Bone & Joint Open最新文献

Aims: We sought to explore staff experience of a paediatric randomized controlled trial (RCT), comparing operative fixation and nonoperative treatment for displaced medial epicondyle fractures.

Methods: A total of 20 staff (eight surgeons and 12 research delivery staff) recruiting to the RCT in 18 NHS Trusts across the UK took part in a telephone/online qualitative interview. Interviews were informed by Heideggerian Phenomenology and thematic analysis.

Results: We identified the concept of 'leading through expertise' demonstrated through two themes: 1) choosing ways of making it work; and 2) enabling parental/child decision making. Staff drew on their clinical and organizational expertise to take a position of equipoise and invested time to make the trial work within their local context. Building trust and confidence and using creative ways to engage with children enabled parent/child decision making in the context of uncertainty. Recruitment was sustained by the energy, enthusiasm, and expertise of staff, by the local investigator and research delivery staff, the digital resources, and the support of the trial team. Recruitment was hindered by clinical pressures, a variable research culture, and lack of consistent digital access.

Conclusion: For this relatively rare injury in children, 'leadership through expertise' was critical for successful trial recruitment. National and local networks of surgeons were imperative to support the trial activity. The development of similar networks among research delivery staff could improve knowledge exchange and enhance trial activities. Parental/child trust and confidence to decide about trial participation could be enabled by work to deepen child engagement in research. Educational tools engaging children may help to support family decision making in an emergency context.

Aims: Patella fractures can greatly impact knee function and quality of life. The primary aim of this study was to assess patient-reported outcomes one-year post-patella fracture. A secondary aim was to evaluate outcome differences based on sex, age, fracture classification, treatment modality, and patients' expectations.

Methods: This observational study included all patients aged ≥ 18 years at injury with a registered patella fracture in the Swedish Fracture Register between 1 January 2011 and 31 December 2023. The Short Musculoskeletal Function Assessment (SMFA) questionnaire measured patient-reported outcomes, focusing on the bother and mobility indices. Changes in SMFA and EuroQol five-dimension questionnaire (EQ-5D) scores were analyzed from pre-injury (recall) to one year post-injury. Patients' expectations and recovery status were assessed separately.

Results: Among the 8,726 study participants, 27% (n = 2,339) completed the one-year follow-up assessment of patient-reported outcome measures. A significant overall decline in function was observed one year post-injury, indicated by a mean increase of 9.1 (95% CI 8.4 to 9.8) in the bother index and 12.2 (95% CI 11.4 to 13.0) in the mobility index. A minor difference was observed, with females reporting somewhat less successful outcomes than males. A more pronounced functional decline was observed in patients aged ≤ 65 years compared to their older counterparts (those aged > 65 years). Patients receiving operative treatment showed a greater decline in functional outcomes, as measured by SMFA scores, than those managed nonoperatively. More complex fractures, as categorized by the AO/Orthopaedic Trauma Association classification, were associated with worse outcomes. Complete recovery was more probable for patients anticipating such an outcome.

Conclusion: Patella fractures result in a measurable decline in patient-reported functional outcomes one year after injury. Several variables, including fracture morphology, the prescribed treatment, and psychological factors, play a role in the outcome.

Aims: The primary outcome was to determine the proportion of patients with adhesive capsulitis who required reintervention following a treatment of hydrodistension. The secondary outcome was to identify predictors of reintervention.

Methods: A total of 712 hydrodistension procedures from six NHS trusts were included for statistical analysis. Minimum follow-up was 18 months. The primary outcome was the reintervention rate. Reintervention was defined as a subsequent steroid injection, arthroscopic capsular release, or repeat hydrodistension. The secondary outcome was to determine predictors of reintervention. Patient demographic characteristics, duration of symptoms, previous treatment, diabetic status, insulin usage, and glycated haemoglobin (HbA1c) were recorded. Logistic regression models were run for the primary and secondary outcomes.

