Routine use of antibiotic-laden bone cement in total knee arthroplasty is a cost-effective practice in the single-payer healthcare system.

PURPOSE: The purpose of this study was to determine the cost-effectiveness of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) from the perspective of a single-payer healthcare system. METHODS: A cost-utility analysis (CUA) was performed over a 2-year time horizon comparing primary TKA with either ALBC or regular bone cement (RBC) from the perspective of the single-payer Canadian healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality-adjusted life years (QALYs). Model inputs for cost, utilities and probabilities were derived from the literature as well as regional and national databases. One-way deterministic sensitivity analysis was performed. RESULTS: Primary TKA with ALBC was found to be more cost-effective compared to primary TKA with RBC with an incremental cost-effectiveness ratio (ICER) of -3,637.79 CAD/QALY. The use of routine ALBC remained cost-effective even with cost increases of up to 50% per bag of ALBC. TKA with ALBC was no longer cost-effective if the rate of PJI following this practice increased 52%, or the rate of PJI following the use of RBC decreased 27%. CONCLUSIONS: The routine use of ALBC in TKA is a cost-effective practice in the single-payer Canadian healthcare system. This remains to be the case even with a 50% increase in the cost of ALBC. Policy makers and hospital administrators of single-payer healthcare systems can leverage this model to inform their local funding policies. Future prospective reviews and randomized controlled trials from the perspective of various healthcare models can further shed light on this issue. LEVEL OF EVIDENCE: III.

Randomized Controlled Trial of Sensor-Guided Knee Balancing Compared to Standard Balancing Technique in Total Knee Arthroplasty.

BACKGROUND: Despite advances in total knee arthroplasty (TKA) technology, up to 1 in 5 patients remain dissatisfied. This study sought to evaluate if sensor-guided knee balancing improves postoperative clinical outcomes and patient satisfaction compared to a conventional gap balancing technique. METHODS: We undertook a prospective double-blind randomized controlled trial of patients presenting for elective primary TKA to determine a difference in TKA soft tissue balance between a standard gap balancing (tensiometer) approach compared to augmenting the balance using a sensor-guided device. The sensor-guided experimental group had adjustments made to achieve a balanced knee to within 15 pounds of intercompartmental pressure difference. Secondary outcomes included differences in clinical outcome scores at 6 months and 1 year postoperative, including the Oxford Knee Score and Knee Society Score and patient satisfaction. RESULTS: The sample comprised of 152 patients, 76 controls and 76 experimental sensor-guided cases. Within the control group, 36% (27/76) of knees were unbalanced based on an average coronal plane intercompartmental difference >15 pounds, compared to only 5.3% (4/76) within the experimental group (P < .0001). There were no significant differences in 1-year postoperative flexion, Knee Society Score, or Oxford scores. Overall, TKA patient satisfaction at 1 year was comparable, with 81% of controls and experimental cases reporting they were very satisfied (P = .992). CONCLUSION: Despite the use of the sensor-guided knee balancer device to provide additional quantitative feedback in the evaluation of the soft tissue envelope during TKA, we were unable to demonstrate improved clinical outcomes or patient satisfaction compared to our conventional gap balancing technique.

Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy.

The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. Given its infrequency, there is scarcity of literature describing appropriate surgical management and operative technique for addressing this instability. This study reports a case of gross hip instability following hip arthroscopy, describing a novel technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft. Level of evidence V, Case Study.

Relationship between the alpha and beta angles in diagnosing CAM-type femoroacetabular impingement on frog-leg lateral radiographs.

PURPOSE: Alpha and beta angles are commonly used radiographic measures to assess the sphericity of the proximal femur and distance between the pathologic head-neck junction and the acetabular rim, respectively. The aim of this study was to explore the relationship between these two measurements on frog-leg lateral hip radiographs. METHODS: Fifty frog-leg lateral hip radiographs were evaluated by two orthopaedic surgeons and two radiologists. Each reviewer measured the alpha and beta angles on two separate occasions to determine the relationship between positive alpha and beta angles and the inter- and intra-observer reliability of these measurements. RESULTS: There was no significant association between positive alpha and beta angles, [kappa range -0.043 (95 % CI -0.17 to 0.086) to 0.54 (95 % CI 0.33-0.75)]. Intra-observer reliability was high [alpha angle intra-class correlation coefficient (ICC) range 0.74 (95 % CI 0.58-0.84) to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.95-0.98)]. CONCLUSIONS: There is no statistical or functional relationship between readings of positive alpha and beta angles. The radiographic measurements resulted in high intra-observer and fair-to-moderate inter-observer reliability. Results of this study suggest that the presence of a CAM lesion on lateral radiographs as suggested by a positive alpha angle does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle and thus may not be the best measure of functional impingement. Understanding the relationship between these two aspects of femoroacetabular impingement improves a surgeon's ability to anticipate potential operative management.

