A systematic review of the barriers and facilitators impacting patient enrolment in clinical trials for lung cancer.

PURPOSE: Clinical research trials are needed to enhance the medical care and treatment for lung cancer, which remains the leading cause of cancer-related deaths worldwide. While clinical trials allow for the development of novel therapies to treat cancer, the recruitment of lung cancer patients to trials is low. This review aimed to identify and synthesise the available literature concerning barriers and facilitators affecting lung cancer patients' decisions to enrol in clinical trials to guide future cancer research efforts. METHODS: Four databases were systematically searched: Academic Search Complete, CINHAL, PubMed, and PsycINFO in August 2023. A supplemental grey literature search was also conducted alongside this. Articles were quality appraised using CASP and JMI checklists, and results were narratively synthesised. RESULTS: Eighteen articles of varied design met the inclusion criteria, and results were mapped onto the Capability, Opportunity, and Motivation Behaviour (COM-B) Model to help structure and conceptualise review findings. Evidence suggests that the decision to enrol in a trial is multifaceted and informed by: when and how study information is presented, travel and trial eligibility, and altruistic hopes and fears. CONCLUSIONS: There is need to address the many different concerns that lung cancer patients have about participating in a clinical trial through the supply of accessible and timely trial information, and via the reduction of travel, expansion of study eligibility criteria, and recognition of a person's altruistic wishes, hopes, fears, and family-oriented concerns. Future research should aim to work alongside lung cancer patients, clinicians, and other stakeholders to increase research accessibility.

Less pain reported 5 years after cementless compared to cemented unicompartmental knee replacement: an analysis of pain, neuropathy, and co-morbidity scores.

PURPOSE: To compare patient-reported pain scores and assess the influence of neuropathy and co-morbidity, on knee pain following cemented and cementless medial unicompartmental knee replacement (UKR) 5 years after surgery. METHOD: In this longitudinal study, 262 cemented and 262 cementless Oxford UKR performed for the same indications and with the same techniques were recruited. Patients were reviewed at five years, evaluating patient-reported pain and association with clinical outcomes. Intermittent and Constant Osteoarthritis Pain (ICOAP), PainDETECT (PD), Charnley score, Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were compared. RESULTS: In both cohorts, intermittent pain was more common than constant pain (47% vs 21%). Cementless knees reported significantly less pain than cemented (ICOAP-Total 5/100 vs 11/100, p < 0.0001). A greater proportion of cementless knees experienced no pain at all (ICOAP = 0/100, 61% vs 43%, p < 0.0001) and 75% fewer experienced severe or extreme pain. Pain sub-scores in PD, OKS and AKSS follow this trend. Pain was unlikely to be neuropathic (PD positive: 5.26%), but patients reporting high levels of 'strongest' pain were three times more likely to be neuropathic. Patients with co-morbidities (Charnley C) experienced greater pain than those without (Charnley A+B) across all knee-specific scores, despite scores being knee specific. CONCLUSION: Both cemented and cementless UKR in this study had substantially less pain than that reported in literature following TKR. Cementless UKR had significantly less pain than cemented UKR in all scores. Two-thirds of patients with a cementless UKR had no pain at all at 5 years, and pain experienced was most likely to be mild and intermittent with no patients in severe or extreme pain. Patients with cementless UKR that had higher levels of pain were more likely to have co-morbidity or evidence or neuropathic pain. It is unclear why cementless UKR have less pain than cemented; further study is necessary.

Fixed lateral unicompartmental knee replacement is a reliable treatment for lateral compartment osteoarthritis after mobile-bearing medial unicompartmental replacement.

PURPOSE: Lateral osteoarthritis following medial unicompartmental knee replacement (UKR) is usually treated with total knee replacement, however, lateral UKR is a less invasive option that preserves a well-functioning medial UKR. This study aimed to determine the 5-year outcome of the cemented Fixed Lateral Oxford UKR (FLO) when used for the treatment of severe lateral disease after medial Oxford unicompartmental knee replacement. METHODS: Forty-four knees with lateral bone-on-bone osteoarthritis (n = 43) and avascular necrosis (n = 1) treated with the FLO following medial Oxford UKR were followed up prospectively. The Oxford Knee Score (OKS) and Tegner Activity Score (TAS) were collected pre- and post-operatively. Life-table analysis was used to determine survival rates. RESULTS: The mean patient age at the time of FLO surgery was 74.4 years with a mean time of 12.1 years between the primary medial UKR and the conversion to a bi-UKR with a FLO. Mean follow-up of the FLO was 3.5 years. After FLO no intra-operative or medical complications, re-admissions, or mortality occurred. There was one reoperation in which a bearing was exchanged for a medial bearing dislocation. There were no revisions of the FLO, so the FLO survival rate at 5 years was 100% (24 at risk). The mean pre-operative OKS was 22, which significantly (p < 0.0001) improved to a mean of 42, 42, and 40 at 1, 2, and 5 years, respectively. The median TAS had a non-significant improvement from 2.5 (Range 0-8) pre-operatively to 2 (Range 1-6) at 5 years postoperatively. CONCLUSION: The FLO is a reliable treatment for lateral osteoarthritis following medial UKR. At 5 years there was a 100% survival of the FLO with a mean OKS of 40. LEVEL OF EVIDENCE: IV, Prospective Case Series.

