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Cooper GM, Bayram JM, Clement ND. The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients. Sci Rep 2024; 14:8032. [PMID: 38580681 PMCID: PMC10997604 DOI: 10.1038/s41598-024-58050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 03/25/2024] [Indexed: 04/07/2024] Open
Abstract
This systematic review and meta-analysis aimed to determine the impact of presurgical waiting times on pre-/post-operative joint specific pain and function, health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements. MEDLINE, EMBASE, PUBMED, and CENTRAL databases were searched from inception until 30th January 2023 (CRD42022288128). Secondary literature and unpublished datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded. PRISMA 2020 reporting and GRADE certainty of evidence guidelines were followed. Residual maximum likelihood meta-analysis and linear meta-regression was performed to elucidate the influence of presurgical waiting time. Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, capturing 89,996 patients (60.6% female, mean age 67.4 years) between 2001 and 2022. A significant deterioration in joint function (mean difference (MD):0.0575%; 95% CI 0.0064, 0.1086; p = 0.028(4d.p.); I2 = 73.1%) and HRQOL (MD: 0.05%; 95% CI - 0.0001.0009; p = 0.011(4 d.p.); I2 = 80.6%) was identified per additional day of waiting. Despite qualitative evidence, meta-analysis could not observe a relationship with postoperative outcome data. Patient responses to delayed THR and TKR surgery were unanimously negative. Immediate action should seek to reduce the increased patient anxiety and significant reductions in pre-operative joint functionality and HRQOL associated with prolonged pre-surgical waiting time, whilst mitigating any potential deleterious post-operative effects.
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Affiliation(s)
- G M Cooper
- University of Edinburgh Medical School, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| | - J M Bayram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - N D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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Hall AJ, Clement ND, MacLullich AMJ, White TO, Duckworth AD. Vaccination against COVID-19 reduced the mortality risk of COVID-positive hip fracture patients to baseline levels: the nationwide data-linked IMPACT Protect study. Osteoporos Int 2024; 35:353-363. [PMID: 37897507 DOI: 10.1007/s00198-023-06954-w] [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: 06/08/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023]
Abstract
This nationwide study used data-linked records to assess the effect of COVID-19 vaccination among hip fracture patients. Vaccination was associated with a lower risk of contracting COVID-19 and, among COVID-positive patients, it reduced the mortality risk to that of COVID-negative patients. This provides essential data for future communicable disease outbreaks. PURPOSE COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. METHODS This nationwide cohort study included all patients aged > 50 years that sustained a hip fracture in Scotland between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to government-managed population level records of COVID-19 vaccination and laboratory testing. RESULTS There were 13,345 patients with a median age of 82.0 years (IQR 74.0-88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34-0.48, p < 0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12-3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk of death (OR 0.93, CI 0.53-1.60, p = 0.783). CONCLUSION Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents data that will be valid in the management of future outbreaks.
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Affiliation(s)
- Andrew J Hall
- Golden Jubilee Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK.
- School of Medicine, University of St Andrews, North Haugh, St Andrews, KY16 9TF, UK.
- National Treatment Centre - Fife Orthopaedics, NHS Fife, Kirkcaldy, UK.
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK.
| | - N D Clement
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - A M J MacLullich
- Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, UK
- Ageing & Health Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - T O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), Edinburgh, UK
| | - A 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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Panth S, Wilson E, Chen B, Clement ND. Accelerated Care of Patients with Hip Fractures is Associated with Lower Risk of Delirium and Infection, and a Shorter Length of Hospital Stay: Systematic Review and Meta-analysis of Level One Evidence. Indian J Orthop 2024; 58:1-10. [PMID: 38161403 PMCID: PMC10754779 DOI: 10.1007/s43465-023-01026-x] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/12/2023] [Indexed: 01/03/2024]
Abstract
Objectives The aim of this systematic review was to assess the impact of time to surgery on patient mortality, peri-operative complication rates and length of stay following a hip fracture using level one data. Data Sources Multiple databases (PubMed, Embase, Medline (Ovid), and Cochrane Library) were searched using terms for "hip fracture" and the intervention "early surgery". Results were filtered to only included randomised controlled trials in the English language published from the year 2000. Study Selection All results were imported into Covidence and screened by two separate reviewers with conflicts resolved by a third reviewer. Studies were included if they reported data on the relationship between time to theatre and at least one of the outcome measures (mortality, peri-operative complications, and length of stay in hospital). Three papers were finalised to include in this review. Data Extraction Once selected, each paper had a bias assessment completed by two separate reviewers using the Cochrane RoB2 tool. Any conflicts were resolved by a third reviewer. Data Synthesis Data from each paper were inputted into RevMan5 for analysis. Approximated sample mean and standard deviation were collected from each paper and included for analysis. RevMan5 was then used to generate forest plots and report data on relative risk and mean difference. Conclusions This review has shown that accelerated care of patients with hip fractures was associated with lower risks of delirium and infection, and a shorter length of hospital stay. However, the effect of time to surgery on patient mortality is not clear, as the standard care group had a lower mortality than expected for the population at risk and had surgery on average within 24-h of presentation.
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Affiliation(s)
- S. Panth
- University of Edinburgh Medical School, 47 Little France Cres, Little France, Edinburgh, EH16 4TJ UK
| | - E. Wilson
- University of Edinburgh Medical School, 47 Little France Cres, Little France, Edinburgh, EH16 4TJ UK
| | - B. Chen
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, Suzhou, China
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
| | - N. D. Clement
- University of Edinburgh Medical School, 47 Little France Cres, Little France, Edinburgh, EH16 4TJ UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
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Clement ND, Edwards J, Afzal I, Abbott S, Jones S, Radha S, Kader D. Posterior stabilised total knee arthroplasty is associated with improved post-operative knee specific function, health related quality of life and greater satisfaction when compared to cruciate retaining protheses. Eur J Orthop Surg Traumatol 2023; 33:3411-3418. [PMID: 37142803 DOI: 10.1007/s00590-023-03565-3] [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] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/23/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE To assess whether there were differences in knee specific function, health related quality of life (HRQoL), and satisfaction between patients with a cruciate retaining (CR) or a posterior stabilised (PS) total knee arthroplasty (TKA) at 1 and 2 years postoperatively. METHODS A retrospective review of TKA (CR and PS) patients from a prospectively collected arthroplasty database. Patient demographics, body mass index and ASA grade, Oxford knee score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 1 year and 2 years postoperatively. Regression was used to adjust for confounding factors. RESULTS The sample included 3122 TKA, of which 1009 (32.3%) were CR and 2112 (67.7%) were PS. The PS group were more likely to be female (odd ratio (OR) 1.26, p = 0.003) and undergo resurfacing of the patella (OR 6.63, p < 0.001). There was a significantly greater improvement in the 1 year OKS in the PS group (mean difference (MD) 0.9, p = 0.016). The PS TKA was independently associated with a greater 1 year (MD 1.1, 95% CI 0.4 to 1.9, p = 0.001) and 2 years (MD 0.8, p = 0.037) post-operative improvements in OKS. PS TKA was also independently associated with a greater 1 year (MD 0.021, p = 0.024) and 2 years (MD 0.022, p = 0.025) post-operative and change in EQ-5D utility compared to the CR group. The PS group was more likely to be satisfied with their outcome at 1 year (OR 1.75, p < 0.001) and at 2 years (OR 1.38, p = 0.001) when adjusting for confounders. CONCLUSION PS TKA was associated with a better knee specific function and HRQoL when compared to CR, but the clinical significance of this is not clear. However, the PS group was more likely to be satisfied with their outcome compared to the CR group.
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Affiliation(s)
- N D Clement
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J Edwards
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK.
| | - I Afzal
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK
| | - S Abbott
- St Georges University Hospitals NHS Foundation Trust, London, UK
| | - S Jones
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK
| | - S Radha
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK
| | - D Kader
- Southwest London Orthopaedic Elective Centre, Epsom General Hospital, Epsom, Surrey, KT18 7EG, UK
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Heinz NR, Clement ND, Young RN, Duckworth AD, White TO, Molyneux SG. Rate and factors associated with surgical site infection following aseptic revision fixation of orthopaedic trauma injuries. Eur J Orthop Surg Traumatol 2023; 33:3511-3517. [PMID: 37202609 PMCID: PMC10651543 DOI: 10.1007/s00590-023-03573-3] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/05/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE The primary aim of this study was to define the rate of infection following revision of fixation for aseptic failure. The secondary aims were to identify factors associated with an infection following revision and patient morbidity following deep infection. METHODS A retrospective study was undertaken to identify patients who underwent aseptic revision surgery during a 3-year period (2017-2019). Regression analysis was used to identify independent factors associated with SSI. RESULTS Eighty-six patients were identified that met the inclusion criteria, with a mean age of 53 (range 14-95) years and 48 (55.8%) were female. There were 15 (17%) patients with an SSI post revision surgery (n = 15/86). Ten percent (n = 9) of all revisions acquired a 'deep infection', which carried a high morbidity with a total of 23 operations, including initial revision, being undertaken for these patients as salvage procedures and three progressed to an amputation. Alcohol excess (odds ratio (OR) 1.61, 95% CI 1.01-6.36, p = 0.046) and chronic obstructive pulmonary disease (OR 11.1, 95% CI 1.00-133.3, p = 0.050) were independently associated with an increased risk of SSI. CONCLUSION Aseptic revision surgery had a high rate of SSI (17%) and deep infection (10%). All deep infections occurred in the lower limb with the majority of these seen in ankle fractures. Alcohol excess and COPD were independent risk factors associated with an SSI and patients with a history of these should be counselled accordingly. LEVEL OF EVIDENCE Retrospective Case Series, Level IV.
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Affiliation(s)
- N R Heinz
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK.
| | - N D Clement
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
- University of Edinburgh, Edinburgh, UK
| | - R N Young
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - A D Duckworth
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
- University of Edinburgh, Edinburgh, UK
| | - T O White
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - S G Molyneux
- Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
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Watson M, Coughlan D, Clement ND, Murray IR, Murray AD, Miller SC. Biomechanical parameters of the golf swing associated with lower back pain: A systematic review. J Sports Sci 2023; 41:2236-2250. [PMID: 38446499 DOI: 10.1080/02640414.2024.2319443] [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] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 02/08/2024] [Indexed: 03/07/2024]
Abstract
Low back pain (LBP) is the most common injury in golfers of all abilities. The primary aim of this review was to improve understanding of human golf swing biomechanics associated with LBP. A systematic review using the PRISMA guidelines was performed. Nine studies satisfying inclusion criteria and dually reporting golf swing biomechanics and LBP were identified. Human golf swing biomechanics potentially associated with LBP include: reduced lumbar flexion velocity; reduced transition phase length; reduced lumbar torsional load; earlier onset of erector spinae contraction; increased lumbar lateral flexion velocity; reduced or greater erector spinae activity; and earlier onset of external oblique contraction. These potential associations were undermined by a very limited and conflicting quality of evidence, study designs which introduced a severe potential for bias and a lack of prospective study design. There is no conclusive evidence to support the commonly held belief that LBP is associated with "poor" golf swing technique. The potential associations identified should be further investigated by prospective studies of robust design, recruiting participants of both sexes and dexterities. Once firm associations have been identified, further research is required to establish how this knowledge can be best integrated into injury prevention and rehabilitation.
