A non-randomised pragmatic trial for the early detection and prevention of surgical wound complications using an advanced hydropolymer wound dressing and smartphone technology: The EDISON trial protocol.

Total hip or knee arthroplasty is a highly effective intervention for treating the symptoms of degenerative joint disease or osteoarthritis (OA), often an unwelcome consequence of obesity. A safe and common surgical procedure, hip and knee arthroplasty procedures are not immune to the occurrence of postoperative complications such as surgical site infection (SSI) or surgical wound dehiscence (SWD). While published rates of SSI following hip or knee arthroplasty are low, 1% to 2% in some cases, it is the resulting wound complication and its clinical management and the impact on patient well-being and return to daily life for the 1% to 2% that is of concern. Postoperative complications such as SSI are a major cost driver to the health care system following arthroplasty and often result in extended lengths of stay, readmission for further surgery, primary and community nursing visits, and are a costly burden to health care settings. Early identification of a wound complication through post-discharge surveillance using a fully transparent dressing and smartphone technology and patient education may ameliorate contributing factors or reduce the likelihood of a complication occurring in the first instance. This clinical trial is a non-randomised pragmatic convenience sample carried out in 200 participants of both sexes receiving either a TKA or THA. There will be equal allocation to two groups (100 hips and 100 knees), with 50 in each allocation receiving the interventional dressing and 50 as control. The dressing will be applied prior to discharge and participants will be provided with education on postoperative wound care, when to contact home care nursing for a potential wound problem, and use of their smartphone to capture and send images of their incision site to the study nurses. Participants will also be followed up by home care nursing services at day 14 for suture removal and wound assessment. Participants will complete a patient-reported outcomes survey on day 14 and followed up on day 30 after surgery for wound assessment. The results of this trial may provide a novel pathway using a fully transparent dressing and digital technologies for the prevention of acute readmissions because of wound complications through early detection and intervention.

Alcohol exposure during pregnancy altered childhood developmental trajectories in a rural South African community.

AIM: This study examined the effects of prenatal alcohol exposure on childhood development trajectories in a rural South African community between 2003 and 2008. METHODS: We assessed 121 children at 7-12 months (year one) and 5-6 years (year five) using the Griffiths Mental Developmental Scales - Extended Revised, which measures sensorimotor, cognitive and social development, with lower scores indicating developmental delay. We also interviewed their mothers or caregivers. Three groups were identified: 29 with foetal alcohol syndrome (FAS) or partial FAS (pFAS), 57 more who had been exposed to alcohol and 35 controls who had not. RESULTS: The scale's total score was higher in the controls than in the FAS/pFAS group at year one and year five and in the alcohol-exposed group at year five. Many groups' trajectories declined when compared with global norms, but the trajectories in the FAS/pFAS and the alcohol-exposed groups declined more than the controls for eye-hand and performance and total score. Earlier pregnancy recognition in the FAS/pFAS group correlated strongly (r = -0.77) with higher GQ in year five. CONCLUSION: FAS/pFAS and prenatal alcohol exposure affected the Griffiths scores more than the control group. Efforts are needed to detect pregnancy early and reduce alcohol exposure.

Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis.

AIM: To determine the prevalence of musculoskeletal disorders and anatomical regions which are most frequently injured in ballet dancers. METHODS: Published (AMED, CiNAHL, EMBASE, SPORTDiscus, psycINFO, MEDLINE, the Cochrane Library) and grey literature databases (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) were searched from their inception to 25th May 2015 for papers presenting data on injury prevalence in ballet dancers. Two reviewers independently identified all eligible papers, data extracted and critically appraised studies. Study appraisal was conducted using the CASP appraisal tool. Pooled prevalence data with 95% confidence intervals were estimated to determine period prevalence of musculoskeletal disorders and anatomical regions affected. RESULTS: Nineteen studies were eligible, reporting 7332 injuries in 2617 ballet dancers. The evidence was moderate in quality. Period prevalence of musculoskeletal injury was 280% (95% CI: 217-343%). The most prevalent musculoskeletal disorders included: hamstring strain (51%), ankle tendinopathy (19%) and generalized low back pain (14%). No papers explored musculoskeletal disorders in retired ballet dancers. CONCLUSIONS: Whilst we have identified which regions and what musculoskeletal disorders are commonly seen ballet dancers. The long-term injury impact of musculoskeletal disorders in retired ballet dancers remains unknown.

