The virtual knee clinic - A tool to streamline new outpatient referrals.

INTRODUCTION: Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol. METHODS: Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation. RESULTS: 1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p < 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) DISCUSSION: The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel.

Severe arthritis predicts greater improvements in function following total knee arthroplasty.

PURPOSE: Although excellent outcomes are routinely reported following total knee replacement, up to 20 % of patients remain dissatisfied. The aim of this study was to determine whether pre-operative radiographic classification was associated with functional outcomes following surgery. METHODS: A retrospective review of a prospective arthroplasty database identified 256 patients that fulfilled the inclusion criteria over an 18-month period. Baseline demographic data on all patients were collected prospectively. All pre-operative radiographs were assessed using the Kellgren and Lawrence (K&L) classification system. Patients were prospectively assessed using the American Knee Society Score pre-operatively and at 1, 3 and 5 years post-surgery. RESULTS: An association was found between the pre-operative radiographic severity of arthritis and the pre-operative American Knee Society Knee (AKSK) scores, with worsening radiographic grade corresponding to worsening AKSK scores (p = 0.020). There was an association between K&L classification and improvement in AKSK scores from pre-operative to 1 year (p = 0.003) and 3 years (p = 0.04), with K&L grades 3 and 4 demonstrating the most significant improvements. On multivariate regression analysis, K&L classification was the only significant predictor of improvement in AKSK at 1 year (p = 0.009). No correlation was found between K&L grade and the American Knee Society Functional Scores at any stage. CONCLUSIONS: The results of this study may help to improve satisfaction rates in total knee replacement by targeting treatment. Patients can be counselled that although radiographic severity of arthritic changes can predict knee-specific functional improvement, the extent of their global functional improvement cannot. LEVEL OF EVIDENCE: IV.

A study of thromboprophylactic practices of Scottish orthopaedic surgeons in patients undergoing total hip replacements. Should practice change with new guidelines?

Despite increasing scientific investigation, the best method for preventing postoperative thromboembolism in patients undergoing a total hip replacement (THR) remains unclear. National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the prevention of thromboembolism have caused much controversy. We surveyed Scottish surgeons regarding their thromboprophylaxis prescribing after THR. Questionnaires were sent to all Scottish orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing a THR. Comparison was made with a previous survey done in 2003. The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of aspirin from 51% to 64%. The use of low molecular weight heparin has remained constant at 51%. No surgeons routinely use warfarin, un-fractionated heparin or fondaparinux. Use of graded compression stockings has increased from 59% to 70%. In conclusion, there is increasing evidence that patients undergoing THR should receive extended prophylaxis for up to 35 days. Oral agents such as dabigatran and rivaroxaban have offered a new option for oral extended prescribing. The results in change of practice must be closely audited.

Manipulation under anaesthesia and early physiotherapy facilitate recovery of patients with frozen shoulder syndrome.

AIM: The aim of this study was to examine the efficacy of manipulation under anaesthesia (MUA) followed by early physiotherapy in treating frozen shoulder syndrome. METHODS: In a prospective trial conducted between 26th August 2002 and 25th June 2004 in 86 patients with frozen shoulder syndrome, MUA was performed as a day procedure. Main outcomes were Disabilities of the Arm, Shoulder and Hand (DASH) score, a visual analogue score (VAS) for pain and range of movement, which were measured preoperatively and at six weeks postprocedure. RESULTS: Fifty (58.1%) patients had complete data. The average age was 54.5 years. The mean duration of symptoms until MUA was 13 months. The mean DASH score decreased from 48.07 to 15.84 (p < 0.0005). The mean VAS reduced from 6.07 to 1.88 (p < 0.0005). Flexion improved from 104.18 to 157.56 (p < 0.0005); abduction from 70.48 to 150.00 (p < 0.0005); and external rotation from 13.88 to 45.62 (p < 0.0005). CONCLUSION: MUA combined with early physiotherapy alleviates pain and facilitates recovery of function in patients with frozen shoulder syndrome.

Surgery performed by supervised registrars does not adversely affect medium-term functional outcomes after total knee replacement.

