Patient-Reported Outcomes following Single- and Multiple-Radius Total Knee Replacement: A Randomized, Controlled Trial

Although single-radius (SR) designs of total knee replacement (TKR) have theoretical benefits, the clinical advantage conferred by such designs is unknown. The aim of this randomized, controlled study was to compare the short-term clinical outcomes of the two design rationales. A total of 105 knees were randomized to receive either a single radius (Scorpio, Stryker; SR Group) or multiple radius (AGC, Zimmer Biomet; MR group) TKR. Patient-reported outcomes (Oxford Knee Score [OKS] and Knee Society Score [KSS]) were collected at 6 weeks, 6 months, and 1 year following surgery. No knees were revised. There was no difference in primary outcomes: OKS was 39.5 (95% confidence interval [CI]: 36.9–42.1) in the SR group and 38.1 (95% CI: 36.0–40.3) in the MR group (p = 0.40). KSS was 168.4 (95% CI: 159.8–177.0) in the SR group; 159.5 (95% CI 150.5–168.5) in the MR group (p = 0.16). There was a small but statistically significant difference in the degree of change of the objective subscale of the KSS, favoring the SR design (p = 0.04), but this is of uncertain clinical relevance. The reported benefits of SR designs do not provide demonstrable functional advantages in the short term

The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty.

AIMS: Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. METHODS: Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system. RESULTS: Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001). CONCLUSION: The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It has been shown to be reliable, repeatable and pragmatic. The implications for patient care and health economics are discussed. Cite this article: Bone Jt Open 2021;2(8):638-645

Pathogenesis and treatment options for hemophilic synovitis

INTRODUCTION: Hemophilia is characterized by recurrent bleeding episodes, most commonly in the knees, elbows and ankles. Repeated hemarthroses lead to synovial hypertrophy and a vicious cycle of chronic synovitis arises, leading to destruction of the joint. AREAS COVERED: This article covers the pathogenesis of chronic hemophilic synovitis and its treatment by means of different types of synovectomy. EXPERT OPINION: Both radiosynovectomy (RS) and arthroscopic synovectomy considerably improve the frequency of bleeding episodes. RS is the best option for patients with synovitis unresponsive to a three-month trial of hematological prophylaxis. If the bleeding is refractory to three successive episodes of RS at six monthly intervals, arthroscopic synovectomy is indicated. Open synovectomy should be reserved for adults with elbow synovitis requiring radial head removal and synovectomy in the same surgical session. RS is effective and safe, and particularly helpful in patients with inhibitors as they are at greatest risk of bleeding episodes and have the highest risk of complications of surgery

Platelet-Rich Plasma in the Treatment of Patellar Tendinopathy: A Systematic Review

BACKGROUND: Patellar tendinopathy (PT) is a major cause of morbidity in both high-level and recreational athletes. Whilst there is good evidence for the effectiveness of eccentric exercise regimens in its treatment, a large proportion of patients have disease which is refractory to such treatments. This has led to the development of novel techniques including platelet-rich plasma (PRP) injection, which aims to stimulate a normal healing response within the abnormal patellar tendon. However, little evidence exists at present to support its use. PURPOSE:The aim of this systematic review was to determine the safety and effectiveness of PRP in the treatment of PT, and to quantify its effectiveness relative to other therapies for PT. STUDY DESIGN: Systematic review. METHODS: A systematic review was conducted in accordance with the PRISMA guidelines. A literature review was conducted of the Medline, EMBASE and Cochrane databases, as well as trial registries. Both single-arm and comparative studies were included. The outcomes of interest were pain (as measured by visual-analogue or other, comparable scoring systems), functional scores and return to sport. Study quality and risk of bias were assessed using the MINORS score (for non-randomised studies) and the Cochrane risk of bias tool. RESULTS: Eleven studies fitted the inclusion criteria. Of these, two were randomised, controlled trials (RCTs), and one was a prospective, non-randomised cohort study. The remainder were single-arm case series. All noncomparative studies demonstrated a significant improvement in pain and function following PRP injection. Complications and adverse outcomes were rare. The results of the comparative studies were inconsistent and superiority of PRP over control treatments could not be conclusively demonstrated. CONCLUSION: PRP is a safe and promising therapy in the treatment of recalcitrant PT. However, its superiority over other treatments such as physiotherapy remains unproven. Further RCTs are required to determine the relative effectiveness of the many available treatments for PT, and to determine the subgroups of patients who stand to gain the most from the use of these therapies

Revision shoulder hemiarthroplasty and total shoulder arthroplasty a systematic review and meta-analysis.

