Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0443.R1
Luckshman Bavan, Catharine S Bradley, Yashvi Verma, Simon P Kelley
Aims: The primary aims of this study were to determine the time to sonographic correction of decentred hips during treatment with Pavlik harness for developmental dysplasia of the hip (DDH) and investigate potential risk factors for a delayed response to treatment.
Methods: This was a retrospective cohort study of infants with decentred hips who underwent a comprehensive management protocol with Pavlik harness between 2012 and 2016. Ultrasound assessments were performed at standardized intervals and time to correction from centring of the femoral head was quantified. Hips with < 40% femoral head coverage (FHC) were considered decentred, and hips with > 50% FHC and α angles > 60° were considered corrected. Survival analyses using log-rank tests and Cox regression were performed to investigate potential risk factors for delayed time to correction.
Results: A total of 108 infants (158 hips) successfully completed the bracing protocol and were included in the study. Mean age at treatment initiation was 6.9 weeks (SD 3.8). All included hips centred within two weeks of treatment initiation. At two, five, eight, and 12 weeks following centring of the femoral head, 13% (95% CI 8 to 19), 67% (95% CI 60 to 74), 98% (95% CI 95 to 99), and 99% (95% CI 98 to 100) of hips had cumulatively achieved sonographic correction, respectively. Low α angles at presentation were found to be a risk factor for delayed time to correction (hazard ratio per 1° decrease in α angle 1.04 (95% CI 1.01 to 1.06); p = 0.006).
Conclusion: The majority of decentred hips undergoing Pavlik treatment achieved sonographic correction within eight weeks of centring and radiological severity at presentation was a predictor for slower recovery. These findings provide valuable insights into hip development during Pavlik treatment and will inform the design of future prospective studies investigating the optimal time required in harness.
目的:本研究的主要目的是确定使用帕夫利克支架治疗发育性髋关节发育不良(DDH)期间脱位髋关节超声矫正的时间,并调查治疗反应延迟的潜在危险因素。方法:这是一项回顾性队列研究,研究对象为2012年至2016年期间接受帕夫利克托具综合治疗方案的髋关节脱位婴儿。以标准化间隔进行超声评估,并量化从股骨头定心到矫正的时间。股骨头覆盖率< 40% (FHC)的髋关节被认为是去中心化的,股骨头覆盖率为50%(>)和α角度为> 60°的髋关节被认为是矫正的。使用log-rank检验和Cox回归进行生存分析,以调查延迟纠正时间的潜在危险因素。结果:共有108名婴儿(158髋)成功完成支具方案并纳入研究。治疗开始时的平均年龄为6.9周(SD 3.8)。所有患者均在治疗开始的两周内以髋部为中心。股骨头居中后2周、5周、8周和12周,分别有13% (95% CI 8 ~ 19)、67% (95% CI 60 ~ 74)、98% (95% CI 95 ~ 99)和99% (95% CI 98 ~ 100)的髋累计完成超声矫正。呈现时α角低是延迟矫正时间的危险因素(α角每降低1°的风险比为1.04 (95% CI 1.01 ~ 1.06);P = 0.006)。结论:大多数接受Pavlik治疗的脱位髋关节在定心后8周内实现了超声矫正,放射学的严重程度是恢复较慢的预测因素。这些发现为Pavlik治疗期间的髋关节发育提供了有价值的见解,并将为未来前瞻性研究的设计提供信息,研究安全带所需的最佳时间。
{"title":"Optimizing time in harness.","authors":"Luckshman Bavan, Catharine S Bradley, Yashvi Verma, Simon P Kelley","doi":"10.1302/0301-620X.107B1.BJJ-2024-0443.R1","DOIUrl":"https://doi.org/10.1302/0301-620X.107B1.BJJ-2024-0443.R1","url":null,"abstract":"<p><strong>Aims: </strong>The primary aims of this study were to determine the time to sonographic correction of decentred hips during treatment with Pavlik harness for developmental dysplasia of the hip (DDH) and investigate potential risk factors for a delayed response to treatment.</p><p><strong>Methods: </strong>This was a retrospective cohort study of infants with decentred hips who underwent a comprehensive management protocol with Pavlik harness between 2012 and 2016. Ultrasound assessments were performed at standardized intervals and time to correction from centring of the femoral head was quantified. Hips with < 40% femoral head coverage (FHC) were considered decentred, and hips with > 50% FHC and α angles > 60° were considered corrected. Survival analyses using log-rank tests and Cox regression were performed to investigate potential risk factors for delayed time to correction.</p><p><strong>Results: </strong>A total of 108 infants (158 hips) successfully completed the bracing protocol and were included in the study. Mean age at treatment initiation was 6.9 weeks (SD 3.8). All included hips centred within two weeks of treatment initiation. At two, five, eight, and 12 weeks following centring of the femoral head, 13% (95% CI 8 to 19), 67% (95% CI 60 to 74), 98% (95% CI 95 to 99), and 99% (95% CI 98 to 100) of hips had cumulatively achieved sonographic correction, respectively. Low α angles at presentation were found to be a risk factor for delayed time to correction (hazard ratio per 1° decrease in α angle 1.04 (95% CI 1.01 to 1.06); p = 0.006).</p><p><strong>Conclusion: </strong>The majority of decentred hips undergoing Pavlik treatment achieved sonographic correction within eight weeks of centring and radiological severity at presentation was a predictor for slower recovery. These findings provide valuable insights into hip development during Pavlik treatment and will inform the design of future prospective studies investigating the optimal time required in harness.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"118-123"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910982","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2023-1400.R2
Siddharth Rele, Cade Shadbolt, Chris Schilling, Sharmala Thuraisingam, Jason Trieu, Emma L P Choong, Daniel Gould, Nicholas F Taylor, Michelle M Dowsey, Peter F M Choong
Aims: The Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI) have been validated primarily among general surgical procedures. To date, the validity of these measures has not been assessed in patients undergoing arthroplasty.
