Do Patients With Insulin-Dependent and Non-Insulin-Dependent Diabetes Have Different Risks for Complications After Total Ankle Arthroplasty?

BACKGROUND: Patients with diabetes undergoing total ankle arthroplasty tend to be at greater risk for complications than those without diabetes. However, the effect of diabetes severity and how it impacts the risk for perioperative complications is less clear. The purpose of this study was to compare (1) complications, (2) length of hospital stay, and (3) readmissions within 30 days for total ankle arthroplasty (TAA) patients without diabetes, patients with non-insulin-dependent diabetes, and patients with insulin-dependent diabetes. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a total of 1803 patients undergoing TAA between 2007 and 2019 were collected. The relationship between diabetes status (no diabetes [n = 1,589], insulin-dependent [n = 169], and non-insulin-dependent [n = 45]) and outcomes were compared. Multivariate linear regression models were used to adjust for confounding variables such as age, sex, race, body mass index, smoking, steroid use, hypertension, chronic obstructive pulmonary disease, anesthesia type, dyspnea, and outpatient status. Statistical significance was set at P <.05. RESULTS: Insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days (odds ratio 6.47, 95% CI 0.79-33.66; P = .043). Hospital length of stay was also increased in patients with non-insulin-dependent diabetes (ß = 0.21, 95% CI 0.02-0.40; P = .031) and insulin-dependent diabetes (ß = 0.40, 95% CI 0.04-0.76; P = .028). However, neither diabetic state demonstrated a statistically significant increase in readmissions or wound complications within 30 days. CONCLUSION: Patients with insulin-dependent diabetes included in this cohort were at increased risk of having an infection within 30 days after TAA. Additionally, patients with diabetes status had an increased hospital length of stay. These results can inform patients on their potential outcomes after total ankle arthroplasty based on their diabetes status. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The significance of heterotopic ossification following total ankle arthroplasty: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to evaluate the prevalence and clinical significance of heterotopic ossification (HO) following total ankle replacement (TAR). METHODS: During August 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies reporting HO following TAR. Data regarding surgical characteristics, pathological characteristics, subjective clinical outcomes, ankle range of motion, radiographic outcomes, reoperation rates were extracted and analysed. RESULTS: Twenty-seven studies with 2639 patients (2695 ankles) at a weighed mean follow-up time of 52.8 ± 26.9 months were included. The pooled prevalence rate was 44.6% (0.25; 0.66). The implant with the highest rate of HO was the INBONE I (100%) and BOX (100%) implants. The most common modified Brooker staging was grade 1 (132 patients, 27.0%). Random effects models of standardized mean differences found no difference in American orthopedic foot and ankle society (AOFAS) scores, visual analog scale scores (VAS) and ankle range of motion (ROM) between patients with HO and patients without HO. Random effects models of correlation coefficients found no correlation between AOFAS, VAS and ROM and the presence of HO. The surgical intervention rate for symptomatic HO was 4.2%. CONCLUSION: This systematic review and meta-analysis found that HO is a common finding following TAR that is not associated with inferior clinical outcomes. Surgical intervention was required only for moderate-to-severe, symptomatic HO following TAR. This study is limited by the marked heterogeneity and low level and quality of evidence of the included studies. Further higher quality studies are warranted to determine the precise prevalence and impact of HO on outcomes following TAR.

From jargon to clarity: Improving the readability of foot and ankle radiology reports with an artificial intelligence large language model.