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Affiliation(s)
- M Watson
- European Tour Health and Performance Institute, European Tour Group, Virginia Water, UK
- Medical and Scientific Department, The R&A, St Andrews, UK
| | - D Coughlan
- European Tour Health and Performance Institute, European Tour Group, Virginia Water, UK
- Medical and Scientific Department, The R&A, St Andrews, UK
- London Sport Institute, Middlesex University, London, UK
| | - N D Clement
- European Tour Health and Performance Institute, European Tour Group, Virginia Water, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
| | - I R Murray
- European Tour Health and Performance Institute, European Tour Group, Virginia Water, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
| | - A D Murray
- European Tour Health and Performance Institute, European Tour Group, Virginia Water, UK
- Medical and Scientific Department, The R&A, St Andrews, UK
- Department of Sports and Exercise/Physical Activity for Health, University of Edinburgh, Edinburgh, UK
| | - S C Miller
- Department of Sports and Exercise Medicine, Queen Mary University of London, London, UK
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Chen B, Clement ND, MacDonald D, Hamilton DF, Gaston P. Cost-utility analysis of total knee arthroplasty using 10-year data from a randomised controlled trial: Implant design influences quality-adjusted life year gain. Knee 2023; 44:79-88. [PMID: 37542953 DOI: 10.1016/j.knee.2023.07.002] [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: 03/12/2023] [Revised: 06/04/2023] [Accepted: 07/14/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The aim of this study was to perform a cost-utility analysis for total knee arthroplasty (TKA) over a 10-year follow up period. METHODS Two-hundred and twelve patients were randomised to receive either a Kinemax or a Triathlon TKA. Patients were assessed pre-operatively, and at 6 months, and 1, 3, 7 and 10 years postoperatively. The costs of the primary and revision surgery were accounted for. One-year quality-adjusted life year (QALY) gain was used to estimate 10-year gains using the established annual health gain discounts. RESULTS Forty-eight patients died and eight were revised during the follow up period. Overall QALY gain per patient over the 10-year period was 2.594 and the cost per patient was £6559, which resulted in a cost per QALY of £2761 at 10 years. The Triathlon group had a significantly greater QALY gain compared with the Kinemax (mean difference (MD) 0.53, 95% CI 0.03-1.03, P = 0.02), which resulted in a cost per QALY for the Triathlon group of £2521 compared with £3107 for the Kinemax group at 10 years. The 5% annual discount resulted in a significantly lower QALY gain (MD 0.135, 95% CI 0.201-0.354, P = 0.002), whereas the 3.5% annual discount resulted in non-significant difference in QALY gain compared with the actual gain (MD 0.021, 95% CI -0.084 to 0.077, P = 0.292). CONCLUSIONS TKA was a cost-effective intervention, and the Triathlon was associated with a greater cost effectiveness at 10 years. The 3.5% annual discounts for QALY gain would seem to be the most accurate, with an underestimation being observed with the 5% discount.
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Affiliation(s)
- B Chen
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
| | - N D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK; Department of Orthopaedics, University of Edinburgh, Little France, Edinburgh, UK.
| | - D MacDonald
- Department of Orthopaedics, University of Edinburgh, Little France, Edinburgh, UK
| | - D F Hamilton
- Department of Orthopaedics, University of Edinburgh, Little France, Edinburgh, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - P Gaston
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK; Department of Orthopaedics, University of Edinburgh, Little France, Edinburgh, UK
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Clement ND, Gaston MS, Simpson AH. Fractures in elderly mice demonstrate delayed ossification of the soft callus: a cellular and radiographic study. Eur J Orthop Surg Traumatol 2023; 33:977-985. [PMID: 35239001 PMCID: PMC10125932 DOI: 10.1007/s00590-022-03235-w] [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] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to assess the cellular age-related changes in fracture repair and relate these to the observed radiographic assessments at differing time points. METHODS Transverse traumatic tibial diaphyseal fractures were created in 12-14 weeks old (young n = 16) and 18 months old (elderly n = 20) in Balb/C wild mice. Fracture calluses were harvested at five time points from 1 to 35 days post fracture for histomorphometry (percent of cartilage and bone), radiographic analysis (total callus volume, callus index, and relative bone mineral content). RESULTS The elderly mice produced an equal amount of cartilage when compared to young mice (p > 0.08). However, by day 21 there was a significantly greater percentage of bone at the fracture site in the young group (mean percentage 50% versus 11%, p < 0.001). It was not until day 35 when the elderly group produced a similar amount of bone compared to the young group at 21 days (50% versus 53%, non-significant (ns)). The callus area and callus index on radiographic assessment was not significantly different between young and elderly groups at any time point. Relative bone mineral content was significantly greater in the young group at 14 days (545.7 versus -120.2, p < 0.001) and 21 days (888.7 versus 451.0, p < 0.001) when compared to the elderly group. It was not until day 35 when the elderly group produced a similar relative bone mineral content as the young group at 21 days (888.7 versus 921.8, ns). CONCLUSIONS Elderly mice demonstrated a delay in endochondral ossification which was associated with a decreased relative bone mineral content at the fracture site and may help assess these cellular changes in a clinical setting.
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Affiliation(s)
- N. D. Clement
- Department of Orthopaedics and Trauma, University of Edinburgh, Little France, Edinburgh, EH16 4SA UK
| | - M. S. Gaston
- Department of Orthopaedics and Trauma, University of Edinburgh, Little France, Edinburgh, EH16 4SA UK
| | - A. H. Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Little France, Edinburgh, EH16 4SA UK
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Clement ND, Afzal I, Liu P, Phoon KM, Asopa V, Sochart DH, Kader DF. The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty. Arthroplasty 2022; 4:33. [PMID: 35918759 PMCID: PMC9345743 DOI: 10.1186/s42836-022-00132-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background The health-related quality of life of patients awaiting a total knee arthroplasty (TKA) deteriorates with increasing time to surgery and identification of those with the worst quality of life may help to prioritize patients. The aims were to identify and validate independent variable(s) associated with a health state worse than death (WTD) in patients awaiting a TKA and whether these variables influenced patients-reported outcome measures. Methods A retrospective cohort of 5857 patients undergoing a primary TKA was identified from an established arthroplasty database. Patient demographics, body mass index (BMI), index of multiple deprivation, Oxford Knee Score (OKS), EuroQoL five dimension (EQ-5D) 3 level, and visual analogue scale (EQ-VAS) were collected preoperatively and one year postoperatively. An EQ-5D utility of less than zero was defined as WTD. A randomly selected subset of patients (n = 3076) was used to validate the variable that was most predictive of a state WTD and to assess the influence on patient-reported outcomes. Results There were 771 (13.2%) patients with a health state WTD. Increasing social deprivation (P = 0.050), worse preoperative OKS (P < 0.001), or EQ-VAS (P < 0.001) were independently associated with a health state WTD. The OKS was the most reliable predictor (area under curve 88.9%, 95% CI 87.8 to 90.1, P < 0.001) of a health state WTD. A threshold value of 16 or less, 80% sensitive and specific, was validated and confirmed to have a negative predictive value of 97.5%. Patients with an OKS of 16 or less had a significantly greater improvement in their OKS (difference 6.9, P < 0.001) and EQ-5D score (difference 0.257, P < 0.001). When adjusting for confounding factors, a health status WTD was not associated with worse postoperative OKS (difference –0.6, 95% CI –1.4 to 0.3, P = 0.177), EQ-5D (difference –0.016, 95% CI –0.036 to 0.003, P = 0.097) or patient satisfaction (difference –1.8, 95% CI –4.3 to 0.7, P = 0.162). Conclusion A threshold score 16 or less in OKS was a reliable predictor of a health status WTD and was associated with a greater improvement in knee-specific and health-related quality of life following TKA.
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Peacock CJH, Fu H, Asopa V, Clement ND, Kader D, Sochart DH. The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review. Arthroplasty 2022; 4:40. [PMID: 36050799 PMCID: PMC9438335 DOI: 10.1186/s42836-022-00144-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively.
Materials and methods
A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools.
Results
Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively.
Conclusions
Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.
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Robinson PG, Kay RS, MacDonald D, Murray AD, Clement ND. Golfers have greater preoperative and equal postoperative function when undergoing total knee arthroplasty compared to non-golfers. Eur J Orthop Surg Traumatol 2022; 33:1083-1089. [PMID: 35362779 PMCID: PMC8973671 DOI: 10.1007/s00590-022-03253-8] [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] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Background Approximately 10% to 20% of patients with joint arthroplasties are golfers. The aim of this study was to assess if being a golfer is associated with functional outcomes, satisfaction or improvement in quality of life (QoL) compared to non-golfers following total knee arthroplasty. Methods All patients undergoing primary total knee arthroplasty (TKA) over a one-year period at a single institution were included with one-year postoperative outcomes. Patients were retrospectively followed up to assess if they had been golfers at the time of their surgery. Multivariate linear regression analysis was performed to assess the independent association of preoperative golfing status on postoperative function and health-related outcomes. Results The study cohort consisted of a total of 514 patients undergoing TKA. This included 223 (43.3%) male patients and 291 (56.7%) female patients, with an overall mean age of 70 (SD 9.5) years. The preoperative Oxford Knee Score (OKS) was significantly higher in golfers when adjusting for confounders (Diff 3.4 [95% CI 1 to 5.8], p = 0.006). There was no difference in postoperative outcomes between golfers and non-golfers. There was however a trend towards a higher Forgotten Joint Score (FJS) in the golfers (difference 9.3, 95% CI − 0.2 to 18.8, p = 0.056). Of the 48 patients who reported being golfers at the time of their surgery, 43 (89.6%) returned to golf and 88.4% of those were satisfied with their involvement in golf following surgery. Conclusions Golfers had better preoperative and equal postoperative knee specific function compared to non-golfers. The majority of golfers returned to golf by one year and were satisfied with their involvement in the game. Level of evidence III.
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Affiliation(s)
- P G Robinson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,PGA European Tour Performance Institute, Virginia Water, UK
| | - R S Kay
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK.
| | - D MacDonald
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A D Murray
- PGA European Tour Performance Institute, Virginia Water, UK.,Sports and Exercise Medicine, University of Edinburgh, Edinburgh, UK.,Medical and Scientific Department, The R&A, St. Andrews, UK
| | - N D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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12
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Stirling PHC, Ng N, Jenkins PJ, Clement ND, Duckworth AD, McEachan JE. Hand-arm vibration and outcomes of surgery for Dupuytren's contracture. Occup Med (Lond) 2021; 71:219-222. [PMID: 34104973 DOI: 10.1093/occmed/kqab070] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Dupuytren's contracture was recently designated a prescribed occupational disease when it occurs in patients with previous hand-arm vibration (HAV) exposure. AIMS The aims of this study were to describe the impact of self-reported HAV exposure on upper limb function and satisfaction following surgery for Dupuytren's contracture. METHODS Paired pre- and postoperative Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient satisfaction questionnaires were prospectively collected from all patients undergoing surgery for Dupuytren's contracture over a 6-year period. Patients self-reported HAV exposure duration. RESULTS Results were available for 425 hands (65%) at mean 13 months postoperatively. There were 111 patients (26%) that reported HAV exposure. The prevalence of HAV exposure was significantly greater in male compared with female patients (32% versus 4%; P < 0.001). A statistically significant difference in preoperative (difference 7.47; 95% confidence interval 4.78-10.17; P < 0.001) and postoperative QuickDASH score (difference 6.78; 95% confidence interval 2.69-10.88; P < 0.001) was observed between the two groups, but difference in QuickDASH improvement was not significantly different (difference 1.76; 95% confidence interval -1.58 to 5.10; P > 0.05). No significant difference in satisfaction rate or return to work was observed between the two groups. CONCLUSIONS Previous HAV exposure influenced the pre and postoperative function in patients undergoing surgery for Dupuytren's contracture, but had no effect on satisfaction or return to work. Further prospective research will be required to determine whether the introduction of a compensatory framework will have a more profound effect on the functional outcomes of surgery.