Methods: This retrospective cohort study included patients undergoing primary total hip and knee arthroplasty between April 2013 and December 2019. Complications within 90 days of surgery were graded using the CD classification and converted to CCI. Validity was established by assessing the association between both measures and discharge to inpatient rehabilitation, length of stay, and costs.
Results: Among 2,884 patients, 414 (14.4%) had an in-hospital complication and 643 (22.3%) had a complication within 90 days. Each increase in CD grade was associated with USD$1,895.48 (95% CI 1,734.77 to 2,056.18) of additional costs, an additional 1.24 days' length of stay (95% CI 1.15 to 1.33), and 43% (95% CI 26 to 62%) greater odds of discharge to inpatient rehabilitation. Each ten-unit increase in CCI score was associated with USD$1,698.55 (95% CI 1,561.8 to 1,835.3) higher costs, an additional 1.09 days' length of stay (95% CI 1.02 to 1.17), and 33% (95% CI 19% to 49%) greater odds of discharge to inpatient rehabilitation.
Conclusion: Both the CD classification and CCI appear valid and applicable to patients undergoing total joint replacement.
目的:Clavien-Dindo (CD)分类和综合并发症指数(CCI)主要在普通外科手术中得到验证。迄今为止,这些措施的有效性尚未在接受关节置换术的患者中得到评估。方法:本回顾性队列研究纳入了2013年4月至2019年12月期间接受原发性全髋关节置换术的患者。手术90天内的并发症使用CD分级并转换为CCI。通过评估两种措施与出院至住院康复、住院时间和费用之间的关系来确定有效性。结果:2884例患者中,414例(14.4%)出现院内并发症,643例(22.3%)在90天内出现并发症。每增加一次CD等级,额外费用增加1,895.48美元(95% CI 1,734.77至2,056.18),住院时间增加1.24天(95% CI 1.15至1.33),出院康复的几率增加43% (95% CI 26至62%)。CCI评分每增加10个单位,费用增加1,698.55美元(95% CI 1,561.8至1,835.3),住院时间增加1.09天(95% CI 1.02至1.17),出院康复的几率增加33% (95% CI 19%至49%)。结论:CD分型和CCI对全关节置换术患者均有效,适用。
{"title":"Validation of the Clavien-Dindo classification and Comprehensive Complication Index as measures of morbidity following total hip and knee arthroplasty.","authors":"Siddharth Rele, Cade Shadbolt, Chris Schilling, Sharmala Thuraisingam, Jason Trieu, Emma L P Choong, Daniel Gould, Nicholas F Taylor, Michelle M Dowsey, Peter F M Choong","doi":"10.1302/0301-620X.107B1.BJJ-2023-1400.R2","DOIUrl":"https://doi.org/10.1302/0301-620X.107B1.BJJ-2023-1400.R2","url":null,"abstract":"<p><strong>Aims: </strong>The Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI) have been validated primarily among general surgical procedures. To date, the validity of these measures has not been assessed in patients undergoing arthroplasty.</p><p><strong>Methods: </strong>This retrospective cohort study included patients undergoing primary total hip and knee arthroplasty between April 2013 and December 2019. Complications within 90 days of surgery were graded using the CD classification and converted to CCI. Validity was established by assessing the association between both measures and discharge to inpatient rehabilitation, length of stay, and costs.</p><p><strong>Results: </strong>Among 2,884 patients, 414 (14.4%) had an in-hospital complication and 643 (22.3%) had a complication within 90 days. Each increase in CD grade was associated with USD$1,895.48 (95% CI 1,734.77 to 2,056.18) of additional costs, an additional 1.24 days' length of stay (95% CI 1.15 to 1.33), and 43% (95% CI 26 to 62%) greater odds of discharge to inpatient rehabilitation. Each ten-unit increase in CCI score was associated with USD$1,698.55 (95% CI 1,561.8 to 1,835.3) higher costs, an additional 1.09 days' length of stay (95% CI 1.02 to 1.17), and 33% (95% CI 19% to 49%) greater odds of discharge to inpatient rehabilitation.</p><p><strong>Conclusion: </strong>Both the CD classification and CCI appear valid and applicable to patients undergoing total joint replacement.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"81-88"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0634.R1
Matt L Costa, Andy Appelboam, Nick A Johnson, Inger Mechlenburg, Per H Gundtoft
Traditionally, patients with a fracture of the distal radius are treated in a cast if they do not require surgery. If the fracture requires manipulation, the cast is moulded to hold the reduction and maintain normal anatomical alignment during healing. However, is a cast necessary for patients whose fracture does not require manipulation? Removable splints are an alternative treatment option. Such splints have the advantage that they can be adjusted to improve fit around the wrist as swelling reduces, and can be removed and reapplied for the purpose of washing or, in some cases, exercise. However, evidence for their safety and effectiveness in the management of distal radius fractures is lacking. DRAFT3 is a multicentre randomized non-inferiority trial and economic analysis designed to determine the safety and effectiveness of removable splints as an alternative to casts in the treatment of distal radius fractures that do not require manipulation.
