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Simpson AHRW, Clement ND, Simpson SA, Pandit H, Smillie S, Leeds AR, Conaghan PG, Kingsbury SR, Hamilton D, Craig P, Ray D, Keerie C, Kinsella E, Bell-Higgs A, McGarty A, Beadle C, Howie CR, Norrie J. A preoperative package of care for osteoarthritis, consisting of weight loss, orthotics, rehabilitation, and topical and oral analgesia (OPPORTUNITY): a two-centre, open-label, randomised controlled feasibility trial. Lancet Rheumatol 2024; 6:e237-e246. [PMID: 38423028 DOI: 10.1016/s2665-9913(23)00337-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Osteoarthritis of the knee is a major cause of disability worldwide. Non-operative treatments can reduce the morbidity but adherence is poor. We hypothesised that adherence could be optimised if behavioural change was established in the preoperative period. Therefore, we aimed to assess feasibility, acceptability, and recruitment and retention rates of a preoperative package of non-operative care in patients awaiting knee replacement surgery. METHODS We did an open-label, randomised controlled, feasibility trial in two secondary care centres in the UK. Eligible participants were aged 15-85 years, on the waiting list for a knee arthroplasty for osteoarthritis, and met at least one of the thresholds for one of the four components of the preoperative package of non-operative care intervention (ie, weight loss, exercise therapy, use of insoles, and analgesia adjustment). Participants were randomly assigned (2:1) to either the intervention group or the standard of care (ie, control) group. All four aspects of the intervention were delivered weekly over 12 weeks. Participants in the intervention group were reviewed regularly to assess adherence. The primary outcome was acceptability and feasibility of delivering the intervention, as measured by recruitment rate, retention rate at follow-up review after planned surgery, health-related quality of life, joint-specific scores, and adherence (weight change and qualitative interviews). This study is registered with ISRCTN, ISRCTN96684272. FINDINGS Between Sept 3 2018, and Aug 30, 2019, we screened 233 patients, of whom 163 (73%) were excluded and 60 (27%) were randomly assigned to either the intervention group (n=40) or the control group (n=20). 34 (57%) of 60 participants were women, 26 (43%) were men, and the mean age was 66·8 years (SD 8·6). Uptake of the specific intervention components varied: 31 (78%) of 40 had exercise therapy, 28 (70%) weight loss, 22 (55%) analgesia adjustment, and insoles (18 [45%]). Overall median adherence was 94% (IQR 79·5-100). At the final review, the intervention group lost a mean of 11·2 kg (SD 5·6) compared with 1·3 kg (3·8) in the control group (estimated difference -9·8 kg [95% CI -13·4 to -6·3]). A clinically significant improvement in health-related quality o life (mean change 0·078 [SD 0·195]) were reported, and joint-specific scores showed greater improvement in the intervention group than in the control group. No adverse events attributable to the intervention occurred. INTERPRETATION Participants adhered well to the non-operative interventions and their health-related quality of life improved. Participant and health professional feedback were extremely positive. These findings support progression to a full-scale effectiveness trial. FUNDING Versus Arthritis.
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Affiliation(s)
- A Hamish R W Simpson
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK.
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Sharon A Simpson
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Hemandt Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - Susie Smillie
- School of Social and Political Sciences, University of Glasgow, Glasgow, UK
| | - Anthony R Leeds
- Parker Institute, Frederiksberg Hospital, Copenhagen, Denmark
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - David Hamilton
- Research Centre for Health, Glasgow Caledonian University, Glasgow, UK
| | - Peter Craig
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - David Ray
- Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Arlene McGarty
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Christine Beadle
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Colin R Howie
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Oliver WM, Nicholson JA, Bell KR, Carter TH, White TO, Clement ND, Duckworth AD, Simpson AHRW. Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study. Eur J Orthop Surg Traumatol 2024; 34:909-918. [PMID: 37773419 PMCID: PMC10858097 DOI: 10.1007/s00590-023-03725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing and estimate the accuracy of 6wk ultrasound in predicting nonunion. METHODS Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n = 10/12) with those that developed a nonunion (n = 2/12). RESULTS The mean scan duration was 8 min (5-12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, the absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). The absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures < 8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion). CONCLUSIONS Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Jamie A Nicholson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Katrina R Bell
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - A Hamish R W Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Department of Orthopaedics and Trauma, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
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Setchfield K, Gorman A, Simpson AHRW, Somekh MG, Wright AJ. Effect of skin color on optical properties and the implications for medical optical technologies: a review. J Biomed Opt 2024; 29:010901. [PMID: 38269083 PMCID: PMC10807857 DOI: 10.1117/1.jbo.29.1.010901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024]
Abstract
Significance Skin color affects light penetration leading to differences in its absorption and scattering properties. COVID-19 highlighted the importance of understanding of the interaction of light with different skin types, e.g., pulse oximetry (PO) unreliably determined oxygen saturation levels in people from Black and ethnic minority backgrounds. Furthermore, with increased use of other medical wearables using light to provide disease information and photodynamic therapies to treat skin cancers, a thorough understanding of the effect skin color has on light is important for reducing healthcare disparities. Aim The aim of this work is to perform a thorough review on the effect of skin color on optical properties and the implication of variation on optical medical technologies. Approach Published in vivo optical coefficients associated with different skin colors were collated and their effects on optical penetration depth and transport mean free path (TMFP) assessed. Results Variation among reported values is significant. We show that absorption coefficients for dark skin are ∼ 6 % to 74% greater than for light skin in the 400 to 1000 nm spectrum. Beyond 600 nm, the TMFP for light skin is greater than for dark skin. Maximum transmission for all skin types was beyond 940 nm in this spectrum. There are significant losses of light with increasing skin depth; in this spectrum, depending upon Fitzpatrick skin type (FST), on average 14% to 18% of light is lost by a depth of 0.1 mm compared with 90% to 97% of the remaining light being lost by a depth of 1.93 mm. Conclusions Current published data suggest that at wavelengths beyond 940 nm light transmission is greatest for all FSTs. Data beyond 1000 nm are minimal and further study is required. It is possible that the amount of light transmitted through skin for all skin colors will converge with increasing wavelength enabling optical medical technologies to become independent of skin color.
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Affiliation(s)
- Kerry Setchfield
- University of Nottingham, Faculty of Engineering, Optics and Photonics Research Group, Nottingham, United Kingdom
| | - Alistair Gorman
- University of Edinburgh, School of Engineering, Edinburgh, United Kingdom
| | - A. Hamish R. W. Simpson
- University of Edinburgh, Department of Orthopaedics, Division of Clinical and Surgical Sciences, Edinburgh, United Kingdom
| | - Michael G. Somekh
- University of Nottingham, Faculty of Engineering, Optics and Photonics Research Group, Nottingham, United Kingdom
- Zhejiang Lab, Hangzhou, China
| | - Amanda J. Wright
- University of Nottingham, Faculty of Engineering, Optics and Photonics Research Group, Nottingham, United Kingdom
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Makaram NS, Simpson AHRW. Explanatory and pragmatic trials in orthopaedics - Have we done the right studies? Injury 2023; 54 Suppl 5:110905. [PMID: 37400326 DOI: 10.1016/j.injury.2023.110905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
Recent decades have seen marked advances in the quality of clinical orthopaedic trauma research, and with this has come a rise in the number of randomised clinical trials (RCTs) being conducted in orthopaedic trauma. These trials have been largely valuable in driving evidence-based management of injuries which previously had clinical equipoise. However, though RCTs are traditionally seen as the 'gold standard' of high-quality research, this research method is comprised primarily of two entities, explanatory and pragmatic designs, each with its own strengths and limitations. Most orthopaedic trials lie within a continuum between these designs, with varying degrees of both pragmatic and explanatory features. In this narrative review we provide a summary of the nuances within orthopaedic trial design, the advantages and limitations of such designs, and suggest tools which may aid clinicians in the appropriate selection and evaluation of trial designs.
