Patient-Reported Outcomes in Total Ankle Arthroplasty: Patient Specific Versus Standard Instrumentation.

BACKGROUND: Total ankle arthroplasty (TAA) can now be performed using patient-specific instrumentation (PSI). Advantages include the ability to preoperatively plan and reduce the number of intraoperative surgical steps. The aim of this study was to compare PSI with standard instrumentation (SI) in a nonrandomized retrospective cohort study with respect to patient-reported outcome measures (PROMs). Secondary aims were to compare complications, reoperations, tourniquet time, fluoroscopy time, and postoperative alignment. METHODS: In all, 159 patients (111 men, 48 women) undergoing a total of 168 Infinity TAA (Stryker, Memphis, TN) using PSI (Prophecy, Stryker, Memphis, TN) or SI between 2014 and 2021 were included with a minimum follow-up of 12 months. The PROMs were obtained preoperatively and at 1 year, and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and European Quality of Life 5 Dimension 3 Level (EQ-5D-3L). Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time, and intraoperative fluoroscopy times were obtained from the hospital records. RESULTS: There were 61 TAAs in the PSI group and 107 TAAs in the SI group. There was no significant difference in total MOXFQ, AOS, or EQ-5D. There was a significantly reduced tourniquet time (PSI mean: 95.39 minutes, SI mean: 116.87 minutes, P < .001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, P < .001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, P = .005). CONCLUSION: This study supports the use of PSI to decrease operative time, reduce intraoperative fluoroscopy, improve accuracy of implantation, and improve postoperative alignment in TAA. There was a significant difference (P = .032) in favor of PSI in the walking/standing domain of the MOXFQ at 12 months but no significant difference in overall PROMs. LEVELS OF EVIDENCE: Level III, Retrospective.

The effect of high dose antibiotic impregnated cement on rate of surgical site infection after hip hemiarthroplasty for fractured neck of femur: a protocol for a double-blind quasi randomised controlled trial.

BACKGROUND: Mortality following hip hemiarthroplasty is in the range of 10-40% in the first year, with much attributed to post-operative complications. One such complication is surgical site infection (SSI), which at the start of this trial affected 4.68% of patients in the UK having this operation. Compared to SSI rates of elective hip surgery, at less than 1%, this figure is elevated. The aim of this quasi randomised controlled trial (RCT) is to determine if high dose antibiotic impregnated cement can reduce the SSI in patients at 12-months after hemiarthroplasty for intracapsular fractured neck of femur. METHODS: 848 patients with an intracapsular fractured neck of femur requiring a hip hemiarthroplasty are been recruited into this two-centre double-blind quasi RCT. Participants were recruited before surgery and quasi randomised to standard care or intervention group. Participants, statistician and outcome assessors were blind to treatment allocation throughout the study. The intervention consisted of high dose antibiotic impregnated cement consisting of 1 gram Clindamycin and 1 gram of Gentamicin. The primary outcome is Health Protection Agency (HPA) defined deep surgical site infection at 12 months. Secondary outcomes include HPA defined superficial surgical site infection at 30 days, 30 and 90-day mortality, length of hospital stay, critical care stay, and complications. DISCUSSION: Large randomised controlled trials assessing the effectiveness of a surgical intervention are uncommon, particularly in the speciality of orthopaedics. The results from this trial will inform evidence-based recommendations for antibiotic impregnated cement in the management of patients with a fractured neck of femur undergoing a hip hemiarthroplasty. If high dose antibiotic impregnated cement is found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip hemiarthroplasty. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN25633145.

Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report.

LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A qualitative study with orthopaedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery.

BACKGROUND: Pain catastrophizing (PC) moderates surgical outcomes and behavioural interventions are recommended to optimise post-operative results. Less is known about surgeons' experiences of providing care and their attitudes towards the use of interventions in practice. OBJECTIVE: It is therefore invaluable to understand surgeons' views on how best to support patients who may be at risk of suboptimal recovery. Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a hospital setting. The surgical decision-making process, views of PC and the use of behavioural interventions in surgical practice were explored. RESULTS: Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons' decision-making process, when pathologies and symptoms do not match, psychological factors pertaining to unsatisfactory outcomes, a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery. CONCLUSION: Orthopaedic surgeons face challenges in identifying who is likely to reach optimal versus suboptimal outcome. Surgeons are becoming increasingly aware of patient psychological distress being detrimental to outcomes, and they support the use of behavioural interventions to optimise post-operative outcomes or stop unnecessary treatments. The surgeons accept the use of a screening tool in surgical practice with better access to support services with input from allied health professionals. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans.

