The Supercapsular Percutaneously Assisted Total Hip Approach Does Not Provide Any Clinical Advantage Over the Conventional Posterior Approach for THA in a Randomized Clinical Trial.

BACKGROUND: The supercapsular percutaneously assisted total hip (SuperPATH) approach was designed to be a less-invasive surgical approach to THA. This approach may have advantages, including less pain, more rapid mobilization, and shorter hospital length of stay. However, few published studies have compared the SuperPATH technique to existing standard approaches in a randomized, controlled manner. QUESTIONS/PURPOSES: In this study, we asked: (1) Do patients with SuperPATH demonstrate improved early function, using the timed up and go (TUG) and timed stair climbing (TSC) tests as instruments for assessment during the first 100 days postoperatively? (2) Are patient-reported outcomes, in the form of Oxford Hip Scores, better for the SuperPATH group during the first 3 months postoperatively? (3) Are opioid consumption and pain score in the first month postoperatively different between patients undergoing SuperPATH and patients undergoing a standard posterior approach? (4) Are patients with SuperPATH able to discontinue using mobility aids and return to work more quickly? METHODS: Between February 2017 and May 2019, 46% (46 of 101) of patients were recruited among 101 patients who met our inclusion criteria. Those 46 patients were randomized into two groups on the day of surgery; 54% (25 of 46) were assigned to the study group (SuperPATH approach) and 46% (21 of 46) were assigned to the control group (posterior approach). The SuperPATH technique uses the plane between the gluteus medius and the external rotators while preserving the piriformis and the superior aspect of the capsule. A percutaneous accessory portal is required for acetabular reaming and cup insertion. The posterior approach involves releasing short rotators and partially releasing the quadratus femoris while retaining the gluteus maximus's insertion site. The two groups did not differ in BMI, gender, American Society of Anesthesiologists class, surgical side, or diagnosis. The length of stay, component position, and blood loss were similar between the groups, but the operative time was longer in the SuperPATH group than in the group with the posterior approach. One patient from the control group was lost to follow-up and was excluded. Three patients in the study group had complications. The TUG and TSC tests are timed tasks for the patient. In the TUG test, patients stand from sitting, walk 3 meters and turn, walk back, and sit down. The TSC test measures the time taken to ascend and descend 10 steps. Patients were followed for 24 months for any complications. RESULTS: The TUG time at 100 days was 8.9 ± 2.6 seconds in the SuperPATH group and 8.7 ± 2.2 seconds in the posterior group (mean difference -0.2 seconds [95% CI -1.8 to 1.4]; p = 0.98); results were similar at other timepoints. The TSC time at 100 days was 11.6 ± 4.7 seconds in the SuperPATH group and 10.8 ± 3.6 seconds in the posterior group (mean difference -0.7 seconds [95% CI -3.5 to 2.1]; p = 0.88), and there were no differences between the two groups at all timepoints. The Oxford Hip Score showed no difference at any point postoperatively. At 6 weeks, it was 36 ± 5.9 points in the SuperPATH group and 38 ± 8.6 in the posterior group (mean difference 1.7 points [95% CI -2.7 to 6.1]; p = 0.51). At 3 months, it was 42± 6.7 points in the SuperPATH group and 41 ± 10.2 points in the posterior group (mean difference 0.7 points [95% CI -6.2 to 4.9]; p = 0.34). Patients' pain scores did not show any differences at all tested timepoints (mean difference 1 [95% CI -0.2 to 2.2]; p = 0.102). Total opioid consumption in the posterior group was higher in the first 2 weeks than that in the SuperPATH group (mean difference 6 [95% CI 2.3 to 9.9]; p = 0.001), but there was no difference in either group by week 4 (mean difference 0.4 [95% CI -0.5 to 1.4]; p = 0.36). There was no difference in return to work between the SuperPATH group and the posterior approach group (mean difference 6 days [95% CI -29 to 41]; p = 0.74). Discontinuation of mobility aids was similar between the two groups (mean difference 0.9 days [95% CI -25 to 27]; p = 0.94). CONCLUSION: The SuperPATH approach had no clinical advantages over the posterior approach, resulted in more complications, and only showed a short-term reduction in pain. The results of our small randomized controlled trial can be used to calculate future sample sizes, but our data suggest that any differences favoring the SuperPATH approach are likely to be small and transient. This approach should not be used routinely in clinical practice until an adequately powered trial shows clinically important differences in patient-relevant endpoints. The improved postoperative recovery is likely multifactorial and not dependent on the invasiveness of the approach. LEVEL OF EVIDENCE: Level II, therapeutic study.

