The effect of HIV prevalence, CD4 counts and disease severity on the outcome of total knee arthroplasty for haemophilic arthropathy: a systematic review and meta-analysis

PURPOSE

End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count.

METHODS

A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan-Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV.

RESULTS

Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94%, 86%, and 76% respectively. NJR-reported survivorship for males < 55 years was 94%, 90%, and 86%. Survivorship improved over time (1973-2018), and correlated inversely with HIV prevalence. Infection rate was 5%, compared to 0.5-1% in the NJR. Infection was not significantly increased with higher HIV prevalence, and CD4 + count had no effect. Complications were inconsistently reported.

CONCLUSION

Survivorship was similar at 5 years but declined thereafter, and infection rate was six-fold higher. HIV was related to worse survivorship, but not increased infection. Meta-analysis was limited by inconsistent reporting, and standardised reporting is required in future studies.

Machine learning models to predict surgical case duration compared to current industry standards: scoping review

BACKGROUND

Surgical waiting lists have risen dramatically across the UK as a result of the COVID-19 pandemic. The effective use of operating theatres by optimal scheduling could help mitigate this, but this requires accurate case duration predictions. Current standards for predicting the duration of surgery are inaccurate. Artificial intelligence (AI) offers the potential for greater accuracy in predicting surgical case duration. This study aimed to investigate whether there is evidence to support that AI is more accurate than current industry standards at predicting surgical case duration, with a secondary aim of analysing whether the implementation of the models used produced efficiency savings.

METHOD

PubMed, Embase, and MEDLINE libraries were searched through to July 2023 to identify appropriate articles. PRISMA extension for scoping reviews and the Arksey and O'Malley framework were followed. Study quality was assessed using a modified version of the reporting guidelines for surgical AI papers by Farrow et al. Algorithm performance was reported using evaluation metrics.

RESULTS

The search identified 2593 articles: 14 were suitable for inclusion and 13 reported on the accuracy of AI algorithms against industry standards, with seven demonstrating a statistically significant improvement in prediction accuracy (P < 0.05). The larger studies demonstrated the superiority of neural networks over other machine learning techniques. Efficiency savings were identified in a RCT. Significant methodological limitations were identified across most studies.

CONCLUSION

The studies suggest that machine learning and deep learning models are more accurate at predicting the duration of surgery; however, further research is required to determine the best way to implement this technology.

Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review

BACKGROUND

Difficulty kneeling following total knee arthroplasty (TKA) remains highly prevalent, and has cultural, social, and occupational implications. With no clear evidence of superiority, whether or not to resurface the patella remains debatable. This systematic review examined whether resurfacing the patella (PR) or not (NPR) influences kneeling ability following TKA.

METHODS

This systematic review was conducted by following PRISMA guidelines. Three electronic databases were searched utilizing a search strategy developed with the aid of a department librarian. Study quality was assessed using MINROS criteria. Article screening, methodological quality assessment and data extraction were performed by two independent authors, and a third senior author was consulted if consensus was not reached.

RESULTS

A total of 459 records were identified, with eight studies included in the final analysis, and all deemed to be level III evidence. The average MINORS score was 16.5 for comparative studies and 10.5 for non-comparative studies. The total number of patients was 24,342, with a mean age of 67.6 years. Kneeling ability was predominantly measured as a patient-reported outcome measure (PROM), with two studies also including an objective assessment. Two studies demonstrated a statistically significant link between PR and kneeling, with one demonstrating improved kneeling ability with PR and the other reporting the opposite. Other potential factors associated with kneeling included gender, postoperative flexion, and body mass index (BMI). Re-operation rates were significantly higher in the NPR cohort whereas PR cohorts had higher Feller scores, patient-reported limp and patellar apprehension.

CONCLUSION

Despite its importance to patients, kneeling remains not only under-reported but also ill-defined in the literature, with no clear consensus regarding the optimum outcome assessment tool. Conflicting evidence remains as to whether PR influences kneeling ability, and to clarify the situation, large prospective randomized studies are required.