Long term outcomes after lateral anal sphincterotomy for anal fissure: a retrospective cohort study.

PURPOSE: Lateral anal sphincterotomy is the gold standard of surgical treatment for anal fissure. Patients undergoing this procedure are warned about the risk of incontinence; however, there are few reports on long-term outcomes. We conducted this study to investigate long-term outcomes after lateral anal sphincterotomy, focusing specifically on postoperative incontinence. METHODS: Patients who underwent lateral anal sphincterotomy at a university teaching hospital between 1998 and 2004 were sent questionnaires to allow us to assess their continence according to the Cleveland Continence Score. RESULTS: The response rate was 58 % and the responders comprised 25 men and 13 women, with a median age of 49 years (range 16-82 years). The success rate for fissure healing following surgery was 92 %, being significantly more likely in patients with textbook symptoms (p = 0.016) and those with chronic disease (p = 0.006). The overall complication rate was 13.2 %. Long-term objective and symptomatic incontinence were reported by two (5.6 %) patients, one of whom required a colostomy. CONCLUSION: Success rates after lateral anal sphincterotomy were satisfactory, but careful patient selection based on symptoms and disease chronicity may improve results further. Patients with predisposing risk factors for the development of incontinence, particularly multiparous women, are arguably better treated with non-surgical options.

A systematic review to determine the reliability of knee joint position sense assessment measures.

BACKGROUND: The assessment of joint position sense (JPS) is the most widely used measurement of knee proprioceptive capability within the literature. However, it remains unclear what the most reliable method is to assess this. The purpose of this study was to determine the intra- and inter-rater reliability of the various methods used to assess knee JPS. METHODS: A systematic review of published and unpublished literature sources was conducted up to June 2012. All studies principally assessing the reliability (intra- or inter-rater) or reproducibility of a JPS of the knee were included. The methodological quality of each study was reviewed using the Critical Appraisal Skills Programme tool. RESULTS: A total of 18 studies were eligible, assessing the reliability of JPS with 456 knees. The reliability of four methods of JPS has been recorded: position replication using a model, image recorded angulation, electrogoniometry and dynamometry/angular motion chair. Intra-rater reliability was good for the assessment of JPS using photographs and digital images, and replicating knee position using a paper model, this was good but variable when electrogoniometry was used, and moderate but variable when assessed using dynamometry/angle motion chairs. The assessment of JPS by image recorded angulation, electrogoniometry and dynamometry/angular motion chair has demonstrated good inter-rater reliability. CONCLUSIONS: Whilst JPS methods appear to have variable reliability, the four assessment methods should be further assessed with pathological populations such as those following patellar dislocation or anterior cruciate ligament rupture. This will better facilitate the generalisability of JPS assessment methods to inform clinical practice.

Universal prevention is associated with lower prevalence of fetal alcohol spectrum disorders in Northern Cape, South Africa: a multicentre before-after study.

