Publications by authors named "Abtin Alvand"

40 Publications

Patient-Reported Function and Quality of Life After Revision Total Knee Arthroplasty: An Analysis of 10,727 Patients from the NHS PROMs Program.

J Arthroplasty 2021 Mar 19. Epub 2021 Mar 19.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford, UK.

Background: The aim of the study was to investigate changes in patient-reported outcome measures (PROMs) after revision total knee arthroplasty (rTKA).

Methods: A total of 10,727 patients undergoing elective rTKA were recruited from the UK National Health Service PROMs data set from 2013 to 2019. PROMs were collected at baseline and six months to assess joint function (Oxford Knee Score, OKS) and quality of life (EQ-5D). Associations with a change in the OKS (COKS) were investigated through multiple linear regression.

Results: The mean COKS was 12.4 (standard deviation 10.7) points. A total of 6776 of 10,329 (65.6%) patients demonstrated increase in the OKS above the minimal important change of 7.5 points. The median change in the EQ-5D utility was 0.227 (interquartile range 0.000 to 0.554). A total of 4917 of 9279 (53.0%) patients achieved a composite endpoint of improvement greater than the minimal important change for joint function and 'better' QoL as per the Paretian analysis. A total of 7477 of 10,727 (69.7%) patients reported satisfaction with rTKA. A total of 7947 of 10,727 (74.1%) patients felt surgery was a success. A total of 4888 of 10,632 (46.0%) patients reported one or more adverse events. A higher preoperative OKS was associated with a lower COKS (coefficient -0.63 [95% confidence interval -0.67 to -0.60]). Other factors associated with a lower COKS were postoperative complication(s), age under 60 years, longer duration of knee problems, patients who identified as disabled, problems in EQ-5D dimensions of anxiety/depression and self-care, comorbid conditions (circulatory problems, diabetes, and depression), and earlier year of procedure in the data set.

Conclusion: Two-thirds of patients experienced a meaningful improvement in joint function after rTKA. However, there was a high frequency of patient-reported complications. These findings may enable better informed discussion of the risks and benefits of discretionary rTKA.
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http://dx.doi.org/10.1016/j.arth.2021.03.037DOI Listing
March 2021

Evidence for the validity of a patient-based instrument for assessment of outcome after revision knee arthroplasty.

Bone Joint J 2021 Apr;103-B(4):627-634

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK.

Aims: To estimate the measurement properties for the Oxford Knee Score (OKS) in patients undergoing revision knee arthroplasty (responsiveness, minimal detectable change (MDC-90), minimal important change (MIC), minimal important difference (MID), internal consistency, construct validity, and interpretability).

Methods: Secondary data analysis was performed for 10,727 patients undergoing revision knee arthroplasty between 2013 to 2019 using a UK national patient-reported outcome measure (PROM) dataset. Outcome data were collected before revision and at six months postoperatively, using the OKS and EuroQol five-dimension score (EQ-5D). Measurement properties were assessed according to COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) guidelines.

Results: A total of 9,219 patients had complete outcome data. Mean preoperative OKS was 16.7 points (SD 8.1), mean postoperative OKS 29.1 (SD 11.4), and mean change in OKS + 12.5 (SD 10.7). Median preoperative EQ-5D index was 0.260 (interquartile range (IQR) 0.055 to 0.691), median postoperative EQ-5D index 0.691 (IQR 0.516 to 0.796), and median change in EQ-5D index + 0.240 (IQR 0.000 to 0.567). Internal consistency was good with Cronbach's α 0.88 (baseline) and 0.94 (post-revision). Construct validity found a high correlation of OKS total score with EQ-5D index ( = 0.76 (baseline), = 0.83 (post-revision), p < 0.001). The OKS was responsive with standardized effect size (SES) 1.54 (95% confidence interval (CI) 1.51 to 1.57), compared to SES 0.83 (0.81 to 0.86) for the EQ-5D index. The MIC for the OKS was 7.5 points (95% CI 5.5 to 8.5) based on the optimal cut-off with specificity 0.72, sensitivity 0.60, and area under the curve 0.66. The MID for the OKS was 5.2 points. The MDC-90 was 3.9 points. The OKS did not demonstrate significant floor or ceiling effects.

Conclusion: This study found that the OKS was a useful and valid instrument for assessment of outcome following revision knee arthroplasty. The OKS was responsive to change and demonstrated good measurement properties. Cite this article:  2021;103-B(4):627-634.
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http://dx.doi.org/10.1302/0301-620X.103B4.BJJ-2020-1560.R1DOI Listing
April 2021

Revision knee replacement for prosthetic joint infection: Epidemiology, clinical outcomes and health-economic considerations.

Knee 2021 Jan 23;28:417-421. Epub 2021 Jan 23.

Nuffield Orthopaedic Centre, Windmill Road, Oxford OX2 9JA, UK. Electronic address:

Prosthetic joint infection (PJI) is a devastating complication of knee replacement surgery. Recent evidence has shown that the burden of disease is increasing as more and more knee replacement procedures are performed. The current incidence of revision total knee replacement (TKR) for PJI is estimated at 7.5 cases per 1000 primary joint replacement procedures at 10 years. Revision TKR for PJI is complex surgery, and is associated to a high rate of post-operative complications. The 5-year patient mortality is comparable to some common cancer diagnoses, and more than 15% of patients require re-revision by 10 years. Patient-reported outcome measures (PROMs) including joint function may be worse following revision TKR for PJI than for aseptic indications. The complexity and extended length of the treatment pathway for PJI places a significant burden on the healthcare system, highlighting it as an area for future research to identify the most clinically and cost-effective interventions.
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http://dx.doi.org/10.1016/j.knee.2020.12.024DOI Listing
January 2021

High mortality following revision hip arthroplasty for periprosthetic femoral fracture.

Bone Joint J 2020 Dec;102-B(12):1670-1674

Division of Orthopaedics, Rheumatology and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.

Aims: To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications.

Methods: The study cohort consisted of THAs recorded in the National Joint Registry between 2003 and 2015, linked to national mortality data. First revision THAs for PFF, infection, dislocation, and aseptic loosening were identified. We used a flexible parametric model to estimate the cumulative incidence function of death at 90 days, one year, and five years following first revision THA and primary THA, in the presence of further revision as a competing risk. Analysis covariates were age, sex, and American Society of Anesthesiologists (ASA) grade.

Results: A total of 675,078 primary and 74,223 first revision THAs were included (of which 6,131 were performed for PFF). Following revision for PFF, mortality ranged from 9% at 90 days, 21% at one year, and 60% at five years in the highest risk group (males, ≥ 75 years, ASA ≥ 3) to 0.6%, 1.4%, and 5.5%, respectively, for the lowest risk group (females, < 75 years, ASA ≤ 2). Mortality was greater in all groups following first revision THA for PFF than for primary THA. Compared to mortality risk after first revision THA for infection, dislocation, or aseptic loosening, revision for PFF was associated with higher five-year mortality in all groups except males < 75 years with an ASA ≤ 2.