The Psychological Impact of COVID-19 on Arthroplasty Surgeons.

BACKGROUND: After the COVID-19 pandemic declaration in March 2020, all the elective total joint replacement surgeries in Canada were abruptly canceled for an indefinite period of time. The principal objective of this study was to determine the prevalence of psychological morbidity experienced by arthroplasty surgeons during the peak of the first wave of the COVID-19 pandemic. Secondary objectives included characterizing influential variables affecting the surgeon's well-being and suggesting directives for improvement. METHODS: This study surveyed Canadian Arthroplasty Society (CAS) members regarding their psychological well-being using the validated General Health Questionnaire (GHQ-12), the Center for Epidemiological Studies Depression (CES-D) scale, and the Personal Wellbeing Index-Adult (PWI-A). As well, the survey included questions regarding concerns about COVID-19, precautionary measures, personal well-being, and sociodemographic characteristics. RESULTS: A total of 80 surgeons (52% of those surveyed) completed the questionnaire, representing all 10 provinces in Canada. The prevalence of emotional distress and depression were 38% and 29%, respectively. Psychological morbidity most commonly resulted from concerns of loss of income/operating time, experiences of emotional conflict, and generalized safety worries. The surgeons commonly (93%) demonstrated insight in recognizing the impact of COVID-19 on their emotional health. CONCLUSION: Canadian arthroplasty surgeons demonstrated emotional resilience and insight during COVID-19. Continual communication, as well as remuneration action plans, could improve the mental well-being of at-risk individuals.

Adductor canal block with or without added magnesium sulfate following total knee arthroplasty: a multi-arm randomized controlled trial.

PURPOSE: Postoperative analgesia following total knee arthroplasty (TKA) often includes intrathecal opioids, periarticular injection (PAI) of local anesthetic, systemic multimodal analgesia, and/or peripheral nerve blockade. The adductor canal block (ACB) provides analgesia without muscle weakness and magnesium sulphate (MgSO4) may extend its duration. The purpose of this trial was to compare the duration and quality of early post-TKA analgesia in patients receiving postoperative ACB (± MgSO4) in addition to standard care. METHODS: Elective TKA patients were randomized to: 1) sham ACB, 2) ropivacaine ACB, or 3) ropivacaine ACB with added MgSO4. All received spinal anesthesia with intrathecal morphine, intraoperative PAI, and multimodal systemic analgesia. Patients and assessors remained blinded to allocation. Anesthesiologists knew whether patients had received sham or ACB but were blinded to MgSO4. The primary outcome was time to first analgesic (via patient-controlled analgesia [PCA] with iv morphine) following ACB. Secondary outcomes were morphine consumption, side effects, visual analogue scale pain scores, satisfaction until 24 hr postoperatively, and length of stay. RESULTS: Of 130 patients, 121 were included. Nine were excluded post randomization: four were protocol violations, three did not meet inclusion criteria, and two had severe pain requiring open label blockade. There were no differences in the median [interquartile range] time to first PCA request: sham, 310 min [165-550]; ropivacaine ACB, 298 min [120-776]; and ropivacaine ACB with MgSO4, 270 min [113-780] (P = 0.96). Similarly, we detected no differences in resting pain, opioid consumption, length of stay, or associated side effects until 24 hr postoperatively. CONCLUSION: We found no analgesic benefit of a postoperative ACB, with or without added MgSO4, in TKA patients undergoing spinal anesthesia and receiving intrathecal morphine, an intraoperative PAI, and multimodal systemic analgesia. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02581683); registered 21 October 2015.

