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Lloyd TD, Neal‐Smith G, Fennelly J, Claireaux H, Bretherton C, Carr AJ, Murphy M, Kendrick BJ, Palmer AJR, Wong J, Sharma P, Osei‐Bonsu PK, Ashcroft G, Baigent T, Shirland E, Espey R, Stokes M, Liew I, Dhawal A, Watchorn D, Lum J, Qureshi M, Khaled AS, Kauser S, Hodhody G, Rogers S, Haywood‐Alexander B, Sheikh G, Mahapatra P, Twaij H, Chicco M, Arnaout F, Atherton T, Mutimer J, Sinha P, Oliver E, Stedman T, Gadd R, Kutuzov V, Sattar M, Robiati L, Plastow R, Howe T, Hassan A, Lau B, Collins J, Doshi A, Tan G, Baskaran D, Hari Sunil Kumar K, Agarwal R, Horner M, Gwyn R, Masud S, Beaumont O, Pilarski A, Lebe M, Dawson‐Bowling S, Nolan D, Tsitskaris K, Beamish RE, Jordan C, Alsop S, Hibbert E, Deshpande G, Gould A, Briant‐Evans T, Kilbane L, Crowther I, Ingoe H, Naisbitt A, Gourbault L, Muscat J, Goh EL, Gill J, Elbashir M, Modi N, Archer J, Ismael S, Petrie M, O'Brien H, McCormick M, Koh NP, Lloyd T, King A, Ikram A, Peake J, Yoong A, Rye DS, Newman M, Naraen A, Myatt D, Kapur R, Sgardelis P, Kohli S, Culverhouse‐Mathews M, Haynes S, Boden H, Purmah A, Shenoy R, Raja S, Koh NP, Donovan R, Yeomans D, Ritchie D, Larkin R, Aladwan R, Hughes K, Unsworth R, Cooke R, Samra I, Barrow J, Michael K, Byrne F, Anwar R, Karatzia L, Drysdale H, Wilson H, Jones R, Dass D, Liaw F, Aujla R, Kheiran A, Bell K, Ramavath AL, Telfer R, Nachev K, Lawrence H, Garg V, Shenoy P, Lacey A, Byrom I, Simons M, Manning C, Cheyne N, Williams J. Peri‐operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study. Anaesthesia 2020; 75:1050-1058. [DOI: 10.1111/anae.15056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 12/20/2022]
Affiliation(s)
- T. D. Lloyd
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - G. Neal‐Smith
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - J. Fennelly
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - H. Claireaux
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - C. Bretherton
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - A. J. Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - M. Murphy
- University of Oxford UK
- NHS Blood and Transplant Oxford UK
| | - B. J. Kendrick
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - A. J. R. Palmer
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
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Palmer AJR, Lloyd TD, Gibbs VN, Shah A, Dhiman P, Booth R, Murphy MF, Taylor AH, Kendrick BJL. The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study. Anaesthesia 2020; 75:479-486. [PMID: 32037522 DOI: 10.1111/anae.14989] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2019] [Indexed: 12/29/2022]
Abstract
Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.
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Affiliation(s)
- A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - T D Lloyd
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - V N Gibbs
- NHS Blood and Transplant, Oxford, UK
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - P Dhiman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - R Booth
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M F Murphy
- NHS Blood and Transplant and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A H Taylor
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B J L Kendrick
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Abstract
Aims The aim of this study was to determine the stability of a new short femoral stem compared with a conventional femoral stem in patients undergoing cementless total hip arthroplasty (THA), in a prospective randomized controlled trial using radiostereometric analysis (RSA). Patients and Methods A total of 53 patients were randomized to receive cementless THA with either a short femoral stem (MiniHip, 26 patients, mean age: 52 years, nine male) or a conventional length femoral stem (MetaFix, 23 patients, mean age: 53 years, 11 male). All patients received the same cementless acetabular component. Two-year follow-up was available on 38 patients. Stability was assessed through migration and dynamically inducible micromotion. Radiographs for RSA were taken postoperatively and at three, six, 12, 18, and 24 months. Results At two years, there was significantly less subsidence (inferior migration) of the short femoral stem (head, 0.26 mm, 95% confidence interval (CI) 0.08 to 0.43, sd 0.38; tip, 0.11 mm, 95% CI -0.08 to 0.31, sd 0.42) compared with the conventional stem (head, 0.62 mm, 95% CI 0.34 to 0.90, sd 0.56, p = 0.02; tip, 0.43 mm, 95% CI 0.21 to 0.65, sd 0.44, p = 0.03). There was no significant difference in dynamically inducible micromotion, rate of complications or functional outcome. Conclusion This study demonstrates that the short femoral stem has a stable and predictable migration. However, longer-term survival analysis still needs to be determined. Cite this article: Bone Joint J 2018;100-B:1148–56.