A qualitative study to understand patients' experiences of their post-operative outcomes following forefoot surgery.

Background: Hallux valgus and hallux rigidus are two common forefoot conditions causing deformity, pain, functional limitations, disability and deteriorating health status resulting in the requirement for surgery. Even when surgery is performed by an experienced surgeon, there remains a potential for patients to experience dissatisfaction and unfavourable outcomes. Adverse results are moderated by psychosocial variables; however, there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery. Objective: The study aimed to qualitatively explore patients' experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery. Semi-structured interviews with 15 patients who received surgery for hallux valgus and/or hallux rigidus were conducted. Results: Thematic analysis generated five themes: physical limitations, the psychosocial impact of surgical recovery, regaining normality, patients' expectations for physical recovery and an altered body-image. Physical and psychosocial factors were inter-related. Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. The women reported weight related issues and were limited in their footwear and clothing choices, negatively impacting on their self-esteem. Conclusion: A forefoot condition is multifaceted, with patients experiencing a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Patients need to be supported holistically with the use of a biopsychosocial model. A multidisciplinary approach to care and treatment within the forefoot surgical pathway with the inclusion of allied health professionals will enable to better support patients to enhance their outcomes.

Valgus knee injuries: evaluation and documentation using a simple technique of stress radiography.

Clinical assessment of post traumatic ligament laxity is subjective. Stress radiographs provide an objective and permanent record of the laxity. We describe a simple method of stress radiography to help evaluate and to document valgus knee injuries. In this study we have correlated the X-ray findings with those at arthroscopy. No specialised equipment is required and radiation exposure to the patient and the surgeon is minimal. With the patient under general anaesthesia the injured and the normal knee are firmly bound together. A valgus stress is applied to both the knees simultaneously and a radiograph is taken. The opening of the medial joint space is measured as in the figure 1, i.e. the perpendicular distance between the tangent drawn to the subchondral bone of the femoral condyles, and the most medial point of the tibial plateau. The opening of the medial joint space provides a direct measure of valgus laxity. The ratio of the medial joint opening to the normal knee is calculated. A ratio of two or more is indicative of an associated anterior or posterior cruciate ligament rupture in addition to medial collateral ligament injury.

Femoral shaft osteotomy for malunited femoral fractures presenting with varus OA of the knee.

Seven patients presenting between 1992 and 1999 with osteoarthritic knee symptoms in consequence of old malunited femoral shaft fractures, were treated by open femoral shaft osteotomy. The osteotomies were sited at the apex of the deformity and were fixed by locked intramedullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on symptoms and function. The mean age at presentation was 48 years and the mean time from fracture was 28 years. The mean time to osteotomy union was 28 months. Five of the seven patients reported excellent pain relief and functional improvement. These patients presented a difficult management problem at an age that would be worryingly young for total knee replacement. Arthroplasty has been avoided in all but one of this cohort, and is still far from imminent in the remainder, after a mean follow-up period of 5 years.

Hydroxyapatite-coated femoral components in total knee arthroplasty: medium term results.

Thirty-six consecutive total knee arthroplasties with hydroxyapatite (HA)-coated femoral components were prospectively followed up according to a standardised protocol for a mean period of 10 years (range, 7-11 years). Clinical and radiologic examination was performed at each follow-up evaluation. One patient (1 knee) was lost to follow up at 7 years, and 4 other patients (6 knees) died. Radiographs were studied for signs of loosening and presence of lucencies. Survival analysis was performed using a life table with revision as the criterion for failure. Two knees (1 patient) were revised because of aseptic loosening. The tibial component of one other knee was revised because of osteolysis in the medial tibial condyle. In the remaining knees, no radiologic evidence of loosening was seen. The survival of the femoral component at a mean follow-up time of 7 years, when 31.5 knees were at risk, was 94% with revision for femoral aseptic loosening as the end point. At 10 years, when 24 knees were at risk, the survival remained 94%.