Tendon healing is a complex process that often results in compromised healing of the tendon tissue. It has recently been shown that temporal changes in the expression profile and the histological tissue quality of the tendons occur during the early healing process after acute Achilles tendon rupture. Whether these changes are accompanied by an altered healing process, is not yet known and was the aim of the present study. Tendon biopsies were obtained from 24 patients with acute Achilles tendon rupture at the time of surgery (2–9 days after rupture) and examined histologically as well as on RNA level. Histologically, the tendon architecture, the amount of aligned collagen, glycosaminoglycan and fat as well as the cellularity, vascularity and immune cell infiltration were determined. On RNA level the expression of markers for the modeling/remodeling (MMPs and TIMPs), collagens (1, 3, 5), tendon markers (scleraxis, tenomodulin), pro- and anti-inflammatory markers (IL-1beta, IL6, IL10, IL33, TNFa, TGF-beta1, COX2) and immune cell markers (CD3, CD68, CD80, CD206) were analyzed by Real-Time PCR. To determine the clinical outcome, the patients were followed up 12 months after the operation and the following scores were recorded: Subjective score, Tegner score, Visual Analog Scale (VAS) pain, VAS function, Matles Test, Achilles tendon total rupture score (ATRS), Therman 100-points score, Heel rise test. Statistics: Spearman correlation analysis. Correlation analysis shows that early post-rupture surgery is associated with better clinical outcome (ATRS Score: p=0.022). Histologically, a good functional healing outcome shows a positive correlation to the amount of aligned collagen (Heel Rise Test: p = 0.009) and glycosaminoglycans in the tendon (Heel Rise Test: p = 0.026, Matles difference: p = 0.029), as well as a negative correlation to the fat content (Thermann score: p = 0.018, subjective score: p = 0.027, VAS function: p = 0.031). On RNA level, a good healing outcome correlates with increased expression of MMP13, collagen 1, 3, 5 (Heel Rise Test: p = 0.019, p = 0.048, p = 0.030), and TIMP2 (Tegner Score: p = 0.040), TGF-beta1 (Thermann Score: p = 0.032) and CD80 (ATRS: p = 0.025, Thermann score:, p = 0.032). Whereas a limited healing outcome is associated with an increased expression of MMP2 (Heel Rise Test: p = 0.033), MMP3 (Matles Test: p=0.001, Heal Rise test p = 0.017), and IL33 (Tegner Score: p = 0.047). The results of the study show a clear relationship between the tendon biology at the time of the surgery and the clinical and functional healing outcome 12 months after the operation. Especially matrix formation and remodeling play a crucial role, while the examined immunological factors seem to influence the tendon healing to a lesser extent. The modulation of matrix formation could potentially lead to improved treatment options in the future

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients.

Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries.

The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836).

Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups.

Increasingly more emphasis is being placed on Patient Reported Outcome Measures (PROMs). There are many used and reported in clinical studies, but there are no universally accepted or preferred measures. It is important for a researcher with a non-clinical background to understand how these assessments are performed, the type of information provided by each of the measures, and which diseases states are best reported by each measure

Abstract

Physical outcome following total knee arthroplasty is variable. Satellite cells are undifferentiated myogenic precursors considered to be muscle stem cells. We hypothesised that; the recovery of muscle strength and physical function following knee arthroplasty would be influenced by the underlying number of muscle satellite cells. 16 patients provided a distal quadriceps muscle biopsy at time of surgery. Satellite cells were identified with a primary mouse antibody for Pax7 – a cytoplasmic protein marker, and the myonuclei with DAPI. Positive cells were identified on the basis of immunofluorescent staining in association with nuclear material, and confirmed by position under the basal lamina. Patient function was assessed using a validated physical assessment protocol, the Aggregated Locomotor Function (ALF) score, muscle strength assessed using the leg extensor power-rig, and clinical outcome assessed with the Oxford Knee Score (OKS) pre-operatively and at 1 year post operatively. Muscle satellite cell content varied amongst the patient group (Positive Staining Index 3.1 to 11.4). Satellite cell content at time of surgery correlated with change in outcomes between pre-operative and 1 year assessments in all assessed parameters (ALF, r = 0.31; muscle power, r = 49; OKS, r = 0.33). Regression analysis employing a forward stepwise selection technique employed satellite cell volume in models of pre-operative to 1 year change for all outcome parameters. Physical function (satellite cell content, patient age and pre-operative ALF score) adjusted R2 = 0.92; Muscle power (pre-operative power and satellite cell content) adjusted R2 = 0.38; Clinical outcome (pre-operative OKS and satellite cell content) adjusted R2 = 0.28. Muscle satellite cell content influences recovery of muscle power and physical function following total knee arthroplasty. Importantly it is also associated with change in clinical scores; suggesting it to be a biomarker for patient outcomes

