Unbiased gene expression analysis of the delayed fracture healing observed in Zucker diabetic fatty rats.

Aims: Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods: Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results: Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion: These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients.

Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory arthritis undergoing elective surgery.

Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.

Impact of computed tomography metal artifact reduction protocol on periprosthetic tissue characterization after total hip arthroplasty: A cadaveric study.

Metal artifact reduction (MAR) has improved computed tomography (CT) imaging of total hip arthroplasty (THA) but the assessment of osteolysis and implant to bone contact relies on the accurate depiction of bone defects, cancellous bone, and cement. This study evaluates the impact of available single and dual-energy protocols on periprosthetic tissue characterization in a cadaveric phantom. Bilateral THA was performed on a fresh frozen cadaveric pelvis with simulated osteolytic cavities. CT acquisitions with projection-based MAR and noise equivalence were performed using single energy 140 kVp, single energy 150 kVp with 0.6 mm tin filtration, and dual-energy at 100/150 kVp with 0.6 mm tin filtration, from which simulated energies were extracted. Image subtraction, segmentation, region of interest histograms, and line profiles were used to characterize tissue density and separation. Tissue densities were heavily dependent on the energy profile of the protocol. Cancellous bone ranged from 182 to 45 HU and cement from 1012 to 131 HU using 140 kVp compared to dual-energy with weighted high energy tube, respectively. Spectral separation between cancellous bone, osteolytic defect, and cement was reduced for all protocols compared with 140 kVp. Spectral overlap was most severe using dual-energy with heavily weighted high-energy tubes. Dual-energy algorithms reduced trabecular contrast within the cancellous bone and cortical edge response. Although the dual-energy acquisition has been proposed as an additive to projection-based MAR techniques in THA, reduced density and contrast in clinically relevant periprosthetic tissue compared to 140 kVp single energy may limit its use in characterizing periprosthetic tissues.

Geographic variation in the frequency and potency of postoperative opioid prescriptions for extremity fracture surgery. A retrospective cohort study.

Introduction: There is increasing evidence that the prescription opioid crisis is spreading internationally. However, there is scarce literature comparing contemporary prescribing practices between units in different countries, particularly in the context of this evolving international problem. We sought to determine the patterns of postoperative opioid prescribing in three hospitals from geographically distinct regions. Methods: This is a retrospective cohort study involving patients from three hospitals: XXX, Maine, USA; XXX, Scotland; and XXX, Australia. The health records, surgical details, and frequency and potency of discharge prescriptions were analyzed for 350 patients receiving surgery for isolated wrist or ankle fractures. Regression analysis was used to identify independent predictors of prescription opioid provision. Results: Following ankle fracture surgery, Aberdeen patients (OR 6.0, 95% CI 3.0-11.5) and Adelaide patients (11.8, 95% CI 4.1-39.6) were significantly more likely to receive a prescription for opioids than those in Augusta (p < 0.001). For distal radius fractures, this was also the case (Aberdeen OR 21.2, 95% CI 7.2-79.3, Adelaide OR 21.6, 95% CI 7.3-81.3). For both fracture groups, the potency of prescription provided (measured in morphine milligram equivalents) was not significantly different. When opioids were included in the discharge prescription, Adelaide prescribers favored strong opioids, Aberdeen prescribers selected weak opioids, and prescribers in Augusta chose an even distribution of both types (p < 0.001). Multivariate analysis demonstrated that the odds of receiving prescription opioids were significantly influenced by geographic location and decreased by advancing patient age. Conclusions: Geographic location is a key factor influencing the provision of postoperative opioids. We found no association with fracture type, patient demographic factors or intra-operative practices. Prescriber culture is likely an influential determinant of postoperative opioid provision. Emphasis on patient and prescriber education regarding the risks of prescription opioids and their potential long-term sequelae is key if we wish to change modifiable prescriber behavior.

Intramedullary nail: the past, present and the future - a review exploring where the future may lead us.

