes. Method: The patient population (n=90; 39 men, 51 women; mean age 45 years; range 26–79 yr; standard deviation, 9.8 yr) was acquired from the original multi-center, prospective, observational Bryan Disc Study by the European Consortium. The presence of HO was defined in accordance with the McAfee classification based on cervical lateral x-rays at 12 months post surgery and interpreted by an independent neurosurgeon and a radiologist. Secondary outcome measurements included Odom’s criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey. Results: 16 out of the total 90 patients (17.8%) experienced HO. 6 patients (6.7%) experienced Grade 3 and 4 HO. 10 patients’ (11%) artificial discs demonstrated movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months post-operatively. 4 of these patients had HO of Grade 3 or 4. Male sex ([chi]. 2. = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01–1.19) were associated with development of HO. Discussion: HO is known to restrict movement of large joint and lumbar disc replacements. Our study demonstrates male sex and older age as potential risk factors in development of HO after cervical disc arthroplasty. There is a strong association between HO and subsequent loss of movement of implanted cervical artificial discs. Failure to preserve motion may expedite the onset of symptomatic adjacent segment level disease making this an important complication requiring further investigation. Grade 3 or 4 HO limited movement in 4.4% of patients