RéSUMé: OBJECTIF: L'analgésie postopératoire suivant une arthroplastie totale du genou (ATG) inclut souvent des opioïdes intrathécaux, une injection périarticulaire (IPA) d'anesthésique local, une analgésie multimodale systémique, et/ou des blocs des nerfs périphériques. Le bloc du canal des adducteurs (BCA) permet une analgésie sans faiblesse musculaire et le sulfate de magnésium (MgSO4) pourrait prolonger sa durée. L'objectif de cette étude était de comparer la durée et la qualité de l'analgésie post-ATG précoce chez les patients recevant un BCA postopératoire (± MgSO4) en plus des soins standard. MéTHODE: Des patients devant subir une ATG non urgente ont été randomisés à recevoir : 1) un BCA placebo (groupe témoin), 2) un BCA avec ropivacaïne, ou 3) un BCA avec ropivacaïne et MgSO4. Tous ont reçu une rachianesthésie avec morphine intrathécale, une IPA peropératoire, et une analgésie multimodale systémique. L'allocation a été faite à l'insu des patients et des évaluateurs. Les anesthésiologistes savaient si les patients avaient reçu un placebo ou un BCA, mais n'étaient pas informés de l'ajout ou non de MgSO4. Le critère d'évaluation principal était le temps jusqu'à la première prise d'analgésique (via une analgésie contrôlée par le patient [ACP] avec de la morphine iv) après le BCA. Les critères secondaires comprenaient la consommation de morphine, les effets secondaires, les scores de douleur sur l'échelle visuelle analogue, la satisfaction jusqu'à 24 heures postopératoires, et la durée de séjour. RéSULTATS: Sur 130 patients, 121 ont été inclus. Neuf ont été exclus après la randomisation : quatre l'ont été en raison de violations du protocole, trois ne répondaient pas aux critères d'inclusion, et deux ont ressenti des douleurs graves nécessitant un bloc sans insu. Aucune différence n'a été observée dans le temps médian [écart interquartile] jusqu'à la première demande d'ACP : placebo, 310 min [165-550]; BCA ropivacaïne, 298 min [120-776]; et BCA ropivacaïne avec MgSO4, 270 min [113-780] (P = 0,96). De la même manière, nous n'avons détecté aucune différence dans la douleur au repos, la consommation d'opioïdes, la durée de séjour, ou les effets secondaires associés jusqu'à 24 heures postopératoires. CONCLUSION: Nous n'avons trouvé aucun avantage analgésique à un BCA postopératoire, avec ou sans ajout de MgSO4, chez les patients subissant une ATG sous rachianesthésie et recevant de la morphine intrathécale, une IPA peropératoire, et une analgésie multimodale systémique. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02581683); enregistrée le 21 octobre 2015.

Short stay total joint arthroplasty program: patient factors predicting readmission

Background: The aim of this study was to evaluate the effectiveness of our short stay arthroplasty program as measured by 30-day readmission rate and the rate of transfer to inpatient care. Risk factors for readmission/transfer were also evaluated and contrasted with current patient screening criteria. Methods: We retrospectively reviewed 297 charts for all primary total joint arthroplasties completed in the short stay program during an 18-month period. Data included readmission and patient characteristics such as age, sex, comorbidities, the American Society of Anesthesiologists (ASA) physical classification grade, body mass index (BMI) and the number of preoperative medications. Results: The 30-day readmission rate was 2.6% (n = 8). With the inclusion of patients transferred to the inpatient hospital, the overall failure rate of our short stay program was 6.7% (n = 20). Multivariable modelling controlling for age, BMI and ASA suggested that those with an in-hospital complication were 11.4 times more likely to be readmitted or transferred to inpatient care (p < 0.001) with a trend for patients who were taking more medications (p = 0.09). Conclusion: The current readmission rate from this program is comparable to previously published data in the arthroplasty literature. However, several patients required transfer to inpatient care, which significantly impacted the effectiveness of the short stay program. Risk factors for readmission/transfer are not completely accounted for by current presurgical screening criteria. Further evaluation of the Blaylock Risk Assessment Screening Score is required to determine its value for predicting hospital readmission.