Results: In total, 176/712 patients (24.7%) required further treatment. We found the following factors to be predictors of repeat intervention: female sex (p = 0.036), diabetics (p = 0.003), patients with a HbA1c ≥ 48 mmol/mol (p = 0.011), and patients who had received previous steroid injections (p = 0.002). Age and duration of symptoms did not correlate with increased risk of reintervention.

Conclusion: Hydrodistension may be considered an effective treatment for adhesive capsulitis, with the majority of patients in our cohort not requiring further intervention. We identified predictors of reintervention, which may assist in patient counselling and treatment planning. Although the optimal first-line management for adhesive capsulitis remains uncertain, hydrodistension represents a cost-effective, widely accessible, and minimally invasive option. Further comparative studies are warranted to establish its place in the treatment algorithm.

Aims: The number of hip fractures is increasing, with significant mortality and morbidity, particularly among frail and comorbid patients. Enhanced recovery after surgery (ERAS) pathways have proven effective in elective orthopaedics, but this has not been investigated in people with hip fractures. This study aimed to identify current perioperative practice and develop a cohesive ERAS pathway tailored for hip fracture patients, to standardize and optimize care.

Methods: We conducted a cross-sectional survey-based study across trauma professionals. The survey was disseminated to an expert panel via direct mailing through research collaboratives and social media. Net promoter scores (NPS) were used to quantify survey responses, with a score of over 30 indicating that respondents felt strongly that a particular intervention should be included in the ERAS pathway.

Results: Responses were received from 51 institutions and a variety of trauma professionals. Respondents rated preoperative, perioperative, and postoperative interventions for inclusion in an ERAS pathway. Highly rated preoperative intervention included nerve blockade (NPS = 81) and delirium risk assessment (NPS = 69). Avoidance of intraoperative hypotension (NPS = 45) was the only perioperative intervention scoring above 30. Key postoperative interventions included geriatric review (NPS = 74) and Day 0 mobilization (NPS = 53). Overall, 87.5% of respondents expressed willingness to join a trial comparing ERAS to standard care.

Conclusion: This study highlights the need for a standardized ERAS pathway for people who experience hip fractures. Key recommendations include preoperative optimization, early mobilization, and multidisciplinary input, all of which align with existing ERAS guidelines. Further research should focus on conducting feasibility studies to refine and validate this pathway.

Aims: Regardless of one's alignment philosophy and belief in ligament releases, the precise estimation of soft-tissue laxities is crucial in total knee arthroplasty (TKA). This study prospectively assessed the reliability of surgeons' and assistants' measurements of ligament tension during robotic arm-assisted TKA.

Methods: A prospective, surgeon-blinded study was performed in 123 patients undergoing TKA by six surgeon/assistant pairs. Ligament tensions were captured using manual stress and instrumented distraction techniques for four gaps: medial extension, lateral extension, medial flexion, and lateral flexion. Assessors were blinded during gap measurements. The primary outcome was intrarater and inter-rater reliability using intraclass correlation coefficients (ICCs). Secondary outcomes were the reliability of manual compared with instrumented distraction measures and comparison of planned pre-resection virtual gaps against actual post-implantation laxities.

Results: The intrarater mean ICC for surgeons' measurements of gap laxities was 0.95 (0.90 to 0.97) and 0.94 (0.91 to 0.96) for assistants' measurements. These results indicate excellent reliability for all four gaps for both surgeons and assistants. For inter-rater reliability, both extension gaps returned an ICC > 0.90, indicating excellent reliability between surgeons and assistants. Lateral flexion ICC was 0.75 and medial flexion 0.86, indicating good reliability. Comparing manual with instrumented distraction techniques, the mean ICC was 0.72, indicating moderate reliability (0.55 to 0.88). The mean difference between planned and final gap measures was 0.5 mm (-1.5 to 3.0, SD 0.71).

Conclusion: Surgeons' ability to assess knee laxities using manual stressing during robotic arm-assisted TKA has excellent intrarater and good-to-excellent inter-rater reliability. Distraction values for the medial side were more reliable than the lateral side, where constitutional laxity and the technical challenge of assessment may increase variability. High reliability of manual stressed gap assessment in robotic arm-assisted TKA should give surgeons confidence in using this information for measuring and achieving soft-tissue balance.

Aims: This retrospective observational study aimed to determine the in vivo joint loads in the knee after total knee arthroplasty during early postoperative rehabilitation involving different physiotherapy exercises and to analyze how these loads change over the first three weeks postoperatively.

Methods: Nine patients (six males, three females) with a primary instrumented total knee replacement participated in the study. A total of 19 selected physical therapy exercises of varying load levels were performed on the ninth (SD 3) and 21st (SD 6) postoperative day. During these sessions, the peak resultant knee contact force (F_{res max}) and loading patterns were measured to assess joint loading dynamics.

Results: F_{res max} varied across different exercises, ranging from a minimum of 15% body weight (% BW) during seated leg swings to a maximum of 195% BW during stair ascent. Joint loads increased from the ninth to the 21st postoperative day for all activities, except for a few relaxed status exercises where a decrease was observed. Load-bearing activities with crutches had the highest knee joint loads.

Conclusion: All exercises remained below the forces of walking on ground level indicating safety for the postoperative rehabilitation. Physical therapists should consider these loads in relation to daily activities when designing treatment plans also referring to the different loads in different exercises.

Aims: The primary aims were to determine what outcome domains, outcome measurement instruments, and outcome measurement timepoints are reported in randomized controlled trials (RCTs) involving people with patellar dislocations. The secondary aims were to determine what primary outcomes were used and how a recurrent patellar dislocation was defined when this was used as an outcome.

Methods: We searched MEDLINE, Embase, CINAHL, the Cochrane Database of Controlled Trials, and trial registries (last search: January 2024) for RCTs evaluating treatments for people with a patellar dislocation irrespective of age or sex. We identified the unique outcomes in included studies and mapped these onto the World Health Organization's International Classification of Functioning, Disability and Health (WHO ICF) framework to identify the measured domains. We synthesized results into tables, figures, and text. A critical appraisal of included studies was not required for this systematic review.

Results: From the 70 included studies, we identified 141 unique outcomes. The most commonly used unique outcome was a recurrent ipsilateral patellar dislocation (used in 55 studies), but only 17/55 studies (31%) reported how this was defined (i.e. the criteria required for a recurrent ipsilateral patellar dislocation event to be recorded). Unique outcomes mapped onto 66 second-level domains of the WHO ICF framework, and 56% (593/1,052) in the 'activities and participation' domain. Included studies used 42 different patient-reported outcome measures (PROMs), most commonly the Kujala Patellofemoral Score (71%, 50/70 studies), but 28 PROMs (60%) were used only once. In all, 31 different primary outcomes were identified from 47 included studies, with 14 primary outcomes (45%) used only once among included studies. The Kujala Patellofemoral Score was also the most common primary outcome (38%, 18/47 studies). Outcome measurement timepoints varied, but the most common timeframe for primary outcome measurement was > one to three years (46%, 16/35 studies that provided data).

Conclusion: The variability in the outcome domains, PROMs, and primary outcomes measured in RCTs evaluating patellar dislocation treatments highlights that a core outcome set is needed. This process is underway and is being informed by this systematic review's findings.

Aims: The objective of this study was to perform a long-term comparative analysis of patients who underwent total hip arthroplasty (THA) with a history of previous ipsilateral hip arthroscopy (PA) to a propensity-score matched control group of primary THA with no prior hip arthroscopy (NPA).

Methods: Data were analyzed from patients who underwent primary THA for symptomatic hip osteoarthritis between November 2010 and November 2013. Patients included had completed a minimum of ten years of patient-reported outcome measure questionnaires. The PA group was propensity-score matched 1:1 based on age at THA, BMI, sex, robotic assistance, approach, and laterality to the NPA group. Clinical hip arthroplasty outcome thresholds, complications, and revision surgery rates were compared between cohorts. A Kaplan-Meier analysis was performed to assess survivorship.

Results: A total of 108 patients were included, 54 in each group. The groups displayed comparable outcomes at minimum ten-year follow-up, for modified Harris Hip Score (mHHS) (p = 0.370), Harris Hip Score (HHS) (p = 0.370), Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) (p = 0.380), Forgotten Joint Score (FJS) (p = 0.250), visual analogue scale (VAS; p = 0.150), and patient satisfaction (p = 0.310). The two groups reached Patient Acceptable Symptom State (PASS) for FJS, HHS, and HOOS-JR at similar rates (p > 0.05). The PA group exhibited a significantly higher complication rate, with 11 major complications compared to two in the NPA group, translating to a relative risk of 2.8 (p < 0.033). Among the major complications in the PA group, nine required revision surgery, resulting in a relative risk of 4.5 (p < 0.047).

Conclusion: Patients undergoing primary THA with a history of prior hip arthroscopy achieve similar long-term functional outcomes compared to a propensity-matched control group. However, they face a 2.8-fold increased risk of complications and a 4.5-fold higher risk of major complications requiring revision THA.

Aims: Postoperative periprosthetic femoral fractures (POPFFs) following hip arthroplasty pose complex challenges, with differences in management and outcomes across healthcare facilities. However, there is limited published literature on such variability to inform improvement initiatives. This study aims to quantify the between-hospital variations in surgical management and short-term outcomes.

Methods: Administrative hospitalizations data from all 177 NHS hospital Trusts in England were analyzed for patients aged 18 years and above with a primary diagnosis of POPFF between April 2016 and December 2022. Patient demographic characteristics, comorbidities, procedures, length of stay, in-hospital mortality, 30-day total mortality (in or out of hospital), and emergency 30-day all-cause readmissions were extracted. Multilevel models with random intercepts for hospitals and funnel plots assessed the non-random variations between hospitals in procedures and outcomes.

Results: Among 39,035 hospitalized patients, 66% were female (n = 25,720), with a median age of 82 years (IQR 73 to 88). Hospital variation existed in treatment outcomes, with adjusted intraclass correlation coefficients for fixation without revision, revision, and no surgical procedure of 4.0%, 3.8%, and 2.4%, respectively. Funnel plots revealed hospital outliers for procedure choice after adjusting for age, sex, and number of comorbidities - among 177 hospitals, nine (5.1%) exceeded the upper 95% control limit for fixation and 17 (9.6%) did so for revision; outlier proportions were 14.1% for length of stay, 3.9% for emergency 30-day readmission, and 1.1% for mortality.

Conclusion: Inter-hospital variation exists for the management and short-term outcomes following POPFFs in England. This warrants further explanation to better understand the reasons for this.

Aims: The epidemiology of proximal humerus fractures (PHFs) has been described in terms of incidence, fracture complexity, and general time trends, but current literature on time trends in PHF complexity is limited. This study aims to explore possible time trends in PHF complexity and report the distribution of different types of PHF from January 1944 to December 2020.

Methods: The city of Malmö, Sweden, has one emergency hospital where acute fractures are treated, and radiographs have been saved for almost a century. One author reviewed and classified relevant radiological examinations in individuals aged ≥ 18 years with a PHF during 17 sample years from 1944 to 2020 in Malmö using the Neer and AO classifications.

Results: Of the 3,031 identified PHFs, 2,216 (73%) were sustained by women (mean age 69 years (SD 14)) and 815 (27%) by men (mean age 59 years (SD 17)). We saw no obvious time trend in fracture complexity overall, for men and women separately, or for different age groups. Fracture complexity according to AO was higher in older than younger age groups, which was true also with the Neer classification for women. However, for men, according to the Neer classification, the fracture complexity was higher in younger than older age groups.

Conclusion: We found no obvious time trend in fracture complexity with the Neer or AO classification systems from 1944 to 2020.