Conclusion: Mortality risk after revision THA for PFF is high, reaching 60% at five years in the highest risk patient group. In comparison to other common indications for revision, PFF demonstrated the highest overall risk of mortality at five years. These estimates can be used in the surgical decision-making process and when counselling patients and carers regarding surgical risk. Cite this article: 2020;102-B(12):1670-1674.
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http://dx.doi.org/10.1302/0301-620X.102B12.BJJ-2020-0367.R1DOI Listing
December 2020

30-day outcome after orthopaedic surgery in patients assessed as negative for COVID-19 at the time of surgery during the peak of the pandemic.

Bone Jt Open 2020 Aug 10;1(8):474-480. Epub 2020 Aug 10.

Nuffield Orthopaedic Centre, Oxford, UK.

Introduction: The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic.

Method: A retrospective, single centre, observational cohort study of all patients undergoing surgery between 17 March 2020 and 3May 2020 was performed. Outcomes were stratified by British Orthopaedic Association COVID-19 Patient Risk Assessment Tool. Patients who were SARS-CoV-2 positive at the time of surgery were excluded.

Results: Overall, 96 patients assessed as negative for SARS-CoV-2 at the time of surgery underwent 100 emergency or urgent orthopaedic procedures during the study period. Within 30 days of surgery 9.4% of patients (n = 9) were found to be SARS-CoV-2 positive by nasopharyngeal swab. The overall 30 day mortality rate across the whole cohort of patients during this period was 3% (n = 3). Of those testing positive for SARS-CoV-2 66% (n = 6) developed significant COVID-19 related complications and there was a 33% 30-day mortality rate (n = 3). Overall, the 30-day mortality in patients classified as BOA low or medium risk (n = 69) was 0%, whereas in those classified as high or very high risk (n = 27) it was 11.1%.

Conclusion: Orthopaedic surgery in SARS-CoV-2 negative patients who transition to positive within 30 days of surgery carries a significant risk of morbidity and mortality. In lower risk groups, the overall risk of becoming SARS-CoV-2 positive, and subsequently developing a significant postoperative related complication, was low even during the peak of the pandemic. In addition to ensuring patients are SARS-CoV-2 negative at the time of surgery it is important that the risk of acquiring SARS-CoV-2 is minimized through their recovery.Cite this article: 2020;1-8:474-480.
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http://dx.doi.org/10.1302/2633-1462.18.BJO-2020-0119.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7659684PMC
August 2020

Management of aseptic failure of the mobile-bearing Oxford unicompartmental knee arthroplasty.

Knee 2020 Dec 13;27(6):1721-1728. Epub 2020 Nov 13.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford, UK.

Background: Unicompartmental knee arthroplasty (UKA) accounts for 9.1% of primary knee arthroplasties (KAs) in the UK. However, wider uptake is limited by higher revision rates compared with total knee arthroplasties (TKA) and concerns over subsequent poor function. The aim of this study was to understand the revision strategies and clinical outcomes for aseptic, failed UKAs at a high-volume centre.

Methods: This was a retrospective, single-centre cohort study of 48 patients (31 female, 17 male) with 52 revision UKAs from 2006 to 2018. Median time to revision was 67 (range 4-180) months. Indications for revision were progression of osteoarthritis (n = 31 knees, 59.6%), unexplained pain (n = 10 knees, 19.2%), aseptic loosening (n = 6 knees, 11.5%), medial collateral ligament incompetence (n = 3 knees, 5.8%) and recurrent bearing dislocation (n = 2 knees, 3.8%). Technical details of surgery, complications and functional outcome were recorded.

Results: Failed UKAs were revised to primary TKAs (n = 29 knees, 55.8%), revision TKAs (n = 9 knees, 17.3%), bicompartmental KAs (n = 11 knees, 21.2%), or unicompartmental-to-unicompartmental KAs (n = 3 knees, 5.8%). Median follow up was 81 (range 24-164) months. Four patients (7.7%) died from unrelated causes. No re-revisions were identified. Surgical complications required re-operation in five knees (9.6%). Median Oxford Knee Score at latest follow up was 38 (range 9-48) points and median EQ5D3L index 0.707 (range -0.247 to 1.000).

Conclusions: Aseptic, revision UKA at a high-volume centre had good clinical outcomes. Bicompartmental KA demonstrated excellent function and should be considered an alternative to TKA for progression of osteoarthritis for appropriately trained surgeons.
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http://dx.doi.org/10.1016/j.knee.2020.10.003DOI Listing
December 2020

Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties.

J Arthroplasty 2021 02 19;36(2):664-669. Epub 2020 Aug 19.

Royal National Orthopaedic Hospital, London, United Kingdom.

Background: Multiply revised total knee arthroplasties (TKAs) may present with large anterior soft tissue defects, which can be challenging to reconstruct. In the rare cases where local flaps are insufficient, we use free latissimus dorsi (LD) myocutaneous flaps to achieve soft tissue coverage. This study looked to determine implant survivorship, infection status, and patient-reported outcomes of patients undergoing simultaneous revision TKA and LD flaps in a tertiary unit.

Methods: This was a retrospective study of 18 consecutive patients who had revision TKA and free LD flap reconstruction. Twelve were male and the median age was 65 years (range, 35-83). Patients had undergone a median of 4 previous arthroplasty procedures (range, 3-6). Median follow-up was 49 months (range, 18 to 110). The primary outcome was revision-free implant survival. Secondary outcomes included soft tissue integrity, Oxford Knee Score, and EuroQol 5-domain score at latest follow-up.

Results: At latest follow-up, 14 of 18 patients had maintained their implant. Seven patients were infection-free, 7 were on suppressive antibiotics with the implant in situ, and 4 had undergone above-knee amputation. Five-year implant survival was 75% (95% confidence interval, 46-90). At median follow-up (49 months), mean Oxford Knee Score was 13.4 (range, 2-35) and mean EuroQol 5-domain index was 0.071 (range:-0.427 to 0.747).

Conclusion: LD free flap is a viable option for limb salvage in patients with large anterior soft tissue defects following multiple revisions of TKA. However, functional outcomes can be poor and there is a significant risk of ongoing infection and amputation in this complex patient cohort.
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http://dx.doi.org/10.1016/j.arth.2020.08.030DOI Listing
February 2021

Debridement, antibiotics and implant retention (DAIR) for the management of knee prosthetic joint infection.