Introduction Although total knee arthroplasty (TKA) is an index procedure for orthopaedic registrars, there is a lack of published research as to the effects of surgery when performed by supervised trainees. The aim of this study was to compare functional outcomes up to five years after primary TKA performed by consultants and trainee surgeons. Methods A retrospective analysis was conducted of prospectively collected data for 609 consecutive patients (339 female, 270 male) undergoing TKA. Patients were assessed preoperatively as well as at 18 months, three years and five years postoperatively, and American Knee Society objective knee and functional scores (AKSK and AKSF) were recorded. Results Surgery was performed by a consultant in 465 cases and a supervised trainee in 144 cases. There were no significant differences between the two groups in preoperative patient characteristics, operative time (p=0.15), transfusion rates (p=0.84), length of stay (p=0.98), manipulation under anaesthesia (p=0.69), or mortality rates at one year (p=0.73) or five years (p=0.81). Postoperatively, the median magnitude of improvement in AKSK (48 points for consultant group vs 45 points for trainee group, p=0.74) and in AKSF (both groups 15, p=0.995) was similar between the groups. AKSK and AKSF scores were similar at all timepoints up to five years following surgery, and there was no difference in the median range of motion (both groups 100°, IQR: 18°) at five years (p=0.43). Conclusions TKA performed by supervised registrars gives functional outcomes that are equivalent to consultant performed TKA, without affecting postoperative range of movement, or increasing operative time, length of stay or transfusion rates. Rates of postoperative MUA and mortality are also comparable.

A conservative approach is feasible in unexplained pain after knee replacement: a selected cohort study.

Pain is the main indication for performing total knee replacement (TKR). In most patients after TKR there is an improvement, but a few continue to have pain. Generally, the cause of the pain can be addressed when it is identified. However, unexplained pain can be more difficult to manage because revision surgery is likely to be unrewarding in this group. In our study of 622 cemented TKRs in 512 patients with a mean age of 69 years (23 to 90) treated between January 1995 and August 1998, we identified 24 patients (knees) with unexplained pain at six months. This group was followed for five years (data was available for 18 knees in the study) [corrected] and ten patients (55.5%) went on to show an improvement without intervention. In the case of unexplained pain, management decisions must be carefully considered, but reassurance can be offered to patients that the pain will improve in more than half with time.

Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.

We have evaluated the quality of life and functional outcome after unilateral primary total hip replacement (THR). Between 5 January 1998 and 31 July 2000, we recruited a consecutive series of 627 patients undergoing this procedure and investigated them prospectively. Each was assessed before operation and reviewed after six months, 18 months, three years and five years. The Short Form-36 Health Survey (SF-36) and Harris Hip scores were evaluated at each appointment. All dimensions of the SF-36 except for mental health and general health perception, improved significantly after operation and this was maintained throughout the follow-up. The greatest improvement was seen at the six-month assessment. On average, women reported lower SF-36 scores pre-operatively, but the gender difference did not continue post-operatively. The Harris Hip scores improved significantly after operation, reaching a plateau after 18 months. The improved quality of life was sustained five years after THR.

Does a history of cardiac disease or hypertension increase mortality following primary elective total hip arthroplasty?

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at 'high risk' for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004; 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction; 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on preoperative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at three months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within three months. Increasing age was the only significant risk factor for early mortality (p<0.001). Longer-term mortality at two and five years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (p<0.001) with long-term mortality in patients who survived more than three months. This remained significant (p=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor and ASA was also a predictor of death, as has been previously shown. The overall long-term mortality following THAwas less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients who have one of these common risk factors when seeking primary elective THA.

Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis?

A total of 370 consecutive primary total knee replacements performed for osteoarthritis were followed up prospectively at 6, 18, 36 and 60 months. The Knee Society score and complications (perioperative mortality, superficial and deep wound infection, deep-vein thrombosis and revision rate) were recorded. By dividing the study sample into subgroups based on the body mass index overall, the body mass index in female patients and the absolute body-weight. The outcome in obese and non-obese patients was compared. A repeated measures analysis of variance showed no difference in the Knee Society score between the subgroups. There was no statistically-significant difference in the complication rates for the subgroups studied. Obesity did not influence the clinical outcome five years after total knee replacement.

Total knee replacement in morbidly obese patients. Results of a prospective, matched study.

