Reliability and Responsiveness of Patient-Reported Outcome Measures of Neck Disability to Physical Therapy: Comparison of the Copenhagen, Northwick Park, and Neck Bournemouth Questionnaires and the Neck Disability Index.

OBJECTIVE: The purpose of this study was to identify the external and internal reliability and responsiveness of the validated patient-reported outcome measures (PROMs) of neck pain to a standardized regimen of physiotherapy administered acutely after mild whiplash injury using the clinically significant improvement components of the Patient Global Impression of Change (PGIC) as the outcome measure. METHODS: Eighty-six patients with neck pain alone were referred for physiotherapy within 2 weeks of whiplash injury. They completed the Copenhagen, Northwick Park (NP), and Neck Bournemouth (NBQ) questionnaires and the Neck Disability Index (NDI) before starting and after treatment when they also completed the PGIC. Treatment comprised deep soft tissue massage, myofascial releases, muscle energy techniques, joint articulation and manipulation techniques, and a home exercise program. The duration of treatment was between 3 and 6 weeks. A PGIC of 6 or 7 was considered to be clinically significant improvement. RESULTS: The external reliability of the PROMs was >0.7 and internal >0.87. All components of the PROMs contributed to the final score except headache in the Copenhagen and upper-limb dysesthesia in the NP. The most reliable questionnaire was the NBQ, which was significantly more responsive than the Copenhagen (P = .008). The NBQ was slightly more responsive than the NDI and NP. The NBQ and NDI were successfully completed more frequently than the NP and Copenhagen. CONCLUSION: The NP, NDI, and NBQ are all reliable and responsive measures of change after physiotherapy for neck pain after acute whiplash injury.

Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study.

BACKGROUND: Acute avulsion fractures of the base of the fifth metatarsal are common and are treated in a variety of ways. The aims of this study were to compare pain, functional outcome, and time taken off work after treatment with a walking boot or a short-leg cast. METHODS: Of 39 patients with acute avulsion fractures of the base of the fifth metatarsal, 23 were treated with a short-leg cast and 16 with a walking boot, according to the preference of the consultant present at outpatient clinic. Functional outcome was assessed by the Visual Analogue Scale Foot and Ankle Questionnaire (VAS FA), pain, and other complaints on presentation and at 3, 6, 9, and 12 weeks after injury. The VAS FA scores were compared between the 2 groups by a paired Student t test. RESULTS: The mean time to return to the level of pain and function before injury was approximately 9 weeks after treatment in the walking boot group and 12 weeks with a short-leg cast. Patients with walking boots reported less pain between 3 and 12 weeks than did those with short-leg casts after 6 (P = .06), 9 (P = .020), and 12 weeks (P = .33). Function was significantly better with Aircast walking boots after 3 (P = .006), 6 (P = .002), and 9 weeks (P = .002) but not after 12 weeks (P = .09). Patients returned to their preinjury level of driving after 6 weeks with walking boots and 12 weeks with short-leg casts (P = .006). Employed patients took a mean of 35.8 days off work (range, 28-42 days), fewer with boots (31.5 days) than with short-leg casts (39.2 days). CONCLUSION: The walking boot was better treatment than a short-leg cast for avulsion fractures of the base of the fifth metatarsal. Patients had an improved combined level of pain and function 3 weeks earlier, at 9 weeks post injury, when managed in a walking boot. LEVEL OF EVIDENCE: Level II, prospective comparative series.

The thermal effects of lavage on 57 ox femoral heads prepared for hip resurfacing arthroplasty.