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Affiliation(s)
- N S Makaram
- Specialty Registrar (StR) in Trauma and Orthopaedics, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom.
| | - A Hamish R W Simpson
- Professor of Orthopaedics and Trauma, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom
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Makaram NS, Hall AJ, Clement ND, MacLullich AJ, Simpson AHRW. Lessons learned from hip fracture registries - From the Scottish perspective to global practice. Injury 2023; 54 Suppl 5:110935. [PMID: 37451905 DOI: 10.1016/j.injury.2023.110935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/18/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
Hip fracture is the most common serious orthopaedic injury affecting older people. In Scotland, 7000 patients sustain a hip fracture each year, and this is projected to rise to 10,300 a year by 2029. In this narrative review, we describe the origin and evolution of the Scottish Hip Fracture Audit, including key elements which have improved hip fracture care and outcomes within Scotland, and the current state of play of hip fracture registries around the world. We go on to discuss future directions for data driven improvements in hip fracture care, including international standardised data collection and a global minimum common dataset for hip fracture registries.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom, EH16 4SU; The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom, EH16 4SU.
| | - Andrew J Hall
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom, EH16 4SU
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom, EH16 4SU
| | - Alasdair J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, United Kingdom
| | - A Hamish R W Simpson
- The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom, EH16 4SU
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Setchfield K, Gorman A, Simpson AHRW, Somekh MG, Wright AJ. Relevance and utility of the in-vivo and ex-vivo optical properties of the skin reported in the literature: a review [Invited]. Biomed Opt Express 2023; 14:3555-3583. [PMID: 37497524 PMCID: PMC10368038 DOI: 10.1364/boe.493588] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023]
Abstract
Imaging non-invasively into the human body is currently limited by cost (MRI and CT scan), image resolution (ultrasound), exposure to ionising radiation (CT scan and X-ray), and the requirement for exogenous contrast agents (CT scan and PET scan). Optical imaging has the potential to overcome all these issues but is currently limited by imaging depth due to the scattering and absorption properties of human tissue. Skin is the first barrier encountered by light when imaging non-invasively, and therefore a clear understanding of the way that light interacts with skin is required for progress on optical medical imaging to be made. Here we present a thorough review of the optical properties of human skin measured in-vivo and compare these to the previously collated ex-vivo measurements. Both in-vivo and ex-vivo published data show high inter- and intra-publication variability making definitive answers regarding optical properties at given wavelengths challenging. Overall, variability is highest for ex-vivo absorption measurements with differences of up to 77-fold compared with 9.6-fold for the in-vivo absorption case. The impact of this variation on optical penetration depth and transport mean free path is presented and potential causes of these inconsistencies are discussed. We propose a set of experimental controls and reporting requirements for future measurements. We conclude that a robust in-vivo dataset, measured across a broad spectrum of wavelengths, is required for the development of future technologies that significantly increase the depth of optical imaging.
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Affiliation(s)
- Kerry Setchfield
- Optics and Photonics Research Group, Faculty of Engineering, University of Nottingham, NG7 2RD, UK
| | | | - A Hamish R W Simpson
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, EH8 9YL, UK
| | - Michael G Somekh
- Optics and Photonics Research Group, Faculty of Engineering, University of Nottingham, NG7 2RD, UK
| | - Amanda J Wright
- Optics and Photonics Research Group, Faculty of Engineering, University of Nottingham, NG7 2RD, UK
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Makaram NS, Lamb SE, Simpson AHRW. Are we doing the right surgical trials? Bone Joint Res 2023; 12:372-374. [PMID: 37287314 DOI: 10.1302/2046-3758.126.bjr-2023-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | | | - A Hamish R W Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
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Yapp LZ, Scott CEH, MacDonald DJ, Howie CR, Simpson AHRW, Clement ND. Primary knee arthroplasty for osteoarthritis restores patients' health-related quality of life to normal population levels. Bone Joint J 2023; 105-B:365-372. [PMID: 36924161 DOI: 10.1302/0301-620x.105b4.bjj-2022-0659.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
This study investigates whether primary knee arthroplasty (KA) restores health-related quality of life (HRQoL) to levels expected in the general population. This retrospective case-control study compared HRQoL data from two sources: patients undergoing primary KA in a university-teaching hospital (2013 to 2019), and the Health Survey for England (HSE; 2010 to 2012). Patient-level data from the HSE were used to represent the general population. Propensity score matching was used to balance covariates and facilitate group comparisons. A propensity score was estimated using logistic regression based upon the covariates sex, age, and BMI. Two matched cohorts with 3,029 patients each were obtained for the adjusted analyses (median age 70.3 (interquartile range (IQR) 64 to 77); number of female patients 3,233 (53.4%); median BMI 29.7 kg/m2 (IQR 26.5 to 33.7)). HRQoL was measured using the three-level version of the EuroQol five-dimension questionnaire (EQ-5D-3L), and summarized using the Index and EuroQol visual analogue scale (EQ-VAS) scores. Patients awaiting KA had significantly lower EQ-5D-3L Index scores than the general population (median 0.620 (IQR 0.16 to 0.69) vs median 0.796 (IQR 0.69 to 1.00); p < 0.001). By one year postoperatively, the median EQ-5D-3L Index score improved significantly in the KA cohort (mean change 0.32 (SD 0.33); p < 0.001), and demonstrated no clinically relevant differences when compared to the general population (median 0.796 (IQR 0.69 to 1.00) vs median 0.796 (IQR 0.69 to 1.00)). Compared to the general population cohort, the postoperative EQ-VAS was significantly higher in the KA cohort (p < 0.001). Subgroup comparisons demonstrated that older age groups had statistically better EQ-VAS scores than matched peers in the general population. Patients awaiting KA for osteoarthritis had significantly poorer HRQoL than the general population. However, within one year of surgery, primary KA restored HRQoL to levels expected for the patient's age-, BMI-, and sex-matched peers.
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Affiliation(s)
- Liam Z Yapp
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Deborah J MacDonald
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin R Howie
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Hamish R W Simpson
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Bone & Joint Research , London, UK
| | - Nick D Clement
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Farrow L, Jenkins PJ, Dunstan E, Murray A, Blyth MJG, Simpson AHRW, Clement ND. Predicted waiting times for orthopaedic surgery : an urgent need to address the deficit in capacity. Bone Joint Res 2022; 11:890-892. [PMID: 36513099 PMCID: PMC9792871 DOI: 10.1302/2046-3758.1112.bjr-2022-0404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cite this article: Bone Joint Res 2022;11(12):890-892.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK,Grampian Orthopaedics, Woodend Hospital, Aberdeen, UK, Luke Farrow. E-mail:
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Yapp LZ, Clement ND, Moran M, Clarke JV, Simpson AHRW, Scott CEH. The estimated lifetime risk of revision after primary knee arthroplasty is influenced by age, sex, and indication. Bone Joint J 2022; 104-B:1313-1322. [DOI: 10.1302/0301-620x.104b12.bjj-2021-1631.r3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Aims The aim of this study was to assess factors associated with the estimated lifetime risk of revision surgery after primary knee arthroplasty (KA). Methods All patients from the Scottish Arthroplasty Project dataset undergoing primary KA during the period 1 January 1998 to 31 December 2019 were included. The cumulative incidence function for revision and death was calculated up to 20 years. Adjusted analyses used cause-specific Cox regression modelling to determine the influence of patient factors. The lifetime risk was calculated as a percentage for patients aged between 45 and 99 years using multiple-decrement life table methodology. Results The estimated lifetime risk of revision ranged between 32.7% (95% confidence interval (CI) 22.6 to 47.3) for patients aged 45 to 49 years and 0.6% (95% CI 0.1 to 4.5) for patients aged over 90 years. At 20 years, the overall cumulative incidence of revision (6.8% (95% CI 6.6 to 7.0)) was significantly less than that of death (66.3% (95% CI 65.4 to 67.1)). Adjusted analyses demonstrated converse effect of increasing age on risk of revision (hazard ratio (HR) 0.5 (95% CI 0.5 to 0.6)) and death (HR 3.6 (95% CI 3.4 to 3.7)). Male sex was associated with increased risks of revision (HR 1.1 (95% CI 1.1 to 1.2); p < 0.001) and death (HR 1.4 (95% CI 1.3 to 1.4); p < 0.001). Compared to patients undergoing primary KA for osteoarthritis, patients with inflammatory arthropathy had a higher risk of death (HR 1.7 (95% CI 1.7 to 1.8); p < 0.001), but were less likely to be revised (HR 0.9 (95% CI 0.7 to 1.0); p < 0.001). Patients with a greater number of comorbidities (HR 1.4 (95% CI 1.3 to 1.4)) and greater levels of socioeconomic deprivation (HR 1.4 (95% CI 1.4 to 1.5)) were at increased risk of death, but neither increased the risk of revision. Conclusion The estimated lifetime risk of revision KA varied depending on patient sex, age, and underlying diagnosis. Patients aged between 45 and 49 years had a one in three risk of undergoing revision surgery within their lifetime, which decreased with age to one in 159 in those aged 90 years or more. Cite this article: Bone Joint J 2022;104-B(12):1313–1322.