The effect of activity on the outcome of cementless mobile bearing unicompartmental knee replacements.

BACKGROUND: Many surgeons consider high activity levels a contraindication to Unicompartmental Knee Replacement (UKR). Cementless fixation is of particular concern given the lack of cement to augment primary stability. We assessed the effect of pre and post-operative activity levels on the outcomes of cementless UKRs. METHODS: A prospective cohort of 1000 medial cementless mobile bearing UKR were analysed. Patients were categorised by their pre-operative and highest post-operative Tegner Activity Score (TAS) and results compared between groups. Outcomes of interest included implant survival, Oxford Knee Score (OKS) and the American Knee Society Score - Objective/Functional (AKSS-O/F). RESULTS: Increasing post-operative activity were not associated with higher revision rates. The 10-year survival of the high activity group (TAS ≥ 5, 96.7% (CI 91.3-98.8), and low/medium activity group (TAS ≤ 4, 98.1% (CI 96.5-99.0)) were not significantly different (p = 0.57). The mean 10-year OKS of the high activity group (46.5, SD 3.1) was significantly (p < 0.001) higher than that of the low/medium activity group (41.3, SD 7.7). There was a significant trend for increasing activity being associated with increasing AKSS-F at 5-years (p < 0.001) and 10 years (p = 0.01) and increasing AKSS-O at 5 years (p < 0.001). Higher pre-operative activity did not significantly increase revision rates and resulted in significantly higher 5-year post-operative scores. CONCLUSIONS: Neither higher pre-operative nor post-operative activity were associated with increased revision rates, but both were associated with better post-operative function. Therefore activity should not be considered a contraindication to cementless mobile bearing UKR and not be restricted post-operatively.

The effect of body mass index on the outcomes of cementless medial mobile-bearing unicompartmental knee replacements.

PURPOSE: Given an increasingly overweight population, unicompartmental knee replacements (UKRs) are being performed in patients with higher body mass indices (BMIs). There are concerns that cemented fixation will not last. Cementless fixation may offer a solution, but the long term results in different BMI groups has not been assessed. We studied the effect of BMI on the outcomes of cementless UKRs. METHODS: A prospective cohort of 1000 medial cementless mobile-bearing UKR with a mean follow up of 6.6 years (SD 2.7) were analysed. UKRs were categorised into four BMI groups: (1) ≥ 18.5 to < 25 kg/m2 (normal), (2) 25 to < 30 kg/m2 (overweight), (3) 30 to < 35 kg/m2 (obese class 1) and (4) ≥ 35 kg/m2 (obese class 2). Implant survival was assessed using endpoints reoperation and revision. Functional outcomes were assessed. RESULTS: Ten-year cumulative revision rate for the normal (n = 186), overweight (n = 434), obese class 1 (n = 213) and obese class 2 (n = 127) groups were 1.8% (CI 0.4-7.4), 2.6% (CI 1.3-5.1), 3.8% (CI 1.5-9.2) and 1.7% (CI 0.4-6.8) with no significant differences between groups (p = 0.79). The 10-year cumulative reoperation rates were 2.7% (CI 0.8-8.2), 3.8% (CI 2.2-6.6), 5.2% (CI 2.5-10.7) and 1.7% (CI 0.4-6.8) with no significant differences between groups (p = 0.44). The 10-year median Oxford Knee Score were 43.0, 46.0, 44.0 and 38.0 respectively. CONCLUSION: Cementless mobile-bearing UKR has low 10-year reoperation and revision rates across in all BMI groups, and there are no significant differences between the groups. Although higher BMI groups had slightly worse functional outcomes, the improvement in function compared to preoperatively  tended to be better. This study suggests that BMI should not be considered a contraindication for the cementless mobile-bearing UKR.

Comparison of five-year clinical outcomes of 524 cemented and cementless medial unicompartmental knee replacements.