The results of 41 consecutive total knee replacements performed on morbidly obese patients with a body mass index > 40 kg/m(2), were compared with a matched group of 41 similar procedures carried out in non-obese patients (body mass index < 30 kg/m(2)). The groups were matched for age, gender, diagnosis, type of prosthesis, laterality and pre-operative Knee Society Score. We prospectively followed up the patients for a mean of 38.5 months (6 to 66). No patients were lost to follow-up. At less than four years after operation, the results were worse in the morbidly obese group compared with the non-obese, as demonstrated by inferior Knee Society Scores (mean knee score 85.7 and 90.5 respectively, p = 0.08; mean function score 75.6 and 83.4, p = 0.01), a higher incidence of radiolucent lines on post-operative radiographs (29% and 7%, respectively, p = 0.02), a higher rate of complications (32% and 0%, respectively, p = 0.001) and inferior survivorship using revision and pain as end-points (72.3% and 97.6%, respectively, p = 0.02). Patients with a body mass index > 40 kg/m(2) should be advised to lose weight prior to total knee replacement and to maintain weight reduction. They should also be counselled regarding the inferior results which may occur if they do not lose weight before surgery.

The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project.

The issue of the safety of performing simultaneous, bilateral total knee replacement (SBTKR) for patients with bilateral knee osteoarthritis remains controversial. Several small series have reported inconclusive findings and the few large series published are contradictory. We present data retrieved from the Scottish Arthroplasty Project on over 19,000 total knee replacements (TKR) performed in Scotland between 1989 and 1999. The trends in the practice of SBTKR are shown together with the associated mortality from the procedure compared with unilateral or staged, bilateral TKR. The data shows that there was no statistically significant difference in the 90-day mortality between unilateral TKR, staged TKR or SBTKR. In addition, the length of stay for SBTKR has reduced, equaling that of unilateral TKR since 1993. Despite an initial increase in the percentage of consultants performing SBTKR early in the decade, since 1993, only approximately 25% of knee arthroplasty surgeons in Scotland per year ever performed a SBTKR.

The pre-operative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty.

AIMS: The pre-operative level of haemoglobin is the strongest predictor of the peri-operative requirement for blood transfusion after total knee arthroplasty (TKA). There are, however, no studies reporting a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of haemoglobin that would predict the requirement for blood transfusion in patients who undergo TKA. PATIENTS AND METHODS: Analysis of receiver operator characteristic (ROC) curves of 2284 consecutive patients undergoing unilateral TKA was used to determine gender specific thresholds predicting peri-operative transfusion with the highest combined sensitivity and specificity (area under ROC curve 0.79 for males; 0.78 for females). RESULTS: Threshold levels of 13.75 g/dl for males and 12.75 g/dl for females were identified. The rates of transfusion in males and females, respectively above these levels were 3.37% and 7.11%, while below these levels, they were 16.13% and 28.17%. Pre-operative anaemia increased the rate of transfusion by 6.38 times in males and 6.27 times in females. Blood transfusion was associated with an increased incidence of early post-operative confusion (odds ratio (OR) = 3.44), cardiac arrhythmia (OR = 5.90), urinary catheterisation (OR = 1.60), the incidence of deep infection (OR = 4.03) and mortality (OR = 2.35) one year post-operatively, and increased length of stay (eight days vs six days, p < 0.001). CONCLUSION: Uncorrected low pre-operative levels of haemoglobin put patients at potentially modifiable risk and attempts should be made to correct this before TKA. Target thresholds for the levels of haemoglobin pre-operatively in males and females are proposed. TAKE HOME MESSAGE: Low pre-operative haemoglobin levels put patients at unnecessary risk and should be corrected prior to surgery.

A postal survey of current thromboprophylactic practices of consultant orthopaedic surgeons in the treatment of fracture of the hip.

Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature.

Natural history of fixed flexion deformity following total knee replacement: a prospective five-year study.

We investigated fixed flexion deformity (FFD) after total knee replacement (TKR). Data relating to 369 cruciate-retaining unilateral TKRs performed at a single institution were collected prospectively. Fixed flexion was measured pre-operatively and at one week, six months, 18 months, three years and five years after surgery. Using binary logistic regression, pre-operative FFD was a predictor of post-operative FFD > 10 degrees at one week (p = 0.006) and six months (p = 0.003) following surgery. Gender was a predictor at one week (p = 0.0073) with 24% of women showing a FFD > 10 degrees compared with 37% of men. We have shown that a gradual improvement in knee extension can be expected up to three years after surgery in knees with FFD. By this time residual FFD is mild or absent in the majority of patients, including those who had a severe pre-operative FFD.

Weight change following total hip replacement: a comparison of obese and non-obese patients.

