Abstract

By next summer the number of patients in the tranexamic acid group will be much higher, probably around 50–60.

Introduction

Total knee replacements (TKR) are among the commonest operations performed in orthopaedic practice. Literature review showed that 10-30% of patients who underwent TKR needed 1-3 units of blood.

Tranexamic acid (TXA) has been popularised as an effective way to reduce blood loss and subsequent blood transfusion.

Our aim was to investigate the value of TXA in reducing blood loss and blood transfusion after TKR and other clinical outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), ischaemic heart diseases and mortality.

Bilateral simultaneous total knee replacement surgery remains controversial with arguments for and against its use. Doing sequentially staged TKR's is a safer procedure and may have additional benefits as set out below.

If both knees need to be replaced we have often seen that the symptoms of the contralateral knee improve after the one knee is replaced and that patients wait some time before having the opposite knee replaced.

During a retrospective case note analysis, a significant difference was found in prosthesis survival, between two cohorts of patients who underwent different total knee replacements. The first cohort included 70 patients who underwent Kinemax Plus total knee replacement, the second cohort included 58 patients who underwent PFC Total Knee replacement. All patients were under the care of one Consultant Orthopaedic Surgeon. Interestingly, the Kinemax Plus cohort was found to have a higher rate of revision compared to the PFC cohort. A detailed comparison was carried out between the two groups to identify any obvious cause for the disparity.

The two cohorts were found to be well matched with respect to age, sex, ASA grade, underlying pathology and operative technique. Median follow up being 6 years and 5 years for the Kinemax Plus and PFC groups respectively.

There were 11 failed prostheses in the Kinemax Plus cohort, 7 undergoing revision with the remaining 4 patients offered revision but unwilling to have surgery. Wear of the polyethylene tibial insert was the most obvious finding at revision, present in six of the seven revisions. 97% of the Kinemax Plus Prostheses were intact at 5 years but by 8 years only 87% were intact. There were no revisions performed in the PFC cohort.

Post-operative x-ray analysis was undertaken to rule out prosthesis malalignment as a cause for the increased failure rate. The coronal alignment of the prostheses (CAK) was calculated and all post operative x-rays were within the normal limits of 4-10 degrees.

Analysis of the explanted Kinemax Plus polyethylene liners was undertaken. In six cases, the polyethylene bearing surfaces displayed severe surface and subsurface delamination. This suggests massive fatigue and fatigue wear. Only one implant showed localised delamination.

These findings suggest the hypothesis of weak polyethylene particle interface strength.

As allergic reactions to implant wear are gaining more attention [4], the incorporation of ceramic materials to device design appears to be a promising development. In particular, ceramic femoral components of total knee replacements have been designed to produce less wear under standard [1] and adverse [5] implant conditions.

Whereas the wear reduction effect of ceramics is generally accepted for hip implants, the corresponding effect for knee implants is not proven. Ezzet et al. reported a wear reduction of 42% for standard wear conditions [2] and of 55% for adverse wear conditions [3] when compared to a geometrically identical CoCr femoral component. In contrast to these findings, an analysis of the EndoLab® database has indicated wear rates of ceramic knee implants that are comparable to traditional low wear material couplings (Figure 1), and are within the range of clinically established devices.

The purpose of this study was to directly compare two TKR designs, one fixed bearing and one mobile bearing, each made of traditional CoCr to one made of alumina matrix composite (BIOLOX®delta, CeramTec, Germany) ceramic material. The BPK-S Rotating Platform System (Peter-Brehm, Germany; Figure 2) and the MULTIGEN PLUS fixed bearing (Lima, Italy) were knee simulator wear tested according to ISO 14243-1 (2002). A total of three specimens plus one loaded soak control for each group (four groups in total) was subjected to 5 million standard gait cycles. The anterior-posterior (AP) and internal-external rotational (IE) motion of the implants resulting from the external load application of this force controlled test was recorded continuously. Wear was determined gravimetrically. The surface appearance of contact areas was analyzed by light microscopy and particle analysis was performed according to ISO 18129. For the mobile bearing groups, a mean wear rate of 2.47 mg per million cycles (StdDev. 0.38) was determined for the CoCr implant and of 1.10 mg per million cycles (StdDev. 0.46) for the BIOLOX®deltaimplant (Figure 3). The total AP and IE motion of the two groups did not differ. However, motion during stance phase was considerably higher for the ceramic group, indicating reduced frictional resistance (data not shown).

