ARthroscopy in Knee OsteoArthritis (ARK-OA): a multicentre study assessing compliance to national guidelines.

INTRODUCTION: The use of arthroscopy to alleviate the symptoms of osteoarthritis has been questioned by recent high quality evidence. This has led to the development of guidelines by specialist and national bodies advocating against its use. AIMS: To examine the trends of the rates of arthroscopy in patients with knee osteoarthritis over the past five years and determining compliance with guidelines. METHODS: Multi-centre, retrospective audit in five hospital trusts in the United Kingdom. The number of arthroscopies performed by month from 2013 to 2017 was identified through hospital coding. Fifty randomly selected records from the year 2017 were further analysed to assess compliance with NICE guidelines. RESULTS: Between 2013 and 2017, the number of arthroscopies performed annually in five trusts dropped from 2028 to 1099. In the year 2017, 17.7% of patients with no mechanical symptoms and moderate-to-severe arthritis pre-operatively had arthroscopy. CONCLUSION: Knee arthroscopy continues to be used as a treatment for osteoarthritis, against national guidelines. Whilst overall numbers are declining, further interventions, including implementation of high-quality conservative care is required to further eliminate unnecessary procedures.

A comparison of electronic and manual dynamometry and goniometry in patients with fracture of the distal radius and healthy participants.

UNLABELLED: The purpose of this study was to assess the intra-rater and inter-rater reliability of electronic and manual dynamometry and goniometry in healthy volunteers, and the inter-instrument reliability in the assessment of healthy volunteers and patients recovering after a fracture of the distal radius. Grip strength, grip fatigue, pinch strength and range of motion were assessed in all participants with both the manual and electronic instruments by two physiotherapists and orthopaedic specialist trainee. The measures of dynamometry demonstrated excellent reliability (intra-class correlation coefficient >0.90), with the instruments found to be interchangeable with the exception of the grip fatigue. Variable intra-rater and inter-rater reliability was demonstrated with all planes of movement for the goniometry measures regardless of the instrument used. The results of this study support the continued use of dynamometry in the clinical setting, but raise questions regarding the use of goniometry measurements. LEVEL OF EVIDENCE: Diagnostic level III.

Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study.

BACKGROUND: Knee arthroscopy has historically been a common treatment for knee osteoarthritis. However, multiple Randomised Controlled Trials along with a Cochrane review has led NICE to recommend that arthroscopy is not used in the vast majority of patients that have knee osteoarthritis. These recommendations have been replicated internationally. The use of arthroscopy for knee osteoarthritis has decreased; however, it is still prevalent. This study examines the factors that are perceived to influence decision-making using a theoretical framework that was developed for behaviour change research (Theoretical Domains Framework). This study will allow future work to develop and evaluate an intervention specifically targeted to the barriers identified. METHODS: A multimodal approach was used including questionnaire research and semi-structured interviews with all grades of physician offering a knee arthroscopy service in a Level One Trauma Centre in the West Midlands, U.K. Focus groups with patients were also conducted. Mixed methods analysis was used, with descriptive statistics for quantitative data, and thematic content analysis for qualitative data. RESULTS: A total of 26 surgeons responded to questionnaires, with 6 semi-structured interviews taking place. All surgical grades were represented. Two focus groups of six patients were performed. The results identified 13 beliefs across 12 domains (some beliefs were represented across domains). The beliefs that there was a pressure from patients to do something, that there were limited other options available, that surgeons wanted to meet patients expectations, and that there was a time pressure in clinic appeared to be the predominant barriers. CONCLUSIONS: Using the Theoretical Domains Framework, this paper has described the relevant barriers and enablers to the implementation of NICE guidance regarding arthroscopy use in patients with knee osteoarthritis. The next step in this process is the development of a targeted intervention, and we discuss the barriers that are most likely to alter practice if targeted through an intervention, and how such an intervention could look. Such an intervention would require evaluation within the clinical setting.

Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

Aims: The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods: Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results: Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion: For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

A systematic review of patient-reported outcome measures used to assess Achilles tendon rupture management: what's being used and should we be using it?

