Diagnostic Validity of Physical Examination Maneuvers and Patient Reported History for Shoulder Pathology

Shoulder pain and disability can pose a diagnostic challenge for clinicians owing to the numerous etiologies than can exist and the potential for multiple disorders to co-exist. There are an abundance of physical examination maneuvers available to clinicians to utilize in their clinical decision making. Additionally the patient history may be an important diagnostic tool in patients with shoulder pathology. The evidence in support of most clinical tests is weak or absent and only a few studies have formally assessed the measurement properties of history findings. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers and patient reported history for shoulder pathology. We recruited consecutive shoulder patients who were referred to two tertiary orthopedic clinics. The patient first completed a questionnaire on the history of their pathology. The surgeon then took a thorough history and indicated his or her certainty about each possible diagnosis. The clinician performed the physical examination for diagnoses where uncertainty remained. We considered arthroscopy the reference standard for patients who underwent surgery and magnetic resonance imaging with arthrogram for patients who did not. We calculated the sensitivity, specificity, and likelihood ratios and investigated whether combinations of the top tests provided stronger predictions of the presence or absence of disease. Finally we assessed whether a tool could be developed from the history items that could be used for triaging patients. None of the tests were highly sensitive for rotator cuff or labral pathology. The physical examination and history agreed in 75% of cases. Of those that did not agree, the physical examination misdirected the diagnosis in 47% of our cases. In particular history items were strong predictors of anterior and posterior instability and subscapularis tears and were combined in a tool to be utilized for screening patients. In conclusion, no test in isolation is sufficient to diagnose a patient with rotator cuff disease or labral pathology. The patient reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument

Protocol for determining the diagnostic validity of physical examination maneuvers for shoulder pathology

Background: Shoulder complaints are the third most common musculoskeletal problem in the general population. There are an abundance of physical examination maneuvers for diagnosing shoulder pathology. The validity of these maneuvers has not been adequately addressed. We propose a large Phase III study to investigate the accuracy of these tests in an orthopaedic setting. Methods. We will recruit consecutive new shoulder patients who are referred to two tertiary orthopaedic clinics. We will select which physical examination tests to include using a modified Delphi process. The physician will take a thorough history from the patient and indicate their certainty about each possible diagnosis (certain the diagnosis is absent, present or requires further testing). The clinician will only perform the physical examination maneuvers for diagnoses where uncertainty remains. We will consider arthroscopy the reference standard for patients who undergo surgery within 8 months of physical examination and magnetic resonance imaging with arthrogram for patients who do not. We will calculate the sensitivity, specificity and positive and negative likelihood ratios and investigate whether combinations of the top tests provide stronger predictions of the presence or absence of disease. Discussion. There are several considerations when performing a diagnostic study to ensure that the results are applicable in a clinical setting. These include, 1) including a representative sample, 2) selecting an appropriate reference standard, 3) avoiding verification bias, 4) blinding the interpreters of the physical examination tests to the interpretation of the gold standard and, 5) blinding the interpreters of the gold standard to the interpretation of the physical examination tests. The results of this study will inform clinicians of which tests, or combination of tests, successfully reduce diagnostic uncertainty, which tests are misleading and how physical examination may affect the magnitude of the confidence the clinician feels about their diagnosis. The results of this study may reduce the number of costly and invasive imaging studies (MRI, CT or arthrography) that are requisitioned when uncertainty about diagnosis remains following history and physical exam. We also hope to reduce the variability between specialists in which maneuvers are used during physical examination and how they are used, all of which will assist in improving consistency of care between centres. © 2013 Somerville et al.; licensee BioMed Central Ltd

Functional outcomes of acutely infected knee arthroplasty: A comparison of different surgical treatment options

© 2015 8872147 Canada Inc. Background: An infected total knee arthroplasty (TKA) can be treated with irrigation and débridement with polyethylene exchange (IDPE) or a 2-staged revision (2SR). Although research has examined infection eradication rates of both treatments, patient outcomes have not been reported. We examined patient-reported outcomes following treatment compared with matched, noninfected controls. Methods: We retrospectively identified patients with infected TKAs who had undergone the index procedure between May 1991 and November 2011. Patient-reported outcomes included the 12-item Short Form Health Survey, Western Ontario and McMaster Universities Arthritis Index, and Knee Society Scores as well as range of motion. Patients with noninfected primary TKAs matched by age and age-adjusted Charlson Comorbidity Index score were used as controls. Intention-to-treat groups of 2SR and IDPE were used, with the IDPE group subdivided into successful and unsuccessful groups. Results: We included 145 patients with infected TKAs with mean follow-up of 64.2 months and 145 controls with a mean follow-up of 35.4 months in our analysis. Outcomes of the controls and the successful IDPE groups were equivalent. The 2SR cohort had lower scores in all categories than controls. There was a 39% success rate in eradicating infection with IDPE. Patients in whom IDPE failed had lower scores in all categories than controls. There was no difference between the failed IDPE group and the 2SR group. Conclusion: Controversy regarding treatment options for acutely infected TKA has been focused on infection eradication. However, functional outcomes following treatment need to be taken into consideration. Patients whose infections were successfully treated with IDPE had equivalent outcomes to controls