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Affiliation(s)
- P H C Stirling
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.,Fife Virtual Hand Clinic, UK
| | - N Ng
- Fife Virtual Hand Clinic, UK
| | | | - N D Clement
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - A D Duckworth
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - J E McEachan
- Fife Virtual Hand Clinic, UK.,Queen Margaret Hospital, Dunfermline KY12 0SU, UK
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13
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Lin CMA, Orman A, Clement ND, Deehan DJ. 392 Patient Reported Comorbidity Is Not A Reliable Data Source: A Systematic Review of The Literature. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.551] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Introduction
There is currently an increased demand for elective orthopaedic surgery. However, due to financial, time and resource limitations, there is a pressing need to identify those who would benefit most with the lowest risk of complications. Comorbidities play a fundamental part in this decision and the traditional way to ascertain this is through medical record data ion during pre-operative assessment, but this can be time-consuming and expensive. We therefore set out to establish whether patient self-reported comorbidities are reliable as a principal source of information.
Method
Searches of PubMed and Medline were performed by two independent researchers. Inclusion criteria were any published study assessing the reliability of at least one patient reported comorbidity against their medical record or clinical assessment as gold standard.
Results
There were 27 studies included 12 concluded with unreliability, 11 with reliability, 4 inconclusive. Factors found to affect the concordance included gender, age, ethnicity, level of education, living alone, marital status, number or severity of comorbidities and depression.
Conclusions
The majority of studies concluded that patient self-reported comorbidities are unreliable, even when their results showed good concordance. Although patient reported data is useful, it is not reliable enough to be used as a standalone measure.
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Affiliation(s)
- C M A Lin
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A Orman
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - N D Clement
- Department of Orthopaedics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - D J Deehan
- Department of Orthopaedics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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14
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Stirling PHC, Jenkins PJ, Duckworth AD, Clement ND, McEachan JE. Comorbid status influences quality of life following carpal tunnel decompression. Hand Surg Rehabil 2020; 40:338-342. [PMID: 33340720 DOI: 10.1016/j.hansur.2020.12.003] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/16/2022]
Abstract
The aim of this study was to characterize the change in health-related quality of life following carpal tunnel decompression. Pre- and postoperative Euroqol 5 Dimensions scores were collected prospectively over three years. Outcomes were available for 435 of 563 patients (77%); mean age was 62 years. Comorbid status was described using the Charlson Comorbidity Index. Change in Euroqol 5 Dimensions scores declined with increasing age and Charlson Comorbidity Index: the greatest improvement in quality of life occurred in the youngest group (+0.07 vs. -0.07 in the oldest group; p < 0.001) and patients with the lowest Comorbidity Index (+0.05 vs. -0.07 in the highest comorbidity group; p < 0.001). Charlson Comorbidity Index was an independent predictor of worse change in Euroqol 5 Dimensions scores on regression analysis. Carpal tunnel decompression results in significant improvement in health-related quality of life in younger patients with minimal comorbidities, but not in older patients with more comorbidities. We advise interpreting the Euroqol 5 Dimensions scores with caution in this patient cohort. LEVEL OF EVIDENCE: III (cohort study).
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Affiliation(s)
- P H C Stirling
- Department of Hand Surgery, Queen Margaret Hospital, Dunfermline, Whitefield Rd, Dunfermline KY12 0SU, United Kingdom.
| | - P J Jenkins
- Department of Orthopaedic Surgery, Glasgow Royal Infirmary, 84 Castle St, Glasgow G4 0SF, United Kingdom
| | - A D Duckworth
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - N D Clement
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - J E McEachan
- Department of Hand Surgery, Queen Margaret Hospital, Dunfermline, Whitefield Rd, Dunfermline KY12 0SU, United Kingdom
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15
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Clement ND, Ng N, MacDonald D, Scott CEH, Howie CR. One-year Oxford knee scores should be used in preference to 6-month scores when assessing the outcome of total knee arthroplasty. Knee Surg Relat Res 2020; 32:43. [PMID: 32859278 PMCID: PMC7456047 DOI: 10.1186/s43019-020-00060-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 04/22/2020] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose The primary aim of this study was to assess whether there was a clinically significant difference in the mean Oxford knee score (OKS) between 6 and 12 months after total knee arthroplasty (TKA). The secondary aim was to identify variables associated with a clinically significant change in the OKS between 6 and 12 months. Methods A retrospective cohort study was undertaken using an established arthroplasty database of 1574 primary TKA procedures. Patient demographics, body mass index (BMI), comorbidities, OKS and EuroQoL 5-domain (EQ-5D) score were collected preoperatively and at 6 and 12 months postoperatively. A clinically significant change in the OKS was defined as 5 points or more. Results There was a 1.1-point increase in the OKS between 6 and 12 months postoperatively, which was statistically significant (95% confidence (CI) 0.8–1.3, p < 0.0001). There were 381 (24.2%) patients who had a clinically significant improvement in their OKS from 6 to 12 months. After adjusting for confounding, patients with a lower BMI (p = 0.028), without diabetes mellitus (p < 0.001), a better preoperative OKS (p < 0.001) or a worse 6-month OKS (p < 0.001) were more likely to have a clinically significant improvement. A 6-month OKS < 36 points was a reliable predictor of a clinically significant improvement in the 6-month to 12-month OKS (area under the curve 0.73, 95% CI 0.70–0.75, p < 0.001). Conclusion Overall, there was no clinically significant change in the OKS from 6 to 12 months; however, a clinically significant improvement was observed in approximately a quarter of patients and was more likely in those scoring less than 36 points at 6 months. Level of evidence: retrospective diagnostic study, level III.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, The Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK
| | - N Ng
- Department of Orthopaedics, The Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK.
| | - D MacDonald
- Department of Orthopaedics, The Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK.,Department of Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK
| | - C E H Scott
- Department of Orthopaedics, The Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK
| | - C R Howie
- Department of Orthopaedics, The Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK.,Department of Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK
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16
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Clement ND, Afzal I, Demetriou C, Deehan DJ, Field RE, Kader D. There is no clinically important difference in the Oxford knee scores between one and two years after total knee arthroplasty: The one-year score could be used as the benchmark timepoint to assess outcome. Knee 2020; 27:1212-1218. [PMID: 32711884 DOI: 10.1016/j.knee.2020.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 12/17/2019] [Revised: 05/05/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim was to assess the whether there was a clinically important change in the Oxford knee score (OKS) between one and two years after total knee arthroplasty (TKA), and to identify predictors associated with a clinically important change. METHODS A retrospective cohort study was undertaken using an established arthroplasty database of 5857 primary TKA. Patient demographics, body mass index, social deprivation, OKS and EuroQoL five-domain (EQ-5D) score were collected preoperatively and at one and two years postoperatively. A clinically important change in the OKS was defined as ≥5 points. RESULTS There was a 0.2 point increase in the OKS between one and two years, which was statistically significant (95% confidence interval (CI) 0.1 to 0.4, p < .0001), but not clinically important. A better preoperative OKS (p < .001) and in contrast a worse one year OKS (p < .001) were independently associated with a greater improvement from one to two years. There were 1006 (17.3%) patients that had a clinically important improvement in the OKS between one and two years. Receiver operating characteristic curve analysis showed that a one year OKS of less than 35 was a reliable predictor of a clinically important improvement between one and two years (area under the curve 0.77, 95% CI 0.76 to 0.78, p < .001). CONCLUSION There was not a clinically important change in the OKS from one to two years after TKA when assessed as a group. However, individual patients with a one year OKS of less than 35 may demonstrate a clinically important improvement at two years. LEVEL OF EVIDENCE Retrospective diagnostic study, Level III.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Freeman Hospital, Newcastle, UK; Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK; South West of London Orthopaedic Elective Centre, Epson, UK.
| | - I Afzal
- South West of London Orthopaedic Elective Centre, Epson, UK
| | - C Demetriou
- South West of London Orthopaedic Elective Centre, Epson, UK
| | - David J Deehan
- Department of Orthopaedics, Freeman Hospital, Newcastle, UK
| | - R E Field
- South West of London Orthopaedic Elective Centre, Epson, UK
| | - D Kader
- South West of London Orthopaedic Elective Centre, Epson, UK
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17
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Clement ND, Calliess T, Christen B, Deehan DJ. An alternative technique of restricted kinematic alignment of the femur and gap balanced alignment of the tibia using computer aided navigation. Bone Joint Res 2020; 9:282-284. [PMID: 32728428 PMCID: PMC7376307 DOI: 10.1302/2046-3758.96.bjr-2020-0119.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 11/15/2022] Open
Affiliation(s)
| | - T Calliess
- articon, Specialist Practice for Joint Surgery, Bern, Switzerland
| | - B Christen
- articon, Specialist Practice for Joint Surgery, Bern, Switzerland
| | - D J Deehan
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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18
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Clement ND, Bell A, Simpson P, Macpherson G, Patton JT, Hamilton DF. Robotic-assisted unicompartmental knee arthroplasty has a greater early functional outcome when compared to manual total knee arthroplasty for isolated medial compartment arthritis. Bone Joint Res 2020; 9:15-22. [PMID: 32435451 PMCID: PMC7229306 DOI: 10.1302/2046-3758.91.bjr-2019-0147.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 12/03/2022] Open
Abstract
Aims The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA. Methods A powered (1:3 ratio) cohort study was performed. A total of 30 patients undergoing rUKA were propensity score matched to 90 patients undergoing mTKA for isolated medial compartment arthritis. Patients were matched for age, sex, body mass index (BMI), and preoperative function. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were collected preoperatively and six months postoperatively. The Forgotten Joint Score (FJS) and patient satisfaction were collected six months postoperatively. Length of hospital stay was also recorded. Results There were no significant differences in the preoperative demographics (p ⩾ 0.150) or function (p ⩾ 0.230) between the groups. The six-month OKS was significantly greater in the rUKA group when compared with the mTKA group (difference 7.7, p < 0.001). There was also a greater six-month postoperative EQ-5D (difference 0.148, p = 0.002) and FJS (difference 24.2, p < 0.001) for the rUKA when compared to the mTKA. No patient was dissatisfied in the rUKA group and five (6%) were dissatisfied in the mTKA, but this was not significant (p = 0.210). Length of stay was significantly (p < 0.001) shorter in the rUKA group (median two days, interquartile range (IQR) 1 to 3) compared to the mTKA (median four days, IQR 3 to 5). Conclusion Patients with isolated medial compartment arthritis had a greater knee-specific functional outcome and generic health with a shorter length of hospital stay after rUKA when compared to mTKA. Cite this article: Bone Joint Res 2019;9(1):15–22.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Bell
- Spire Murrayfield Hospital, Edinburgh, UK
| | - P Simpson
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Edinburgh, UK. Spire Murrayfield Hospital, Edinburgh, UK
| | - G Macpherson
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Edinburgh, UK. Spire Murrayfield Hospital, Edinburgh, UK
| | - J T Patton
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Edinburgh, UK. Spire Murrayfield Hospital, Edinburgh, UK
| | - D F Hamilton
- Department of Orthopaedics, University of Edinburgh, University of Edinburgh, Edinburgh, UK
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19
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Stirling PHC, Jenkins PJ, Clement ND, Duckworth AD, McEachan JE. Occupation classification predicts return to work after carpal tunnel decompression. Occup Med (Lond) 2020; 70:415-420. [DOI: 10.1093/occmed/kqaa061] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear.
