Aims

To develop a multidisciplinary health research agenda (HRA) utilizing expertise from various disciplines to identify and prioritize evidence uncertainties in orthopaedics, thereby reducing research waste.

Purpose: To evaluate the benefits of standardization on the reliability of the physical examination of the hip by rheumatologists and orthopaedic surgeons. Methods: Six subjects with mild to severe hip osteoarthritis (OA) were examined by 6 examiners (4 rheumatologists, 2 orthopedic surgeons) experienced in the assessment of hip OA using a 6x6 Latin square design. Subjects were examined, followed by a standardization meeting and, a day later, by post-standardization examinations. 33 hip examination maneuvers were evaluated, including range of motion, pain, tenderness, muscle strength, leg length and gait. The order of examinations was randomized for each examiner. For dichotomous signs, agreement was calculated as the prevalence-adjusted bias-adjusted kappa (PABAK). Ordinal and continuous variables were analyzed by ANOVA, using the proportion of variance due to rheumatologists to calculate a reliability coefficient (Rc). Results: Subjects’ mean age was 61 years (range 49–65), mean BMI was 24 (range 21–30), mean WOMAC pain on walking was 52 mm (range 21–81mm). 23/33 (70%) hip examinations were reliable after standardization. Two new items resulted from the standardization meeting. Pre-/post-standardization reliability for select hip examinations using PABAK were as follows: Gait 0.06/0.52; pain on internal rotation 0.60/0.52; pain on external rotation 0.24/0.72; pain on flexion 0.46/0.82; Patrick test for hip pain 0.78/0.80; Thomas test 0.60/0.88; Trendelenburg test 0.36/0.06. Pre-/post-standardization reliability for select hip examinations using Rc were as follows: hip flexion strength 0.83/0.95; hip abduction strength 0.90/0.86; hip adduction strength 0.87/0.86; ROM internal rotation (supine) 0.87/0.94; ROM external rotation (supine) 0.87/0.80. Conclusions: Moderate to very good agreement was present for many hip examinations prior to standardization. Improved reliability was achieved after standardization for many but not all hip assessments. This will be important for improved outcome studies of early hip OA

Background: General practitioners (GPs), orthopaedic surgeons, neurosurgeons, rheumatologists and pain consultants manage the majority of patients with chronic low back pain (CLBP) in the Republic of Ireland. However, little is known about their attitudes and beliefs and the factors that influenced them. This study aimed to investigate factors that influenced doctors’ attitudes and beliefs to CLBP. Method: A cross-sectional questionnaire was mailed to a random sample of GPs (n=750; 35%), and all orthopaedic surgeons (n=81), neurosurgeons (n=9), rheumatologists (n=26), and pain consultants (n=24) in the republic of Ireland. The questionnaire pack contained a demographic data form, two clinical vignettes, and an attitudes measure, the Pain Attitudes and Beliefs Scale (PABS.PT). Approval was obtained from the UCD Human Research Ethics Committee. Results: The response rate was 58% (n=523). Doctors were qualified 23.4±9.4 years. Analysis of the vignettes showed there was no significant difference (p> 0.05) between those who had undertaken postgraduate education (PGE) regarding referral rates to physiotherapy, investigations, or secondary care. Prescription rates were significantly lower for those who had undertaken PGE (88% v 94%, χ. 2. =4.95, p< 0.05), as was their biomedical score on the PABS.PT (41.3 v 43.1, df=507, p=0.03). The number of years since qualification was dichotomised (1–23 yrs, > 23 yrs), and there was no significant difference in the management of the vignettes, except referral rates for investigations which was greater for doctors qualified > 23 years (3% v 52%, χ. 2. =10.71, p=0.001). Conclusion: Demographic factors (PGE and the number of years since qualification) did not significantly influence doctors’ practice behaviour