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Affiliation(s)
- Liam Z. Yapp
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
- Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D. Clement
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
- Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew Moran
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
- Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jon V. Clarke
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
- Golden Jubilee University National Hospital, Clydebank, UK
| | - A. Hamish R. W. Simpson
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
- Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E. H. Scott
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
- Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Abstract
AIMS The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA). METHODS This is a retrospective study of patients undergoing primary KA for osteoarthritis in a university teaching hospital (Royal Infirmary of Edinburgh) (1 January 2013 to 31 December 2019). Pre- and postoperative (one-year) data were prospectively collected for 3,181 patients (median age 69.9 years (interquartile range (IQR) 64.2 to 76.1); females, n = 1,745 (54.9%); median BMI 30.1 kg/m2 (IQR 26.6 to 34.2)). The reliability of the EQ-5D-3L was measured using Cronbach's alpha. Responsiveness was determined by calculating the anchor-based minimal clinically important difference (MCID), the minimal important change (MIC) (cohort and individual), the patient-acceptable symptom state (PASS) predictive of satisfaction, and the minimal detectable change at 90% confidence intervals (MDC-90). RESULTS The EQ-5D-3L demonstrated good internal consistency with an overall Cronbach alpha of 0.75 (preoperative) and 0.88 (postoperative), respectively. The MCID for the Index score was 0.085 (95% confidence interval (CI) 0.042 to 0.127) and EQ-VAS was 6.41 (95% CI 3.497 to 9.323). The MICCOHORT was 0.289 for the EQ-5D and 5.27 for the EQ-VAS. However, the MICINDIVIDUAL for both the EQ-5D-3L Index (0.105) and EQ-VAS (-1) demonstrated poor-to-acceptable reliability. The MDC-90 was 0.023 for the EQ-5D-3L Index and 1.0 for the EQ-VAS. The PASS for the postoperative EQ-5D-3L Index and EQ-VAS scores predictive of patient satisfaction were 0.708 and 77.0, respectively. CONCLUSION The meaningful values of the EQ-5D-3L Index and EQ-VAS scores can be used to measure clinically relevant changes in health-related quality of life in patients undergoing primary KA.Cite this article: Bone Joint Res 2022;11(9):619-628.
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Affiliation(s)
- Liam Z Yapp
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin R Howie
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Deborah J MacDonald
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Hamish R W Simpson
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Department of Orthopaedics, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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14
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Clement RGE, Hall AC, Wong SJ, Howie SEM, Simpson AHRW. Septic arthritis in an in vivo murine model induced by Staphylococcus aureus : a comparison between actions of the haemolysin toxin and the effects of the host immune response. Bone Joint Res 2022; 11:669-678. [PMID: 36066341 PMCID: PMC9533245 DOI: 10.1302/2046-3758.119.bjr-2022-0016.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aims Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection. Methods Adult male C57Bl/6 mice (n = 75) were randomized into three groups to receive 1.0 to 1.4 × 107 colony-forming units (CFUs)/ml of 8325-4, DU1090, or saline into the right stifle joint. Chondrocyte death was assessed by confocal microscopy. Histological changes to inoculated joints were graded for inflammatory responses along with gait, weight changes, and limb swelling. Results Chondrocyte death was greater with 8325-4 (96.2% (SD 5.5%); p < 0.001) than DU1090 (28.9% (SD 16.0%); p = 0.009) and both were higher than controls (3.8% (SD 1.2%)). Histology revealed cartilage/bone damage with 8325-4 or DU1090 compared to controls (p = 0.010). Both infected groups lost weight (p = 0.006 for both) and experienced limb swelling (p = 0.043 and p = 0.018, respectively). Joints inoculated with bacteria showed significant alterations in gait cycle with a decreased stance phase, increased swing phase, and a corresponding decrease in swing speed. Conclusion Murine joints inoculated with Hla-producing 8325-4 experienced significantly more chondrocyte death than those with DU1090, which lack the toxin. This was despite similar immune responses, indicating that Hla was the major cause of chondrocyte death. Hla-deficient DU1090 also elevated chondrocyte death compared to controls, suggesting a smaller additional deleterious role of the immune system on cartilage. Cite this article: Bone Joint Res 2022;11(9):669–678.
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Affiliation(s)
- Rhys G E Clement
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Andrew C Hall
- Deanery of Biomedical Sciences, The University of Edinburgh, Edinburgh, UK
| | - Seng J Wong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Sarah E M Howie
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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15
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Graham SM, Jalal MMK, Lalloo DG, Hamish R W Simpson A. The effect of anti-retroviral therapy on fracture healing : an in vivo animal model. Bone Joint Res 2022; 11:585-593. [PMID: 35942801 PMCID: PMC9396923 DOI: 10.1302/2046-3758.118.bjr-2021-0523.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS A number of anti-retroviral therapies (ART) have been implicated in potentially contributing to HIV-associated bone disease. The aim of this study was to evaluate the effect of combination ART on the fracture healing process. METHODS A total of 16 adult male Wistar rats were randomly divided into two groups (n = eight each): Group 1 was given a combination of Tenfovir 30 mg, Lamivudine 30 mg, and Efavirenz 60 mg per day orally, whereas Group 2 was used as a control. After one week of medication preload, all rats underwent a standardized surgical procedure of mid-shaft tibial osteotomy fixed by intramedullary nail with no gap at the fracture site. Progress in fracture healing was monitored regularly for eight weeks. Further evaluations were carried out after euthanasia by micro-CT, mechanically and histologically. Two blinded orthopaedic surgeons used the Radiological Union Scoring system for the Tibia (RUST) to determine fracture healing. RESULTS The fracture healing process was different between the two groups at week 4 after surgery; only two out of eight rats showed full healing in Group 1 (ART-treated), while seven out of eight rats had bone union in Group 2 (control) (p = 0.040). However, at week eight postoperatively, there was no statistical difference in bone healing; seven out of eight progressed to full union in both groups. CONCLUSION This study demonstrated that combination ART resulted in delayed fracture healing at week 4 after surgery in rats, but did not result in the development of nonunion.Cite this article: Bone Joint Res 2022;11(8):585-593.
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Affiliation(s)
- Simon M Graham
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Liverpool Orthopaedic and Trauma Service, Department of Orthopaedic and Trauma Surgery, Liverpool University Hospital Foundation Trust, Liverpool, UK
| | - Murtadhah M K Jalal
- Department of Orthopaedic and Trauma Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK.,The Scottish Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh, UK.,Basra Health Directorate, Univeristy of Basra, Basra, Iraq
| | - David G Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - A Hamish R W Simpson
- Department of Orthopaedic and Trauma Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK.,The Scottish Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh, UK.,Bone & Joint Research, London, UK
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16
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Tsang STJ, Ferreira N, Simpson AHRW. The reconstruction of critical bone loss : the holy grail of orthopaedics. Bone Joint Res 2022; 11:409-412. [PMID: 35731230 PMCID: PMC9233404 DOI: 10.1302/2046-3758.116.bjr-2022-0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shao-Ting J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK.,Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nando Ferreira
- Division Orthopaedic Surgery Department of Surgical Sciences, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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17
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Hall AJ, Clement ND, MacLullich AMJ, Simpson AHRW, Johansen A, White TO, Duckworth AD. The delivery of an emergency audit response to a communicable disease outbreak can inform future orthopaedic investigations and clinical practice : lessons from IMPACT Hip Fracture Global Audits. Bone Joint Res 2022; 11:346-348. [PMID: 35642472 PMCID: PMC9233410 DOI: 10.1302/2046-3758.116.bjr-2022-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Ageing & Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Antony Johansen
- University Hospital of Wales, Cardiff University, Cardiff, UK.,National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Tim O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
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18
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Hall AJ, Clement ND, MacLullich AMJ, Simpson AHRW, White TO, Duckworth AD. The IMPACT of COVID-19 on trauma & orthopaedic surgery provides lessons for future communicable disease outbreaks : minimum reporting standards, risk scores, fragility trauma services, and global collaboration. Bone Joint Res 2022; 11:342-345. [PMID: 35642467 PMCID: PMC9233405 DOI: 10.1302/2046-3758.116.bjr-2022-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342–345.