{"title":"Do patients with minimally displaced distal radial fractures need a plaster cast?","authors":"Matt L Costa, Andy Appelboam, Nick A Johnson, Inger Mechlenburg, Per H Gundtoft","doi":"10.1302/0301-620X.107B1.BJJ-2024-0634.R1","DOIUrl":"10.1302/0301-620X.107B1.BJJ-2024-0634.R1","url":null,"abstract":"<p><p>Traditionally, patients with a fracture of the distal radius are treated in a cast if they do not require surgery. If the fracture requires manipulation, the cast is moulded to hold the reduction and maintain normal anatomical alignment during healing. However, is a cast necessary for patients whose fracture does not require manipulation? Removable splints are an alternative treatment option. Such splints have the advantage that they can be adjusted to improve fit around the wrist as swelling reduces, and can be removed and reapplied for the purpose of washing or, in some cases, exercise. However, evidence for their safety and effectiveness in the management of distal radius fractures is lacking. DRAFT3 is a multicentre randomized non-inferiority trial and economic analysis designed to determine the safety and effectiveness of removable splints as an alternative to casts in the treatment of distal radius fractures that do not require manipulation.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"7-9"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0245.R2
Mark J G Blyth, Nick D Clement, Xin Y Choo, James Doonan, Angus MacLean, Bryn G Jones
Aims: The aim of this study was to perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).
Methods: Ten-year follow-up of patients who were randomized to rUKA (n = 64) or mUKA (n = 65) was performed. Patients completed the EuroQol five-dimension health questionnaire preoperatively, at three months, and one, two, five, and ten years postoperatively, which was used to calculate quality-adjusted life years (QALY) gained and the incremental cost-effectiveness ratio (ICER). Costs for the index and additional surgery and healthcare costs were calculated.
Results: mUKA had a lower survival for reintervention (84.8% (95% CI 76.2 to 93.4); p = 0.001), all-cause revision (88.9% (95% CI 81.3 to 96.5); p = 0.007) and aseptic revision (91.9% (95% CI 85.1 to 98.7); p = 0.023) when compared to the rUKA group at ten years, which was 100%. The rUKA group had a greater QALY gain per patient (mean difference 0.186; p = 0.651). Overall rUKA was the dominant intervention, being cost-saving and more effective with a greater health-related quality of life gain. On removal of infected reinterventions (n = 2), the ICER was £757 (not discounted) and £481 (discounted). When including all reintervention costs, rUKA was cost-saving when more than 100 robotic cases were performed per year. When removing the infected cases, rUKA was cost-saving when undertaking more than 800 robotic cases per year.
Conclusion: rUKA had lower reintervention and revision risks at ten years, which was cost-saving and associated with a greater QALY gain, and was the dominant procedure. When removing the cost of infection, which could be a random event, rUKA was a cost-effective intervention with an ICER (£757) which was lower than the willingness-to-pay threshold (£20,000).
目的:本研究的目的是进行增量成本-效用分析,并评估与人工(mUKA)相比,机械臂辅助内侧单室膝关节置换术(rUKA)的差异成本和病例量对成本效益的影响。方法:对随机选择rUKA组(64例)和mUKA组(65例)的患者进行10年随访。患者术前、术后3个月、1年、2年、5年、10年分别填写EuroQol五维健康问卷,用于计算获得的质量调整生命年(QALY)和增量成本-效果比(ICER)。计算了该指数的成本以及额外的手术和医疗费用。结果:mUKA的再干预生存率较低(84.8% (95% CI 76.2 ~ 93.4);p = 0.001),全因修正(88.9%,95% CI 81.3 ~ 96.5);p = 0.007)和无菌修订(91.9% (95% CI 85.1 ~ 98.7);p = 0.023),与十年后的rUKA组相比,成功率为100%。rUKA组每位患者的QALY增加更大(平均差0.186;P = 0.651)。总的来说,rUKA是主要的干预措施,节省了成本,更有效,健康相关的生活质量也得到了提高。在移除受感染的再干预物(n = 2)时,ICER为757英镑(未打折)和481英镑(打折)。当包括所有再干预费用时,rUKA每年进行100多例机器人手术,节省了成本。在移除感染病例时,rUKA每年使用800多台机器人进行手术,节省了成本。结论:rUKA术后10年再干预和翻修风险较低,节省成本,QALY获益较大,是优势手术。在排除感染成本(这可能是一个随机事件)后,rUKA是一种具有成本效益的干预措施,其ICER(757英镑)低于支付意愿阈值(2万英镑)。