Purpose: Only 20% of women presenting with fragility fracture are subsequently investigated for Osteoporosis (OP). Blurred lines of responsibility between the orthopedic surgeons (OS) and the general practitioners may partly explain this situation. OPTIMUS is a 3 year health management program, lead by an OS and a rheumatologist, whose objective is to improve the rate of initiation of and persistence on treatment of OP in patients sustaining a fragility fracture visiting an OS at the Centre hospitalier universitaire de Sherbrooke. Method: All outpatients aged 50 years and older in which a fragility fracture is suspected by the OS are informed by a nurse practitioner about the OPTIMUS program. The first 200 patients seen at the Hôtel-Dieu site of the CHUS represent the control group. Inpatients with hip fragility fracture are evaluated by a rheumatologist. After signed consent, outpatient participants are randomized to one out of two intervention groups: The Minimal Intervention group includes nurse counseling and written general information transmitted to both patient and treating physician. Same information is given in the Intensive Intervention group. Blood tests and osteodensitometry are also performed and results transmitted to the treating physician along with personalized guidelines for treatment of the patient’s OP. In both interventions, patients are reached by phone at fixed intervals. Additional rounds of intervention are repeated as needed to increase the rates and persistence of appropriate treatment. Results: Over the first 6 months, the OS team identified 300 patients, 30% of which suffered from hip fracture. Acceptance rates to OPTIMUS management program were close to 95% with direct contact as compared to 50% with delayed phone contact. 5% of outpatients could not name a treating physician and thus had to be seen in rheumatology. The results during the first 18 months of the project will assess the feasibility of OPTIMUS’ interventions. Conclusion: There is a substantial care gap in the management of OP, despite the availability of diagnostic modalities and effective treatment. Involving orthopedic surgeons as key leaders of a multidisciplinary team implementing a systematic approach to identify patient with OP should help to close this care gap

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations). Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions. Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion. MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden

The December 2013 Foot & Ankle Roundup. 360 . looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.

It is important to remember that osteoarthritis is a noninflammatory condition that can affect 1, 2 or all 3 compartments of the knee. Moreover, this disease is a continuum from very mild to very severe involvement of the soft tissue, articular cartilage and bone. For this reason, a variety of nonsurgical and surgical options are indicated. The rheumatologist and/or orthopedist must understand the stage of the disease and fit that both to the pathology, age, activity level, and functional needs of the patient. For that reason, each of the options discussed today have an indication. The important issue about tricompartmental replacement is that we have improved technology and technique and the indications of today are broader than those of 20 years ago. Hopefully, they will continue to evolve both in terms of materials and instruments. The American Rheumatologic Association (ARA) has stated that joint replacement has been the major improvement in the care of the arthritic patient. The tricompartmental solution is the treatment of choice in patients with inflammatory arthritis such as rheumatoid arthritis as well as the solution in osteoarthritic patients with tricompartmental disease. There is an indication for osteotomy, unicompartmental replacement and perhaps patellofemoral replacement. I think the next frontier will be to find disease modifying osteoarthritic drugs (DMOADS) that will provide disease intervention as the DMARDs have done in rheumatoid arthritis. Moreover, cartilage repair combined with osteotomy will hopefully allow us to prevent progression of this disease

Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation. Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments. 28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services. This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016

The results of 75 total hip replacements in 42 children with juvenile chronic arthritis are reported after a mean follow-up of 5.4 years. Their ages ranged from 11 to nearly 17 years at operation and many had active disease. Severe pain and marked stiffness of the hips were limiting their independence. At least half of the children were still growing and continued to grow after operation. The patients were carefully selected and gratifying results were obtained, but pre-operative assessment and overall supervision by a rheumatologist are important. Technical difficulties related to the size and maldevelopment of the hip are discussed. There was no infection and the single case of loosening of a femoral component after nine years has been successfully revised