BACKGROUND: Intramedullary nails (IMNs) are the current gold standard treatment for long bone diaphyseal and selected metaphyseal fractures. The design of IMNs has undergone many revisions since its invention in the 16th century, with a dramatic increase in novel designs in recent years aiming to further improve intramedullary fixation techniques. AIMS: To map the evolution of IMNs in orthopedic surgery, discuss the limitations and complications of current IMNs and identify novel IMNs that may influence future design innovations. METHODS: We undertook a scoping review on the status of orthopedic IMNs by reviewing Google Scholar with the following keywords. Publications and patents selected for retrieval were initially assessed on the title and abstract by five independent reviewers. 52 papers were retrieved for complete text examination, and secondary references were checked from these papers. The results were discussed within the research group and consensus was obtained describing novel IMNs. RESULTS: Novel IMN designs include growth factor and/or antimicrobial coatings targeting fracture healing and perioperative infection risk, respectively; minimally invasive expandable IMNs to avoid the need for interlocking screws; and novel materials such as carbon fiber for their theoretically superior biomechanical properties and avoidance of artifact on CT and MRI imaging. CONCLUSION: The novel IMNs proposed in recent years collectively aim to improve intramedullary fixation techniques by reducing operative time and radiation exposure, improving fracture healing or monitoring bone cancer progression. However, more research and development are necessary to solve these complex problems.

Cemented Revision Hip Arthroplasty With Femoral Impaction Bone Grafting.

Long-stemmed uncemented implants are commonly used during revision hip arthroplasty but may be difficult to re-revise. Impaction bone grafting allows for the use of a shorter cemented stem during revision hip arthroplasty and may restore bone stock in patients with substantial femoral defects. Femoral impaction bone grafting is particularly beneficial in younger patients, who are more likely to require additional revision procedures in the future. The surgical technique used at our institution includes improvements to previous methods including the use of modular tamps and nonirradiated, size-profiled bone graft.

Does Time to Theatre Affect the Ability to Achieve Fracture Reduction in Tibial Plateau Fractures?

Surgical management of displaced tibial plateau fracture (TPF) is often delayed due to accompanying soft tissue injuries sustained at the time of injury. The primary aim of this study was to assess the effect of time to surgery on fracture reduction in cases of TPF. The secondary aim was to assess the effect of preoperative demographics and residual articular step on Lysholm Scores and Knee Injury and Osteoarthritis Outcome Scores (KOOS) following fixation. Patients between 2006 and 2017, managed by a single surgeon, were prospectively enrolled in the study. Reduction of articular step, defined as <2 mm, was assessed by a single blinded examiner. A total of 117 patients were enrolled, 52 with Schatzker II, 4 with Schatzker IV, and 61 with Schatzker VI fractures. Patients were followed up to a mean of 3.9 years. Analysis showed that the ability to achieve fracture reduction was negatively influenced by time to theatre, with the odds of achieving reduction decreasing 17% with each subsequent day post injury (p = 0.002). Furthermore, an increased time to theatre was associated with a reduced Lysholm score at one year (p = 0.01). The ability to achieve fracture reduction did not influence PROMs within the study period. We conclude that delay in surgical fixation negatively affects fracture reduction in TPF and may delay recovery. However, residual articular step does not necessarily influence PROMs over the mid-term.

The impact of a hands-on arthrocentesis workshop in undergraduate medical education.

BACKGROUND: To evaluate the impact of a training programme for arthrocentesis on procedural skills enhancement and self-confidence in medical students. METHODS: Participants were provided a structured workshop on injection models. A self-confidence questionnaire and medical knowledge assessment were performed. Retention of knowledge and skills were assessed at a later time point during a formal OSCE examination and compared to participants who had not attended a lecture and clinical attachments only. P-values, 95% confidence intervals about the mean, standard error of the mean, and standard deviations of the differences were calculated. RESULTS: All participants gained self-confidence, and improvement of their skills was significant. The mean self-confidence with performing an arthrocentesis procedure increased from 1.3 pre- to 5.9 points post-workshop (10-point Likert scale). The knee was the joint students felt most confident with (1.3 to 6.5 points). Knowledge on the selection of corticosteroid preparations (1.2 to 5.8 points) gained substantially, as well as confidence in providing post-injection advice (1.9 to 6.6 points). Upon the OSCE examination, attendance to the workshop resulted in a significant higher total score (16.2 vs 14.8 points, p < 0.05). CONCLUSIONS: A workshop for arthrocentesis procedures, in conjunction with other learning activities, is well suited to increasing skills and self-confidence in fourth year medical students and allows for developing important baseline knowledge and practicing invasive techniques without risk to a patient. TRIAL REGISTRATION: This trial has been approved by the human research ethics committee of the University of Adelaide (Ethics approval No H-2019-134).

