A comprehensive analysis of the pre- and postoperative responses to each of the 12 Oxford knee score questions one year following knee arthroplasty.

AIMS: To assess the pre- and postoperative responses to each of the 12 individual Oxford Knee Score (OKS) questions and percentages of those that were better, same or worse after primary knee arthroplasty (KA). METHODS: A single centre retrospective cohort study conducted over a 24-month period which included 3259 patients with completed OKS preoperatively and 1-year after KA. There were 1286 males and 1973 females, with an overall mean age of 70.0 (range 34-94). The mean scores for each question of the OKS were compared between baseline and 1-year. The percentage of patients who reported better, the same or worse postoperative symptoms for each question were calculated and represented on a heatmap. RESULTS: There were significant (p < 0.001) improvements in all 12 questions, all of which demonstrated moderate (Q2, Q7) or large effect sizes. Improvements in individual question responses varied. Symptoms of pain and limping demonstrated the greatest improvement, with 86% of patients enjoying a positive change in their symptoms. Despite this improvement 1067 (41.4%) continued to have mild to severe pain in their knee, and 442 (17.3%) patients limped often to all the time when walking postoperatively. Whereas other questions that did not improve to the same extent for example washing and drying only improved in 53% of patients but only 347 (13.5%) had moderate/extreme trouble or found it impossible to do this postoperatively. Preoperatively four questions (Q1, Q6, Q7, Q8) demonstrated floor effects, postoperatively all questions apart from question 7 (kneeling) demonstrated ceiling effects. CONCLUSION: The mean improvement and outcome at 1-year for each of the 12 questions varied according to the patient's preoperative response. As a clinical tool, the heatmap (improvement, same and worse) will enable communication to patients about their potential change in their knee specific symptoms according to their preoperative responses. LEVEL OF EVIDENCE: Retrospective study, Level III.

The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients.

This systematic review and meta-analysis aimed to determine the impact of presurgical waiting times on pre-/post-operative joint specific pain and function, health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements. MEDLINE, EMBASE, PUBMED, and CENTRAL databases were searched from inception until 30th January 2023 (CRD42022288128). Secondary literature and unpublished datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded. PRISMA 2020 reporting and GRADE certainty of evidence guidelines were followed. Residual maximum likelihood meta-analysis and linear meta-regression was performed to elucidate the influence of presurgical waiting time. Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, capturing 89,996 patients (60.6% female, mean age 67.4 years) between 2001 and 2022. A significant deterioration in joint function (mean difference (MD):0.0575%; 95% CI 0.0064, 0.1086; p = 0.028(4d.p.); I2 = 73.1%) and HRQOL (MD: 0.05%; 95% CI - 0.0001.0009; p = 0.011(4 d.p.); I2 = 80.6%) was identified per additional day of waiting. Despite qualitative evidence, meta-analysis could not observe a relationship with postoperative outcome data. Patient responses to delayed THR and TKR surgery were unanimously negative. Immediate action should seek to reduce the increased patient anxiety and significant reductions in pre-operative joint functionality and HRQOL associated with prolonged pre-surgical waiting time, whilst mitigating any potential deleterious post-operative effects.

Golfers are physically more active and have greater health associated quality of life than non-golfers following lower limb arthroplasty.

Background: The health benefits of physical activity are well recognised. This study assessed whether golfers were more physically active after lower limb arthroplasty when compared to those that did not play golf (primary outcome). In addition pre and postoperative changes in health-associated quality of life (HAQoL) and joint specific outcomes between golfers and none golfers were assessed (secondary outcomes). Methods: There were 304 patients [THA (n = 155) or TKA (n = 149)] prospectively registered during a 4-month period undergoing lower limb arthroplasty. The mean age was 70.0 (range 37-92, standard deviation 10.2) years and included 188 (61%) females and 120 (39%) males. They completed pre and postoperative questionnaires assessing recreational activity, physical activity, HAQoL (EuroQol [EQ]), joint specific health (Oxford scores), and satisfaction. Results: Golfers (n = 33, 10.9%) were more likely to achieve longer than 3 hours of moderate activity during a week (48.5% vs 38.0%, odds ratio (OR) 3.4, p = 0.045) and achieved their recommended activity level (96.8% vs 77.7%, OR 8.6, p = 0.015) compared to non-golfers following arthroplasty. Postoperative EQ5D (p = 0.034) and EQVAS (p = 0.019) were significantly greater in golfers. The joint specific Oxford hip score was greater in golfers compared to non-golfers (mean difference 5.6, p = 0.022), however no difference was observed in the Oxford knee score following TKA (p = 0.495). Conclusion: Golfers were more likely to achieve their weekly recommended level of physical activity and had a greater HAQoL relative to those that did not play golf following lower limb arthroplasty. More specifically after THA golfers also had a greater postoperative joint specific outcome, but no such advantage was observed in those following TKA. Evidence Level: Level II, diagnostic study.