AIM: To compare the outcomes of cemented and cementless Unicompartmental Knee Replacements (UKR) at 5 years after surgery. METHODS: 262 cemented and 262 cementless medial mobile-bearing UKR, implanted by four high-volume surgeons using identical indications and surgical techniques, were reviewed by independent physiotherapists at 5 years. Survival, Oxford Knee Score (OKS), American Knee Society Score (AKSS), and EQ-5D-5L were assessed. The cementless cohort was mainly implanted after the cemented. Each cohort was divided into early and late sub-groups and compared, to assess if any differences were due to progressive improvement in surgical practice over time. RESULTS: There were no significant differences between the cohorts for demographics, pre-operative scores, and 5-year revision (0.8%), re-operation (1.5%), and complication rates (5%). The cementless cohort had significantly better 5-year OKS (43v41, p = 0.008), AKSS-Objective (94v90, p = 0.049) and EQ-5D-5L (0.81v0.87, p = 0.0001). Pain sub-scores within OKS, AKSS, and EQ-5D-5L were also significantly better in the cementless cohort, and the differences were proportionally much greater and more significant than differences in their respective overall scores. There was no significant improvement in scores between the early and late subgroups of the cohorts, whereas the 'early-cementless' cohort had significantly better scores than the contemporaneously implanted 'late-cemented' cohort. This suggests that differences found were due to implant type, instead of improved surgical practice over time. CONCLUSION: Cementless UKR is associated with better clinical outcomes than cemented UKR, which is primarily due to improved pain relief. Both cemented and cementless UKR are safe with low reoperation and complication rates, and a 5-year survival of 99%.

The effect of age on the outcomes of cementless mobile bearing unicompartmental knee replacements.

PURPOSE: Unicompartmental Knee Replacements (UKR) are being performed in patients with increasing demands and life expectancies with surgical concerns that cemented fixation will not last. Cementless fixation may offer a solution, but the results in different age groups have not been assessed. The effect of age at surgery on the outcomes of cementless UKRs was investigated. METHODS: A prospective cohort of 1000 medial cementless mobile bearing UKR were analysed. Patients were categorised into four age groups (< 55, 55 to < 65, 65 to < 75 and ≥ 75 years). Implant survival was assessed using endpoints reoperation, revision and major revision requiring revision knee replacement components. Functional outcomes were assessed. RESULTS: 10 year cumulative revision rate for the < 55, 55 to < 65, 65 to < 75 and ≥ 75 groups were 2.1% (CI 0.6-6.1), 1.8% (CI 0.6-5.3), 3.2% (CI 1.5-6.5) and 4.1% (1.7-9.6) with no differences between groups (p = 0.52). Two of the 22 revisions were considered major. The 10 year cumulative reoperation rates were 4.5% (CI 2.0-10.0), 3.0% (CI 1.3-6.5), 3.8% (CI 2.0-7.1) and 4.1% (CI 1.7-9.6) with no differences between groups (p = 0.81). The 10 year median Oxford Knee Scores were 42.5, 46.5, 45 and 42.5, respectively. The 10 year median Objective American Knee Society Scores were 95 for all age groups. CONCLUSION: The cementless mobile bearing UKR has low reoperation and revision rates and similar functional outcomes in all age groups. Cementless UKR should be used in all age groups and age should not be considered a contraindication. LEVEL OF EVIDENCE: III.

Acceptable outcomes with unicompartmental knee replacement and PCL deficiency are achievable: a case series of nine patients.

PURPOSE: Posterior cruciate ligament (PCL) deficiency is considered to be a contraindication for unicompartmental knee replacement (UKR); however, there is no evidence to support or contradict this. There are occasional circumstances where UKR in PCL deficient patients have been performed where the patient otherwise satisfies the indications for UKR. The aim of this paper is to describe the outcome of UKR in PCL deficient patients. METHODS: A retrospective study of patients with painful medial compartment osteoarthritis and PCL deficiency treated with Oxford UKR between 2006 and 2015 was undertaken. Clinical records from a prospectively recorded database were reviewed and outcomes were assessed based on revision rate, Oxford Knee Score (OKS), American Knee Society score and Tegner Activity Score. RESULTS: Nine patients were identified. The median age at surgery was 51 years (range 42-80) and median follow-up was 6 years (range 1-10). There was one bearing dislocation requiring open exchange. The outcome of seven patients was excellent (OKS > 41). Two patients, who were both elderly, had good outcomes (OKS 41 and 39). One patient had a poor outcome, but it is not clear if this was related to the knee as she had a learning disability and examination and radiographs of the knee were satisfactory. CONCLUSION: The results of this small series suggest that excellent results can be achieved with UKR for selected patients with medial osteoarthritis in a PCL deficient knee that was functioning well before the osteoarthritis developed. On the basis of this a larger study should be undertaken. Until more results are available PCL deficiency should be considered a relative contra-indication to UKR. LEVEL OF EVIDENCE: IV.

Oxford domed lateral unicompartmental knee arthroplasty.

