Exploring the role of the built environment and psychosocial mediators on knee function in knee osteoarthritis patients in Singapore: a cross-sectional study.

OBJECTIVES: (1) To examine if a more accessible built environment (BE) is significantly associated with better knee function outcomes in knee osteoarthritis (OA) patients. (2) To assess if the relationship between BE and knee function is mediated by fear of movement and self-efficacy. DESIGN: Cross-sectional study. SETTING: Two tertiary hospitals in Singapore. PARTICIPANTS: 212 knee OA patients (mean: 63.81±8.27 years old), majority female (69.8%). INCLUSION CRITERIA: (i) meets National Institute for Health and Care Excellence criteria for knee OA, (ii) independent community ambulant. EXCLUSION CRITERIA: (i) alternative diagnosis to knee OA, (ii) secondary osteoarthritis, (iii) severe medical and/or cognitive comorbidity impairing activities of daily living, (iv) previous knee arthroplasty, (v) wheelchair bound, or (vi) pregnant. PRIMARY AND SECONDARY OUTCOME MEASURES; STATISTICS: How self-efficacy (Arthritis Self-Efficacy Scale-8 (ASES-8)) and fear of movement (Brief Fear of Movement (BFOM)) mediates impact of overall BE (IPAQ-Environment module: Access to Destinations) and five item-specific domains of BE accessibility on knee function (Knee Injury and Osteoarthritis Outcome Score-12 (KOOS-12)). For variables significantly correlated with BE and KOOS-12 in bivariate Pearson correlation tests, mediation analysis was performed with confounders adjusted. RESULTS: Total BE (r=0.142, p=0.038) and accessibility to transit station (r=0.161, p=0.019) were positively correlated with KOOS-12. Structural barriers (r=-0.138, p=0.045) were negatively correlated with KOOS-12. ASES-8 was a significant mediator in the relationship between accessibility to transit station and KOOS-12 (coeff=0.87, 95% CI=(0.24, 1.69), p=0.005) and between total BE and KOOS-12 (coeff=0.25, 95% CI=(0.10, 0.45), p=0.004). BFOM was a marginally significant mediator between structural barriers and KOOS-12 (coeff=-0.36, 95% CI=(-0.86, -0.02); p=0.054). CONCLUSION: More accessible BE and lesser structural barriers in the BE are associated with better knee function. Self-efficacy mediates the relationship between overall BE accessibility and knee function. Fear of movement mediates the negative association between barriers in the BE and knee function.Applications include assessing BE barriers and psychosocial mediators in clinician consultations, developing multidisciplinary integrated care models and urban designers planning mobility friendly BEs. TRIAL REGISTRATION NUMBER: The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

Does concomitant thyroid disorder lead to worse outcomes in frozen shoulder? - A systematic review.

BACKGROUND: Frozen shoulder is a common pathology characterized by significant shoulder pain, range of motion limitation and physical disability. There exists a clear association between the prevalence of frozen shoulder and thyroid disease. However, the effects of concomitant thyroid disease on clinical outcomes of frozen shoulder are less well established. This study aims to evaluate if the presence of thyroid disease predisposes to poorer clinical outcomes in patients with frozen shoulder. METHODOLOGY: The study was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered with PROSPERO. Two databases (PubMed and Embase) were searched from date of inception to 9 January 2024. Human studies reporting clinical outcomes of patients with concomitant thyroid disorder and frozen shoulder were included. Risk of bias was assessed based on the Quality In Prognosis Studies (QUIPS) tool and quality of evidence was judged based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework in the domains of range of motion, responsiveness to treatment or timeliness of recovery, and multidimensional scoring systems. RESULTS: Seven studies comprising 167,397 subjects (mean age 52.7 to 58 years, female proportion 67.1%), including 49,314 patients with concomitant thyroid disorder and frozen shoulder were included. Amongst the seven included studies: one study reported improved clinical outcomes in patients with concomitant frozen shoulder and hypothyroidism, one study reported that presence of thyroid disorder led to worse outcomes, while the remaining five studies did not demonstrate evidence of statistically worse outcomes in patients with concomitant thyroid disorder. Based on the GRADE framework, there was no consistent prognostic association between thyroid disorder and frozen shoulder in the domains of range of motion, responsiveness to treatment or timeliness of recovery, and multidimensional scoring systems, and the quality of evidence ranged from 'Very Low' to 'Low'. RISK OF BIAS ASSESSMENT: Based on the QUIPS tool, three studies were assessed to have low risk of bias, while four studies were assessed to have moderate risk of bias. CONCLUSION: Though there exists an association between the prevalence of frozen shoulder and thyroid disorder, there is no consistent evidence in available literature to suggest that concomitant thyroid disorder predisposes to worse clinical outcomes.

