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Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_7 | Pages 2 - 2
1 May 2019
Holland G Brown G Goudie S Brenkel I Walmsley P
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Prosthetic joint infections provide complex management, due to often-difficult diagnosis, need for multiple surgeries and increased technical and financial requirements. “2 in 1” single stage approaches have been advocated due to reduction in risks, costs and complications. This study aimed to investigate the results of single stage revision using metaphyseal sleeves for infected primary Total Knee Replacement (TKR).

Prospective data was collected on all patients presenting with an infected primary TKR over an 8-year period (2009–17). All revision procedures were undertaken in a single stage using metaphyseal sleeves.

26 patients were included, 2 of which had previously failed 2 stage revision and 3 failed DAIR procedures. Mean age was 72.5. Mean BMI was 33.4. Median ASA 2. Mean time to revision was 3.5 years range 3 months to 12 years. Six patients had actively discharging sinuses at the time of surgery. Only 4 of the 26 patients had no positive microbiological cultures from deep tissue samples or joint aspirates.

Only one patient has a recurrence of infection. This patient did not require further surgery and is treated on long term antibiotic suppression and is systemically well.

There were statistically significant improvements in both the pain and function component of AKSS scores. There was no significant improvement in flexion, however mean extension and total range of movement both showed statistically significant improvements.

Using Metaphyseal sleeves in single stage revision for infected TKR are safe and lead to an improvement in pain, function and have excellent efficacy for eradication of infection.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_12 | Pages 3 - 3
1 Jun 2016
Beattie N Maempel J Roberts S Brown G Walmsley P
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By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants.

This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively.

There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921).

This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_7 | Pages 55 - 55
1 May 2016
Brown G
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Significance

In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Objective: To develop patient reported outcome (PRO) recovery graphs for knee function, activity level, and pain relief to be used as a shared decision making tool for total knee replacement surgery.

Methods

A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the recovery curve means and standard deviations of four PROs at six time points: pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years post-operatively for total knee replacement surgery. The recovery graphs are stratified by percentile (10%, 26%, 50%, 75%, and 90%) The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The minimum clinically important difference (MCID) was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. The LEAS and LPS are used to measure patients’ expectations for pain relief and activity improvement. Prior to discussing surgery, patients are asked to report their pre-operative pain and activity levels and to specify their expected pain relief and activity improvement one year after surgery.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_7 | Pages 54 - 54
1 May 2016
Brown G
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Significance

Increasing health care costs are bankrupting the United States and other industrialized countries. To control and/or reduce costs in health care, hospitals, payers, and patients are turning to evidence-based meta-analyses and health economic analyses to identify medical treatments that provide value (value=outcome/cost). Objective: To determine if clinical outcome (patient reported outcomes) analyses or value/economic analyses are more likely to provide the evidence needed for adoption of new technologies in arthroplasty.

Methods

A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the minimum clinically important differences (MCIDs) for PROs used for total knee replacement surgery. The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The MCID was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. For clinical meta-analyses, new technologies must demonstrate statistically significant better PROs and the difference must be greater than the MCID. For economic analyses, quality adjusted life years (QALYs) are used. For example, if a total knee replacement (TKR) improved a patient's health-related quality of life by 10% (0.10) and the assumed implant life is 15 years, the patient received 1.5 QALYs (0.10 × 15 years). If the total cost of care for the knee replacement surgery is $30,000, the cost per QALY is $20,000 ($30,000/1.5 QALYs).


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_1 | Pages 52 - 52
1 Jan 2016
Brown G
Full Access

Significance

In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Hypothesis: One year post-operative pain relief and activity level expectations can be measured pre-operatively and used for shared decision making.