The aim was to investigate whether or not the pre-operative injection of cortico-steroids into the knee influences the infection rate of a subsequent total knee replacement. This was a case controlled study, in which it was calculated that 152 controls and 38 infected cases would give sufficient power to the study. The infection group had to have had a delay in wound healing or have had a revision for infection. A total of 32.8% had had an injection at some time pre-operatively. The average number of injections was 2.23, with a range of 1–15. 37% were performed by a G.P., 35% by an orthopaedic surgeon, and 22% by a rheumatologist.79% had the injection within 12 months of surgery. The rate of injection was the same in the two groups. There was no significant difference in the infection rate between the two groups (OR 1.38; 95%CI 0.55–3.31). Despite recent literature indicating that there is a 10% increase in infection in patients having steroid injections into the hip prior to THR this study does not confirm this risk in patients undergoing TKR

Background and Purpose: How outcomes of clinical trials are reported alters the way treatment effectiveness is perceived. Clinicians interpret outcomes of trials more favourably when results are presented in relative rather than in absolute terms. However, the face validity of different methods is unclear. We aimed to explore which methods clinicians find clearest, most interpretable, and useful. Methods and Results: We purposively sampled clinicians who see patients with low back pain (LBP) and presented them with summary reports of a hypothetical trial, reporting the results using a variety of different methods. We explored participants’ preferences for these different methods and how they would like to see future trials reported. We interviewed 14 clinicians (GPs, manual therapists, psychologists, a rheumatologist, and surgeons). Participants felt that clinical trial reports were not written with them in mind. They were familiar with mean differences, proportion improved, and number needed to treat (NNT); and unfamiliar with standardised mean difference (SMD), odds ratios and relative risk. They found the proportion improved, relative risk and NNT more intuitively understandable, and were concerned that between-group mean difference, relative risk and odds ratios may mislead. Participants thought each method uniquely contributed to their overall understanding, and that using a variety of methods to report future trials may prevent erroneous portrayal of treatment effect. Conclusion: Clinicians who see patients with low back pain currently find it difficult to interpret LBP trials. Using a suite of methods to report outcomes may aid clinicians’ interpretation and the transition of research into practice. Conflict of Interest: None. Sources of Funding: Barts and the London Charity

Aims

Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space.

Introduction: Intra-articular steroid injection has long been used to treat osteoarthritis of the knee and hip by orthopaedic surgeons, rheumatologists and general practitioners. Recent literature has shown conflicting results with regard to its safety. We aimed to investigate whether a relationship exists between preoperative intra-articular steroid injection and postoperative infection in total knee arthroplasty (TKA). Patients and Methods: We reviewed the records of all patients having TKA between April 2005 and April 2007 in University Hospital Aintree, Liverpool. The operations were carried out by 6 consultants. Exclusion criteria for analysis were: previous knee infection, revision knee surgery, fracture around the knee, skin disorders, diabetes, blood transfusion, rheumatoid arthritis and immunosuppressive medication. Eligible patients were divided into two groups: group I had received intra-articular steroid injection (each subject receiving 1–3 (mean 1.6) injections between 1–12 (mean 5) months before TKA); group II had received no injection. Mean follow-up was 17 months. Results: 425 patients had TKA, of which 361 met our criteria. 121 patients in group I and 240 patients in group II. No-one in group I developed acute infection. In group II, 7 patients developed acute infection (5 superficial and 2 deep) between 1 and 6 weeks (mean 3.7 weeks) post-operatively. There were no late infections. The difference in infection rate between groups I and II was not statistically significant (P=0.1, Fisher’s exact test). Conclusion: We found no evidence that intra-articular steroid injection prior to TKA increased the incidence of postoperative infection