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Affiliation(s)
- Andrew J Hall
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK.,Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
| | - Alasdair M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.,Department of Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma, University of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, UK.,Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, UK
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19
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Clement ND, Skinner JA, Haddad FS, Simpson AHRW. Prioritization versus rationing of healthcare - elective surgery is not optional surgery : how should priority be assessed to ensure equity? Bone Joint Res 2022; 11:301-303. [PMID: 35579001 PMCID: PMC9130670 DOI: 10.1302/2046-3758.115.bjr-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John A Skinner
- Department of Orthopaedics, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Fares S Haddad
- Department of Orthopaedics, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal , London, UK
| | - A Hamish R W Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
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20
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Brzeszczynski F, Brzeszczynska J, Duckworth AD, Murray IR, Simpson AHRW, Hamilton DF. The effect of sarcopenia on outcomes following orthopaedic surgery : a systematic review. Bone Joint J 2022; 104-B:321-330. [PMID: 35227092 DOI: 10.1302/0301-620x.104b3.bjj-2021-1052.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature. METHODS A systematic search was conducted in MEDLINE, EMBASE, and Google Scholar databases according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies involving sarcopenic patients who underwent defined orthopaedic surgery and recorded postoperative outcomes were included. The quality of the criteria by which a diagnosis of sarcopenia was made was evaluated. The quality of the publication was assessed using Newcastle-Ottawa Scale. RESULTS A total of 365 studies were identified and screened, 26 full-texts were reviewed, and 19 studies were included in the review. A total of 3,009 patients were included, of whom 2,146 (71%) were female and 863 (29%) were male. The mean age of the patients was 75.1 years (SD 7.1). Five studies included patients who underwent spinal surgery, 13 included hip or knee surgery, and one involved patients who underwent fixation of a distal radial fixation. The mean follow-up was 1.9 years (SD 1.9; 5 days to 5.6 years). There was wide heterogeneity in the measurement tools which were used and the parameters for the diagnosis of sarcopenia in the studies. Sarcopenia was associated with at least one deleterious effect on surgical outcomes in all 19 studies. The postoperative rate of mortality was reported in 11 studies (57.9%) and sarcopenia was associated with poorer survival in 73% (8/11) of these. The outcome was most commonly assessed using the Barthel Index (4/19), and sarcopenic patients recorded lower scores in 75% (3/4) of these. Sarcopenia was defined using the gold-standard three parameters (muscle strength, muscle quantity or quality, and muscle function) in four studies (21%), using two parameters in another four (21%) and one in the remaining 11 (58%). The methodological quality of the studies was moderate to high. CONCLUSION There is much heterogeneity in the reporting of the parameters which are used for the diagnosis of sarcopenia, and evaluating the outcome of orthopaedic surgery in sarcopenic patients. However, what data exist suggest that sarcopenia impairs recovery and increases postoperative mortality, especially in patients undergoing emergency surgery. Further research is required to develop processes that allow the accurate diagnosis of sarcopenia in orthopaedics, which may facilitate targeted pre- and postoperative interventions that would improve outcomes. Cite this article: Bone Joint J 2022;104-B(3):321-330.
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Affiliation(s)
- Filip Brzeszczynski
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Joanna Brzeszczynska
- Institute of Biomedical and Environmental Health Research, University of the West of Scotland, Paisley, UK.,Department of Molecular Biophysics, University of Lodz, Lodz, Poland
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - A Hamish R W Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.,Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - David F Hamilton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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21
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Affiliation(s)
| | - Nick D. Clement
- Royal Infirmary of Edinburgh , Edinburgh, UK
- Department of Orthopaedics and Trauma, University of Edinburgh Queen's Medical Research Institute, Edinburgh, UK
| | - Shenqi Zhang
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qingyun Xue
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - A. Hamish R. W. Simpson
- Royal Infirmary of Edinburgh , Edinburgh, UK
- Department of Orthopaedics and Trauma, University of Edinburgh Queen's Medical Research Institute, Edinburgh, UK
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22
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Yapp LZ, Clement ND, Moran M, Clarke JV, Simpson AHRW, Scott CEH. Long-term mortality rates and associated risk factors following primary and revision knee arthroplasty : 107,121 patients from the Scottish Arthroplasty Project. Bone Joint J 2022; 104-B:45-52. [PMID: 34969267 DOI: 10.1302/0301-620x.104b1.bjj-2021-0753.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to determine the long-term mortality rate, and to identify factors associated with this, following primary and revision knee arthroplasty (KA). METHODS Data from the Scottish Arthroplasty Project (1998 to 2019) were retrospectively analyzed. Patient mortality data were linked from the National Records of Scotland. Analyses were performed separately for the primary and revised KA cohorts. The standardized mortality ratio (SMR) with 95% confidence intervals (CIs) was calculated for the population at risk. Multivariable Cox proportional hazards were used to identify predictors and estimate relative mortality risks. RESULTS At a median 7.4 years (interquartile range (IQR) 4.0 to 11.6) follow-up, 27.8% of primary (n = 27,474/98,778) and 31.3% of revision (n = 2,611/8,343) KA patients had died. Both primary and revision cohorts had lower mortality rates than the general population (SMR 0.74 (95% CI 0.73 to 0.74); p < 0.001; SMR 0.83 (95% CI 0.80 to 0.86); p < 0.001, respectively), which persisted for 12 and eighteight years after surgery, respectively. Factors associated with increased risk of mortality after primary KA included male sex (hazard ratio (HR) 1.40 (95% CI 1.36 to 1.45)), increasing socioeconomic deprivation (HR 1.43 (95% CI 1.36 to 1.50)), inflammatory polyarthropathy (HR 1.79 (95% CI 1.68 to 1.90)), greater number of comorbidities (HR 1.59 (95% CI 1.51 to 1.68)), and periprosthetic joint infection (PJI) requiring revision (HR 1.92 (95% CI 1.57 to 2.36)) when adjusting for age. Similarly, male sex (HR 1.36 (95% CI 1.24 to 1.49)), increasing socioeconomic deprivation (HR 1.31 (95% CI 1.12 to 1.52)), inflammatory polyarthropathy (HR 1.24 (95% CI 1.12 to 1.37)), greater number of comorbidities (HR 1.64 (95% CI 1.33 to 2.01)), and revision for PJI (HR 1.35 (95% 1.18 to 1.55)) were independently associated with an increased risk of mortality following revision KA when adjusting for age. CONCLUSION The SMR of patients undergoing primary and revision KA was lower than that of the general population and remained so for several years post-surgery. However, approximately one in four patients undergoing primary and one in three patients undergoing revision KA died within tenten years of surgery. Several patient and surgical factors, including PJI, were associated with the risk of mortality within ten years of primary and revision surgery. Cite this article: Bone Joint J 2022;104-B(1):45-52.
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Affiliation(s)
- Liam Zen Yapp
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Nick D Clement
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Matthew Moran
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK.,Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - A Hamish R W Simpson
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Chloe E H Scott
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
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23
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Abstract
Aims Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning. Methods A total of 54 patients with distal radial fractures were included in the study. Each underwent posteroanterior (PA) and lateral radiographs of the injured wrist with an aluminium step wedge. Overall 27 patients underwent routine DXA scanning of the hip and lumbar spine, with 13 undergoing additional DXA scanning of the uninjured forearm. Analysis of radiographs was performed on ImageJ and Matlab with calculations of cortical measures, cortical indices, combined cortical scores, and aluminium equivalent grading. Results Cortical measures showed varying correlations with the forearm DXA results (range: Pearson correlation coefficient (r) = 0.343 (p = 0.251) to r = 0.521 (p = 0.068)), with none showing statistically significant correlations. Aluminium equivalent grading showed statistically significant correlations with the forearm DXA of the corresponding region of interest (p < 0.017). Conclusion Cortical measures, cortical indices, and combined cortical scores did not show a statistically significant correlation to forearm DXA measures. Aluminium-equivalent is an easily applicable method for estimation of BMD from digital radiographs in the preoperative setting. Cite this article: Bone Joint Res 2021;10(12):830–839.