BACKGROUND AND PURPOSE: Previously, we have documented surface temperatures recorded by thermography great enough to cause osteonecrosis of the femoral head during hip resurfacing. We now performed an in vitro investigation with 3 questions: (1) whether water irrigation reduced bone surface temperature, (2) whether external bone temperatures were similar to core temperatures, and (3) whether blunting of the reamer affected temperature generation. METHODS: Using an ox-bone model, 57 femoral heads were peripherally reamed. The surface temperatures of bone were measured using a thermal camera and internal bone temperatures were measured using 2 theromocouples. We measured the effects of cooling with water at room temperature and with ice-cooled water. Progressive blunting of reamers was assessed over the 57 experiments. RESULTS: Mean and maximum temperatures generated during peripheral reaming were greater when no irrigation was used. Ice-cold saline protected femoral heads from thermal damage. External bone temperatures were much greater than internal temperatures, which were not sufficiently elevated to cause osteonecrosis regardless of lavage. Blunting of the reamer was not found to have a statistically significant effect in this study. INTERPRETATION: Cooling with ice-cooled water is recommended. Internal bone temperatures are not elevated despite the high surface temperatures reached during femoral head resurfacing.

A comparison of 2 cementing techniques in hip resurfacing using human femoral heads.

INTRODUCTION: Hip resurfacing remains a valid option in young male patients. The creation of the optimum cement mantle aids fixation of the femoral component. If the cement mantle is too thick the prosthesis can remain proud leading to early failure or if it penetrates too far into the femoral head, it may cause osteonecrosis. METHOD: 18 of 96 femoral heads collected from patients undergoing total hip arthroplasty were matched for their surface porosity. They were randomly allocated into 2 different cementing groups. Group 1 had the traditional bolus of cement technique, while group 2 had a modified cementing technique (swirl) where the inside of the femoral component was lined with an even layer of low viscosity cement. RESULTS: The traditional bolus technique had significantly greater cement mantle thickness in 3 of 4 zones of penetration (p = 0.002), greater and larger air bubble formation (6 of 9 in bolus technique vs. 1 in 9 in swirl technique, p = 0.05) and more incomplete cement mantles compared with the swirl technique. There was no relationship to femoral head porosity. CONCLUSION: The swirl technique should be used to cement the femoral component in hip resurfacing. Long-term clinical studies would conform if this translates into increased survivorship of the femoral component.

Clinical tests for carpal tunnel syndrome in contemporary practice.

INTRODUCTION: A study conducted to establish the most accurate combination of questionnaire and physical signs for the diagnosis of carpal tunnel syndrome. METHOD: Nerve conduction studies confirmed 70 patients with having carpal tunnel syndrome who were enrolled along with 70 age- and sex-matched controls. Patients were assessed using a symptom questionnaire, Phalen's test, Hoffmann-Tinel's sign, hand elevation test, carpal compression test, tourniquet test, pressure aesthesiometry and two-point discrimination. RESULTS: Through multivariate analysis, the best combination of tests was tourniquet, carpal compression and Phalen's tests but the difference between these and hand elevation test alone was negligible. CONCLUSION: The hand elevation test may be used in isolation and is superior to questionnaires and other physical signs in the clinical diagnosis of carpal tunnel syndrome.

A comparison of neck movement in the soft cervical collar and rigid cervical brace in healthy subjects.

OBJECTIVE: The soft cervical collar has been prescribed for whiplash injury but has been shown to be clinically ineffective. As some authors report superior results for managing whiplash injury with a cervical brace, we were interested in comparing the mechanical effectiveness of the soft collar with a rigid cervical brace. Therefore, the purpose of this study was to measure ranges of motion in subjects without neck pain using a soft cervical collar and a rigid brace compared with no orthosis. METHODS: Fifty healthy subjects (no neck or shoulder pain) aged 22 to 67 years were recruited for this study. Neck movement was measured using a cervical range of motion goniometer. Active flexion, extension, right and left lateral flexion, and right and left rotation were assessed in each subject under 3 conditions: no collar, a soft collar, and a rigid cervical brace. RESULTS: The soft collar and rigid brace reduced neck movement compared with no brace or collar, but the cervical brace was more effective at reducing motion. The soft collar reduced movement on average by 17.4%; and the cervical brace, by 62.9%. The effect of the orthoses was not affected by age, although older subjects had stiffer necks. CONCLUSION: Based on the data of the 50 subjects presented in this study, the soft cervical collar did not adequately immobilize the cervical spine.