{"title":"Robotic arm-assisted medial compartment knee arthroplasty is a cost-effective intervention at ten-year follow-up.","authors":"Mark J G Blyth, Nick D Clement, Xin Y Choo, James Doonan, Angus MacLean, Bryn G Jones","doi":"10.1302/0301-620X.107B1.BJJ-2024-0245.R2","DOIUrl":"https://doi.org/10.1302/0301-620X.107B1.BJJ-2024-0245.R2","url":null,"abstract":"<p><strong>Aims: </strong>The aim of this study was to perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).</p><p><strong>Methods: </strong>Ten-year follow-up of patients who were randomized to rUKA (n = 64) or mUKA (n = 65) was performed. Patients completed the EuroQol five-dimension health questionnaire preoperatively, at three months, and one, two, five, and ten years postoperatively, which was used to calculate quality-adjusted life years (QALY) gained and the incremental cost-effectiveness ratio (ICER). Costs for the index and additional surgery and healthcare costs were calculated.</p><p><strong>Results: </strong>mUKA had a lower survival for reintervention (84.8% (95% CI 76.2 to 93.4); p = 0.001), all-cause revision (88.9% (95% CI 81.3 to 96.5); p = 0.007) and aseptic revision (91.9% (95% CI 85.1 to 98.7); p = 0.023) when compared to the rUKA group at ten years, which was 100%. The rUKA group had a greater QALY gain per patient (mean difference 0.186; p = 0.651). Overall rUKA was the dominant intervention, being cost-saving and more effective with a greater health-related quality of life gain. On removal of infected reinterventions (n = 2), the ICER was £757 (not discounted) and £481 (discounted). When including all reintervention costs, rUKA was cost-saving when more than 100 robotic cases were performed per year. When removing the infected cases, rUKA was cost-saving when undertaking more than 800 robotic cases per year.</p><p><strong>Conclusion: </strong>rUKA had lower reintervention and revision risks at ten years, which was cost-saving and associated with a greater QALY gain, and was the dominant procedure. When removing the cost of infection, which could be a random event, rUKA was a cost-effective intervention with an ICER (£757) which was lower than the willingness-to-pay threshold (£20,000).</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"72-80"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142911046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0894
Peter Thompson, Mohammed Khattak, P J Joseph, Daniel C Perry, Timothy F Cootes, Claudia Lindner, Dileep Karthikappallil, Hesham Zaman, Grace Airey, Saad Maqsood, Tom Hughes, Shuja Ahmad, James McEvoy, Graeme Wilson, Ha P Do Le, Fatima Tariq, Sohan Shah, Dhawal Patel, Ross McAllister, Anil Singh Dhadwal, Joseph Fennelly, William Lloyd, Amir Varasteh, Kieran Almond, Henry Crouch-Smith
Aims: The aims of this study were to develop an automatic system capable of calculating four radiological measurements used in the diagnosis and monitoring of cerebral palsy (CP)-related hip disease, and to demonstrate that these measurements are sufficiently accurate to be used in clinical practice.
Methods: We developed a machine-learning system to automatically measure Reimer's migration percentage (RMP), acetabular index (ACI), head shaft angle (HSA), and neck shaft angle (NSA). The system automatically locates points around the femoral head and acetabulum on pelvic radiographs, and uses these to calculate measurements. The system was evaluated on 1,650 pelvic radiographs of children with CP (682 females and 968 males, mean age 8.3 years (SD 4.5)). Each radiograph was manually measured by five clinical experts. Agreement between the manual clinical measurements and the automatic system was assessed by mean absolute deviation (MAD) from the mean manual measurement, type 1 and type 2 intraclass correlation coefficients (ICCs), and a linear mixed-effects model (LMM) for assessing bias.
Results: The MAD scores were 5.7% (SD 8.5%) for RMP, 4.3° (SD 5.4°) for ACI, 5.0° (SD 5.2°) for NSA, and 5.7° (SD 6.1°) for HSA. Overall ICCs quantifying the agreement between the mean manual measurement and the automatic results were 0.91 for RMP, 0.66 for ACI, 0.85 for NSA, and 0.73 for HSA. The LMM showed no statistically significant bias.
Conclusion: The results showed excellent agreement between the manual and automatic measurements for RMP, good agreement for NSA, and moderate agreement for HSA and ACI. The performance of the system is sufficient for application in clinical practice to support the assessment of hip migration based on RMP. The system has the potential to save clinicians time and to improve patient care by enabling more comprehensive, consistent, and reliable monitoring of hip migration in children with CP.