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Affiliation(s)
- Greg Robertson
- Department of Orthopaedics and Trauma, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK.,Department of Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Robert Wallace
- Department of Orthopaedics and Trauma, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - A Hamish R W Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
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24
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Affiliation(s)
- Khalid Al-Hourani
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shao-Ting Jerry Tsang
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - A Hamish R W Simpson
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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25
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Nicholson JA, Oliver WM, MacGillivray TJ, Robinson CM, Simpson AHRW. 3D ultrasound reconstruction of sonographic callus : a novel imaging modality for early evaluation of fracture healing. Bone Joint Res 2021; 10:759-766. [PMID: 34851197 PMCID: PMC8696520 DOI: 10.1302/2046-3758.1012.bjr-2021-0250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS The aim of this study was to establish a reliable method for producing 3D reconstruction of sonographic callus. METHODS A cohort of ten closed tibial shaft fractures managed with intramedullary nailing underwent ultrasound scanning at two, six, and 12 weeks post-surgery. Ultrasound capture was performed using infrared tracking technology to map each image to a 3D lattice. Using echo intensity, semi-automated mapping was performed to produce an anatomical 3D representation of the fracture site. Two reviewers independently performed 3D reconstructions and kappa coefficient was used to determine agreement. A further validation study was undertaken with ten reviewers to estimate the clinical application of this imaging technique using the intraclass correlation coefficient (ICC). RESULTS Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus of ≥ one cortex on the 3D reconstruction and when present all achieved union. Compared to six-week radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8% sensitive and 100% specific to predict union). At 12 weeks, nine patients had bridging callus at ≥ one cortex on 3D reconstruction (100%-sensitive and 100%-specific to predict union). Presence of sonographic bridging callus on 3D reconstruction demonstrated excellent reviewer agreement on ICC at 0.87 (95% confidence interval 0.74 to 0.96). CONCLUSION 3D fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of early fracture healing. Cite this article: Bone Joint Res 2021;10(12):759-766.
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Affiliation(s)
- Jamie A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - William M Oliver
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Tom J MacGillivray
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - C Michael Robinson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Thompson JW, Simpson AHRW, Haddad FS. Integrated care systems, research, and innovation. Bone Joint Res 2021; 10:591-593. [PMID: 34490784 PMCID: PMC8479565 DOI: 10.1302/2046-3758.109.bjr-2021-0281.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Joshua W Thompson
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - A Hamish R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK.,Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
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Scott CEH, Holland G, Gillespie M, Keenan OJ, Gherman A, MacDonald DJ, Simpson AHRW, Clement ND. The ability to kneel before and after total knee arthroplasty : the role of the pattern of osteoarthritis and the position of the femoral component. Bone Joint J 2021; 103-B:1514-1525. [PMID: 34465156 DOI: 10.1302/0301-620x.103b9.bjj-2020-2129.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to investigate the ability to kneel after total knee arthroplasty (TKA) without patellar resurfacing, and its effect on patient-reported outcome measures (PROMs). Secondary aims included identifying which kneeling positions were most important to patients, and the influence of radiological parameters on the ability to kneel before and after TKA. METHODS This prospective longitudinal study involved 209 patients who underwent single radius cruciate-retaining TKA without patellar resurfacing. Preoperative EuroQol five-dimension questionnaire (EQ-5D), Oxford Knee Score (OKS), and the ability to achieve four kneeling positions were assessed including a single leg kneel, a double leg kneel, a high-flexion kneel, and a praying position. The severity of radiological osteoarthritis (OA) was graded and the pattern of OA was recorded intraoperatively. The flexion of the femoral component, posterior condylar offset, and anterior femoral offset were measured radiologically. At two to four years postoperatively, 151 patients with a mean age of 70.0 years (SD 9.44) were included. Their mean BMI was 30.4 kg/m2 (SD 5.36) and 60 were male (40%). They completed EQ-5D, OKS, and Kujala scores, assessments of the ability to kneel, and a visual analogue scale for anterior knee pain and satisfaction. RESULTS The ability to kneel in the four positions improved in between 29 (19%) and 53 patients (35%) after TKA, but declined in between 35 (23%) and 46 patients (30%). Single-leg kneeling was most important to patients. After TKA, 62 patients (41%) were unable to achieve a single-leg kneel, 76 (50%) were unable to achieve a double-leg kneel, 102 (68%) were unable to achieve a high-flexion kneel and 61 (40%) were unable to achieve a praying position. Posterolateral cartilage loss significantly affected preoperative deep flexion kneeling (p = 0.019). A postoperative inability to kneel was significantly associated with worse OKS, Kujala scores, and satisfaction (p < 0.05). Multivariable regression analysis identified significant independent associations with the ability to kneel after TKA (p < 0.05): better preoperative EQ-5D and flexion of the femoral component for single-leg kneeling; the ability to achieve it preoperatively and flexion of the femoral component for double-leg kneeling; male sex for high-flexion kneeling; and the ability to achieve it preoperatively, anterior femoral offset, and patellar cartilage loss for the praying position. CONCLUSION The ability to kneel was important to patients and significantly influenced knee-specific PROMs, but was poorly restored by TKA with equal chances of improvement or decline. Cite this article: Bone Joint J 2021;103-B(9):1514-1525.
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Affiliation(s)
- Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - George Holland
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Oisin J Keenan
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anda Gherman
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
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Nicholson JA, Clement ND, Clelland AD, MacDonald DJ, Simpson AHRW, Robinson CM. Acute plate fixation of displaced midshaft clavicular fractures is not associated with earlier return of normal shoulder function when union is achieved. Bone Jt Open 2021; 2:522-529. [PMID: 34254832 PMCID: PMC8325980 DOI: 10.1302/2633-1462.27.bjo-2021-0049.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management. Methods Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol. Results Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks. Conclusion Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment. Cite this article: Bone Jt Open 2021;2(7):522–529.
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Affiliation(s)
- Jamie A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Andrew D Clelland
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | | | | | - C Mike Robinson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Yapp LZ, Walmsley PJ, Moran M, Clarke JV, Simpson AHRW, Scott CEH. Infographic: The effect of hospital case volume on re-revision following revision total knee arthroplasty. Bone Joint J 2021; 103-B:600-601. [PMID: 33789483 DOI: 10.1302/0301-620x.103b4.bjj-2021-0370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Liam Z Yapp
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
| | - Phil J Walmsley
- Department of Trauma and Orthopaedic Surgery, Victoria Hospital, Kirkcaldy, UK
| | - Matthew Moran
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Golden Jubilee National Hospital, Clydebank, UK
| | | | - Chloe E H Scott
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Nicholson JA, Yapp LZ, Keating JF, Simpson AHRW. Monitoring of fracture healing. Update on current and future imaging modalities to predict union. Injury 2021; 52 Suppl 2:S29-S34. [PMID: 32826052 DOI: 10.1016/j.injury.2020.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/22/2020] [Accepted: 08/07/2020] [Indexed: 02/02/2023]
Abstract
Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion. This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).
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Affiliation(s)
- J A Nicholson
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom.
| | - L Z Yapp
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
| | - J F Keating
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
| | - A H R W Simpson
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
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Abstract
AIMS The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). METHODS This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. RESULTS From 1998 to 2019, 8,301 patients (8,894 knees) underwent RTKA surgery in Scotland (median age at RTKA 70 years (interquartile range (IQR) 63 to 76); median follow-up 6.2 years (IQR 3.0 to 10.2). In all, 4,764 (53.6%) were female, and 781 (8.8%) were treated for infection. Of these 8,894 knees, 957 (10.8%) underwent a second revision procedure. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95% CI 86.5 to 88.1). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was significantly associated with lower risk of re-revision (HR 0.78 (95% CI 0.64 to 0.94, p < 0.001)). The risk of re-revision steadily declined in centres performing > 20 cases per year; risk reduction was 16% with > 20 cases; 22% with > 30 cases; and 28% with > 40 cases. The lowest level of risk was associated with the highest volume centres. CONCLUSION The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA. Cite this article: Bone Joint J 2021;103-B(4):602-609.
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Affiliation(s)
- Liam Z Yapp
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
| | - Phil J Walmsley
- Department of Trauma and Orthopaedic Surgery, Victoria Hospital, Kirkcaldy, UK
| | - Matthew Moran
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Golden Jubilee National Hospital, Clydebank, UK
| | | | - Chloe E H Scott
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Nicholson JA, Fox B, Dhir R, Simpson AHRW, Robinson CM. The accuracy of computed tomography for clavicle non-union evaluation. Shoulder Elbow 2021; 13:195-204. [PMID: 33897851 PMCID: PMC8039767 DOI: 10.1177/1758573219884067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/06/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The primary aim of this study is to determine the accuracy of CT scanning when evaluating non-union of the clavicle. METHODS A retrospective review was performed of all CT scans undertaken for suspected nonunion of midshaft clavicle fractures over a 10-year period. The influence of scan timing, callus and patient characteristics was evaluated. RESULTS One hundred eighty-four CT scans were analysed. No patient was incorrectly diagnosed with union (n = 85). Ninety-nine scans were reported as non-union with inadequate bridging callus, 19 of which were united at operation or on repeat CT imaging and represented delayed unions. Atrophic callus was found in 57 patients and all of which had a confirmed non-union (positive predictive value 100%). A hypertrophic callus was found in 42 patients, all of the delayed unions were found in this group (positive predictive value for non-union 55%, p < 0.001). CT compared to radiographs showed greater inter-observer agreement for union (weighted kappa 0.75 vs. 0.50 respectively). Overall, CT is 100% sensitive and 81.7% specific for non-union diagnosis. DISCUSSION CT has excellent accuracy to determine clavicle union but approximately one in five suspected non-unions went onto unite. Hypertrophic callus finding resulted in a delayed union in approximately half of the cases in our study.