Is success written in the stars? The effect of zodiac sign on the outcome of total knee arthroplasty

AIM

There are 12 signs of the zodiac, each attributed with its own specific personality traits, desires and attitudes. The aim of the study was to evaluate the effect of zodiac sign on patient-reported outcome measures (PROMS) following primary total knee arthroplasty (TKA).

METHOD

Patients undergoing primary TKA during a 2-year period (January 2019 to December 2020) were identified retrospectively. Patient demographics, Oxford Knee Score (OKS), EuroQol 5-dimension (EQ-5D) (baseline, 1 and 2 years) and patient satisfaction scores (1 and 2 years) were collected. Each patient's zodiac sign was assigned from their date of birth.

RESULTS

There were 509 patients (228 males [44.8%] and 281 females [55.2%]) with a mean age of 70.9 years and a mean BMI of 30.3. There were no significant differences in gender (p=0.712), age (p=0.088), BMI (p=0.660), or pre-operative OKS (p=0.539). Aries and Gemini (0.366) had the worst and Pisces the best (0.595) pre-operative EQ-5D scores (p=0.038). When adjusting for confounding, Aries (p=0.031) had a greater improvement in EQ-5D at 1 year, although this was not maintained at 2 years. When adjusting for confounding, Pisceans had significantly less of an improvement in OKS at both 1 (p=0.022) and 2 years (p=0.042) and also had a significantly lower risk of satisfaction at 2 years (odds ratio 0.41, p=0.043).

CONCLUSION

Zodiac sign was associated with outcome following TKA. Pisceans had the best pre-operative EQ-5D scores, but the least improvement in the post-operative joint specific score (OKS) and were less likely to be satisfied, despite achieving an equal improvement in their health-related quality of life (EQ-5D). Aries started with the lowest pre-operative EQ-5D scores but achieved the best scores at 1 year. Our study shows that an individual's zodiac sign may serve as a useful predictive factor for functional outcomes and satisfaction following TKA. However, our findings are the result of multiple testing in a large dataset following a data trawl, and correlation does not necessarily equal causation even in a real-world registry.

The effect of BMI and other factors on post-operative length of stay: A multivariable regression analysis of 860 patients undergoing total knee arthroplasty

BACKGROUND

There is a trend towards minimising length of stay (LOS) after total knee arthroplasty (TKA), as greater LOS is associated with poorer outcomes and higher costs. Patient factors known to influence LOS post-TKA include age and ASA grade. Evidence regarding the effect of body mass index (BMI) in particular is conflicting, with some studies finding that increased BMI predicts increased LOS, while others have found no relationship. Few previous studies, which have mostly been conducted outside the UK, have examined the effect of living alone or socioeconomic deprivation, which may be confounders.

METHODS

We conducted a retrospective cohort study of 1031 consecutive primary TKAs performed between 1 April 2021 and 31 December 2021 in a single high-volume arthroplasty centre. A multivariable negative binomial regression model was performed for the 860 patients with complete data, using pre-operative (BMI, age, gender, ASA grade, smoking, ethnicity, socioeconomic deprivation, living arrangement, EQ5D quality of life score, and indication for surgery) and peri-operative variables (surgeon, surgical approach, tourniquet use, a.m./p.m operation, operation side, duration, and day of the week).

RESULTS

Mean LOS was 2.6 days. BMI and socioeconomic deprivation had no effect on LOS (P > 0.05). Increased LOS was associated with living alone, lower EQ5D, age and ASA grade (all P < 0.001), p.m. operation (P < 0.01), female gender and duration of surgery (P < 0.05).

CONCLUSION

BMI and socioeconomic status were not correlated with LOS after TKA. Living alone, which has not been previously reported and lower pre-operative EQ5D status were significant risk factors, which merit consideration in pre-operative planning and counselling.

The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty

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.