Biomechanical Study Comparing Cut-out Resistance of the X-Bolt® and Dynamic Hip Screw at Various Tip-Apex Distances.

BACKGROUND: Bone quality in hip fractures is poor and there is a need to not only correctly position metalwork within the femoral head, but also for implants to resist cut-out. New implant designs may help to reduce metalwork cut-out, leading to fewer failures of fixation. This study compared the cut-out strength of a Dynamic Hip Screw (DHS) to that of an X-Bolt® (X-Bolt Orthopaedics, Dublin, Ireland) implant in an osteoporotic Sawbones® (Sawbones, Vashon Island, WA) model. METHODS: An unstable fracture model (AO 31-A2) was created using low-density 5 pound per cubic foot (pcf) Sawbones®. The DHS and X-Bolts® were inserted into the Sawbones® femoral head at Tip-Apex Distances (TAD) of 10mm, 15mm, 20mm, 25mm, 30mm and 40mm. A cyclic-loading Instron® machine (Instron Corp., Norwood, MA) pushed the bone at a compression rate of 5mm per minute at a 20-degree angle to the axis of the implant with an upper force limit of 4000N. Maximum force reached and load to failure, defined as movement of the implant by 5mm, were recorded. Four implants were used per group to give a total of 48 tests between the two groups. RESULTS: The X-Bolt® demonstrated a superior average maximum total load push-out force compared to the DHS group for all of the TAD configurations tested. The maximum force reached in the X-Bolt® group was significantly higher than that in the DHS group at a TAD of 10mm (X-Bolt® 3299.25N vs. DHS 2843.75N, P<0.029) and 30mm (X-Bolt® 2908.25N vs. DHS 2030N, P<0.029). The X-Bolt® also had a higher load to failure than the DHS group at all of the TAD values tested. CONCLUSIONS: The X-Bolt® implant gave superior performance compared to the standard DHS, as reflected by a greater push-out force in an osteoporotic Sawbones® model.

Surgical Technique to Manage Periprosthetic Fractures of the Knee in Patients with Infected Leg Ulcers: A Report of Two Cases.

CASES: We describe 2 cases of nonagenarians with periprosthetic knee fractures that were not amenable to either standard internal fixation nor prosthesis revision because of infected leg ulcers in the same limb. The fractures were internally fixed by percutaneous insertion of medial and lateral plates that spanned the knee. Both patients returned to their baseline level of activity without developing surgical site infections. CONCLUSIONS: Percutaneous bridging plates that span the knee are a useful option for treating these difficult cases.

Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study.

BACKGROUND: Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave. METHODS: A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees' Association. RESULTS: There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks' gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees. CONCLUSION: Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.

Vancouver B2 Peri-Prosthetic Fractures in Cemented Femoral Implants can be Treated With Open Reduction and Internal Fixation Alone Without Revision.

BACKGROUND: The aim of this study is to assess the outcomes of 52 consecutive Vancouver B2 peri-prosthetic fractures around cemented polished double-tapered stems treated by open reduction and internal fixation in 2 trauma centers in 2 countries. METHODS: Outcomes included modified Harris Hip Score (mHHS), Harris Pain Score, and return to pre-injury mobility. Fracture healing was assessed; implant subsidence measured and complications including re-operations reported. RESULTS: No patient was lost to follow-up. Median patient age at operation was 82 years (range 43-98); Harris pain scores showed minimal pain (median 42, range 10-44) at latest follow-up. Median total subsidence at 1 year was 1.1 mm (range 0-5.4), the majority of which occurred within the cement mantle. No subsequent femoral stem revision was required (median 2.9 years, 0-10); however, there were 3 re-operations: 1 re-operation for pre-existing recurrent dislocation involving head liner exchange and 2 for repeat fixation due to metal fatigue. Two additional fractures occurred below the new plating, requiring further plating whilst still retaining the original stems. CONCLUSION: Anatomical reduction and open reduction and internal fixation of Vancouver B2 peri-prosthetic fractures should be considered as an appropriate treatment solution for frail elderly patients with a peri-prosthetic fracture around cemented polished double-tapered stems.

A Deep Learning Approach to Non-linearity in Wearable Stretch Sensors.