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Affiliation(s)
- Jamie A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh,
Edinburgh, UK
| | - B Fox
- Department of Orthopaedic Surgery, University of Edinburgh,
Edinburgh, UK
| | - R Dhir
- Department of Orthopaedic Surgery, University of Edinburgh,
Edinburgh, UK
| | - AHRW Simpson
- Department of Orthopaedic Surgery, University of Edinburgh,
Edinburgh, UK
| | - CM Robinson
- Department of Orthopaedic Surgery, University of Edinburgh,
Edinburgh, UK
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Yapp LZ, Clarke JV, Moran M, Simpson AHRW, Scott CEH. National operating volume for primary hip and knee arthroplasty in the COVID-19 era: a study utilizing the Scottish arthroplasty project dataset. Bone Jt Open 2021; 2:203-210. [PMID: 33739125 PMCID: PMC8009902 DOI: 10.1302/2633-1462.23.bjo-2020-0193.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Aims The COVID-19 pandemic led to a national suspension of “non-urgent” elective hip and knee arthroplasty. The study aims to measure the effect of the COVID-19 pandemic on total hip arthroplasty (THA) and total knee arthroplasty (TKA) volume in Scotland. Secondary objectives are to measure the success of restarting elective services and model the time required to bridge the gap left by the first period of suspension. Methods A retrospective observational study using the Scottish Arthroplasty Project dataset. All patients undergoing elective THAs and TKAs during the period 1 January 2008 to 31 December 2020 were included. A negative binomial regression model using historical case-volume and mid-year population estimates was built to project the future case-volume of THA and TKA in Scotland. The median monthly case volume was calculated for the period 2008 to 2019 (baseline) and compared to the actual monthly case volume for 2020. The time taken to eliminate the deficit was calculated based upon the projected monthly workload and with a potential workload between 100% to 120% of baseline. Results Compared to the period 2008 to 2019, primary TKA and THA volume fell by 61.1% and 53.6%, respectively. Since restarting elective services, Scottish hospitals have achieved approximately 40% to 50% of baseline monthly activity. With no changes in current workload, by 2021 there would be a reduction of 9,180 and 10,170 for THA and TKA, respectively. Conversely, working at 120% baseline monthly output, it would take over four years to eliminate the deficit for both TKA and THA. Conclusion This national study demonstrates the significant impact that COVID-19 pandemic has had on overall THA and TKA volume. In the six months after resuming elective services, Scottish hospitals averaged less than 50% normal monthly output. Loss of operating capacity will increase treatment delays and likely worsen overall morbidity. Cite this article: Bone Joint Open 2021;2(3):203–210.
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Affiliation(s)
- Liam Z Yapp
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - Matthew Moran
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, NHS Public Health Scotland, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Chloe E H Scott
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.,Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Sehgal A, Burnett R, Howie CR, Simpson AHRW, Hamilton DF. The use of pedobarographic analysis to evaluate movement patterns in unstable total knee arthroplasty: A proof of concept study. Knee 2021; 29:110-115. [PMID: 33610117 DOI: 10.1016/j.knee.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Definition and clinical diagnosis of instability in TKA is challenging. Sensitive and objective biomechanical tools to aid diagnosis are currently lacking. This proof-of-concept study evaluates the use of pressure mat analyses to identify abnormal biomechanical loading patterns associated with TKA instability within an outpatient clinical setting. METHODS Twenty participants were examined: 10 patients with suspected unilateral TKA instability and 10 healthy controls. Participants underwent bilateral stance and gait tests measuring time and limb loading pressure parameters. Gait was divided into three phases: heel strike, mid-foot and toe off. Pressure recordings are expressed relative to bodyweight. Between-limb loading discrepancies were calculated in TKA patients and controls, and these differences were then compared between groups. Statistical significance was accepted at p < 0.05. RESULTS TKA patients consistentlyoffloadedpressure away from the operated limb, whereas healthy controls exhibited more even limb loading throughout bilateral stance (p < 0.05). TKA patients exhibited greater discrepancy in overall step contact time between limbs (-0.09 s ± 0.16 s; p = 0.016) compared to controls (0.06 s ± 0.08 s; p = 0.04). Post-hoc tests showed significant between-group differences during midfoot (-0.04 s ± 0.07 s; p = 0.03) and toe-off (0.05 s ± 0.14 s; p = 0.013). Between-group differences in limb loading discrepancy were evident at heel strike (-9.24% ± 2.11%; p = 0.0166) and toe-off (-10.34% ± 5.51%; p = 0.0496). DISCUSSION Pedobarographic measurements demonstrated differences in mechanical loading patterns in patients with TKA instability compared to healthy controls during functional tasks and warrants further investigation. This may prove to be a useful clinical diagnostic tool in identifying patients that would benefit from revision surgery or physical therapy.
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Nicholson JA, Oliver WM, MacGillivray TJ, Robinson CM, Simpson AHRW. Sonographic bridging callus at six weeks following displaced midshaft clavicle fracture can accurately predict healing. Bone Joint Res 2021; 10:113-121. [PMID: 33543996 PMCID: PMC7937413 DOI: 10.1302/2046-3758.102.bjr-2020-0341.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AIMS To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. METHODS Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph. RESULTS A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R2 = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three. CONCLUSION Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113-121.
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Affiliation(s)
- Jamie A. Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - William M. Oliver
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Downie S, Stillie A, Moran M, Sudlow C, Simpson AHRW. A prospective longitudinal study investigating outcomes including patient-reported outcome measures after surgery for metastatic bone disease. Bone Jt Open 2021; 2:79-85. [PMID: 33573398 PMCID: PMC7925207 DOI: 10.1302/2633-1462.22.bjo-2020-0173.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims Surgery is often indicated in patients with metastatic bone disease (MBD) to improve pain and maximize function. Few studies are available which report on clinically meaningful outcomes such as quality of life, function, and pain relief after surgery for MBD. This is the published protocol for the Bone Metastasis Audit — Patient Reported Outcomes (BoMA-PRO) multicentre MBD study. The primary objective is to ascertain patient-reported quality of life at three to 24 months post-surgery for MBD. Methods This will be a prospective, longitudinal study across six UK orthopaedic centres powered to identify the influence of ten patient variables on quality of life at three months after surgery for MBD. Adult patients managed for bone metastases will be screened by their treating consultant and posted out participant materials. If they opt in to participate, they will receive questionnaire packs at regular intervals from three to 24 months post-surgery and their electronic records will be screened until death or five years from recruitment. The primary outcome is quality of life as measured by the European Organisation for Research and the Treatment of Cancer Quality of Life questionnaire (EORTC-QLQ) C30 questionnaire. The protocol has been approved by the Newcastle & North Tyneside 2 Research Ethics Committee (REC ref 19/NE/0303) and the study is funded by the Royal College of Physicians and Surgeons of Glasgow (RCPSG) and the Association for Cancer Surgery (BASO-ACS). Discussion This will be the first powered study internationally to investigate patient-reported outcomes after orthopaedic treatment for bone metastases. We will assess quality of life, function, and pain relief at three to 24 months post-surgery and identify which patient variables are significantly associated with a good outcome after MBD treatment. Cite this article: Bone Jt Open 2021;2(2):79–85.