The number of shoulder replacements performed each year continues to increase, and the need for revision replacements has grown accordingly. The outcome of a revision replacement may influence which primary implant is selected and the timing of primary surgery, particularly in younger patients. The aim of this study was to establish the expected improvement in shoulder function and implant survival following revision of a hemiarthroplasty and revision of an anatomical total shoulder arthroplasty (TSA). A systematic review and meta-analysis were performed of all studies reporting shoulder scores or implant survival following revision hemiarthroplasty or revision TSA. MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports were searched. 15 studies were included, reporting on 593 revision anatomical shoulder replacements. There was large variation in the magnitude of improvement in shoulder scores following revision surgery. Over 80% of revision replacements last 5 years and over 70% last 10 years. There was no significant difference in shoulder scores or implant survival according to the type of primary implant. The belief that revision of a shoulder hemiarthroplasty may lead to improved outcomes compared to revision of a TSA is not supported by the current literature

How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic.

AIMS: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. METHODS: A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. RESULTS: A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P2, surgery within one month) patients underwent surgery, and 15% (3/20) of P3 ( three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P3 and P4 patients were expedited to 'Urgent' based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P2, 36% (70/196) of P3, and 26% (184/720) of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. CONCLUSION: Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P2 were most likely to undergo surgery, including those deemed high-risk. This model, which includes assessment of biopsychosocial factors alongside disease severity, can assist in equitably prioritizing the substantial list of patients now awaiting planned orthopaedic surgery worldwide. Cite this article: Bone Jt Open 2021;2(2):134-140

The effect of bearing surface on risk of periprosthetic joint infection in total hip arthroplasty: a systematic review and meta-analysis

AIMS: Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and it has been suggested that the choice of bearing surface may influence the risk of PJI after THA. The objective of this meta-analysis was to compare the rate of PJI between metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC) bearings. PATIENTS AND METHODS: Electronic databases (Medline, Embase, Cochrane library, Web of Science, and Cumulative Index of Nursing and Allied Health Literature) were searched for comparative randomized and observational studies that reported the incidence of PJI for different bearing surfaces. Two investigators independently reviewed studies for eligibility, evaluated risk of bias, and performed data extraction. Meta-analysis was performed using the Mantel–Haenzel method and random-effects model in accordance with methods of the Cochrane group. RESULTS: Our search strategy revealed 2272 studies, of which 17 met the inclusion criteria and were analyzed. These comprised 11 randomized controlled trials and six observational studies. The overall quality of included studies was high but the observational studies were at high risk of bias due to inadequate adjustment for confounding factors. The overall cumulative incidence of PJI across all studies was 0.78% (1514/193 378). For each bearing combination, the overall incidence was as follows: MoP 0.85% (1353/158 430); CoP 0.38% (67/17 489); and CoC 0.53% (94/17 459). The meta-analysis showed no significant difference between the three bearing combinations in terms of risk of PJI. CONCLUSION: On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. Future research, including basic science studies and large, adequately controlled registry studies, may be helpful in determining whether implant materials play a role in determining the risk of PJI following arthroplasty surgery

Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty.

INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001). CONCLUSIONS: For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world

Pseudotumors in association with well-functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging.

Many papers have been published recently on the subject of pseudotumors surrounding metal-on-metal hip resurfacing and replacement prostheses. These pseudotumors are sterile, inflammatory lesions within the periprosthetic tissues and have been variously termed masses, cysts, bursae, collections, or aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL). The prevalence of pseudotumors in patients with a well-functioning metal-on-metal hip prosthesis is not well known. The purpose of this study was to quantify the prevalence of pseudotumors adjacent to well-functioning and painful metal-on-metal hip prostheses, to characterize these lesions with use of magnetic resonance imaging, and to assess the relationship between their presence and acetabular cup position with use of three-dimensional computed tomography