Correction: Accelerated Care of Patients with Hip Fractures is Associated with Lower Risk of Delirium and Infection, and a Shorter Length of Hospital Stay: Systematic Review and Meta-analysis of Level One Evidence.

[This corrects the article DOI: 10.1007/s43465-023-01026-x.].

Accelerated Care of Patients with Hip Fractures is Associated with Lower Risk of Delirium and Infection, and a Shorter Length of Hospital Stay: Systematic Review and Meta-analysis of Level One Evidence.

Objectives: The aim of this systematic review was to assess the impact of time to surgery on patient mortality, peri-operative complication rates and length of stay following a hip fracture using level one data. Data Sources: Multiple databases (PubMed, Embase, Medline (Ovid), and Cochrane Library) were searched using terms for "hip fracture" and the intervention "early surgery". Results were filtered to only included randomised controlled trials in the English language published from the year 2000. Study Selection: All results were imported into Covidence and screened by two separate reviewers with conflicts resolved by a third reviewer. Studies were included if they reported data on the relationship between time to theatre and at least one of the outcome measures (mortality, peri-operative complications, and length of stay in hospital). Three papers were finalised to include in this review. Data Extraction: Once selected, each paper had a bias assessment completed by two separate reviewers using the Cochrane RoB2 tool. Any conflicts were resolved by a third reviewer. Data Synthesis: Data from each paper were inputted into RevMan5 for analysis. Approximated sample mean and standard deviation were collected from each paper and included for analysis. RevMan5 was then used to generate forest plots and report data on relative risk and mean difference. Conclusions: This review has shown that accelerated care of patients with hip fractures was associated with lower risks of delirium and infection, and a shorter length of hospital stay. However, the effect of time to surgery on patient mortality is not clear, as the standard care group had a lower mortality than expected for the population at risk and had surgery on average within 24-h of presentation.

Vaccination against COVID-19 reduced the mortality risk of COVID-positive hip fracture patients to baseline levels: the nationwide data-linked IMPACT Protect study.

This nationwide study used data-linked records to assess the effect of COVID-19 vaccination among hip fracture patients. Vaccination was associated with a lower risk of contracting COVID-19 and, among COVID-positive patients, it reduced the mortality risk to that of COVID-negative patients. This provides essential data for future communicable disease outbreaks. PURPOSE: COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. METHODS: This nationwide cohort study included all patients aged > 50 years that sustained a hip fracture in Scotland between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to government-managed population level records of COVID-19 vaccination and laboratory testing. RESULTS: There were 13,345 patients with a median age of 82.0 years (IQR 74.0-88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34-0.48, p < 0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12-3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk of death (OR 0.93, CI 0.53-1.60, p = 0.783). CONCLUSION: Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents data that will be valid in the management of future outbreaks.

Cost-utility analysis of total knee arthroplasty using 10-year data from a randomised controlled trial: Implant design influences quality-adjusted life year gain.