Methods

A web–based system for prospectively collecting patient reported outcomes (PROs) has been developed. The data set for total hip/knee replacement surgery includes: (1) European quality of life, EQ-5D; Oxford Hip Score/Oxford Knee Score; (3) Lower Extremity Activity Scale (LEAS); and (4) Pain Likert Scale (PLS). The EQ-5D was selected as the health related quality of life (HRQL) general outcome measure because it has been adopted by multiple international joint replacement registries (Swedish Hip Arthroplasty Register, Norwegian Arthroplasty Register, United Kingdom National Joint Registry). The EQ-5D can be used to calculate quality adjusted life years (QALYs) for economic and/or comparative effectiveness analyses. The OHS/OKS questionnaires are used by the United Kingdom National Joint Registry and the New Zealand Joint Registry. The LEAS and PLS are used to measure patient's expectations for pain relief and functional improvement by asking patients to report their pre-operative pain and activity level before surgery and asking patients to report their pain and activity level expectations one year after surgery.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_1 | Pages 53 - 53
1 Jan 2016
Brown G
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Significance

In ideal shared decision making (SDM), evidence-based treatment options, their likelihood of success, and the probability of adverse events is discussed with the patient. However, current SDM is fundamentally flawed because evidence for patient-specific treatment effectiveness and patient-specific adverse event risks is lacking. Observational outcome registries are better than randomized clinical trials for determining patient prognostic factors for outcomes and adverse events. No orthopaedic SDM clinical tools exist to predict patient-specific outcomes. Hypothesis: A patient-specific shared decision making tool can predict clinically significant outcomes and adverse events for total knee replacement (TKR) surgery.

Methods

A web–based prospective observational outcome registry collects patient reported outcomes (PROs) for TKR surgery. The data set for TKR surgery includes: (1) European quality of life (EQ-5D); (2) Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Pain Likert Scale (PLS). A TKR outcome calculator predicts patient-specific functional outcome with a regression model using patient-specific pre-operative Oxford Knee Scores, diagnosis, co-morbidities, and demographics. Patient-specific joint infection relative risk is calculated using diagnosis, co-morbidities, and demographics. Functional outcomes are presented as minimum clinically important differences (MCIDs). MCID=σΔ/2.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_2 | Pages 13 - 13
1 Feb 2015
Rogers D Gardner A MacLean S Brown G Darling A
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Objectives

This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication.

Design

A single group retrospective analysis.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_12 | Pages 60 - 60
1 Jul 2014
Brown G
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The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the aspirin controversy is presumably resolved, there is no medical evidence for the “optimal” VTE prophylaxis regime for individual patients.

A risk-stratified multi-modal VTE prophylaxis protocol was developed and adopted by consensus. VTE risk factors and bleeding risk factors were categorised into six VTE/bleeding risk levels: (1) pre-operative vitamin K antagonists (VKA) use, (2) bleeding risk factors, (3) hypercoagulable state, (4) pre-operative anti-platelet therapy [clopidogrel use], (5) VTE risk factors, (6) no VTE or bleeding risk factors. The pharmacologic agents used for each risk level were: (1) resume VKA with low molecular weight heparin (LMWH) bridge, (2) pharmacologic agents contra-indicated and mechanical prophylaxis only, (3) VKA for 90 days with LMWH bridge, (4) resume anti-platelet therapy, (5) LMWH in hospital and discharge on aspirin for 90 days, (6) aspirin for 90 days (starting in hospital). In addition to pharmacologic treatment, all patients received multi-modal prophylaxis including early mobilisation, mechanical foot pumps, and neuraxial anesthesia when not contra-indicated. Prior to surgery, a VTE/bleeding risk factor checklist was completed determining the risk level. The intervention cohort included all TJA patients from January 1, 2010 to December 31, 2012. The comparison cohort included all TJA patients from the year prior to implementation of the protocol at the same community hospital. Thirty day all-cause non-elective re-admissions, 30 day same-site re-operations, 90 day VTE events, and protocol compliance were abstracted from the electronic medical record.

