High accuracy of positioning custom triflange acetabular components in tumour and total hip arthroplasty revision surgery

Aims

Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions.

Methods

A multicentre observational cohort study in Australia between February 2017 and March 2021 included consecutive patients undergoing acetabular reconstruction with CTACs in rTHA (Paprosky 3A/3B defects) or tumour resection (including Enneking P2 peri-acetabular area). Of 103 eligible patients (104 hips), 34 patients (35 hips) were analyzed.

Results

CTAC positioning was generally accurate, with minor deviations in cup inclination (mean 2.7°; SD 2.84°), anteversion (mean 3.6°; SD 5.04°), and rotation (mean 2.1°; SD 2.47°). Deviation of the hip centre of rotation (COR) showed a mean vector length of 5.9 mm (SD 7.24). Flange positions showed small deviations, with the ischial flange exhibiting the largest deviation (mean vector length of 7.0 mm; SD 8.65). Overall, 83% of the implants were accurately positioned, with 17% exceeding malpositioning thresholds. CTACs used in tumour resections exhibited higher positioning accuracy than rTHA cases, with significant differences in inclination (1.5° for tumour vs 3.4° for rTHA) and rotation (1.3° for tumour vs 2.4° for rTHA). The use of intraoperative navigation appeared to enhance positioning accuracy, but this did not reach statistical significance.

Conclusion

This study demonstrates favourable CTAC positioning accuracy, with potential for improved accuracy through intraoperative navigation. Further research is needed to understand the implications of positioning accuracy on implant performance and long-term survival.

Trajectories of Quality of Life After Pelvic Exenteration: A Latent Class Growth Analysis

BACKGROUND

Information on the course of quality of life after surgery for advanced cancers within the pelvis is important to guide patient decision-making; however, the current evidence is limited.

OBJECTIVE

To identify quality-of-life trajectory classes and their predictors after pelvic exenteration.

DESIGN

Prospective cohort study.

SETTINGS

Highly specialized quaternary pelvic exenteration referral center.

PATIENTS

Patients undergoing pelvic exenteration due to advanced/recurrent cancers within the pelvis between July 2008 and July 2022.

MAIN OUTCOME MEASURES

Quality-of-life data included the 36-item Short-Form Survey (physical and mental component scores) and the Functional Assessment of Cancer Therapy-Colorectal instruments, which were collected at 11 distinct points from baseline to 5 years postoperatively. Predictors included patient characteristics and surgical outcomes. Latent class analysis was used to identify the likelihood of a better quality-of-life class, and logistic regression models were used to identify predictors of the identified classes.

RESULTS

The study included 565 participants. Two distinct quality-of-life trajectory classes were identified for the Physical Component Score (class 1: high stable and class 2: high decreasing). Three distinct classes were identified for the Mental Component Score (class 1: high increasing, class 2: moderate stable, and class 3: moderate decreasing) and for Functional Assessment of Cancer Therapy-Colorectal total score (class 1: high increasing, class 2: high decreasing, and class 3: low decreasing). Across the 3 quality-of-life domains, overall survival probabilities were also higher in class 1 ( p < 0.0001). Age, repeat exenteration, neoadjuvant therapy, surgical margin, length of operation, and hospital stay were significant predictors of quality-of-life classes.

LIMITATIONS

This study was conducted at a single highly specialized quaternary pelvic exenteration referral center, and findings may not apply to other centers.

CONCLUSIONS

This study demonstrates that quality of life after pelvic exenteration diverges into distinct trajectories, with most patients reporting an optimal course. See Video Abstract .