BACKGROUND: The aim of this study was to perform a cost-utility analysis for total knee arthroplasty (TKA) over a 10-year follow up period. METHODS: Two-hundred and twelve patients were randomised to receive either a Kinemax or a Triathlon TKA. Patients were assessed pre-operatively, and at 6 months, and 1, 3, 7 and 10 years postoperatively. The costs of the primary and revision surgery were accounted for. One-year quality-adjusted life year (QALY) gain was used to estimate 10-year gains using the established annual health gain discounts. RESULTS: Forty-eight patients died and eight were revised during the follow up period. Overall QALY gain per patient over the 10-year period was 2.594 and the cost per patient was £6559, which resulted in a cost per QALY of £2761 at 10 years. The Triathlon group had a significantly greater QALY gain compared with the Kinemax (mean difference (MD) 0.53, 95% CI 0.03-1.03, P = 0.02), which resulted in a cost per QALY for the Triathlon group of £2521 compared with £3107 for the Kinemax group at 10 years. The 5% annual discount resulted in a significantly lower QALY gain (MD 0.135, 95% CI 0.201-0.354, P = 0.002), whereas the 3.5% annual discount resulted in non-significant difference in QALY gain compared with the actual gain (MD 0.021, 95% CI -0.084 to 0.077, P = 0.292). CONCLUSIONS: TKA was a cost-effective intervention, and the Triathlon was associated with a greater cost effectiveness at 10 years. The 3.5% annual discounts for QALY gain would seem to be the most accurate, with an underestimation being observed with the 5% discount.

Rate and factors associated with surgical site infection following aseptic revision fixation of orthopaedic trauma injuries.

PURPOSE: The primary aim of this study was to define the rate of infection following revision of fixation for aseptic failure. The secondary aims were to identify factors associated with an infection following revision and patient morbidity following deep infection. METHODS: A retrospective study was undertaken to identify patients who underwent aseptic revision surgery during a 3-year period (2017-2019). Regression analysis was used to identify independent factors associated with SSI. RESULTS: Eighty-six patients were identified that met the inclusion criteria, with a mean age of 53 (range 14-95) years and 48 (55.8%) were female. There were 15 (17%) patients with an SSI post revision surgery (n = 15/86). Ten percent (n = 9) of all revisions acquired a 'deep infection', which carried a high morbidity with a total of 23 operations, including initial revision, being undertaken for these patients as salvage procedures and three progressed to an amputation. Alcohol excess (odds ratio (OR) 1.61, 95% CI 1.01-6.36, p = 0.046) and chronic obstructive pulmonary disease (OR 11.1, 95% CI 1.00-133.3, p = 0.050) were independently associated with an increased risk of SSI. CONCLUSION: Aseptic revision surgery had a high rate of SSI (17%) and deep infection (10%). All deep infections occurred in the lower limb with the majority of these seen in ankle fractures. Alcohol excess and COPD were independent risk factors associated with an SSI and patients with a history of these should be counselled accordingly. LEVEL OF EVIDENCE: Retrospective Case Series, Level IV.

Posterior stabilised total knee arthroplasty is associated with improved post-operative knee specific function, health related quality of life and greater satisfaction when compared to cruciate retaining protheses.

PURPOSE: To assess whether there were differences in knee specific function, health related quality of life (HRQoL), and satisfaction between patients with a cruciate retaining (CR) or a posterior stabilised (PS) total knee arthroplasty (TKA) at 1 and 2 years postoperatively. METHODS: A retrospective review of TKA (CR and PS) patients from a prospectively collected arthroplasty database. Patient demographics, body mass index and ASA grade, Oxford knee score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 1 year and 2 years postoperatively. Regression was used to adjust for confounding factors. RESULTS: The sample included 3122 TKA, of which 1009 (32.3%) were CR and 2112 (67.7%) were PS. The PS group were more likely to be female (odd ratio (OR) 1.26, p = 0.003) and undergo resurfacing of the patella (OR 6.63, p < 0.001). There was a significantly greater improvement in the 1 year OKS in the PS group (mean difference (MD) 0.9, p = 0.016). The PS TKA was independently associated with a greater 1 year (MD 1.1, 95% CI 0.4 to 1.9, p = 0.001) and 2 years (MD 0.8, p = 0.037) post-operative improvements in OKS. PS TKA was also independently associated with a greater 1 year (MD 0.021, p = 0.024) and 2 years (MD 0.022, p = 0.025) post-operative and change in EQ-5D utility compared to the CR group. The PS group was more likely to be satisfied with their outcome at 1 year (OR 1.75, p < 0.001) and at 2 years (OR 1.38, p = 0.001) when adjusting for confounders. CONCLUSION: PS TKA was associated with a better knee specific function and HRQoL when compared to CR, but the clinical significance of this is not clear. However, the PS group was more likely to be satisfied with their outcome compared to the CR group.

