The importance of cup position on the performance of total hip replacements (THR) has been demonstrated in Pelvic movement data for walking for 39 unilateral THR patients was acquired (Leeds Biomedical Research Centre). Patient's elected walking speed was used to group patients into high- and low-functioning (mean speed, 1.36(SD 0.09)ms−1 and 0.85(SD 0.08)ms−1 respectively). A computational algorithm (Python3.7) was developed to calculate cup version during gait cycle. Inputs were pelvic angles and initial cup orientation (assumed to be 45° inclination and 7° version, anterior pelvic plane was parallel to radiological frontal plane). Outputs were cup version angles during a gait cycle (101 measurements/cycle). Minimum, maximum and average cup version during gait cycle were measured for each patient. Two-sample t-test (p=0.05) was used to compare groups.Abstract
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Clavicle fractures are common, yet debate exists regarding which patients would benefit from conservative versus operative management. Traditionally shortening greater than 2cm has been accepted as an indicator for surgery. However, clavicle length varies between individuals. In a cadaveric study clavicle shortening greater than 15% was suggested to affect outcomes. There is no clinical correlation of this in the literature. In this study we investigate outcomes following middle third clavicle fractures and the effect of percentage shortening on union rates. We identified a consecutive series of adults with primary midshaft clavicle fractures presenting to our institution from April 2015-March 2017. Clinical records and radiographs were reviewed to elicit outcomes. Time to union was measured against factors including; percentage shortening, displacement, comminution and smoking. Statistical significance was calculated.Abstract
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The mechanisms underlying abnormal joint mechanics are poorly understood despite it being a major risk factor for developing osteoarthritis. This study investigated the response of a 3D in vitro bone cell model to mechanical load. Human MSC cells (Y201) embedded in 3D type I collagen gels were differentiated in osteogenic media for 7-days in deformable, silicone plates. Gels were loaded once (5000 µstrain, 10Hz, 3000 cycles), RNA extracted 1-hr post load and assessed by RT-qPCR and RNAseq analysis (n=5/treatment). Cell shape and phenotype were assessed by immunocytochemistry and phalloidin staining. Data was analysed by Minitab.Abstract
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A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures. A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods.Aims
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Excessive standing posterior pelvic tilt (PT), lumbar spine stiffness, low pelvic Incidence (PI), and severe sagittal spinal deformity (SSD) have been linked to increased dislocation rates. We aimed to compare the prevalence of these 4 parameters in unstable and stable primary Total Hip Arthroplasty (THA) patients. In this retrospective cohort study, 40 patients with instability following primary THA for osteoarthritis were referred for functional analysis. All patients received lateral X-rays in standing and flexed seated positions to assess functional pelvic tilt and lumbar lordosis (LL). Computed tomography scans were used to measure pelvic incidence and acetabular cup orientation. Literature thresholds for “at risk” spinopelvic parameters were standing pelvic tilt ≤ −10°, lumbar flexion (LLstand – LLseated) ≤ 20°, PI ≤ 41°, and sagittal spinal deformity (PI – LLstand mismatch) ≥ 10°. The prevalence of each risk factor in the dislocation cohort was calculated and compared to a previously published cohort of 4042 stable THA patients.Introduction
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A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type.Aims
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The reduction in mobility due to hip diseases in children is likely to affect their physical activity (PA) levels. Physical inactivity negatively influences quality of life and health. Our aim was to objectively measure PA in children with hip disease, and correlate it with the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility Score. A total of 28 children (12 boys and 16 girls) with hip disease aged between 8and 17 years (mean 12 (SD 3)) were studied between December 2018 and July 2019. Children completed the PROMIS Paediatric Item Bank v. 2.0 – Mobility Short Form 8a and wore a hip accelerometer (ActiGraph) for seven consecutive days. Sedentary time (ST), light PA (LPA), moderate to vigorous PA (MVPA), and vigorous PA were calculated from the accelerometers' data. The PROMIS Mobility score was classified as normal, mild, and moderate functions, based on the PROMIS cut scores on the physical function metric. A one-way analysis of covariance (ANCOVA) was used to assess differences among mobility (normal; mild; moderate) and measured PA and relationships between these variables were assessed using bivariate Pearson correlations.Aims
Methods
The aim of this study was to compare robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) in order to determine the changes in the anatomy of the knee and alignment of the lower limb following surgery. An analysis of 38 patients who underwent TKA and 32 who underwent bi-UKA was performed as a secondary study from a prospective, single-centre, randomized controlled trial. CT imaging was used to measure coronal, sagittal, and axial alignment of the knee preoperatively and at three months postoperatively to determine changes in anatomy that had occurred as a result of the surgery. The hip-knee-ankle angle (HKAA) was also measured to identify any differences between the two groups.Aims
Methods
A proximal femur fracture (PFF) is a common orthopaedic presentation, with an incidence of over 25,000 cases reported in the Australian and New Zealand Hip Fracture Registry (ANZHFR) in 2018. Hip fractures are known to have high mortality. The purpose of this study was to determine the utility of the Clinical Frailty Scale (CFS) in predicting 30-day and one-year mortality after a PFF in older patients. A retrospective review of all fragility hip fractures who met the inclusion/exclusion criteria of the ANZHFR between 2017 and 2018 was undertaken at a single large volume tertiary hospital. There were 509 patients included in the study with one-year follow-up obtained in 502 cases. The CFS was applied retrospectively to patients according to their documented pre-morbid function and patients were stratified into five groups according to their frailty score. The groups were compared using Aims
Methods
Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis.
Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of pre-operative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function.
An algorithm to determine the constitutional alignment of the lower limb once arthritic deformity has occurred would be of value when undertaking kinematically aligned total knee arthroplasty (TKA). The purpose of this study was to determine if the arithmetic hip-knee-ankle angle (aHKA) algorithm could estimate the constitutional alignment of the lower limb following development of significant arthritis. A matched-pairs radiological study was undertaken comparing the aHKA of an osteoarthritic knee (aHKA-OA) with the mechanical HKA of the contralateral normal knee (mHKA-N). Patients with Grade 3 or 4 Kellgren-Lawrence tibiofemoral osteoarthritis in an arthritic knee undergoing TKA and Grade 0 or 1 osteoarthritis in the contralateral normal knee were included. The aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA) measured on standing long leg radiographs. The primary outcome was the mean of the paired differences in the aHKA-OA and mHKA-N. Secondary outcomes included comparison of sex-based differences and capacity of the aHKA to determine the constitutional alignment based on degree of deformity.Aims
Methods
Cam morphology develops during adolescence and predisposes individuals to future hip pain and osteoarthritis. An improved understanding of cam development is required to determine whether the process is modifiable. The aim of this study was to characterise the risk factors, timing, and pathogenesis of cam formation.Background
Hypothesis/Purpose
Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of preoperative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function.
Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis.
Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques. A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.Aims
Methods
To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes’ disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes’ disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either ‘in’ or ‘out’) before a final consensus meeting with representatives of surgeons, patients, and parents.Aims
Methods
To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem. Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing.Aims
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