The composition of cell-based therapies obtained from point-of-care devices/systems which mechanically dissociate lipoaspirate: a scoping review of the literature

Purpose

Cell-based therapies using lipoaspirate are gaining popularity in orthopaedics due to their hypothesised regenerative potential. Several ‘point-of-care’ lipoaspirate-processing devices/systems have become available to isolate cells for therapeutic use, with published evidence reporting their clinical relevance. However, few studies have analysed the composition of their ‘minimally-manipulated’ cellular products in parallel, information that is vital to understand the mechanisms by which these therapies may be efficacious. This scoping review aimed to identify devices/systems using mechanical-only processing of lipoaspirate, the constituents of their cell-based therapies and where available, clinical outcomes.

Methods

PRISMA extension for scoping reviews guidelines were followed. MEDLINE, Embase and PubMed databases were systematically searched to identify relevant articles until 21^st April 2022. Information relating to cellular composition and clinical outcomes for devices/systems was extracted. Further information was also obtained by individually searching the devices/systems in the PubMed database, Google search engine and contacting manufacturers.

Results

2895 studies were screened and a total of 15 articles (11 = Level 5 evidence) fulfilled the inclusion criteria. 13 unique devices/systems were identified from included studies. All the studies reported cell concentration (cell number regardless of phenotype per millilitre of lipoaspirate) for their devices/systems (range 0.005–21 × 10⁶). Ten reported cell viability (the measure of live cells- range 60–98%), 11 performed immuno-phenotypic analysis of the cell-subtypes and four investigated clinical outcomes of their cellular products. Only two studies reported all four of these parameters.

Conclusion

When focussing on cell concentration, cell viability and MSC immuno-phenotypic analysis alone, the most effective manual devices/systems were ones using filtration and cutting/mincing. However, it was unclear whether high performance in these categories would translate to improved clinical outcomes. Due to the lack of standardisation and heterogeneity of the data, it was also not possible to draw any reliable conclusions and determine the role of these devices/systems in clinical practice at present.

Level of Evidence

Level V Therapeutic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00537-0.

The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review

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.

Artificial intelligence for image analysis in total hip and total knee arthroplasty : a scoping review

AIMS

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are.

METHODS

The Embase, MEDLINE, and PubMed libraries were systematically searched to identify relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley framework were followed. Study quality was assessed using a modified Methodological Index for Non-Randomized Studies tool. AI performance was reported using either the area under the curve (AUC) or accuracy.

RESULTS

Of the 455 studies identified, only 12 were suitable for inclusion. Nine reported implant identification and three described predicting risk of implant failure. Of the 12, three studies compared AI performance with orthopaedic surgeons. AI-based implant identification achieved AUC 0.992 to 1, and most algorithms reported an accuracy > 90%, using 550 to 320,000 training radiographs. AI prediction of dislocation risk post-THA, determined after five-year follow-up, was satisfactory (AUC 76.67; 8,500 training radiographs). Diagnosis of hip implant loosening was good (accuracy 88.3%; 420 training radiographs) and measurement of postoperative acetabular angles was comparable to humans (mean absolute difference 1.35° to 1.39°). However, 11 of the 12 studies had several methodological limitations introducing a high risk of bias. None of the studies were externally validated.

CONCLUSION

These studies show that AI is promising. While it already has the ability to analyze images with significant precision, there is currently insufficient high-level evidence to support its widespread clinical use. Further research to design robust studies that follow standard reporting guidelines should be encouraged to develop AI models that could be easily translated into real-world conditions. Cite this article: Bone Joint J 2022;104-B(8):929-937.

Environmental sustainability in orthopaedic surgery

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Methods

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.

Results

A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.

Conclusion

Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary.

Cite this article: Bone Jt Open 2022;3(8):628–640.

P12 Sustainability: staff knowledge of which items of waste can be recycled in the orthopaedic operating theatre

Introduction

NHS England generates over 20 million tonnes of CO2 per year, representing 4% of the nation's greenhouse gas emissions. One third of all hospital waste comes from operating theatres. Our aim was to investigate the degree of knowledge of sustainable waste segregation amongst theatre staff in an elective orthopaedic centre and identify ways to improve their waste segregation practice.

Methods

Over a one-week period, 20 randomly selected theatre staff of different roles, completed a questionnaire asking them which disposal bin 11 commonly used orthopaedic theatre items should be placed in – general waste or recycling. After initial data collection, posters specifically identifying recyclable items were created and displayed in each operating theatre. Following this intervention, data was re-collected from another 20 randomly selected theatre staff using the same questionnaire.