TRAYECTORIAS EN LA CALIDAD DE VIDA DESPUS DE EXENTERACIN PLVICA ANLISIS DE CRECIMIENTO DE CLASES LATENTES

ANTECEDENTES:La información sobre la evolución en la calidad de vida después de cirugía en cánceres avanzados situados en la pelvis es importante para guiar la toma de decisiones sobre el paciente; sin embargo, la evidencia actual es muy limitada.OBJETIVO:Identificar las clases de trayectorias en la calidad de vida y sus factores pronóstico después de la exenteración pélvica.DISEÑO:Estudio de cohortes prospectivo.AJUSTES:Centro de referencia altamente especializado en la exenteración pélvica cuaternaria.PACIENTES:Todos aquellos sometidos a exenteración pélvica por cáncer avanzados/recurrentes situados en la pelvis entre Julio de 2008 y Julio de 2022.PRINCIPALES MEDIDAS DE RESULTADO:Los datos sobre la calidad de vida incluyeron el Cuestionario de Salud SF-36 (puntuaciones de componentes físicos y mentales) y la evaluación funcional entre la terapia del cáncer/-herramientas colorrectales, recopilados en 11 puntos distintos desde el diagnóstico hasta los 5 años después de la operación.Los predictores incluyeron las características de los pacientes y los resultados quirúrgicos. Se utilizó el análisis de clases latentes para identificar la probabilidad de una mejor calidad de vida y se utilizaron modelos de regresión logística para identificar predictores de las clases identificadas.RESULTADOS:El estudio incluyó a 565 participantes. Se identificaron dos clases distintas de trayectorias de calidad de vida para la puntuación del componente físico (clase 1: alta estable y clase 2: alta decreciente), se identificaron tres clases distintas para la puntuación del componente mental (clase 1: alta creciente; clase 2: moderadamente estable; y clase 3: moderada disminución) y para la evaluación funcional de la terapia contra el cáncer-puntuación total colorrectal (clase 1: aumento alto; clase 2: disminución alta; y clase 3: disminución baja). En los tres dominios de calidad de vida, las probabilidades de supervivencia general también fueron mayores en las clases 1 (p <0,0001). La edad, las exenteraciones pélvicas repetidas, la terapia neoadyuvante, el margen quirúrgico, la duración de la operación y la estadía hospitalaria fueron predictores significativos en las clases de calidad de vida.LIMITACIONES:El presente estudio fué realizado en un único centro de referencia altamente especializado en exenteración pélvica cuaternaria y es posible que los hallazgos no se apliquen a otros centros.CONCLUSIONES:Demostramos con nuestro estudio que la calidad de vida después de la exenteración pélvica diverge en trayectorias distintas, y que la mayoría de los pacientes nos reportaron de una évolución óptima. (Traducción-Dr. Xavier Delgadillo ).

Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges?

INTRODUCTION

Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery.

METHODS

A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality).

RESULTS

A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]).

CONCLUSIONS

Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.

Complexity of surgery and treatment burden in patients with peritoneal malignancy is not determined by addition of hyperthermic intraperitoneal chemotherapy

BACKGROUND

This study describes surgical and quality of life outcomes in patients with peritoneal malignancy treated by cytoreductive surgery (CRS) alone compared with a subgroup treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

Peritoneal malignancy patients undergoing surgery between 2017 and 2023 were included. The cohort was divided into patients treated by CRS and HIPEC and those treated by CRS without HIPEC (including CRS only or maximal tumour debulking (MTB)). Main outcomes included surgical outcomes, survival, and quality of life. Groups were compared using non-parametric tests and log-rank test was used to compare survival curves.

RESULTS

403 had CRS and HIPEC, 25 CRS only and 15 MTB. CRS and HIPEC patients had a lower peritoneal carcinomatosis index (12.0 vs. 17.0 vs. 35.0; P < 0.001) and longer surgical operative time (9.3 vs. 8.3 vs. 5.2 h; P < 0.001), when compared to CRS only and MTB, respectively. No other significant difference between groups was observed.

CONCLUSIONS

The optimal management of selected patients with resectable peritoneal malignancy incorporates a combined strategy of CRS and HIPEC. When HIPEC is not utilized, due to significant residual disease or comorbidity precluding safe delivery, CRS alone is associated with good outcomes. Hospital stay and complications are acceptable but not significantly different to the CRS and HIPEC group. CRS alone is a complex intervention requiring comparable resources with good outcomes. In view of our findings 'intention to treat' with CRS and HIPEC should be the basis for resource allocation and funding.

Evaluating geographical disparities on clinical outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Rural Australians typically encounter disparities in healthcare access leading to adverse health outcomes, delayed diagnosis and reduced quality of life (QoL) parameters. These disparities may be exacerbated in advanced malignancies, where treatment is only available at highly specialised centres with appropriate multidisciplinary expertise. Thus, this study aims to determine the association between patient residence on oncological, surgical and QoL outcomes following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).

METHODS

A retrospective analysis was conducted on consecutive patients undergoing CRS and HIPEC at Royal Prince Alfred Hospital from January 2017 to March 2022. On the basis of their postcode of residence, patients were stratified into metropolitan and regional groups. Data encompassing demographics, oncological, surgical and QoL outcomes were compared. Statistical analysis included chi-square test, t-tests and Kaplan-Meier survival curves.