Contexte: Cette étude avait pour but d'évaluer l'efficacité de notre programme d'arthroplastie court séjour sur la base du taux de réadmission à 30 jours et du taux de conversion en hospitalisation. Les facteurs de risque de réadmission/conversion ont aussi été évalués et mis en parallèle avec les critères actuels de sélection des patients. Méthodes: Nous avons passé en revue de manière rétrospective les 297 dossiers d'arthroplasties totales primaires effectuées dans le cadre du programme court séjour sur une période de 18 mois. Les données incluaient les réadmissions et les caractéristiques des patients telles que âge, sexe, comorbidités, score ASA (classification de l'état de santé physique selon l'American Society of Anesthesiologists), indice de masse corporelle (IMC) et nombre de médicaments courants. Résultats: Le taux de réadmission à 30 jours a été de 2,6 % (n = 8). En incluant les cas de conversion en hospitalisation, le taux d'échec global de notre programme court séjour a été de 6,7 % (n = 20). Après ajustement selon un modèle multivarié tenant compte de l'âge, de l'IMC et de la classification de l'ASA, les patients ayant présenté une complication justifiant l'hospitalisation étaient 11,4 fois plus susceptibles d'être réadmis ou hospitalisés (p < 0,001), avec une tendance proportionnelle au nombre de médicaments courants avant l'intervention (p = 0,09). Conclusion: Le taux actuel de réadmission pour ce programme est comparable aux données publiées antérieurement dans la littérature sur l'arthroplastie. Toutefois, plusieurs patients ont eu besoin d'être hospitalisés, ce qui a eu un impact significatif sur l'efficacité du programme court séjour. Les facteurs de risque de réadmission/conversion ne sont pas entièrement expliqués par les critères de sélection préchirurgicaux actuels. Il faudra continuer d'évaluer le score Blaylock d'estimation des risques pour en déterminer l'utilité à prédire les réhospitalisations.

Outcomes of hip and knee total joint arthroplasty in a Canadian inmate population over a 10-year period

Background: Little information exists regarding the risk of complications in inmates who receive total hip or knee arthroplasties in Canada. Inmates tend to be less healthy owing to socioeconomic factors and an increased number of medical and psychiatric comorbidities. We compared revision and complication rates of total joint replacements in a cohort of incarcerated Canadians versus a cohort of non-inmates. Methods: We obtained a list of all Canadian inmate inpatient hospital visits with diagnostic/procedure codes of primary hip or knee arthroplasty within the last 10 years from our institution's discharge abstract database. Demographic data and information related to the perioperative course, along with any data related to postoperative complications/readmissions, were obtained through manual chart review. Results: The inmate group consisted of 20 men (mean age 58 yr) with a total of 24 primary total joint arthroplasties; the comparison group included 171 men (mean age 62 yr). Postoperatively, the inmates had a 4-fold increased risk of major complication compared with non-inmates (33.3% v. 7.6%; odds ratio 4.21, p = 0.01). The inmates' revision rate was 20.8% compared with 5.8% in the comparison group (p = 0.03). The most common cause for revision in the inmate group was infection, with a rate of 16.7% compared with 3.5% in the comparison group (p = 0.03). Conclusion: Patients requiring total joint arthroplasty who are inmates in the Canadian penitentiary system are at increased risk of complication and revision surgeries following total joint arthroplasty.

Contexte: Il y a peu de données concernant le risque de complications chez les détenus opérés pour une prothèse totale de la hanche ou du genou au Canada. Les détenus tendent à être en moins bonne santé en raison de divers facteurs socioéconomiques et d'un nombre accru de comorbidités médicales et psychiatriques. Nous avons comparé les taux de révision et de complications suite à des arthroplasties articulaires totales dans une cohorte de Canadiens incarcérés comparée à une cohorte d'individus non incarcérés. Méthodes: Nous avons extrait de la base de données sur les congés des patients de notre établissement la liste de toutes les consultations de détenus hospitalisés assorties aux codes de diagnostics et d'interventions concernant les arthroplasties de la hanche ou du genou au cours des 10 dernières années. Les données démographiques et les renseignements relatifs à la période périopératoire, de même que les données concernant les complications postopératoires ou réadmissions ont été obtenus au moyen d'un examen manuel des dossiers. Résultats: Le groupe de détenus se composait de 20 hommes (âgés en moyenne de 58 ans) totalisant 24 arthroplasties articulaires totales primaires; le groupe de comparaison incluait 171 hommes (âgés en moyenne de 62 ans). En période postopératoire, les détenus étaient exposés à un risque 4 fois plus élevé de complications majeures, comparativement aux individus non incarcérés (33,3 % c. 7,6 %; risque relatif 4,21, p = 0,01). Le taux de révision chez les détenus a été de 20,8 %, contre 8 % dans le groupe de comparaison (p = 0,03). La plus fréquente cause de révision chez les détenus était l'infection, avec un taux de 16,7 %, contre 3,5 % dans le groupe de comparaison (p = 0,03).