Results

Results from the initial questionnaire showed general waste and recyclable items were correctly identified by staff in 65% (78/120 responses) and 59% (59/100 responses), respectively. Following the educational intervention, the percentage of correct responses increased to 68.3% (82/120 responses) and 85% (85/100 responses); i.e. staff knowledge of what can go into a recycling bin improved by 36%.

Conclusion

Educating staff by placing posters in the operating theatre can improve knowledge of what orthopaedic theatre items can be recycled and is a simple and effective way of producing sustainable change in surgery. Guiding and empowering individuals to exercise sustainable practice in the operating theatre will help the NHS to overcome the significant challenge of achieving net zero carbon by 2045.

Take-home message

Educating staff by placing posters in the operating theatre is a simple and effective way of improving waste segregation practice and will help the health service to overcome the significant challenge of achieving net zero carbon.

Mapping analysis to predict the associated EuroQol five-dimension three-level utility values from the Oxford Knee Score : a prediction and validation study

Aims

The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA).

Methods

A retrospective cohort of 5,857 patients was used to create the prediction models, and a second cohort of 721 patients from a different centre was used to validate the models, all of whom underwent TKA. Patient characteristics, BMI, OKS, and EQ-5D-3L were collected preoperatively and one year postoperatively. Generalized linear regression was used to formulate the prediction models.

Results

There were significant correlations between the OKS and EQ-5D-3L preoperatively (r = 0.68; p < 0.001) and postoperatively (r = 0.77; p < 0.001) and for the change in the scores (r = 0.61; p < 0.001). Three different models (preoperative, postoperative, and change) were created. There were no significant differences between the actual and predicted mean EQ-5D-3L utilities at any timepoint or for change in the scores (p > 0.090) in the validation cohort. There was a significant correlation between the actual and predicted EQ-5D-3L utilities preoperatively (r = 0.63; p < 0.001) and postoperatively (r = 0.77; p < 0.001) and for the change in the scores (r = 0.56; p < 0.001). Bland-Altman plots demonstrated that a lower utility was overestimated, and higher utility was underestimated. The individual predicted EQ-5D-3L that was within ± 0.05 and ± 0.010 (minimal clinically important difference (MCID)) of the actual EQ-5D-3L varied between 13% to 35% and 26% to 64%, respectively, according to timepoint assessed and change in the scores, but was not significantly different between the modelling and validation cohorts (p ≥ 0.148).

Conclusion

The OKS can be used to estimate EQ-5D-3L. Predicted individual patient utility error beyond the MCID varied from one-third to two-thirds depending on timepoint assessed, but the mean for a cohort did not differ and could be employed for this purpose.

Cite this article: Bone Jt Open 2022;3(7):573–581.

Comparison of the accuracy of 2D and 3D templating methods for planning primary total hip replacement: a systematic review and meta-analysis

There are advocates of both two-dimensional (2D) and three-dimensional (3D) templating methods for planning total hip replacement.

The aim of this study was to compare the accuracy of implant size prediction when using 2D and 3D templating methods for total hip arthroplasty, as well as to compare the inter- and intra-observer reliability in order to determine whether currently available methods are sufficiently reliable and reproducible.

Medline, EMBASE and PubMed were searched to identify studies that compared the accuracy of 2D and 3D templating for total hip replacement.

Results were screened using the PRISMA flowchart and included studies were assessed for their level of evidence using the Oxford CEBM criteria. Non-randomized trials were critically appraised using the MINORS tool, whilst randomized trials were assessed using the CASP RCT checklist.

A series of meta-analyses of the data for accuracy were also conducted.

Ten studies reported that 3D templating is an accurate and reliable method of templating for total hip replacement. Six studies compared 3D templating with 2D templating, all of which concluded that 3D templating was more accurate, with three finding a statistically significant difference.

The meta-analyses showed that 3D CT templating is the most accurate method.