Is Kinesiophobia Associated With Quality of Life, Level of Physical Activity, and Function in Older Adults With Knee Osteoarthritis?

BACKGROUND: Beyond knee pain itself, the fear of movement, also known as kinesiophobia, recently has been proposed as a potential factor contributing to disability and functional limitation in patients with knee osteoarthritis (OA). Nevertheless, the available evidence on the association of kinesiophobia with patient-reported outcome measures (PROMs) in knee OA remains limited. QUESTIONS/PURPOSES: Among patients with nonoperatively treated knee OA, we asked: (1) Is kinesiophobia associated with decreased quality of life (QoL), functional outcomes, and physical activity? (2) What are the patient disease and psychosocial demographic factors associated with kinesiophobia? METHODS: This was a multicenter, cross-sectional study of 406 general orthopaedic patients from two urban, referral-based tertiary hospitals in Singapore under a single healthcare group who received nonoperative treatment for knee OA. Between July 2020 and January 2022, a total of 1541 patients were treated for knee OA nonoperatively. Based on that, 60% (923) of patients were rejected due to refusal to participate in the study, 3% (52) of patients were enrolled but did not show up for their appointments for data collection, and a further 10% (160) had incomplete data sets, leaving 26% (406) for this study's analysis. The mean age of patients was 64 ± 8 years, 69% were women, and 81% were Chinese. The level of kinesiophobia in patients was measured using the Brief Fear of Movement scale, a validated 6-item questionnaire ranging from a score of 6 to 24 to measure kinesiophobia in OA, with higher scores representing higher levels of kinesiophobia. In terms of PROMs, the QoL and functional level of patients were measured using the QoL and activities of daily living (ADL) components of the widely validated 12-item Knee Injury and Osteoarthritis Outcome Score (KOOS-12). The KOOS-12 is a questionnaire consisting of 12 items encompassing three domains (QoL, ADL, and pain), with each item ranging from 0 to 4 and higher scores representing worse outcomes. The University of California, Los Angeles (UCLA) Activity Scale was used to measure the level of physical activity in patients. The UCLA score is a descriptive 10-level activity scale ranging from a score of 1 to 10, with higher scores representing greater physical activity levels. A directed acyclic graph, which is a relationship map used to depict and visualize the confounders between the studied variables, was used to identify the confounders between kinesiophobia and PROMs (QoL, function, and physical activity). An ordinal regression model was used to explore: (1) the association between kinesiophobia (as measured using the Brief Fear of Movement scale) and PROMs (as measured using KOOS QoL, KOOS ADL, and the UCLA Activity Scale), adjusting for key confounders such as age, gender, pain, side of arthritis, OA duration/severity, and psychosocial factors (for example, depression, anxiety, and education levels), and (2) the association between kinesiophobia (Brief Fear of Movement scale) and various patient disease and psychosocial demographic factors. RESULTS: After accounting for confounders, greater kinesiophobia (higher Brief Fear of Movement scores) was associated with lower QoL (KOOS QoL score adjusted IQR OR 0.69 [95% confidence interval (CI) 0.53 to 0.90]; p = 0.007) and lower physical activity (UCLA score adjusted IQR OR 0.68 [95% CI 0.52 to 0.90]; p = 0.007); however, there was no association between kinesiophobia and function (KOOS ADL score adjusted IQR OR 0.90 [95% CI 0.70 to 1.17]; p = 0.45). After adjusting for age, gender, OA duration, pain, and BMI, higher levels of anxiety (Patient Health Questionnaire 2 [PHQ-2] anxiety score adjusted OR 2.49 [95% CI 1.36 to 4.58]; p = 0.003) and depression (PHQ-2 depression score adjusted OR 3.38 [95% CI 1.73 to 6.62]; p < 0.001) were associated with higher levels of kinesiophobia. Education level, OA disease severity, side of arthritis (unilateral versus bilateral), and history of previous injury or surgery on the knee were not associated with kinesiophobia. CONCLUSION: Clinicians should assess for kinesiophobia and other psychological comorbidities such as depression and anxiety at the point of initial evaluation and subsequent follow-up of knee OA with simple validated tools like the Brief Fear of Movement scale (kinesiophobia) in the clinic. This allows for clinicians to identify high-risk individuals and offer evidence-based treatment such as cognitive behavioral therapies with a multidisciplinary team, including a physical therapist and psychologist, to manage these psychological comorbidities and improve outcomes in patients with knee OA. While kinesiophobia was found to be associated with poorer QoL and physical activity, future studies including larger observational cohort studies should be conducted to determine causal and prognostic relationships between kinesiophobia and outcomes in knee OA. LEVEL OF EVIDENCE: Level III, prognostic study.