For the fixed bearing groups, a mean wear rate of 12.01 mg per million cycles (StdDev. 3.28) was determined for the CoCr implant and of 1.78 mg per million cycles (StdDev. 0.40) for the BIOLOX®delta implant.

Based upon the EndoLab® experience the ceramic total knee replacements tested perform as good as the best performing metallic total knee replacements. However it can be concluded that for the two implant systems tested the wear rate is reduced by more than 50% by using ceramic on polyethylene articulation when compared to an identical cobald crome design.

Introduction

The input mechanical properties of knee replacement bearing materials, such as elastic modulus and Poisson's ratio, significantly contribute to the accuracy of computational models. They should therefore be determined from independent experimental studies, under similar test conditions to the clinical and experimental conditions, to provide reliability to the models. In most cases, the reported values in the literature for the elastic modulus and Poisson's ratio of the bearing materials have been measured under tensile test conditions, in contrast to the compressive operating conditions of the total knee replacements (TKR). This study experimentally determined the elastic modulus and Poisson's ratio of conventional and moderately cross-linked ultra-high molecular weight polyethylene (UHMWPE) under compressive test conditions. These material parameters will be inputs to future computational models of TKR.

Osteolysis commonly causes total knee replacement (TKR) failure, often associated with asymptomatic large defects. Detection and size estimation of lytic defects is important for the indications and planning of revision surgery. Our study compares the utility of fluoroscopic-guided plain X-rays and computed topography (CT) in osteolysis detection and volume appreciation.

Three cadaveric specimens were imaged at baseline and following the creation of reamed defects (small, medium and large approximately = 1, 5 & 10 cm3 volume respectively) in the tibia and femur with TKR component implantation at each timepoint. Imaging was with fluoroscopic-guided plain X-rays (Anteroposterior & Lateral [APL], Paired Oblique [OBL]) as well as rapid-acquisition spiral Computed Topography [CT] with a beam-hardening artefact removal algorithm.

Three arthroplasty surgeons estimated the size of the lesion, if present, and confidence (none=0, fair=1, excellent=2) in their assessment on randomly presented images. Each surgeon performed two assessments of each image one month apart.

The accuracy of detecting lesions was determined using the area under the receiver-operating curve (AU-ROC) obtained from a logistic regression with adjustment for assessment sequence, observer, knee and bone. Volume appreciation and assessor confidence were determined using Kappa and the mean average of confidence scores respectively.

The AU-ROC using combinations of either APL/OBL/CT (0.83) or OBL/CT (0.83) resulted in superior detection of lesions (p<0.05) compared to APL (0.75) or OBL alone (0.77). Correct volume appreciation was highest with APL/OBL/CT (kappa=0.52), followed by APL/OBL (0.51) and was superior (p<0.05) to APL (0.29) or CT alone (0.31). Small and medium defects were more often missed than large with all modalities (20.3 vs. 39.7 %). Femoral defects were missed more often than tibial defects (40% vs. 28.7%) and small lesions missed more with CT (50%) versus APL (48%) and Oblique (40%). CT missed 19% of large sized defects, attributed mostly to femoral (29.1%) rather than tibial defects (8.3%)

Greater confidence was derived from use of CT (1.29) and APL (1.19) [Interquartile range (IQR) 1,2] when compared to OBL (.98, IQR 1,1) [p<.01]. Also, there was greater confidence regarding judgement of tibial defects (1.25, IQR 1,2) compared with femoral defects (1.05, IQR 1,1) [p<.01].