Maximum temperatures of 89°C recorded during the mechanical preparation of 35 femoral heads for resurfacing.

BACKGROUND AND PURPOSE: We noticed that our instruments were often too hot to touch after preparing the femoral head for resurfacing, and questioned whether the heat generated could exceed temperatures known to cause osteonecrosis. PATIENTS AND METHODS: Using an infra-red thermal imaging camera, we measured real-time femoral head temperatures during femoral head reaming in 35 patients undergoing resurfacing hip arthroplasty. 7 patients received an ASR, 8 received a Cormet, and 20 received a Birmingham resurfacing arthroplasty. RESULTS: The maximum temperature recorded was 89°C. The temperature exceeded 47°C in 28 patients and 70°C in 11. The mean duration of most stages of head preparation was less than 1 min. The mean time exceeded 1 min only on peripheral head reaming of the ASR system. At temperatures lower than 47°C, only 2 femoral heads were exposed long enough to cause osteonecrosis. The highest mean maximum temperatures recorded were 54°C when the proximal femoral head was resected with an oscillating saw and 47°C during peripheral reaming with the crown drill. The modified new Birmingham resurfacing proximal femoral head reamer substantially reduced the maximum temperatures generated. Lavage reduced temperatures to a mean of 18°C. INTERPRETATION: 11 patients were subjected to temperatures sufficient to cause osteonecrosis secondary to thermal insult, regardless of the duration of reaming. In 2 cases only, the length of reaming was long enough to induce damage at lower temperatures. Lavage and sharp instruments should reduce the risk of thermal insult during hip resurfacing.

Anti-embolism stockings and proximal indentation.

The authors of this study noticed that the elastic garters of below knee anti-embolism stockings (AES) were indenting the proximal calves of patients after application and feared this might be interrupting venous return. This was lower on one ward which had a rigorous standardized protocol for sizing and checking stockings. Hypotheses were that proximal indentation caused higher proximal than distal pressures (reverse gradients) and that by adopting the standardized protocol throughout the unit, proximal indentation could be reduced. Fifty-seven patients were recruited after total hip replacement (THR) or total knee replacement (TKR) in a regional orthopaedic centre. The authors implemented the standardized protocol for sizing stockings and measured the pressures under them. After implementation of the standardized protocol, proximal indentation fell from 53% to 19% (p<0.05), incorrectly sized stockings from 74% to 34% (p<0.05) and removal of stockings by patients from 32% to 0% (p<0.05). In total, 21% of patients had reverse gradients which occurred in 41% of legs with proximal indentation and 8% without. When reverse gradients or proximal indentation exist, AES may not be as effective and may be counterproductive. A standardized protocol of nursing practice is critical to optimizing AES after THR and TKR. More in-vivo research is needed on AES after hip and knee replacement.

The porosity of the bone cement interface of 96 human femoral heads prepared for hip resurfacing.

PURPOSE: The porosity of the femoral head prepared for hip resurfacing has not been previously described. This is important as greater pore size increases the penetration of bone cement and excessive cement penetration can cause osteonecrosis. METHODS: 96 osteoarthritic femoral heads were harvested at total hip arthroplasty and prepared for hip resurfacing. The porosity of the bone cement interface in hip resurfacing was calculated from digitised black and white photographs using MatLab software. RESULTS: The mean porosity was 0.63. Increased porosity was associated with larger femoral heads in both the coronal and sagittal dimensions and cysts in the femoral head. It was not associated with gender, age, body mass index (BMI), smoking, alcohol or corticosteroid consumption. CONCLUSION: The porosity of the femoral head has been shown to be 0.63. Future studies of cementing techniques in hip resurfacing should include this porosity in their designs. The surgeon prior to hip resurfacing should consider altering his cementing technique when cysts are present on the preoperative radiographs.

Cemented polished tapered stems in patients less than 50 years of age: a minimum 10-year follow-up.