A lack of premature termination codon read-through efficacy of PTC124 (Ataluren) in a diverse array of reporter assays.

The drug molecule PTC124 (Ataluren) has been described as a read-through agent, capable of suppressing premature termination codons (PTCs) and restoring functional protein production from genes disrupted by nonsense mutations. Following the discovery of PTC124 there was some controversy regarding its mechanism of action with two reports attributing its activity to an off-target effect on the Firefly luciferase (FLuc) reporter used in the development of the molecule. Despite questions remaining as to its mechanism of action, development of PTC124 continued into the clinic and it is being actively pursued as a potential nonsense mutation therapy. To thoroughly test the ability of PTC124 to read through nonsense mutations, we conducted a detailed assessment comparing the efficacy of PTC124 with the classical aminoglycoside antibiotic read-through agent geneticin (G418) across a diverse range of in vitro reporter assays. We can confirm the off-target FLuc activity of PTC124 but found that, while G418 exhibits varying activity in every read-through assay, there is no evidence of activity for PTC124.

Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS.

BACKGROUND: Knee and hip arthroplasty constitutes a large percentage of hospital elective surgical procedures. The Blaylock Risk Assessment Screening Score (BRASS) was designed to identify patients in need of discharge planning. The purpose of this study was to evaluate whether the BRASS was associated with length of stay (LOS) in hospital following elective arthroplasty. METHODS: We retrospectively reviewed the charts of individuals undergoing primary elective arthroplasty for knee or hip osteoarthritis who had a documented BRASS score. RESULTS: In our study cohort of 241, both BRASS (p < 0.001) and replacement type (hip v. knee; p = 0.048) were predictive of LOS. Higher BRASS was associated with older patients (p < 0.001), higher American Society of Anesthesiologists score (p < 0.001) and longer LOS (p < 0.001). We found a specificity of 83% for a BRASS greater than 8 and a hospital stay longer than 5 days and a specificity of 92% for a BRASS greater than 10. CONCLUSION: The BRASS represents a novel and significant predictor of LOS following elective arthroplasty. Patients with higher BRASS are more likely to stay in hospital 5 days or more and should receive pre-emptive social work consultations to facilitate timely discharge planning and hospital resources.

CONTEXTE: Les arthroplasties du genou et de la hanche représentent un fort pourcentage des interventions chirurgicales non urgentes pratiquées dans les hôpitaux. Le score BRASS (Blaylock Risk Assessment Screening Score) a été conçu pour reconnaître les patients dont il faut planifier le congé de l'hôpital. Le but de la présente étude était de vérifier s'il y a un lien entre le score BRASS et la durée du séjour hospitalier (DSH) après une arthroplastie non urgente. MÉTHODES: Nous avons analysé rétrospectivement les dossiers de patients soumis à une arthroplastie primaire non urgente du genou ou de la hanche dont le score BRASS avait été documenté. RÉSULTATS: Dans la cohorte de 241 patients de notre étude, le score BRASS (p < 0,001) et le type d'arthroplastie (hanche c. genou, p = 0,048) ont été des facteurs prédicteurs de la DSH. Un score BRASS plus élevé était associé à un âge plus avancé des patients (p < 0,001), à un score plus élevé à l'échelle de l'American Society of Anesthesiologists (p < 0,001) et à une DSH plus longue (p < 0,001). Nous avons observé une spécificité de 83 % pour un score BRASS supérieur à 8 et un séjour hospitalier de plus de 5 jours, et une spécificité de 92 % pour un score BRASS supérieur à 10. CONCLUSION: Le score BRASS constitue un nouveau prédicteur important de la DSH après une arthroplastie non urgente. Les patients dont le score BRASS est plus élevé, risquent davantage de séjourner plus de 5 jours à l'hôpital et devraient bénéficier de consultations préventives auprès du personnel des Services sociaux afin de faciliter la planification des congés en temps opportun et d'assurer l'utilisation efficace des ressources hospitalières.

