Preoperative symptom burden in the knee replacement population - the role of the Oxford knee score

The Oxford Knee Score (OKS) represents a validated Patient Reported Outcome Score (PROM), routinely utilised following knee replacement (TKR). Healthcare commissioners have proposed its application as a threshold criterion to define eligibility for TKR, despite an absence of supporting evidence. This thesis explores the role of preoperative OKS, using local and national PROMs data, as a measure of symptom burden and highlights potential issues as a threshold criterion tool. Examination of the preoperative OKS profile in three orthopaedic centres showed a normal distribution profile, and wide-ranging preoperative symptom burden. Some patients appeared to proceed to TKR with a seemingly minimal symptom burden, raising question about TKR selection criteria. Further analysis of national PROMs data confirmed wide variability in preoperative symptom burden prior to TKR to be common practice. Some variation existed between centres and individual surgeons, but patient level factors were a greater contributor, suggesting poor selection criteria may not be to blame. Case note analysis of a TKR cohort from a single centre identified that those with a high preoperative OKS still exhibited a significant symptom burden, remaining clinically justified for TKR. An appropriate consultation process was evident, rejecting inappropriate selection criteria as an explanation. Analysis of linked national pre- and postoperative OKS data showed that patients with highest preoperative OKS had best overall outcomes following TKR, despite minimal change in OKS. Preoperative OKS&LT;16 was associated with worse outcomes and minimal further benefit as OKS decreased. Preoperative OKS alone may not encapsulate the true clinical indications for TKR. Utilisation of OKS-based thresholds, may exclude equally eligible patients, risking greater inequity and variation in TKR practice. Restricting TKR to those with the worst preoperative OKS may compromise subsequent outcomes. Its role as an indicator of preoperative symptom burden and potential eligibility for TKR should be used with extreme caution.</p

Preoperative symptom burden in the knee replacement population - the role of the Oxford knee score

The Oxford Knee Score (OKS) represents a validated Patient Reported Outcome Score (PROM), routinely utilised following knee replacement (TKR). Healthcare commissioners have proposed its application as a threshold criterion to define eligibility for TKR, despite an absence of supporting evidence. This thesis explores the role of preoperative OKS, using local and national PROMs data, as a measure of symptom burden and highlights potential issues as a threshold criterion tool. Examination of the preoperative OKS profile in three orthopaedic centres showed a normal distribution profile, and wide-ranging preoperative symptom burden. Some patients appeared to proceed to TKR with a seemingly minimal symptom burden, raising question about TKR selection criteria. Further analysis of national PROMs data confirmed wide variability in preoperative symptom burden prior to TKR to be common practice. Some variation existed between centres and individual surgeons, but patient level factors were a greater contributor, suggesting poor selection criteria may not be to blame. Case note analysis of a TKR cohort from a single centre identified that those with a high preoperative OKS still exhibited a significant symptom burden, remaining clinically justified for TKR. An appropriate consultation process was evident, rejecting inappropriate selection criteria as an explanation. Analysis of linked national pre- and postoperative OKS data showed that patients with highest preoperative OKS had best overall outcomes following TKR, despite minimal change in OKS. Preoperative OKS&amp;LT;16 was associated with worse outcomes and minimal further benefit as OKS decreased. Preoperative OKS alone may not encapsulate the true clinical indications for TKR. Utilisation of OKS-based thresholds, may exclude equally eligible patients, risking greater inequity and variation in TKR practice. Restricting TKR to those with the worst preoperative OKS may compromise subsequent outcomes. Its role as an indicator of preoperative symptom burden and potential eligibility for TKR should be used with extreme caution.</p

Circumferential Periosteal Release to Treat Paediatric Leg Length Discrepancy: Medium Term Outcomes.

This study aims to report the medium term outcomes of circumferential periosteal release of the distal femur and distal tibia in treating paediatric leg length discrepancy (LLD). A retrospective case series was performed on all patients undergoing circumferential periosteal release of the distal femur and/or tibia between 2006 and 2019. Data collected included demographics, surgical indications, post-operative leg lengths, and complications. Leg length discrepancy was calculated as actual values and percentages of the longest limb length. Final actual and percentage discrepancies were compared to initial discrepancies using a paired -test. Patterns of discrepancy over time were analysed using linear mixed models. Eighteen patients (11 males) were identified, who underwent 25 procedures. The mean age at first surgery was 5.8 (range, 2-13). The commonest indication was congenital limb deficiency (7 patients). Five patients underwent repeat periosteal release, and one patient had three releases. The mean follow-up was 63 months [standard deviation (SD), 33.9]. Fifteen patients had sufficient data for statistical analysis.The mean actual discrepancy decreased from 2.07 cm (SD, 1.07) to 1.12 cm (SD, 1.62), and the mean relative discrepancy from 4.3% (SD, 2.8) to 1.5% (SD, 2.4). Significant mean reductions were seen in both actual discrepancies [0.61 cm (95% CI: 0.05-1.16; = 0.034)], and percentage discrepancy [2.10% (95% CI: 1.0-3.1, = <0.001]). In five patients, the operated limb overgrew the contralateral limb. Patients whose operated limb overgrew still had a reduction in LLD, with a mean residual discrepancy less than 1 cm (mean 0.7 cm, 95% CI: From -0.9 to 2.4). Circumferential periosteal release produces a significant decrease in both actual and percentage LLD. We believe this procedure is best indicated in younger patients with congenital LLD in whom the discrepancy is predicted to increase as they age. Circumferential periosteal release produces a significant decrease in LLD. This procedure can be used to manage symptoms during growth, particularly at the point where orthotic usage may become problematic, and to potentially reduce the magnitude of surgery needed at an older age. Chatterton BD, Kuiper JH, Williams DP. Circumferential Periosteal Release to Treat Paediatric Leg Length Discrepancy: Medium Term Outcomes. Strategies Trauma Limb Reconstr 2023;18(2):67-72. [Abstract copyright: Copyright © 2023; The Author(s).

Aneurysmal bone cysts: A UK wide tumor center experience

Background and ObjectivesThis multicenter retrospective series of consecutive extra-spinal aneurysmal bone cysts aims to identify risk factors for treatment failure.MethodsAneurysmal bone cysts treated within seven collaborating centers with over 12-months follow-up were eligible for inclusion. Survival analyses were performed to identify variables associated with recurrence using log-rank tests and Cox proportional hazard regression.ResultsOne hundred and fifteen (M:F 60:55) patients were included. Median age at presentation was 13 years and median follow-up was 27 months. Seventy-five patients underwent surgical curettage and 27% of these required further intervention for recurrence. Of the 30 patients who underwent biopsy with limited percutaneous curettage as initial procedure, 47% required no further treatment. Patients under 13 years (log-rank p = 0.006, HR 2.3, p = 0.011) and those treated who had limited curettage (log-rank p = 0.001, HR 2.7, p = 0.002) had a higher risk of recurrence/persistence.ConclusionsThere is a high risk of recurrence following surgical treatment for aneurysmal bone cysts and this risk is higher in young patients. However, the cyst heals in a substantial number of patients who have a limited curettage at the time of biopsy