Quantifying physical and psychological outcomes after periprosthetic femoral fracture in older adults

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common and effective treatments for osteoarthritis. Falls risk is increased after these surgeries due to age, proprioceptive changes and leg weakness. One devastating consequence of falling after these surgeries, both functionally and psychologically, is a peri-prosthetic femoral fracture (PFF). Existing research on PFF has focused on surgical management and not the functional or psychological impacts to the person after this injury. Hypothesis/Objectives: The study objectives are: 1) To evaluate the subjective and objective functional and psychological outcomes after sustaining a PFF, and 2) to estimate the prevalence of falls since the PFF and future falls risk. Proposed Methods: Participants will be recruited through the Orthopedic Outpatient Clinic at London Health Sciences Center. A self-report questionnaire will measure subjective functional ability (e.g., walking, driving) and psychological (e.g., depression, social isolation) outcomes. Future falls risk will be measured with the Falls Risk in Older People in a Community Setting (FROP-Com) scale and fear of falling by the Activities-specific Balance Confidence (ABC) scale. Participants will perform physical performance tests: 30-Second Sit to Stand Test and Step Test for measuring lower limb strength and balance, respectively. Data will be summarized in means and standard deviations or proportions and percentages as appropriate. Future Implications: There is limited knowledge about the functional and psychological outcomes after PFF post-THA/TKA. Understanding the effects that PFF can have on older adults is critical to health providers and patients in order to set appropriate rehabilitation goals to improve quality of life

Significant cost savings and similar patient outcomes associated with early discharge following total knee arthroplasty

© 2019 Joule Inc. or its licensors. Background: A substantial portion of the cost of total knee arthroplasty (TKA) results from the postoperative inpatient length of stay (LOS). Considering the annual increase in TKAs, reducing LOS represents a potential for cost savings. We sought to compare in-hospital costs and patient-reported outcomes for an early discharge protocol compared with the standard LOS following TKA. Methods: We conducted a retrospective matched cohort study, matching patients on age, sex, body mass index and preoperative Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) score. We compared costs associated with time in the operating room, intraoperative pain control and inpatient stay as well as 1-year postoperative patient-reported outcomes between early discharge and standard LOS groups. Results: We included 50 patients in our study (25 per group). The average LOS in the early discharge group was 26.5 hours, compared with 48.9 hours in the standard care group. The early discharge group had higher intraoperative costs associated with pain control (mean difference 26.98, 95% confidence interval 14.41-37.90, p \u3c 0.01); however, this difference was offset by substantial savings associated with the reduced LOS. The mean total cost for the early discharge group was $649.62 ±$281.71 versus $1279.71 ±$515.98 for the standard care group. There were no significant differences in SF12 or WOMAC scores between groups at 1 year postoperative. Conclusion: In-hospital costs were significantly lower with a postoperative day 1 discharge protocol than with standard LOS following TKA, with no difference in patient-reported outcomes

Use of the Corail stem for revision total hip arthroplasty: Evaluation of clinical outcomes and cost

© 2019 Joule Inc. or its licensors. Background: With the growing number of total hip arthroplasty (THA) procedures performed, revision surgery is also proportionately increasing, resulting in greater health care expenditures. The purpose of this study was to assess clinical outcomes and cost when using a collared, fully hydroxyapatite-coated primary femoral stem for revision THA compared to commonly used revision femoral stems. Methods: We retrospectively identifed patients who underwent revision THA with a primary stem between 2011 and 2016 and matched them on demographic variables and reason for revision to a similar cohort who underwent revision THA. We extracted operative data and information on in-hospital resource use from the patients\u27 charts to calculate average cost per procedure. Patient-reported outcomes were recorded preoperatively and 1 year postoperatively. Results: We included 20 patients in our analysis, of whom 10 received a primary stem and 10, a typical revision stem. There were no signifcant between-group differences in mean Western Ontario and McMaster Universities Osteoarthritis Index score, Harris Hip Score, 12-Item Short Form Health Survey (SF-12) Mental Composite Scale score or Physical Composite Scale score at 1 year. Operative time was signifcantly shorter and total cost was signifcantly lower (mean difference -3707.64, 95% confdence interval -5532.85 to -1882.43) with a primary stem than with other revision femoral stems. Conclusion: We found similar clinical outcomes and signifcant institutional cost savings with a primary femoral stem in revision THA. This suggests a role for a primary femoral stem such as a collared, fully hydroxyapatite-coated stem for revision THA

Effect of the extent of release for knee balancing on post-operative limb coronal alignment after primary total knee arthroplasty