Evaluating the association of radiographic parameters of proximal humerus fractures managed conservatively with functional outcomes.

INTRODUCTION: Treatment of proximal humerus fractures remains controversial. Understanding the factors that can affect the long-term functional outcomes can aid with management choices. This primary aim of this paper is to evaluate the association of radiographic parameters with functional outcomes. METHODS: Radiographic parameters [Caput-collum-diaphyseal (CCD) angles, Y-scapular angles, and humeral head height (HHH)] were studied. The patients were split into varus and valgus groups based on the CCD angles and retroverted and anteverted groups based on Y-scapular angles. Functional outcome was measured by Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), and quick Disabilities of Arm, Shoulder and Hand score at 1 year follow-up. Intra- and interrater reliability were measured with the intraclass correlation coefficients (ICCs). Receiver operator curve (ROC) analysis and logistic regression analysis defined the optimal value for abnormalities on radiographic evaluation as an outcome predictor. RESULTS: 111 patients were recruited (mean age 69, 78% female). Median final radiographic assessment was at 7 months. Mean initial/final CCD was 119o /111o (varus, n = 36) and 153o/140o (valgus, n = 75). Mean initial/final Y-scapula angle was 27o/27o (retroversion, n = 101) and 70o/40o (anteversion, n = 9). There was a significant relationship between OSS and final Y-scapular angle in the retroverted group (adj coeff 0.034, p = 0.009) with optimum predictive retroversion angulation of 25o predicting poor functional outcome (OSS < 40), area under the ROC curve of 0.614. Higher initial valgus and retroversion significantly predicted more change in the final angle (adj coeff - 0.349, p = 0.002, adj coeff - 0.527, p < 0.001 respectively). Both intra-rater and inter-rater reliability for the radiographic parameters were excellent (ICC > 0.9). CONCLUSION: Radiographic parameters whilst having excellent reliability, have a limited ability to predict short-term functional recovery. The extent of retroversion is the most important predictor for functional recovery with 25o a cut-off guide. Fractures with a higher initial valgus and retroversion tend to displace more.

Deltoid tuberosity index for proximal humerus fracture: reliability and a predictor of systemic osteoporosis in an Asian population.

