Patient-reported outcome measures for patellofemoral disorders: a systematic review.

INTRODUCTION: Patellofemoral conditions include, but are not limited to, anterior knee pain syndrome and patellar instability. Patients and surgeons may find it difficult to identify the specific source of the symptoms and clinical scenarios, so patient-reported outcome measures (PROMs) may be a useful diagnostic aid. There are a number of available PROMs for patellofemoral conditions, which are often used indistinctly. This systematic review explores the available PROMs for patellofemoral conditions, their use and methodological quality. METHODS: A systematic review was conducted, searching for scientific articles relating to PROMs in patellofemoral conditions, from inception to July 2022. Scoring systems including physician-directed or imagining assessment were not included. All types of conditions in the patellofemoral joint were considered. RESULTS: Twenty-two relevant PROMs were encountered, divided into four categories: eight PROMs for anterior knee pain syndrome, five for patellar instability, four for other patellofemoral conditions and five for non-specific PROMs. CONCLUSIONS: While many PROMs have been found used in patellofemoral research, only few of them have showed sufficient methodological quality. In addition, PROMs employed in PF literature are often inaccurately chosen. This review may help authors to better understand the characteristics of specific patellofemoral PROMs, in order to select the more appropriate and recommended ones. LEVEL OF EVIDENCE: Level II.

Orthopaedic patients underestimate their body weight too: a cross-sectional study.

INTRODUCTION: The relation between a large body mass and comorbidity, certain types of cancers and musculoskeletal disorders has been extensively documented. However, a high proportion of overweight patients appears unaware of the medical risks of their condition and frequently underestimates their body weight. This observation is prevalent across numerous medical specialties and settings. METHODS: This study analysed the misperception of obesity status in a cohort of 1137 patients attending an orthopaedic clinic by means of self-completed questionnaires and objective biometrics. RESULTS: Patients displayed a poor estimation of the self-body mass index (34.6%), especially among larger individuals, with 45.15% of pre-obese and 21.17% of obese patients previously attempting weight-loss. A direct association between low educational achievement and obesity rates was observed in orthopaedic patients. DISCUSSION: Obesity is a well-known contributor to many conditions, including musculoskeletal diseases. Despite this association, many obese patients consider their body mass as normal. Misperception of self-body weight has been documented in many medical specialities, and this study confirms the same scenario in orthopaedic patients. CONCLUSION: The association between self-image distortion and obesity observed in this study may assist in the evaluation and management of obesity cases in orthopaedic clinics.

The quadriceps active ratio: a dynamic MRI-based assessment of patellar height.

INTRODUCTION: Patella alta (PA) is one of the primary correctable risk factors for patellofemoral instability (PFI). Both an accurate diagnosis of PA and a clinically relevant target for correction are necessary for optimal treatment. An ideal test for PA should relate the position of the patella to the femur rather than tibia, should do so with the quadriceps contracted and the patellar tendon under tension and should have good sensitivity and specificity. None of the currently used radiographic tests PA meet these criteria, most of which are based on the position of the patella relative to the tibia with diagnostic cutoffs based on 2 standard deviations from the mean rather than optimal sensitivity and specificity. The authors describe the quadriceps active ratio (Q+R), an MRI-based assessment of PA based on patellofemoral contact under quadriceps activated with a cutoff based on optimal sensitivity a specificity for PFI. MATERIAL-METHODS: Ninety-four participants investigated for knee pain or instability with a clinically indicated MRI were recruited. Routine MRI sequences were obtained, with the addition of a quadriceps contracted sagittal T1-weighted sequence. Participants presenting with PFI were identified. Those with trochlear dysplasia were identified and excluded from analysis so that patellar height could be assessed against PFI without being confounded by trochlear dysplasia. Q+R and patellotrochlear index (PTI) were calculated from the remaining 78 scans by 3 consultant orthopaedic surgeons at three time points. In 54 of these cases, a lateral radiograph was available from which the Insall-Salvati, modified Insall-Salvati, Caton-Deschamps and Blackburn-Peel ratios were also calculated. Intra- and inter-observer reliability was assessed for the Q+R. A cutoff value for the Q+R based on optimal sensitivity and specificity for the diagnosis of PFI was calculated from receiver-operator characteristic (ROC) curves and compared to the PTI. The cutoff for the Q+R was compared for sensitivity and specificity for the diagnosis of PFI against the radiographic ratios. RESULTS: The Q+R had satisfactory or better ICC values across time points and surgeons. The Q+R was superior to the PTI on area under curve ROC analysis (0.76 vs 0.74). A cutoff value of 0.12 for the Q+R gave sensitivity of 79% and specificity of 55% for the diagnosis of PFI. The radiographic indices were generally insensitive for this diagnosis of PFI with sensitivities ranging from 0-66%. CONCLUSION: The Q+R is a reliable diagnostic test for patellar height assessment, showing good intra- and inter-rater consistency, and greater diagnostic accuracy than the PTI. A Q+R value of 0.12 is a good test for clinically significant PA. Of the radiographic indices, the Insall-Salvati ratio had the best diagnostic accuracy.