Aims
To investigate predictors of RTW following CTD.
Methods
We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010.
Results
Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2–6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P < 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9–6.5) and non-manual workers (6.2; 95% CI 4.8–7.6) (P > 0.05). Median pre-operative (difference 15.9; 95% CI 4.5–25) and post-operative (difference 43.2; 95% CI 13.6–43.2) hand function scores were significantly worse in patients who did not RTW (P < 0.05).
Conclusions
Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.
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Affiliation(s)
- P H C Stirling
- Queen Margaret Hospital, Dunfermline KY, UK
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | | | - N D Clement
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - A D Duckworth
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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20
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Ng N, Patton JT, Burnett R, Clement ND. Sagittal alignment of the cemented femoral component in revision total knee arthroplasty influences the anterior and posterior condylar offset: Stem length does not affect these variables. Knee 2020; 27:477-484. [PMID: 31892431 DOI: 10.1016/j.knee.2019.10.025] [Citation(s) in RCA: 4] [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] [Received: 12/10/2018] [Revised: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The position of the femoral component can influence knee kinematics by altering the posterior (PCO) and anterior condylar offset (ACO). The primary aim of this study was to assess whether the length of the cemented stem influences the sagittal position of the femoral component after revision total knee arthroplasty (rTKA). The secondary aim was to determine the influence of the sagittal position on PCO and ACO. METHODS There were 172 consecutive patients over a seven-year period that underwent rTKA with a cemented semi-constrained prosthesis. The 172 patients were separated into two groups: 115 with short stems (50 mm) and 57 with longer stems (100 or 150 mm). Using rotationally acceptable lateral radiographs, the degree of flexion(+)/extension(-) of the femoral components, PCO, and ACO were measured. RESULTS There was no significant difference (p > 0.25) between the two groups for sagittal position, PCO, or ACO. The average flexion of the femoral component with short stems was 2.2 ± 4.1° and 2.2 ± 3.4° for long stems (difference = 0.0, 95% confidence intervals (CI) -1.3 to 1.2). The average PCO ratio was 1.02 ± 0.15 for short stems and 0.99 ± 0.17 for long stems (difference = 0.03, 95% CI -0.02 to 0.08). The average ACO ratio was at 0.07 ± 0.08 for short stems and 0.08 ± 0.08 for long stems (difference = 0.01, 95% CI -0.01 to 0.04). There was a significant correlation between sagittal alignment of the femoral component and PCO (flexion increased PCO, r = 0.39, p < 0.0001) and ACO (flexion decreased ACO, r = -0.34, p < 0.0001). CONCLUSIONS Cemented stem length does not influence the position of femoral component in the sagittal axis, PCO, or ACO. Surgical technique and sizing of the femoral component may be more predictive.
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Affiliation(s)
- N Ng
- University of Edinburgh Medical School, UK.
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21
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Clement ND, Weir D, Holland J, Gerrand C, Deehan DJ. Meaningful changes in the Short Form 12 physical and mental summary scores after total knee arthroplasty. Knee 2019; 26:861-868. [PMID: 31109846 DOI: 10.1016/j.knee.2019.04.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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] [Received: 12/20/2017] [Revised: 01/16/2019] [Accepted: 04/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to identify minimal clinically important difference (MCID), minimal important change (MIC) and minimal detectable change (MDC) for the Short Form (SF-) 12 physical and mental component summary (PCS, MCS) scores after total knee arthroplasty (TKA) using an anchor based methodology. METHODS During a 10-year period, 2589 TKA were performed. SF-12 PCS and MCS scores were recorded preoperatively and at one year postoperatively. At one year, patients were asked "How much did the knee replacement surgery improve the quality of your life?" Their response was recorded as: a great improvement, moderate improvement, little improvement, no improvement at all, or the quality of my life is worse. Patients recording a little (n = 211) and no (n = 115) were used to calculate the MCID and the MIC. The MDC90 was calculated using distribution based methods for the whole cohort. RESULTS The MCID was 1.8 (p = 0.04) for the PCS and 1.5 (p = 0.33) for the MCS score. The MIC was 2.7 (p = 0.04) for the PCS and -1.4 (p = 0.17) for the MCS score. The MDC90 was 8.9 for the PCS and 13.8 for the MCS score. CONCLUSION The MCID for the PCS can be used to compare the outcomes between groups, and the MIC can be used to ensure that a clinical difference has been observed for a cohort of patients. The values for the MDC90 can be used to assess whether or not an individual patient has experienced a change.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DD, UK.
| | - D Weir
- Department of Orthopaedics, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DD, UK
| | - J Holland
- Department of Orthopaedics, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DD, UK
| | - C Gerrand
- Department of Orthopaedics, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DD, UK
| | - D J Deehan
- Department of Orthopaedics, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DD, UK
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22
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Robinson PG, Clement ND, Hamilton D, Blyth MJG, Haddad FS, Patton JT. A systematic review of robotic-assisted unicompartmental knee arthroplasty: prosthesis design and type should be reported. Bone Joint J 2019; 101-B:838-847. [PMID: 31256672 DOI: 10.1302/0301-620x.101b7.bjj-2018-1317.r1] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [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: 11/05/2022]
Abstract
AIMS Robotic-assisted unicompartmental knee arthroplasty (UKA) promises accurate implant placement with the potential of improved survival and functional outcomes. The aim of this study was to present the current evidence for robotic-assisted UKA and describe the outcome in terms of implant positioning, range of movement (ROM), function and survival, and the types of robot and implants that are currently used. MATERIALS AND METHODS A search of PubMed and Medline was performed in October 2018 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included "robotic", "knee", and "surgery". The criteria for inclusion was any study describing the use of robotic UKA and reporting implant positioning, ROM, function, and survival for clinical, cadaveric, or dry bone studies. RESULTS A total of 528 articles were initially identified from the databases and reference lists. Following full text screening, 38 studies that satisfied the inclusion criteria were included. In all, 20 studies reported on implant positioning, 18 on functional outcomes, 16 on survivorship, and six on ROM. The Mako (Stryker, Mahwah, New Jersey) robot was used in 32 studies (84%), the BlueBelt Navio (Blue Belt Technologies, Plymouth, Minnesota) in three (8%), the Sculptor RGA (Stanmore Implants, Borehamwood United Kingdom) in two (5%), and the Acrobot (The Acrobot Co. Ltd., London, United Kingdom) in one study (3%). The most commonly used implant was the Restoris MCK (Stryker). Nine studies (24%) did not report the implant that was used. The pooled survivorship at six years follow-up was 96%. However, when assessing survival according to implant design, survivorship of an inlay (all-polyethylene) tibial implant was 89%, whereas that of an onlay (metal-backed) implant was 97% at six years (odds ratio 3.66, 95% confidence interval 20.7 to 6.46, p < 0.001). CONCLUSION There is little description of the choice of implant when reporting robotic-assisted UKA, which is essential when assessing survivorship, in the literature. Implant positioning with robotic-assisted UKA is more accurate and more reproducible than that performed manually and may offer better functional outcomes, but whether this translates into improved implant survival in the mid- to longer-term remains to be seen. Cite this article: Bone Joint J 2019;101-B:838-847.
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Affiliation(s)
| | - N D Clement
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - D Hamilton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - M J G Blyth
- Glasgow Royal Infirmary Orthopaedic Research Unit, Glasgow, UK
| | - Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
| | - J T Patton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
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Clement ND, Bardgett M, Merrie K, Furtado S, Bowman R, Langton DJ, Deehan DJ, Holland J. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019; 8:275-287. [PMID: 31346456 PMCID: PMC6609865 DOI: 10.1302/2046-3758.86.bjr-2018-0300.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/03/2023] Open
Abstract
Objectives Our primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age. Patients and Methods A prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones. Results Mean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02). Conclusion Exeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups. Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019;8:275–287. DOI: 10.1302/2046-3758.86.BJR-2018-0300.R1.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Bardgett
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - K Merrie
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Furtado
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - R Bowman
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - D J Langton
- Northern Retrieval Registry, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - D J Deehan
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
| | - J Holland
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne, UK
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Stirling P, Clement ND, MacDonald D, Patton JT, Burnett R, Macpherson GJ. Early functional outcomes after condylar-stabilizing (deep-dish) versus standard bearing surface for cruciate-retaining total knee arthroplasty. Knee Surg Relat Res 2019; 31:3. [PMID: 32660531 PMCID: PMC7219520 DOI: 10.1186/s43019-019-0001-7] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
AIMS The primary study aim was to compare early knee-specific function of patients undergoing cemented total knee arthroplasty (TKA) with either a cruciate-retaining (CR) polyethylene insert or a highly congruent condylar-stabilizing (CS) insert. Secondary aims were to compare general health and satisfaction between the groups. METHODS A total of 418 consecutive primary TKAs were identified retrospectively. Demographics and preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were collected prospectively. PROMs consisted of Oxford Knee Scores, EuroQol-5 Dimensions scores, and Short Form-12 scores. RESULTS A total of 54 (12.9%) patients received a CS insert and 364 patients received a CR TKA. The CS group had a significantly (odds ratio (OR) 2.9; p = 0.002) greater proportion of females (77.8% versus 54.9%). The only significant difference in postoperative PROMs was a higher Short Form-12 physical component score in the CR group (difference 3.1; 95% confidence interval (CI) 0.1 to 6.1; p = 0.04). Linear regression analysis demonstrated no significant difference for all postoperative PROMs (p > 0.25). There was no significant difference in satisfaction rate (OR 0.94; 95% CI 0.42 to 2.12; p = 0.56) or pain visual analogue score (difference 6.1; 95% CI -1.9 to 14.0; p = 0.14) between the groups. CONCLUSION More congruent CS inserts have equivalent PROMs and patient satisfaction at 1 year compared with less congruent CR inserts. These represent an option for surgeons undertaking TKA where increased congruency is desired.