RESULTS

Among the 317 patients, 228 (72%) were categorised as metropolitan and 89 (28%) as regional. Metropolitan patients presented higher rates of recurrence (61.8% versus 40.0%, p = 0.014) and shorter overall mean survival [3.8 years (95% CI: 3.44-4.09) versus 4.2 years (95% CI: 3.76-4.63), p = 0.019] compared with regional patients. No other statistically significant differences were observed in oncological, surgical and QoL outcomes.

CONCLUSIONS

Most oncological, surgical and QoL parameters did not differ by geographical location of patients undergoing CRS and HIPEC for peritoneal malignancies at a high-volume quaternary referral centre. Observed differences in recurrence and survival may be attributed to the selective nature of surgical referrals and variable follow-up patterns. Future research should focus on characterising referral pathways and its influence on post-operative outcomes.

Establishing a hierarchy of total knee arthroplasty patients' goals and its congruity to health professionals' perceptions: a cohort study

BACKGROUND

To formulate a hierarchy of primary goals of patients prior to total knee arthroplasty (TKA) and evaluate the agreement between patients and health professionals regarding this hierarchy of patient goals.

METHODS

The five most important goals for each of 110 consecutive patients booked for total knee arthroplasty between June and October 2019 were identified. Goals were grouped into themes and then a hierarchy formulated. This hierarchy was randomized and provided to 94 health professionals, including orthopaedic surgeons (n = 49), rheumatologists (n = 16), physiotherapists (n = 16) and general practitioners (n = 13). These health professionals ranked the provided goals based on their belief of what was most important to patients.

RESULTS

Ten overarching goals were identified, with the five most important goals to patients being improving mobility, reducing knee pain, improving daily tasks, participating in social & leisure activities and regaining knee range of motion. Health professionals ranked these goals highly similar to patients with the exceptions being that health professionals ranked quality of life near the top of the hierarchy (much higher than patients) and ranked improving mobility in the bottom half (much lower than patients). Ranking of these goals was similar between each health professional group.

CONCLUSION

Pain and mobility are the most important goals to patients, with health professionals correctly identifying these as such. However, health professionals ranked quality of life higher, and mobility lower in the hierarchy than patients. This incongruity should be considered by health professionals when educating and communicating treatment outcomes.

Impact of Preoperative Mental Health on Surgical Outcomes Following Robotic-assisted Radical Prostatectomy

OBJECTIVES

To explore the association between preoperative mental health status and surgical outcomes following robotic-assisted radical prostatectomy (RARP).

METHODS

This cohort study included consecutive patients undergoing RARP surgery for prostate cancer between October 2016 and May 2022 at a major public hospital in Sydney, Australia. The primary outcome was preoperative self-reported mental health status measured using the mental component score from the Short Form 36 survey. Other variables included patients' characteristics, surgical outcomes, postoperative quality of life, pain and decision regret. Data were analysed using linear regression analysis.

RESULTS

A total of 266 men underwent RARP during the studied period. Of these, 242 patients (91%) completed the preoperative survey and were analyzed. Poorer preoperative mental health had significant univariate associations with younger age (P = .025), reduced access to economic resources (P = .043), diagnosis of a mental illness (P = .033), poorer mental health at 6 weeks and 6 months postoperatively (both P <.001), greater pain (P = .001), and higher decision regret (P = .001) 6 weeks following surgery. In the multivariate analysis, poorer preoperative mental health status was associated with younger age (P = .028) and poorer mental health at 6 weeks (P <.001) and 6 months (P = .025) postoperatively.

CONCLUSION

For patients undergoing RARP, poor preoperative mental health status was associated with younger age and poorer postoperative mental health. Future studies should investigate if targeted preoperative psychological interventions would improve postoperative mental health outcomes, specifically in younger men undergoing RARP.

Tenosynovial giant cell tumours: experience at an Australian tertiary referral centre for musculoskeletal tumours with minimum two-year follow-up

Aims

Tenosynovial giant cell tumour (TGCT) is a rare benign tumour of the musculoskeletal system. Surgical management is fraught with challenges due to high recurrence rates. The aim of this study was to describe surgical treatment and evaluate surgical outcomes of TGCT at an Australian tertiary referral centre for musculoskeletal tumours and to identify factors affecting recurrence rates.

Methods

A prospective database of all patients with TGCT surgically managed by two orthopaedic oncology surgeons was reviewed. All cases irrespective of previous treatment were included and patients without follow-up were excluded. Pertinent tumour characteristics and surgical outcomes were collected for analysis.