Fractures in elderly mice demonstrate delayed ossification of the soft callus: a cellular and radiographic study.

OBJECTIVES: The aim of this study was to assess the cellular age-related changes in fracture repair and relate these to the observed radiographic assessments at differing time points. METHODS: Transverse traumatic tibial diaphyseal fractures were created in 12-14 weeks old (young n = 16) and 18 months old (elderly n = 20) in Balb/C wild mice. Fracture calluses were harvested at five time points from 1 to 35 days post fracture for histomorphometry (percent of cartilage and bone), radiographic analysis (total callus volume, callus index, and relative bone mineral content). RESULTS: The elderly mice produced an equal amount of cartilage when compared to young mice (p > 0.08). However, by day 21 there was a significantly greater percentage of bone at the fracture site in the young group (mean percentage 50% versus 11%, p < 0.001). It was not until day 35 when the elderly group produced a similar amount of bone compared to the young group at 21 days (50% versus 53%, non-significant (ns)). The callus area and callus index on radiographic assessment was not significantly different between young and elderly groups at any time point. Relative bone mineral content was significantly greater in the young group at 14 days (545.7 versus -120.2, p < 0.001) and 21 days (888.7 versus 451.0, p < 0.001) when compared to the elderly group. It was not until day 35 when the elderly group produced a similar relative bone mineral content as the young group at 21 days (888.7 versus 921.8, ns). CONCLUSIONS: Elderly mice demonstrated a delay in endochondral ossification which was associated with a decreased relative bone mineral content at the fracture site and may help assess these cellular changes in a clinical setting.

Golfers have greater preoperative and equal postoperative function when undergoing total knee arthroplasty compared to non-golfers.

BACKGROUND: Approximately 10% to 20% of patients with joint arthroplasties are golfers. The aim of this study was to assess if being a golfer is associated with functional outcomes, satisfaction or improvement in quality of life (QoL) compared to non-golfers following total knee arthroplasty. METHODS: All patients undergoing primary total knee arthroplasty (TKA) over a one-year period at a single institution were included with one-year postoperative outcomes. Patients were retrospectively followed up to assess if they had been golfers at the time of their surgery. Multivariate linear regression analysis was performed to assess the independent association of preoperative golfing status on postoperative function and health-related outcomes. RESULTS: The study cohort consisted of a total of 514 patients undergoing TKA. This included 223 (43.3%) male patients and 291 (56.7%) female patients, with an overall mean age of 70 (SD 9.5) years. The preoperative Oxford Knee Score (OKS) was significantly higher in golfers when adjusting for confounders (Diff 3.4 [95% CI 1 to 5.8], p = 0.006). There was no difference in postoperative outcomes between golfers and non-golfers. There was however a trend towards a higher Forgotten Joint Score (FJS) in the golfers (difference 9.3, 95% CI - 0.2 to 18.8, p = 0.056). Of the 48 patients who reported being golfers at the time of their surgery, 43 (89.6%) returned to golf and 88.4% of those were satisfied with their involvement in golf following surgery. CONCLUSIONS: Golfers had better preoperative and equal postoperative knee specific function compared to non-golfers. The majority of golfers returned to golf by one year and were satisfied with their involvement in the game. LEVEL OF EVIDENCE: III.

Factors associated with a clinically significant improvement in health-related quality of life after total knee arthroplasty.

BACKGROUND: The aim was to identify independent preoperative factors associated with changes in health-related quality of life (HRQoL) following total knee arthroplasty (TKA), and whether these could be used as indicators for surgery. METHODS: A retrospective study of 3127 TKA patients was undertaken that included 1194 (38.2%) male and 1933 (61.8%) female patients, with a mean age of 70.5 years (standard deviation 9.0). Patient demographics, body mass index and ASA grade, Oxford Knee Score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 2 years postoperatively. RESULTS: When adjusting for confounding factors, obesity grade II (p = 0.002), ASA grade 3 (p = 0.002), and a better preoperative OKS (p < 0.001) or EQ-5D score (p < 0.001) were associated with a decreased improvement in the HRQoL at 2-years. A preoperative EQ-5D of < 0.8 (95.7% specific, AUC ≥ 67.0%) or an OKS of < 36 (97.1% specific, AUC ≥ 58.1%) was associated with a clinically significant improvement HRQoL. Patella resurfacing (n = 1454, 46.5%) was not independently associated with a clinical or statistically significant improvement in HRQoL. According to preoperative factors, no subgroup of patients benefited more from patella resurfacing according to improvement in their HRQoL. CONCLUSION: ASA grade 3, grade II obesity, a better preoperative EQ-5D or OKS were independently associated with a lesser improvement in HRQoL. The thresholds identified in the EQ-5D or OKS for a clinically significant improvement in HRQoL may be used as potential indicators for referral for TKA. Patella resurfacing was not independently associated with a clinically important improvement in HRQoL. LEVEL OF EVIDENCE: Retrospective diagnostic study, Level III.