We report the outcome of 58 consecutive polished tapered stems in 47 patients younger than 50 years, with a minimum of 10 years of follow-up. No stems were revised for aseptic loosening or osteolysis. The Harris hip scores were good or excellent in 76% of the patients. There was excellent preservation of proximal bone. Despite higher patient weight and frequent previous surgery, the outcome of polished tapered stems in patients younger than 50 years is comparable to the general population undergoing total hip arthroplasty and superior to other non-polished tapered stem designs in young patients. Cup wear and cup failure were significantly worse in this group, with a higher incidence of periarticular osteolysis. Polished tapered stem designs are the benchmark for comparison to other arthroplasty options in young patients.

Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results.

The aim of this study was to compare the midterm functional outcomes of total knee arthroplasty (TKA) and total hip arthroplasty (THA). A cross-sectional postal audit survey of all consecutive patients who had a primary joint replacement at one orthopedic center 5 to 8 years ago was conducted. Participants completed an Oxford hip score or Oxford knee score, which are self-report measures of functional ability. Completed questionnaires were returned from 1112 THA patients and 613 TKA patients, giving a response rate of 72%. The median Oxford knee score of 26 was significantly worse than the median Oxford hip score of 19 (P < .001). In conclusion, TKA patients experience a significantly poorer functional outcome than THA patients 5 to 8 years postoperatively.

The effect of bone porosity on the shear strength of the bone-cement interface.

This study investigated the relationship of bone porosity and bone-cement interface shear strength. One hundred forty-six samples were taken from the distal metaphysis of 20 bovine femora. After cementation, the shear strength of the bone-cement interface was tested. According to the porosity, the samples were divided into four groups. Group I (porosity <80%) had a median interface shear strength of 4.03 MPa, group II (80% or=90%) 14.85 MPa. The differences between the four groups were statistically significant. Greater porosity yielded a stronger bone-cement interface shear strength under the identical cementation technique. The optimum porosity of cancellous bone is more than 90% which can be found by reaming or drilling to deeper bone in cemented acetabular fixation.

The role of physiotherapy in the treatment of whiplash associated disorders: a prospective study.

OBJECTIVES: Prospective longitudinal study to evaluate the effect of physiotherapy on whiplash associated disorders (WAD). MATERIALS AND METHODS: A total of 141 patients suffering from grades I-III WAD after a road traffic accident were employed. Validated neck Bournemouth Questionnaire was used in order to look at the effect of treatment on the symptoms. RESULTS: The mean age was 40 (+/-14) years. The mean length of the treatment was 6 (+/-3.4) weeks. The mean individual effect size was 0.97 (95% CI 0.8-1.2). A total of 67% of the patients who started their treatment in the first 3 months post-injury improved compared to 48% in those who started physiotherapy after 3 months (P = 0.025). In both groups the applied treatment almost halved the number of patients taken sick leave. CONCLUSION: Physiotherapy is effective in the treatment of whiplash injury, especially in order to get the patients fit to go back to their previous employment.

The functional outcome of the fractured clavicle.

BACKGROUND: The severity of symptoms, rate and completeness of recovery after closed treatment of the fractured clavicle has not been fully explored. METHODS: The severity and duration of pain, analgesic requirements, ability to perform daily activities, return to work, driving and sport along with appearance of the shoulder were recorded in 56 patients between 1 and 2 years after fracture. Radiographs were assessed by Robinson's classification [8]. RESULTS: Twenty-two out of 56 patients described functional restriction 1-2 years after injury. The majority of patients ceased to experience pain (34/56) and returned to work (19/46) within 3 months. Thirty-eight out of 56 patients noted cosmetic deformity, the severity of which was associated with worse functional outcome (p = 0.002). The degree of fracture displacement was associated with cosmetic deformity (p = 0.02) and functional outcome (p = 0.015). CONCLUSION: The majority of patients perceive a cosmetic deformity and 22/56 impaired function after clavicular fracture.

Impaction bone grafting of the acetabulum at hip revision using a mix of bone chips and a biphasic porous ceramic bone graft substitute.