Results

There were 111 total cases included in the study; 71 (64%) were female, the mean age was 36 years (SD 13.6), and the knee (n = 64; 57.7%) was the most commonly affected joint. In all, 60 patients (54.1%) had diffuse-type (D-TGCT) disease, and 94 patients (84.7%) presented therapy-naïve as "primary cases" (PC). The overall recurrence rate was 46.8% for TGCT. There was a statistically significant difference in recurrence rates between D-TGCT and localized disease (75.0% vs 13.7%, relative risk (RR) 3.40, 95% confidence interval (CI) 2.17 to 5.34; p < 0.001), and for those who were referred in the "revision cases" (RC) group compared to the PC group (82.4% vs 48.9%, RR 1.68, 95% CI 1.24 to 2.28; p = 0.011). Age, sex, tumour volume, and mean duration of symptoms were not associated with recurrence (p > 0.05).

Conclusion

Recurrence rates remain high even at a tertiary referral hospital. Highest rates are seen in D-TGCT and "revision cases". Due to the risks of recurrence, the complexity of surgery, and the need for adjuvant therapy, this paper further supports the management of TGCT in a tertiary referral multi-disciplinary orthopaedic oncology service.

Impact of geographical health disparities on outcomes following pelvic exenteration at a centralised quaternary referral centre

INTRODUCTION

Pelvic exenteration (PE) is an ultra-radical procedure performed for primary or recurrent malignancies confined to the pelvis. Health outcomes for rural Australian populations are generally inferior compared to those from metropolitan centres, however, the effect of geographical location on outcomes following PE is poorly defined. The aim of this study was to investigate how geographical location affects oncological, quality of life (QoL) and survival outcomes following PE.

METHODS

Consecutive patients undergoing PE between 1994 and 2022 at a single centre were included. Patient post codes were linked with the Australian Statistical Geography Standard Remoteness Structure to stratify patients into five groups based on the geographical location of their residence. Primary outcome measures included patient survival, QoL and oncological outcomes.

RESULTS

A total of 953 patients were included, of which 626 (65.7%) were from major cities, 227 (23.8%) inner regional, 84 (8.8%) outer regional, 9 (0.9%) remote, and 7 (0.7%) very remote areas. Rural patients were more likely to undergo PE for primary rectal cancer (p = 002) and less likely for recurrent, non-rectal carcinoma (p = 0.027). Rural patients less frequently had health insurance (p < 0.001) but were more likely to have undergone neoadjuvant radiotherapy (p = 0.022). No difference in length-of-admission, in-hospital complication rates, QoL at 36 months or survival was observed between groups.

CONCLUSIONS

Despite geographical disparities, rural populations undergoing PE achieved equally favourable outcomes as populations from metropolitan areas. Enhancing access to specialised care may facilitate better outcomes of patients residing in regional and remote areas.

Decipher Score predicts prostate specific antigen persistence after prostatectomy

BACKGROUND

The aim of this study was to evaluate genomic risk of patients with persistent prostate specific antigen (PSA) using mRNA expression analysis and a validated prognostic genomic-risk classifier.

METHODS

Monocentric retrospective study including all patients who underwent radical prostatectomy (RP) by one surgeon and Decipher Test from October 2013 to December 2018. PSA persistent population was defined as all patients with two consecutive PSA>0.1 ng/mL at follow-up after the surgery. Neurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) was performed intraoperatively for research of positive surgical margins. Multivariate analysis was performed for persistent PSA (pPSA) predictors. A specific localized, organ-confined, and negative margins sub-population with PSA persistence was compared to a similar sub-population without PSA persistence for genomic differential expression analyses.

RESULTS

A total of 564 patients were included and 61 of them had pPSA. Preoperative PSA was higher in the PSA persistent group (11.6 [6.4, 21.2] vs. 6.2 [4.7, 9.2] P=0.00010), as well as PSA density (PSAd) (0.3 [0.2, 0.5] vs. 0.2 [0.1, 0.3] P=0.0001). Postoperative characteristics, Gleason Score, and positive surgical margins were significantly higher in the PSA persistent population. 31 patients had pPSA in our specific subpopulation and were compared to 217 patients with no pPSA. On multivariate analysis, only Decipher Score (OR=5.64 [1.28; 24.89], P=0.022) and preoperative PSA (OR=1.06, [1.02; 1.09], P=0.001) were significant predictors for PSA persistence. We found two genes to be significantly upregulated with a 2.5-fold change in our specific subpopulation (SERPINB11 and PDE11A).