AIMS: Prevalence of fetal alcohol spectrum disorders (FASDs) is remarkably high in several provinces of South Africa; yet population-level knowledge of the harms of maternal drinking remains low. In two heavily affected areas, we assessed effectiveness of interventions to heighten awareness of these harms and to alter social norms about drinking in pregnancy. METHODS: FASD prevalence, maternal knowledge and drinking behaviours were investigated in two Northern Cape Province towns, before and after interventions which included highlighting FASD using local media and health promotion talks at health facilities. Independently, two dysmorphologists and a neuropsychometrist examined children at 9 and 18 months. RESULTS: Pre-intervention maternal knowledge of alcohol harms was low and FASD prevalence 8.9% (72/809). Interventions reached high coverage and knowledge levels increased substantially. FASD prevalence was 5.7% post-intervention (43/751; P = 0.02); 0.73 lower odds, controlling for maternal age and ethnicity (95% confidence interval = 0.58-0.90). No change was detected in more severe FASD forms, but in the whole population, median dysmorphology scores reduced from 4 [inter-quartile range (IQR) = 2-7] to 3 (IQR = 1-6; P = 0.002). CONCLUSION: This, the first prevention study using FASD outcomes, suggests that universal prevention might reduce FASD by ∼30% and have population-level effects. This supports intensifying universal interventions where knowledge of harms of maternal drinking is low. These efforts need to be accompanied by alcohol-dependence treatment to lower more severe FASD forms.

The reliability and validity of radiological assessment for patellar instability. A systematic review and meta-analysis.

OBJECTIVE: To determine the discriminative validity and reliability of the evidence base using meta-analysis. MATERIALS AND METHODS: A review of published sources using the databases AMED, CINHAL, EMBASE, MEDLINE, Scopus and the Cochrane Library, and for unpublished material was conducted. All studies assessing the reliability, validity, sensitivity or specificity of magnetic resonance imaging (MRI), computed tomography (CT) or ultrasound (US) of the patellofemoral joint of patients following patellar dislocation, subluxation or instability, were included. A meta-analysis was performed to assess the difference in radiological measurements between healthy controls and subjects with patellar instability in order to assess discrimination validity. A narrative assessment was used to evaluate the inter- and intra-observer reliability as well as the sensitivity and specificity of specific radiological measurements. RESULTS: A total of 27 studies were reviewed. The findings indicated that there was acceptable inter-observer and intra-observer reliability and validity for different methods of assessing patellar height and the sulcus angle with X-ray, MRI and CT methods, and the tibial tubercle-trochlear groove (TT-TG) assessed using CT. There was poor reliability or validity for the assessment of severity of trochlear dysplasia and the sulcus angle using US. CONCLUSION: There is insufficient evidence to determine the reliability, validity, sensitivity or specificity of tests such as the congruence angle, lateral patellar displacement, lateral patellar tilt, trochlear depth, boss height, the crossing sign or Wiberg patellar classification. A critical appraisal of the literature identified a number of recurrent methodological limitations. Further study is recommended to evaluate the reliability and validity of these radiological outcomes using well-designed radiological trials.

Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review.

OBJECTIVES: Little has been published about which physiotherapy interventions are used to treat patients with instability of the patella. The purpose of this study was to review the literature systematically to determine the clinical outcomes of rehabilitation for patients following a lateral patellar dislocation. DATA SOURCES: AMED, CINHAL, Cochrane Library, EMBASE, MEDLINE, PEDro and Scopus database searches were performed from their inception to August 2009. A search of unpublished and grey literature databases was undertaken, in addition to contacting all authors of included publications. REVIEW METHODS: All publications presenting the outcomes of patients following a conservatively managed lateral patellar dislocation were included. All eligible articles were appraised critically using the Critical Appraisal Skills Programme appraisal tool. Data on interventions, cohort characteristics, outcome measures and results were extracted. A narrative research synthesis method approach was adopted. RESULTS: In total, 29 publications were eligible for inclusion in this review. Although a proportion of patients experienced recurrent instability and dislocation episodes after rehabilitation, a large proportion of patients reported acceptable outcomes following physiotherapy. No randomised controlled clinical trials were identified assessing different physiotherapy interventions. The evidence base included a number of under-powered studies which poorly described the specific physiotherapy interventions prescribed. CONCLUSIONS: Further, well-designed randomised controlled trials assessing different conservative management strategies with specific patient groups, to provide pre-intervention as well as follow-up data, are required to determine the optimal clinical outcomes of physiotherapy for patients following a lateral patellar dislocation.