Background and Purpose of Study: The SCAS assesses patients with spinal pain who have failed routine conservative treatment and/or whose referral details indicate secondary care opinion may be necessary. Patients are assessed by Advanced Musculoskeletal Physiotherapy Practitioners (AMPs) working under the supervision of a Consultant Rheumatologist. Although a rare occurrence, the early detection of spinal metastases in this patient population is essential. The purpose of this study was to retrospectively assess the case notes of those patients with an eventual diagnosis of spinal metastases to evaluate early indicators of the disease. Methods: The reports of all spinal MRI scans requested by the SCAS over a two year period were reviewed for the presence of spinal metastases. On those patients whose MRI results were positive the incidence and frequency of ‘red flags’ documented in the patients case notes was recorded. Results of recent blood tests, Xrays and bone scans were also reviewed. Results: A total of 16 patients with spinal metastases were diagnosed over a two year period from a patient population of 3200, a prevalence of 0.5%. The most commonly occurring red flags were first onset of spinal symptoms over the age of 50 (81%), progressive pain unresponsive to conservative intervention (57%), previous history of cancer (38%) and unexplained weight loss (38%). 9 patients had undergone previous Xray, 4 of which were suggestive of metastatic disease. 3 patients had undergone previous bone scan, 2 of which were suggestive of metastatic disease. Conclusion: Findings suggest that for spinal patients presenting with the most commonly occurring red flags, urgent MRI scan should be requested. Xray and ESR levels were not useful in the definitive differential diagnosis of spinal metastases

Background: General practitioners (GPs), orthopaedic surgeons, rheumatologists and pain consultants manage the majority of patients with chronic low back pain (CLBP) in primary and secondary care settings in the Republic of Ireland. Little is known about their attitudes and beliefs to CLBP, although the existing literature highlights a range of factors influencing such beliefs including: past experience, education, time and resources. 1. This study aimed to investigate factors influencing attitudes and beliefs of Irish doctors to the management of CLBP patients. Method: A multiple case studies design of semi-structured audiotaped interviews (30 minutes) was conducted on a purposeful sample of GPs (n=7) and Consultants (n=7: orthopaedic surgeons, n=2; Pain consultants, n=2; Rheumatologists n=2 Neurosurgeon, n=1) in July 2006. Questions were devised based on the results of a systematic review of the literature of the topic. All interviews were subsequently transcribed, coded and a cross case analysis was constructed. Approval was obtained from the UCD Human Research Ethics Committee. Results: The main emerging themes included Doctors current holistic management (referral for physical and mental health treatment), the negative impact of lack of resources on treatment options (lack of multidisciplinary services and prolonged waiting times for Consultant appointments), the influence of the medicolegal system on patients (increased stress) and Doctors (increased referral rates for investigations and procedures). Conclusion: Doctors’ attitudes and beliefs regarding CLBP management may have important influences on both patient outcomes and resource utilization within the health service. These findings will inform a national postal survey of Doctors attitudes to CLBP

With Lord Darzi’s vision of the future of the NHS, it has become clear that quality of care will be the next focus and the hospitals providing acute orthopaedics and trauma services will have to deliver best and most efficient care for the patients being admitted with fractured neck of femur. This study is aimed at recognizing the changes and organization required at a district general hospital and their initial effect on the quality of services being provided locally. Management of patient with hip fracture involves several specialties within the hospital as well as primary care setup. An audit of A& E waiting time showed significant variation in the delay before transferring the patients to the ward which was addressed by Fast-Track system. In the ward, preoperative assessment was standardized by agreement between orthopaedics and anaesthetics department. Three daytime lists were initiated specifically for hip fracture patients, resulting in increase in the number of patients going to theatre within 48 hours of admission, from 75% to 86%. A protocol was agreed between orthopaedic surgeons and rheumatologists for starting anti-resorptive therapy for these patients in order to decrease the chances of future fragility fractures. Impact of this measure will be assessed in due course. One senior middle grade surgeon was given the charge of managing NOF lists and to coordinate the medical management of these patients. Hospital has also started taking part in National Hip Fracture Database and a HCA has been assigned the duty of uploading the data to NHFD database. A acre pathway is being developed to streamline the whole peri-operative and after discharge management of these patients. With just about a year left before the implementation of healthcare commissioning, it is vital that trusts start working on best and most efficient care for all patients. Hospital will have to publish their quality accounts from next year and their tariffs will be linked to patient reported outcome measures. This study highlights the main issues and the potentially vital role of orthopaedic specialists in developing the required services