BACKGROUND AND PURPOSE: One of the greatest problems of revision hip arthroplasty is dealing with lost bone stock. Good results have been obtained with impaction grafting of allograft bone. However, there have been problems of infection, reproducibility, antigenicity, stability, availability of bone, and cost. Thus, alternatives to allograft have been sought. BoneSave is a biphasic porous ceramic specifically designed for use in impaction grafting. BoneSave is 80% tricalcium phosphate and 20% hydroxyapatite. Previous in vitro and in vivo studies have yielded good results using mixtures of allograft and BoneSave, when compared with allograft alone. This study is the first reported human clinical trial of BoneSave in impaction grafting. METHODS: We performed a single-institution, multi-surgeon, prospective cohort study. 43 consecutive patients underwent revision hip arthroplasty using BoneSave and allograft to restore missing bone in the acetabulum. 9 patients had cemented acetabular components implanted and 34 uncemented. 10 patients had cemented femoral components implanted and 1 had an uncemented femoral component. 32 patients did not have their femoral component revised. RESULTS: No patients were lost to follow-up. At a mean follow-up of 24 (11-48) months, there were no re-revisions and there was no implant migration. 1 acetabular component had confluent lucent lines at the implant-graft interface. Complications were rare (1 fracture, 2 dislocations). Patient satisfaction with the procedure was high. INTERPRETATION: Short-term results indicate that impaction grafting of BoneSave and allograft is an effective method of dealing with loss of bone stock at revision hip surgery.

An 18-year comparison of hybrid total hip replacement and Birmingham hip resurfacing in active young patients.

AIM: To compare the long-term clinical and radiological results of metal-on-polyethylene hybrid total hip replacement (THA) with metal-on-metal Birmingham hip resurfacing (BHR) in young, active patients. PATIENTS AND METHODS: From the 1st consecutive 63 hips in young, active patients who underwent BHR by the senior author, 54 (51 patients) were matched to patients who had undergone THA with regard to age, gender, body mass index and preoperative levels of activity. Radiologically, all hips were assessed for migration and osteolysis, THAs for polyethylene wear and BHRs for a pedestal sign. Patient-reported outcomes, mortality and revision rates were compared. RESULTS: The mean follow-up of the patients with a hybrid THR was 19.9 years and for those with a BHR, 17.6 years. 13 patients with a hybrid THR and 5 with a BHR had died. 1 hybrid THR and 3 BHRs were lost to follow-up. The revision rate of the hybrid THRs was 14/54 and of the BHRs 6/54. Log rank comparison of Kaplan-Meier survival estimates demonstrated a significantly lower mortality in the BHR group (p = 0.039; hazard ratio [HR] = 0.37 [95% CI, 0.15-0.95]) but a non-significant difference in revision rates (p = 0.067; HR = 0.43 [95% CI, 0.18-1.06]). The BHRs recorded superior OHS (p = 0.03), UCLA (p = 0.0096), and EuroQol visual analogue scores (p = 0.03). Significantly more BHRs had run, played sport and undertaken heavy manual labour in the month preceding follow-up. CONCLUSION: After 18 years, patients with BHRs remained more active with a lower mortality rate but demonstrated no significant difference in revision rates. Both groups demonstrated progressive radiological changes at long-term follow-up.

Effect of autologous salvaged blood on postoperative natural killer cell precursor frequency.