BACKGROUND: Currently, there is no consensus regarding the optimal management for patients following an Achilles tendon rupture. To allow comparisons between different treatments, a universally accepted outcome measure is required. However, there are currently a range of these reported within the literature. OBJECTIVE: To recommend the most suitable patient-reported outcome measure for the assessment of patients following an Achilles tendon rupture, based on a systematic review of first what is currently used and second evidence of validity. METHODS: The electronic databases MEDLINE, EMBASE and AMED were searched up to September 2010. Predefined inclusion and exclusion criteria were applied to identify what outcome measures are reported in the literature. Aspects of validity were defined and a checklist used to determine which aspects have been evaluated. RESULTS: Twenty-one outcome measures in 50 research papers were identified. The most commonly used was the American Orthopaedic Foot and Ankle Society hind-foot score. Of the 21 outcome measures, only 4 cited independent validation data. Of these four, only the 'Achilles tendon Total Rupture Score' reported evidence to support multiple facets of validity, as defined by a predetermined criteria checklist. CONCLUSIONS: The Achilles tendon Total Rupture Score was identified as the only outcome measure which has demonstrated multiple facets of validity for use in this patient group. However, even this tool has limitations. Researchers should be aware of the limitations of the available outcome measurement tools and check on their validity before use in clinical research.

A national macroinvertebrate dataset collected for the biomonitoring of Ireland's river network, 2007-2018.

The Environmental Protection Agency (EPA) in Ireland is responsible for the ecological monitoring and assessment of 37 hydrometric areas covering 46 river catchments and over 13,000 km of river channel nationwide. The national river monitoring program commenced in 1971 and has developed further since 2007 into the National Rivers Water Framework Directive (WFD) Monitoring Program following the implementation of the WFD across the European Union. The monitoring program is designed to obtain sufficiently representative information to assess ecological quality for each water body assessed. Consequently, macroinvertebrate data have been collected at over 2,900 river survey stations on a minimum 3-year cycle to fulfil these requirements. While the EPA has collected these data for water quality assessments we recognize that the data have value beyond this one purpose. We provide a summary of how these 10,987 data records, covering the years 2007 to 2018, have been collected and used to deepen understanding of water quality, biodiversity and general ecological health of Ireland's river network.

UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius.

BACKGROUND: In high-income countries, 6% of all women will have sustained a fracture of the wrist (distal radius) by the age of 80 years and 9% by the age of 90 years. Advances in orthopaedic surgery have improved the outcome for patients: many such fractures can be treated in a plaster cast alone, but others require surgical fixation to hold the bone in place while they heal. The existing evidence suggests that modern locking-plate fixation provides improved functional outcomes, but costs more than traditional wire fixation. METHODS: In this multicentre trial, we randomly assigned 461 adult patients having surgery for an acute dorsally displaced fracture of the distal radius to either percutaneous Kirschner-wire fixation or locking-plate fixation. The primary outcome measure was the Patient-Rated Wrist Evaluation© (PRWE) questionnaire at 12 months after the fracture. In this surgical trial, neither the patients nor the surgeons could be blind to the intervention. We also collected information on complications and combined costs and quality-adjusted life-years (QALYs) to assess cost-effectiveness. RESULTS: The baseline characteristics of the two groups were well balanced and over 90% of patients completed follow-up. Both groups of patients recovered wrist function by 12 months. There was no clinically relevant difference in the PRWE questionnaire score at 3 months, 6 months or 12 months [difference at 12 months: -1.3; 95% confidence interval (CI) -4.5 to 1.8; p=0.398]. There was no difference in the number of complications in each group and small differences in QALY gains (0.008; 95% CI -0.001 to 0.018); Kirschner-wire fixation represents a cost-saving intervention (-£727; 95% CI -£588 to -£865), particularly in younger patients. CONCLUSIONS: Contrary to the existing literature, and against the increasing use of locking-plate fixation, this trial shows that there is no difference between Kirschner wires and volar locking plates for patients with dorsally displaced fractures of the distal radius. A Kirschner-wire fixation is less expensive and quicker to perform. TRIAL REGISTRATION: Current Controlled Trials ISRCTN31379280. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 17. See the NIHR Journals Library website for further project information.