Is knee arthroscopy under local anaesthetic a patient-friendly technique? A prospective controlled trial.

PURPOSE: To determine that when the patient chooses their intervention, whether there is any difference in duration of surgery, effectiveness, patient satisfaction and recovery time between two methods of anaesthesia, local anaesthetic (LA) and general anaesthesia (GA) in knee arthroscopy (KA). METHODS: Inclusion criteria were medically fit, adults, undergoing unilateral KA, in a native knee as a day case. Exclusion criteria were requirement for ligament reconstruction or meniscal repair, pre-existing regional sensory impairment or active psychiatric condition. A prospective comparator controlled trial was conducted. The experimental group received local anaesthetic into the joint and no tourniquet. This was compared to a standard treatment, using GA with tourniquet. The LA group received 40 ml of anaesthetic consisting of 20 ml 0.5 % bupivacaine with adrenaline and 20 ml of 1 % lignocaine with adrenaline. Pre- and postoperative visual analogue score were completed, and patient's satisfaction was assessed using a scale of one to five. Operative and recovery time was recorded. RESULTS: There was a significant decrease in recovery time for the LA group, 14 min 55 s, compared to 72 min 25 s (p = 0.004). Pain levels in the LA group were significantly decreased compared to the GA group. No failures of LA resulting in conversion to GA; no difference in patient satisfaction between the two groups 4.88/5 in the GA group and 4.81/5 in the LA group. 48 patients joined the LA group, and 34 patients joined the GA group. Both groups displayed similar demographic variables and underwent similar intraarticular interventions. CONCLUSION: When patients undergoing KA choose their method of anaesthesia, LA is a reliable option. Use of LA results in decreased recovery time and postoperative pain, with similar levels of patient satisfaction when compared to GA.

A single plain ring is not associated with increased bacterial load on hands: An experimental study among healthcare worker students undertaking mock surgery.

BACKGROUND: Adequate hand hygiene is considered as one of the most effective strategies in healthcare-related infection prevention. The potential negative effect of rings in hand disinfection and thus, in increased nosocomial infections rates is still controversial. Therefore, the present study was designed with the purpose of examining if rings frequently exposed to surgical scrubbing were associated or not with increased bacterial counts. METHODS: 32 volunteers were randomized into 4 groups: A (no rings), B (participants wore a ring), C (no rings and performed surgical scrubbing with chlorhexidine every 48 h) and D (participants wore a ring and performed surgical scrubbing every 48 h). Glove juice samples were obtained at day 0 (T0) and after a 90-min mock-surgery on day 14 (T1). Quantitative (number of UFC/mL) and qualitative data (microorganism type) were collected as study variables. RESULTS: All groups were comparable at T0. All ring carriers obtained negative cultures at T1. Ring presence was not associated with higher bacterial counts; comparisons between A vs B groups and C vs D groups showed no statistically significant differences (p = 0.076 and 1.000). T1 negative cultures were more frequent in participants performing surgical scrubbing every second day (93.8 % vs 75 %), although this difference did not reach statistical significance (p = 0.332). CONCLUSIONS: The presence of single plain ring does not seem to be associated with an increased hand bacterial load. Regular surgical scrubbing with chlorhexidine impregnated sponges reduces bacterial contamination of hands, even in the presence of plain rings.