Socioeconomic deprivation status predicts both the incidence and nature of Achilles tendon rupture.

PURPOSE: The aim of this study was to describe the epidemiology of Achilles tendon rupture (ATR) and its relationship with socioeconomic deprivation status (SEDS). The hypothesis was that ATR occurs more frequently in socioeconomically deprived patients. Secondary aims were to determine variations in circumstances of injury between more and less deprived patients. METHODS: A 6-year retrospective review of consecutive patients presenting with ATR was undertaken. The health-board population was defined using governmental population data and SEDS was defined using the Scottish Index of Multiple Deprivation. The primary outcome was an epidemiological description and comparison of incidence in more and less deprived cohorts. Secondary outcomes included reporting of the relationship between SEDS and patient and injury characteristics with univariate and binary logistic regression analyses. RESULTS: There were 783 patients (567 male; 216 female) with ATR. Mean incidence for adults (≥ 18 years) was 18.75/100,000 per year (range 16.56-23.57) and for all ages was 15.26/100,000 per year (range 13.51 to 19.07). Incidence in the least deprived population quintiles (4th and 5th quintiles; 18.07 per 100,000/year) was higher than that in the most deprived quintiles (1st and 2nd; 11.32/100,000 per year; OR 1.60, 95%CI 1.35-1.89; p < 0.001). When adjusting for confounding factors, least deprived patients were more likely to be > 50 years old (OR 1.97; 95%CI 1.24-3.12; p = 0.004), to sustain ATR playing sports (OR 1.72, 95%CI 1.11-2.67; p = 0.02) and in the spring (OR 1.65, 95%CI 1.01-2.70; p = 0.045) and to give a history of preceding tendinitis (OR 4.04, 95%CI 1.49-10.95; p = 0.006). They were less likely to sustain low-energy injuries (OR 0.44, 95%CI 0.23-0.87; p = 0.02) and to be obese (OR 0.25-0.41, 95%CI 0.07-0.90; p ≤ 0.03). CONCLUSIONS: The incidence of ATR was higher in less socioeconomically deprived populations and the hypothesis was therefore rejected. Significant variations in patient and predisposing factors, mechanisms of injury and seasonality were demonstrated between most and least deprived groups, suggesting that circumstances and nature of ATR may vary with SEDS and these are not a homogenous group of injuries. LEVEL OF EVIDENCE: Prognostic Study Level III.

Diabesity: a superadded effect contributing to worse total primary hip replacement operative outcomes for patients with diabetes and obesity.

INTRODUCTION: Although the independent effects of diabetes mellitus and obesity on total hip replacement (THR) outcomes have been widely studied, their combined effect remains uncharacterised. This study aimed to assess the influence of diabesity on primary THR operative outcomes. MATERIALS AND METHODS: A retrospective study was performed comparing the outcomes of patients with diabesity (diabetes mellitus and obesity [BMI ≥ 30]) with a control cohort after primary THR using an established arthroplasty database. Data were collected pre-operatively and 12 months post-operatively, including Oxford Hip Score (OHS), EuroQol 5-dimensions (EQ5D), post-operative satisfaction and complication rates. RESULTS: 2323 THRs were analysed, of which 94 (4%) had diabesity. Diabesity was independently associated with significantly worse OHS improvement post-operatively (- 1.85 points, 95% CI - 2.93 to - 0.76, p = 0.001). This reduction in addition to the independent effect of obesity (- 0.69 points, 95% CI - 1.18 to - 0.21, p = 0.005) resulted in an overall 2.54 point OHS reduction for patients with diabesity. Diabesity was not associated with EQ5D score change or post-operative satisfaction. Diabesity was independently associated with a worse pre-operative EQ5D score (-0.08 points, 95% CI -0.12 to -0.03, p = 0.002). When combining the associated risk of obesity (Odds Ratio (OR) 1.71, 95% CI 1.15-2.54, p = 0.008) with the superadded effect of diabesity (OR 2.37, 95% CI 1.19-4.71, p = 0.014) the rate of superficial wound infection post-operatively was significantly increased (OR 4.05, 95% CI 1.38-11.95). Obesity was associated with a significantly increased risk of deep infection (OR 3.67, 95% CI 1.55-8.68, p = 0.003), but no additive effect of diabetes was found. CONCLUSIONS: Diabesity confers a superadded effect over established associations between THR outcomes and obesity and diabetes individually. Patients with diabesity experience worse improvement in hip-specific functional outcome, worse post-operative quality of life, and an increased risk of superficial and deep wound infection following THR.