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Affiliation(s)
- R. J. Ferguson
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - J. A. Broomfield
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - T. T. Malak
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - A. J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - D. Whitwell
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - B. Kendrick
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - A. Taylor
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
| | - S. Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, University of Oxford, Botnar Research
Centre, Oxford, UK
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Ferguson RJ, Broomfield JA, Malak TT, Palmer AJR, Whitwell D, Kendrick B, Taylor A, Glyn-Jones S. Infographic: Primary stability of a short bone-conserving femoral stem. Bone Joint J 2018; 100-B:1146-1147. [PMID: 30168763 DOI: 10.1302/0301-620x.100b9.bjj-2018-0863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- R J Ferguson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - J A Broomfield
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - T T Malak
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - D Whitwell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - B Kendrick
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - A Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - S Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
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Malak TT, Broomfield JAJ, Palmer AJR, Hopewell S, Carr A, Brown C, Prieto-Alhambra D, Glyn-Jones S. Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review. Bone Joint Res 2016; 5:206-14. [PMID: 27267795 PMCID: PMC4921042 DOI: 10.1302/2046-3758.56.2000568] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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] [Received: 09/17/2015] [Accepted: 03/23/2016] [Indexed: 12/24/2022] Open
Abstract
Objectives High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA). Methods We conducted a systematic review of studies evaluating surrogate markers for predicting long-term outcome in primary THA. Long-term outcome was defined as revision rate of an implant at ten years according to National Institute of Health and Care Excellence guidelines. We conducted a search of Medline and Embase (OVID) databases. Separate search strategies were devised for the Cochrane database and Google Scholar. Each search was performed to include articles from the date of their inception to June 8, 2015. Results Our search strategy identified 1082 studies of which 115 studies were included for full article review. Following review, 17 articles were found that investigated surrogate markers of long-term outcome. These included one systematic review, one randomised control trial (RCT), one case control study and 13 case series. Validated surrogate markers included Radiostereometric Analysis (RSA) and Einzel-Bild-Röntgen-Analyse (EBRA), each measuring implant migration and wear. We identified five RSA studies (one systematic review and four case series) and four EBRA studies (one RCT and three case series). Patient Reported Outcome Measures (PROMs) at six months have been investigated but have not been validated against long-term outcomes. Conclusions This systematic review identified two validated surrogate markers of long-term primary THA outcome: RSA and EBRA, each measuring implant migration and wear. We recommend the consideration of RSA in the pre-market testing of new implants. EBRA can be used to investigate acetabular wear but not femoral migration. Further studies are needed to validate the use of PROMs for post-market surveillance. Cite this article: T. T. Malak, J. A. J. Broomfield, A. J. R. Palmer, S. Hopewell, A. Carr, C. Brown, D. Prieto-Alhambra, S. Glyn-Jones. Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review. Bone Joint Res 2016;5:206–214. DOI: 10.1302/2046-3758.56.2000568.
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Affiliation(s)
- T T Malak
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - J A J Broomfield
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - A J R Palmer
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - S Hopewell
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - A Carr
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - C Brown
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - D Prieto-Alhambra
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
| | - S Glyn-Jones
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Lane, Oxford OX3 7LD, UK
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Dean BJF, Jones LD, Palmer AJR, Macnair RD, Brewer PE, Jayadev C, Wheelton AN, Ball DEJ, Nandra RS, Aujla RS, Sykes AE, Carr AJ. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016; 5:178-84. [PMID: 27179004 PMCID: PMC4921043 DOI: 10.1302/2046-3758.55.2000596] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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] [Received: 11/03/2015] [Accepted: 03/08/2016] [Indexed: 01/29/2023] Open
Abstract
Objectives The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). Conclusions Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively. Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596.