{"title":"Automating radiological measurements of the hip in children with cerebral palsy.","authors":"Peter Thompson, Mohammed Khattak, P J Joseph, Daniel C Perry, Timothy F Cootes, Claudia Lindner, Dileep Karthikappallil, Hesham Zaman, Grace Airey, Saad Maqsood, Tom Hughes, Shuja Ahmad, James McEvoy, Graeme Wilson, Ha P Do Le, Fatima Tariq, Sohan Shah, Dhawal Patel, Ross McAllister, Anil Singh Dhadwal, Joseph Fennelly, William Lloyd, Amir Varasteh, Kieran Almond, Henry Crouch-Smith","doi":"10.1302/0301-620X.107B1.BJJ-2024-0894","DOIUrl":"10.1302/0301-620X.107B1.BJJ-2024-0894","url":null,"abstract":"<p><strong>Aims: </strong>The aims of this study were to develop an automatic system capable of calculating four radiological measurements used in the diagnosis and monitoring of cerebral palsy (CP)-related hip disease, and to demonstrate that these measurements are sufficiently accurate to be used in clinical practice.</p><p><strong>Methods: </strong>We developed a machine-learning system to automatically measure Reimer's migration percentage (RMP), acetabular index (ACI), head shaft angle (HSA), and neck shaft angle (NSA). The system automatically locates points around the femoral head and acetabulum on pelvic radiographs, and uses these to calculate measurements. The system was evaluated on 1,650 pelvic radiographs of children with CP (682 females and 968 males, mean age 8.3 years (SD 4.5)). Each radiograph was manually measured by five clinical experts. Agreement between the manual clinical measurements and the automatic system was assessed by mean absolute deviation (MAD) from the mean manual measurement, type 1 and type 2 intraclass correlation coefficients (ICCs), and a linear mixed-effects model (LMM) for assessing bias.</p><p><strong>Results: </strong>The MAD scores were 5.7% (SD 8.5%) for RMP, 4.3° (SD 5.4°) for ACI, 5.0° (SD 5.2°) for NSA, and 5.7° (SD 6.1°) for HSA. Overall ICCs quantifying the agreement between the mean manual measurement and the automatic results were 0.91 for RMP, 0.66 for ACI, 0.85 for NSA, and 0.73 for HSA. The LMM showed no statistically significant bias.</p><p><strong>Conclusion: </strong>The results showed excellent agreement between the manual and automatic measurements for RMP, good agreement for NSA, and moderate agreement for HSA and ACI. The performance of the system is sufficient for application in clinical practice to support the assessment of hip migration based on RMP. The system has the potential to save clinicians time and to improve patient care by enabling more comprehensive, consistent, and reliable monitoring of hip migration in children with CP.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"124-132"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7617337/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0241.R1
Simon N van Laarhoven, Sjoerd P F T Nota, Gijs G van Hellemondt, Berend W Schreurs, Ate B Wymenga, Petra J C Heesterbeek
Aims: Tibial fixation in revision total knee arthroplasty (rTKA) can present surgical challenges. It has been suggested that appropriate fixation in at least two of the three anatomical zones (epiphysis, metaphysis, and diaphysis) is essential for implant survival. However, supporting clinical data are lacking. In this retrospective case-control study, we investigated the relationship between zonal fixation of hybrid rTKA tibial components and re-revision total knee arthroplasty for aseptic loosening (rrTKA-AL).
Methods: All consecutive rTKAs with hybrid tibial components (May 2006 to December 2020) were screened for subsequent rrTKA-AL. A control group was randomly selected from the remaining cohort. Postoperative radiographs of rTKAs were scored in random order by three blinded observers for zonal fixation in the epiphysis (bone resection level below, at, or above fibular head; 0 to 2), metaphysis (number of sufficiently cemented zones; 0 to 4), and diaphysis (canal filling ratio (CFR); %). The intraclass correlation coefficient (ICC) was calculated to quantify the agreement between observers. Multivariate logistic regression analysis was performed to assess the relationship between zonal fixation and rrTKA-AL.
Results: Overall, 33 patients underwent a further rrTKA-AL from a total of 1,173 rTKAs where hybrid tibial components (2.8%) were used. Patients requiring rrTKA-AL had a significantly lower epiphyseal bone resection level (OR 0.43; 95% CI 0.23 to 0.76; p = 0.006), lower number of adequately cemented zones (OR 0.50; 95% CI 0.30 to 0.79; p = 0.004), but no difference in CFR (p = 0.858). Furthermore, patients needing rrTKA-AL had more frequently previous revisions (p = 0.047), a higher rate of a prior use of a stemmed tibial component (p = 0.011), and a higher Anderson Orthopaedic Research Institute classification (p < 0.001). Agreement of zonal fixation between observers was good (ICC 0.79 to 0.87).
Conclusion: Patients in need of subsequent rrTKA-AL had lower epiphyseal bone resection levels and a lower number of sufficiently metaphyseal cemented zones following rTKA. These results emphasize the importance of appropriate metaphyseal fixation at rTKA. With this information, orthopaedic surgeons can identify patients at greater risk for rrTKA-AL and optimize their surgical technique in revision knee arthroplasty surgery.