Biomechanical parameters of the golf swing associated with lower back pain: A systematic review.

Low back pain (LBP) is the most common injury in golfers of all abilities. The primary aim of this review was to improve understanding of human golf swing biomechanics associated with LBP. A systematic review using the PRISMA guidelines was performed. Nine studies satisfying inclusion criteria and dually reporting golf swing biomechanics and LBP were identified. Human golf swing biomechanics potentially associated with LBP include: reduced lumbar flexion velocity; reduced transition phase length; reduced lumbar torsional load; earlier onset of erector spinae contraction; increased lumbar lateral flexion velocity; reduced or greater erector spinae activity; and earlier onset of external oblique contraction. These potential associations were undermined by a very limited and conflicting quality of evidence, study designs which introduced a severe potential for bias and a lack of prospective study design. There is no conclusive evidence to support the commonly held belief that LBP is associated with "poor" golf swing technique. The potential associations identified should be further investigated by prospective studies of robust design, recruiting participants of both sexes and dexterities. Once firm associations have been identified, further research is required to establish how this knowledge can be best integrated into injury prevention and rehabilitation.

LBP has the highest incidence of any injury in elite, sub-elite and recreational golfers, causing a significant burden of injury worldwide.There is very limited and conflicting evidence that some human biomechanical factors in the golf swing may be associated with LBP.Prospective studies investigating the full movement pattern are required in order to improve understanding of the potential relationship between the biomechanics of the golf swing and LBP.

The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review.

BACKGROUND: To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively. MATERIALS AND METHODS: A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools. RESULTS: Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively. CONCLUSIONS: Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.

The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty.

BACKGROUND: The health-related quality of life of patients awaiting a total knee arthroplasty (TKA) deteriorates with increasing time to surgery and identification of those with the worst quality of life may help to prioritize patients. The aims were to identify and validate independent variable(s) associated with a health state worse than death (WTD) in patients awaiting a TKA and whether these variables influenced patients-reported outcome measures. METHODS: A retrospective cohort of 5857 patients undergoing a primary TKA was identified from an established arthroplasty database. Patient demographics, body mass index (BMI), index of multiple deprivation, Oxford Knee Score (OKS), EuroQoL five dimension (EQ-5D) 3 level, and visual analogue scale (EQ-VAS) were collected preoperatively and one year postoperatively. An EQ-5D utility of less than zero was defined as WTD. A randomly selected subset of patients (n = 3076) was used to validate the variable that was most predictive of a state WTD and to assess the influence on patient-reported outcomes. RESULTS: There were 771 (13.2%) patients with a health state WTD. Increasing social deprivation (P = 0.050), worse preoperative OKS (P < 0.001), or EQ-VAS (P < 0.001) were independently associated with a health state WTD. The OKS was the most reliable predictor (area under curve 88.9%, 95% CI 87.8 to 90.1, P < 0.001) of a health state WTD. A threshold value of 16 or less, 80% sensitive and specific, was validated and confirmed to have a negative predictive value of 97.5%. Patients with an OKS of 16 or less had a significantly greater improvement in their OKS (difference 6.9, P < 0.001) and EQ-5D score (difference 0.257, P < 0.001). When adjusting for confounding factors, a health status WTD was not associated with worse postoperative OKS (difference -0.6, 95% CI -1.4 to 0.3, P = 0.177), EQ-5D (difference -0.016, 95% CI -0.036 to 0.003, P = 0.097) or patient satisfaction (difference -1.8, 95% CI -4.3 to 0.7, P = 0.162). CONCLUSION: A threshold score 16 or less in OKS was a reliable predictor of a health status WTD and was associated with a greater improvement in knee-specific and health-related quality of life following TKA.