Trends in Cemented Fixation in Hemiarthroplasty for Hip Fractures in Canada.

Bacground: The use of cemented fixation is widely recommended in hip arthroplasty for hip fractures, although it is not used universally. Methods: We describe the trends in cementing prevalence in hemiarthroplasty for hip fractures in Canada for patients ≥55 years old between April 2017 and March 2022. Results: The national prevalence of cemented fixation increased from 43% in 2017/18 to 58% in 2021/22, but there was a large variety of both the baseline prevalence and the trends across the country and between individual hospitals. The proportion of surgeons only performing cementless fixation fell from 30% to 21% between 2018/19 and 2021/22. Conclusions: As cemented fixation is now universally recommended, more coordination is needed to track these trends and to help drive implementation of this evidence-based practice across Canada.

The aspherical human hip: implication for early osteoarthritis.

One marker for early-onset hip arthritis is femoral acetabular impingement. The current standard way of quantifying impingement is manual calculation of anatomical measures on plain radiographs, including the α-angle. Such measurements are user-dependent and prone to error. We provided a robust computational alternative and proposed using numerical fitting of geometrical shapes. We applied least-squares fitting of an ellipse to the femoral head contour and used the difference between the ellipse axes as a quantification method. The results showed a good correlation between the new measure and previous definitions of the α-angle.

Residential mobility and mental health.

We examine the extent to which residential relocation within and between tenure types is associated with changes in mental health. We focus on four types of housing transition - rent-to-own, own-to-rent, own-to-own, and rent-to-rent - using Australian and UK panel data sets from 2001 to 2017. In both countries, transitions into homeownership and moves away from the mortgaged edges toward the unburdened mainstream of outright ownership are positively associated with mental health. On the other hand, shifts by mortgagors towards more precarious positions on the edges of ownership precipitate dips in mental health when there is exposure to high levels of payment and investment risks. Clearly, residential moves can both alleviate and introduce different kinds of risks that affect affordability. Moreover, tenure transitions have impacts on mental health beyond the impacts of payment and investment risks. However, we observe some cross-national differences in findings. In Australia, loss of homeownership has a negative impact on mental health that outweighs the mental health impacts of attaining ownership. In the UK, these findings are reversed. Acute housing affordability problems following moves in Australia, but not in the UK, are a significant driver of mental health outcomes. These differences have institutional explanations.

Identification and Optimization of Novel Inhibitors of the Polyketide Synthase 13 Thioesterase Domain with Antitubercular Activity.

There is an urgent need for new tuberculosis (TB) treatments, with novel modes of action, to reduce the incidence/mortality of TB and to combat resistance to current treatments. Through both chemical and genetic methodologies, polyketide synthase 13 (Pks13) has been validated as essential for mycobacterial survival and as an attractive target for Mycobacterium tuberculosis growth inhibitors. A benzofuran series of inhibitors that targeted the Pks13 thioesterase domain, failed to progress to preclinical development due to concerns over cardiotoxicity. Herein, we report the identification of a novel oxadiazole series of Pks13 inhibitors, derived from a high-throughput screening hit and structure-guided optimization. This new series binds in the Pks13 thioesterase domain, with a distinct binding mode compared to the benzofuran series. Through iterative rounds of design, assisted by structural information, lead compounds were identified with improved antitubercular potencies (MIC < 1 µM) and in vitro ADMET profiles.

SAR and biological evaluation of 3-azabicyclo[3.1.0]hexane derivatives as µ opioid ligands.

3-Azabicyclo[3.1.0]hexane compounds were designed as novel achiral µ opioid receptor ligands for the treatment of pruritus in dogs. In this paper, we describe the SAR of this class of opioid ligand, highlighting changes to the lead structure which led to compounds having picomolar binding affinity, selective for the µ receptor over δ and κ subtypes. Some subtleties of functional activity will also be described.

Myofascial pain in patients waitlisted for total knee arthroplasty.

