Aims

Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

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Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Aims

During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon’s decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.

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The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

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Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care.

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies. Cite this article: Bone Joint J 2024;106-B(2):114–120

Aims

To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

In-hospital length of stay (LOS) and discharge disposition following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, we wished to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge disposition following robotic-arm assisted (RO THA) versus conventional technique Total Hip Arthroplasty (CO THA). This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge disposition was comparable between the two groups. In the multivariate model, age, need for PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days. Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in discharge destination. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies

The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime. IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation

Aims

Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

While pre-soaking grafts in vancomycin has demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. The primary aim of this study was to determine the cost-effectiveness of vancomycin pre-soaking during primary ACLR to prevent post-operative joint infections. The secondary aims of the study were to establish the breakeven cost-effectiveness threshold of the technique. A Markov model was used to determine cost effectiveness and the incremental cost effectiveness ratio of additional vancomycin pre-soaking compared to intravenous antibiotic prophylaxis alone. A repeated meta-analysis of nine cohort studies (Level III evidence) was completed to determine the odds ratio of infection with vancomycin pre-soaking compared to intravenous antibiotics alone. Estimated costs and transitional probabilities for further surgery were obtained from the literature. Breakeven threshold analysis was performed. The vancomycin soaking technique provides an expected cost saving of $600AUD per patient. There was an improvement in the quality-adjusted life years of 0.007 compared to intravenous antibiotic prophylaxis alone (4.297 versus 4.290). If the infection rate is below 0.023% with intravenous antibiotics alone or the additional intervention cost more than $1000AUD, the vancomycin wrap would no longer be cost-effective. For $30AUD, the vancomycin soaking technique provides a $600AUD cost saving by both reducing the risk of ACLR related infection and economic burden of infection. Treating septic arthritis represents a mean cost per patient of 6 times compared to that of the primary surgery. There has been no previous cost-effectiveness study of the vancomycin wrap technique. The vancomycin pre-soaking technique is a highly cost-effective method to prevent post-operative septic arthritis following primary ACLR

The February 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

Aims. Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon. Methods. SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments. Discussion. There is currently no high-quality evidence comparing the clinical and cost effectiveness of the tension suture repair to the traditional tension band wiring currently offered for the internal fixation of displaced fractures of the olecranon. The Simple Olecranon Fracture Fixation Trial (SOFFT) is a randomized controlled trial with sufficient power and design rigour to provide this evidence for the subtype of Mayo grade IIA fractures. Cite this article: Bone Jt Open 2023;4(1):27–37

Aims. The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness. Methods. A group of 130 patients who had received an AP tibial component were matched for demographic factors of age, BMI, American Society of Anesthesiologists (ASA) grade, sex, and preoperative Knee Society Score (KSS) to create a comparison group of 130 patients who received a MB tibial component. Functional outcome was assessed prospectively by KSS, quality of life by 12-Item Short-Form Health Survey questionnaire (SF-12), and range of motion (ROM), and implant survivorships were compared. The SF six-dimension (6D) was used to calculate the incremental cost effectiveness ratio (ICER) for AP compared to MB tibial components using quality-adjusted life year methodology. Results. The AP group had a mean KSS-Knee of 83.4 (standard deviation (SD) 19.2) and the MB group a mean of 84.9 (SD 18.2; p = 0.631), while mean KSS-Function was 75.4 (SD 15.3) and 73.2 (SD 16.2 p = 0.472), respectively. The mental (44.3 vs 45.1; p = 0.464) and physical (44.8 vs 44.9; p = 0.893) dimensions of the SF-12 and ROM (97.9° vs 99.7°; p = 0.444) were not different between the groups. Implant survivorship at five years were 99.2% and 97.7% (p = 0.321). The AP group had a greater SF-6D gain of 0.145 compared to the MB group, with an associated cost saving of £406, which resulted in a negative ICER of -£406/0.145 = -£2,800. Therefore, the AP tibial component was dominant, being a more effective and less expensive intervention. Conclusion. There were no differences in functional outcomes or survivorship at five years between AP and MB tibial components in patients aged 70 years and older, however the AP component was shown to be more cost-effective. In the UK, only 1.4% of all total knee arthroplasties use an AP component; even a modest increase in usage nationally could lead to significant financial savings. Cite this article: Bone Jt Open 2022;3(12):969–976

Purposes of the study and background. Cognitive Functional Therapy (CFT) is a psychologically informed, physiotherapist-led intervention that targets the biopsychosocial complexity of persistent low back pain (LBP). CFT has demonstrated positive outcomes in two randomised controlled trials (RCT) but has not previously been evaluated in the United Kingdom National Health Service (NHS). This study aimed to determine the feasibility of completing a definitive RCT, that will evaluate the clinical and cost-effectiveness of CFT in comparison to usual physiotherapy care (UPC) for people with persistent LBP in the NHS. Methods and results. A two-arm parallel feasibility RCT compared CFT with UPC in participants with persistent LBP. Data concerning study processes, resources, management and patient reported outcome measures (disability, pain intensity, quality of life and psychosocial function) were collected at baseline, three and six-month follow-up, analysed and evaluated in order to establish feasibility. Sixty participants (n=30 CFT and n=30 UPC) were recruited with 71.6% (n=43) retained at six-month follow-up. CFT was delivered to fidelity, relevant and clinically important outcome data were rigorously collected and CFT was tolerated by participants with no safety concerns. The Roland-Morris disability questionnaire was the most suitable primary outcome measure and sample size calculations were completed for a definitive RCT. Intention to treat analysis indicated a signal of effect in favour of CFT with moderate and large between group effect sizes observed across outcome measures at six-month follow-up. Conclusion. It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future fully powered clinical and cost effectiveness RCT could be completed. Conflicts of interest: No conflicts of interest. Sources of funding: Chartered Society of Physiotherapy, Physiotherapy Research Foundation

Aims

The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults.