Bone & Joint Open最新文献

Aims: The classic, widely accepted approach for one-stage hip revision arthroplasty in patients with periprosthetic joint infection (PJI) is the cemented exchange. This approach provides stable implant anchoring despite bone defects after removal of infected components, and facilitates local antibiotic delivery. This study aims to investigate the efficacy of cementless one-stage hip revision arthroplasty using a gentamicin-eluting bone graft substitute (GBGS) to address both bone defect filling and antibiotic elution.

Methods: We conducted a prospective analysis of 20 patients with confirmed PJI undergoing cementless one-stage hip revision arthroplasty using GBGS. The GBGS was used to fill femoral and acetabular defects during implantation. Clinical outcomes, radiographs, adverse events, and patient-reported outcome measures (PROMs) including Harris Hip Score (HHS) and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) were assessed. Patients received 12 weeks of systemic antibiotics and were followed up for at least 24 months.

Results: The mean age of the cohort was 66.3 years (SD 8.4; 46 to 80), with ten female and ten male patients. On average, 13.2 ml (SD 3.9; 5 to 17) of GBGS was applied to bone defects. No reinfections occurred during the follow-up period of 3.3 years (SD 0.92; 2.1 to 4.8). We observed 15 serious adverse events (SAEs), none of which were associated with the product. All cases showed good bony consolidation and prosthesis integration at 12 months. Significant improvements were seen in HHS (preoperative mean: 47.7; final visit mean: 80.1; p < 0.001) and EQ-5D-5L score (preoperative mean: 0.43; 12-month mean: 0.88; p < 0.001).

Conclusion: This prospective pilot study is the first to demonstrate the safety and feasibility of single-stage cementless hip exchange arthroplasty using GBGS in managing PJI and associated bone defects. The technique resulted in significant improvements in functional outcomes and quality of life, with a good safety profile. Further studies with larger cohorts are warranted to validate these findings.

Aims: Soft-tissue sarcoma (STS) is a rare, aggressive malignancy with a high risk of recurrence when invading surrounding structures, and the optimal treatment strategy for safe surgical margins is still unclear. This study aimed to evaluate the safety and efficacy of combined local inactivation by ablation in STS during limb-sparing surgery in high-risk STS patients.

Methods: A retrospective cohort study was conducted on 44 patients between 1 January 2018 and 31 December 2022, at a tertiary medical centre. The patients were divided into two groups based on whether combined microwave in situ ablation (MWA) was performed during surgery (MWA group, n = 24 vs Control group, n = 20). The two groups were compared for postoperative complications, local disease-free survival (DFS), overall survival (OS), and progression-free survival (PFS).

Results: At the last follow-up, 12 patients in the Control group and eight patients in the MWA group experienced local recurrence. The MWA group showed longer local DFS than the Control group (48.02 (SD 4.70), 95% CI 38.81 to 57.23 vs 33.91 (SD 6.54), 95% CI 21.10 to 46.71; p = 0.047). Postoperative complications showed no significant difference (MWA: 33.3% vs Control 25%, p = 0.143). No significant differences were observed in the median OS (MWA: 53.10 (SD 6.91), 95% CI 39.55 to 66.75) compared with Control (58.30 (SD 4.66), 95% CI 49.16 to 67.44; p = 0.512) and median PFS (MWA: 16.67 (SD 3.75), 95% CI 9.32 to 23.97) compared with Control (12.62 (SD 5.88), 95% CI 1.10 to 24.09; p = 0.691) between the two groups.

Conclusion: The combined in situ ablation inactivation in high-risk STS during limb-sparing surgery can improve local tumour control and prolong local disease-free survival.

Aims: We aimed to determine if a home-based hip exercise programme, designed to use strength and flexibility exercises to modify pelvic positioning, is superior to usual care in reducing pain and improving function and quality of life in patients with symptomatic femoroacetabular impingement (FAI).

Methods: This was a single-blind parallel-group randomized controlled trial. Eligible participants were aged ≥ 16 years and diagnosed with symptomatic cam FAI. A sample size of 94 was needed to detect a clinically important difference. Participants were randomly allocated to: 1) an eight-week home-based exercise programme focused on posterior pelvic tilt supervised by a physiotherapist every two weeks in addition to usual care; and 2) usual care. The primary outcome measure was function (patient-reported 33-Item International Hip Outcome Tool (iHOT-33)) and secondary outcome measures were quality of life (EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), and pain (visual analogue scale (VAS)) at baseline, nine weeks, and six months. The Mann-Whitney U test was used to test between-group differences in scores using a two-tailed level of significance of p < 0.05.

Results: A total of 95 participants were recruited (48 intervention, 47 control), 55 were males (57.9%), the mean age was 32 years (SD 8.5), and both groups were similar at baseline. There were no statistically significant differences in the primary outcome measure between groups at nine weeks and six months for function (nine weeks: p = 0.394, 95% CI -15.5 to 6.5; six months: p = 0.526, 95% CI -8.8 to 13.7). There were no statistically significant differences in the secondary outcome measures between groups: pain (nine weeks: p = 0.153, 95% CI -0.4 to 2.4; six months: p = 0.743, 95% CI -1.1 to 1.7), and quality of life (quality of life VAS nine weeks: p = 0.877, 95% CI -10.0 to 6.0; six months: p = 0.269, 95% CI -15.0 to 5.0; index value nine weeks: p = 0.815, 95% CI -0.067 to 0.052; six months: p = 0.217, 95% CI -0.099 to 0.020).