AIMS: To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome. METHODS: A total of 325 consecutive domed lateral UKAs undertaken for the recommended indications were included, and their functional and survival outcomes were assessed. The effects of age, weight, activity, and the presence of full-thickness erosions of cartilage in the patellofemoral joint on outcome were evaluated. RESULTS: Median follow-up was seven years (3 to 14), and mean age at surgery was 65 years (39 to 90). Median Oxford Knee Score (OKS) was 43 (interquartile range (IQR) 37 to 47), with 260 (80%) achieving a good or excellent score (OKS > 34). Revisions occurred in 34 (10%); 14 (4%) were for dislocation, of which 12 had no recurrence following insertion of a new bearing, and 12 (4%) were revised for medial osteoarthritis (OA). Ten-year survival was 85% (95% confidence interval (CI) 79 to 90, at risk 72). Age, weight, activity, and patellofemoral erosions did not have a significant effect on the clinical outcome or survival. CONCLUSION: Domed lateral UKA provides a good alternative to total knee arthroplasty (TKA) in the management of lateral compartment OA. Although dislocation is relatively easy to treat successfully, the dislocation rate of 4% is high. It is recommended that the stability of the bearing is assessed intraoperatively. If the bearing can easily be displaced, the fixed rather than the mobile bearing version of the Oxford lateral tibial component should be inserted instead. Younger age, heavier weight, high activity, and patellofemoral erosions did not detrimentally affect outcome, so should not be considered contraindications. Cite this article: Bone Joint J 2020;102-B(8):1033-1040.

The clinical outcomes of cementless unicompartmental knee replacement in patients with reduced bone mineral density.

BACKGROUND: Osteoporosis and osteopenia are conditions characterised by reduced bone mineral density (BMD). There is concern that bone with reduced BMD may not provide sufficient fixation for cementless components which primarily rely on the quality of surrounding bone. The aim of our study was to report the midterm clinical outcomes of patients with reduced BMD undergoing cementless unicompartmental knee replacements (UKR). Our hypothesis was that there would be no difference in outcome between patients with normal bone and those with reduced BMD. METHODS: From a prospective cohort of 70 patients undergoing cementless UKR surgery, patients were categorised into normal (n = 20), osteopenic (n = 38) and osteoporotic groups (n = 12) based on their central dual-energy X-ray absorptiometry (DEXA) scans according to the World Health Organization criteria. Patients were followed up by independent research physiotherapists and outcome scores; Oxford Knee Score (OKS), Tegner score, American Knee Society Score Functional (AKSS-F) and Objective (AKSS-O) were recorded preoperatively and at a mean of 4 years postoperatively. The prevalence of reoperations, revisions and mortality was also recorded at a mean of 5 years postoperatively. RESULTS: There were no significant differences in the midterm postoperative OKS (P = 0.83), Tegner score (P = 0.17) and AKSS-O (P = 0.67). However, the AKSS-F was significantly higher (P = 0.04) in normal (90, IQR 37.5) compared to osteoporotic (65, IQR 35) groups. There were no significant differences (P = 0.82) between normal and osteopenic bone (80, IQR 35). The revision prevalence was 5%, 2.6% and 0% in the normal, osteopenic and osteoporotic groups respectively. The reoperation prevalence was 5%, 7.9% and 0% respectively. There were no deaths in any group related to the implant. CONCLUSIONS: We found that patients with reduced BMD could safely undergo cementless UKR surgery and have similar clinical outcomes to those with normal BMD. However, larger studies with longer follow-up are needed to confirm our findings and ensure that cementless fixation is safe in patients with reduced BMD.

Ten-year clinical and radiographic results of 1000 cementless Oxford unicompartmental knee replacements.

PURPOSE: Unicompartmental knee replacement (UKR) has substantial benefits over total knee replacement (TKR) but has higher revision rates. The cementless Oxford UKR was introduced to address this but there are concerns about fixation and tibial plateau fractures. The first long-term study of the device with clinical and radiographic outcomes is reported. METHODS: The first 1000 medial cementless Oxford UKR were prospectively identified and followed up by independent physiotherapists. Survival was calculated using the endpoints reoperation, revision, revision to TKR, major revision requiring revision TKR components and patient mortality. The Oxford Knee Score (OKS), Tegner Activity Score and American Knee Society Score (AKSS) were recorded and radiographs analysed. RESULTS: The ten year survival was 96.6% (CI 94.8-97.8), 97.5% (CI 95.7-98.5), 98.9% (CI 97.7-99.4) and 99.6% (CI 98.8-99.9) using reoperation, revision, revision to TKR and major revision as the endpoint, respectively. Commonest causes for revision were bearing dislocation (n = 7, 0.7%), disease progression (n = 4, 0.4%) and pain (n = 2, 0.2%). There was one lateral tibial plateau fracture and one femoral component loosening. At 10 years, the mean OKS was 41.2 (SD 9.8), Tegner 2.8 (SD 1.3), AKSS-O 89.1 (SD 13.0) and AKSS-F 80.4 (SD 14.6). There were no pathological radiolucencies or complete radiolucent lines. There were no implant-related deaths. CONCLUSIONS: The cementless Oxford UKR is a safe procedure with excellent long-term clinical results. Our results suggest that reliable fixation was achieved with only one (0.1%) revision for loosening (femoral), no radiographic evidence of loosening in the remaining cases and no fractures related to implantation. LEVEL OF EVIDENCE: III.