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Affiliation(s)
- B J F Dean
- Botnar Musculoskeletal Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - L D Jones
- John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - A J R Palmer
- John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - R D Macnair
- Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Morriston, Swansea SA6 6NL, UK
| | - P E Brewer
- South Yorkshire Deanery, Northern General Hospital, Sheffield, UK
| | - C Jayadev
- South Yorkshire Deanery, Northern General Hospital, Sheffield, UK
| | - A N Wheelton
- Health Education North West, Regatta Place, Brunswick Business Park, Liverpool, L3 4BL, UK
| | - D E J Ball
- Health Education North West, Regatta Place, Brunswick Business Park, Liverpool, L3 4BL, UK
| | - R S Nandra
- West Midlands, Queen Elizabeth Medical Centre, University Hospital Birmingham, Birmingham B15 2TH, UK
| | - R S Aujla
- Botnar Musculoskeletal Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - A E Sykes
- Botnar Musculoskeletal Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - A J Carr
- Botnar Musculoskeletal Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
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Palmer AJR, Malak TT, Broomfield J, Holton J, Majkowski L, Thomas GER, Taylor A, Andrade AJ, Collins G, Watson K, Carr AJ, Glyn-Jones S. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013. BMJ Open Sport Exerc Med 2016; 2:e000082. [PMID: 27900161 PMCID: PMC5117047 DOI: 10.1136/bmjsem-2015-000082] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/23/2015] [Accepted: 01/01/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years. Methods A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence. Results 11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40–44 for females and 35–39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population). Conclusions The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.
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Affiliation(s)
- A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - T T Malak
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - J Broomfield
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - J Holton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - L Majkowski
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - G E R Thomas
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - A Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - A J Andrade
- Royal Berkshire Hospital NHS Trust , Reading , UK
| | - G Collins
- Centre for Statistics in Medicine, University of Oxford , Oxford , UK
| | - K Watson
- Public Health England , Oxford , UK
| | - A J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - S Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
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Abstract
Osteoarthritis is a major source of pain, disability, and socioeconomic cost worldwide. The epidemiology of the disorder is complex and multifactorial, with genetic, biological, and biomechanical components. Aetiological factors are also joint specific. Joint replacement is an effective treatment for symptomatic end-stage disease, although functional outcomes can be poor and the lifespan of prostheses is limited. Consequently, the focus is shifting to disease prevention and the treatment of early osteoarthritis. This task is challenging since conventional imaging techniques can detect only quite advanced disease and the relation between pain and structural degeneration is not close. Nevertheless, advances in both imaging and biochemical markers offer potential for diagnosis and as outcome measures for new treatments. Joint-preserving interventions under development include lifestyle modification and pharmaceutical and surgical modalities. Some show potential, but at present few have proven ability to arrest or delay disease progression.
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Affiliation(s)
- S Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - R Agricola
- Department of Orthopaedics, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - A J Price
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - T L Vincent
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - H Weinans
- Department of Orthopaedics, University Medical Centre Utrecht, Netherlands
| | - A J Carr
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Palmer AJR, Ayyar-Gupta V, Dutton SJ, Rombach I, Cooper CD, Pollard TC, Hollinghurst D, Taylor A, Barker KL, McNally EG, Beard DJ, Andrade AJ, Carr AJ, Glyn-Jones S. Protocol for the Femoroacetabular Impingement Trial (FAIT): a multi-centre randomised controlled trial comparing surgical and non-surgical management of femoroacetabular impingement. Bone Joint Res 2014; 3:321-7. [PMID: 25431439 PMCID: PMC4248299 DOI: 10.1302/2046-3758.311.2000336] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 12/11/2022] Open
Abstract
AIMS Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head-neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis. METHODS FAIT is a multicentre superiority parallel two-arm randomised controlled trial comparing physiotherapy and activity modification with arthroscopic surgery for the treatment of symptomatic FAI. Patients aged 18 to 60 with clinical and radiological evidence of FAI are eligible. Principal exclusion criteria include previous surgery to the index hip, established osteoarthritis (Kellgren-Lawrence ≥ 2), hip dysplasia (centre-edge angle < 20°), and completion of a physiotherapy programme targeting FAI within the previous 12 months. Recruitment will take place over 24 months and 120 patients will be randomised in a 1:1 ratio and followed up for three years. The two primary outcome measures are change in hip outcome score eight months post-randomisation (approximately six-months post-intervention initiation) and change in radiographic minimum joint space width 38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Bone Joint Res 2014;3:321-7.
