Research priorities to reduce the impact of musculoskeletal disorders: a priority setting exercise with the child health and nutrition research initiative method.

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Determining the stress biomarker profile in patients undergoing total knee replacement and the relationship with outcome at 12 months.

BACKGROUND: Total knee replacement (TKR) is the commonest joint arthroplasty procedure worldwide. Despite excellent outcomes, some studies have reported dissatisfaction in up to 20% of patients. There is evidence of an association between the biochemical stress response to surgery and outcomes. The objective of this study is to describe the stress biomarker profile for TKR, and correlate this with patient outcomes. METHODS: A prospective cohort study of 50 patients undergoing primary TKR was conducted. Serum IL-6, TNF-α, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were measured immediately pre- and post-operatively, and on Days 1 and 3. Follow-up questionnaires including the Oxford Knee Score (OKS) and EuroQol five dimensions (EQ-5D) were completed at 12-months. Univariate analysis was completed using a linear regression model (p < 0.05). RESULTS: Serum IL-6, NLR, and PLR all increased to Day 1 post-operatively, and decreased by Day 3. TNF-α values increased across all time points. Statistical analysis found a significant negative correlation (r = -0.414; p = 0.005) between pre-operative IL-6 and 12-month OKS. There was a significant positive correlation between pre-operative NLR and 12 month OKS (r = 0.272; p = 0.039) and 12 month EQ5D (r = 0.268; p = 0.043). CONCLUSION: This is the first study to describe the biochemical stress response to TKR. The results raise the potential for a pre-operative risk stratification tool for patients based on IL-6 and NLR measurements. Further research should be conducted to explore the underlying mechanisms involved, and investigate interventions to reduce pre-operative physiological stress with a view to improving post-operative outcomes.

Tibial component sizing and alignment of TKR components does not significantly affect patient reported outcome measures at six months. A case series of 474 participants.

OBJECTIVES: Total knee replacement (TKR) is an effective means of alleviating the symptoms of end stage osteoarthritis. However, 20% of patients report dissatisfaction one year post-operatively. Previous literature has demonstrated contradictory evidence regarding the relationship between alignment and tibial component sizing with patient reported outcome measures (PROMs). We aim to investigate the association between alignment of TKR components and effect of tibial component sizing on PROMs. METHOD: A prospective, multicentre case series was performed at six centres. Baseline characteristics were collected at recruitment. Coronal and sagittal plain films were taken day one post-operatively. Trained medical professionals blinded to outcome measured the alignment and degree of over/underhang of the tibial component in the coronal and sagittal place, with Oxford Knee Score (OKS) measured six months post-operatively. RESULTS: 474 patients were recruited. Malaligned TKRs caused no significant difference in mean OKS change at six months (independent t-test) (p > 0.05). A multivariate regression model taking into account age, gender, body mass index and baseline OKS also demonstrated no significant difference (p > 0.05). With regards to tibial component sizing, 125 (27%) of patients had appropriately sized tibial components, 120 (26%) had overhang and 219 (53%) had underhang with no significant difference in OKS between the groups (p > 0.05). CONCLUSION: Tibial component sizing and alignment does not significantly affect short-term function, as measured by OKS, after total knee replacement. Dissatisfaction after TKR is likely due to other factors other than alignment of implant.

Does malalignment affect patient reported outcomes following total knee arthroplasty: a systematic review of the literature.

BACKGROUND: Total knee replacement is an effective treatment for knee arthritis. While the majority of TKAs have demonstrated promising long-term results, up to 20 % of patients remain dissatisfied with the outcome of surgery at 1 year. Implant malalignment has been implicated as a contributing factor to less successful outcomes. Recent evidence has challenged the relationship between alignment and patient reported outcome measures. Given the number of procedures per year, clarity on this integral aspect of the procedure is necessary. OBJECTIVE: To investigate the association between malalignment and PROMS following primary TKA. METHODS: A systematic review of MEDLINE, CINHAL, and EMBASE was carried out to identify studies published from 2000 onwards. The study protocol including search strategy can be found on the PROSPERO database for systematic reviews. RESULTS: From a total of 2107 citations, 18 studies fulfilled the inclusion criteria, comprising of 2214 patients. Overall 41 comparisons were made between a malalignment parameter and a PROM, with 30 comparisons (73 %) demonstrating no association. However, 50 % (n = 9) of the studies with 'Low risk' radiological assessment methods have reported a statistically significant association between one or more parameter of malalignment and PROMS. CONCULSION: When considering malalignment in an individual parameter, there is an inconsistent relationship with PROMs scores. Malalignment may be related to worse PROMs scores, but if that relationship exists it is weak and of dubious clinical significance. However, this evidence is subject to limitations mainly related to the methods of assessing alignment post operatively and by the possibility that the premise of traditional mechanical alignment is erroneous. Larger longitudinal studies with a standardised, timely, and robust method for assessing alignment outcomes are required.