A Cost-Utility Analysis of Robotic Arm-Assisted Total Hip Arthroplasty: Using Robotic Data from the Private Sector and Manual Data from the National Health Service.

Purpose: The aim was to assess the cost-effectiveness of robotic arm-assisted total hip arthroplasty (rTHA) compared with manual total hip arthroplasty (mTHA) and to assess the influence of annual volume on the relative cost-effectiveness of rTHA. Methods: A database of both rTHA (n = 48 performed in a private centre) and mTHA (n = 512 performed in the National Health Service) was used. Patient demographics, preoperative Oxford hip score, forgotten joint score, EuroQol 5-dimensional 3-level (EQ-5D), and postoperative EQ-5D were recorded. Two models for incremental cost-effectiveness ratios using cost per quality-adjusted life year (QALY) for rTHA were calculated based on a unit performing 100 rTHAs per year: 10-year follow-up and a lifetime time horizon (remaining life expectancy of a 69-year-old patient). Results: When adjusting for confounding factors, rTHA was independently associated with a 0.091 (p=0.029) greater improvement in the EQ-5D compared to mTHA. This resulted in a 10-year time horizon cost per QALY for rTHA of £1,910 relative to mTHA, which increased to £2,349 per QALY when discounted (5%/year). When using the 10-year time horizon cost per QALY was approximately £3,000 for a centre undertaking 50 rTHAs per year and decreased to £1,000 for centre undertaking 200 rTHAs per year. Using a lifetime horizon, the incremental unadjusted cost per QALY gained was £980 and £1432 when discounted (5%/year) for rTHA compared with mTHA. Conclusions: Despite the increased cost associated with rTHA, it was a cost-effective intervention relative to mTHA due to the associated greater health-related quality of health gain, according to the EQ-5D outcome measure.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors.

PURPOSE: The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture. METHODS: A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years. RESULTS: Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050). CONCLUSION: The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture. LEVEL OF EVIDENCE: III.

Vancouver B and C periprosthetic fractures around the cemented Exeter Stem: sex is associate with fracture pattern.

INTRODUCTION: The aim of this study was to identify factors associated with the level of periprosthetic fracture involving a cemented polished tapered stem: Vancouver B or Vancouver C. METHODS: A retrospective cohort study of 181 unilateral periprosthetic fractures involving Exeter stems was assessed by three observers (mean age 78.5, range 39-103; mean BMI 27.1, 17-39; 97 (54%) male). Patient demographics, deprivation scores, BMI and time since primary prosthesis were recorded. Femoral diameter, femoral cortical thickness, Dorr classification and distal cement mantle length were measured from calibrated radiographs. Interobserver reliability was calculated using intraclass correlation coefficients (ICCs). Univariate and multivariate analysis was performed to identify associations with Vancouver B or C fractures. RESULTS: 160/181 (88%) Vancouver B and 21/181 (12%) Vancouver C-level fractures occurred at a mean of 5.9 ± 5.4 years (0.2-26.5) following primary surgery. Radiographic measurements demonstrated excellent agreement (ICC > 0.8, p < 0.001). Mortality was significantly higher following Vancouver C compared to B fractures: 90 day 14/160 Vs 5/21 (p = 0.05); 1 year 29/160 Vs 8/21 (p = 0.03). Univariate analysis demonstrated that Vancouver C fractures were associated with female sex, bisphosphonate use, cortical bone thickness, and distal cement mantle length (p < 0.05). On multivariate analysis, only female sex was an independent predictor of Vancouver C-level fractures (R2 =0.354, p = 0.005). CONCLUSION: Most PFFs involving the Exeter stem design are Vancouver B-type fractures and appear to be independent of osteoporosis. In contrast, Vancouver C periprosthetic fractures display typical fragility fracture characteristics and are associated with female sex, thinner femoral cortices, longer distal cement mantles and high mortality.