This review supports the hypothesis that 3D templating is an accurate and reliable method of preoperative planning, which is more accurate than 2D templating for predicting implant size. However, further research is needed to ascertain the significance of this improved accuracy and whether it will yield any clinical benefit.

The safe resumption of elective orthopaedic services following the first wave of the COVID-19 pandemic : a review of 2,316 consecutive cases and implications for recovery following further waves

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Methods

A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019.

Results

A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery.

Conclusion

Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery.

Level of evidence: III

Cite this article: Bone Jt Open 2022;3(1):42–53.

The accuracy and reliability of preoperative digital 2D templating in prosthesis size prediction in uncemented versus cemented total hip arthroplasty: a systematic review and meta-analysis

The purpose of this study was to compare the accuracy and the inter- and intra-observer reliability of preoperative digital 2D templating in prosthesis size prediction for the planning of cemented or uncemented THA.

This study was registered in the NIHR PROSPERO database (ID: CRD42020216649) and conducted according to the PRISMA guidelines. A search of electronic databases in March 2021 found 29 papers overall. The quality of evidence was assessed using the IHE Quality Appraisal of Case Series Studies Checklist and the CASP Randomised Controlled Trials Checklist. A meta-analysis was conducted, and the accuracy was presented as proportions and the inter- and intra-observer reliability were measured using intraclass correlation coefficients (ICC).

Accuracy within one prosthesis size (±1) for cemented stems was 0.89 (95% confidence interval (CI) 0.83–0.95), cemented cups 0.78 (95% CI 0.67–0.89), uncemented stems 0.74 (95% CI 0.66–0.82) and uncemented cups 0.73 (95% CI 0.67–0.79) (test of group differences: p = 0.010). Inter-observer reliability (ICC) for uncemented cups was 0.88 (95% CI 0.85–0.91), uncemented stems 0.86 (95% CI 0.81–0.91), cemented stems 0.69 (95% CI 0.54–0.84) and cemented cups 0.68 (95% CI 0.55–0.81) (test of group differences: p = 0.004). Due to lack of data, intra-observer reliability (ICC) could only be calculated for uncemented prostheses, which for the stems was 0.90 (95% CI 0.88–0.92) and for the cups was 0.87 (95% CI 0.83–0.90) (test of group differences: p = 0.124).

The accuracy of preoperative digital templating is greater for cemented prostheses, but the inter-observer reliability is greater for uncemented prostheses. The intra-observer reliability showed a high level of agreement for uncemented prostheses.

Cite this article: EFORT Open Rev 2021;6:1020-1039. DOI: 10.1302/2058-5241.6.210048

Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review

Approximately 60,000 cemented femoral stems are implanted in the UK each year with the majority being manufactured from stainless steel containing 10–15% nickel. Nickel hypersensitivity has been reported in up to 13% of the general population and there is a concern that nickel hypersensitivity might adversely affect the outcome of total hip replacement (THR). We reviewed the current literature on the potential link between nickel hypersensitivity and THR complications, and the usefulness of patch testing.

We conducted a literature search in PubMed, MEDLINE and EMBASE databases. The level of evidence and the quality of the selected studies were assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Methodological Index for Non-Randomised Studies tool, respectively.

Twenty-six studies met the inclusion criteria, reporting on 1852 patients who underwent primary or revision THR. All studies detailed skin patch testing and recorded prevalence of nickel hypersensitivity from 1.5% to 33.3%. Five studies reported a rise in Nickel hypersensitivity following THR, while four reported a decreased prevalence post-operatively. Eight studies concluded that metal hypersensitivity could have developed following THR, while seven studies did not support a link between metal hypersensitivity and THR complications. Four of the studies recommended routine patch testing pre-operatively, but three others concluded that routine patch testing was not indicated.

We have not identified a link between nickel hypersensitivity and THR complications, and the role of patch testing remains unclear. Further large-scale studies would be required to investigate this relationship and to clarify the role of patch testing in facilitating implant selection.