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Affiliation(s)
- Samantha Downie
- Orthopaedics and Trauma Department, The University of Edinburgh, Edinburgh, UK
| | - Alison Stillie
- Department of Clinical Oncology, Western General Hospital, Edinburgh, UK
| | - Matthew Moran
- Orthopaedics and Trauma Department, The University of Edinburgh, Edinburgh, UK
| | - Catherine Sudlow
- Division of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Edinburgh, UK
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Clement ND, Ng N, Simpson CJ, Patton RFL, Hall AJ, Simpson AHRW, Duckworth AD. The prevalence, mortality, and associated risk factors for developing COVID-19 in hip fracture patients: a systematic review and meta-analysis. Bone Joint Res 2020; 9:873-883. [PMID: 33350316 PMCID: PMC9021904 DOI: 10.1302/2046-3758.912.bjr-2020-0473.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS The aims of this meta-analysis were to assess: 1) the prevalence of coronavirus disease 2019 (COVID-19) in hip fracture patients; 2) the associated mortality rate and risk associated with COVID-19; 3) the patient demographics associated with COVID-19; 4) time of diagnosis; and 5) length of follow-up after diagnosis of COVID-19. METHODS Searches of PubMed, Medline, and Google Scholar were performed in October 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Search terms included "hip", "fracture", and "COVID-19". The criteria for inclusion were published clinical articles reporting the mortality rate associated with COVID-19 in hip fracture patients. In total, 53 articles were identified and following full text screening 28 articles satisfied the inclusion criteria. RESULTS A total of 28 studies reported the mortality of COVID-19-positive patients, of which 21 studies reported the prevalence of COVID-19-positive patients and compared the mortality rate to COVID-19-negative patients. The prevalence of COVID-19 was 13% (95% confidence interval (CI) 11% to 16%) and was associated with a crude mortality rate of 35% (95% CI 32% to 39%), which was a significantly increased risk compared to those patients without COVID-19 (odds ratio (OR) 7.11, 95% CI 5.04 to 10.04; p < 0.001). COVID-19-positive patients were more likely to be male (OR 1.51, 95% CI 1.16 to 1.96; p = 0.002). The duration of follow-up was reported in 20 (71.4%) studies. A total of 17 studies reported whether a patient presented with COVID-19 (n = 108 patients, 35.1%) or developed COVID-19 following admission (n = 200, 64.9%), of which six studies reported a mean time to diagnosis of post-admission COVID-19 at 15 days (2 to 25). CONCLUSION The prevalence of COVID-19 was 13%, of which approximately one-third of patients were diagnosed on admission, and was associated with male sex. COVID-19-positive patients had a crude mortality rate of 35%, being seven times greater than those without COVID-19. Due to the heterogenicity of the reported data minimum reporting standards of outcomes associated with COVID-19 are suggested. Cite this article: Bone Joint Res 2020;9(12):873-883.
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Affiliation(s)
- Nicholas D Clement
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Nathan Ng
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Cameron J Simpson
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Robyn F L Patton
- Medical School, Biomedical Sciences, Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Andrew James Hall
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.,The Department of Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Hamish R W Simpson
- The Department of Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.,The Department of Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Affiliation(s)
- Shao-Ting Jerry Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK.,Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Brzeszczyńska J, Brzeszczyński F, Hamilton DF, McGregor R, Simpson AHRW. Role of microRNA in muscle regeneration and diseases related to muscle dysfunction in atrophy, cachexia, osteoporosis, and osteoarthritis. Bone Joint Res 2020; 9:798-807. [PMID: 33174473 PMCID: PMC7672326 DOI: 10.1302/2046-3758.911.bjr-2020-0178.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
MicroRNAs (miRNAs) are a class of small non-coding RNAs that have emerged as potential predictive, prognostic, and therapeutic biomarkers, relevant to many pathophysiological conditions including limb immobilization, osteoarthritis, sarcopenia, and cachexia. Impaired musculoskeletal homeostasis leads to distinct muscle atrophies. Understanding miRNA involvement in the molecular mechanisms underpinning conditions such as muscle wasting may be critical to developing new strategies to improve patient management. MicroRNAs are powerful post-transcriptional regulators of gene expression in muscle and, importantly, are also detectable in the circulation. MicroRNAs are established modulators of muscle satellite stem cell activation, proliferation, and differentiation, however, there have been limited human studies that investigate miRNAs in muscle wasting. This narrative review summarizes the current knowledge as to the role of miRNAs in the skeletal muscle differentiation and atrophy, synthesizing the findings of published data. Cite this article: Bone Joint Res 2020;9(11):798-807.
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Affiliation(s)
- Joanna Brzeszczyńska
- School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Department of Molecular Biophysics, University of Lodz, Lodz, Poland
| | | | - David F Hamilton
- School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Robin McGregor
- Cardiovascular and Metabolic Disease Center, College of Medicine, Inje University, Busan, South Korea
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Affiliation(s)
- Chloe E H Scott
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Pankaj Pankaj
- School of Engineering University of Edinburgh, Edinburgh, UK
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Hamilton DF, Beard DJ, Barker KL, Macfarlane GJ, Tuck CE, Stoddart A, Wilton T, Hutchinson JD, Murray GD, Simpson AHRW. Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial. BMJ 2020; 371:m3576. [PMID: 33051212 PMCID: PMC7551789 DOI: 10.1136/bmj.m3576] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty. DESIGN Parallel group randomised controlled trial. SETTING 13 secondary and tertiary care centres in the UK providing postoperative physiotherapy. PARTICIPANTS 334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol. INTERVENTIONS All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist). MAIN OUTCOME MEASURES Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery. RESULTS 334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval -0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, -0.78 to 0.28, P=0.36) or worst pain (0.22 points, -0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval -14.25 to 4.96, P=0.34). CONCLUSIONS Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures. TRIALS REGISTRATION Current Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445.
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Affiliation(s)
- David F Hamilton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gary J Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology) Group, University of Aberdeen, Aberdeen, UK
| | - Christopher E Tuck
- Usher Institute of Population Health, University of Edinburgh, Edinburgh, UK
| | - Andrew Stoddart
- Usher Institute of Population Health, University of Edinburgh, Edinburgh, UK
| | - Timothy Wilton
- Department of Orthopaedics, Royal Derby Hospital, Derby, UK
| | | | - Gordon D Murray
- Usher Institute of Population Health, University of Edinburgh, Edinburgh, UK
| | - A Hamish R W Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh EH16 4SB, UK
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Affiliation(s)
- S-T. Jerry Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
- Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David W. Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Bridget L. Atkins
- Bone Infection Unit, Nuffield Orthopaedic Hospital, Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Affiliation(s)
- A Hamish R W Simpson
- Department of Orthopaedic Surgery, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Graham Dall
- Department of Orthopaedic Surgery, Borders General Hospital, Melrose, UK
| | - Jürgen G Haas
- Infection Medicine, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- S-T Jerry Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, and Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - A Hamish R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, and Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Hamilton DF, Burnett R, Patton JT, MacPherson GJ, Simpson AHRW, Howie CR, Gaston P. Reduction in patient outcomes but implant-derived preservation of function following total knee arthroplasty: longitudinal follow-up of a randomized controlled trial. Bone Joint J 2020; 102-B:434-441. [PMID: 32228078 DOI: 10.1302/0301-620x.102b4.bjj-2019-0767.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIMS There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes. METHODS A mid-term follow-up of the remaining 125 patients from a randomized cohort of total knee arthroplasty patients (initially comprising 212 recruited patients), comparing modern (Triathlon) and traditional (Kinemax) prostheses was undertaken. Functional outcomes were assessed with the Oxford Knee Score (OKS), knee range of movement, pain numerical rating scales, lower limb power output, timed functional assessment battery, and satisfaction survey. Data were linked to earlier assessment timepoints, and analyzed by repeated measures analysis of variance (ANOVA) mixed models, incorporating longitudinal change over all assessment timepoints. RESULTS The mean follow-up of the 125 patients was 8.12 years (7.3 to 9.4). There was a reduction in all assessment parameters relative to earlier assessments. Longitudinal models highlight changes over time in all parameters and demonstrate large effect sizes. Significant between-group differences were seen in measures of knee flexion (medium-effect size), lower limb power output (large-effect size), and report of worst daily pain experienced (large-effect size) favouring the Triathlon group. No longitudinal between-group differences were observed in mean OKS, average daily pain report, or timed performance test. Satisfaction with outcome in surviving patients at eight years was 90.5% (57/63) in the Triathlon group and 82.8% (48/58) in the Kinemax group, with no statistical difference between groups (p = 0.321). CONCLUSION At a mean 8.12 years, this mid-term follow-up of a randomized controlled trial cohort highlights a general reduction in measures of patient function with patient age and follow-up duration, and a comparative preservation of function based on implant received at time of surgery. Cite this article: Bone Joint J 2020;102-B(4):434-441.