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Affiliation(s)
- P Stirling
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK.
| | - N D Clement
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - D MacDonald
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - J T Patton
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - R Burnett
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - G J Macpherson
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
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Stirling P, MacKenzie SP, Maempel JF, McCann C, Ray R, Clement ND, White TO, Keating JF. Patient-reported functional outcomes and health-related quality of life following fractures of the talus. Ann R Coll Surg Engl 2019; 101:399-404. [PMID: 31155885 DOI: 10.1308/rcsann.2019.0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The primary aim of this study was to investigate patient-reported outcomes following talar fractures. Secondary aims were to investigate health-related quality of life and to determine whether it is influenced by functional outcome. MATERIALS AND METHODS This retrospective study identified 56 talar fractures over eight years. Patients were contacted by post and the Olerud and Molander score (OMS), Manchester-Oxford Foot and Ankle scores (MOXFQ) and Euroqol-5D-3L collected. RESULTS The mean age was 35.2 years (range 13-78 years). There were four cases (7.1%) of avascular necrosis and one (1.8%) non-union occurred. Data from patient-reported outcome measures were available for 42 patients (75.0%) with a median follow-up of 67.1 months (range 23.2-111.8 months). Mean OMS was 60.0 (standard deviation ± 29.51) and median MOXFQ was 30.33 (interquartile range 47.13). Median Euroqol-5D-3L index was 0.74 (interquartile range 0.213) and median Euroqol-5D-3L visual analogue score was 80 (interquartile range 21). Older age, open fractures, multiple injuries and subsequent avascular necrosis were associated with worse patient-reported outcomes (P < 0.05), with older age, avascular necrosis and open fractures found to be independent predictors of poor OMS, and avascular necrosis and open fractures independently predicting MOXFQ score on regression analysis (P < 0.05). Poor self-reported function, measured by OMS and MOXFQ, correlated with worse health-related quality of life as measured by the Euroqol-5D-3L index (OMS: r = 0.764, P < 0.001; MOXFQ: r = 0.824, P < 0.001) and visual analogue score (OMS: r = 0.450, P = 0.003; MOXFQ: r=0.559, P < 0.001). CONCLUSIONS Older age, avascular necrosis and open fractures predict poorer functional outcomes following talar fractures. Patients with worse limb-specific functional outcomes are more likely to have a worse perception of health-related quality of life.
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Affiliation(s)
- P Stirling
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - S P MacKenzie
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - J F Maempel
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - C McCann
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - R Ray
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - N D Clement
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - T O White
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
| | - J F Keating
- Orthopaedic Trauma Service, Royal Infirmary of Edinburgh , Edinburgh, Scotland , UK
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Clement ND, Howard TA, Immelman RJ, MacDonald D, Patton JT, Lawson GM, Burnett R. Patellofemoral arthroplasty versus total knee arthroplasty for patients with patellofemoral osteoarthritis: equal function and satisfaction but higher revision rate for partial arthroplasty at a minimum eight years’ follow-up. Bone Joint J 2019; 101-B:41-46. [PMID: 30601045 DOI: 10.1302/0301-620x.101b1.bjj-2018-0654.r2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 11/05/2022]
Abstract
AIMS The primary aim of this study was to compare the knee-specific functional outcome of patellofemoral arthroplasty with total knee arthroplasty (TKA) in the management of patients with patellofemoral osteoarthritis. PATIENTS AND METHODS A total of 54 consecutive Avon patellofemoral arthroplasties were identified and propensity-score-matched to a group of 54 patients undergoing a TKA with patellar resurfacing for patellofemoral osteoarthritis. The Oxford Knee Score (OKS), the 12-Item Short-Form Health Survey (SF-12), and patient satisfaction were collected at a mean follow up of 9.2 years (8 to 15). Survival was defined by revision or intention to revise. RESULTS There was no significant difference in the mean OKS (p > 0.60) or SF-12 scores (p > 0.28) between the groups. There was a lower rate of satisfaction at the final follow-up for the TKA group (78% vs 87%) but this was not statistically significant (odds ratio 0.56, p = 0.21). Length of stay was significantly shorter (p = 0.008) for the Avon group (difference 1.8 days, 95% confidence interval (CI) 0.4 to 3.2). The ten-year survival for the Avon group was 92.3% (95% CI 87.1 to 97.5) and for the TKA group was 100% (95% CI 93.8 to 100). This difference was not statistically significant (log-rank test, p = 0.10). CONCLUSION Patients undergoing an Avon patellofemoral arthroplasty have a shorter length of stay, and a functional outcome and rate of satisfaction that is equal to that of TKA. The benefits of the Avon arthroplasty need to be balanced against the increased rate of revision when compared with TKA.
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Affiliation(s)
- N D Clement
- The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - T A Howard
- The Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - J T Patton
- The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - G M Lawson
- The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - R Burnett
- The Royal Infirmary of Edinburgh, Edinburgh, UK
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Keenan OJF, Clement ND, Nutton R, Keating JF. Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy. Knee 2019; 26:207-212. [PMID: 30473375 DOI: 10.1016/j.knee.2018.11.008] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/17/2018] [Accepted: 11/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The primary aim was to assess survival of opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early conversion to total knee arthroplasty (TKA). METHODS During the 18-year period (1994-2011) 111 opening wedge HTO were performed at the study centre. Mean age was 45 years (range 18-68) and the majority male (84%). Mean follow-up was 12 (range six to 21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed. RESULTS Forty (36.0%) HTO failed at a mean of 6.3 years (range one to 15). By Kaplan-Meier analysis, the five-year survival rate was 84% (95% confidence interval (CI) 82.6-85.4), 10-year rate 65% (95% CI 63.5-66.5) and 15-year rate 55% (95% CI 53.3-56.7). Cox regression analysis identified older age (hazard ratio (HR) 1.07 for each additional year, 95% CI 1.03-1.11, p b 0.001) and female gender (HR 2.37, 95% CI 1.06-5.33, p = 0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62-0.81, p b 0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26-4.91, p = 0.01) risk of failure in patients aged 47 years old or more. CONCLUSION The risk of early conversion to TKA is significantly increased in females and those older than 47. These risk factors should be considered pre-operatively when planning intervention for isolated medial compartment osteoarthritis.
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Affiliation(s)
- O J F Keenan
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
| | - N D Clement
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - R Nutton
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - J F Keating
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Makaram N, Clement ND, Hoo T, Nutton R, Burnett R. Survival of the low contact stress rotating platform total knee replacement is influenced by age: 1058 implants with a minimum follow-up of 10 years. Knee 2018; 25:1283-1291. [PMID: 30232026 DOI: 10.1016/j.knee.2018.08.020] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/19/2018] [Accepted: 08/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The low contact stress (LCS) mobile-bearing total knee replacement (TKR) was designed to minimise polyethylene wear, aseptic loosening and osteolysis. However, registry data suggests there is a significantly greater revision rate associated. The primary aim of this study was to assess long-term survivorship of the LCS TKR performed at a single high-volume centre. Secondary aims were to assess survival by mechanism of failure and identify predictors of revision. METHODS During a 13-year period (1993-2006) 1091 LCS TKRs were performed by two senior surgeons. Thirty-three with incomplete data were excluded. The patients were retrospectively identified from an arthroplasty register. Mean age was 69 (range 30-96) years. Five hundred seventy-seven TKRs were performed in females, 481 in males. Mean follow-up was 14 years (SD 4.3). RESULTS There were 59 revisions during the study period: 14 (23.7%) for infection, 18 (30.5%) for instability, and 27 (45.8%) for polyethylene wear. Three hundred ninety-two patients died. All-cause survival at 10 years was 95% (95%CI 91.7-98.3) and at 15 years was 93% (95%CI 88.6-97.8). Survival at 10 years according to mechanism of failure was: infection 99% (95%CI 94-100%), instability 98% (95%CI 94-100%), and polyethylene wear 98% (95%CI 92-100). Of the 27 with polyethylene wear, only 19 (70.4%) had osteolysis requiring component revision, the other eight (29.6%) had polyethylene exchanges. Cox regression analysis identified younger age as the only predictor of revision (HR 0.96, 95%CI 0.94-0.99, p = 0.003), with a four percent decreased risk of revision for each increase in year of age. CONCLUSIONS The LCS TKR demonstrates excellent long-term survivorship with a low rate of revision for osteolysis, however this risk is increased in younger patients.
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Affiliation(s)
- N Makaram
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
| | - N D Clement
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - T Hoo
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - R Nutton
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - R Burnett
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Clement ND, Bardgett M, Weir D, Holland J, Gerrand C, Deehan DJ. The rate and predictors of patient satisfaction after total knee arthroplasty are influenced by the focus of the question: a standard satisfaction question is required. Bone Joint J 2018; 100-B:740-748. [PMID: 29855236 DOI: 10.1302/0301-620x.100b6.bjj-2017-1292.r1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [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 primary aim of this study was to assess the rate of patient satisfaction one year after total knee arthroplasty (TKA) according to the focus of the question asked. The secondary aims were to identify independent predictors of patient satisfaction according to the focus of the question. Patients and Methods A retrospective cohort of 2521 patients undergoing a primary unilateral TKA were identified from an established regional arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 12-Item Short-Form Health Survey (SF-12) scores were collected preoperatively and one year postoperatively. Patient satisfaction was assessed using four questions, which focused on overall outcome, activity, work, and pain. Logistic regression analysis was used to identify independent preoperative predictors of increased stiffness when adjusting for confounding variables. Results Using patient satisfaction with the overall outcome (n = 2265, 89.8%) as the standard, there was no difference in the rate of satisfaction for pain relief (n = 2277, odds ratio (OR) 0.95, 95% confident intervals (CI) 0.79 to 1.14, p = 0.60), but patients were more likely to be dissatisfied with activities (79.3%, n = 2000/2521, OR 2.22, 95% CI 1.96 to 2.70, p < 0.001) and work (85.8%, n = 2163/2521, OR 1.47, 95% CI 1.23 to 1.75, p < 0.001). Logistic regression analysis identified different predictors of satisfaction for each of the focused satisfaction questions. Overall satisfaction was influenced by diabetes (p = 0.03), depression (p = 0.004), back pain (p < 0.001), and SF-12 physical (p = 0.008) and mental (p = 0.01) components. Satisfaction with activities was influenced by depression (p = 0.001), back pain (p < 0.001), WOMAC stiffness score (p = 0.03), and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with work was influenced by depression (p = 0.007), back pain (p < 0.001), WOMAC function (p = 0.04) and stiffness (p = 0.05) scores, and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with pain relief was influenced by diabetes (p < 0.001), back pain (p < 0.001), and SF-12 mental component (p = 0.04). Conclusion The focus of the satisfaction question significantly influences the rate and the predictors of patient satisfaction after TKA. Cite this article: Bone Joint J 2018;100-B:740-8.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - M Bardgett
- Department of Orthopaedics, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - D Weir
- Department of Orthopaedics, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - J Holland
- Department of Orthopaedics, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - C Gerrand
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - D J Deehan
- Department of Orthopaedics, Freeman Hospital, Newcastle-upon-Tyne, UK
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Freeman Hospital, High Heaton, Newcastle-upon-Tyne, UK
| | - D J Deehan
- Department of Orthopaedics, Freeman Hospital, High Heaton, Newcastle-upon-Tyne, UK
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Yeoman TFM, Clement ND, Macdonald D, Moran M. Recall of preoperative Oxford Hip and Knee Scores one year after arthroplasty is an alternative and reliable technique when used for a cohort of patients. Bone Joint Res 2018; 7:351-356. [PMID: 29922455 PMCID: PMC5987682 DOI: 10.1302/2046-3758.75.bjr-2017-0259.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 11/05/2022] Open
Abstract
Objectives The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient's recollection of their own preoperative OHS and OKS one year following surgery. Methods A total of 335 patients (mean age 72.5; 22 to 92; 53.7% female) undergoing total hip arthroplasty (n = 178) and total knee arthroplasty (n = 157) were prospectively assessed. Patients undergoing hip and knee arthroplasty completed an OHS or OKS, respectively, preoperatively and were asked to recall their preoperative condition while completing the same score one year after surgery. Results A mean difference of 0.04 points (95% confidence intervals (CI) -15.64 to 15.72, p = 0.97) between the actual and the recalled OHS was observed. The mean difference in the OKS was 1.59 points (95% CI -11.57 to 14.75, p = 0.10). There was excellent reliability for the 'average measures' intra-class correlation for both the OHS (r = 0.802) and the OKS (r = 0.772). However, this reliability was diminished for the individuals OHS (r = 0.670) and OKS (r = 0.629) using single measures intra-class correlation. Bland-Altman plots demonstrated wide variation in the individual patient's ability to recall their preoperative score (95% CI ± 16 for OHS, 95% CI ± 13 for OKS). Conclusion Prospective preoperative collection of OHS and OKS remains the benchmark. Using recalled scores one year following hip and knee arthroplasty is an alternative when used to assess a cohort of patients. However, the recall of an individual patient's preoperative score should not be relied upon due to the diminished reliability and wide CI.Cite this article: T. F. M. Yeoman, N. D. Clement, D. Macdonald, M. Moran. Recall of preoperative Oxford Hip and Knee Scores one year after arthroplasty is an alternative and reliable technique when used for a cohort of patients. Bone Joint Res 2018;7:351-356. DOI: 10.1302/2046-3758.75.BJR-2017-0259.R1.