Cite this article: EFORT Open Rev 2021;6:825-838. DOI: 10.1302/2058-5241.6.210051

Cell-based therapies for the treatment of sports injuries of the upper limb

Introduction: The use of cell-based therapies in the management of sports injuries of the upper limb is increasingly popular despite the limited scientific evidence available for their use. We aim to evaluate the evidence for the use of cell-based therapies in these injuries and recommend areas for further research.Areas covered: In accordance with a published protocol (PROSPERO; Registration No. CRD42020193258), a comprehensive search of the literature was performed using the MEDLINE and EMBASE databases from inception to June 2020. All human studies reporting on the clinical, histological, or radiological outcomes following the use of cell-based therapies in the management of epicondylitis or rotator cuff pathology were included in this study. This resulted in 22 studies being included in this review, all of which underwent risk of bias assessments.Expert opinion: The evidence for the use of cell-based therapies in upper limb sports injuries is limited and generally of low quality. Given the heterogeneity in the cell types used, their harvesting methods and cell amounts, future research should be targeted at developing standardization of the reporting of these studies and more direct comparative studies looking at the efficacy of the different cell types.

Cell-based therapy in soft tissue sports injuries of the knee: a systematic review

INTRODUCTION

An ever-increasing number of clinics are offering purportedly 'regenerative' stem-cell treatments, although cell-based therapies may not primarily act as stem cells and have shown the ability to regenerate end-target tissues in some clinical studies only. We aim to systematically review the evidence for their use in soft-tissue sports injuries of the knee.

AREAS COVERED

A search for articles pertaining to the use of preparations of, or containing, mesenchymal stem cells (MSCs) in human subjects in sports knee injuries yielded 14 relevant results for inclusion after screening: 7 used cultured MSCs, 5 bone marrow concentrate (BMC), and the remaining 2 evaluated stromal vascular fraction (SVF) and tenocyte-like-cells. Most studies were level 3 or lower (n = 9).

EXPERT OPINION

There is insufficient high-quality evidence for the use of cell-based therapies that demonstrates either ligamentous or tendinous healing, meniscal volume restoration, or post-traumatic osteoarthritis amelioration/regression. Methods of cell harvesting, preparation, and application are highly heterogenous. Efforts should be directed toward standardization of protocols and their reporting, starting with more basic scientific investigations of MSCs and their niche, as well as rigorous, large clinical RCTs adhering to the reporting principles set out by recent expert consensus.

The results of meniscal allograft transplantation surgery: what is success?

BACKGROUND

Meniscal allograft transplantation (MAT) may improve symptoms and function, and may limit premature knee degeneration in patients with symptomatic meniscal loss. The aim of this retrospective study was to examine patient outcomes after MAT and to explore the different potential definitions of 'success' and 'failure'.

METHODS

Sixty patients who underwent MAT between 2008 and 2014, aged 18-50 were identified. Six validated outcome measures for knee pathologies, patient satisfaction and return to sport were incorporated into a questionnaire. Surgical failure (removal of most/all the graft, revision MAT or conversion to arthroplasty), clinical failure (Lysholm < 65), complication rates (surgical failure plus repeat arthroscopy for secondary allograft tears) and whether patients would have the procedure again were recorded. Statistics analysis included descriptive statistics, with patient-reported outcome measures reported as median and range. A binomial logistic regression was performed to assess factors contributing to failure.

RESULTS

Forty-three patients (72%) responded, mean age 35.6 (±7.5). 72% required concomitant procedures, and 44% had Outerbridge III or IV chondral damage. The complication rate was 21% (9). At mean follow-up of 3.4 (±1.6) years, 9% (4) were surgical failures and 21% (9) were clinical failures. Half of those patients considered a failure stated they would undergo MAT again. In the 74% (32) reporting they would undergo MAT again, median KOOS, IKDC and Lysholm scores were 82.1, 62.1 and 88, compared to 62.2, 48.5 and 64 in patients who said they would not. None of the risk factors significantly contributed to surgical or clinical failure, although female gender and number of concomitant procedures were nearly significant. Following MAT, 40% were dissatisfied with type/level of sport achieved, but only 14% would not consider MAT again.