The McMaster osteotomy-a novel surgical treatment to chronic slipped capital femoral epiphysis: description of surgical technique and case study.

Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder that can lead to complex proximal femur deformities and devastating consequences such as avascular necrosis, femoroacetabular impingement syndrome and early-onset osteoarthritis. Existing surgical techniques are often insufficient to fully address the constellation of multiplanar deformities in patients with severe SCFE. Therefore, the McMaster Osteotomy, a novel intertrochanteric proximal femur osteotomy, was developed to improve anatomic correction and hip mechanics in patients with chronic SCFE. The McMaster Osteotomy was implemented in two patients (A: 16-year-old male, B: 17-year-old female) with proximal femur deformities due to chronic SCFE. Surgical planning was facilitated with a 3D-printed pelvic model generated from a CT scan of a patient with the SCFE deformity. Patient B also underwent concurrent arthroscopic osteochondroplasty and labral repair. Pre- and post-operative function and radiographic measurements were recorded. Post-operatively, patient A's neck-shaft angle improved from 125° to 136°, Southwick angle from 52° to 33°, neck length from 66 mm to 80 mm and hip internal rotation from 5° to 25°. Patient B's post-operative neck-shaft angle improved from 122° to 136°, Southwick angle from 25° to 15°, neck length from 76 mm to 84 mm, hip internal rotation from 5° to 20° and alpha angle from 87.6° to 44.3°. Both patients are pain-free and have obtained full union of their osteotomies. The McMaster Osteotomy is a versatile technique that can produce a more anatomic reconstruction of hip anatomy and restoration of abductor mechanics. As an extracapsular technique, the risk of femoral head avascular necrosis is minimized.

Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study.

BACKGROUND: Tibial shaft fractures are the most common long bone fracture and are prone to complications such as nonunion requiring reoperations to promote fracture healing. We aimed to determine the fracture characteristics associated with tibial fracture nonunion, and their predictive value on the need for reoperation. We further aimed to evaluate the predictive value of a previously-developed prognostic index of three fracture characteristics on nonunion and reoperation rate. METHODS: We conducted an observational study and developed a risk factor list from previous literature and key informants in the field of orthopaedic surgery, as well as via a sample-to-redundancy strategy. We evaluated 22 potential risk factors for the development of tibial fracture nonunion in 200 tibial fractures. We also evaluated the predictive value of a previously-identified prognostic risk index on secondary intervention and/or reoperation rate. Two individuals independently extracted the data from 200 patient electronic medical records. An independent reviewer assessed the initial x-ray, the post-operative x-ray, and all available sequential x-rays. Regression and chi-square analysis was used to evaluate potential associations. RESULTS: In our cohort of patients, 37 (18.5%) had a nonunion and 27 (13.5%) underwent a reoperation. Patients with a nonunion were 97 times (95% CI 25.8-366.5) more likely to have a reoperation. Multivariable logistic regression revealed that fractures with less than 25% cortical continuity were predictive of nonunion (odds ratio = 4.72; p = 0.02). Such fractures also accounted for all of the reoperations identified in our sample. Furthermore, our data provided preliminary validation of a previous risk index predictive of reoperation that includes the presence of a fracture gap post-fixation, open fracture, and transverse fracture type as variables, with an aggregate of fracture gap and an open fracture yielding patients with the highest risk of developing a nonunion. CONCLUSIONS: We identified a significant association between degree of cortical continuity and the development of a nonunion and risk for reoperation in tibial shaft fractures. In addition, our study supports the predictive value of a previous prognostic index, which inform discussion of prognosis following operative management of tibial fractures.

Continuous infusion of bupivacaine following total knee arthroplasty: a randomized control trial pilot study.