CONCLUSIONS

We found unique genomic features of patients with pPSA, whilst confirming previous clinical findings that this condition behaves to a worse prognosis. Given this high genomic risk, further imaging studies should be performed to select patients for early treatment intensification.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Custom designed and 3D-printed titanium pelvic implants for acetabular reconstruction after tumour resection

BACKGROUND

Reconstructive procedure following resection of large pelvic tumours around the hip joint remains a complex challenge.

METHODS

This study presents a retrospective case series of patients presenting with benign or malignant pelvic tumour for which an internal hemipelvectomy including the hip joint and subsequent reconstruction with a custom designed 3-dimensional printed titanium pelvic implant (3DPPI) has been performed between August 2013 and January 2018.

RESULTS

15 consecutive patients with a median age of 33.9 years (IQR 26.4-72.2) and a median BMI of 20.7 kg/m2 (IQR 19.0-33.3) were reviewed after median follow-up of 33.8 months (IQR 24.0-78.1). The majority of patients presented with a malignant tumour as their principal diagnosis (n = 13, 86.7%). The median surgical time was 5.5 hours (IQR 4.5-8.5) and median peri-operative blood loss was 5000 ml (IQR 2000-10000). The median MSTS score at follow-up was 63.3% (IQR 51.7-86.7%). The median NRS in rest was 0.0 (IQR 0.0-5.0), the median NRS during activity was 2.0 (IQR 0.5-7.0) and the median HOOS-PS was 76.6% (IQR 67.9-91.0). 4 patients had implant-specific complications (n = 4, 26.6%); 1 hip dislocation (Henderson type 1a), 3 structural complications (type 3a), 1 deep infection (type 4a) and 1 local tumour recurrence (type 5b). At follow-up, 4 out of 15 implants were classified as a failure, resulting in an implant survival rate of 73.3%.

CONCLUSIONS

Acceptable peri-operative outcomes, functional results, complication rates and short-term implant survival can be achieved in a cohort of complex patients undergoing 3DPPI reconstruction after hemipelvectomy including the acetabulum.

Trends in shoulder surgery patient-reported outcome measures

Patient-reported outcome measures (PROMs) are a vital part of the toolkit for the current practice of orthopedic surgery. We are witnessing the expansion of the use of PROMs in clinical practice and in research; the ultimate direction of this expansion is unclear. The purpose of this systematic review was to identify the trends in the use of PROMs in major upper limb publications over a 7-year period. We retrospectively reviewed all articles published in 6 of the most influential upper limb orthopedic journals based on impact factor from January 2013 to January 2020. PubMed, Medline, and Embase were used to access the abstracts for all articles published for this period. We included all articles related to shoulder arthroplasty, shoulder instability, rotator cuff surgery, and involving the use of PROMs. There were 4175 articles identified from the selected journals over the chosen time period, of which 607 were eligible for inclusion in the study. The number of articles reporting PROMs increased from 57 in 2013 to 115 in 2019, which was a 102% increase. The total number of PROM usages recorded was 1593 which was comprised of 63 different scoring systems, with each article using a median of 3 different PROMs. The most commonly used score in articles originating from North America was the American Shoulder and Elbow Surgeons score (216 uses in 273 articles; 78.1%), from Europe it was the Constant-Murley Score (129 uses in 183 articles; 70.4%), and from Asia it was the American Shoulder and Elbow Surgeons score (80 uses in 126 articles; 63.4%). The use of PROMs is evolving with an increasing prevalence of and diversity of PROMs being used in upper limb surgery. There is geographical variation in the use of PROMs, and a variety of systems used, with only 3 of the top 10 most used PROMs reporting on patient satisfaction or wellbeing. Given that a diverse range of PROMs study a diverse range of conditions and procedures, there may not be a need for a consensus on the best overall use of PROMs, but there may be ideal PROMs suited to answer specific questions.

Surgical, survival and quality of life outcomes in over 1000 pelvic exenterations: lessons learned from a large Australian case series

BACKGROUND

To determine surgical, survival and quality of life outcomes across different tumour streams and lessons learned over 28 years.

METHODS

Consecutive patients undergoing pelvic exenteration at a single, high volume, referral hospital, between 1994 and 2022 were included. Patients were grouped according to their tumour type at presentation as follows, advanced primary rectal cancer, other advanced primary malignancy, locally recurrent rectal cancer, other locally recurrent malignancy and non-malignant indications. The main outcomes included, resection margins, postoperative morbidity, long-term overall survival, and quality of life outcomes. Non-parametric statistics and survival analyses were performed to compare outcomes between groups.