BACKGROUND: The purpose of this study was to evaluate the efficacy of an Artificial Intelligence Large Language Model (AI-LLM) at improving the readability foot and ankle orthopedic radiology reports. METHODS: The radiology reports from 100 foot or ankle X-Rays, 100 computed tomography (CT) scans and 100 magnetic resonance imaging (MRI) scans were randomly sampled from the institution's database. The following prompt command was inserted into the AI-LLM: "Explain this radiology report to a patient in layman's terms in the second person: [Report Text]". The mean report length, Flesch reading ease score (FRES) and Flesch-Kincaid reading level (FKRL) were evaluated for both the original radiology report and the AI-LLM generated report. The accuracy of the information contained within the AI-LLM report was assessed via a 5-point Likert scale. Additionally, any "hallucinations" generated by the AI-LLM report were recorded. RESULTS: There was a statistically significant improvement in mean FRES scores in the AI-LLM generated X-Ray report (33.8 ± 6.8 to 72.7 ± 5.4), CT report (27.8 ± 4.6 to 67.5 ± 4.9) and MRI report (20.3 ± 7.2 to 66.9 ± 3.9), all p < 0.001. There was also a statistically significant improvement in mean FKRL scores in the AI-LLM generated X-Ray report (12.2 ± 1.1 to 8.5 ± 0.4), CT report (15.4 ± 2.0 to 8.4 ± 0.6) and MRI report (14.1 ± 1.6 to 8.5 ± 0.5), all p < 0.001. Superior FRES scores were observed in the AI-LLM generated X-Ray report compared to the AI-LLM generated CT report and MRI report, p < 0.001. The mean Likert score for the AI-LLM generated X-Ray report, CT report and MRI report was 4.0 ± 0.3, 3.9 ± 0.4, and 3.9 ± 0.4, respectively. The rate of hallucinations in the AI-LLM generated X-Ray report, CT report and MRI report was 4%, 7% and 6%, respectively. CONCLUSION: AI-LLM was an efficacious tool for improving the readability of foot and ankle radiological reports across multiple imaging modalities. Superior FRES scores together with superior Likert scores were observed in the X-Ray AI-LLM reports compared to the CT and MRI AI-LLM reports. This study demonstrates the potential use of AI-LLMs as a new patient-centric approach for enhancing patient understanding of their foot and ankle radiology reports. Jel Classifications: IV.

Surgical management of spiral oblique fractures of the fifth metatarsal leads to faster return to play in athletes: A systematic review.

PURPOSE: The purpose of this systematic review was to evaluate outcomes following both operative and nonoperative management of spiral oblique fractures of the fifth metatarsal. METHODS: During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following operative and nonoperative management of dancer's fractures. Data regarding subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. RESULTS: Ten studies were included in this review. In total, 125 patients underwent operative treatment for dancer's fractures and 365 patients underwent nonoperative treatment for dancer's fractures. The weighted mean follow-up in the operative cohort was 15.3 ± 32.7 months and the weighted mean follow-up in the nonoperative cohort was 30.6 ± 24.3 months. The overall union rate in the operative cohort was 99.2% and the overall union rate in the nonoperative cohort was 98.6%. The weighted mean time to return to sport was 15.4 ± 6.7 and 22.4 ± 4.4 weeks in the operative cohort and nonoperative cohort, respectively. The complication rate in the operative cohort and nonoperative cohort was 12.0% and 15.1%, respectively. CONCLUSION: This current systematic review demonstrated comparable radiographic outcomes together with low failure rate and low complication rate following both operative and nonoperative management of dancer's fracture at short-term follow-up. However, faster return to sport rates was observed in the operative cohort, suggesting that surgical management of displaced spiral oblique fractures of the fifth metatarsal should be the mainstay treatment option. However, the under-reporting of data, marked heterogeneity between studies and paucity of comparative studies limits the generation of any robust conclusions; thus, further high-quality comparative studies are warranted. LEVEL OF EVIDENCE: Level IV.

Implications of obesity in patients with foot and ankle pathology.

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m2. It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.

Intra-Tendinous Ganglion Cyst of the Peroneus Tertius: A Case Report and Literature Review.