HYPOTHESIS AND BACKGROUND: Fragility fracture of the proximal humerus is a common occurrence. Current literature suggests that poor local bone density is a significant predictor of surgical fixation failure. The deltoid tuberosity index (DTI) is a simple radiographic tool that strongly correlates with local humeral bone mineral density (BMD), aiding surgical planning to consider adjuncts or arthroplasty. However, there is a lack of data in the reliability of assessment of DTI, as well as its correlation to systemic osteoporosis. Our study investigates the reliability of DTI as a predictor of systemic osteoporosis. METHODS: A retrospective cohort of patients with proximal humeral fracture (PHF) treated at a trauma center in Singapore from August 2017 to July 2018 were recruited. Four raters at different levels of varying clinical seniority measured DTI using shoulder radiographs. The dual-energy x-ray absorptiometry (DEXA) BMD scan of the hip and lumbar spine was used to diagnose osteoporosis. Area under the receiver operating characteristic curve analysis was calculated to study the diagnostic utility of DTI for predicting the risk of osteoporosis. RESULTS: Our study sample had 87 patients comprising 18 men and 69 women, mainly of Chinese ethnicity (84%), and with a mean age of 69.7 years (standard deviation 9.52, range 39-92). For assessment of DTI, there was good intrarater reliability among 4 raters (correlation coefficient range 0.805-0.843) and excellent interrater reliability between all raters (intraclass correlation coefficient 0.898, 95% confidence interval [CI] 0.784-0.950, P < .001). Based on the BMD, 55.2% (n = 48) had osteoporosis, with a T score <2.5. The highest correlation of DTI to BMD was with femoral neck density at 0.580. The DTI cutoff of 1.6 had the highest combined sensitivity and false positive rate, with areas under the curve of 0.682 (95% CI 0.564-0.799) for the overall population and 0.706 (95% CI 0.569-0.842) for patients aged <75 years. CONCLUSION: The DTI is a simple and reliable tool and has a strong applicability in clinical practice to enhance preoperative planning in the surgical fixation of PHF. DTI with a cutoff of 1.6 may help prompt clinicians to initiate workup and thus manage underlying osteoporosis.

Impact of introducing 3D printing-assisted surgery into clinical practice for traumatic pelvic and acetabular fractures.

Background: Given the novelty of three-dimensional (3D) printing-assisted fracture surgery in orthopaedics, surgeon familiarity is limited and learning curve is high. As such, it is unclear how the introduction of 3D printing into clinical practice for pelvic and acetabular fracture surgery would impact perioperative outcomes. The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures. Methods: We retrospectively identified consecutive patients who underwent surgical fixation of traumatic pelvic and acetabular fractures from 2018 to 2022 at a single tertiary hospital. The patients included in the study were divided into two groups: (1) 3D printing-assisted surgery and (2) conventional surgery. Baseline demographics and perioperative outcomes of total surgical duration, estimated blood loss, blood transfusion, number fluoroscopy images, fluoroscopy duration and postoperative disposition were recorded and compared between the two groups. Results: In total, 26 patients were included in the present study, with 3D printing-assisted surgery being used in 34.6 % (n = 9) of cases. There were no significant differences in baseline demographics or fracture type between the 3D printing group and conventional group. As compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, shorter surgical duration (299.8 ± 88.2 vs 309.1 ± 143.1 min), lesser estimated blood loss (706.3 ± 330.0 vs 800.0 ± 584.2 ml), lower transfusion rates (50.0 % vs 52.9 %), lower number of intraoperative fluoroscopy images (62.8 ± 74.5 vs 71.6 ± 47.9 images) and shorter fluoroscopy duration (235.0 ± 79.2 vs 242.3 ± 83.5 min), although statistical significance was not achieved. None of the patients in the present study developed surgical complications postoperatively. Conclusion: The introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.

Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores.

Background: Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs. Methods: A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established. Results: Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC): -0.135, P = .013, OSS: AC: 0.072, P = .002], abduction [QuickDASH: AC: -0.115, P = .021, OSS: AC: 0.059, P = .005], and extension [QuickDASH: AC: -0.304, P = .020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively. Conclusion: Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.

Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial.

BACKGROUND: Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates. OBJECTIVE: Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone. METHODS: A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability. RESULTS: Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals. CONCLUSIONS: The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models. TRIAL REGISTRATION: ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54352.

Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting-A Pilot Study.

Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.

A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis.