RESULTS

Of the 1023 pelvic exenterations performed, 981 (95.9%) unique patients were included. Most patients underwent pelvic exenteration due to locally recurrent rectal cancer (N = 321, 32.7%) or advanced primary rectal cancer (N = 286, 29.2%). The rates of clear surgical margins (89.2%; P < 0.001) and 30-days mortality were higher in the advanced primary rectal cancer group (3.2%; P = 0.025). The 5-year overall survival rates were 66.3% in advanced primary rectal cancer and 44.6% in locally recurrent rectal cancer. Quality of life outcomes differed across groups at baseline, but generally had good trajectories thereafter. International benchmarking revelled excellent comparative outcomes.

CONCLUSIONS

The results of this study demonstrate excellent outcomes overall, but significant differences in surgical, survival and quality of life outcomes across patients undergoing pelvic exenteration due to different tumour streams. The data reported in this manuscript can be utilized by other centres as benchmarking as well as proving both subjective and objective outcome details to support informed decision-making for patients.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial

OBJECTIVE

To evaluate the effects of a patient decision aid for people considering shoulder surgery.

METHODS

Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes.

RESULTS

409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome.

CONCLUSIONS

In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge.

PRACTICE IMPLICATIONS

Research is needed to understand reasons for the lack of anticipated effects.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression

BACKGROUND

Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA.

METHODS

The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression.

RESULTS

In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively.

CONCLUSION

Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE

The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally.

METHODS

A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated.

RESULTS

There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%).

CONCLUSIONS

Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.

Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study

OBJECTIVE

To develop and user test a patient decision aid for people with subacromial pain syndrome that presents evidence-based information on the benefits and harms of subacromial decompression surgery and rotator cuff repair surgery.

DESIGN

Mixed-methods study outlining the development of a patient decision aid.

SETTING

We assembled a multidisciplinary steering group, and used existing decision aids and decision science to draft the decision aid. Participants were recruited through social media (not restricted by country nor setting), local hospitals and the authors' collaboration network.

PARTICIPANTS

People with shoulder pain and health professionals who manage people with shoulder pain.

PRIMARY AND SECONDARY OUTCOMES

We interviewed participants to gather feedback on the decision aid, assessed useability and acceptability (using qualitative and quantitative methods) and performed iterative cycles of redrafting the decision aid and reinterviewing participants as necessary. Interview data were analysed using thematic analysis. Quantitative data were summarised descriptively.

RESULTS

We interviewed 26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 general practitioners, 3 chiropractors and 1 osteopath) and 14 people with shoulder pain. Most health professionals and people with shoulder pain rated all aspects of decision aid acceptability as adequate-to-excellent (eg, length, presentation, comprehensibility). Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (eg, treatment options, summary of benefits, harms and practical issues, questions to ask a health professional, graphics, formatting). However, some aspects of the decision aid elicited divergent views among health professionals (eg, causes and symptoms of shoulder pain, evidence on benefits and harms).

CONCLUSION

This decision aid could be an acceptable and valuable tool for helping people with subacromial pain syndrome make informed treatment choices. A randomised controlled trial evaluating whether this decision aid reduces people's intentions to undergo shoulder surgery and facilitates informed treatment choices is underway.Trial registration number ACTRN12621000992808.

The Impact of Room-Sharing on Length of Stay After Total Hip or Knee Arthroplasty: A Retrospective Study

Background

Prolonged length of stay (LOS) after elective total hip (THA) and knee (TKA) arthroplasty is often associated with worse patient outcomes. Social support through room-sharing has been identified as a factor that may reduce LOS in a hospital setting, but has not yet been examined in an orthopedic population. The aim of this study was to evaluate the effect of single- vs shared-room accommodation after elective TKA or THA on hospital LOS.

Method

A retrospective study was conducted using data from hospital medical records at our institution. Patients receiving unilateral, elective THA or TKA over a 2-year period were eligible. Patients were allocated to either a single room or four-bed shared room. The primary outcome was LOS; secondary outcomes included complications, discharge destination, and return to operating theater.

Results

One hundred eighty-five patients (70 THA, 115 TKA; mean age 65.74 ± 10.38, 59% female) were included, of whom 82 were allocated to a single room and 103 to a shared room. There was no statistically significant difference in LOS between the 2 groups (5.18 ± 2.21 days [single] vs 4.88 ± 2.12 days [shared]; mean difference −0.29 [95% CI −0.92-0.33], P = .36). Analysis modeling for multiple confounders found no association among room allocation, LOS, and discharge destination. However, more patients in single rooms required discharge to rehabilitation (27% vs 9%) and return to theater (7% vs 1%).