CONCLUSIONS

None of the risk factors examined were linked to surgical or clinical failure. Whilst less favourable outcomes are seen with Outerbridge Grade IV, these patients should not be excluded from potential MAT. Inability to return to sport is not associated with failure since 73% of these patients would undergo MAT again. The disparity between 'clinical failure' and 'surgical failure' outcomes means these terms may need re-defining using a specific/bespoke MAT scoring system.

Patellectomy for osteoarthritis: a new tension preserving surgical technique to reconstruct the extensor mechanism with retrospective review of long-term follow-up

Background

The management of severe patellofemoral arthritis in young patients remains a significant problem. For many, patellofemoral replacement is not a desirable option. Current surgical techniques for patellectomy disrupt the extensor lever arm causing weakness. We describe a new technique that maintains the extensor mechanism tension and a case series showing good results for patella-only arthritis at a mean follow-up of 11 years.

Methods

Eight patellectomies were performed using a new surgical technique in patients with a mean age of 38 years, and an average follow-up of 11 years (range 8–16 years). Patients were followed up using a pain visual analogue scale, Lysholm knee score and patient-reported outcome measures.

Results

All patients experienced pain relief following surgery. Those with patella-only arthritis had better outcomes than patients who had patella and trochlea disease. All patients had either full or near full extension. Lysholm scores were better in patients who had disease confined to the patella.

Conclusion

We believe patellectomy with this tension-preserving technique has a role for the management of anterior knee pain secondary to severe patella-only arthritis in young patients where arthroplasty is not desirable.

The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom

BACKGROUND

Musculoskeletal symptoms are common reasons for patients seeking medical attention. Basic competency in musculoskeletal medicine is therefore essential for all clinicians. To our knowledge, this is the first assessment of the competency in musculoskeletal medicine of medical students in the United Kingdom.

METHODS

Medical students were enrolled after passing final university examinations and being awarded degrees of Bachelor of Medicine, Bachelor of Surgery (MBBS) or Medicinae Baccalaureus, Baccalaureus Chirurgiae (MBChB) in 2013 and were assessed with use of the Freedman and Bernstein musculoskeletal cognitive examination tool.

RESULTS

Two hundred and thirty students were recruited, of whom 210 were suitable for inclusion. Only 21% (forty-four students) passed the assessment. Mandatory exposure to musculoskeletal medicine during medical school consisted of orthopaedics for 100% of participants for a mean duration of 2.65 weeks, rheumatology for 96% of participants for a mean duration of 2.5 weeks, and sports medicine for 1% of participants for a mean duration of two weeks. There was a significant difference (p = 0.002) in scores between those with career interests in musculoskeletal specialties (69.3%) and the rest of the cohort (54.9%). There was also a significant difference (p = 0.001) in scores between participants with career interests in general practice (42%) and the rest of the cohort (56%). Only 40% of participants considered themselves competent in musculoskeletal medicine. Fifty-five percent thought that musculoskeletal conditions would be an important component of their future practice.

CONCLUSIONS

Our findings suggest that medical schools may be currently failing to ensure that medical students have a basic competence in musculoskeletal medicine. Further investigation is warranted to fully assess the current training provided by U.K. medical schools in musculoskeletal medicine, and appropriate steps must be taken to improve the quantity and quality of training in musculoskeletal medicine in the United Kingdom.

The intracapsular atraumatic arthroscopic technique for closure of the hip capsule

The hip joint capsule is a critical static stabilizer of the hip. During hip arthroscopy, the capsule is breached to gain exposure to treat femoroacetabular impingement lesions. There have been recent concerns regarding hip instability after hip arthroscopy, and relatively few techniques have been described for atraumatic arthroscopic closure of the hip capsule. We describe an atraumatic, inside-out, 2-portal technique to repair the capsule.

Mucous cystadenoma of the appendix: is it safe to remove it by a laparoscopic approach?