BACKGROUND: Physical activity is a guideline-recommended first-line intervention for people with knee osteoarthritis. Physical activity levels, and its potential correlates, is underexplored in Asian populations with knee osteoarthritis. METHODS: Participants enrolled in a longitudinal study in Singapore self-reported physical activity (UCLA activity score), function (Knee Osteoarthritis Outcome Score [KOOS-12]), kinesiophobia (Brief fear of movement [BFOM]), self-efficacy (ASES-8), and quality of life (EQ-5D-5 L). One-Way ANOVA was used to test the difference in outcomes between UCLA categories, while ordinal logistic regression was used to identify the associated factors to physical activity level. RESULTS: Seventy-three percent of all enrolled participants (n = 311/425) reported either inactivity or low physical activity (median 4, IQR 3-5). Significant, weak, positive correlations were observed be-tween UCLA activity score and either KOOS-12 (Spearman's rho: 0.1961; p < 0.001), ASES-8 (0.1983; p = 0.004), or EQ-5D-5 L (0.2078; p < 0.001). A significant, weak, negative correlation was observed between physical activity and BFOM (-0.2183; p < 0.001). Significant differences in function between groups (moderate vs. inactive or low physical activity) were not clinically important. Participants with obesity, from the eldest age category (i.e. ≥75), or who identified as Malay or female, were less physically active than those with a healthy BMI, below the age of 54, or who identified as Chinese or male, respectively. CONCLUSION: Healthcare professionals in Asia should be aware of the large proportion of people with knee osteoarthritis who are either inactive or have low physical activity levels. Screening for, and offering interventions to promote, physical activity and its correlates should be prioritised.

Cost and outcomes of Hospital-based Usual cAre versus Tele-monitor self-directed Rehabilitation (HUATR) in patients with total knee arthroplasty: A randomized, controlled, non-inferiority trial.

OBJECTIVE: To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA). DESIGN: In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points). RESULTS: In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs. CONCLUSIONS: In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup.

Study on proximal humerus evaluation of effective treatment (SPHEER) - what is the effect of rehabilitation compliance on clinical outcomes of proximal humerus fractures.

INTRODUCTION: Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance. METHODS: Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables. RESULTS: 107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001). CONCLUSION: Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research. LEVEL OF EVIDENCE: II, cohort study.

Social determinants of outcomes in nonoperatively treated proximal humerus fractures.

Background: Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year. Methods: One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index. Results: Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001). Conclusions: The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.

Adaptation and validation of the chronic illness-related shame scale among patients with knee osteoarthritis in Singapore.

BACKGROUND: Osteoarthritis (OA) of the knee is one of the most common and disabling conditions worldwide. A neglected aspect of knee OA is its psychosocial impact, such as shame. However, assessment tools to measure shame among patients diagnosed with knee OA are lacking. In this study, the psychometric properties of the Chronic Illness-related Shame Scale (CISS) were evaluated among knee OA patients in Singapore. METHODS: Adaptations were made to CISS for use among the knee OA population. An exploratory factor analysis (EFA) was performed to analyze the factor structure. Cronbach's Alpha and corrected item-total correlations were used to evaluate the internal consistency. Spearman correlation coefficient was used to test the correlation between CISS and Patient Health Questionnaire-4 (PHQ-4) to determine the validity of the instrument. RESULTS: The EFA yielded a one-factor structure, with an eigenvalue of 4.78 explaining 68.25% of variance. Cronbach Alpha was 0.92, which indicated good internal consistency. The Spearman correlation revealed a significant correlation between CISS and PHQ-4. CONCLUSIONS: The adapted CISS is a valid and reliable instrument to measure shame for knee OA patients. Both research and clinical settings can benefit from the use of the adapted CISS for assessing shame among knee OA patients.

Discordance Between Self-Reported and Performance-Based Physical Function in Patients Who Have Knee Osteoarthritis: Associations With Pain Intensity and Negative Affect.

BACKGROUND: Although self-reported measures of physical disability are strong indication criterion for total knee arthroplasty (TKA) in painful knee osteoarthritis (OA), some patients may report greater-than-observed disability. Contributing factors to this discordance are relatively unexplored. We aimed to examine whether pain and negative affect, including anxiety and depression, were associated with the discordance of self-reported measures with performance-based measures (PPM) of physical function. METHODS: We used cross-sectional data (n = 212) from two randomized rehabilitation trials in knee OA. All patients were assessed for knee pain intensity and symptoms of anxiety and depression. Self-reported function was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical-function subscale. Objective performance-based measures (PPMs) of physical function were assessed by timed gait and stair tests. Continuous discordance scores were quantified by the difference in percentiles between WOMAC and PPMs (WOMAC-PPM), where a positive discordance, WOMAC-PPM >0, implied greater perceived than observed disability. RESULTS: Around 1 in 4 patients had >20 percentile units in WOMAC-PPM discordance. In Bayesian regression analyses, knee pain intensity had >99% posterior probability of positive associations with WOMAC-PPM discordance. Among patients awaiting TKA, anxiety intensity had approximately 99% probability of positive associations with discordance, and these associations had >65% probability of exceeding 10 percentile units. In contrast, depression had low (79% to 88%) probability of any association with discordance. CONCLUSION: In patients who have knee OA, a sizable proportion reported substantially greater physical disability than actually observed. Pain and anxiety intensity, but not depression, were meaningful predictors of this discordance. If validated, our findings may help in refining patient selection criteria for TKA.