Combining all imaging modalities was synergistic and the most sensitive and specific means of defect detection and volume appreciation. CT provided more confidence, superior detection and volume appreciation when used in combination with APL/OBL versus APL/OBL alone. There is also additional value when APL is combined with OBL.

Introduction

To meet the demands of younger more active patients more robust pre-clinical wear testing methods are required, in order to simulate a wider range of activities. A new electromechanical simulator (Simulation Solutions, UK) with a greater range of motion, a driven abduction/adduction axis and improved input kinematic following has been developed to meet these requirements, as well as requirements of the relevant international standards. This study investigated the wear of a fixed bearing total knee replacement using this new electromechanical knee simulator, comparing with previous data from a pneumatic simulator.

Summary sentence

The bowing of the femur defines a curvature plane to which the proximal and distal femoral anatomic landmarks have a predictable interrelationship. This plane can be a helpful adjunct for computer navigation to define the pre-operative, non-diseased anatomy of the femur and more particularly the rotational alignment of the femoral component in total knee arthroplasty (TKA).

Sensitive and accurate measures of osteolysis around TKR are needed to enhance clinical management and assist in planning revision surgery. Therefore, our aim was to examine, in a cadaver model of osteolysis around TKR, the sensitivity of detection and the accuracy of measuring osteolysis using Xray, CT and MRI.

Fifty-four simulated osteolytic lesions were created around six cadaver knees implanted with either a cemented or cementless TKR. Twenty-four lesions were created in the femur and thirty in the tibia ranging in size from 0.7 cm3 to 14 cm3. Standard anteroposterior and lateral fluoroscopically guided radiographs, CT and MRI scans with metal reduction protocols were taken of the knees prior to the creation of lesions and at every stage as the lesion sizes were enlarged. The location, number and size of the lesions from images obtained by each method were recorded.

The sensitivity of osteolytic lesion detection was 44% for plain radiographs, 92% for CT and 94% for MRI. On plain radiographs, 54% of lesions in the femur and 37% of lesions in the tibia were detected. None of the six posterior lesions created in the tibia were detected on the AP radiographs; however, three of these six lesions were detected on the lateral radiographs. CT was able to detect lesions of all sizes, except for four lesions in the posterior tibia (mean volume of 1.2 cm3, range 1.06–1.47 cm3). Likewise, MRI was very sensitive in detecting lesions of all sizes, with the exception of three lesions, two of which were in the femur and one was in the medial condyle of the tibia (mean volume of 1.9 cm3, range 1.09–3.14 cm3). Notably, all six posterior tibial lesions, which could not be detected using AP radiographs, were detected by MRI.

This study demonstrates the high sensitivity of both CT and MRI (which uses no ionising radiation) to detect simulated knee osteolysis and can therefore be used to detect and monitor progression of osteolysis around TKR. The study also shows the limitations of plain radiographs to assess osteolysis.

Tibial and femoral loosening are major causes for implant failure in total knee arthroplasty. Jefferey (1991) reported a significantly lower rate of loosening when varus or valgus was within 3 degrees of mechanical axis in an eight year follow up. Coulle (Dec1999) reported 48% unacceptable alignment in non-navigated knees and Reed (Aug 2002) reported 35% alignments deviating more than 3 degrees from mechanical axis when navigation was not used.

We report our series of 286 navigated knee replacements using the Aesculap Search system (21 cases) and the Aesculap e-motion versions 4.2, 4.3 and 4.4 (265 cases) between April 2003 and December 2012 by the author (A.D) and analysed the correction achieved against the zero mechanical axis. Postoperative measurement of the angles on long length films was done in 23 cases. This matched with the intraoperative corrections achieved as studied using per-operative computer data stored for every case. We continued to use the data stored in the AESCULAP System to correlate the findings in the rest of the cases. The average mechanical axis achieved was 1.3 degrees. All cases had mechanical axes within 3 degrees.