Wound closure in flexion versus extension following total knee arthroplasty: a systematic review.

Optimising knee range of motion following total knee arthroplasty (TKA) is important for patient satisfaction, functional outcome and early rehabilitation to promote accelerated discharge. Historically, wound closure following TKA has been performed in extension. It has been suggested that knee position during wound closure may influence range of motion and clinical outcomes following TKA. The purpose of this study was to determine whether TKA wounds should be closed in flexion or extension. An electronic search of MEDLINE, EMBASE, CINAHL and AMED databases was made in addition to a review of unpublished material. All included papers were critically appraised using a modified PEDro (Physiotherapy Evidence Database) critical appraisal tool. Three papers were eligible, assessing 237 TKAs. On analysis, patients with TKA wounds closed in flexion had greater flexion range of motion and required less domiciliary physiotherapy compared to those with wounds closed in full extension. The specific degree of knee flexion used when closing total knee replacement wounds may be an important variable to clinical outcome. However, the present evidence-base is limited in both size and methodological quality.

Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

There is no consensus in the literature regarding the optimal timing of surgical reconstruction of the ruptured anterior cruciate ligament (ACL). Previous authors have suggested that early reconstruction may facilitate an early return to work or sport but may increase the incidence of post-operative complications such as arthrofibrosis. This study systematically reviewed the literature to determine whether ACL reconstruction should be performed acutely following rupture. Medline, CINAHL, AMED, EMBASE databases and grey literature were reviewed with a meta-analysis of pooled mean differences where appropriate. Six papers including 370 ACL reconstructions were included. Early ACL reconstructions were considered as those undertaken within a mean of 3 weeks post-injury; delayed ACL reconstructions were those undertaken a minimum of 6 weeks post-injury. We found there was no difference in clinical outcome between patients who underwent early compared to delayed ACL reconstruction. However, this conclusion is based on the current literature which has substantial methodological limitations.

Clinical and radiological outcomes of fixed- versus mobile-bearing total knee replacement: a meta-analysis.

Controversy exists regarding the clinical and radiological differences in outcomes between fixed- and mobile-bearing total knee replacements (TKR). The aim of this study was to compare these two TKR designs using a meta-analysis of the electronic databases MEDLINE, EMBASE, CINAHL and AMED in addition to a review of unpublished material. All included papers were critically appraised using a modified PEDro critical appraisal tool. Thirty-three studies were eligible, assessing the outcomes of 3532 TKRs. Analysis suggested that there was no significant difference in clinical or radiological outcomes and complication rates between fixed- and mobile-bearing TKRs.

Immobilization Regime Following Lateral Patellar Dislocation: A Systematic Review and Meta-Analysis of the Current Evidence Base.

Historically, patients following patellar dislocation have been immobilized in a cylinder plaster of Paris cast for around 6 weeks. However, there remains controversy over whether immobilization should be advocated following this injury. There also remains debate over the methods and duration for which patients are immobilized. A systematic review was undertaken to assess these questions. The electronic databases MEDLINE, EMBASE, CINAHL, and AMED, in addition to a review of unpublished material, was undertaken. All of the included papers were appraised using the CASP appraisal tool. Two studies were eligible, assessing the outcomes of 177 lateral patellar dislocations. The results suggested that there is no significant difference in clinical outcomes when using a cylinder cast or posterior splint in full extension compared to an elastic bandage. No studies were identified specifically assessing the clinical outcomes of patients immobilized compared to those not immobilized, or assessing different durations of immobilization. The present evidence base is insufficient in both size and methodological quality to justify the use of immobilization for patients following a lateral patellar dislocation.

The reliability and validity of assessing medio-lateral patellar position: a systematic review.