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Affiliation(s)
- David F Hamilton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Richard Burnett
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - James T Patton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Gavin J MacPherson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Colin R Howie
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Paul Gaston
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
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Nicholson JA, Clement ND, Clelland AD, MacDonald D, Simpson AHRW, Robinson CM. Displaced Midshaft Clavicle Fracture Union Can Be Accurately Predicted with a Delayed Assessment at 6 Weeks Following Injury: A Prospective Cohort Study. J Bone Joint Surg Am 2020; 102:557-566. [PMID: 31977816 DOI: 10.2106/jbjs.19.00955] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is unclear if clinical recovery following a midshaft clavicle fracture can accurately predict fracture-healing. The additional information that can be assessed at 6 weeks after injury may have superior predictive value compared with information available at the time of the injury. METHODS A prospective study of all patients (≥16 years of age) who sustained a fully displaced midshaft clavicle fracture was performed. We assessed patient demographic characteristics, injury factors, functional scores, and radiographic predictors with a standardized protocol at 6 weeks. Conditional stepwise regression modeling was used to assess which factors independently predicted nonunion at 6 months after the injury as determined by computed tomography (CT). The nonunion predictor 6-week model was compared with a previously validated model based on factors available at the time of the injury, which included smoking, comminution, and fracture displacement. RESULTS At 6 months, 200 patients completed follow-up. The CT-defined nonunion rate was 14% (27 of 200). Of the functional scores, the QuickDASH (the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) had the highest accuracy on receiver operator characteristic (ROC) curve analysis with a 39.8-point threshold, above which was associated with nonunion (area under curve [AUC], 76.8%; p < 0.001). Sixty-nine percent of the cohort had a QuickDASH score of <40 points at 6 weeks, and 95% (131 of 138) of these patients had fracture union. On regression modeling, a QuickDASH score of ≥40 points (p = 0.001), no callus on radiographs (p = 0.004), and fracture movement on examination (p = 0.001) were significant predictors of nonunion. If none were present, the predicted nonunion risk was 3%, found in 40% (80 of 200) of the cohort. Conversely, if ≥2 of the predictors were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The nonunion predictor model at 6 weeks appeared to have superior accuracy (AUC, 87.3%) when compared with the nonunion predictor model at the time of injury (AUC, 64.8%) for fracture-healing on ROC curve analysis. CONCLUSIONS Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. One in 4 patients are at an increased risk of nonunion and may benefit from operative intervention. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jamie A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, United Kingdom
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Simpson AHRW, Howie CR, Kinsella E, Hamilton DF, Conaghan PG, Hankey C, Simpson SA, Bell-Higgs A, Craig P, Clement ND, Keerie C, Kingsbury SR, Leeds AR, Ross HM, Pandit HG, Tuck C, Norrie J. Osteoarthritis Preoperative Package for care of Orthotics, Rehabilitation, Topical and oral agent Usage and Nutrition to Improve ouTcomes at a Year (OPPORTUNITY); a feasibility study protocol for a randomised controlled trial. Trials 2020; 21:209. [PMID: 32075663 PMCID: PMC7031939 DOI: 10.1186/s13063-019-3709-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/07/2019] [Indexed: 11/23/2022] Open
Abstract
Background Patients’ pre-operative health and physical function is known to influence their post-operative outcomes. In patients with knee osteoarthritis, pharmacological and non-pharmacological options are often not optimised prior to joint replacement. This results in some patients undergoing surgery when they are not as fit as they could be. The aim of this study is to assess the feasibility and acceptability of a pre-operative package of non-operative care versus standard care prior to joint replacement. Methods/design This is a multicentre, randomised controlled feasibility trial of patients undergoing primary total knee replacement for osteoarthritis. Sixty patients will be recruited and randomised (2:1) to intervention or standard care arms. Data will be collected at baseline (before the start of the intervention), around the end of the intervention period and a minimum of 90 days after the planned date of surgery. Adherence will be reviewed each week during the intervention period (by telephone or in person). Participants will be randomised to a pre-operative package of non-operative care or standard care. The non-operative care will consist of (1) a weight-loss programme, (2) a set of exercises, (3) provision of advice on analgesia use and (4) provision of insoles. The intervention will be started as soon as possible after patients have been added to the waiting list for joint replacement surgery to take advantage of the incentive for behavioural change that this will create. The primary outcomes of this study are feasibility outcomes which will indicate whether the intervention and study protocol is feasible and acceptable and whether a full-scale effectiveness trial is warranted. The following will be measured and used to inform study feasibility: rate of recruitment, rate of retention at 90-day follow-up review after planned surgery date, and adherence to the intervention estimated through review questionnaires and weight change (for those receiving the weight-loss aspect of intervention). In addition the following information will be assessed qualitatively: analysis of qualitative interviews exploring acceptability, feasibility, adherence and possible barriers to implementing the intervention, and acceptability of the different outcome measures. Discussion The aims of the study specifically relate to testing the feasibility and acceptability of the proposed effectiveness trial intervention and the feasibility of the trial methods. This study forms the important first step in developing and assessing whether the intervention has the potential to be assessed in a future fully powered effectiveness trial. The findings will also be used to refine the design of the effectiveness trial. Trial registration ISRCTN registry, ID: ISRCTN96684272. Registered on 18 April 2018.
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Affiliation(s)
- A Hamish R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Colin R Howie
- Department of Trauma and Orthopaedics, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Level 2, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - David F Hamilton
- Department of Trauma and Orthopaedics, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine and NIHR Leeds Biomedical Research Centre, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - Catherine Hankey
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, UK
| | - Sharon Anne Simpson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, UK
| | - Anna Bell-Higgs
- Counterweight Ltd, 85 Great Portland Street, First Floor, London,, W1W 7LT, UK
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, UK
| | - Nicholas D Clement
- Department of Trauma and Orthopaedics, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Level 2, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine and NIHR Leeds Biomedical Research Centre, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - Anthony R Leeds
- The Parker (arthritis) Institute, Copenhagen University Hospital, Bispebjerg og Frederiksberg, Nordre Fasanvej 57, DK-2000, Frederiksberg, Denmark
| | - Hazel M Ross
- Counterweight Ltd, 85 Great Portland Street, First Floor, London,, W1W 7LT, UK
| | - Hemant G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine and NIHR Leeds Biomedical Research Centre, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - Chris Tuck
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Level 2, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Level 2, Nine Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
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Dall GF, Tsang STJ, Gwynne PJ, MacKenzie SP, Simpson AHRW, Breusch SJ, Gallagher MP. Unexpected synergistic and antagonistic antibiotic activity against Staphylococcus biofilms. J Antimicrob Chemother 2019; 73:1830-1840. [PMID: 29554250 DOI: 10.1093/jac/dky087] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/15/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives To evaluate putative anti-staphylococcal biofilm antibiotic combinations used in the management of periprosthetic joint infections (PJIs). Methods Using the dissolvable bead biofilm assay, the minimum biofilm eradication concentration (MBEC) was determined for the most commonly used antimicrobial agents and combination regimens against staphylococcal PJIs. The established fractional inhibitory concentration (FIC) index was modified to create the fractional biofilm eradication concentration (FBEC) index to evaluate synergism or antagonism between antibiotics. Results Only gentamicin (MBEC 64 mg/L) and daptomycin (MBEC 64 mg/L) were observed to be effective antistaphylococcal agents at clinically achievable concentrations. Supplementation of gentamicin with daptomycin, vancomycin or ciprofloxacin resulted in a similar or lower MBEC than gentamicin alone (FBEC index 0.25-2). Conversely, when rifampicin, clindamycin or linezolid was added to gentamicin, there was an increase in the MBEC of gentamicin relative to its use as a monotherapy (FBEC index 8-32). Conclusions This study found that gentamicin and daptomycin were the only effective single-agent antibiotics against established Staphylococcus biofilms. Interestingly the addition of a bacteriostatic antibiotic was found to antagonize the ability of gentamicin to eradicate Staphylococcus biofilms.
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Affiliation(s)
- G F Dall
- Department of Orthopaedic Surgery, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK.,School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - S-T J Tsang
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK.,Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - S P MacKenzie
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - S J Breusch
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - M P Gallagher
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
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Nicholson JA, Tsang STJ, MacGillivray TJ, Perks F, Simpson AHRW. What is the role of ultrasound in fracture management?: Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019; 8:304-312. [PMID: 31463038 PMCID: PMC6691369 DOI: 10.1302/2046-3758.87.bjr-2018-0215.r2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management. Methods A review of relevant literature was undertaken, including articles indexed in PubMed with keywords "ultrasound" or "sonography" combined with "diagnosis", "fracture healing", "impaired fracture healing", "nonunion", "microbiology", and "fracture-related infection". Results The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation. Conclusion Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing.Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304-312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2.
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Affiliation(s)
- J A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - S T J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - T J MacGillivray
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - F Perks
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
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Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
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