Abstract

Abstract

Patient reported outcomes have become validated objective measures of success in research studies. They take time and effort to develop and administer. However, to remain relevant and universal PROMS should be gathered routinely and used to manage evidence-based change in healthcare systems. To ensure that they are adopted individual clinician involvement is key however a framework for comparison and relevance promotes engagement. Several examples will be presented of system change using PROMS and PREMS as well as using routine data to defend patient selection. How and what we present depends on whom we are expecting to influence.

Patient-reported outcomes (PROs) are widely used in the orthopaedic field to assess the impact of conservative and surgical interventions from a patient's perspective. Available instruments cover a range of outcome parameters, such as pain, function, stiffness, quality of life or joint awareness. Choice of instrument for a specific study for clinical practice should include the appraisal of the psychometric characteristics of the measure. The presentation will focus on the assessment of the psychometric characteristics of PRO instruments and provide criteria for evaluating those. The concepts of objectivity, reliability and validity will be explained in the context of PRO instrument and the interpretation of score points derived from PRO instruments will be discussed detailing concepts such as minimal important change/difference, norm data, and thresholds based on external criteria. Finally, international guidelines that define standards for the various procedures on development, validation and translation of PRO instruments will be summarised.

Summary. Movement analysis (IMA) and activity monitoring (AM) using a body-fixed inertia-sensor can discriminate patients with ankle injuries from controls and between patients of different pathology or post-injury time. Weak correlations with PROMs show its added value in objectifying outcome assessment. Introduction. Ankle injuries often result in residual complaints calling for objective methods to score outcome alongside subjective patient-reported outcome measures (PROMs). Inertial motion analysis (IMA) and activity monitoring (AM) using a body-fixed sensor have shown clinical validity in patients suffering knee, hip and spine complaints. This study investigates the feasibility of IMA and AM 1) to differentiate patients suffering ankle injuries from healthy controls, 2) to compare different ankle injuries, 3) to monitor ankle patients during recovery. Methods. 32 patients suffering ankle problems (ankle sprain, n=17, 42 ±26yrs; operatively managed ankle fracture, n=15, 44 ±17yrs) during short-term recovery (6weeks to 3months post-trauma) were compared to 22 matched healthy controls (41 ±13yrs). Function was measured using IMA: Gait, Sit-Stand (STS) and 10s one-leg Balance test (OLB) were performed while wearing a 3D inertia-sensor at the lower back. Physical activity was measured during 4 successive days using a 3D accelerometer (AM), attached at the upper leg. Validated algorithms were used to derive motion parameters (e.g. speed for gait, bending angle for STS, sway area for OLB, # steps for AM). Moreover three ankle specific questionnaires were completed: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), Foot and Ankle Ability Measure (FAAM), AOFAS ankle-hindfoot score. Data was analysed using paired t-tests, one-way ANOVA and Pearson's r. Results. Both patient groups performed worse in function (IMA), activity (AM) and scales (PROM). Even at 3 months mean walking speed (−26%) and cadence (−9%) were slower while pelvic obliquity during ST (+18%) and sway during OLB (+230%) was higher than in controls (p<0.05). Activity was less regarding step/day (−31%) and sit-stand transfers (−11%, p<0.05). Also PROMs were significantly worse in patients (range 17–37%). Comparing in-between patients, significant differences were found in PROMs and function (IMA) with fracture patients walking slower (−30%) or showing more sway during one-legged balance (+250%). Mean activity scores (steps, bouts, cadence) were also less for fractures (p>0.05). During recovery, PROMs improved significantly, while function (IMA) and activity (AM) only showed small or selective improvements (e.g. 8° reduction in bending angle during ST, 20% increase in cadence). Only weak to moderate correlations were found between PROM, IMA (r-range: 0.32–0.79) and AM parameters (r-range: 0.31–0.71). Discussion & Conclusion. Function, physical activity and PROMs were impaired in patients with ankle injuries compared to healthy subjects, with the fracture group performing worse on IMA and PROMs than the sprain group. In this first study ever to measure activity in ankle patients, it was shown that e.g. fracture patients walk ca. half as many steps and bouts as age-matched controls even though at 6weeks they were unable to walk 20m without walking aids (floor effect of IMA function test). The lack of improvements in IMA and AM during recovery while PROMs improved significantly, together with the few and only weak-to-moderate correlations between PROMs, IMA and AM shows that subjective and objective recovery differ and highlight the added value of IMA and AM for objectifying routine clinical outcome assessment