We were thus able to achieve a high level of correction of the mechanical axes predictable to achieve better clinical outcomes.

The wear particles released from the polyethylene (PE) tibial insert of modular total knee replacements (TKRs) have been shown to cause wear particle induced osteolysis, which may necessitate revision surgery [1]. Wear occurs at the backside surface of the PE insert of modular TKRs, resulting from the relative movement between the PE insert and the tibial tray [2]. Wear particles generated from the backside surface of the PE insert have been shown to be smaller in size than those originating from the articular surface [1], and may therefore have increased biological activity and osteolytic potential [3-4]. The ability to predict backside micromotion and contact pressure by finite element simulation has previously been demonstrated by O'Brien et al. [6-7]. Although the effect of insert thickness on articular surface contact pressure has been investigated [5], the effects of insert thickness on backside contact pressures, backside micromotion, and wear has not received adequate attention. Brandt et al. [2] has suggested that increased insert thickness was associated with increased backside damage (Fig. 1). In the present study, finite element simulations were conducted using the Sigma - Press Fit Condylar TKR (Sigma-PFC®, DePuy Orthopedics Inc., Warsaw, IN) with inserts of different insert thickness ranging between 5, 10, 15, 20 and 25 mm. The TKRs were simulated under ISO 14343-2 [8]. A non-linear PE material model was implemented by means of the J2-plasticity theory [6] and the effects of insert thickness on backside micromotion and contact pressure were analyzed. At the peak loading of the simulated gait cycle (time=13%), the 5 mm thick PE insert showed a greater backside peak contact pressure than the 25 mm thickness PE insert. Increasing insert thickness from 5 mm to 25 mm lead to approximately 15% greater peak micromotion at the modular interface (Fig. 2). This effect may be attributed to the ability of the PE material to distribute the load more evenly through deformation at the modular interface and reduce micromotion for thinner inserts. It is suggested that increased insert thickness results in increased moments at the modular interface that could lead to increased backside wear in silico. Although an increase in PE insert thickness was only associated with a moderate increase in backside micromotion in the present study, it was deemed likely that backside micromotion could be accelerated for thicker inserts in vivo as the PE locking mechanism has been shown to degrade after extended implantation periods.

The trabecular metal Monoblock TKR is comprised of a porous tantalum base plate with the polyethylene liner embedded directly in the porous metal. An alternative design, the trabecular metal Modular TKR, allows polyethylene liner insertion into the locking base plate after base plate implantation, but removes the low modulus of elasticity that was inherent in the Monoblock design. The purpose of this study was to compare the fixation of the Monoblock and Modular trabeucular metal base plates in a randomised controlled trial.

Fifty subjects (30 female) were randomly assigned to receive the uncemented trabecular metal Monoblock or uncemented trabecular metal Modular knee replacement. A standard procedure of tantalum marker insertion in the proximal tibial and polyethylene liner was followed with uniplanar radiostereometric analysis (RSA) examinations immediately post-operatively and at 6 week, 3 month, 6 month, and 12 month follow-ups. The study was approved by the Research Ethics Board and all subjects signed an Informed Consent Form.

Twenty-one subjects received Monoblock components and 20 received Modular components. An intra-operative decision to use cemented implants occurred in 5 cases and 4 subjects did not proceed to surgery after enrollment. The clinical precision of implant migration measured as maximum total point motion (MTPM) was 0.13 mm (upper limit of 95% confidence interval of double exams). Implant migration at 12 months was 0.88 ± 0.64 mm (mean and standard deviation; range 0.21 – 2.84 mm) for the Monoblock group and 1.60 ± 1.51 mm (mean and standard deviation; range 0.27 – 6.23 mm) for the Modular group. Group differences in 12 month migration approached clinical significance (p = 0.052, Mann Whitney U-test).