BACKGROUND This article presents a rare case of an intra-tendinous ganglion cyst of the peroneus tertius. Ganglion cysts are benign lesions frequently seen in hand pathologies, but they are rarely seen in the foot and ankle. This article discusses the present case and similar previously reported cases in the English literature. CASE REPORT We present a case of a 58-year-old man with a 3-year history of right foot pain caused by a mass located at the dorso-lateral aspect of the midfoot. Preoperative MRI demonstrated a ganglion cyst arising from the peroneus tertius tendon sheath. The lesion was successfully decompressed in the office; however, it recurred 7 months later. As it was symptomatic, we elected to proceed with surgical resection. During dissection, it became apparent that the cyst was arising from an intrasubstance tear of the peroneus tertius tendon, and a branch of the superficial peroneal nerve was noted to be adherent to the pseudo-capsule. Following excision of the lesion and its expansile pseudo-capsule, the tear was repaired with tubularization of the tendon and external neurolysis of the nerve was performed. At 6 months after surgery, there was no recurrence of the lesion, and the patient was pain free and had regained normal physical function. CONCLUSIONS Intra-tendinous ganglion cysts are rare, especially in the foot and ankle. This makes it challenging for an accurate preoperative diagnosis. When a tendon is arising from a tendon sheath, we recommend exploration of the underlying tendon for an associated tear.

Supramalleolar osteotomy for the treatment of ankle osteoarthritis leads to favourable outcomes and low complication rates at mid-term follow-up: a systematic review.

PURPOSE: The purpose of this systematic review was to evaluate both the clinical and radiographic outcomes following supramalleolar osteotomy (SMO) in patients with ankle osteoarthritis, and to analyse the level of evidence (LOE) and quality of evidence (QOE) of the included studies. METHODS: A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following SMO for the treatment of ankle osteoarthritis were included and assessed. The level and quality of evidence of the included studies were also evaluated. RESULTS: Twenty-four studies with 1160 patients (1182 ankles) were included. Overall, 78.8% patients presented with post-traumatic ankle osteoarthritis. The weighted mean AOFAS score improved from 52.6 ± 9.7 (range 33.8-78.4) preoperatively to 78.1 ± 5.7 postoperatively at weighted mean follow-up of 50.4 ± 18.6 months (range 24.5-99.0). The most frequently utilised radiographic parameter was the tibial anterior surface angle, which improved from a preoperative weighted mean of 86.3° ± 5.6° (range 76.0°-102.0°) to a postoperative weighted mean of 89.9° ± 3.7° (range 84.9°-99.6°). The complication rate was 5.1% with non-union as the most commonly reported complication (1.6%). Secondary procedures were carried out in 28.2% of patients, the most common of which was implant and hardware removal (17.6%). The failure rate was 6.8%. Two studies were LOE II, 3 studies were LOE III, and 19 studies were LOE IV. The mean Modified Coleman Methodology Score was 59.3 ± 6.6 and the mean MINORS criteria score of all the included studies was 9.5 ± 3.7. CONCLUSION: This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. However, a moderate reoperation rate (28.2%) was reported. A low failure rate (6.8%) was reported, which must be interpreted in light of the shortcomings of the design of the included studies and a relatively short follow-up period. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data which underscores the need for further higher quality research to be conducted. Our review highlights that SMO may be an effective and safe procedure in the setting of early-to-intermediate-stage ankle osteoarthritis. LEVEL OF EVIDENCE: IV.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review.

Background: There is minimal literature on the use of suture tape augmentation in the treatment of chronic lateral ankle instability (CLAI), prompting an investigation on its use and effect during surgery of the lateral ankle. Purpose: To evaluate the evidence for the use of suture tape augmentation in the treatment of CLAI and the outcomes after this procedure. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated the use of suture tape for CLAI. Outcome measures included the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society (AOFAS) score, return to play, and radiological improvement in anterior talar translation and talar tilt angle. Quantitative and qualitative analyses were performed. Results: There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with level 4) including 334 patients (334 ankles) that underwent suture-tape augmentation. The mean age was 27.3 years, 67.3% were women, and the mean follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted postoperative AOFAS score was 95, and 87.7% were able to return to sports. Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies that compared Broström repair and suture tape augmentation, there were no significant differences between the procedures in recurrent instability (mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I 2 = 0%; P = .78), Foot and Ankle Ability Measure (MD, 1.24 [95% CI, -3.73 to 6.21]; I 2 = 66%; P = .63), talar tilt angle improvement (MD, -0.07 [95% CI, -0.68 to 0.54]; I 2 = 0%; P = .42), or anterior talar translation improvement (MD, -0.06 [95% CI, -0.69 to 0.56]; I 2 = 0%; P = .77). Conclusion: Suture tape augmentation did not significantly improve clinical or radiological outcomes in the setting of modified Broström repair for CLAI. There is currently insufficient evidence to recommend suture tape augmentation for all patients at this time.