Background

In the United Kingdom (UK), the fastest growing population demographic is the over 85 years of age, but despite this, outcomes achieved in the octogenarian population with a Unicompartmental Knee Replacement (UKR) are underrepresented in the literature. The Elective Orthopaedic Centre, Epsom, has an established patient reported outcome measures (PROMs) programme into which all patients are routinely enrolled. We aim to investigate the outcome of medial UKR using the oxford phase 3 implant in octogenarians.

Background

Despite an ageing population and a rise in the number of joint replacements being performed, the mean age of patients undergoing surgery remains static. One explanation for this is continued concern over the risks of performing surgery on the very elderly. We aim to investigate the outcome of Total Knee Replacement (TKR) in a nonagenarian population.

Background

PROMS and PREMS are a fundamental and essential part of the NHS. Chilectomy and fusion procedures for hallux rigidus produce varied outcomes due to their subjective nature. PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to compare what PROMS/PREMS for chilectomy/fusion for hallux rigidus are at UHSM including variance across osteoarthritis grades.

Background

This article reviews four commonly used approaches to assess patient responsiveness to a treatment or therapy [Return To Normal (RTN), Minimal Important Difference (MID), Minimal Clinically Important Difference (MCID), OMERACT-OARSI (OO)], and demonstrates how each of the methods can be formulated in a multi-level modelling (MLM) framework.

Introduction

We used patient reported outcome measures (PROMS) to evaluate qualitative and societal outcomes of trauma.

This investigation of elite male collegiate basketball players aims to determine 1) the change in 3D dynamic functional variables across a single season and 2) correlate cross-season changes in functional variables with changes in clinical and quantitative ultrasound measures. Eleven male college basketball players (mean age 19, range 18–21 years) from a single team underwent baseline patellar tendon shear wave (SW) elastography and dynamic function at the start of the season (Visit1) and at a late-season time point (Visit2). Players reported their VISA-P scores every two weeks across their 24-week season. Each athlete performed a box-ground-box jump five times while 3D lower extremity kinematic and kinetic variables were collected. Functional measures included for landing (LAND) and take-off (TOFF) phases: knee valgus angle, valgus torque, and peak limb force. Knee valgus angular impulse and ground contact time were also measured. Paired t-tests and Pearson correlation coefficients (r) compared Visit1 and Visit2 variables and assessed the strength of linear dependency, respectively. The mean change in VISA-P score was 15.18 (+/-8.55). No functional variables were different across the season. Clinical, quantitative ultrasound and functional variables were moderately correlated with take-off valgus moment, landing force, take-off force and contact time. Other correlations were low (< 0.4). Our analyses have shown moderate correlations between important clinical, quantitative imaging and function measurements. These correlations reflect the changes that occur between relevant time points and which relate internal structure and external function.