Knee 2020 Dec 17;27(6):2013-2015. Epub 2020 Sep 17.

Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom. Electronic address:

Background: While two-stage revision arthroplasty is viewed as the gold standard for the treatment of knee periprosthetic joint infection (PJI) in terms of infection eradication, it is associated with significant cost along with patient morbidity and mortality. Debridement, antibiotics, and implant retention (DAIR) is an attractive option as it has demonstrated better patient outcomes, comparable implant longevity to primary arthroplasty, and significantly reduced cost when successful. Given the heterogeneity of what is defined as a DAIR the literature is highly variable in terms of its efficacy from the perspective of infection eradication.

Methods: In the setting of a previously well-functioning, well-fixed arthroplasty with an acceptable soft tissue envelope and a treatable organism we report our methods for proceeding with a DAIR procedure, both unicompartmental and total knee.

Results: With the above methods we have demonstrated improved patient outcomes when compared to one- or two-stage arthroplasty with lower patient morbidity. Implant longevity in the setting of a successful DAIR is equivalent to those of a primary arthroplasty.

Conclusions: With appropriate indications and good surgical technique as described we believe DAIR is an excellent option in the treatment of periprosthetic joint infection. We hope that with a well-defined protocol as outlined we can gain a better understanding of the efficacy of DAIR procedure with more homogeneity to the procedure to better define when they are most successful while improving patient outcomes and reducing cost.
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http://dx.doi.org/10.1016/j.knee.2020.08.011DOI Listing
December 2020

Manipulation Under Anesthetic After Primary Knee Arthroplasty Is Associated With a Higher Rate of Subsequent Revision Surgery.

J Arthroplasty 2020 09 11;35(9):2640-2645.e2. Epub 2020 Apr 11.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Biomedical Research Unit, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford, UK.

Aim: To determine the association between manipulation under anesthetic (MUA) after primary knee arthroplasty and subsequent revision surgery.

Methods: Patients undergoing primary knee arthroplasty from April 2011 to April 2016 with minimum 1-year follow-up to April 2017 were identified from the national hospital episode statistics for England. The first arthroplasty per patient, per side, was included; cases with a record of subsequent infection or periprosthetic fracture were excluded. Patients undergoing MUA within 1 year to the same knee were identified, defining the populations for the MUA and non-MUA cohorts. Mortality-adjusted Kaplan-Meier survival analysis (revision arthroplasty) was performed to a maximum of 6 years. A Cox proportional hazards model was used to determine the hazard for revision, adjusting for type of primary arthroplasty, gender, age group, year, comorbidity index, obesity, regional deprivation, rurality, and ethnicity.

Results: A total of 309,650 primary arthroplasty cases (309,650 patients) were included. MUA within 1 year was recorded in 6882 patients (2.22%; 95% confidence interval [95% CI], 2.17-2.28) defining the MUA cohort; all others were included in the parallel non-MUA cohort. At 6 years, the mortality-adjusted estimated implant survival rate in the MUA cohort was 91.2% (95% CI, 90.0-92.2) in comparison to 98.1% (95% CI, 98.0-98.2) in the non-MUA cohort. In the fully adjusted model, this corresponded to an adjusted hazard for revision of 5.03 (hazard ratio; 95% CI, 4.55-5.57).

Conclusion: Patients who underwent MUA within 1 year of primary arthroplasty were at a 5-fold increased risk of subsequent revision even after excluding cases of infection or fracture. Further investigation of the etiology of stiffness after primary knee arthroplasty and the optimal treatment options to improve outcomes is justified.
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http://dx.doi.org/10.1016/j.arth.2020.04.015DOI Listing
September 2020

Paediatric and adolescent anterior cruciate ligament reconstruction surgery.

Bone Joint J 2020 Feb;102-B(2):239-245

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; NIHR Biomedical Research Unit, Botnar Research Centre, Oxford, UK.

Aims: Anterior cruciate ligament (ACL) surgery in children and the adolescent population has increased steadily over recent years. We used a national database to look at trends in ACL reconstruction and rates of serious complications, growth disturbance, and revision surgery, over 20 years.

Methods: All hospital episodes for patients undergoing ACL reconstruction, under the age of 20 years, between 1 April 1997 and 31 March 2017, were extracted by procedure code from the national Hospital Episode Statistics (HES). Population standardized rates of intervention were determined by age group and year of treatment. Subsequent rates of serious complications including reoperation for infection, growth disturbance (osteotomy, epiphysiodesis), revision reconstruction, and/or contralateral ACL reconstruction rates were determined.

Results: Over the 20 year period, 16,125 ACL reconstructions were included. The mean age of patients was 16.9 years (SD 2.0; 27.1% female, n = 4,374/16,125). The majority of procedures were observed in the 15 to 19 years age group. The rate of ACL reconstruction increased 29-fold from 1997 to 1998, to 2016 to 2017. Within 90 days of ACL reconstruction, the rate of reoperation for infection was 0.31% (95% confidence interval (CI) 0.23 to 0.41, n = 50/16,125) and the rate of pulmonary embolism was 0.037% (95%.CI 0.014 to 0.081, n = 6/16,125). Of those with minimum five-year follow-up following ACL reconstruction (n = 7,585), 1.00% of patients subsequently underwent an osteotomy (95% CI 0.79 to 1.25, n = 76/7,585), 0.09% an epiphysiodesis (95% CI 0.04 to 0.19, n = 7/7,585), 7.46% revision ACL reconstruction (95% CI 6.88 to 8.08, n = 566/7,585), and 6.37% contralateral ACL reconstruction (95% CI 5.83 to 6.94, n = 483/7,585).

Conclusion: Rates of paediatric and adolescent ACL reconstruction have increased 29-fold over the last 20 years. Despite the increasing rate in the younger population, the risk of serious complications, including further surgery for growth disturbance is very low. The results of our study provide a point of reference for shared decision making in the management of ACL injury in the paediatric and adolescent population. Cite this article: 2020;102-B(2):239-245.
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http://dx.doi.org/10.1302/0301-620X.102B2.BJJ-2019-0420.R2DOI Listing
February 2020

Mortality and adverse joint outcomes following septic arthritis of the native knee: a longitudinal cohort study of patients receiving arthroscopic washout.

Lancet Infect Dis 2020 03 17;20(3):341-349. Epub 2019 Dec 17.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford, UK.

Background: The short-term and long-term consequences of septic arthritis are uncertain. We aimed to determine risk of mortality and adverse joint outcomes following septic arthritis of the native knee.