Obesity should not be considered a contraindication to medial Oxford UKA: long-term patient-reported outcomes and implant survival in 1000 knees.

PURPOSE: Some health providers ration knee arthroplasty on the basis of body mass index (BMI). There is no long-term data on the outcome of medial mobile-bearing unicompartmental knee arthroplasty (UKA) in different BMI groups. This study aimed to determine the effect of patient body mass index (BMI) on patient-reported outcomes and long-term survival of medial UKA in a large non-registry cohort. Our hypothesis is that increasing BMI would be associated with worse outcomes. METHODS: Data were analysed from a prospective cohort of 1000 consecutive medial mobile-bearing Oxford UKA with mean 10-year follow-up. Patients were grouped: BMI < 25, BMI 25 to < 30, BMI 30 to < 35 and BMI 35+. Oxford Knee Score (OKS) and Tegner Activity Score were assessed at 1, 5 and 10 years. Kaplan-Meier survivorship was calculated and compared between BMI groups. RESULTS: All groups had significant improvement in OKS and Tegner scores. BMI 35 + kg/m2 experienced the greatest overall increase in mean OKS of 17.3 points (p = 0.02). There was no significant difference in ten-year survival, which was, from lowest BMI group to highest 92%, 95%, 94% and 93%. CONCLUSION: There was no difference in implant survival between groups, and although there was no consistent trend in postoperative OKS, the BMI 35+ group benefited the most from UKA. Therefore, when UKA is used for appropriate indications, high BMI should not be considered to be a contraindication. Furthermore rationing based on BMI seems unjustified, particularly when the commonest threshold (BMI 35) is used. LEVEL OF EVIDENCE: III.

The impact of patient-specific instrumentation on unicompartmental knee arthroplasty: a prospective randomised controlled study.

PURPOSE: Patient-specific instrumentation (PSI) has been proposed as a means of improving surgical accuracy and ease of implantation during technically challenging procedures such as unicompartmental knee arthroplasty (UKA). The purpose of this prospective randomised controlled trial was to compare the accuracy of implantation and functional outcome of mobile-bearing medial UKAs implanted with and without PSI by experienced UKA surgeons. METHODS: Mobile-bearing medial UKAs were implanted in 43 patients using either PSI guides or conventional instrumentation. Intra-operative measurements, meniscal bearing size implanted, and post-operative radiographic analyses were performed to assess component positioning. Functional outcome was determined using the Oxford Knee Score (OKS). RESULTS: PSI guides could not be used in three cases due to concerns regarding accuracy and registration onto native anatomy, particularly on the tibial side. In general, similar component alignment and positioning was achieved using the two systems (n.s. for coronal/sagittal alignment and tibial coverage). The PSI group had greater tibial slope (p = 0.029). The control group had a higher number of optimum size meniscal bearing inserted (95 vs 52%; p = 0.001). There were no differences in OKS improvements (n.s). CONCLUSION: Component positioning for the two groups was similar for the femur but less accurate on the tibial side using PSI, often with some unnecessarily deep resections of the tibial plateau. Although PSI was comparable to conventional instrumentation based on OKS improvements at 12 months, we continue to use conventional instrumentation for UKA at our institution until further improvements to the PSI guides can be demonstrated. LEVEL OF EVIDENCE: Therapeutic, Level I.

The Interaction of Caseload and Usage in Determining Outcomes of Unicompartmental Knee Arthroplasty: A Meta-Analysis.