Medio-lateral patellar position is regarded as a sign of patellofemoral pain syndrome and patellar instability. Its assessment is important in accurately performing patellofemoral therapeutic taping techniques. The purpose of this paper is to systematically review the literature to determine the reliability and validity of evaluating medio-lateral patellar position. An electronic database search was performed accessing AMED, British Nursing Index, CINAHL, the Cochrane database, EMBASE, Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Zetoc to July 2008. Conference proceedings and grey literature were also scrutinised for future publications. All human subject, clinical trials, assessing the inter- or intra-tester reliability, or the criterion validity, were included. A CASP tool was employed to evaluate methodological quality. Nine papers including 237 patients (306 knees) were reviewed. The findings of this review suggest that the intra-tester reliability of assessing medio-lateral patellar position is good, but that inter-tester reliability is variable. The criterion validity of this test is at worse moderate. These are based on a limited evidence-base. Further study is recommended to compare the McConnell (1986) [McConnell J. The management of chondromalacia patellae: a long term solution. Australian Journal of Physiotherapy 1986;32(4):215-23] and Herrington (2002) [Herrington LC. The inter-tester reliability of a clinical measurement used to determine the medial/lateral orientation of the patella. Manual Therapy 2002;7(3):163-7] methods of assessing medio-lateral patellar position in patients with well-defined patellofemoral disorders.

An evaluation of the clinical tests and outcome measures used to assess patellar instability.

A literature review was undertaken to determine which clinical tests and outcome measures have been described to diagnose and evaluate patellar instability, and to assess the literature examining the sensitivity and specificity of these diagnostic tests, or the reliability, validity and responsiveness of the outcome measures identified. An electronic search was undertaken using standard databases as well as a hand search of specialist journals, reference lists and local medical libraries. All English language publications describing and/or evaluating diagnostic tests and outcome measures for patellar instability patients were included. On review, 104 papers and 64 textbooks were included. Eighteen diagnostic tests and 10 outcome measures were identified. Of these only five diagnostic tests (Bassett's sign; apprehension test; gravity subluxation test; clinical assessment of the tibial tubercle to trochlear groove value; Q-angle) and seven outcome measures (modified International Knee Documentation Committee knee ligament standard evaluation form; Kujala anterior knee pain scale; Fulkerson knee instability scale; Lysholm knee scoring scale; Tegner activity level scale; Short Form-36; Musculoskeletal Function Assessment injury and arthritis survey) had been assessed for accuracy in five studies. The sensitivity, specificity, reliability or validity, of these tests remains unclear for this patient population. Further work is needed to assess the appropriateness of the identified tests and outcomes for patellar instability cohorts.

When Should Open Reduction and Internal Fixation Ankle Fractures Begin Weight Bearing? A Systematic Review.

The objective of this paper was to review the literature to assess when open reduction and internal fixation ankle fractures should commence weight bearing for the best outcome. An electronic search was undertaken of the databases AMED, Cinahl, Embase, Medline (via Ovid), Pedro and Pubmed, from their inception to November 2005. References lists were scrutinised and a hand search was also performed. We included all English language, human subject, controlled clinical trials, comparing the effects of early against later weight bearing following open reduction and internal fixation of ankle fractures. Two reviewers independently assessed the methodological quality of the literature using the PEDro (Physiotherapy Evidence Database) scoring system. Five papers comprising of 366 ankle fractures were reviewed. Overall, there was no significant difference between commencing early, compared to later weight bearing in subjects following open reduction and internal fixation, when evaluated against function, pain, range of movement, radiological assessment, complications, and return to work. The evidence reviewed was generally poor, with numerous methodological design limitations. The literature suggested that were was little difference between encouraging early or delayed weight bearing after open reduction and internal fixation of ankle fractures. Neither early nor later weight bearing significantly improves or jeopardises outcomes. However, due to the plethora of methodological limitations and limited evidence, it is not possible to reference this conclusion with conviction. Further large, well-designed randomized controlled trials are required to evaluate this area.