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Affiliation(s)
- T F M Yeoman
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - N D Clement
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, EdinburghA, UK
| | - D Macdonald
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - M Moran
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
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Abstract
AIMS The primary aim of this study was to assess whether patient satisfaction one year after total knee arthroplasty (TKA) changed with longer follow-up. The secondary aims were to identify predictors of satisfaction at one year, persistence of patient dissatisfaction, and late onset dissatisfaction in patients that were originally satisfied at one year. PATIENTS AND METHODS A retrospective cohort consisting of 1369 patients undergoing a primary TKA for osteoarthritis that had not undergone revision were identified from an established arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Short Form 12 (SF-12) questionnaire scores were collected preoperatively, and one and five years postoperatively. In addition, patient satisfaction was assessed at one and five years postoperatively. Logistic regression analysis was used to identify independent predictors of satisfaction at one and five years. RESULTS The overall rate of satisfaction did not change from one (91.7%, n = 1255) to five (90.1%, n = 1234) years (p = 0.16). Approximately half (n = 53/114) of the patients who were dissatisfied at one year became satisfied with their TKA at five years, whereas 6% (n = 74/1255) of those who were satisfied at one year became dissatisfied at five years. At one year, patients with lung disease (p = 0.04), with depression (p = 0.001), with back pain (p < 0.001), undergoing unilateral TKA (p = 0.001), or with a worse preoperative WOMAC pain score (p = 0.04) were more likely to be dissatisfied. Patients with gastric ulceration (p = 0.04) and a worse WOMAC stiffness score (p = 0.047) were at increased risk of persistent dissatisfaction at five years. In contrast, a worse WOMAC pain score (p = 0.01) at one year was a predictor of dissatisfaction in previously satisfied patients at five years. CONCLUSION Three groups of dissatisfied patients exist after TKA: 'early' dissatisfaction at one year, 'persistent' dissatisfaction with longer follow-up, and 'late' dissatisfaction developing in previously satisfied patients at one year. All three groups have different independent predictors of satisfaction, and potentially addressing risk factors specific to these groups may improve patient outcome and their satisfaction. Cite this article: Bone Joint J 2018;100-B:161-9.
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Affiliation(s)
- N D Clement
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
| | - M Bardgett
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
| | - D Weir
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
| | - J Holland
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
| | - C Gerrand
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
| | - D J Deehan
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DD, UK
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Clement ND, MacDonald D, Burgess AG, Howie CR. Articular surface mounted navigated total knee arthroplasty improves the reliability of component alignment. Knee Surg Sports Traumatol Arthrosc 2018; 26:1471-1477. [PMID: 28210787 PMCID: PMC5907621 DOI: 10.1007/s00167-017-4433-x] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/16/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The primary aim was to compare the early knee-specific functional outcome after articular surface mounted (ASM) navigation with non-navigated TKA. The secondary aims were to compare general physical and mental health improvement, patient satisfaction, and reliability of component alignment in the sagittal and coronal planes between ASM navigated TKA with that of non-navigated TKA. METHODS Prospective functional outcome and radiographic data were collect for 123 patients undergoing ASM navigation and 172 patients undergoing non-navigated TKA by a high volume single surgeon. Pre-operative and one-year Oxford knee score (OKS) and short form (SF-) 12 scores were collected. Patient satisfaction was also assessed at one year. Implant position was assessed on post-operative radiographs (alpha, beta, gamma, and sigma angles) by a blinded observer. RESULTS There was no significant difference for improvement in OKS, SF-12 physical or mental components, or satisfaction between the groups one year following surgery. The non-navigation group was significantly more likely to have outliers (greater than 3 degrees) in femoral varus/valgus coronal alignment [odds ratio (OR) 4.5, 95% confidence interval (CI) 1.0-20.7, p = 0.049] and for posterior tibial slope (OR 8.3, 95% CI 1.1-65.0, p = 0.03). CONCLUSIONS ASM navigation significantly reduces the number of outliers for the femoral and tibial components when compared to conventional non-navigation alignment. However, the short-term functional outcome is not influenced by the surgical technique used. If the surgeon wants to reduce their number of outliers, then ASM navigation should be considered but the overall functional outcome in the short term is not influenced. LEVEL OF EVIDENCE III Therapeutic investigation, retrospective cohort study.
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Affiliation(s)
- N. D. Clement
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA UK
| | | | - A. G. Burgess
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA UK
| | - C. R. Howie
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA UK
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Clement ND, Makaram N, Bell J, Tiemessen CH, Mehdi SA, Livingston SJ. Columbus® computer navigated total knee arthroplasty: Gap balancing versus measured resection. Knee 2017; 24:1442-1447. [PMID: 28970126 DOI: 10.1016/j.knee.2017.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 03/27/2017] [Revised: 07/01/2017] [Accepted: 08/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to compare the medium term functional outcome and patient satisfaction of gap balanced (GB) with measured resection (MR) total knee arthroplasty (TKA) using computer navigation. METHODS A cohort of 144 consecutive computer navigated TKA were retrospectively identified from an arthroplasty database. Functional assessment using the Oxford Knee Score (OKS) and patient satisfaction were obtained from 113 patients at a mean follow-up of 5.4 (range four to seven) years. There were 44 patients in the GB group and 69 patients in the MR group. RESULTS The mean OKS for the GB group was 36.9 (SD 9.2) and for the MR was 33.6 (SD 9.8), with a difference of 3.3 (95% CI 0.3 to 6.3) points, which was statistically significant (p=0.01). Linear regression analysis confirmed the independent effect of surgical technique when adjusting for confounding factors and surgeon, with the GB group achieving a greater post-operative OKS (R2=0.39, 3.0 points, 95% CI 1.2 to 4.8, p=0.001). There was a greater rate of patient satisfaction in the GB group (88.6%, n=39/44) compared to the MR group (81.1%, n=56/69), but this was not statistically significant (odds ratio 1.8, 95% CI 0.6 to 5.5, p=0.31). CONCLUSION Computer navigated Columbus® TKA using a GB technique results in a statistically significantly greater functional outcome but no significant difference in patient satisfaction in the medium term compared to patients undergoing a MR technique.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK
| | - N Makaram
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK.
| | - J Bell
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK
| | - C H Tiemessen
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK
| | - S A Mehdi
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK
| | - S J Livingston
- Department of Orthopaedics and Trauma, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK
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Duckworth AD, Clement ND, McEachan JE, White TO, Court-Brown CM, McQueen MM. Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly. Bone Joint J 2017; 99-B:964-972. [PMID: 28663405 DOI: 10.1302/0301-620x.99b7.bjj-2016-1112.r2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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: 11/02/2016] [Accepted: 03/01/2017] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. PATIENTS AND METHODS Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. RESULTS A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). CONCLUSION These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964-72.
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Affiliation(s)
- A D Duckworth
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - N D Clement
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - J E McEachan
- Queen Margaret Hospital, Dunfermline KY12 0SU, UK
| | - T O White
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - C M Court-Brown
- University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - M M McQueen
- University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
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Goudie EB, Clement ND, Murray IR, Lawrence CR, Wilson M, Brooksbank AJ, Robinson CM. The Influence of Shortening on Clinical Outcome in Healed Displaced Midshaft Clavicular Fractures After Nonoperative Treatment. J Bone Joint Surg Am 2017; 99:1166-1172. [PMID: 28719555 DOI: 10.2106/jbjs.16.01010] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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 We aimed to evaluate the effect of clavicular shortening, measured with 3-dimensional computed tomography (3DCT), on functional outcomes and satisfaction in patients with healed displaced midshaft clavicular fractures up to 1 year following injury. METHODS The data used in this study were collected as part of a multicenter, prospective randomized controlled trial of open reduction and plate fixation compared with nonoperative treatment for acute, displaced midshaft clavicular factures. Patients who were randomized to nonoperative treatment and had healed by 1 year were included in the present study. Clavicular shortening relative to the uninjured, contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at 6 weeks, 3 months, 6 months, and 1 year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, and Short Form-12 (SF-12) scores and patient satisfaction. RESULTS In the original trial, 105 patients were randomized to nonoperative treatment. Thirteen patients were lost to follow-up, leaving 92 patients, and an additional 16 (17%) developed nonunion and were excluded from the present study. Of the remaining 76 patients, 48 who had a 3DCT scan that included the whole length of both clavicles were included in the present study. The shortening of the injured clavicles, relative to the contralateral side, was a mean (and standard deviation) of 11.3 ± 7.6 mm, with a mean proportional shortening of 8%. Proportional shortening did not significantly correlate with the DASH (p ≥ 0.42), Constant (p ≥ 0.32), or SF-12 (p ≥ 0.08) scores at any point during follow-up. There was no significant difference in the mean DASH or Constant scores at any follow-up time point when the cutoff for shortening was defined as 1 cm (p ≥ 0.11) or as 2 cm (p ≥ 0.35). There was no significant difference in clavicular shortening between satisfied and unsatisfied patients (p ≥ 0.49). CONCLUSIONS The present study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed displaced midshaft clavicular fractures up to 1 year following injury. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- E B Goudie
- 1The Edinburgh Shoulder Clinic, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom 2Department of Trauma and Orthopaedics, The Glasgow Royal Infirmary, Glasgow, United Kingdom
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Simpson AHRW, Keenan G, Nayagam S, Atkins RM, Marsh D, Clement ND. Low-intensity pulsed ultrasound does not influence bone healing by distraction osteogenesis: a multicentre double-blind randomised control trial. Bone Joint J 2017; 99-B:494-502. [PMID: 28385939 DOI: 10.1302/0301-620x.99b4.bjj-2016-0559.r1] [Citation(s) in RCA: 14] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/02/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis. PATIENTS AND METHODS A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame. RESULTS There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p = 0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042). CONCLUSION LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. Cite this article: Bone Joint J 2017;99-B:494-502.