An RCT pilot-study was conducted to assess efficacy of a 48-h continuous local infiltration of intra-articular bupivacaine (0.5% at 2 cc/h) versus placebo (0.5% saline at 2 cc/h) in decreasing PCA morphine consumption following TKA. Secondary outcomes included 48-h VAS pain, opioid side effects, length of stay, and knee function scores up to 1-year postoperatively. Of 67 randomized patients, 49 completed the trial including 24 bupivacaine, and 25 placebo patients. Mean 48-h PCA morphine consumption did not differ significantly between treatment (39 mg ± 27.1) and placebo groups (53 mg ± 30.4) (P = .137). The intervention did not improve pain scores, or any other outcome studied. Given study results we would conclude that analgesia outcomes with a multimodal analgesia regimen are not significantly improved by adding 48 h of 0.5% bupivacaine infiltration at 2 cc/h.

Development of the Veterans Healthcare Administration (VHA) Ophthalmic Surgical Outcome Database (OSOD) project and the role of ophthalmic nurse reviewers.

Currently, ophthalmic surgical cases are not included in the Veterans Administration Surgical Quality Improvement Project data collection. Furthermore, there is no comprehensive protocol in the health system for prospectively measuring outcomes for eye surgery in terms of safety and quality. There are 400,000 operative cases in the system per year. Of those, 48,000 (12%) are ophthalmic surgical cases, with 85% (41,000) of those being cataract cases. The Ophthalmic Surgical Outcome Database Pilot Project was developed to incorporate ophthalmology into VASQIP, thus evaluating risk factors and improving cataract surgical outcomes. Nurse reviewers facilitate the monitoring and measuring of these outcomes. Since its inception in 1778, the Veterans Administration (VA) Health System has provided comprehensive healthcare to millions of deserving veterans throughout the U.S. and its territories. Historically, the quality of healthcare provided by the VA has been the main focus of discussion because it did not meet a standard of care comparable to that of the private sector. Information regarding quality of healthcare services and outcomes data had been unavailable until 1986, when Congress mandated the VA to compare its surgical outcomes to those of the private sector (PL-99-166). 1 Risk adjustment of VA surgical outcomes began in 1987 with the Continuous Improvement in Cardiac Surgery Program (CICSP) in which cardiac surgical outcomes were reported and evaluated. 2 Between 1991 and 1993, the National VA Surgical Risk Study (NVASRS) initiated a validated risk-adjustment model for predicting surgical outcomes and comparative assessment of the quality of surgical care in 44 VA medical centers. 3 The success of NVASRS encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care, thus developing the National Surgical Quality Improvement Program (NSQIP) in 1994. 4 According to a prospective study conducted between 1991-1997 in 123 VA medical centers by Khuri et al., the 30-day mortality and morbidity rates for major surgeries had decreased by 9% and 30%, respectively. 5 Recently renamed the VA Surgical Quality Improvement Program (VASQIP) in 2010, the quality of surgical outcomes has continued to improve among all documented surgical specialties. Ophthalmic surgery is presumed to have a very low mortality rate and therefore has not been included in the VASQIP database.

Three-dimensional printing in orthopaedic surgery: a scoping review.

Three-dimensional printing (3DP) has become more frequently used in surgical specialties in recent years. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production.The purpose of this review was to understand the current uses of 3DP in orthopaedic surgery, the geographical and temporal trends of its use, and its impact on peri-operative outcomesOne-hundred and eight studies (N = 2328) were included, published between 2012 and 2018, with over half based in China.The most commonly used material was titanium.Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3DP (N = 63), followed by final implants (N = 32) and PSI (N = 22).Take-home message: Overall, 3DP is becoming more common in orthopaedic surgery, with wide range of uses, particularly in complex cases. 3DP may also confer some important peri-operative benefits. Cite this article: EFORT Open Rev 2020;5:430-441. DOI: 10.1302/2058-5241.5.190024.

Anterior Capsule Reconstruction of the Native Hip: A Technique Guide.

This is a technique guide for open anterior capsule reconstruction in unstable native hips due to Ehlers-Danlos syndrome. Ehlers-Danlos syndrome is a connective tissue disease that predisposes an individual to hypermobility of their soft tissues and recurrent subluxations and dislocations of their joints. This may lead to constant instability, guarding of the hip, and subsequent arthritic changes and poor quality of life. We demonstrate anterior capsule reconstruction of the hip using an Achilles tendon allograft performed through a direct anterior approach to the hip (Heuter's approach). This technique guide outlines in detail the surgical steps required to accomplish this reconstructive procedure. Furthermore, a narrated surgical video is provided that clearly depicts the anticipated result of the increased constrained provided to the hip from the anterior capsule reconstruction using an Achilles tendon allograft.