Mucinous cystadenoma is an uncommon neoplasm of the appendix usually discovered intraoperatively. Its clinical significance lies in the possible rupture and consequent spillage of mucin into the peritoneal cavity, leading to pseudomyxoma peritonei. Even if laparoscopy has been successfully used to perform appendectomy, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin during surgery. We report a case of mucous cystadenoma of the appendix, which was successfully removed using a laparoscopic approach. At a 12-month follow-up assessment, the patient was free of disease. We believe that the laparoscopic approach is safe if surgery can be performed without grasping the lesion, and if the specimen is removed through the abdominal wall using a bag. Conversion to laparotomy should be considered if the lesion must be traumatically grasped, or if the tumor clearly extends beyond the appendix.

Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees?

BACKGROUND

It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery.

METHODS

Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration.

RESULTS

The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33).

CONCLUSIONS

In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.

Hepatectomy using intraoperative ultrasound-guided radiofrequency ablation

Radiofrequency (RF) ablation is emerging as a new therapeutic method for management of hepatic tumors. Here we report a new technique for hepatectomy using ultrasound-guided RF, which renders liver resection a less complex surgical procedure. Under intraoperative ultrasound (IOUS) guidance, a Cool-Tip RF probe is inserted into the liver parenchyma surrounding the tumor. A zone of coagulative desiccation is created around the tumor ensuring a 1-cm resection margin. Then, using a scalpel, the liver parenchyma is divided, and the tumor is removed with minimal blood loss. RF works by the conversion of RF waves into heat. Coagulative desiccation occurs and results in sealing of blood and biliary vessels. This is a new technique for liver resection that enables the surgeon to operate in a virtually bloodless field without the use of ischemia, sutures, or ties. It also spares the need for intraoperative blood transfusion and postoperative intensive care unit facilities, and it reduces the length of in patient stay.

Resection of renal metastases to the pancreas: a surgical challenge

BACKGROUND

Metastasis to the pancreas from renal cell carcinoma (RCC) is distinctly uncommon. Most cases are detected at an advanced stage of the disease and are thus unsuitable for resection. A solitary RCC metastasis to the head of pancreas is rarely encountered and, although it is potentially amenable to surgical resection, surgeons may be hesitant to perform pancreatoduodenectomy.

CASES OUTLINES

Two patients with a solitary RCC metastasis to the head of pancreas were treated by pancreatoduodenectomy, while a third with multiple RCC metastases declined any treatment. Two of the patients were asymptomatic, and one presented with anaemia and mild abdominal pain. Computed tomography (CT) and angiography were used to exclude other metastases and to assess resectability of the pancreatic tumour. All three patients are still alive, those with resectable disease at 2 years and 9 years and the one with irresectable disease at 4 years.

DISCUSSION

Isolated RCC metastasis to the pancreas is a rare event. Patients present either on follow-up imaging or with symptoms such as mild abdominal pain, weight loss, jaundice, anaemia or gastrointestinal bleeding (whether occult or overt). Dynamic spiral CT can visualise the tumour and exclude distant metastasis. Angiography often reveals a highly vascularised tumour and will help to assess resectability. In the absence of widespread disease, pancreatic resection can provide long-term survival in metastatic RCC, although few cases have been reported with lengthy follow-up. The prognosis is better than for pancreatic adenocarcinoma.

Prognosis following a second whiplash injury

Five percent of the population have suffered a whiplash injury. Of these, 43% suffer long-term symptoms. We undertook a retrospective study of 79 patients who had suffered two whiplash injuries. The severity of each patient's symptoms was assessed after the first and second injuries using the Gargan and Bannister classification. Overall, 84% of patients reported increased symptoms following the second injury. Ninety-seven percent of patients who had been symptom free before the second injury reported persisting discomfort.

Immunoglobulin-like domains define the nerve growth factor binding site of the TrkA receptor

Nerve growth factor (NGF) is involved in the development and maintenance of the nervous system. NGF binds with high affinity to the extracellular region of the tyrosine kinase receptor TrkA. This domain comprises leucine and cysteine rich motifs, followed by two immunoglobulin like (Ig-like) domains. We describe the expression and purification of recombinant Ig-like domains. Fluorescence and circular dichroism spectroscopy show that the protein is folded into a compact globular structure and contains mainly beta-sheet secondary structure. Recombinant protein binds to NGF and can inhibit NGF bioactivity both in vitro and in vivo.