BACKGROUND: Outcomes after unicompartmental knee arthroplasty (UKA) are variable and influenced by caseload (UKA/y) and usage (percentage of knee arthroplasty that are UKA), which relates to indications. This meta-analysis assesses the relative importance of these factors. METHODS: MEDLINE (Ovid), Embase (Ovid), and Web of Science (ISI) were searched for consecutive series of cemented Phase 3 Oxford medial UKA. The primary outcome was revision rate/100 observed component years (% pa) with subgroup analysis based on caseload and usage. RESULTS: Forty-six studies (12,520 knees) with an annual revision-rate ranging from 0% to 4.35% pa, mean 1.21% pa (95% confidence interval [CI], 0.97-1.47), were identified. In series with mean follow-up of 10-years, the revision-rate was 0.63% pa (95% CI, 0.46-0.83), equating to a 94% (95% CI, 92%-95%) 10-year survival. Aseptic loosening, lateral arthritis, bearing dislocation, and unexplained pain were the predominant failure mechanisms with revision for patellofemoral problems and polyethylene wear exceedingly rare. The lowest revision-rates were achieved with caseload >24 UKA/y (0.88% pa; 95% CI, 0.63-1.61) and usage >30% (0.69% pa; 95% CI, 0.50-0.90). Usage was more important than caseload; with high usage (≥20%), the revision-rate was low, whether the caseload was high (>12 UKA/y) or low (≤12 UKA/y; (0.94% pa; 95% CI, 0.69-1.23 and 0.85% pa; 95% CI, 0.65-1.08), respectively); with low usage (<20%), the revision-rate was high, whether the caseload was high or low (1.58% pa; 95% CI, 0.57-3.05 and 1.76% pa; 95% CI, 1.21-2.41, respectively). CONCLUSION: To achieve optimum results, surgeons, whether high or low caseload, should adhere to the recommended indications such that ≥20%, or ideally >30% of their knee arthroplasties are UKA. If they do this, then they can expect to achieve results similar to those of the long-term series, which all had high usage (>20%) and an average 10-year survival of 94%.

Evidence-Based Indications for Mobile-Bearing Unicompartmental Knee Arthroplasty in a Consecutive Cohort of Thousand Knees.

BACKGROUND: The indications for unicompartmental knee arthroplasty remain controversial. Previously recommended contraindications include the following: age under 60 years, weight 180 lb (82 kg) or over, patients undertaking heavy labor, chondrocalcinosis, and exposed bone in the patellofemoral joint. This study explores whether these contraindications are valid in mobile-bearing unicompartmental knee arthroplasty. METHODS: Using a prospective series of 1000 consecutive medial unicompartmental knee arthroplasties in which the reported contraindications were not applied, the functional outcome and survival in patients with or without contraindications were compared. RESULTS: Of the 1000 consecutive unicompartmental knee arthroplasties (818 patients), 68% (678 knees) would be considered contraindicated based on published contraindications. At a mean follow-up of 10 years (5-17), there was no difference in American Knee Society (AKS) Objective Scores (P = .05) or Oxford Knee Score (P = .08) between groups. However, knees with contraindications had significantly (P = .02) fewer poor outcomes and significantly better AKS Functional Scores (P < .001) and Tegner Activity Scores (P < .001). At 15 years, no difference in implant survival (P = .33) was observed. The 3% of unicompartmental knee arthroplasties performed in young men (age <60) weighing 180 lb or over with high activity levels, who have been reported to have poor outcomes after fixed-bearing unicompartmental knee arthroplasty, had significantly better AKS Functional Scores (P < .001), Oxford Knee Score (P = .01), and Tegner Activity Score (P < .001) at 10 years. No difference in AKS Objective Scores (P = .54) at 10 years or implant survival at 15 years (P = .75) was seen. CONCLUSION: This large case series provides evidence that patients with the previously reported contraindications do as well as, or even better than, those without contraindications. Therefore these contraindications should not apply to mobile-bearing unicompartmental knee arthroplasty.

Lateral osteophytes do not represent a contraindication to medial unicompartmental knee arthroplasty: a 15-year follow-up.

PURPOSE: Lateral osteophytes have been reported to be associated with lateral compartment disease and as such it is unclear whether medial unicompartmental knee arthroplasty should be performed if these are present. METHODS: Using the OARSI classification system, 0 (no osteophyte) to 3 (large osteophyte), radiographs from a series of cemented meniscal-bearing unicompartmental knee arthroplasty implanted in the setting of full-thickness lateral cartilage where lateral osteophytes were not considered a contraindication were identified and factors associated with the presence and size of lateral osteophytes, and their impact on clinical outcomes and implant survival were assessed. RESULTS: Pre-operative radiographs from 458 knees (392 patients), independently followed up for a mean 10.5 years (range 5.3-16.6), were assessed. Lateral osteophytes were present in 62 % of knees with 18 % scored as Grade 3. Inter-observer reliability was good (kappa = 0.70). The presence and size of lateral osteophytes was associated with younger age at joint replacement (p = 0.01) and increasing BMI (p = 0.01). No association was seen with gender, pre-operative status, assessed using the Oxford Knee Score (OKS), American Knee Society (AKSS) Objective or Functional Score, Tegner activity score, or size of medial tibial lesion. Subgroup analysis of Grade 3 Osteophytes revealed that these were associated with a greater degree of macroscopic ACL damage. At 10 years there was no difference in function (n.s.), and at 15 years no difference in implant survival or mechanism of failure between groups (n.s.). Subgroup analysis of Grade 3 osteophytes found no significant difference in functional outcome at 10 years or implant survival at 15 years. CONCLUSION: The presence of lateral osteophytes is not a contraindication to medial meniscal-bearing unicompartmental knee arthroplasty. The clinical relevance of this study is that it highlights the importance of an appropriate pre-operative assessment of the lateral compartment as in the setting of full-thickness cartilage at operation lateral osteophytes do not compromise long-term functional outcome or implant survival. LEVEL OF EVIDENCE: IV.