Conclusion: Our results demonstrated no statistical differences in pain, function, and quality of life for participants following an eight-week home-based exercised programme supervised by a physiotherapist compared to usual care.

Aims: With the increasing burden of arthroplasty waiting lists within Northern Ireland, this study aims to evaluate the safety, efficacy, and postoperative outcomes following the introduction of a high-volume day-case arthroplasty unit in a district general hospital (South West Acute Hospital (SWAH)), with no previous routine orthopaedic service.

Methods: An independent company was contracted to provide high-volume, day-case arthroplasty. Standardization of care, enhanced recovery after surgery (ERAS) principles, and recruiting experienced staff were important steps in the set-up. This study includes the first 244 total hip arthroplasty (THA) cases performed. A matched cohort of 43 THA patients was compared with patients from the largest elective unit in Northern Ireland (Musgrave Park Hospital) to ensure satisfactory outcomes in the 90-day postoperative period.

Results: Same-day discharge was achieved in 83.7% of cases performed in SWAH which compared with 4.7% of MPH patients (p < 0.001). There was no significant difference in rates of attendance to an out of hours general practioner (7% vs 9.3%, p = 0.693) or emergency department (11.6% vs 16.3%, p = 0.757). Readmission rates (2.3% vs 11.6%) and reoperation rates (2.3% vs 0%) also did not show any significant difference (p = 0.202 and p = 0.500, respectively). No patient in either matched cohort had a venous thromboembolism diagnosed. Between the matched cohorts, there was a significantly higher number of American Society of Anesthesiologists grade I and II patients performed at SWAH (p = 0.003); however, this was likely due to the strict exclusion criteria necessary for the safe implementation of a day-case arthroplasty unit.

Conclusion: An arthroplasty day-case service was safely set up in a district general hospital without a previous orthopaedic unit. More than 80% of these patients were discharged on the same day of surgery. With the ever-increasing pressure, demand, and waiting lists for arthroplasty, this model could prove an important adjunct to existing services.

Aims: The aim of the present study was to understand the experience of surgeons treating patients with unexplained pain after knee arthroplasty and the role they considered revision surgery to have in the management of this condition.

Methods: Semi-structured interviews were performed with seven consultant knee surgeons in the NHS. Interviews were audio-recorded, transcribed verbatim, and de-identified before analysis using reflexive thematic analysis.

Results: Six themes were developed: 1) I need to understand a patient's journey and their expectations; 2) A difficult consultation; 3) I'm the 'fixer'; 4) It's complicated asking for help; 5) I'm uncomfortable operating for truly unexplained pain; and 6) It's a wound I carry with me.

Conclusion: This study has improved our understanding of the important considerations for surgeons when managing patients with unexplained pain after knee arthroplasty. Our study calls for a holistic approach to care that considers patients' experiences, embraces modern pain theory, and fosters collaboration among healthcare providers.

Aims: Clubfoot is the most common congenital foot deformity. Clubfoot management is lacking high-quality research to support clinical decision-making. It has been chosen as one of the elective priorities in research by the James Lind Alliance priority setting. We present the protocol of a consensus-based approach to identify research priorities for clinical trials in clubfoot management.

Methods: A modified Delphi technique will be used, which will involve an initial scoping survey, a two-round Delphi process, and a consensus meeting. The survey will be conducted among key stakeholders in the management of clubfoot, as well as patients and carers in the UK. The priorities identified during this process will each be assigned to core areas of consideration. The final list of research priorities will then be discussed and agreed in a consensus meeting of representative key stakeholders.

Conclusion: While treatment of clubfoot has become more consistent with the use of the Ponseti method, most research is retrospective from single centres, and outcomes are variable. Identifying research priorities in this group of patients through this study will shape and drive the development of multicentre prospective clinical trials deemed most important for improving clinical practice and health outcomes.

Aims: Almost 50% of adolescents who undergo surgery for adolescent idiopathic scoliosis (AIS) do not return to their preoperative levels of physical activity. Considering the potential long-term impacts of surgery, testing postoperative physiotherapy interventions should be a priority in this group. This study aimed to evaluate the feasibility of a future randomized controlled trial (RCT), which compares the effectiveness of an accelerated physiotherapist-led rehabilitation protocol to standard care for patients following surgical correction of AIS.

Methods: A total of 23 participants with AIS were recruited from surgical waiting lists at a single elective orthopaedic hospital. Participants were randomly allocated postoperatively to either a physiotherapist-led intervention of 12 sessions or standard care. Patient-reported outcome measures (PROMs), including Scoliosis Research Society 22-point revised questionnaire, were collected at baseline, six months, and 12 months. Recruitment rate, retention rate, response rate to PROMs, treatment adherence, and safety of the intervention via adverse events were also measured.

Results: Overall, 62% of eligible individuals were consented and there were three withdrawals (surgical delay, unable to travel to appointments). A total of 20 participants remained (intervention n = 9, standard care n = 11). The retention rate was 70% at six months and 65% at 12 months. Overall, treatment adherence was 76%. There were no adverse events related to the intervention.

Conclusion: This feasibility study has indicated that an accelerated physiotherapist-led rehabilitation protocol following surgery for AIS is safe and that patients can be successfully identified, recruited, and randomized to a future RCT. The next iteration of this intervention protocol needs to be developed with relevant stakeholders, including patients and the public, to improve retention rates and treatment adherence.

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.