Does malalignment affect revision rate in total knee replacements: a systematic review of the literature.

To ensure implant durability following Modern total knee replacement (TKR) surgery, one long held principle in condylar total knee arthroplasty is positioning the components in alignment with the mechanical axis and restoring the overall limb alignment to 180° ± 3°. However, this view has been challenged recently. Given the high number of TKR performed, clarity on this integral aspect of the procedure is necessary. To investigate the association between malalignment following primary TKR and revision rates. A systematic review of the literature was conducted using a computerised literature search of Medline, CINHAL, and EMBASE to identify English-language studies published from 2000 through to 2014. Studies with adequate information on the correlation between malalignment and revision rate with a minimum follow-up of 6 months were considered for inclusion. A study protocol, including the detailed search strategy was published on the PROSPERO database for systematic reviews. From an initial 2107 citations, eight studies, with variable methodological qualities, were eligible for inclusion. Collectively, nine parameters of alignment were studied, and 20 assessments were made between an alignment parameter and revision rate. Four out of eight studies demonstrated an association between a malalignment parameter and increased revision rates. In the coronal plane, only three studies assessed the mechanical axis. None of these studies found an association with revision rates, whereas four of the five studies investigating the anatomical axis found an association between malalignment and increased revision rate. This study demonstrates the effect of malalignment on revision rates is likely to be modest. Interestingly, studies that used mechanical alignment in the coronal plane demonstrated no association with revision rates. This questions the premise of patient specific instrumentation devices based on the mechanically aligned knee when considering revision as the endpoint.

Development of an outcome prediction tool for patients considering a total knee replacement--the Knee Outcome Prediction Study (KOPS).

BACKGROUND: Knee osteoarthritis affects 10% of the UK population over 55 years, resulting in pain and decreased quality of life. Knee replacement surgery has a proven benefit, with over 85,000 performed each year in the UK; however, approximately 17% of people are dissatisfied after surgery. Consequently, some Primary Care Trusts have reduced the funding available for knee replacements.Most previous work has focused on the effect of different prostheses and treatment protocols on patient's outcome. However, this has been unable to account for all the variability and there is growing evidence that patient factors may significantly affect outcome. How to identify these at risk patients has been identified as a research priority by the National Institute of Clinical Excellence, the British Orthopedic Association, and the National Joint Registry.The aim of this study is to develop a clinically appropriate outcome prediction tool based on measurable predictors affecting outcome. METHODS/DESIGN: We propose a prospective cohort study, designed to develop and validate an outcome prediction tool based on patient factors.Six hundred patients who are scheduled for total knee replacement secondary to primary osteoarthritis will be recruited before surgery from all six hospitals (NHS and private) that provide total knee replacements to the population of Coventry and Warwickshire (UK). Patients will complete a baseline assessment of patient factors before their operation and will be followed up at 6 and 12 months post surgery. DISCUSSION: A clinically appropriate outcome prediction tool will allow patients to make a more informed decision regarding surgery. Aligning patient expectations with a realistic prediction of outcome should improve satisfaction. Ultimately, this project is likely to inform national policy making and regional service provision.

External fixators in the treatment of midshaft clavicle non-unions: a systematic review.

Non- or mal-union of the clavicle is reported to occur in up to 15 % of conservatively treated fractures: the purpose of this systematic review is to examine the evidence for the use of external fixation in the treatment of clavicular non-union. We performed a search of MEDLINE and Embase, including all papers using external fixators for the treatment of clavicular non-union. Four papers satisfied our eligibility criteria: three case series and one case-control study. Level of evidence and quality assessment scoring were performed using published methods. Due to the heterogeneity of the study populations and interventions, no attempt at meta-analysis was made. External fixation in hypertrophic non-union of the clavicle, but not atrophic non-union, appears to be a reasonable treatment option. A pragmatic, multicentre, randomised controlled trial comparing external fixation and open reduction internal fixation in the treatment of hypertrophic non-union of the clavicle would be valuable.