BACKGROUND: Weight loss is desirable in obese patients prior to hip replacement but poor mobility secondary to hip dysfunction may limit attempts at weight reduction because of reduced exercise tolerance. METHODS: We followed 140 patients prospectively to investigate weight change and functional outcome in obese and non-obese patients following total hip arthroplasty. Weight and the Harris hip score was measured one week prior to surgery and three years post-operatively. RESULTS: Fifty nine patients were obese (BMI > or = 30). The mean weight of obese patients increased from 88 kg pre-operatively to 92 kg following surgery (p<0.001). In non-obese patients pre-operative weight was 69 kg and post-operative weight 70 kg (p=0.106). In the obese group 75% of patients gained a mean of 6.77 kg (p<0.001) and 19% of patients lost a mean of 4.8 kg (p<0.01). In the non-obese group, 60% of patients gained a mean of 4.2 kg (p<0.001) and 31% of patients lost an average of 4.7 kg (p<0.001). The mean Harris hip score was 90 in non-obese patients and 85 in obese patients three years post-operatively (p<0.01). CONCLUSION: Weight increase is common following total hip replacement despite improved function but the magnitude of weight increase appears to be greater in patients who are obese. Obesity was also associated with lower functional hip scores but the differences were small and unlikely to be of clinical significance.

Validation of a prediction model that allows direct comparison of the Oxford Knee Score and American Knee Society clinical rating system.

This study demonstrates a significant correlation between the American Knee Society (AKS) Clinical Rating System and the Oxford Knee Score (OKS) and provides a validated prediction tool to estimate score conversion. A total of 1022 patients were prospectively clinically assessed five years after TKR and completed AKS assessments and an OKS questionnaire. Multivariate regression analysis demonstrated significant correlations between OKS and the AKS knee and function scores but a stronger correlation (r = 0.68, p < 0.001) when using the sum of the AKS knee and function scores. Addition of body mass index and age (other statistically significant predictors of OKS) to the algorithm did not significantly increase the predictive value. The simple regression model was used to predict the OKS in a group of 236 patients who were clinically assessed nine to ten years after TKR using the AKS system. The predicted OKS was compared with actual OKS in the second group. Intra-class correlation demonstrated excellent reliability (r = 0.81, 95% confidence intervals 0.75 to 0.85) for the combined knee and function score when used to predict OKS. Our findings will facilitate comparison of outcome data from studies and registries using either the OKS or the AKS scores and may also be of value for those undertaking meta-analyses and systematic reviews.

Pre-operative predictors of the requirement for blood transfusion following total hip replacement.

We have reviewed prospective data on 1016 patients who underwent unilateral total hip replacement to establish the pre-operative risk factors associated with peri-operative blood transfusion. Most patients who required transfusion were older and were of lower weight, height, pre-operative haemoglobin level and body mass index than patients who were not transfused. Multivariate analysis revealed that only the pre-operative haemoglobin level and the patients weight were identified as significant independent factors increasing the need for transfusion (p < 0.001). A haemoglobin level below 12 g/dl was associated with a threefold increase in transfusion requirement.

Patterns of union in fractures of the waist of the scaphoid.

Eighty-two of 85 patients who had sustained a fracture of the waist of the scaphoid in 1985 were reviewed more than one year after injury. The incidence of nonunion, defined as a clear gap at the fracture site one year after injury, was 12.3%. This was much higher than expected. Most of the patients with nonunion had symptoms and had appreciable restriction of wrist movement. In a further 25% of the patients at review, the site of the fracture could be easily identified although it appeared to have healed. These patients were older and more of them were women. Three-quarters of these patients had symptoms but their wrist movement was essentially normal.

Computerised tomographic assessment of the subtalar joint in calcaneal fractures.

Thirty-six patients with 39 fresh fractures of the calcaneus were investigated by standard radiography and by computerised tomography. It was found that the size and disposition of the fracture fragments and the degree of involvement of the posterior facet of the subtalar joint were more clearly shown by CT scanning. We recommend this technique for assessment and particularly for pre-operative planning.

Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility.

Inter-observer agreement and reproducibility of opinion were assessed for the radiographic diagnosis of union of scaphoid fractures on films taken 12 weeks after injury. Weighted kappa statistics were used to compare the opinions of eight senior observers reviewing 20 sets of good quality radiographs on two occasions separated by two months. There was poor agreement on whether trabeculae crossed the fracture line, whether there was sclerosis at or near the fracture and on whether the proximal part of the scaphoid was avascular. As a consequence, agreement on union also was poor; it appears that radiographs taken 12 weeks after a scaphoid fracture do not provide reliable and reproducible evidence of healing.