The intervention group consisted of 2679 patients (1075 hip arthroplasty patients and 1604 knee arthroplasty patients). The comparison group consisted of 1118 patients (323 hip arthroplasty patients and 795 knee arthroplasty patients). The 30 day all cause non-elective re-admission rate was 2.72% (73/2679) in the intervention group and 4.29% (48/1118) in the comparison group (p=0.0148). The 30 day same-site re-operation rate was 1.38% (37/2679) in the intervention group and 1.25% (14/1118) in the comparison group (p=0.8773). The 90 day VTE event rate was 1.57% (42/2679) in the intervention group and 3.40% (38/1118) in the comparison group (p=0.0007). The VTE rate was higher for knee arthroplasty patients 2.00% (32/1604) than for hip arthroplasty patients 0.93% (10/1075) (p=0.0379). The rate of VTE events was higher for patients that deviated from the VTE protocol 5.03% (10/199) than for all risk groups treated per the protocol 1.29% (32/2481) (p=0.0007).

The risk-stratified multi-modal VTE prophylaxis protocol simultaneously reduced 30 day all-cause non-elective re-admissions and 90 day VTE events. The possible causes for reducing 30 day re-admissions and reducing 90 day VTE events are: (1) reducing bleeding events by using aspirin for VTE prophylaxis in more than 80% of patients, (2) extending VTE prophylaxis to 90 days, and (3) using multi-modal prophylaxis. The risk-stratified multi-modal VTE prophylaxis protocol for total joint arthroplasty is consistent with 9 of the 10 recommendations in the AAOS Clinical Practice Guideline. The risk-stratification checklist provides a standardised tool to assess risks, discuss risks, and make shared decision with patients. Patient treatment that deviated from the protocol had a significantly higher VTE rate (5.03%). Protocol compliance increased each year from 91.1% in 2010 to 94.2% in 2012.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 195 - 195
1 Mar 2010
Brown G Young R
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The posterior compartments of the knee are not routinely visualised during arthroscopy. However, considerable pathology can occur here and be overlooked. The purpose of this study was to assess both the use of posterior knee joint inspection and the use of posterior portals. The operative technique of posterior portal placement is described.

A retrospective audit of all knee arthroscopies performed by a single surgeon from August 2004 to March 2006 was carried out.

108 arthroscopies were performed and posterior portals were used in 20 patients. The posterior portal was used predominately for instrumentation rather than visualisation. The main indication for use of a posterior portal was for meniscal preparation during meniscal repair. Loose bodies were removed from the posterior compartment in six cases. A posterior portal was used to inspect the PCL stump for debridement and possible PCL reconstruction in one patient. There were no specific complications attributable to portal placement.

Posterior portals were utilised in over fifteen percent of cases. These portals are easy to create and are particularly useful in meniscal repair and loose body removal. Specific complications of posterior knee portals have been


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 399 - 399
1 Sep 2005
Moore R Burke J Anjarwalla N Rhamat R Brown G Taylor D Fraser R
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Introduction Magnetic resonance imaging (MRI) is a valid investigation for the diagnosis of intervertebral disc disease, including infection, but it is expensive and difficult to access conveniently for research studies on live animals under anaesthesia. The aim of this study was to compare the MRI signal changes in spines from living and recently deceased sheep.

Methods MRI was conducted on the lumbar spines of six adult sheep from research studies investigating bacterial discitis, chemical discitis and disc degeneration resulting from annular incision. The sheep was anaesthetised and the lumbar spines were imaged with a Siemens Magneton Vision MRI (Numaris VB33G software) using T1 SGE, T1 FSE, STIR and T2 FSE sequences. The sheep were killed with an intravenous overdose of barbiturate and identical images were obtained commencing five minutes post mortem.

Results For each of the disease processes under consideration the MRI contrast relationships were maintained between all of the anatomical structures of interest. The post-mortem images provided improved clarity, particularly in the STIR and T2-weighted sequences, due to the absence of pulsation from the CSF and aorta, as well as the absence of respiratory artefact.

Discussion The MRI appearances of spinal tissues following death correlate well with those in the live animal confirming the validity of this method of investigation. This is particularly relevant for optimisation of a busy clinical resource for research purposes.