{"title":"Association between postoperative zonal fixation of hybrid tibial components in revision total knee arthroplasty and subsequent aseptic loosening.","authors":"Simon N van Laarhoven, Sjoerd P F T Nota, Gijs G van Hellemondt, Berend W Schreurs, Ate B Wymenga, Petra J C Heesterbeek","doi":"10.1302/0301-620X.107B1.BJJ-2024-0241.R1","DOIUrl":"https://doi.org/10.1302/0301-620X.107B1.BJJ-2024-0241.R1","url":null,"abstract":"<p><strong>Aims: </strong>Tibial fixation in revision total knee arthroplasty (rTKA) can present surgical challenges. It has been suggested that appropriate fixation in at least two of the three anatomical zones (epiphysis, metaphysis, and diaphysis) is essential for implant survival. However, supporting clinical data are lacking. In this retrospective case-control study, we investigated the relationship between zonal fixation of hybrid rTKA tibial components and re-revision total knee arthroplasty for aseptic loosening (rrTKA-AL).</p><p><strong>Methods: </strong>All consecutive rTKAs with hybrid tibial components (May 2006 to December 2020) were screened for subsequent rrTKA-AL. A control group was randomly selected from the remaining cohort. Postoperative radiographs of rTKAs were scored in random order by three blinded observers for zonal fixation in the epiphysis (bone resection level below, at, or above fibular head; 0 to 2), metaphysis (number of sufficiently cemented zones; 0 to 4), and diaphysis (canal filling ratio (CFR); %). The intraclass correlation coefficient (ICC) was calculated to quantify the agreement between observers. Multivariate logistic regression analysis was performed to assess the relationship between zonal fixation and rrTKA-AL.</p><p><strong>Results: </strong>Overall, 33 patients underwent a further rrTKA-AL from a total of 1,173 rTKAs where hybrid tibial components (2.8%) were used. Patients requiring rrTKA-AL had a significantly lower epiphyseal bone resection level (OR 0.43; 95% CI 0.23 to 0.76; p = 0.006), lower number of adequately cemented zones (OR 0.50; 95% CI 0.30 to 0.79; p = 0.004), but no difference in CFR (p = 0.858). Furthermore, patients needing rrTKA-AL had more frequently previous revisions (p = 0.047), a higher rate of a prior use of a stemmed tibial component (p = 0.011), and a higher Anderson Orthopaedic Research Institute classification (p < 0.001). Agreement of zonal fixation between observers was good (ICC 0.79 to 0.87).</p><p><strong>Conclusion: </strong>Patients in need of subsequent rrTKA-AL had lower epiphyseal bone resection levels and a lower number of sufficiently metaphyseal cemented zones following rTKA. These results emphasize the importance of appropriate metaphyseal fixation at rTKA. With this information, orthopaedic surgeons can identify patients at greater risk for rrTKA-AL and optimize their surgical technique in revision knee arthroplasty surgery.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"65-71"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142916011","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0170.R1
Christopher N Carender, Nicholas A Bedard, Kristin M Fruth, Michael J Taunton, Mark W Pagnano, Matthew P Abdel
Aims: The purpose of this study was to directly compare the Modular Dual Mobility (MDM) Mobile Bearing Hip System (Stryker, USA) and large femoral heads (LFHs) in revision total hip arthroplasties (THAs) at mid-term follow-up, with specific emphasis on survival free of re-revision for dislocation, any re-revision, dislocation, and the risk of metal-related complications.
Methods: We identified 299 revision THAs performed at a single tertiary care academic institution from March 2011 to July 2014. Aseptic loosening of the acetabular component (n = 65), dislocation (n = 58), and reimplantation as part of a two-stage exchange protocol (n = 57) were the most common reasons for index revision. MDM constructs were used in 123 cases, and LFHs were used in 176 cases. Mean age was 66 years (28 to 93), mean BMI was 31 kg/m2 (18 to 55), and 45% (n = 136) were female. Mean follow-up was seven years (2 to 12).
Results: The ten-year survival free of re-revision for dislocation was 99% (95% CI 95 to 100) in the MDM cohort and 91% (95% CI 84 to 96) in the LFH cohort, with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 7.1 (95% CI 1.3 to 40.8); p = 0.023). The ten-year survival free of any re-revision was 92% (95% CI 82 to 99%) in the MDM cohort and 84% (95% CI 74 to 90) in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.6 (95% CI 1.1 to 5.9); p = 0.024). The ten-year survival free of any dislocation was 95% (95% CI 85 to 99) in the MDM cohort and 87% (95% CI 78 to 92) in the LFH cohort with a significantly increased risk of any dislocation in the LFH cohort (HR 2.7 (95% CI 1.1 to 6.3); p = 0.028). There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.
Conclusion: In this head-to-head comparison, revision THAs with a MDM construct safely and effectively lowered the risk of re-revision for dislocation, any re-revision, and any dislocation compared to LFH at mid-term follow-up. There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.