Physical functioning in patients undergoing hip surgery is commonly assessed in three ways: patient-reported outcome measure (PROM), performance test, or clinician-administered measure. It is recommended that several types of measures are used concurrently to capture an extended picture of function. Patient fatigue and burden, time, resources and logistical constraints of clinic and research appointments mean that collecting multiple measures is seldom feasible, leading to focus on a limited number of measures, if not a single one. While there is evidence that performance-tests and PROMs do not fully correlate, correlations between PROMs, performance tests and clinician-administrated measures are yet to be evaluated. It is also not known if the associations between function and patient characteristics depend on how function is measured. The aim of our study was to use different measures to assess function in the same group of patients before their hip surgery to determine 1. how well PROMs, performance tests and clinician-administrated measures correlate with one another and 2. Whether these measures are associated with the same patient characteristics.

We conducted a cross-sectional analysis of the pre-operative information of 125 participants listed for hip replacement. The WOMAC function subscale, Harris Hip Score (HHS) and walk-, step- and balance-tests were assessed by questionnaire or during a clinic visit. Participant socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients (r). Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures.

None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (r<0.90). The highest correlations were found between the WOMAC-function and the HHS (r=0.7) or the Walk-test (r=0.6), and between the HHS and the walk-test(r=0.7). All the other performance-tests had low correlations with the other measures(r ranging between 0.3 and 0.5).

The associations between patient characteristics and functional scores varied by type of measure. Psychological status was associated with the WOMAC function (p-value<0.0001) but not with the other measures. Age was associated with the performance test measures (p-value ranging from ≤0.01 to <0.0001) but not with the WOMAC function. The clinician-administered (HHS) measure was not associated with age or psychological status.

When evaluating function prior to hip replacement clinicians and researchers should be aware that each assessment tool captures different aspects of function and that patient characteristics should be taken into account. Psychological status influences the perception of function; patients may be able to do more than they think they can do, and may need encouragement to overcome anxiety. A performance test like a walk-test would provide a more comprehensive assessment of function limitations than a step or balance test, although performance tests are influenced by age.

For the most precise description of functional status a combination of measures should be used. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective.

Summary Statement

This paper is the first to compare the results of unicompartmental to total knee arthroplasty revision surgery between cases with explained pain and cases with unexplained pain. Revision surgery for unexplained pain usually results in a less favourable outcome.

This study of collegiate basketball players evaluated change over time (COT) in ultrasound shear wave (SW) elastography metrics across the basketball season, and correlated to morphologic changes on conventional ultrasound imaging, and VISA-P scores. In eleven male collegiate basketball players (mean age 19, age range 18–21), patella tendon (PT) ultrasound and SW elastography of both knees were performed at pre-season and post-season time points, and players reported their VISA-P scores throughout the season. Patella tendinopathy grade and SW metrics were correlated to VISA-P scores using Spearman correlation coefficients. Paired t-test was used to assess differences in mean SW metrics at pre-and post-season timepoints, accounting for leg dominance. 6 of 11 players (54.5%) had baseline patella tendinopathy on ultrasound progressing in 4 players. The mean change in VISA-P score was 15.18 (+/−8.55). No significant correlation was seen between ultrasound grades of tendinopathy and VISA-P. Pre-season SW velocities did not significantly correlate with baseline VISA-P scores. Post-season SW values and SW COT demonstrated strong correlation with change in VISA-P score in dominant and non-dominant knees. Although not statistically significant, there was a trend towards higher SW velocity for tendinopathy in both dominant and non-dominant knees at both study visits. SW metrics of the PT correlated to change in VISA-P scores in the dominant and non-dominant knees, whereas conventional ultrasound grades of patella tendinopathy did not. There was a trend towards higher SW velocities in patella tendinopathy which may indicate detection of change in intrinsic tissue stiffness.

Introduction

ECG contamination of paraspinal EMG measurements is a known issue ^(1,2), with several proposed methods of correction^(3,4). In addition to this some question remains to how much of an effect this contamination actually has on the EMG recordings.