BACKGROUND: Knee pain is one of the major sources of pain and disability in developed countries, particularly in aging populations, and is the primary indication for total knee arthroplasty (TKA) in patients with osteoarthritis (OA). OBJECTIVES: To determine the presence of myofascial pain in OA patients waitlisted for TKA and to determine whether their knee pain may be alleviated by trigger point injections. METHODS: Following ethics approval, 25 participants were recruited from the wait list for elective unilateral primary TKA at the study centre. After providing informed consent, all participants were examined for the presence of active trigger points in the muscles surrounding the knee and received trigger point injections of bupivacaine. Assessments and trigger point injections were implemented on the first visit and at subsequent visits on weeks 1, 2, 4 and 8. Outcome measures included the Timed Up and Go test, Brief Pain Inventory, Centre for Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory and Short-Form McGill Pain Questionnaire. RESULTS: Myofascial trigger points were identified in all participants. Trigger point injections significantly reduced pain intensity and pain interference, and improved mobility. All participants had trigger points identified in medial muscles, most commonly in the head of the gastrocnemius muscle. An acute reduction in pain and improved functionality was observed immediately following intervention, and persisted over the eight-week course of the investigation. CONCLUSION: All patients had trigger points in the vastus and gastrocnemius muscles, and 92% of patients experienced significant pain relief with trigger point injections at the first visit, indicating that a significant proportion of the OA knee pain was myofascial in origin. Further investigation is warranted to determine the prevalence of myofascial pain and whether treatment delays or prevents TKA.

The Spatial Dynamics of Homelessness in Australia: Urbanisation, Intra-City Dynamics and Affordable Housing.

While homelessness in Australia has remained relatively stable at the national level, its spatial distribution is becoming more nuanced. This paper draws on homelessness estimates produced by the Australian Bureau of Statistics to explore the spatial dynamics of homelessness in Australia over a fifteen-year period. Building on existing work, we show that homelessness is becoming more urbanised with evidence of spatial convergence, mainly driven by a surge in severe crowding in our major cities. However, when exploring intra-city patterns, we find distinctive intra-city spatial dynamics featuring strong suburbanisation of 'couch surfing' in state capital cities, contrasting with shifts in severe crowding numbers toward middle and inner regions of most state capitals. We argue that these dynamics reflect the retreat of affordable rental housing supply to the outer suburban fringe, and the coping strategies that 'couch surfers' and those aspiring to live in the inner cities are compelled to follow in response to the changing spatial configuration of affordable housing.

Effect of Osteochondroplasty on Time to Reoperation After Arthroscopic Management of Femoroacetabular Impingement: Analysis of a Randomized Controlled Trial.

Background: A subset of patients with femoroacetabular impingement (FAI) fail arthroscopic management. It is not clear which patients will fail surgical management; however, several surgical and patient factors, such as type of procedure and age, are thought to be important predictors. Purpose: This time-to-event analysis with a 27-month follow-up analysis compared the effect of (1) arthroscopic osteochondroplasty with or without labral repair versus (2) arthroscopic lavage with or without labral repair on the time to reoperation in adults aged 18 to 50 years with FAI. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Eligible participants had been randomized in a previous study trial to a treatment of arthroscopic osteochondroplasty or arthroscopic lavage with or without labral repair. Using the comprehensive data set from the Multinational Femoroacetabular Impingement Randomized controlled Trial, all reoperations until 27 months after surgery were identified. The analysis was conducted using a Cox proportional hazards model, with percentage of patients with a reoperation evaluated in a time-to-event analysis as the outcome. The independent variable was the procedure, with age and impingement subtype explored as potential covariates. The effects from the Cox model were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha level of .05. Results: A total of 108 patients in the osteochondroplasty group and 106 patients in the lavage group were included. The mean age of the patients included in the study was 36 ± 8.5 years. Overall, 27 incident reoperations were identified within the 27-month follow-up, with an incidence rate of 6 per 100 person-years. Within the osteochondroplasty group, 8 incident reoperations were identified (incidence rate, 3.4 per 100 person-years), while within the lavage group, 19 incident reoperations were identified (incidence rate, 8.7 per 100 person-years). The hazard of reoperation for patients undergoing osteochondroplasty was 40% of that of patients undergoing lavage (HR, 0.40 [95% CI, 0.17-0.91] P = .029). Conclusion: This study demonstrated that for adults between the ages of 18 and 50 years with FAI, arthroscopic osteochondroplasty was associated with a 2.5-fold decrease in the hazard of reoperation at any point in time compared with arthroscopic lavage. Registration: NCT01623843 (ClinicalTrials.gov identifier).