Orthopaedic Foot and Ankle Surgeon Industry Compensation Reported by the Open Payments Database.

Background. The current study aims to characterize and explore trends in Open Payments Database (OPD) payments reported to orthopaedic foot and ankle (F&A) surgeons. OPD payments are classified as General, Ownership, or Research. Methods. General, Ownership, and Research payments to orthopaedic F&A surgeons were characterized by total payment sum and number of transactions. The total payment was compared by category. Payments per surgeon were also assessed. Median payments for all orthopaedic F&A surgeons and the top 5% compensated were calculated and compared across the years. Medians were compared through Mann-Whitney U tests. Results. Over the period, industry paid over $39 million through 29,442 transactions to 802 orthopaedic F&A surgeons. The majority of this payment was General (64%), followed by Ownership (34%) and Research (2%). The median annual payments per orthopaedic F&A surgeon were compared to the 2014 median ($616): 2015 ($505; P = .191), 2016 ($868; P = .088), and 2017 ($336; P = .084). Over these years, the annual number of compensated orthopaedic F&A surgeons increased from 490 to 556. Averaged over 4 years, 91% of the total orthopaedic F&A payment was made to the top 5% of orthopaedic F&A surgeons. The median payment for this group increased from $177 000 (2014) to $192 000 (2017; P = .012). Conclusion. Though median payments to the top 5% of orthopaedic F&A surgeons increased, there was no overall change in median payment over four years for all compensated orthopaedic F&A surgeons. These findings shed insight into the orthopaedic F&A surgeon-industry relationship.Levels of Evidence: III, Retrospective Study.

Novel Vacuum-Assisted Method for Harvesting Autologous Cancellous Bone Graft and Bone Marrow From the Proximal Tibial Metaphysis.

BACKGROUND: Autogenous cancellous bone graft and bone marrow aspirate are commonly used in lower extremity fusion procedures to enhance fusion potential, and frequently in revision situations where bone loss and osteolysis may be a feature. The tibial metaphysis is a common donor site for bone graft, with the procedure typically performed using a curette or trephine to harvest the cancellous bone. Some limitations of this technique include suboptimal harvest of the marrow portion in particular, incomplete graft harvest, and loss of graft material during the harvest process. We describe a novel vacuum-assisted bone harvesting device to acquire cancellous bone and marrow from the proximal tibia. METHODS: This is a retrospective study of a single surgeon's consecutive patients who underwent foot and ankle arthrodesis procedures using proximal tibia autograft obtained using a vacuum-assisted bone harvesting device. Descriptive statistics were used to summarize patient and operative characteristics and outcomes. We identified 9 patients with a mean age of 51 years, 4 of whom were female. RESULTS: On average, the skin incision was slightly more than 2 cm, and 27 mL of solid graft and 16 mL of liquid phase aspirate were collected. At 6 weeks after the procedure, there was minimal to no pain at the donor site, and we did not observe any fractures or other complications. CONCLUSIONS: We report the use of a novel vacuum-assisted curette device to harvest bone graft from the proximal tibial metaphysis for use in foot and ankle fusions. This device has been reliable and efficient in clinical practice. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act.

BACKGROUND: The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty. METHODS: We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral. RESULTS: Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period. CONCLUSION: Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments. LEVEL OF EVIDENCE: Level II, prognostic study.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management.

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.