Methods: We did a retrospective cohort study in patients who received arthroscopic knee washout for septic arthritis in England between April 1, 1997, and March 31, 2017, using data in the national Hospital Episode Statistics database. Patients with previous knee surgery to the same knee were excluded. Mortality within 90 days, adverse joint outcomes (arthrodesis, amputation, arthroplasty) within 1 year, and arthroplasty within 15 years were determined. Mortality in patients with a primary admitting diagnosis of septic arthritis (ICD-10) was compared with that in patients in whom septic arthritis was a secondary diagnosis.

Findings: 12 132 patients were included (mean age 56·6 years [SD 24·9]) of whom 4307 (36%) were female. In 10 195 (84%) patients with septic arthritis as the primary admitting diagnosis, 90-day mortality was 7·05% (95% CI 6·56-7·57; 719 patients), rising to 22·69% (20·80-24·68; 418 patients) in 1842 patients older than 79 years. Secondary septic arthritis diagnosis versus primary diagnosis was associated with an adjusted odds ratio for mortality of 2·10 (95% CI 1·79-2·46; p<0·0001). In 11 393 patients with at least 1 year follow-up, the 1 year rates were 0·13% (95% CI 0·07-0·22; 15 patients) for arthrodesis, 0·40% (0·30-0·54; 46 patients) for amputation, and 1·33%; (1·13-1·56; 152 patients) for arthroplasty. Within 15 years, 159 (8·76%; 95% CI 7·50-10·15) of 1816 patients had received arthroplasty, corresponding to an annual risk of arthroplasty that was about six times that of the general population (risk ratio 6·14, 95% CI 4·95-7·62; p<0·0001).

Interpretation: The consequences of septic knee arthritis in patients undergoing arthroscopic knee washout are serious. These findings highlight the potentially devastating outcomes associated with sepsis from musculoskeletal joint infection.

Funding: National Institute for Health Research.
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http://dx.doi.org/10.1016/S1473-3099(19)30419-0DOI Listing
March 2020

Partial or total knee replacement? Identifying patients' information needs on knee replacement surgery: a qualitative study to inform a decision aid.

Qual Life Res 2020 Apr 17;29(4):999-1011. Epub 2019 Dec 17.

Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK.

Purpose: For patients with end-stage knee osteoarthritis, joint replacement is a widely used and successful operation to help improve quality-of-life when non-operative measures have failed. For a significant proportion of patients there is a choice between a partial or total knee replacement. Decision aids can help people weigh up the need for and benefits of treatment against possible risks and side-effects. This study explored patients' experiences of deciding to undergo knee replacement surgery to identify information priorities, to inform a knee replacement decision aid.

Methods: Four focus groups were held with 31 patients who were candidates for both partial and total knee replacement surgery. Two focus groups included patients with no prior knee replacement surgery (pre-surgery); two with patients with one knee already replaced and who were candidates for a second surgery on their other knee (post-surgery). Data were analysed using Framework Analysis.

Results: Participants described a process of arriving at 'readiness for surgery' a turning point where the need for treatment outweighed their concerns. Referral and personal factors influenced their decision-making and expectations of surgery in the hope to return to a former self. Those with previous knee surgery offered insights into whether their expectations were met. 'Information for decisions' details the practicality and the optimal timing for the delivery of a knee replacement decision aid. In particular, participants would have valued hearing about the experiences of other patients and seeing detailed pictures of both surgical options. Information priorities were identified to include in a decision aid for knee replacement surgery.

Conclusions: Patients' experiences of surgical decision-making have much in common with the Necessity-Concerns Framework. Whilst originally developed to understand drug treatment decisions and adherence, it provides a useful lens to understand decision-making about surgery. The use of a decision aid could enhance decision-making on knee replacement surgery. Ultimately, patients' understanding of the risks and benefits of both surgical options could be improved and in turn, help informed decision-making. The knee replacement decision aid is perceived as a useful tool to be associated with other detailed information resources as recommended.
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http://dx.doi.org/10.1007/s11136-019-02381-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142054PMC
April 2020

The Leukocyte Esterase Test for Periprosthetic Joint Infection Is Not Affected by Prior Antibiotic Administration.

J Bone Joint Surg Am 2019 Apr;101(8):739-744

The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: It has been demonstrated that administration of antibiotics prior to performing diagnostic testing for periprosthetic joint infection can interfere with the accuracy of the standard diagnostic tests. Therefore, the purpose of this study was to evaluate the effects of antibiotic administration prior to performing the synovial leukocyte esterase strip test for periprosthetic joint infection.

Methods: We identified 121 patients who underwent revision hip or knee arthroplasty for a Musculoskeletal Infection Society (MSIS)-confirmed periprosthetic joint infection. All patients also had a leukocyte esterase strip test performed. Patients in one group (32%) took antibiotics prior to the diagnostic workup, whereas patients in another group (68%) did not receive antibiotics within 2 weeks of the diagnostic workup. The leukocyte esterase strip test, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), synovial white blood-cell (WBC) count, and polymorphonuclear neutrophil (PMN) percentage were collected and were compared between the 2 groups.

Results: The median serum ESR (85 compared with 67 mm/hr for patients who did not and did receive antibiotics; p = 0.009), CRP (16.5 compared with 12.9 mg/L; p = 0.032), synovial WBC count (45,675 compared with 9,650 cells/µL; p < 0.0001), and PMN percentage (93% compared with 88%; p = 0.004) were all significantly lower for patients receiving antibiotics. Furthermore, the administration of antibiotics resulted in a significant decrease in the sensitivity of all tests, except leukocyte esterase: ESR (79.5% in the antibiotics cohort compared with 92.7% in the no-antibiotics cohort [relative risk (RR) for false-negative results, 2.8; p = 0.04]), CRP (64.2% compared with 81.8% [RR, 1.9; p = 0.03]), WBC count (69.3% compared with 93.4% [RR, 5.0; p = 0.001]), PMN percentage (74.4% compared with 91.5% [RR, 3.0; p = 0.01]), and leukocyte esterase (78% compared with 83% [RR, 1.6; p = 0.17]). The rate of negative cultures was higher in the antibiotics group at 30.7% compared with the no-antibiotics group at 12.1% (p = 0.015).

Conclusions: This current study and previous studies have demonstrated that the administration of premature antibiotics can compromise the results of standard diagnostic tests for periprosthetic joint infection, causing significant increases in false-negative results. However, in this study, the leukocyte esterase strip test maintained its performance even in the setting of antibiotic administration. Antibiotic administration prior to diagnostic workups for periprosthetic joint infection stands to interfere with diagnosis. The leukocyte esterase strip test can be used as a reliable diagnostic marker for diagnosing periprosthetic joint infection even when prior antibiotics are administered.

Level Of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00615DOI Listing
April 2019

Objectively Assessing Intraoperative Arthroscopic Skills Performance and the Transfer of Simulation Training in Knee Arthroscopy: A Randomized Controlled Trial.