Singapore KneE osTeoarthritis CoHort (SKETCH): protocol for a multi-centre prospective cohort study.

BACKGROUND: Knee osteoarthritis (OA) is a leading cause of global disability. The understanding of the role of psychosocial factors in knee OA outcomes is still evolving particularly in an Asian context. The primary aim of this study is to explore psychosocial factors that prognosticate short and long-term clinical outcomes, productivity, and healthcare utilization in patients with knee OA. Secondary aims are to explore the mediation and directional relationships and the role it plays in predicting the discordance between self-reported measures (SRM), physical-performance measures (PPMs) and objective clinical parameters. METHODS: A multi-centre prospective cohort study of community ambulant knee OA patients seeking treatment in the tertiary healthcare institutions in Singapore will be conducted. Patients with secondary arthritis, significant cognitive impairment, severe medical comorbidities or previous knee arthroplasty will be excluded. Primary clinical outcome measure is the Knee injury and OA Outcome Score-12 (KOOS-12). Baseline characteristics include sociodemographic status, arthritis status including symptom duration and radiographic severity, comorbidities and functional status through Charlson Comorbidities Index (CCI), Barthel Index (BI) and Parker Mobility Score (PMS). Psychosocial variables include social support, kinesiophobia, negative affect, self-efficacy, injustice, chronic illness shame and the built environment. Clinical outcomes include quality of life, physical performance, global assessment, satisfaction and physical activity levels. Productivity and healthcare utilization will be assessed by a modified OA Cost and Consequences Questionnaire (OCC-Q) and the Work Productivity and Activity Impairment Questionnaire (WPAI). Variables will be collected at baseline, 4, 12 months and yearly thereafter. Regression, mediation and structural equation modelling will be used for analysis. DISCUSSION: Results will allow contextualization, identification, and phenotyping of the critical (and potentially modifiable) psychosocial parameters that predict positive clinical outcomes in the OA population to guide optimization and refinement of healthcare and community. This will facilitate: 1. identification of high-risk knee OA subpopulations that will likely experience poor outcomes and 2. formulation of targeted multidisciplinary comprehensive approaches to address these psychosocial factors to optimize non-surgical treatment care, maximize functional outcomes and create more value-based care model for knee OA. ETHICS AND DISSEMINATION: The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population.