Locking compression plates for the treatment of periprosthetic femoral fractures around well-fixed total hip and knee implants.

There are currently few published studies examining the use of locking compression plates for the treatment of periprosthetic femoral fractures. Fifteen total hip or knee arthroplasty patients with 16 Vancouver type B1 and C fractures with an average age of 76 years were fixed and followed clinically and radiographically for 2 years. Fourteen patients achieved radiographic union by 6 months, and 13 patients were ambulatory by 6 months. There were no intraoperative complications. In summary, locking plates offer a viable treatment option for these difficult fractures. We advocate a minimum of 10 cortices of fixation (with unicortical or bicortical screws and cable combinations) above and below the fracture. Bone grafting should be used if the soft tissue envelope is violated with extensive dissection, and cortical struts should be considered in cases of failed hardware and revision fixation.

An electronic clinic for arthroplasty follow-up: a pilot study.

BACKGROUND: Most outpatient orthopedic follow-up visits for patients who had total joint arthroplasty are routine among those with well-functioning implants. The technology and resources now exist to enable patient assessment without requiring attendance in hospital. We tested an electronic clinic for routine follow-up in a small cohort of arthroplasty patients. METHODS: We randomly assigned primary arthroplasty patients scheduled for routine annual outpatient review into 2 groups: group A completed a Web-based assessment 4 weeks after the clinical assessment, whereas group B completed the Web-based assessment first. Standard clinical questionnaires were included. We also collected radiographic data and information on assessment duration and cost. RESULTS: Forty patients participated in the study. The average age of participants was 58 years. There were 12 men and 8 women in each of the 2 groups. The average total time spent by patients on an outpatient visit was 115 minutes, compared with 52 minutes for the electronic assessment. Participants reported the electronic assessment to be more convenient and less costly. CONCLUSION: This pilot study supports the practical use of an electronic clinic for the follow-up of arthroplasty patients. Further studies examining the complex interaction of factors involved in patient clinics are needed.

Do waiting list initiatives discriminate in favour of those in a higher socioeconomic group?

The UK has a publicly funded health care system with open access to all. In the past, demand for services overwhelmed the resources available. Recent government initiatives have attempted to address this. To achieve shorter waiting times (and guaranteed waiting times), access to additional services has been purchased from the private sector under short-term initiatives, often at sites firth of the home health board. There has been a suspicion that patients from higher socioeconomic groups have benefited differentially from this by rapid access to private health care facilities, due to ease of transport. The aim of this study was to analyse whether a patient's socioeconomic group influenced their access to, and place of, surgery. Patients undergoing a primary total hip or knee arthroplasty in a single health region over a three-year period were identified and their social group was determined by postcode address. Analysis of 3888 patients operated on in four different treatment centres comparing the distribution of patients according to their social group, revealed no bias in the provision of treatment. The study group was comparable to the control population in that health region. In conclusion, the introduction of health policies to reduce time to orthopaedic treatment within one health board area has not resulted in patient bias.

Registration stability of physical templates in hip surgery.

We tested the registration stability of individualized templates in a consecutive study with 80 patients undergoing hip-resurfacing surgery. These templates physically encode registration and navigation parameters but do not require a computer during the actual surgery. The surgical target was the placement of the femoral guidance pin during hip resurfacing, which is a difficult and highly variable task using conventional instruments. The drill trajectory for the guidance pin of the femoral component was planned on a 3D computer model of the femur derived from a preoperative computed tomography (CT) scan. A surface-matched drilling template was designed to perform mechanical registration on the bone surface and had a hole for the drill guide; the template was created using a rapid prototyping machine. Intraoperatively, the individualized template was positioned on the patient anatomy and the pin was drilled into the femoral neck. The final achieved pin orientation and position were measured using an optoelectronic CT-based navigation system. The measured mean deviation between planned and actual central pin alignment of 0.05° in valgus and 2.8° in anteversion shows that the proposed individualized templates for hip resurfacing have reliable registration.