© 2020 Alzahrani et al. Introduction: Outcomes and longevity of total knee arthroplasty (TKA) depend mainly on restoring knee function, through precise bony resection and appropriate soft tissue balancing. The current literature lacks evidence regarding the degree of radiographic change after intra-operative knee balancing. The purpose of our study was to assess the degree of change in coronal lower extremity alignment by comparing pre-operative to post-operative full-length radiographs (FLR) after quantifying the degree of intra-operative knee balancing and corre-late patient-reported outcomes to the extent of balancing required. Patients and Methods: One hundred and fifty-four patients undergoing primary TKA for varus knee osteoarthritis were included in the study. The performed soft tissue releases and bony adjustments to obtain a balanced TKA intra-operatively were prospectively documen-ted and were grouped into minimal, moderate and extensive release groups. Hip-knee-ankle angle (HKA), anatomical femoral-tibial angle (FTA), condylar hip angle (CH), medial proximal tibial angle (MPTA) and condylar plateau angle (CPA) were measured on full-length radiographs both pre-operatively and post-operatively. Frequencies of the soft tissue releases and bony resections in addition to descriptive statistics of the measured angles on the radiographs were recorded. In addition, patient-reported outcome scores (PROMs) were compared between the grouped patients. Results: Of those that were included in the study, 66 knees (42.9%) required minimal release to adequately balance the knee, while 70 (45.5%) required moderate release and 18 (11.7%) required extensive release. No statistically significant differences were found in change of alignment between the groups for all the measured angles. In addition, no difference in PROMs was seen between the groups both pre-and post-operatively. Conclusion: Although we found no association between post-operative coronal alignment of a TKA and the degree of soft tissue release and bony resection, this likely represents the fact that a balanced TKA is dynamic and not dependent on change of single radiographic parameters. Patient-reported outcomes were not impacted by the extent of releases

Three femoral stem designs without corrosion: A review of 2095 stems

© 2020 Naudie et al. Introduction: Corrosion at the head–neck interface of modular components in total hip arthroplasty (THA) has been reported as a cause of failure of modern total hip replacement implants. While this method of failure has been well described, it remains poorly understood. The purpose of this study is to review the three most commonly used uncemented femoral stems at our institution over the last fifteen years and to correlate any established risk factors with rates of revision, particularly corrosion. Methods: We reviewed 2095 patients from March 2000 to September 2015 who underwent total hip arthroplasty with one of three uncemented femoral stem designs. All stems were made of a Ti6Al4V alloy with a 12/14 taper design. We included only those stems coupled with a CoCr head and a highly crosslinked polyethylene liner. We evaluated age, gender, body mass index (BMI), femoral head size, head length, neck angle and offset and correlated these to the incidence of all cause revision, as well as revision excluding infection. Results: There were no recognized corrosion-related revisions identified. There was no association between age, BMI, gender, head length, neck angle and offset to all cause revision or revision with infection excluded (p\u3e0.05). Femoral head size less than 32mm was associated with higher all cause revision rates (OR 4.60 (95% CI 1.8, 11.8)) and when excluding infection as a reason for revision (OR 4.94 (95% CI 1.7, 14.41)). Conclusion: Over the last fifteen years, we have not identified any cases of corrosion with the three most commonly used femoral stems used at out institution. While we acknowledge that no femoral stem is immune to corrosion, certain femoral stem designs may be uniquely resistant to this mode of failure. Level of Evidence: III

Protocol for determining the diagnostic validity of physical examination maneuvers for shoulder pathology

Abstract Background Shoulder complaints are the third most common musculoskeletal problem in the general population. There are an abundance of physical examination maneuvers for diagnosing shoulder pathology. The validity of these maneuvers has not been adequately addressed. We propose a large Phase III study to investigate the accuracy of these tests in an orthopaedic setting. Methods We will recruit consecutive new shoulder patients who are referred to two tertiary orthopaedic clinics. We will select which physical examination tests to include using a modified Delphi process. The physician will take a thorough history from the patient and indicate their certainty about each possible diagnosis (certain the diagnosis is absent, present or requires further testing). The clinician will only perform the physical examination maneuvers for diagnoses where uncertainty remains. We will consider arthroscopy the reference standard for patients who undergo surgery within 8 months of physical examination and magnetic resonance imaging with arthrogram for patients who do not. We will calculate the sensitivity, specificity and positive and negative likelihood ratios and investigate whether combinations of the top tests provide stronger predictions of the presence or absence of disease. Discussion There are several considerations when performing a diagnostic study to ensure that the results are applicable in a clinical setting. These include, 1) including a representative sample, 2) selecting an appropriate reference standard, 3) avoiding verification bias, 4) blinding the interpreters of the physical examination tests to the interpretation of the gold standard and, 5) blinding the interpreters of the gold standard to the interpretation of the physical examination tests. The results of this study will inform clinicians of which tests, or combination of tests, successfully reduce diagnostic uncertainty, which tests are misleading and how physical examination may affect the magnitude of the confidence the clinician feels about their diagnosis. The results of this study may reduce the number of costly and invasive imaging studies (MRI, CT or arthrography) that are requisitioned when uncertainty about diagnosis remains following history and physical exam. We also hope to reduce the variability between specialists in which maneuvers are used during physical examination and how they are used, all of which will assist in improving consistency of care between centres.</p