Arthroscopy 2019 04 14;35(4):1197-1209.e1. Epub 2019 Mar 14.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England.

Purpose: To objectively investigate the transfer validity of simulation training using wireless elbow-worn motion sensors intraoperatively to assess whether surgical simulation leads to improvements in intraoperative arthroscopic performance.

Methods: In this randomized controlled trial, postgraduate year 2 to 3 trainees in nationally approved orthopaedic surgery posts were randomized to standard junior residency training (control group) or standard training plus additional weekly simulation training (intervention group). Both groups performed a supervised real-life diagnostic knee arthroscopy in the operating room at 13 weeks. Performance was measured using wireless elbow-worn motion sensors recording objective surgical performance metrics: number of hand movements, smoothness, and time taken. A participant-supervisor performance ratio was used to adjust for variation in case mix and difficulty. The study took place in a surgical simulation suite and the orthopaedic operating rooms of a university teaching hospital.

Results: The intervention group objectively outperformed the control group in all outcome metrics. Procedures performed by the intervention group required fewer hand movements (544 [interquartile range (IQR), 465-593] vs 893 [IQR, 747-1,242]; P < .001), had smoother movements (25,842 ms [IQR, 20,867-27,468 ms] vs 36,846 ms [IQR, 29,840-53,949 ms]; P < .001), and took less time (320 seconds [IQR, 294-392 seconds] vs 573 seconds [IQR, 477-860 seconds]; P < .001) than those performed by the control group. The cases were comparable between the groups. Standardized to the supervisor's performance, the intervention group required fewer hand movements (1.9 [IQR, 1.5-2.1] vs 3.3 [IQR, 2.2-4.8]; P = .0091), required less time (1.2 [IQR, 1.1-1.7] vs 2.6 [IQR, 1.6-3.0]; P = .0037), and were smoother (2.1 [IQR, 1.8-2.8] vs 4.3 [IQR, 2.8-5.4]; P = .0037) than the control group, but they did not perform as well as their supervisors.

Conclusions: This study uses intraoperative motion-analysis technology to objectively show that surgical simulation training improves actual intraoperative technical skills performance.

Clinical Relevance: The described wireless objective assessment method complements the subjective observational performance assessments commonly used. Further studies are required to assess how these measures of intraoperative performance correlate to patient outcomes. Intraoperative motion analysis is translatable across surgical specialties, offering potential for objective assessment of progression through competency-based training, revalidation, and talent selection for specialist training.
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http://dx.doi.org/10.1016/j.arthro.2018.11.035DOI Listing
April 2019

Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis.

BMJ 2019 Feb 21;364:l352. Epub 2019 Feb 21.

University of Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, BOTNAR Research Centre, Headington, Oxford OX3 7LD, UK.

Objective: To present a clear and comprehensive summary of the published data on unicompartmental knee replacement (UKA) or total knee replacement (TKA), comparing domains of outcome that have been shown to be important to patients and clinicians to allow informed decision making.

Design: Systematic review using data from randomised controlled trials, nationwide databases or joint registries, and large cohort studies.

Data Sources: Medline, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Clinical Trials.gov, searched between 1 January 1997 and 31 December 2018.

Eligibility Criteria For Selecting Studies: Studies published in the past 20 years, comparing outcomes of primary UKA with TKA in adult patients. Studies were excluded if they involved fewer than 50 participants, or if translation into English was not available.

Results: 60 eligible studies were separated into three methodological groups: seven publications from six randomised controlled trials, 17 national joint registries and national database studies, and 36 cohort studies. Results for each domain of outcome varied depending on the level of data, and findings were not always significant. Analysis of the three groups of studies showed significantly shorter hospital stays after UKA than after TKA (-1.20 days (95% confidence interval -1.67 to -0.73), -1.43 (-1.53 to -1.33), and -1.73 (-2.30 to -1.16), respectively). There was no significant difference in pain, based on patient reported outcome measures (PROMs), but significantly better functional PROM scores for UKA than for TKA in both non-trial groups (mean difference -0.58 (-0.88 to -0.27) and -0.32 (-0.48 to -0.15), respectively). Regarding major complications, trials and cohort studies had non-significant results, but mortality after TKA was significantly higher in registry and large database studies (risk ratio 0.27 (0.16 to 0.45)), as were venous thromboembolic events (0.39 (0.27 to 0.57)) and major cardiac events (0.22 (0.06 to 0.86)). Early reoperation for any reason was higher after TKA than after UKA, but revision rates at five years remained higher for UKA in all three study groups (risk ratio 5.95 (1.29 to 27.59), 2.50 (1.77 to 3.54), and 3.13 (1.89 to 5.17), respectively).

Conclusions: TKA and UKA are both viable options for the treatment of isolated unicompartmental osteoarthritis. By directly comparing the two treatments, this study demonstrates better results for UKA in several outcome domains. However, the risk of revision surgery was lower for TKA. This information should be available to patients as part of the shared decision making process in choosing treatment options.

Systematic Review Registration: PROSPERO number CRD42018089972.
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http://dx.doi.org/10.1136/bmj.l352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383371PMC
February 2019

Oral versus Intravenous Antibiotics for Bone and Joint Infection.

N Engl J Med 2019 01;380(5):425-436

From Oxford University Hospitals NHS Foundation Trust (H.-K.L., M.A.M., B.L.A., P.C.M., A.J.B., J.L., R.G., M.R., A.T., B.A., I.B., A.R.B., E.K., T.W., T.H.N.W., L.K.B., A.A., P.B., M.S.) and the Nuffield Departments of Orthopaedics, Rheumatology and Musculoskeletal Science (I.R., R.Z., C.C., A.A.) and Medicine (M.K., C.S., P.C.M., A.J.B., B.A., G.E.T., P.B., M.S.) and the Division of Medical Sciences (B.A.L.), University of Oxford, Oxford, the Division of Infectious Diseases, Imperial College London (H.-K.L., G.C.), Medical Research Council Clinical Trials Unit, University College London (A.S.W.), Royal Free London NHS Foundation Trust (S.W., D.J.F.M., S.H.), Guy's and St. Thomas' NHS Foundation Trust (C.J.H., K.B.), and Public Health England (J.P.), London, University Hospital of Wales, Cardiff (H.C.H.), University Hospital Birmingham NHS Foundation Trust (D.B.) and Heart of England NHS Foundation Trust (N.J., C.E.M., A.F.W., S.S.), Birmingham, Royal National Orthopaedic Hospital NHS Trust, Stanmore (S.W., F.E.F., D.J.F.M.), Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool (J.F., H.E.R.), Cambridge University Hospitals NHS Foundation Trust, Cambridge (E.M., J.M.), Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde (R.A.S., C.V.), and Health Economics and Health Technology Assessment, University of Glasgow (C.G., N.M., A.H.B.), Glasgow, Leeds Teaching Hospital NHS Trust, University of Leeds, Leeds (J.A.T.S.), Ninewells Hospital, NHS Tayside, Dundee (I.A.), Northumbria Healthcare NHS Foundation Trust, Northumberland (S.C.E., D.J.B.), Western General Hospital, NHS Lothian, Edinburgh (R.K.S.), and Hull and East Yorkshire Hospitals NHS Trust, Hull (G.B.) - all in the United Kingdom; University of Bern, Bern, Switzerland (P.S.); Oxford University Clinical Research Unit, Wellcome Trust, Ho Chi Minh City, Vietnam (G.E.T.); and Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya (P.B.). C.F.O. and J.B. are patient representatives and do not have an institutional affiliation.