A case of acute tarsal tunnel syndrome following lateralizing calcaneal osteotomy.

Surgical correction of hindfoot varus is frequently performed with a lateral displacement calcaneal osteotomy. It has rarely been associated with iatrogenic tarsal tunnel syndrome in patients with pre-existing neurological disease. We report the first case of acute postoperative tarsal tunnel syndrome in a neurologically intact patient with post-traumatic hindfoot varus. Early diagnosis and emergent operative release afforded an excellent clinical outcome. Imaging studies can help outrule a compressive hematoma and assess for possible nerve transection; however it is paramount that a high index of suspicion is utilized with judicious operative intervention to minimize long-term sequelae.

Total knee replacement under tourniquet control: A prospective study of the peripheral arterial vasculature using colour-assisted duplex ultrasonography.

BACKGROUND AND PURPOSE: A tourniquet may potentiate rare and devastating arterial complications after total knee replacement (TKR) in patients with peripheral vascular disease (PVD). Most prior studies that evaluated peripheral arterial blood flow primarily used the ankle-brachial index (ABI). METHODS: We assessed the prevalence and risk factors for PVD in a cohort undergoing TKR. Clinical and radiological evaluations, including duplex ultrasonography, were performed one week prior to, and six weeks post-TKR performed under tourniquet control. Forty patients were analysed (20 male, 20 female; mean age 67 yrs, range: 53-80 yrs). MAIN FINDINGS: Hypertension (50%) and hypercholesterolaemia (50%) were the most common co-morbidities. Distal pulses were present in all patients preoperatively. Six patients (15%) had arterial calcification on their preoperative knee X-rays. Three patients (7.5%) had moderate PVD. There was no change in blood flow postoperatively in patients with or without PVD (p > 0.05). Vascular stenosis was less than 50% in all patients preoperatively and postoperatively. No postoperative vascular complications occurred. CONCLUSIONS: Severe PVD is not common in patients undergoing TKR. Performing total knee replacement under tourniquet control does not adversely affect the vasculature in patients with less than 50% vascular occlusion.

Reconstruction of the medial talonavicular joint in simulated flatfoot deformity.

BACKGROUND: Reconstructing the ligamentous constraints of the medial arch associated with adult acquired flatfoot deformity remains a challenge. The purpose of this study was to test the efficacy of several reconstruction techniques of the medial arch. We hypothesized that an anatomic reconstruction of the spring ligament complex would correct the deformity better than other techniques tested. METHODS: Three reconstructions of the medial support structures were performed on each specimen to recreate the different lines of action and insertions of the medial ligamentous complex in 12 specimens with a simulated flatfoot deformity. Talonavicular and tibiocalcaneal (hindfoot) orientations were measured in the axial, sagittal, and coronal planes in the intact, flatfoot, and reconstructed conditions. RESULTS: While each reconstruction technique corrected the deformity (P < .05), proximal fixation of the graft corrected the greatest amount of talonavicular deformity while also correcting hindfoot valgus (P < .05). CONCLUSION: The fixation points and lines of action of a medial arch reconstruction have important implications on deformity correction in a flatfoot model. Despite its fidelity to the native structure, the anatomic spring ligament reconstruction provided the least amount of correction. These findings suggest that other ligamentous structures of the medial arch are critical in supporting the midfoot. CLINICAL RELEVANCE: Reconstruction of the ligamentous supports of the medial arch might be able to correct substantial amounts of deformity without osseous procedures like calcaneal osteotomies or midfoot fusions.