Listeners' perceptions of speech and language disorders.

UNLABELLED: Using semantic differential scales with nine trait pairs, 445 adults rated five audio-taped speech samples, one depicting an individual without a disorder and four portraying communication disorders. Statistical analyses indicated that the no disorder sample was rated higher with respect to the trait of employability than were the articulation, voice, and language disorder conditions; and higher in self-esteem than the fluency, voice, and language disorders. In addition, there were differences among the disorders. Most notably, the language disordered condition was rated significantly lower in decisiveness and reliability and higher in stress level than all other conditions. Within-subject analyses indicated that the variables of age, gender, exposure to individuals with communication disorders, and urban versus rural residency did not affect ratings. These results support previous research indicating the existence of negative stereotypes toward individuals with communication disorders. In addition, they reveal differences in how various disorders were perceived. LEARNING OUTCOMES: Participants will be able to: (1) identify the different methods investigators have used to examine perceptions toward individuals with communicative disorder, (2) recognize that there are differences in how the various communicative disorders are perceived, and (3) discuss the need for public education in order to dispel stereotypes associated with communicative disorders.

Getting fit for hip and knee replacement: a protocol for the Fit-Joints pilot randomized controlled trial of a multi-modal intervention in frail patients with osteoarthritis.

BACKGROUND: Joint replacement provides significant improvements in pain, physical function, and quality of life in patients with osteoarthritis. With a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty reduction in hip and knee replacement patients improves post-operative outcomes. OBJECTIVES: The primary objective is to examine the feasibility of a parallel group RCT comparing a preoperative multi-modal frailty intervention to usual care in pre-frail/frail older adults undergoing elective unilateral hip or knee replacements. The secondary objectives areTo explore potential efficacy of the multi-modal frailty intervention in improving frailty and mobility between baseline and 6 weeks post-surgery using Fried frailty phenotype and short performance physical battery (SPPB) respectively.To explore potential efficacy of the multi-modal frailty intervention on post-operative healthcare services use. METHODS/DESIGN: In a parallel group pilot RCT, participants will be recruited from the Regional Joint Assessment Program in Hamilton, Canada. Participants who are (1) ≥ 60 years old; (2) pre-frail (score of 1 or 2) or frail (score of 3-5; Fried frailty phenotype); (3) having elective unilateral hip or knee replacement; and (4) having surgery wait times between 3 and 10 months will be recruited and randomized to either the intervention or usual care group. The multi-modal frailty intervention components will include (1) tailored exercise program (center-based and/or home-based) with education and cognitive behavioral change strategies; (2) protein supplementation; (3) vitamin D supplementation; and (4) medication review. The main comparative analysis will take place at 6 weeks post-operative. The outcome assessors, data entry personnel, and data analysts are blinded to treatment allocation. Assessments: feasibility will be assessed by recruitment rate, retention rate, and data collection completion. Frailty and healthcare use and other clinical outcomes will be assessed. The study outcomes will be collected at the baseline, 1 week pre-operative, and 6 weeks and 6 months post-operative. DISCUSSION: This is the first study to examine the feasibility of multi-modal frailty intervention in pre-frail/frail older adults undergoing hip or knee replacement. This study will inform the planning and designing of multi-modal frailty interventional studies in hip and knee replacement patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02885337.

Hydroalcoholic seed extract of Coriandrum sativum (Coriander) alleviates lead-induced oxidative stress in different regions of rat brain.