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Affiliation(s)
- A J R Palmer
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - V Ayyar-Gupta
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - S J Dutton
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - I Rombach
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - C D Cooper
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | | | | | - A Taylor
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - K L Barker
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - E G McNally
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - D J Beard
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | | | - A J Carr
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - S Glyn-Jones
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
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Thomas GER, Palmer AJR, Batra RN, Kiran A, Hart D, Spector T, Javaid MK, Judge A, Murray DW, Carr AJ, Arden NK, Glyn-Jones S. Subclinical deformities of the hip are significant predictors of radiographic osteoarthritis and joint replacement in women. A 20 year longitudinal cohort study. Osteoarthritis Cartilage 2014; 22:1504-10. [PMID: 25047637 DOI: 10.1016/j.joca.2014.06.038] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [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: 01/02/2014] [Revised: 06/14/2014] [Accepted: 06/28/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Femoroacetabular Impingement (FAI) and Acetabular Dysplasia are common deformities, which have been implicated as a major cause of hip osteoarthritis (OA). We examined whether these subtle deformities of the hip are associated with the development of radiographic OA and total hip replacement (THR) in women. DESIGN A population-based, longitudinal cohort of 1003 women underwent pelvis radiographs at years 2 and 20. Alpha Angle, Triangular Index Height, Lateral Centre Edge (LCE) angle and Extrusion Index were measured. An alpha angle of greater than 65° was defined as Cam-type FAI. Radiographic OA and the presence of a THR were then determined at 20 years. RESULTS Cam-type FAI was significantly associated with the development of radiographic OA. Each degree increase in alpha angle above 65° was associated with an increase in risk of 5% (Odds Ratio (OR) 1.05 [95% confidence interval (CI) 1.01-1.09]) for radiographic OA and 4% (OR 1.04 [95% CI 1.00-1.08]) for THR. For Acetabular Dysplasia, each degree reduction in LCE angle below 28° was associated with an increase in risk of 13.0% (OR 0.87 [95% CI 0.78-0.96]) for radiographic OA and 18% (OR 0.82 [95% CI 0.75-0.89]) for THR. CONCLUSIONS This study demonstrates that Cam-type FAI and mild Acetabular Dysplasia are predictive of subsequent OA and THR in a large female population cohort. These are independent of age, BMI and joint space and significantly improve current predictive models of hip OA development.
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Affiliation(s)
- G E R Thomas
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK.
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - R N Batra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - A Kiran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - D Hart
- Department of Twin Research & Genetic Epidemiology, King's College London, St Thomas' Hospital Campus, 3rd & 4th Floor South Wing Block D, Westminster Bridge Road, London SE1 7EH, UK
| | - T Spector
- Department of Twin Research & Genetic Epidemiology, King's College London, St Thomas' Hospital Campus, 3rd & 4th Floor South Wing Block D, Westminster Bridge Road, London SE1 7EH, UK
| | - M K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - A Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - D W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - A J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - N K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK; MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - S Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
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Abstract
Treatment for osteoarthritis (OA) has traditionally focused on joint replacement for end-stage disease. An increasing number of surgical and pharmaceutical strategies for disease prevention have now been proposed. However, these require the ability to identify OA at a stage when it is potentially reversible, and detect small changes in cartilage structure and function to enable treatment efficacy to be evaluated within an acceptable timeframe. This has not been possible using conventional imaging techniques but recent advances in musculoskeletal imaging have been significant. In this review we discuss the role of different imaging modalities in the diagnosis of the earliest changes of OA. The increasing number of MRI sequences that are able to non-invasively detect biochemical changes in cartilage that precede structural damage may offer a great advance in the diagnosis and treatment of this debilitating condition.
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Affiliation(s)
- A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington OX3 7LD, UK
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Palmer AJR, Thomas GER, Pollard TCB, Rombach I, Taylor A, Arden N, Beard DJ, Andrade AJ, Carr AJ, Glyn-Jones S. The feasibility of performing a randomised controlled trial for femoroacetabular impingement surgery. Bone Joint Res 2013; 2:33-40. [PMID: 23610700 PMCID: PMC3626218 DOI: 10.1302/2046-3758.22.2000137] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [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] [Received: 10/01/2012] [Accepted: 01/09/2013] [Indexed: 12/02/2022] Open
Abstract
Objectives The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI. Methods Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31). Results Clinical equipoise was demonstrated when surgeons were given
clinical scenarios and asked whether they would manage a patient
operatively or non-operatively. A total of 23 surgeons (77%) who
routinely perform FAI surgery were willing to recruit patients into
a RCT, and 28 patients (90%) were willing to participate. 75% of
responding surgeons believed it was appropriate to randomise patients
to non-operative treatment for ≥ 12 months. Conversely, only eight
patients (26%) felt this was acceptable, although 29 (94%) were
willing to continue non-operative treatment for six months. More
patients were concerned about their risk of developing OA than their
current symptoms, although most patients felt that the two were
of equal importance. Conclusions We conclude that a RCT comparing operative and non-operative
management of FAI is feasible and should be considered a research
priority. An important finding for orthopaedic surgical trials is
that patients without life-threatening pathology appear willing
to trial a treatment for six months without improvement in their
symptoms.
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Affiliation(s)
- A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Windmill Road, Headington, Oxford OX3 7LD, UK
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