Conclusions

Room allocation did not correlate with a difference in LOS in patients undergoing elective THA or TKA.

Online Decision Aids for Knee Arthroplasty: An Environmental Scan

BACKGROUND

Knee arthroplasty is a high-risk, resource-intensive procedure that should be reserved for patients in whom the benefit will outweigh the risks. The provision of high-quality, publicly available decision aids can help patients to balance the benefits against the harms of treatments and to assist informed decision-making. The aim of this study was to identify and evaluate the content and readability of freely available knee arthroplasty decision aids.

METHODS

A systematic search using an environmental scan methodology of publicly available online materials was performed in December 2018. Included materials were assessed for quality using the International Patient Decision Aid Standards instrument (IPDASi), understandability and actionability from a patient's perspective using the Patient Education Materials Assessment Tool (PEMAT), and readability grade level using the Flesch-Kincaid Grade Level and the Gunning Fog Index.

RESULTS

Of 761 online materials screened, 26 decision aids were identified. Only 18 (69%) may be considered to meet criteria to be defined as a decision aid and 4 (15%) met criteria suggesting that the material did not introduce potential harmful bias according to the IPDASi. The mean score (and standard deviation) for all decision aids was 74% ± 12% for understandability and 44% ± 19% for actionability using the PEMAT. Readability indices indicated a mean minimum reading level of Grade 10 (10.8 ± 2.5). No decision aid included a wait-and-see option.

CONCLUSIONS

Few high-quality decision aids exist for patients considering knee arthroplasty and none include a wait-and-see option. Many do not provide actionable options and are pitched at above-average reading levels. Developers need to address these issues to encourage high-quality decision-making, especially for those with low health literacy.

Subacromial analgesia via continuous infusion catheter vs. placebo following arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized trials

BACKGROUND

Subacromial analgesia (SAA) is hypothesized to reduce pain after arthroscopic shoulder surgery by delivering a continuous infusion of local anesthetic directly to the surgical site. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of SAA vs. placebo for pain relief after arthroscopic subacromial shoulder procedures.

METHODS

MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing SAA with placebo after arthroscopic shoulder surgery. Outcomes collected included pain scores (converted to equivalent ordinal visual analog scores; minimal clinically important difference 1.4 cm), oral morphine equivalents used postoperatively, and catheter-related complications. Meta-analysis was performed via a random-effects model. Included trials underwent a risk of bias and quality of evidence assessment.

RESULTS

Nine studies involving 459 participants were included. There were no clinically significant changes for pain scores in SAA at 6-, 12-, 24-, and 48-hour postoperative timepoints. Patients receiving SAA used less morphine equivalents of pain medication at 12 hours only (-0.37 mg, 95% confidence interval: -0.63 to -0.11), but there was no significant difference at 24 and 48 hours. There were no major complications (infection or reoperation). Included trials demonstrated a moderate risk-of-bias, and low to very low quality of evidence for primary outcomes.

CONCLUSION

Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures. Future, high-quality trials are required to further assess the efficacy of SAA against placebo.

Anaesthetic challenges for pelvic reconstruction with custom three-dimensional-printed titanium implants: A retrospective cohort study

Custom 3D printed titanium implant pelvic reconstructive surgery was implemented as a novel technique at our institutions in the last five years. It provided an option for pelvic bone malignancy patients who were previously deemed unsuitable for re-implantation of irradiated resected bone segments, as well as in revision total hip arthroplasty associated with excessive acetabular bone loss. A retrospective cohort study of the anaesthetic management of patients who underwent pelvic reconstructive surgery using custom 3D printed titanium implants from August 2013 to July 2018 was conducted. Twenty-seven patients were included in the study; 23 patients completed single-stage procedures with a mean (standard deviation) duration of surgery of 7.5 (3.3) hours (median 6.8, range 3.0–15.8 hours), and mean intraoperative blood loss of 5400 (3100) mL (median 6000, range 1400–10,000 mL). Surgery involving the sacrum ( n = 7) was associated with longer intensive care stay, longer total length of hospital stay and, in three cases, unplanned two-stage procedures. The twenty procedures not involving the sacrum were successfully completed in a single stage.