Effects of home-based resistance training and neuromuscular electrical stimulation in knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Quadriceps femoris muscle (QFM) weakness is a feature of knee osteoarthritis (OA) and exercise programs that strengthen this muscle group can improve function, disability and pain. Traditional supervised resistance exercise is however resource intensive and dependent on good adherence which can be challenging to achieve in patients with significant knee OA. Because of the limitations of traditional exercise programs, interest has been shown in the use of neuromuscular electrical stimulation (NMES) to strengthen the QFM. We conducted a single-blind, prospective randomized controlled study to compare the effects of home-based resistance training (RT) and NMES on patients with moderate to severe knee OA. METHODS: 41 patients aged 55 to 75 years were randomised to 6 week programs of RT, NMES or a control group receiving standard care. The primary outcome was functional capacity measured using a walk test, stair climb test and chair rise test. Additional outcomes were self-reported disability, quadriceps strength and cross-sectional area. Outcomes were assessed pre- and post-intervention and at 6 weeks post-intervention (weeks 1, 8 and 14 respectively). RESULTS: There were similar, significant improvements in functional capacity for the RT and NMES groups at week 8 compared to week 1 (p ≤ 0.001) and compared to the control group (p < 0.005), and the improvements were maintained at week 14 (p ≤ 0.001). Cross sectional area of the QFM increased in both training groups (NMES: +5.4%; RT: +4.3%; p = 0.404). Adherence was 91% and 83% in the NMES and RT groups respectively (p = 0.324). CONCLUSIONS: Home-based NMES is an acceptable alternative to exercise therapy in the management of knee OA, producing similar improvements in functional capacity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN85231954.

Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.

BACKGROUND: Supervised preoperative muscle strengthening programmes (prehabilitation) can improve recovery after total joint arthroplasty but are considered resource intensive. Neuromuscular electrical stimulation (NMES) has been shown to improve quadriceps femoris muscle (QFM) strength and clinical function in subjects with knee osteoarthritis (OA) however it has not been previously investigated as a prehabilitation modality. METHODS: This pilot study assessed the compliance of a home-based, NMES prehabilitation programme in patients undergoing total knee arthroplasty (TKA). We evaluated its effect on preoperative and postoperative isometric quadriceps femoris muscle (QFM) strength, QFM cross-sectional area (CSA) and clinical function (subjective and objective). Seventeen subjects were recruited with 14 completing the study (NMES group n = 9; Control group n = 5). RESULTS: Overall compliance with the programme was excellent (99%). Preoperative QFM strength increased by 28% (p > 0.05) with associated gains in walk, stair-climb and chair-rise times (p < 0.05). Early postoperative strength loss (approximately 50%) was similar in both groups. Only the NMES group demonstrated significant strength (53.3%, p = 0.011) and functional recovery (p < 0.05) from 6 to 12 weeks post-TKA. QFM CSA decreased by 4% in the NMES group compared to a reduction of 12% in the control group (P > 0.05) at 12 weeks postoperatively compared to baseline. There were only limited associations found between objective and subjective functional outcome instruments. CONCLUSIONS: This pilot study has shown that preoperative NMES may improve recovery of quadriceps muscle strength and expedite a return to normal activities in patients undergoing TKA for OA. Recommendations for appropriate outcome instruments in future studies of prehabilitation in TKA have been provided.

Tourniquets and exsanguinators: a potential source of infection in the orthopedic operating theater?

BACKGROUND AND PURPOSE: Fomites are increasingly being recognised as a source of hospital-acquired infection. We have therefore assessed tourniquets and exsanguinators for the presence of bacterial pathogens in 1 elective and 2 trauma orthopedic hospitals. MATERIAL AND METHODS: Swabs were taken prior to and after decontaminating these devices with 1 of 3 different cleaning modalities. These were then assessed for colony counts and organisms identified. RESULTS: Bacteria commonly implicated in surgical site infections such as coagulase-negative staphylococci, Staphylococcus aureus and Proteus spp. were prevalent. We also found a resistant strain of Acinetobacter and Candida. Exsanguinators were the most heavily contaminated devices, and colony counts in the trauma hospitals were up to 400% higher than in the elective hospital. Alcohol- and non-alcohol-based sterile wipes were both highly effective in decontaminating the devices. INTERPRETATION: Infectious organisms reside on the tourniquets and exsanguinators presently used in the orthopedic theater. These fomites may possibly be a source of surgical site infection. We have demonstrated a simple and effective means of decontaminating these devices between cases.