High early implant migration is associated with an increased risk for late aseptic loosening. Although not statistically significant, the mean migration for the Modular component group was nearly twice that of the Monoblock, which places it at the 1.6 mm threshold for “unacceptable” early migration (Pijls et al 2012). This finding is concerning in light of the recent recall of a similar trabecular metal modular knee replacement and adds validity to the use of RSA in the introduction of new or modified implant designs.

Reference: Pijls, B.G., et al., Early migration of tibial components is associated with late revision: a systematic review and meta-analysis of 21,000 knee arthroplasties. Acta Orthop, 2012. 83(6): p. 614–24.

Introduction

Surface wear of polyethylene is still considered a long-term risk factor for clinical success, particularly as life expectancy and activity levels increase. Computational models have been used extensively for preclinical wear prediction and optimization of total knee replacements (TKR). In most cases, the input wear parameters (wear factors and coefficients) to the computational models have been experimentally measured under average contact stresses to simulate standard activities. These wear studies are not therefore applicable for more adverse conditions that could lead to edge loading and high stress conditions, including higher levels of activities and severe loading conditions. The current study investigated the multidirectional pin-on-plate wear performance of moderately cross-linked ultra-high molecular weight polyethylene (UHMWPE) under high applied nominal contact stress, to be used as inputs to a computational model investigating adverse high stress conditions.

The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome.

We used our arthroplasty database, which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) was identified. A control group of patients ≥ 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10-year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004).

We conclude that Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.

Patient specific instrumentation (PSI) for elective knee replacements in arthritic knees with severe deformities and in revision scenarios is becoming increasingly popular due to the advantage of restoring the limb axes, improved theatre efficiency and outcomes. Currently available systems use CT scan or MRI for pre-operative templating for design considerations with varied accuracy for sizing of implants.

We prospectively evaluated 200 knees in 188 patients with arthritic knees with deformities requiring serial clinical assessment, radiographs and CT scans for PSI templating for TruMatch knee system (DepuySynthes, Leeds, UK). The common indications included severe arthritic deformities, previous limb fractures and in obese limbs with difficult clinical assessment. Surgical procedure was performed on standard lines with the customised cutting blocks.

The ‘lead up’ time between the implant request and the operating date was 5 weeks on an average. We compared the pre op CT images and the best fit post-operative x- rays. The sizing accuracy for femur and tibia was 98.93 % and 95.75% respectively. All blocks fitted the femur and tibia. There were no bail outs, no cutting block breakage, 1 patient had residual deformity of 20 degrees, and 1 patient had late infection. The length of hospital stay, economic viability in terms of theatre turnover, less operating time, cost of sterilisation in comparison to conventional knee replacement surgery with other factors being unchanged was also assessed.

The projected savings was substantial along with improved geometrical restoration of the knee anatomy. We recommend the use of PSI based on CT scan templating in difficult arthritic knees.

The risk of venous thrombo-embolism (VTE) is high in orthopedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out questionnaires to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then OD for 14 or 35 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was Deep Vein Thrombus or Pulmonary Embolism confirmed by Doppler or CTPA. Minor bleed was categorized as dressing soakage or reported wound leakage, major bleed as hematoma requiring revision within 30 days.

509 patients underwent TKR: 200 (39%) received Rivaroxaban only (Group 1), 296 (58%) also received tranexamic acid (Group 2). 13 (3%) patients had no data available. Five patients had a VTE: 4 (2%) in Group 1, 1 (0.3%) in Group 2 [P<0.05]. 39 patients had a minor bleed: 17 (8.5%) in Group 1, 22 (7.4%) in Group 2 [P=0.5]. 2 patients had major bleeds: 1(0.5%) in Group 1 and 1(0.33%) in Group 2 [P=0.69]. There were 30 blood transfusions: 21 (10.5%) in Group 1, 9 (3%) in Group 2 [P<0.0001].