HIV testing rates among pregnant women in Managua, Nicaragua, 2010-2011.

OBJECTIVE: To determine and report the rate and pattern of HIV testing among pregnant women receiving ambulatory prenatal care, and the total number of positive cases in pregnant women in Managua, Nicaragua. METHODS: A retrospective epidemiological review was conducted to assess HIV testing rates among pregnant women in Managua attending district-level health centers in 2010 and 2011, with a focus on a single district (District 6.1). RESULTS: A total of 39.4% of pregnant women receiving prenatal care at Managua health centers in 2010 received an HIV test, and this number increased to 49.8% in 2011 (P < 0.001; phi statistic, 0.10). In 2010, 27 pregnant women in Managua were found to be HIV positive, corresponding to 0.17% of those who were tested. In 2011, 31 tested positive (0.12% of those who were tested). Comparisons between 2010 and 2011 at the District 6.1 level reflect an increase in women who received HIV tests from 24.2% in 2010 to 49.3% in 2011 (P < 0.001; phi statistic, 0.26). In District 6.1, two pregnant women were identified as HIV positive in 2010 and three in 2011, corresponding to 0.32% and 0.13% of pregnant women tested, respectively. CONCLUSIONS: Despite significant improvements in HIV testing rates from 2010 to 2011, the numbers tested remain below the goal recommended by the Pan American Health Organization (PAHO) in order to achieve virtual elimination of mother-to-child transmission by 2015 (> 95%). Patterns of testing demonstrated increased rates coinciding with a health fair in District 6.1, but effects were short-lived. Therefore, new approaches are necessary to bolster prenatal HIV screening efforts within Managua and District 6.1 in Nicaragua.

HIV testing rates among pregnant women in Managua, Nicaragua, 2010-2011 / Tasas de realización de pruebas de detección del VIH en mujeres embarazadas en Managua, Nicaragua, 2010-2011

OBJECTIVE: To determine and report the rate and pattern of HIV testing among pregnant women receiving ambulatory prenatal care, and the total number of positive cases in pregnant women in Managua, Nicaragua. METHODS: A retrospective epidemiological review was conducted to assess HIV testing rates among pregnant women in Managua attending district-level health centers in 2010 and 2011, with a focus on a single district (District 6.1). RESULTS: A total of 39.4% of pregnant women receiving prenatal care at Managua health centers in 2010 received an HIV test, and this number increased to 49.8% in 2011 (P < 0.001; phi statistic, 0.10). In 2010, 27 pregnant women in Managua were found to be HIV positive, corresponding to 0.17% of those who were tested. In 2011, 31 tested positive (0.12% of those who were tested). Comparisons between 2010 and 2011 at the District 6.1 level reflect an increase in women who received HIV tests from 24.2% in 2010 to 49.3% in 2011 (P < 0.001; phi statistic, 0.26). In District 6.1, two pregnant women were identified as HIV positive in 2010 and three in 2011, corresponding to 0.32% and 0.13% of pregnant women tested, respectively. CONCLUSIONS: Despite significant improvements in HIV testing rates from 2010 to 2011, the numbers tested remain below the goal recommended by the Pan American Health Organization (PAHO) in order to achieve virtual elimination of mother-to-child transmission by 2015 (> 95%). Patterns of testing demonstrated increased rates coinciding with a health fair in District 6.1, but effects were short-lived. Therefore, new approaches are necessary to bolster prenatal HIV screening efforts within Managua and District 6.1 in Nicaragua.