The major anaesthetic challenges included massive blood loss, prolonged surgery, interventions to prevent calf compartment syndrome, and perioperative thromboembolism. Preoperative pelvic radiotherapy, malignant tumours, and procedures involving the sacrum were associated with massive intraoperative blood loss and more prolonged surgery.

The effectiveness of robotic hip and knee arthroplasty on patient-reported outcomes: A systematic review and meta-analysis

PURPOSE

The purpose of the study is to determine the effectiveness of semi-active and active robotic hip and knee arthroplasty on post-operative patient-reported outcomes of function, pain, quality of life and satisfaction with surgery.

METHODS

PubMed, Medline, Embase and CENTRAL were searched. Included were comparative studies investigating the effectiveness of semi-active or active robotic hip or knee arthroplasty compared to any other surgical intervention on function, pain, quality of life and satisfaction with surgery. Risk of bias and the strength of the evidence were assessed using the Downs and Black tool and the GRADE system, respectively. Relative risks, mean differences and 95% CI were calculated using random-effects models.

RESULTS

Fourteen studies involving 1342 patients were included. All studies compared robotic to conventional surgery, with active robotic surgery evaluated in total hip or knee arthroplasty and semi-active robotic surgery in total hip or unicompartmental knee arthroplasty. Most studies presented some risk of bias, and the strength of evidence was rated as low to very low quality. Random-effects meta-analyses showed that post-operative functional outcomes were comparable between active robotic and conventional total hip and knee arthroplasty at the short-, medium- and long-term follow-up. No significant difference in pain, quality of life and satisfaction with surgery were reported in individual studies.

CONCLUSIONS

This systematic and meta-analyses indicates that functional outcomes for patients undergoing active robotic total hip and knee arthroplasty were comparable to conventional surgery. Whether semi-active or active robotic hip or knee arthroplasty is effective in improving post-operative pain, quality of life and satisfaction with surgery is unclear. PROSPERO Registration Number: CRD42017059932.

Analysis of mouse keratin 6a regulatory sequences in transgenic mice reveals constitutive, tissue-specific expression by a keratin 6a minigene

The analysis of keratin 6 expression is complicated by the presence of multiple isoforms that are expressed constitutively in a number of internal stratified epithelia, in palmoplantar epidermis, and in the companion cell layer of the hair follicle. In addition, keratin 6 expression is inducible in interfollicular epidermis and the outer root sheath of the follicle, in response to wounding stimuli, phorbol esters, or retinoic acid. In order to establish the critical regions involved in the regulation of keratin 6a (the dominant isoform in mice), we generated transgenic mice with two different-sized mouse keratin 6a constructs containing either 1.3 kb or 0.12 kb of 5' flanking sequence linked to the lacZ reporter gene. Both constructs also contained the first intron and the 3' flanking sequence of mouse keratin 6a. Ectopic expression of either transgene was not observed. Double-label immunofluorescence analyses demonstrated expression of the reporter gene in keratin 6 expressing tissues, including the hair follicle, tongue, footpad, and nail bed, showing that both transgenes retained keratinocyte-specific expression. Quantitative analysis of beta-galactosidase activity verified that both the 1.3 and 0.12 kb keratin 6a promoter constructs produced similar levels of the reporter. Notably, both constructs were constitutively expressed in the outer root sheath and interfollicular epidermis in the absence of any activating stimulus, suggesting that they lack the regulatory elements that normally silence transcription in these cells. This study has revealed that a keratin 6a minigene contains critical cis elements that mediate tissue-specific expression and that the elements regulating keratin 6 induction lie distal to the 1.3 kb promoter region.

A survey of general practitioners' views on autopsy reports

AIMS

To study the views of general practitioners on the quality and utility of autopsy reports, and on autopsies in general.

METHODS

For a period of six months, a questionnaire was enclosed with each autopsy report sent to a general practitioner from the mortuary at Manchester Royal Infirmary.

RESULTS

Most (93.3%) general practitioners found the autopsy report useful, and many (66.7%) thought the bereaved relatives would do so too. However, only a minority (25.2%) would discuss the report with the relatives. A considerable proportion (20.0%) found the cause of death surprising, and a significant number (10.4%) felt the report would modify their future clinical practice. There was approval of autopsies in general, with most (88.6%) agreeing that autopsies reveal lesions not detected in life, and many (74.4%) indicating that loss of the autopsy would impair severely the monitoring of clinical standards.

CONCLUSIONS

General practitioners appreciate autopsy reports, which may have a significant impact on clinical practice. Autopsy reports provide both case audit and information for relatives.