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results, whilst they show a trend towards decreased minor and major bleeding rates, are not significant and require larger studies looking at wound bleeding and leakage.

The risk of venous thrombo-embolism (VTE) is high in orthopaedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post-operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out a questionnaire to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then once a day for 14 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was confirmed by Doppler or CTPA as Deep Vein Thrombus or Pulmonary Embolism. Minor bleed was categorised as dressing soakage or reported wound leakage, major bleed as haematoma requiring revision within 30 days.

509 patients underwent TKR: 200(39%) only received Rivaroxaban (Group 1), 296(58%) also received tranexamic acid (Group 2). 13(3%) of patients had no data available. 5 patients had a VTE: 4 (2%) Group 1, 1 (0.3%) Group 2 (P<0.05). 39 patients had a minor bleed: 17 (8.5%) Group 1, 22 (7.4%) Group 2 (P=0.5). 2 patients had major bleeds: 1 (0.5%) Group 1, 1 (0.33%) Group 2 (P=0.69). Blood transfusions 21: (10.5%)Group 1, 9 (3%) Group 2 (P<0.0001).

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results whilst they show a trend towards decrease bleeding rates in both the minor and major bleeds are not significant, requiring larger studies looking at wound bleeding and leakage.

To examine the performance of film compared to DICOM (Digital Imaging and Communications in Medicine) images in the detection and volume appreciation of periprosthetic osteolysis around total knee replacements.

Simulated osteolytic lesions were created around 3 cadaveric total knee replacements and fluoroscopic-assisted radiography as well as Computed Tomography derived imaging taken. Arthoplasty surgeons then reviewed the hard images (AP, Lateral, Paired Obliques and Computed Tomography) on 2 separate occasions regarding the presence and size of lesions. With a minimum of 2 months since the last assessment, DICOM images taken from the same knees were then assessed by the same 3 arthroplasty surgeons in the same manner using Syngo™ Pictured Archive Communication System on hospital computer monitors.

Area under the ROC for lesions detection and kappa statistic for volume appreciation derived from the DICOM assessments were not superior with statistical significance to film assessments. Combinations of imaging that incorporated Paired Oblique views had superior performance in both hard-copy and DICOM imaging.

Digital imaging in this study has not clearly demonstrated superiority to film images for detection and volume appreciation of periprosthetic osteolysis around total knee replacements. The value of the addition of the oblique view to routine assessment is again demonstrated.

Independent sector treatment centres (ISTCs) were introduced in October 2003 in the United Kingdom in order to reduce waiting times for elective operations and to improve patient choice and experience. Many concerns have been voiced from several authorities over a number of issues related to these centres. One of these concerns was regarding the practice of ‘cherry-picking’. Trusts are paid according to ‘payment by results’ at national tariffs. The national tariff is an average of costs occurring in an average mix of patients. The assumption is that the higher the co-morbidities of the patients the more likely they are to consume a higher amount of resource and to require a longer length of stay. Cherry-picking may also affect the quality of training available to trainees.

This audit was aimed at identifying if, and how much this practice occurs. It also identifies what affect this has on the case-load of patients left for the NHS hospitals.

We looked at the number of co-morbidities amongst 198 consecutive patients undergoing hip and knee primary total arthroplasty at an ISTC, a district general hospital whose PCTs provide patient to the ISTC (Doncaster Royal Infirmary - DRI), and a district general hospital in the same area whose PCT did not provide choice at that time and who therefore did not send patients to the ISTC (Bassetlaw District General Hospital - BDGH). We found a statistically significant difference in the number of co-morbidities per patient at the ISTC compared with the DRI (1.23 vs. 2.05) and the ISTC compared with the BDGH (1.23 vs. 1.76). We were unable to show a statistically significant difference between the DRI and the BDGH. We conclude that cherry-picking does take place, and further work should be done to assess the impact on training and finance.