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Affiliation(s)
- A H R W Simpson
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - G Keenan
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - S Nayagam
- Royal Liverpool Children's and Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, UK
| | - R M Atkins
- Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - D Marsh
- University College London, 102 Princetown Road, Bangor, BT20 3TG, UK
| | - N D Clement
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
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Ray R, Clement ND, Aitken SA, McQueen MM, Court-Brown CM, Ralston SH. High mortality in younger patients with major osteoporotic fractures. Osteoporos Int 2017; 28:1047-1052. [PMID: 27844134 DOI: 10.1007/s00198-016-3827-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 08/23/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED Data were gathered with regard to mortality after fractures in 1006 younger patients. Results revealed that major osteoporotic fractures of the hip and humerus and drinking alcohol to excess were related to an increased risk of mortality. INTRODUCTION Major osteoporotic fractures are known to be associated with increased mortality in older individuals. It is less clear whether this also applies to younger patients. METHODS Date were gathered regarding patient demographics, fracture pattern, mechanism of injury, as well as smoking and alcohol intake at the time of injury in consecutive patients aged between 40 and 55 who presented to a UK trauma centre over a 12-month period. Mortality data was taken from the electronic patient records and was cross referenced with data from the General Registrar Office of Scotland. Cox regression analysis was used to identify independent predictors of mortality after adjusting for confounding factors. RESULTS The study cohort consisted of 1006 patients, of which 53% were male. The commonest mechanism of injury was a fall. We obtained complete data regarding mortality for all patients at a median of 5.4 years (inter-quartile range 5.1 to 5.6). During this period, 46 patients were identified as being deceased. The overall standardised mortality ratio for the cohort was substantially increased relative to the age and sex matched general population with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). Alcohol excess and fractures involving the humerus and the neck of femur were independent predictors of mortality. CONCLUSIONS Young individuals with hip and humerus fractures have a significantly increased mortality risk after their injury relative to the general population. The results of our study suggest that this may be in part due to a high prevalence of alcohol excess.
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Affiliation(s)
- R Ray
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, UK.
| | - N D Clement
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, UK
| | - S A Aitken
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, UK
| | - M M McQueen
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, UK
| | - C M Court-Brown
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, UK
| | - S H Ralston
- Centre for Genomic and Experimental medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, EH4 2XU, UK
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Robinson LW, Clement ND, Herman J, Gaston MS. The Edinburgh visual gait score - The minimal clinically important difference. Gait Posture 2017; 53:25-28. [PMID: 28073083 DOI: 10.1016/j.gaitpost.2016.12.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 08/04/2016] [Revised: 11/09/2016] [Accepted: 12/31/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The primary aim was to define the minimal clinically important difference (MCID) of the Edinburgh Visual Gait Score (EVGS) using correlations with the Gross Motor Function Classification System (GMFCS) and the Functional Assessment Questionnaire (FAQ). The secondary aim was to confirm the numerical value of the MCID in the Gait Profile Score (GPS). METHOD The EVGS and GPS scores for 151 patients with diplegic cerebral palsy (GMFCS Levels I-III) were retrospectively identified from a database held at the study centre. One-hundred and forty-one patients had FAQ data available. RESULTS The EVGS and GPS correlated with increasing GMFCS level (p<0.001) and FAQ score (p<0.001). A gradient of 3.8 (2.9-4.7) for the EVGS and 2.9 (2.1-3.7) for the GPS corresponded to a one-level change in GMFCS level. A gradient of 1.9 (1.3-2.4) for EVGS and 1.5 (1.1-2.0) for GPS corresponded to a one-point change in FAQ. CONCLUSIONS The authors propose an MCID value of 2.4 for the EVGS; representing the improvement in gait score after surgery that is likely to reflect a clinical improvement in function. This MCID is closely related to other studies defining post-operative improvements in kinematic data (GPS) and may offer guidance to post-surgical changes that might reasonably be expected to either improve or prevent deteriorating function.
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Affiliation(s)
- L W Robinson
- University of Edinburgh, Edinburgh, United Kingdom.
| | - N D Clement
- Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - J Herman
- Anderson Gait Analysis Laboratory, Edinburgh, United Kingdom
| | - M S Gaston
- Royal Hospital for Sick Children, Edinburgh, United Kingdom
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Clement ND, MacDonald DJ, Hamilton DF, Burnett R. Posterior condylar offset is an independent predictor of functional outcome after revision total knee arthroplasty. Bone Joint Res 2017; 6:172-178. [PMID: 28360083 PMCID: PMC5376661 DOI: 10.1302/2046-3758.63.bjr-2015-0021.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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] [Received: 12/25/2015] [Accepted: 01/11/2017] [Indexed: 11/20/2022] Open
Abstract
Objectives Preservation of posterior condylar offset (PCO) has been shown to correlate with improved functional results after primary total knee arthroplasty (TKA). Whether this is also the case for revision TKA, remains unknown. The aim of this study was to assess the independent effect of PCO on early functional outcome after revision TKA. Methods A total of 107 consecutive aseptic revision TKAs were performed by a single surgeon during an eight-year period. The mean age was 69.4 years (39 to 85) and there were 59 female patients and 48 male patients. The Oxford Knee Score (OKS) and Short-form (SF)-12 score were assessed pre-operatively and one year post-operatively. Patient satisfaction was also assessed at one year. Joint line and PCO were assessed radiographically at one year. Results There was a significant improvement in the OKS (10.6 points, 95% confidence interval (CI) 8.8 to 12.3) and the SF-12 physical component score (5.9, 95% CI 4.1 to 7.8). PCO directly correlated with change in OKS (p < 0.001). Linear regression analysis confirmed the independent effect of PCO on the OKS (p < 0.001) and the SF-12 physical score (p = 0.02). The overall rate of satisfaction was 85% and on logistic regression analysis improvement in the OKS (p = 0.002) was a significant predictor of patient satisfaction, which is related to PCO; although this was not independently associated with satisfaction. Conclusion Preservation of PCO should be a major consideration when undertaking revision TKA. The option of increasing PCO to balance the flexion gap while maintaining the joint line should be assessed intra-operatively. Cite this article: N. D. Clement, D. J. MacDonald, D. F. Hamilton, R. Burnett. Posterior condylar offset is an independent predictor of functional outcome after revision total knee arthroplasty. Bone Joint Res 2017;6:172–178. DOI: 10.1302/2046-3758.63.BJR-2015-0021.R1.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, UK
| | - D J MacDonald
- Department of Orthopaedics, University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - D F Hamilton
- Department of Orthopaedics, University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - R Burnett
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, UK
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Waterson HB, Clement ND, Eyres KS, Mandalia VI, Toms AD. The early outcome of kinematic versus mechanical alignment in total knee arthroplasty: a prospective randomised control trial. Bone Joint J 2017; 98-B:1360-1368. [PMID: 27694590 DOI: 10.1302/0301-620x.98b10.36862] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [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: 07/08/2015] [Accepted: 06/13/2016] [Indexed: 01/18/2023]
Abstract
AIMS Our aim was to compare kinematic with mechanical alignment in total knee arthroplasty (TKA). PATIENTS AND METHODS We performed a prospective blinded randomised controlled trial to compare the functional outcome of patients undergoing TKA in mechanical alignment (MA) with those in kinematic alignment (KA). A total of 71 patients undergoing TKA were randomised to either kinematic (n = 36) or mechanical alignment (n = 35). Pre- and post-operative hip-knee-ankle radiographs were analysed. The knee injury and osteoarthritis outcome score (KOOS), American Knee Society Score, Short Form-36, Euro-Qol (EQ-5D), range of movement (ROM), two minute walk, and timed up and go tests were assessed pre-operatively and at six weeks, three and six months and one year post-operatively. RESULTS A total of 78% of the kinematically aligned group (28 patients) and 77% of the mechanically aligned group (27 patients) were within 3° of their pre-operative plan. There were no statistically significant differences in the mean KOOS (difference 1.3, 95% confidence interval (CI) -9.4 to 12.1, p = 0.80), EQ-5D (difference 0.8, 95% CI -7.9 to 9.6, p = 0.84), ROM (difference 0.1, 95% CI -6.0 to 6.1, p = 0.99), two minute distance tolerance (difference 20.0, 95% CI -52.8 to 92.8, p = 0.58), or timed up and go (difference 0.78, 95% CI -2.3 to 3.9, p = 0.62) between the groups at one year. CONCLUSION Kinematically aligned TKAs appear to have comparable short-term results to mechanically aligned TKAs with no significant differences in function one year post-operatively. Further research is required to see if any theoretical long-term functional benefits of kinematic alignment are realised or if there are any potential effects on implant survival. Cite this article: Bone Joint J 2016;98-B:1360-8.
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Affiliation(s)
- H B Waterson
- Royal Infirmary of Edinburgh, Little France Crescent, EH16 4SA, UK
| | - N D Clement
- Royal Infirmary of Edinburgh, Little France Crescent, EH16 4SA, UK
| | - K S Eyres
- Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital, Exeter, UK
| | - V I Mandalia
- Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital, Exeter, UK
| | - A D Toms
- Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital, Exeter, UK
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Clement ND, Macdonald D, Burnett R, Simpson AHRW, Howie CR. A patient's perception of their hospital stay influences the functional outcome and satisfaction of total knee arthroplasty. Arch Orthop Trauma Surg 2017; 137:693-700. [PMID: 28331990 PMCID: PMC5401709 DOI: 10.1007/s00402-017-2661-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION To assess whether patient satisfaction with their hospital stay influences the early outcome of total knee arthroplasty (TKA). METHODS During a 5-year period patients undergoing primary TKA at the study centre had prospective outcome data recorded (n = 2264). The Oxford knee score (OKS) and the short form (SF)-12 were recorded pre-operatively and 1 year post-operatively when satisfaction with their TKA was also assessed. Patient satisfaction with their hospital stay was also evaluated and their reasons for it were qualitatively documented. RESULTS Decreasing level of satisfaction with their hospital stay was associated with a significantly worse post-operative OKS (p < 0.001) and SF-12 score (p < 0.001). Multivariable regression analysis confirmed that the patient's perceived level of satisfaction with their hospital stay was an independent predictor of change in the OKS (p < 0.001) and SF-12 score (p < 0.006) after adjusting for confounding variables. Patient satisfaction with their TKA was significantly influenced by their hospital experience, decreasing from 96% in those with an excellent experience to 42% in those with a poor experience. Food, staff/care, and the hospital environment were the most frequent reasons of why patients rated their hospital experience as fair or poor. CONCLUSION A patient's perception of their inpatient hospital experience after surgery is an important modifiable predictor of early functional outcome and satisfaction with TKA.