Background: The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.

Methods: We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.

Results: Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of -1.4 percentage points (90% confidence interval [CI], -4.9 to 2.2; 95% CI, -5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).

Conclusions: Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927 .).
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http://dx.doi.org/10.1056/NEJMoa1710926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522347PMC
January 2019

The 'low-volume acetabulum': dysplasia in disguise.

J Hip Preserv Surg 2018 Dec 16;5(4):399-403. Epub 2018 Oct 16.

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, 125 S 9th St. Ste 1000, Philadelphia, PA, USA.

Although there are well described radiological criteria for diagnosing DDH, our experience has highlighted that a new sub-category of hips exists in which the classic radiographic characteristics for DDH may be normal but the coverage of the femoral head is compromised. The purpose of this study was to validate a simple radiographic measurement method for calculating the depth of the acetabulum in order to detect individuals with 'low-volume' acetabuli and under-covered femoral heads. We identified 24 patients who were suspected of having low-volume acetabuli and compared their radiographs with those of 150 patients with non-dysplastic hips. The radiographic indices measured included the lateral center-edge (CE) angle, the anterior CE angle, the femoral neck-shaft angle, the extrusion index, integrity of the Shenton's line, the crossover sign, and ischial spine sign. We have developed a novel, but a simple method, named the 'coverage index' (CI) to identify the presence of a low-volume acetabulum on plain radiographs. Comparisons were made between the low-volume hips and the non-dysplastic hips. The radiographic parameters indicative of developmental dysplasia of the hip (DDH) were within normal limits in all patients with low-volume acetabuli and therefore these hips could not be classified as 'dysplastic' based on the traditional radiological parameters. There was no difference between the mean radius of the femoral head in two groups. The mean CI was significantly greater in the non-dysplastic group compared with the low-volume acetabula cohort (1.62 ± 0.117 in non-dysplastic group versus 1.07 ± 0.11 in low-volume hips) ( = 0.0001). Orthopaedic surgeons should be aware of a hip abnormality in which the femoral head coverage is deficient, yet all the conventional parameters for measuring coverage, including the center edge angle, are within normal limits. We have introduced a simple radiographic measurement method that may help surgeons identify these patients using the anteroposterior radiographs of the hip.
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http://dx.doi.org/10.1093/jhps/hny036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328753PMC
December 2018

Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding.

Haemophilia 2019 Jan 3;25(1):21-32. Epub 2018 Dec 3.

Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK.

Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.
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http://dx.doi.org/10.1111/hae.13647DOI Listing
January 2019

Knee replacement.

Lancet 2018 11;392(10158):1672-1682

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Oxford, UK.

Knee replacement surgery is one of the most commonly done and cost-effective musculoskeletal surgical procedures. The numbers of cases done continue to grow worldwide, with substantial variation in utilisation rates across regions and countries. The main indication for surgery remains painful knee osteoarthritis with reduced function and quality of life. The threshold for intervention is not well defined, and is influenced by many factors including patient and surgeon preference. Most patients have a very good clinical outcome after knee replacement, but multiple studies have reported that 20% or more of patients do not. So despite excellent long-term survivorship, more work is required to enhance this procedure and development is rightly focused on increasing the proportion of patients who have successful pain relief after surgery. Changing implant design has historically been a target for improving outcome, but there is greater recognition that improvements can be achieved by better implantation methods, avoiding complications, and improving perioperative care for patients, such as enhanced recovery programmes. New technologies are likely to advance future knee replacement care further, but their introduction must be regulated and monitored with greater rigour to ensure patient safety.
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http://dx.doi.org/10.1016/S0140-6736(18)32344-4DOI Listing
November 2018

Diagnosis of periprosthetic joint infection: the utility of next-generation sequencing.

Arthroplast Today 2018 Mar 3;4(1):20-23. Epub 2017 Nov 3.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.

A 62-year-old man who had undergone a primary knee arthroplasty 3 years earlier, presented to the emergency department with an infected prosthesis. He underwent prosthesis resection. All cultures failed to identify the infecting organism. Analysis of the intraoperative samples by next-generation sequencing revealed (an organism that resides in the oral cavity of dogs). It was later discovered that the patient had sustained a dog scratch injury several days earlier. The patient reports that his dog had licked the scratch. Treatment was delivered based on the sensitivity of , and the patient has since undergone reimplantation arthroplasty.
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http://dx.doi.org/10.1016/j.artd.2017.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859284PMC
March 2018

Diagnosis of Periprosthetic Joint Infection: The Potential of Next-Generation Sequencing.

J Bone Joint Surg Am 2018 Jan;100(2):147-154

The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Next-generation sequencing is a well-established technique for sequencing of DNA and has recently gained attention in many fields of medicine. Our aim was to evaluate the accuracy of next-generation sequencing in identifying the causative organism(s) in patients with periprosthetic joint infection.

Methods: In this prospective study, samples were collected from 65 revision arthroplasties (39 knees and 26 hips) and 17 primary arthroplasties (9 hips and 8 knees). Synovial fluid, deep tissue, and swabs were obtained at the time of the surgical procedure and were shipped to the laboratory for next-generation sequencing. Deep-tissue specimens were also sent to the institutional laboratory for culture. Sensitivity and specificity were calculated for next-generation sequencing, using the Musculoskeletal Infection Society (MSIS) definition of periprosthetic joint infection as the standard.

Results: In 28 revisions, the cases were considered to be infected; cultures were positive in 17 cases (60.7% [95% confidence interval (CI), 40.6% to 78.5%]), and next-generation sequencing was positive in 25 cases (89.3% [95% CI, 71.8% to 97.7%]), with concordance between next-generation sequencing and culture in 15 cases. Among the 11 cases of culture-negative periprosthetic joint infection, next-generation sequencing was able to identify an organism in 9 cases (81.8% [95% CI, 48.2% to 97.7%]). Next-generation sequencing identified microbes in 9 (25.0% [95% CI, 12.1% to 42.2%]) of 36 aseptic revisions with negative cultures and in 6 (35.3% [95% CI, 14.2% to 61.7%]) of 17 primary total joint arthroplasties. Next-generation sequencing detected several organisms in most positive samples. However, in the majority of patients who were infected, 1 or 2 organisms were dominant.