目的:本研究的目的是在中期随访中直接比较模块化双活动(MDM)移动轴承髋关节系统(Stryker, USA)和大股骨头(LFHs)在翻修全髋关节置换术(tha)中的应用,特别强调无脱位重新翻修、任何重新翻修、脱位以及金属相关并发症风险的生存。方法:我们选取了2011年3月至2014年7月在一家三级医疗学术机构进行的299例tha修订。髋臼假体无菌性松动(n = 65)、脱位(n = 58)和作为两阶段交换方案的一部分重新植入术(n = 57)是指数翻修的最常见原因。123例使用MDM结构,176例使用LFHs。平均年龄66岁(28 ~ 93岁),平均BMI为31 kg/m2(18 ~ 55岁),女性占45% (n = 136)。平均随访7年(2 ~ 12年)。结果:MDM队列中脱位再次翻修的10年生存率为99% (95% CI 95 ~ 100), LFH队列中脱位再次翻修的10年生存率为91% (95% CI 84 ~ 96), LFH队列中脱位再次翻修的风险显著增加(HR 7.1 (95% CI 1.3 ~ 40.8);P = 0.023)。无任何重新修订的10年生存率在MDM队列中为92% (95% CI 82 - 99%),在LFH队列中为84% (95% CI 74 - 90), LFH队列中任何重新修订的风险显著增加(HR 2.6 (95% CI 1.1 - 5.9);P = 0.024)。MDM组无脱位的10年生存率为95% (95% CI 85 ~ 99), LFH组为87% (95% CI 78 ~ 92), LFH组脱位的风险显著增加(HR 2.7 (95% CI 1.1 ~ 6.3);P = 0.028)。在MDM队列中,没有因金属病或腐蚀而重新修订或再次手术。结论:在这个头对头的比较中,与LFH中期随访相比,使用MDM结构的tha翻修安全有效地降低了因脱位而再次翻修的风险,任何重新翻修的风险以及任何脱位的风险。在MDM队列中,没有因金属病或腐蚀而重新修订或再次手术。
{"title":"Modular dual-mobility constructs outperformed large femoral heads in 299 revision total hip arthroplasties at mid-term follow-up.","authors":"Christopher N Carender, Nicholas A Bedard, Kristin M Fruth, Michael J Taunton, Mark W Pagnano, Matthew P Abdel","doi":"10.1302/0301-620X.107B1.BJJ-2024-0170.R1","DOIUrl":"https://doi.org/10.1302/0301-620X.107B1.BJJ-2024-0170.R1","url":null,"abstract":"<p><strong>Aims: </strong>The purpose of this study was to directly compare the Modular Dual Mobility (MDM) Mobile Bearing Hip System (Stryker, USA) and large femoral heads (LFHs) in revision total hip arthroplasties (THAs) at mid-term follow-up, with specific emphasis on survival free of re-revision for dislocation, any re-revision, dislocation, and the risk of metal-related complications.</p><p><strong>Methods: </strong>We identified 299 revision THAs performed at a single tertiary care academic institution from March 2011 to July 2014. Aseptic loosening of the acetabular component (n = 65), dislocation (n = 58), and reimplantation as part of a two-stage exchange protocol (n = 57) were the most common reasons for index revision. MDM constructs were used in 123 cases, and LFHs were used in 176 cases. Mean age was 66 years (28 to 93), mean BMI was 31 kg/m<sup>2</sup> (18 to 55), and 45% (n = 136) were female. Mean follow-up was seven years (2 to 12).</p><p><strong>Results: </strong>The ten-year survival free of re-revision for dislocation was 99% (95% CI 95 to 100) in the MDM cohort and 91% (95% CI 84 to 96) in the LFH cohort, with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 7.1 (95% CI 1.3 to 40.8); p = 0.023). The ten-year survival free of any re-revision was 92% (95% CI 82 to 99%) in the MDM cohort and 84% (95% CI 74 to 90) in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.6 (95% CI 1.1 to 5.9); p = 0.024). The ten-year survival free of any dislocation was 95% (95% CI 85 to 99) in the MDM cohort and 87% (95% CI 78 to 92) in the LFH cohort with a significantly increased risk of any dislocation in the LFH cohort (HR 2.7 (95% CI 1.1 to 6.3); p = 0.028). There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.</p><p><strong>Conclusion: </strong>In this head-to-head comparison, revision THAs with a MDM construct safely and effectively lowered the risk of re-revision for dislocation, any re-revision, and any dislocation compared to LFH at mid-term follow-up. There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"58-64"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142916015","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0548.R1
Miguel A Fernandez, Freddie Henshaw, William J Carlos, Andrew Kelly, Xavier L Griffin, Matt L Costa
Aims: There is compelling evidence for the use of cemented hip hemiarthroplasty for displaced intracapsular hip fractures; however, the risks of cement are well reported and in rare cases may be associated with haemodynamic collapse. It is therefore important to improve our understanding of haemodynamic instability, intraoperative monitoring, and strategies to reduce the risk to patients.
Methods: We measured arterial blood pressure using the LiDCOrapid Continuous Non-invasive Arterial Pressure (CNAP) finger cuff during surgery in patients enrolled in the WHiTE 5 trial randomized to cemented or modern uncemented hip hemiarthroplasty at a single recruiting site. We observed the incidence, timing, and magnitude of haemodynamic instability at key stages of the surgical procedure.
Results: We obtained measurements from 56 patients, of whom 46 had complete recordings and were used in the analysis. Modest falls in systolic blood pressure (20% to 30%) occurred in four patients (15%) who received a cemented hemiarthroplasty and one patient (5%) in the uncemented group. The fall in blood pressure occurred either within five minutes of cementing or at final hip reduction. We observed concurrent drops in cardiac output (CO) and stroke volume (SV).
Conclusion: We observed the presence of two potential periods for haemodynamic instability during hip hemiarthroplasty surgery: the first was within five minutes of cementing the femoral canal and the second after final reduction of the prosthesis (observed in both cemented and uncemented hemiarthroplasty). The falls in blood pressure appeared to be driven by reduced CO and SV.