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Affiliation(s)
- N D Clement
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK.
| | - D Macdonald
- University of Edinburgh, Little France, Edinburgh, EH16 4SB, UK
| | - R Burnett
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
| | - A H R W Simpson
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
- University of Edinburgh, Little France, Edinburgh, EH16 4SB, UK
| | - C R Howie
- Department of Orthopaedics and Trauma, The Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA, UK
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Abstract
Aims The aim of this study was to report the outcome following primary fixation or a staged protocol for type C fractures of the tibial plafond. Patients and Methods We studied all patients who sustained a complex intra-articular fracture (AO type C) of the distal tibia over an 11-year period. The primary short-term outcome was infection. The primary long-term outcome was the Foot and Ankle Outcome Score (FAOS). Results There were 102 type C pilon fractures in 99 patients, whose mean age was 42 years (16 to 86) and 77 were male. Primary open reduction internal fixation (ORIF) was performed in 73 patients (71.6%), whilst 20 (19.6%) underwent primary external fixation with delayed ORIF. There were 18 wound infections (17.6%). A total of nine (8.8%) were deep and nine were superficial. Infection was associated with comorbidities (p = 0.008), open fractures (p = 0.008) and primary external fixation with delayed ORIF (p = 0.023). At a mean of six years (0.3 to 13; n = 53) after the injury, the mean FAOS was 76.2 (0 to 100) and 72% of patients were satisfied. Conclusion This is currently the largest series reporting the outcome following fixation of complex AO type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated that a satisfactory outcome can be achieved in the appropriate patients using primary ORIF. Cite this article: Bone Joint J 2016;98-B:1106–11.
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Affiliation(s)
- A. D. Duckworth
- Edinburgh Orthopaedic Trauma Unit, Royal
Infirmary of Edinburgh, 51 Little France
Crescent, Edinburgh EH16 4SU, UK
| | - J. G. Jefferies
- Department of Trauma and Orthopaedic Surgery,
Queen Elizabeth University Hospital, 1345
Govan Road, Glasgow, G51
4TF, UK
| | - N. D. Clement
- Edinburgh Orthopaedic Trauma Unit, Royal
Infirmary of Edinburgh, 51 Little France
Crescent, Edinburgh EH16 4SU, UK
| | - T. O. White
- Edinburgh Orthopaedic Trauma Unit, Royal
Infirmary of Edinburgh, 51 Little France
Crescent, Edinburgh EH16 4SU, UK
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Clement ND, Duckworth AD, Jenkins PJ, McEachan JE. Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction. J Hand Surg Eur Vol 2016; 41:624-31. [PMID: 26744508 DOI: 10.1177/1753193415622341] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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] [Received: 07/13/2015] [Accepted: 11/16/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies. LEVEL OF EVIDENCE IV Prognosis, observational cohort study.
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Affiliation(s)
- N D Clement
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Dunfermline, UK
| | - A D Duckworth
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Dunfermline, UK
| | - P J Jenkins
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Dunfermline, UK
| | - J E McEachan
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Dunfermline, UK
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Clement ND, MacDonald D, Dall GF, Ahmed I, Duckworth AD, Shalaby HS, McKinley J. Metallic hemiarthroplasty for the treatment of end-stage hallux rigidus. Bone Joint J 2016; 98-B:945-51. [DOI: 10.1302/0301-620x.98b7.36860] [Citation(s) in RCA: 8] [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] [Received: 07/08/2015] [Accepted: 02/05/2016] [Indexed: 11/05/2022]
Abstract
Aims To examine the mid-term outcome and cost utility of the BioPro metallic hemiarthroplasty for the treatment of hallux rigidius. Patients and Methods We reviewed 97 consecutive BioPro metallic hemiarthroplasties performed in 80 patients for end-stage hallux rigidus, with a minimum follow-up of five years. There were 19 men and 61 women; their mean age was 55 years (22 to 74). No patient was lost to follow-up. Results A total of 12 patients (15 first metatarso-phalangeal joints (MTPJs)) required a revision; one for infection, two for osteolysis and 12 for pain. The all cause rate of survival at five years was 85.6% (95% confidence interval (CI) 83.5 to 87.9). Younger age was a significant predictor of revision (odds ratio 1.09, 95% CI 1.02 to 1.17, p = 0.014) on excluding infection and adjusting for confounding variables (Cox regression). Significant improvements were demonstrated at five years in the Manchester Oxford Foot Questionnaire (13.9, 95% CI 10.5 to 17.2) and in the physical component of the Short Form-12 score (6.5, 95% CI 4.1 to 8.9). The overall rate of satisfaction was 75%. The cost per quality adjusted life year at five years, accounting for a 14% rate of revision was between £4431 and £6361 depending on the complexity and morbidity of the patient. Conclusion The BioPro hemiarthroplasty offers good short to mid-term functional outcome and is a cost effective intervention. The relatively high revision rate is associated with younger age and perhaps the use of this implant should be limited to older patients. Cite this article: Bone Joint J 2016;98-B:945–51.
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Affiliation(s)
- N. D. Clement
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
| | - D. MacDonald
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
| | - G. F. Dall
- Borders General Hospital, Melrose, Roxburghshire, TD6
9BS, UK
| | - I. Ahmed
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
| | - A. D. Duckworth
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
| | - H. S. Shalaby
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
| | - J. McKinley
- Royal Infirmary of Edinburgh, Little
France Crescent, Old Dalkeith Road, Edinburgh, EH16
4SA, UK
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Clement ND, Goudie EB, Brooksbank AJ, Chesser TJS, Robinson CM. Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle. Bone Joint J 2016; 98-B:125-30. [PMID: 26733525 DOI: 10.1302/0301-620x.98b1.36260] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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 This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. METHODS We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. RESULTS The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. DISCUSSION Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. TAKE HOME MESSAGE Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.
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Affiliation(s)
- N D Clement
- Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
| | - E B Goudie
- Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
| | - A J Brooksbank
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
| | - T J S Chesser
- Southmead Hospital, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - C M Robinson
- Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
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Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AHRW. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016; 5:116-21. [PMID: 27073210 PMCID: PMC5009237 DOI: 10.1302/2046-3758.54.2000628] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [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] [Received: 11/20/2015] [Accepted: 02/26/2016] [Indexed: 01/09/2023] Open
Abstract
Objectives The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628.
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Affiliation(s)
- J M Leow
- College of Medicine and Veterinary Medicine, University of Edinburgh, 11 Montague Street, Edinburgh EH8 9QT, UK
| | - N D Clement
- Trauma and Orthopaedics, Orthopaedic Department, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T Tawonsawatruk
- School of Medicine and Dentistry, University of Aberdeen, Westburn Dr, Aberdeen AB25 3BZ, UK
| | | | - A H R W Simpson
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK
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Maempel JF, Clement ND, Ballantyne JA, Dunstan E. Enhanced recovery programmes after total hip arthroplasty can result in reduced length of hospital stay without compromising functional outcome. Bone Joint J 2016; 98-B:475-82. [DOI: 10.1302/0301-620x.98b4.36243] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 03/30/2015] [Accepted: 11/04/2015] [Indexed: 12/27/2022]
Abstract
Aims The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. Patients and Methods Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. Results The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). Conclusion We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. Take home message: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality. Cite this article: Bone Joint J 2016;98-B:475–82.
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Affiliation(s)
- J. F. Maempel
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | - N. D. Clement
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | | | - E. Dunstan
- Victoria Hospital , Hayfield
Road, Kirkcaldy KY2 5AH, Fife, UK
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Maempel JF, Wickramasinghe NR, Clement ND, Brenkel IJ, Walmsley PJ. The pre-operative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty. Bone Joint J 2016; 98-B:490-7. [DOI: 10.1302/0301-620x.98b4.36245] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [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] [Received: 03/30/2015] [Accepted: 11/03/2015] [Indexed: 12/22/2022]
Abstract
Aims The pre-operative level of haemoglobin is the strongest predictor of the peri-operative requirement for blood transfusion after total knee arthroplasty (TKA). There are, however, no studies reporting a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of haemoglobin that would predict the requirement for blood transfusion in patients who undergo TKA. Patients and Methods Analysis of receiver operator characteristic (ROC) curves of 2284 consecutive patients undergoing unilateral TKA was used to determine gender specific thresholds predicting peri-operative transfusion with the highest combined sensitivity and specificity (area under ROC curve 0.79 for males; 0.78 for females). Results Threshold levels of 13.75 g/dl for males and 12.75 g/dl for females were identified. The rates of transfusion in males and females, respectively above these levels were 3.37% and 7.11%, while below these levels, they were 16.13% and 28.17%. Pre-operative anaemia increased the rate of transfusion by 6.38 times in males and 6.27 times in females. Blood transfusion was associated with an increased incidence of early post-operative confusion (odds ratio (OR) = 3.44), cardiac arrhythmia (OR = 5.90), urinary catheterisation (OR = 1.60), the incidence of deep infection (OR = 4.03) and mortality (OR = 2.35) one year post-operatively, and increased length of stay (eight days vs six days, p < 0.001). Conclusion Uncorrected low pre-operative levels of haemoglobin put patients at potentially modifiable risk and attempts should be made to correct this before TKA. Target thresholds for the levels of haemoglobin pre-operatively in males and females are proposed. Take home message: Low pre-operative haemoglobin levels put patients at unnecessary risk and should be corrected prior to surgery. Cite this article: Bone Joint J 2016;98-B:490–7.
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Affiliation(s)
- J. F. Maempel
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | | | - N. D. Clement
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | - I. J. Brenkel
- Victoria Hospital, Hayfield
Road, Kirkcaldy KY2 5AH, UK
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Abstract
INTRODUCTION The aim of this study was to assess the independent effect of radiographic measures of implant position, relative to pre-operative anatomical assessment, on the functional outcome of total hip arthroplasty according to change in the Oxford hip score (OHS) 1 year post surgery. METHODS A prospective cohort study was preformed to assess whether improvement in functional outcome (change in OHS at 1 year) and the relationship with femoral offset and length, and acetabular offset and height. After a power calculation 359 patients were recruited to the study and radiographic measures were performed by blinded observers. Regression analysis was used to assess the independent effect of the four radiographic measurements after adjusting for confounding variables. RESULTS There was a significant (p < 0.001) decrease in acetabular offset [5.3 mm, 95 % confidence interval (CI) 4.4-6.2] and increase in femoral offset (6.1 mm, 95 % CI 5.4-6.8). Hence there was no significant change in overall offset. Femoral offset was the only radiographic measure to be achieved statistical significance (r = 0.198, 95 % CI 0.063-0.333, p = 0.004) in relation to clinical outcome, with increasing offset being associated with a greater improvement in the OHS. On combining femoral and acetabular offset increasing offset was associated with a greater improvement in the OHS (r = 0.10, 95 % CI 0.01-0.19, p = 0.04). CONCLUSION This study supports the long-held biomechanical theory of medialisation of the acetabular component with compensatory increased femoral offset results in improved functional outcome.
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Affiliation(s)
- N. D. Clement
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA UK
| | | | - D. MacDonald
- University of Edinburgh, Little France, Edinburgh, EH16 4SB UK
| | - S. J. Breusch
- Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA UK
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