Conclusions: Next-generation sequencing may be a useful adjunct in identification of the causative organism(s) in culture-negative periprosthetic joint infection. Our findings suggest that some cases of monomicrobial periprosthetic joint infection may have additional organisms that escape detection when culture is used. Further study is required to determine the clinical implications of isolated organisms in samples from patients who are not thought to be infected.

Level Of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.00434DOI Listing
January 2018

ACL and meniscal injuries increase the risk of primary total knee replacement for osteoarthritis: a matched case-control study using the Clinical Practice Research Datalink (CPRD).

Br J Sports Med 2019 Aug 13;53(15):965-968. Epub 2018 Jan 13.

NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.

Objectives: The aim of this study was to investigate whether ACL injury (ACLi) or meniscal injury increases the risk of end-stage osteoarthritis (OA) resulting in total knee replacement (TKR).

Methods: A matched case-control study of all TKRs performed in the UK between January 1990 and July 2011 and recorded in the Clinical Practice Research Datalink (CPRD) was undertaken. The CPRD contains longitudinal data on approximately 3.6 million patients. Two controls were selected for each case of TKR, matched on age, sex and general practitioner location as a proxy for socioeconomic status. Individuals with inflammatory arthritis were excluded. The odds of having TKR for individuals with a CPRD-recorded ACLi were compared with those without ACLi using conditional logistic regression, after adjustment for body mass index, previous knee fracture and meniscal injury. The adjusted odds of TKR in individuals with a recorded meniscal injury compared with those without were calculated.

Results: After exclusion of individuals with inflammatory arthritis, there were 49 723 in the case group and 104 353 controls. 153 (0.31%) cases had a history of ACLi compared with 41 (0.04%) controls. The adjusted OR of TKR after ACLi was 6.96 (95% CI 4.73 to 10.31). 4217 (8.48%) individuals in the TKR group had a recorded meniscal injury compared with 669 (0.64%) controls. The adjusted OR of TKR after meniscal injury was 15.24 (95% CI 13.88 to 16.69).

Conclusion: This study demonstrates that ACLi is associated with a sevenfold increased odds of TKR resulting from OA. Meniscal injury is associated with a 15-fold increase odds of TKR for OA.
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http://dx.doi.org/10.1136/bjsports-2017-097762DOI Listing
August 2019

Prior Generic Arthroscopic Volume Correlates with Hip Arthroscopic Proficiency: A Simulator Study.

J Bone Joint Surg Am 2018 Jan;100(1):e3

Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, United Kingdom.

Background: Changing trends in surgical education and patient expectation are leading to proficiency models of progression and the use of simulators. Hip arthroscopy is increasingly performed and has a steep learning curve mainly addressed during fellowship training. The aim of this study was to assess the impact of previous generic arthroscopic experience on performance at a simulated hip arthroscopy task to both estimate the minimum case numbers that correlate with expert proficiency levels and help to guide selection for hip arthroscopy fellowships.

Methods: Fifty-two participants were recruited to a cross-sectional study. Four consultants (expert hip arthroscopists), 28 trainees (residents and fellows), and 20 novices (interns and medical students) performed a standardized bench-top simulated hip arthroscopy task. A validated global rating scale (GRS) score and motion analysis were used to assess surgical performance. Prior arthroscopic experience was recorded from surgical electronic logbooks. Receiver operating characteristic (ROC) curve analyses were conducted to identify optimum cut-points for task proficiency at both expert and competent GRS levels.

Results: There were significant differences (p < 0.05) between the arthroscopic ability of all experience groups based on GRS assessment and for all motion analysis metrics. There was a significant positive correlation between logbook numbers and GRS scores (p < 0.0001). ROC curve analysis demonstrated that a minimum of 610 prior arthroscopic procedures were necessary to achieve an expert GRS score, and 78 prior arthroscopic procedures were necessary for a competent score.

Conclusions: Performing a basic hip arthroscopy task competently requires substantial previous generic arthroscopic experience. The numbers identified in this study provide targets for residents. Program directors appointing to hip arthroscopy fellowship training posts may find these results useful as a guide during the selection process.
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http://dx.doi.org/10.2106/JBJS.17.00352DOI Listing
January 2018

Operating Room Traffic Increases Aerosolized Particles and Compromises the Air Quality: A Simulated Study.

J Arthroplasty 2018 03 16;33(3):851-855. Epub 2017 Oct 16.

The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Strategies to prevent bacterial fallout and reduce particle count in the operating room (OR) are key components of preventing periprosthetic joint infection. Although OR traffic control is an important factor, a quantitative study has not been performed to investigate the influence of personnel and door opening on OR air quality. This simulated study aimed to examine the influence of these 2 factors on particle density in OR with and without the laminar air flow (LAF).

Methods: Both experiments took place within an empty OR of an arthroplasty unit equipped with an LAF system. First, the number of particles in the air was counted using a particle counting apparatus while 9 persons entered the room, one every 15 minutes. Second, the door was opened and closed starting with zero door openings per minute and increasing to 4 in 15-minute increments. Both experiments were performed once with the LAF turned on and once without.

Results: The number of personnel in the OR and the number of door openings per minute correlate with the density of particles. Both relationships were significantly reduced by turning the LAF on (correlation coefficients <0.4). With the LAF being turned on, the particle density per person decreased from 211.19 to 18.19 particles/ft (P < .001) and the particle density per rate of door openings declined from 117.80 to 1.90 particles/ft (P = .017).

Conclusion: This study confirms that personnel and door opening are a major source of particles in the OR air. Controlling traffic is critical for reduction of particles and is likely to be a key preventative strategy in reducing periprosthetic joint infection. LAF is protective against the negative influence of number of people and door openings.
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http://dx.doi.org/10.1016/j.arth.2017.10.012DOI Listing
March 2018

Clinical Outcome of Massive Endoprostheses Used for Managing Periprosthetic Joint Infections of the Hip and Knee.

J Arthroplasty 2018 03 5;33(3):829-834. Epub 2017 Oct 5.

Nuffield Orthopaedic Centre, Adult Hip and Knee Unit, Oxford, United Kingdom.

Background: Endoprosthetic replacement (EPR) is an option for management of massive bone loss resulting from infection around failed lower limb implants. The aim of this study is to determine the mid-term outcome of EPRs performed in the treatment of periprosthetic joint infection (PJI) and infected failed osteosyntheses around the hip and knee joint and identify factors that influence it.