Skin sensory alteration and kneeling ability following cruciate retaining total knee arthroplasty are not affected by the incision position: A randomised controlled trial of simultaneous bilateral surgery.

PURPOSE: The purpose of this randomised controlled trial was to assess the impact of skin incision location on the patients' ability to kneel. METHODS: A total of 29 patients undergoing bilateral total knee arthroplasty (58 knees) were randomised to receive a lateral or midline incision, with the contralateral limb receiving the alternative option. Cruciate retaining implants were used in all cases by three experienced arthroplasty surgeons. The primary outcome measures assessed functional ability to kneel using an innovative five-point kneeling scale, preferred knee to kneel on and the area of cutaneous sensory loss around the incision at 6 weeks, 6 months and 12 months. Secondary outcome measures were the OKS, KOOS JR, FJS and EQ5D patient reported outcome measures (PROMS), length of surgical scar, overall knee preference and range of motion (ROM). RESULTS: There were no significant differences between the two groups for any primary or secondary outcome measures. Flexion range however, had a significant positive correlation with kneeling score (r = 0.335, p = 0.010). The kneeling score increased at each time point after surgery and was significantly greater at 12 months than preoperatively (2.7 v 3.5, p = 0.015). The area of sensory loss lateral to the incision was significantly less at 6 and 12 months than at 6 weeks (43.6cm2 and 40.1cm2 v 84.1cm2, p < 0.0001). CONCLUSION: The ability to kneel following cruciate retaining total knee arthroplasty is not affected by the incision position but by time and flexion range. TKA improves the ability to kneel by 12 months post-surgery. Sensory loss lateral to the incision reduces with time. LEVEL OF EVIDENCE: Therapeutic Level 2.

Comminuted Patella Fracture in Elderly Patients: A Systematic Review and Case Report.

OBJECTIVES: To review comminuted patella fracture in the elderly patients and examine the surgical options to avoid complications such as fixation failure and poor functional outcome. To provide an example of mesh augmentation in comminuted patella fracture in the elderly patients. DATA SOURCES: A literature review was conducted by the authors independently using Ovid, Medline, Cochrane, PubMed, and Clinical Key in English. We aimed to review data on patients older than 65 with comminuted patella fracture. Search conducted between July and December 2015. STUDY SELECTION: Search terms included patella fracture, elderly, and fixation failure. Abstracts were included if they were a case report, cohort series, or randomized control trial. Further inclusion criteria were that they were available in full text and included patient age(s), operative details, follow-up, and outcome discussion. DATA EXTRACTION: Each study was assessed according to its level of evidence, number of patients, age of patients, fracture patterns described, complications of treatment, and results summarized. DATA SYNTHESIS: Paucity of data and heterogeneity of studies limited statistical analysis. Data are presented as a review table with the key points summarized. CONCLUSION: In patella fracture, age >65 years and comminuted fracture pattern are predictors of increased fixation failure and postoperative stiffness, warranting special consideration. There is a trend toward improved functional outcomes when augmented fixation using mesh or plates is used in this group. Further level 1 studies are required to compare and validate new treatment options and compared them to standard surgical technique of tension band wire construct.

Total knee arthroplasty in patients with extra-articular deformity.

Multiple acceptable options are available for the correction of distal femoral deformity associated with knee arthritis. The treatment modality should be chosen based on the extent of deformity and attention to preservation of the collateral ligaments. Surgical options range from osteotomy alone, arthroplasty with intra-articular correction, or arthroplasty with extra-articular correction. Different implant choices and fixation methods for the osteotomy possess advantages and disadvantages which need to be considered carefully. In addition to discussing principles of management based on current literature, this article includes a case report using a previously undescribed technique using corrective osteotomy, intramedullary nail fixation, and total knee arthroplasty with computer navigation.