OBJETIVO: Determinar y notificar la tasa de realización de pruebas de detección del VIH, los patrones obtenidos y el número de casos positivos en las mujeres embarazadas que recibieron asistencia prenatal ambulatoria, en Managua, Nicaragua. MÉTODOS: Se llevó a cabo un examen epidemiológico retrospectivo para evaluar las tasas de realización de pruebas de detección del VIH en mujeres embarazadas que acudieron a centros de salud de distrito en Managua en el 2010 y el 2011, centrándose en un solo distrito (distrito 6.1). RESULTADOS: El 39,4% de las mujeres embarazadas que recibieron asistencia prenatal en los centros de salud de Managua en el 2010 se sometieron a pruebas de detección del VIH, y esta cifra aumentó a 49,8% en 2011 (P <0,001; ϕ = 0,10). En el 2010, 27 mujeres embarazadas de Managua presentaron resultados positivos en las pruebas de detección del VIH, lo que corresponde a 0,17% de las que se sometieron a estas pruebas; en el 2011, 31 tuvieron resultados positivos, es decir, 0,12% de las embarazadas a las que se realizaron pruebas de detección del VIH. Las comparaciones entre el 2010 y el 2011 en el distrito 6.1 reflejan un aumento de las mujeres que se sometieron a pruebas de detección del VIH de 24,2% en 2010 a 49,3% en 2011 (P < 0,001; ϕ = 0,26). En ese distrito, 2 mujeres embarazadas presentaron resultados positivos en el 2010 y 3 en el 2011, lo que corresponde, respectivamente, a 0,32% y 0,13% de las mujeres embarazadas a las que se les realizaron dichas pruebas. CONCLUSIONES: A pesar de las mejoras considerables en las tasas de realización de pruebas de detección del VIH entre el 2010 y el 2011, las cifras se mantuvieron por debajo de la meta recomendada (> 95%) por la Organización Panamericana de la Salud (OPS) para lograr la eliminación virtual de la transmisión maternoinfantil para el 2015. Los patrones de realización de pruebas evidenciaron que las tasas aumentaron en coincidencia con una feria de salud en el distrito 6.1, aunque los efectos duraron poco. Por consiguiente, es necesario utilizar nuevas estrategias para reforzar las pruebas de detección sistemática del VIH prenatales en Managua y en el distrito 6.1.

No difference in survivorship after unicompartmental knee arthroplasty with or without an intact anterior cruciate ligament.

PURPOSE: Anterior cruciate ligament deficiency (ACLD) has been considered a contraindication for Oxford unicompartmental knee arthroplasty (UKA) because of the reported higher incidence of failure when implanted in ACLD knees. However, given the potential advantages of UKA over total knee arthroplasty (TKA), we have performed UKA in a limited number of patients with ACL deficiency and end-stage medial compartment osteoarthritis (OA) over the past 11 years. The primary aim of this study was to establish the clinical outcome of this cohort; the secondary aim was to compare both clinical and radiographic data with a matched cohort of ACL-intact (ACLI) patients who have undergone UKA for anteromedial OA. METHODS: This retrospective observational study describes the clinical and radiological outcome in 46 medial Oxford UKAs implanted in 42 consecutive patients with ACL deficiency and concomitant symptomatic medial compartment OA at mean follow-up of 5 years. It also compares the outcomes with a matched cohort of UKA patients with an intact ACL (ACLI group). RESULTS: At the time of last follow-up, there was no significant difference in clinical results or survivorship between the two groups in this study. CONCLUSION: The successful short-term results of the ACLD group suggest ACL deficiency may not always be a contraindication to Oxford UKA as previously thought. Until long-term data is available, however, we maintain our recommendation that ACLD be considered a contraindication.

Does a mixed training course on the Oxford unicompartmental knee arthroplasty improve non-technical skills of orthopaedic surgeons?

PURPOSE: To determine whether a mixed course on the Oxford unicompartmental knee arthroplasty (UKA) could improve the non-technical (cognitive) skills of performing UKA. METHODS: 120 delegates consisting of consultant orthopaedic surgeons and advanced surgical trainees attended a 2-day course. 104 (87%) of the delegates had performed total knee arthroplasties, whereas 79 (66%) had performed UKAs. The course consisted of didactic lectures, interactive surgical demonstrations, and practical dry-bone skills workshops. Cognitive skills were assessed at the start (day 1) and end (day 2) of the course using 10 multiple-choice questions. The maximum test score was 10. Multilevel modelling was used to compare the pre- and post-course test scores. The pairings of pre- and post-course scores were not known because of a confidentiality clause. RESULTS: Of the 120 delegates, 71 (59%) took the pre-course test and 120 (100%) took the post-course test. The median score improved significantly from 2 (interquartile range [IQR], 0.5-3.5) to 6 (IQR, 4.5- 7.5) [bootstrap p<0.0001] for every single one of the randomly allocated pairings. Most delegates had poor cognitive skills for the UKA before the course and improved significantly after the course. Sub-analysis of each question topic showed significant improvement in scores for all topics after the course (bootstrap p<0.0001). Nonetheless, the extent to which individual topic scores improved varied widely. The odds ratio for the pre- versus post-course total test score was 4.36. CONCLUSION: A mixed continuing medical education course could enhance the non-technical (cognitive) skills for UKA.