BACKGROUND: Immunosuppression after major surgery increases the risk of infections. Natural killer cells play a pivotal part in defence against infection. We aimed to investigate the immunomodulatory effects of different types of postoperative blood transfusion by use of a new assay for measuring the frequency of peripheral blood natural killer precursor cells (NKpf assay). METHODS: We measured the natural killer cell precursor (NKp) frequency before and 5 days after surgery in 120 patients undergoing joint replacement surgery. The patients were assigned to one of five groups according to the type of transfusion received: non-transfused (n=32), allogeneic non-leukodepleted blood (eight), allogeneic leukodepleted blood (30), autologous predeposited blood (ten), and autologous salvaged blood collected within the first 24 h after surgery (40). We also measured interferon gamma and interleukin 10 concentrations before and after surgery. FINDINGS: The mean postoperative NKp frequency for all patients was lower than the preoperative values, except in patients receiving autologous salvaged blood, which was higher than all other groups (p<0.0001). Postoperative NKp frequencies for patients receiving allogeneic or autologous predeposited blood responded similarly (p=0.99), but these patients had lower NKp frequencies than did the non-transfused group (p<0.0001). Postoperative interferon gamma concentrations were higher in the autologous salvaged blood group (p<0.0001) than in other groups, which did not differ from each other. Interleukin 10 concentrations were similar across all groups (p=0.49). INTERPRETATION: Immunosuppression associated with surgery and blood loss was reflected in a reduced frequency of NKp and decreased interferon gamma. This immunosuppression was reversed by transfusion of autologous salvaged blood, suggesting that this fluid contained immunostimulants.

The Oxford Knee Score; problems and pitfalls.

The Oxford Knee Score is a self-completed patient based outcome score. We audited the outcome of total knee arthroplasty at our unit using the Oxford Knee Score. The hypothesis of this study is that the OKS can be easily and accurately completed by unassisted patients. Of 856 patients who had undergone total knee arthroplasty and were given questionnaires, 769 (90%) responded. 624 (81%) of the respondents managed to complete the questionnaire. A number of the 12 items composing the questionnaire posed problems for the patients and a number of items were left blank. Item 4 (concerning walking time) was omitted in 82 (13%) of the 624 completed questionnaires. Calculation of Cronbach's alpha for internal consistency suggests that there are redundancies within the Score. Limitations in some of the items of the scale suggest the need for reconsideration and reformulation of questions and response categories. This study suggests that where detailed assessment of outcome is required, such as for outcome studies or controlled trials, the Oxford Knee Score, in its present form, is not ideal for use as a postal questionnaire.

The St. Leger total knee replacement. A false economy?

We reviewed the outcome of 53 primary St. Leger total knee replacement (TKR) implanted into 47 patients over a 2-year period from March 1995 and compared the outcome with age and sex matched controls with the Kinemax Plus TKR. All operations were performed to treat osteoarthritis of the knee. The St. Leger replacements were done in a Teaching Hospital by a Consultant surgeon while the Kinemax Plus replacements were done in the same hospital by two other surgical teams. During the period of review, 13 patients (13 knees) with St. Legers died or were too demented to participate, and 4 were lost to follow up. Eleven patients (13 knees) with the Kinemax died or were too demented to cooperate, and 2 patients (2 knees) were lost to follow up. The St. Leger group had inferior Oxford Knee Scores to the Kinemax group but this was not significant. The St. Leger group had significantly worse survivorship of the prosthesis. The St. Leger prosthesis was cheaper (Pound sterling 650) than the Kinemax (Pound sterling 1150). The initial saving was dwarfed by the ultimate cost of revision procedures.

Histology of failed metal-on-metal hip arthroplasty; three distinct sub-types.

The histological specimens from 29 failed metal-on-metal (MoM) hip arthroplasties treated at our institution were reviewed. Five patients had a failed MoM total hip arthroplasty (THA), and 24 patients a failed hip resurfacing. Clinical and radiographic features of each hip were correlated with the histological findings. We report three major histological subtypes. Patients either have a macrophage response to metal debris, a lymphocytic response (ALVAL) or a mixed picture of both. In addition we observe that the ALVAL response is located deep within tissue specimens, and can occur in environments of low wear debris. The macrophage response is limited to the surface of tissue specimens, with normal underlying tissue. Patients with subsequently confirmed ALVAL underwent revision surgery sooner than patients whose histology confirms a macrophage response (3.8 vs. 6.9 years p<0.05). Both histological subtypes (ALVAL and macrophage dominant) are responsible for abnormal soft tissue swellings.