There is a growing need for flexible stretch sensors to monitor real time stress and strain in wearable technology. However, developing stretch sensors with linear responses is difficult due to viscoelastic and strain rate dependent effects. Instead of trying to engineer the perfect linear sensor we take a deep learning approach which can cope with non-linearity and yet still deliver reliable results. We present a general method for calibrating highly hysteretic resistive stretch sensors. We show results for textile and elastomeric stretch sensors however we believe the method is directly applicable to any physical choice of sensor material and fabrication, and easily adaptable to other sensing methods, such as those based on capacitance. Our algorithm does not require any a priori knowledge of the physical attributes or geometry of the sensor to be calibrated, which is a key advantage as stretchable sensors are generally applicable to highly complex geometries with integrated electronics requiring bespoke manufacture. The method involves three-stages. The first stage requires a calibration step in which the strain of the sensor material is measured using a webcam while the electrical response is measured via a set of arduino-based electronics. During this data collection stage, the strain is applied manually by pulling the sensor over a range of strains and strain rates corresponding to the realistic in-use strain and strain rates. The correlated data between electrical resistance and measured strain and strain rate are stored. In the second stage the data is passed to a Long Short Term Memory Neural Network (LSTM) which is trained using part of the data set. The ability of the LSTM to predict the strain state given a stream of unseen electrical resistance data is then assessed and the maximum errors established. In the third stage the sensor is removed from the webcam calibration set-up and embedded in the wearable application where the live stream of electrical resistance is the only measure of strain-this corresponds to the proposed use case. Highly accurate stretch topology mapping is achieved for the three commercially available flexible sensor materials tested.

A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation.

INTRODUCTION: Clinical studies in orthopedics are using patient-reported outcome measures (PROMs) increasingly. PROMs are often being designed for a specific disease or an area of the body with the aim of being patient centered. As yet, none exists specifically for treatment with circular ring external fixation devices. AIM: The purpose of this study is to provide a comprehensive systematic review of the published literature related to the use of PROMs in patients that underwent treatment with circular frames (Ilizarov or Hexapod Type Fixators). METHODS: An online literature search was conducted for English language articles using the Scopus. RESULTS: There were 534 published articles identified. After initial filtering for relevance and duplication, this figure reduced to 17, with no further articles identified through searching the bibliographies. Exclusion criteria removed two articles resulting in 15 articles included in the final review. Out of the 15 studies identified, a total of 10 different scoring measures where used. The majority of studies used a combination of joint/limb-specific and generic health PROMs with an average of 2.5 per study. No paper specifically discussed all eight PROMs criteria when justifying which PROMs they used. CONCLUSION: Our findings indicate that none of the PROMs analyzed in this systematic review are truly representative of the health outcomes specific to this patient group and, therefore, propose that a PROM specific to this patient group needs to be developed. HOW TO CITE THIS ARTICLE: Antonios T, Barker A, Ibrahim I, et al. A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation. Strategies Trauma Limb Reconstr 2019;14(1):34-44.

Scoping review of priority setting of research topics for musculoskeletal conditions.

OBJECTIVE: Describe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified. DESIGN: Scoping review. SETTING AND POPULATION: Studies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included. METHODS AND ANALYSIS: We searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted. RESULTS: Forty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities. CONCLUSIONS: While many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value. PROSPERO REGISTRATION NUMBER: CRD42017059250.

POWIFF- Prospective study of wrist internal fixation of fracture: A protocol for a single centre, superiority, randomised controlled trial to study the efficacy of the VRP (2.0) distal radius plate (Austofix) versus the VA-LCP (Depuy-Synthes) for distal radius fractures.