Lead exposure is known to cause apoptotic neurodegeneration and neurobehavioral abnormalities in developing and adult brain by impairing cognition and memory. Coriandrum sativum is an herb belonging to Umbelliferae and is reported to have a protective effect against lead toxicity. In the present investigation, an attempt has been made to evaluate the protective activity of the hydroalcoholic extract of C. sativum seed against lead-induced oxidative stress. Male Wistar strain rats (100-120 g) were divided into four groups: control group: 1,000 mg/L of sodium acetate; exposed group: 1,000 mg/L lead acetate for 4 weeks; C. sativum treated 1 (CST1) group: 250 mg/kg body weight/day for seven consecutive days after 4 weeks of lead exposure; C. sativum treated 2 (CST2) group: 500 mg/kg body weight/day for seven consecutive days after 4 weeks of lead exposure. After the exposure and treatment periods, rats were sacrificed by cervical dislocation, and the whole brain was immediately isolated and separated into four regions: cerebellum, hippocampus, frontal cortex, and brain stem along with the control group. After sacrifice, blood was immediately collected into heparinized vials and stored at 4 °C. In all the tissues, reactive oxygen species (ROS), lipid peroxidation products (LPP), and total protein carbonyl content (TPCC) were estimated following standard protocols. An indicator enzyme for lead toxicity namely delta-amino levulinic acid dehydratase (δ-ALAD) activity was determined in the blood. A significant (p<0.05) increase in ROS, LPP, and TPCC levels was observed in exposed rat brain regions, while δ-ALAD showed a decrease indicating lead-induced oxidative stress. Treatment with the hydroalcoholic seed extract of C. sativum resulted in a tissue-specific amelioration of oxidative stress produced by lead.

Systematic review of the treatment of periprosthetic distal femur fractures.

OBJECTIVES: To systematically review and compare nonoperative and operative treatments for the management of periprosthetic distal femur fractures adjacent to total knee arthroplasties. Specific operative interventions compared included locked plating, retrograde intramedullary nailing (RIMN), and conventional (nonlocked) plating. Where possible, data were pooled to arrive at summary estimates of treatment effect [odds ratios (ORs) with associated 95% confidence intervals (CIs)]. METHODS: A comprehensive database search (via Pubmed, Medline, Cochrane Database, and the Orthopaedic Trauma Association database) was completed, yielding 44 eligible studies with a total of 719 fractures for analysis. Pertinent outcomes including malunion, nonunion, and the need for secondary surgical procedures were compared statistically. RESULTS: Both locked plating and RIMN demonstrated significant advantages over nonoperative treatment. Some advantages were also observed when locked plating and RIMN were compared with conventional (nonlocked) plates. Comparison of locked plating and RIMN showed no significant differences with regard to nonunion rates (OR = 0.39, 95% CI = 0.13-1.15; P = 0.09) or rate of secondary surgical procedures (OR = 0.65, 95% CI = 0.31-1.35; P = 0.25). However, RIMN demonstrated a significantly higher malunion rate when compared with locked plating (OR = 2.37, 95% CI = 1.17-4.81; P = 0.02). CONCLUSIONS: Locked plating and RIMN offer significant advantages over nonoperative treatment and conventional (nonlocked) plating techniques in the management of periprosthetic femur fractures above total knee arthroplasties. Locked plating demonstrated a trend toward increased nonunion rates when compared with RIMN. Malunion was significantly higher with RIMN compared with locked plating.

Diagnosing Femoroacetabular Impingement From Plain Radiographs: Do Radiologists and Orthopaedic Surgeons Differ?

BACKGROUND: A diagnosis of femoroacetabular impingement (FAI) requires careful history and physical examination, as well as an accurate and reliable radiologic evaluation using plain radiographs as a screening modality. Radiographic markers in the diagnosis of FAI are numerous and not fully validated. In particular, reliability in their assessment across health care providers is unclear. PURPOSE: To determine inter- and intraobserver reliability between orthopaedic surgeons and musculoskeletal radiologists. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Six physicians (3 orthopaedic surgeons, 3 musculoskeletal radiologists) independently evaluated a broad spectrum of FAI pathologies across 51 hip radiographs on 2 occasions separated by at least 4 weeks. Reviewers used 8 common criteria to diagnose FAI, including (1) pistol-grip deformity, (2) size of alpha angle, (3) femoral head-neck offset, (4) posterior wall sign abnormality, (5) ischial spine sign abnormality, (6) coxa profunda abnormality, (7) crossover sign abnormality, and (8) acetabular protrusion. Agreement was calculated using the intraclass correlation coefficient (ICC). RESULTS: When establishing an FAI diagnosis, there was poor interobserver reliability between the surgeons and radiologists (ICC batch 1 = 0.33; ICC batch 2 = 0.15). In contrast, there was higher interobserver reliability within each specialty, ranging from fair to good (surgeons: ICC batch 1 = 0.72; ICC batch 2 = 0.70 vs radiologists: ICC batch 1 = 0.59; ICC batch 2 = 0.74). Orthopaedic surgeons had the highest interobserver reliability when identifying pistol-grip deformities (ICC = 0.81) or abnormal alpha angles (ICC = 0.81). Similarly, radiologists had the highest agreement for detecting pistol-grip deformities (ICC = 0.75). CONCLUSION: These results suggest that surgeons and radiologists agree among themselves, but there is a need to improve the reliability of radiographic interpretations for FAI between the 2 specialties. The observed degree of low reliability may ultimately lead to missed, delayed, or inappropriate treatments for patients with symptomatic FAI.

Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons.

BACKGROUND: Despite the large number of fracture outcome studies, there remains variability in the definitions of fracture-healing. It is unclear how orthopaedic surgeons are diagnosing and managing delayed unions and nonunions in clinical practice. We aimed to explore the current opinions of orthopaedic surgeons with regard to defining, diagnosing, and treating delayed unions and nonunions in extremity fractures. METHODS: We developed a survey using previous literature, key informants in the field of orthopaedic surgery, and a sample-to-redundancy strategy. Our final survey contained four sections and twenty-nine questions focusing on demographics and surgical experience, definitions of fracture union, prognostic factors for union, and the need for clinical trials. The Internet-based survey and follow-up e-mails were continued until our a priori sample size of a minimum of 320 completed and eligible responses were collected. RESULTS: Three hundred and thirty-five surgeons completed the survey. The typical respondent was a North American, male orthopaedic surgeon or consultant over the age of thirty years who had completed trauma fellowship training, worked in an academic practice, supervised residents, and had more than six years of experience in treating orthopaedic injuries. Most surgeons endorsed a lack of standardization in definitions for delayed unions (73%) and nonunions (55%); almost all agreed that defining a delayed union and nonunion should be done on the basis of both radiographic and clinical criteria (88%). Most respondents believed that the degree of soft-tissue injury (approximately 93%), smoking history (approximately 82%), and vascular disease (approximately 76%) increased the risk of healing complications. CONCLUSIONS: Surgeons use similar prognostic factors to define and assess delayed unions and nonunions, but there is a lack of consensus in the definitions of delayed union and nonunion. The need for standardization and future randomized trials was strongly endorsed.

Physical activity after total joint replacement: a cross-sectional survey.

OBJECTIVE: To determine the level of physical activity participants are able to perform at a minimum of 1 year after primary total hip or knee replacement. DESIGN: Cross-sectional survey. SETTING: A tertiary care arthroplasty center. PARTICIPANTS: A total of 170 primary total hip and 184 primary total knee arthroplasty patients. INTERVENTIONS: The University of California Los Angeles (UCLA) activity score was mailed to 242 primary hip and 225 primary knee arthroplasty patients. Patients were abstracted from a prospectively tabulated arthroplasty database and pre-selected for good/excellent clinical outcomes as determined by 1 year postoperative Knee Society (KSS) and Harris Hip (HHS) scores. Clinical outcomes including the Oxford Hip/Knee score were collected preoperatively, and at 6 and 12 months postoperatively. Correlations between UCLA scores, demographics, and clinical outcomes were calculated using Pearson's correlation. MAIN OUTCOME MEASUREMENTS: Harris Hip Score, Oxford Hip Score, Knee Society Score, Oxford Knee Score, and UCLA Activity Scale. RESULTS: : Postal survey response rates for hips were 70.2% (170 of 242) and 81.8% for knees (184 of 225). Mean results at postoperative year 1 include: HHS (94.8), Oxford Hip Score (16.6), KSS clinical score (95.9), KSS function score (95.0), and Oxford Knee score (18.2). For both primary total hip arthroplasty and total knee arthroplasty patients, median UCLA score was 6, indicating moderate activity levels at a mean follow-up of 40.7 months for hips and 36.6 months for knees. CONCLUSIONS: UCLA scores indicate the average total joint replacement patient maintains a moderate activity level, and many perform active/very active levels of activity.

Administering stuttering modification therapy in school settings.

Stuttering modification techniques can be used effectively in the school setting. In fact, speech-language pathologists can use this environment to their advantage to address not only disfluency but also the emotional and behavioral aspects of stuttering. Toward this end, stuttering modification goals and techniques are outlined, with a discussion of how to adapt them to school environments. Specific topics include writing clear, measurable IEP goals, taking advantage of the school setting to implement these goals, administering stuttering modification within a group therapy mode, involving parents and teachers, and monitoring progress.