{"title":"Haemodynamic measurements during hip hemiarthroplasty surgery for hip fracture.","authors":"Miguel A Fernandez, Freddie Henshaw, William J Carlos, Andrew Kelly, Xavier L Griffin, Matt L Costa","doi":"10.1302/0301-620X.107B1.BJJ-2024-0548.R1","DOIUrl":"10.1302/0301-620X.107B1.BJJ-2024-0548.R1","url":null,"abstract":"<p><strong>Aims: </strong>There is compelling evidence for the use of cemented hip hemiarthroplasty for displaced intracapsular hip fractures; however, the risks of cement are well reported and in rare cases may be associated with haemodynamic collapse. It is therefore important to improve our understanding of haemodynamic instability, intraoperative monitoring, and strategies to reduce the risk to patients.</p><p><strong>Methods: </strong>We measured arterial blood pressure using the LiDCO<i>rapid</i> Continuous Non-invasive Arterial Pressure (CNAP) finger cuff during surgery in patients enrolled in the WHiTE 5 trial randomized to cemented or modern uncemented hip hemiarthroplasty at a single recruiting site. We observed the incidence, timing, and magnitude of haemodynamic instability at key stages of the surgical procedure.</p><p><strong>Results: </strong>We obtained measurements from 56 patients, of whom 46 had complete recordings and were used in the analysis. Modest falls in systolic blood pressure (20% to 30%) occurred in four patients (15%) who received a cemented hemiarthroplasty and one patient (5%) in the uncemented group. The fall in blood pressure occurred either within five minutes of cementing or at final hip reduction. We observed concurrent drops in cardiac output (CO) and stroke volume (SV).</p><p><strong>Conclusion: </strong>We observed the presence of two potential periods for haemodynamic instability during hip hemiarthroplasty surgery: the first was within five minutes of cementing the femoral canal and the second after final reduction of the prosthesis (observed in both cemented and uncemented hemiarthroplasty). The falls in blood pressure appeared to be driven by reduced CO and SV.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"103-107"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1302/0301-620X.107B1.BJJ-2024-0354.R1
Ben A Marson, Matilda Gurney, Joseph C Manning, Marilyn James, Reuben Ogollah, Charlotte Durand, Benjamin J Ollivere
Aims: It is unclear if a supportive bandage, removable splint, or walking cast offers the best outcome following low-risk ankle fractures in children. The aim of this study was to evaluate the feasibility of a randomized controlled trial to compare these treatments.
Methods: Children aged five to 15 years with low-risk ankle fractures were recruited to this feasibility trial from 1 February 2020 to 30 March 2023. Children were randomized to supportive bandage, removable splint, or walking cast for two weeks. Follow-up at two, six, and 12 weeks was undertaken to determine feasibility for a definitive trial. Outcomes collected included complications, the Patient-Reported Outcomes Measurement Information System (PROMIS) mobility score, Paediatric Quality of Life Inventory, youth version of the EuroQol five-dimension health questionnaire, and Activities Scale for Kids - Performance.
Results: A total of 87 children from six hospitals were randomized at a rate of 0.9 participants per site per month. Two children in the supportive bandage group crossed over to an alternative device. Complications were reported in six children. One child in the cast group developed skin blisters. One child in cast and one in bandage sustained a reinjury during the 12-week follow-up, and two children (one splint and one cast) required additional immobilization after the two-week treatment for persistent pain. Of the 84 participants who remained in the study at six weeks, 43 (51.2%) returned follow-up questionnaires at six weeks. Of the patient-reported outcome measures (PROMs), proxy-reported PROMIS mobility showed good responsiveness, low ceiling effects, and low missing item rates. In an exploratory analysis, small differences were observed between groups, with no evidence that any of the treatments were superior.
Conclusion: This feasibility study showed acceptable recruitment and retention rates. There remains equipoise regarding the best treatment of these injuries. All three treatments appear well tolerated with similar complication rates. A primary outcome of complications or treatment failure would provide the highest study retention with secondary PROMs and economic analysis.
{"title":"Supportive bandage, removable splint, or walking casts for low-risk ankle fractures in children: a feasibility randomized controlled trial.","authors":"Ben A Marson, Matilda Gurney, Joseph C Manning, Marilyn James, Reuben Ogollah, Charlotte Durand, Benjamin J Ollivere","doi":"10.1302/0301-620X.107B1.BJJ-2024-0354.R1","DOIUrl":"10.1302/0301-620X.107B1.BJJ-2024-0354.R1","url":null,"abstract":"<p><strong>Aims: </strong>It is unclear if a supportive bandage, removable splint, or walking cast offers the best outcome following low-risk ankle fractures in children. The aim of this study was to evaluate the feasibility of a randomized controlled trial to compare these treatments.</p><p><strong>Methods: </strong>Children aged five to 15 years with low-risk ankle fractures were recruited to this feasibility trial from 1 February 2020 to 30 March 2023. Children were randomized to supportive bandage, removable splint, or walking cast for two weeks. Follow-up at two, six, and 12 weeks was undertaken to determine feasibility for a definitive trial. Outcomes collected included complications, the Patient-Reported Outcomes Measurement Information System (PROMIS) mobility score, Paediatric Quality of Life Inventory, youth version of the EuroQol five-dimension health questionnaire, and Activities Scale for Kids - Performance.</p><p><strong>Results: </strong>A total of 87 children from six hospitals were randomized at a rate of 0.9 participants per site per month. Two children in the supportive bandage group crossed over to an alternative device. Complications were reported in six children. One child in the cast group developed skin blisters. One child in cast and one in bandage sustained a reinjury during the 12-week follow-up, and two children (one splint and one cast) required additional immobilization after the two-week treatment for persistent pain. Of the 84 participants who remained in the study at six weeks, 43 (51.2%) returned follow-up questionnaires at six weeks. Of the patient-reported outcome measures (PROMs), proxy-reported PROMIS mobility showed good responsiveness, low ceiling effects, and low missing item rates. In an exploratory analysis, small differences were observed between groups, with no evidence that any of the treatments were superior.</p><p><strong>Conclusion: </strong>This feasibility study showed acceptable recruitment and retention rates. There remains equipoise regarding the best treatment of these injuries. All three treatments appear well tolerated with similar complication rates. A primary outcome of complications or treatment failure would provide the highest study retention with secondary PROMs and economic analysis.</p>","PeriodicalId":48944,"journal":{"name":"Bone & Joint Journal","volume":"107-B 1","pages":"108-117"},"PeriodicalIF":4.9,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142911048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}