BACKGROUND: Distal radial fractures are one of the most common orthopaedic cases that present to the A&E department. Surgical intervention is warranted in displaced intraarticular fractures and fractures with more than the recommended angulation or shortening, and is most commonly treated with volarly placed fixed angle locking plates. The aim of this study is to determine and compare the efficacy of two different plates for surgical treatment of distal radius fractures. The VRP 2.0 is a new plate produced by the Austofix company and this system will be compared against the VA-LP (Variable angle-locking plate) produced by Depuy-Synthes which has been used as the standard treatment device. METHODS AND DESIGN: Patients between the ages of 18 and 80 presenting to the Royal Adelaide Hospital with isolated closed distal radial fractures will be invited to participate in this study. A total of 200 patients are required to provide 90% statistical power at a 5% alpha level to detect a difference of 11.5 points on the PRWE (Patient rated Wrist evaluation) score. The primary outcome measure will be the PRWE score while the secondary outcome measures will include the DASH score, EQ5D score, clinical range of movements, grip strength as well as patient perceived return of function at the wrist and time to resumption to work. These will be measured at 6 weeks, 3 months and 12 months. Radiographic indices including the radial tilt, length, volar inclination and plate prominence will also be measured. Complications will be recorded up to 12 months. Post hoc comparisons will be done using paired t tests. An intention to treat and a per protocol analysis will be done to compare the 2 groups. DISCUSSION: Distal radial fractures are increasingly being treated by internal fixation using volar locking plates. However, there is no prospective study to date comparing one plate against another in terms of outcome and complications. This study could provide more information about the best way to treat these injuries surgically. TRIAL REGISTRATION: The trial is registered with the Australia New Zealand Clinical Trials Registry (ANZCTR). Trial registration date-17/11/2016. Trial registration number- ACTRN12616001590459 .

Time dependent loss of trabecular bone in human tibial plateau fractures.

We investigated if time between injury and surgery affects cancellous bone properties in patients suffering tibial plateau fractures (TPF), in terms of structural integrity and gene expression controlling bone loss. A cohort of 29 TPF, operated 1-17 days post-injury, had biopsies from the fracture and an equivalent contralateral limb site, at surgery. Samples were assessed using micro-computed tomography and real-time RT-PCR analysis for the expression of genes known to be involved in bone remodeling and fracture healing. Significant decreases in the injured vs control side were observed for bone volume fraction (BV/TV, -13.5 ± 6.0%, p = 0.011), trabecular number (Tb.N, -10.5 ± 5.9%, p = 0.041) and trabecular thickness (Tb.Th, -4.6 ± 2.5%, p = 0.033). Changes in these parameters were more evident in patients operated 5-17 days post-injury, compared to those operated in the first 4 days post-injury. A significant negative association was found between Tb.Th (r = -0.54, p < 0.01) and BV/TV (r = -0.39, p < 0.05) in relation to time post-injury in the injured limb. Both BV/TV and Tb.Th were negatively associated with expression of key molecular markers of bone resorption, CTSK, ACP5, and the ratio of RANKL:OPG mRNA. These structure/gene expression relationships did not exist in the contralateral tibial plateau of these patients. This study demonstrated that there is a significant early time-dependent bone loss in the proximal tibia after TPF. This bone loss was significantly associated with altered expression of genes typically involved in the process of osteoclastic bone resorption but possibly also bone resorption by osteocytes. The mechanism of early bone loss in such fractures should be a subject of further investigation. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2865-2875, 2018.

WHAT ARE USER PERSPECTIVES OF EXOSKELETON TECHNOLOGY? A LITERATURE REVIEW.

OBJECTIVES: Exoskeletons are electromechanical devices that are worn by a human operator to increase their physical performance. Several exoskeletons have been developed to restore functional movements, such as walking, for those with paralysis due to neurological impairment. However, existing exoskeletons have limitations with respect to affordability, size, weight, speed, and efficiency, which may reduce their functional application. Therefore, the aim of this scoping review is to collect and narratively synthesize the perspectives of users of exoskeleton technology. METHODS: A systematic literature search was conducted across several healthcare related online databases. RESULTS: A total of 4,619 articles were identified, of which 51 were selected for full review. Only three studies were identified that met the inclusion criteria. Of these, one showed an incongruence between users' expectations and experiences of device use; another reported perspectives on potential rather than actual device use, ranking design features in order of perceived importance; and the other reported ratings of ease of device use in training. CONCLUSIONS: The heterogeneity of studies included within this review, leave the authors unable to suggest consensus as to user perspectives of exoskeleton technology. However, it is apparent that users are able to suggest priorities for exoskeleton design and that users' perspectives of exoskeleton technology might change in response to experience of use. The authors, therefore, suggest that exoskeleton design should be an iterative process, whereby user perspectives are sought, incorporated and refined by tangible experience, to ensure that devices developed are acceptable to and usable by the populations they seek to re-enable.