Introduction: We present here the clinical features and management strategies of patients with gluteus medius and minimus enthesopathy. Methodology: We studied seven patients with lateral hip pain and tenderness on palpation, worse over the tip of the greater trochanter. All of them had a positive Trendelenburg’s sign, and a transient relief of pain on injecting local anaesthetic in the abductor mechanism. All of these patients were tertiary referrals from the rheumatologists, who had at least once injected them with corticosteroids. Results: Four of these seven patients underwent exploration. An insertional tendinopathy of the abductors was noted in all the patients, and was debrided. Two of the patients had, in addition, a tear in the gluteus medius tendon, which was repaired. One patient had an injection of local anaesthetic and Aprotinin in the abductor mechanism with resolution of symptoms. Discussion: Gluteus medius and minimus enthesopathy is a distinct clinical entity. Although the condition has been described in the radiological literature, we were unable to find any reference to the orthopaedic management of this condition. We observed only a small number of patients, and we are thus unable to provide definite answers. Patients presenting with the above clinical features warrant consideration of the diagnosis of abductor enthesopathy. Ultrasound scan or MRI scan helps in confirming the diagnosis. At present, our management protocol involves injecting a local anaesthetic / Aprotinin in the abductor mechanism. However, we are cautious in injecting more than once, as, at operation, we have observed necrosis of the abductor mechanism at its insertion in two patients, similar to that described for Achilles tendon. If this fails, we undetake surgical exploration. The exact surgical procedure is difficult to predict and may involve debridement and repair of the pathological tendon

Purpose of the study: Management of bone and joint infections is a recognised public health concern recently labellised by the establishment of Reference Centres and associated Reference Centres. Among other objectives, these Centres are designed to develop pluridisciplinary expertise in the form of recommended clinical practices (French Health Ministry directive DHOS, May 2008). Material and methods: In response to this tender, a weekly pluridisciplinary meeting was instituted in March 2008 with an orthopaedic surgeon, an infectious disease specialist, an anaesthetist, a pharmacist, microbiologists, a rheumatologist and a diabetologist. The activity and impact on antibiotic consumption in the functional unit of septic surgery was evaluated over a one-year period. Results: From March 2008 to March 200, 35 pluridisciplinary meetings were held and analysed 243 files concerning 133 patients. This consensual approach led to a decrease in the antibiotic consumption in the functional unit. This consumption was 1222 DDJ/1000 days hospitalisation during the last semester of 2007 and 1069 DDJ/1000 days during the last semester of 2008 (p=0.005). During this same period, the activity in the unit increased from 37 patients with infected material (CIM 10 T 84) in 200 to 58 in 2008 and from 27 patients with septic arthritis (codeM00) to 42 in 2008. Similarly the number of indexed pathological conditions in this unit increased from 447 to 548 in 2008 with a fall in the mean duration of the hospital stay from 11 days in 2007 to 9.6 in 2008. The improvements provided by the process of intraoperative sampling provided bacteriological documents in 85% of cases. The analysis of antibiotics prescribed in the functional unit showed a decline in the consumption of antibiotics with week or unknown distribution in bone (amoxicillin + clavulanic acid: −13%; pristinamycin: −72%) and an increase in the prescription (before adaptation to documented bacteriological results) of the association cefotaxime+fosfomycin (5-fole increase in one year). Discussion: This study clearly shows how important regular pluridisciplinary discussion is needed to optimise the management of bone and joint infections and that this approach improves the antibiotic prescription and shortens the hospital stay. Conclusion: This experience proves the pertinence of the Reference Centres and the associated Reference Centres, both economically and medically