BACKGROUND: A patient's experience with knee osteoarthritis (OA) is influenced by many psychosocial contributors that can influence the impact of pain. Such factors are known to explain some of the discordance between objective clinical parameters and patient-reported levels of disability and treatment effectiveness. However, few data are available to help clinicians understand the psychosocial factors that apply to the world's many Asian populations. Insights gained from a qualitative study in such a population may support targeted interventions. QUESTIONS/PURPOSES: In this qualitative study involving a group of Asian patients with knee OA in Singapore, we asked: (1) What psychologic factors contribute to patients' experiences, rehabilitation, and recovery? (2) What social factors contribute to patients' experiences, rehabilitation, and recovery? METHODS: Semistructured interviews eliciting broad patient experiences of managing knee OA were conducted in an urban, referral-based tertiary hospital in central Singapore. Patients were recruited if they met either of the following criteria: Kellgren-Lawrence grade ≥ 3 (minimum of one knee); Knee Injury and Osteoarthritis Outcome Score ≤ 60; or the Pain average (P), interference with Enjoyment of life (E), and interference with General activity (G) (PEG) ≥ 5. All patients had a clinical diagnosis of knee OA, were ambulatory in the community with or without a walking aid, had not undergone partial arthroplasty or TKA, were prescribed nonsurgical treatment, and were conversant in either English or Mandarin. Forty-six patients (30 women and 16 men, mean age 64 years old) were recruited for this study. A thematic analysis with elements of grounded theory and framework analysis was performed using a deductive approach. Psychologic influences specific to patients' behavioral and emotional responses to pain, as well as social factors known to have an impact on the experience of managing knee OA, were identified in the interview transcripts and coded according to established factors from earlier research. An inductive thematic analysis was then applied to the remaining transcripts to identify new themes that emerged from the data. Thematic saturation was attained when study team members agreed data and thematic sufficiency were met in the 46 transcripts. The study team discussed and deemed the 46 transcripts to contain sufficient insights for a reasonably clear understanding of the codes and development of themes to answer the study's research questions. RESULTS: Six main themes related to psychosocial influences on pain emerged. Psychologic factors were "loss of face" because of knee OA, anticipation and avoidance of pain and suffering, and a vicious cycle of negative emotional experiences. The social factors we identified were social and family support, workplace environment and employment uncertainty, and built environment (patients' ability to navigate manmade structures and facilities). CONCLUSION: Psychosocial factors have an important impact on patients' physical, psychologic, and social functioning. Although several of our findings have been addressed previously, the phenomenon of loss of face and the wide spectrum of social and family support dynamics found in our Asian patients with knee OA were new findings. With loss of face, patients were concerned about how others would view the change in them, including movement changes because of knee OA. They appeared to associate the use of walking canes with major disability, loss of respect, and being discriminated against by others, motivating patients to "save face" by dissociating themselves from those stigmas, even at the cost of mobility and independence. An interplay of complex cultural processes (perceived social roles and contributions to family, desire to avoid burdening family, help-seeking behavior, and the preference for unsolicited social support) underpinned by the value of collectivism impacted the behaviors and choices patients exhibited. CLINICAL RELEVANCE: With knowledge about the impact of culturally relevant psychosocial factors on the experience and outcomes of patients with knee OA, clinicians will be able to screen and actively explore these factors more effectively. Especially important themes include pain perception (paying close attention to signs of pain catastrophizing and negative affect), presence of chronic illness shame associated with a diagnosis of knee OA (including the stigma associated with using a walking aid), and level of social support received and contributions of a patient's built environment to kinesiophobia. For patients who are still working, the presence of workplace stressors and management of these stressors should also be explored. Where possible, screening tools that measure psychosocial factors such as pain catastrophizing and emotional distress can also be used as an added layer of screening in busy clinical settings.

The Evolution of Olecranon Fractures and Its Fixation Strategies.

Introduction: Olecranon fractures are a common fracture of the upper extremity. The primary aim was to investigate the evolution of olecranon fractures and fixation method over a period of 12 years. The secondary aim was to compare complication rates of Tension Band Wiring (TBW) and Plate Fixation (PF). Materials and Methods: Retrospective Study for all patients with surgically treated olecranon fractures from 1 January 2005 to 31 December 2016 from a tertiary trauma center. Records review for demographic, injury characteristics, radiographic classification and configuration, implant choices and complications. Results grouped into three 4-year intervals, analyzed comparatively to establish significant trends over 12 years. Results: 262 patients were identified. Demographically, increasing mean age (48.7 to 58.9 years old, p value 0.004) and higher ASA scores (7.1% ASA 3 to 21.0% ASA 3 p value 0.001). Later fractures were more oblique (fracture angle 86.1-100.0 degrees, p value 0.001) and comminuted (Schatzker D type 10.4-30.0%, p value 0.025, single fracture line 94.0-66.0%, p value 0.001). Implant choice, sharp increase in PF compared to TBW (PF 16.0% to PF 80.2%, p value 0.001). Complication-wise, TBW had higher rates of symptomatic implant, implant and bony failures and implant removal. Conclusion: Demographic and fracture characteristic trends suggest that olecranon fractures are exhibiting fragility fracture characteristics (older age, higher ASA scores, more unstable, oblique and comminuted olecranon fractures). Having a high index of suspicion would alert surgeons to consider use of advanced imaging, utilize appropriate fixation techniques and manage the underlying osteoporosis for secondary fracture prevention. Despite this, trends suggest a potential overutilization of PF particularly for stable fracture patterns and the necessary precaution should be exercised.