Methods: We retrospectively reviewed all hip and knee EPRs performed between 2007 and 2014 for the management of chronic infection following complex arthroplasty or fracture fixation. Data recorded included indication for EPR, number of previous surgeries, comorbidities, and organism identified. Outcome measures included PJI eradication rate, complications, implant survival, mortality, and functional outcome (Oxford Hip or Knee Score).

Results: Sixty-nine EPRs (29 knees and 40 hips) were performed with a mean age of 68 years (43-92). Polymicrobial growth was detected in 36% of cases, followed by coagulase-negative staphylococci (28%) and Staphylococcus aureus (10%). Recurrence of infection occurred in 19 patients (28%): 5 were treated with irrigation and debridement, 5 with revision, 1 with above-knee amputation, and 8 remain on long-term antibiotics. PJI eradication was achieved in 50 patients (72%); the chance of PJI eradication was greater in hips (83%) than in knees (59%) (P = .038). The 5-year implant survivorship was 81% (95% confidence interval 74-88). The mean Oxford Hip Score and Oxford Knee Score were 22 (4-39) and 21 (6-43), respectively.

Conclusion: This study supports the use of EPRs for eradication of PJI in complex, multiply revised cases. We describe PJI eradication rate of 72% with acceptable functional outcome.
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http://dx.doi.org/10.1016/j.arth.2017.09.046DOI Listing
March 2018

The impact of patient-specific instrumentation on unicompartmental knee arthroplasty: a prospective randomised controlled study.

Knee Surg Sports Traumatol Arthrosc 2018 Jun 22;26(6):1662-1670. Epub 2017 Aug 22.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Old Road, Oxford, OX3 7LD, UK.

Purpose: Patient-specific instrumentation (PSI) has been proposed as a means of improving surgical accuracy and ease of implantation during technically challenging procedures such as unicompartmental knee arthroplasty (UKA). The purpose of this prospective randomised controlled trial was to compare the accuracy of implantation and functional outcome of mobile-bearing medial UKAs implanted with and without PSI by experienced UKA surgeons.

Methods: Mobile-bearing medial UKAs were implanted in 43 patients using either PSI guides or conventional instrumentation. Intra-operative measurements, meniscal bearing size implanted, and post-operative radiographic analyses were performed to assess component positioning. Functional outcome was determined using the Oxford Knee Score (OKS).

Results: PSI guides could not be used in three cases due to concerns regarding accuracy and registration onto native anatomy, particularly on the tibial side. In general, similar component alignment and positioning was achieved using the two systems (n.s. for coronal/sagittal alignment and tibial coverage). The PSI group had greater tibial slope (p = 0.029). The control group had a higher number of optimum size meniscal bearing inserted (95 vs 52%; p = 0.001). There were no differences in OKS improvements (n.s).

Conclusion: Component positioning for the two groups was similar for the femur but less accurate on the tibial side using PSI, often with some unnecessarily deep resections of the tibial plateau. Although PSI was comparable to conventional instrumentation based on OKS improvements at 12 months, we continue to use conventional instrumentation for UKA at our institution until further improvements to the PSI guides can be demonstrated.

Level Of Evidence: Therapeutic, Level I.
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http://dx.doi.org/10.1007/s00167-017-4677-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5966491PMC
June 2018

The Role of Biomarkers for the Diagnosis of Implant-Related Infections in Orthopaedics and Trauma.

Adv Exp Med Biol 2017 ;971:69-79

The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA.

Diagnosis of implant-related (periprosthetic joint) infections poses a major challenge to infection disease physicians and orthopaedic surgeons. Conventional diagnostic tests continue to suffer from issues of accuracy and feasibility. Biomarkers are used throughout medicine for diagnostic and prognostic purposes, as they are able to objectively determine the presence of a disease or a biological state. There is increasing evidence to support the measurement of specific biomarkers in serum and/or synovial fluid of patients with suspected periprosthetic joint infections. Promising serum biomarkers include interleukin (IL)-4, IL-6, tumour necrosis factor (TNF)-α, procalcitonin, soluble intercellular adhesion molecule 1 (sICAM-1), and D-dimer. In addition to c-reactive protein and leucocyte esterase, promising biomarkers that can be measured in synovial fluid include antimicrobial proteins such as human β-defensin (HBD)-2 and human β-defensin (HBD)-3, and cathelicidin LL-37, as well as several interleukins such as IL-1β, IL-6, IL-8, IL-17, TNF- α, interferon-δ, and vascular endothelial growth factor.
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http://dx.doi.org/10.1007/5584_2017_11DOI Listing
September 2017

Can Surgical Trainees Achieve Arthroscopic Competence at the End of Training Programs? A Cross-sectional Study Highlighting the Impact of Working Time Directives.

Arthroscopy 2017 Jun 16;33(6):1151-1158. Epub 2017 Jan 16.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England.

Purpose: To provide training guidance on procedure numbers by assessing how the number of previously performed arthroscopic procedures relate to both competent and expert performance in simulated arthroscopic shoulder tasks.

Methods: A cross-sectional study that assessed simulated shoulder arthroscopic performance was undertaken. A total of 45 participants of varying experience performed 2 validated tasks: a simple diagnostic task and a more complex Bankart labral repair task. All participants provided logbook numbers for previously performed arthroscopies. Performance was assessed with the Global Rating Scale and motion analysis. Receiver operating characteristic curve analyses were conducted to identify optimum cut points for task proficiency at both "competent" and "expert" levels.

Results: Increasing surgical experience resulted in significantly better performance for both tasks as assessed by Global Rating Scale or motion analysis (P < .0001). Receiver operating characteristic curve analyses demonstrated 52 previous arthroscopies were needed to perform to a competent level at the diagnostic task and 248 to be competent at the complex task. To perform at an expert level, 290 and 476 previous arthroscopies, respectively, were needed.

Conclusions: This study provides quantified guidance for arthroscopic training and highlights the positive relationship between arthroscopic case load and arthroscopic competency. We have estimated that the number of arthroscopies required to achieve competency in a basic arthroscopic task exceed those recommended in some countries. These estimates provide useful guidance to those responsible for training program.

Clinical Relevance: The numbers to achieve competent arthroscopic performance in the assessed simulated tasks exceed what is recommended and what is possible during surgical training programs in some countries.
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http://dx.doi.org/10.1016/j.arthro.2016.10.025DOI Listing
June 2017

Simulation-Based Training Platforms for Arthroscopy: A Randomized Comparison of Virtual Reality Learning to Benchtop Learning.

Arthroscopy 2017 May 7;33(5):996-1003. Epub 2017 Jan 7.

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit, University of Oxford, Oxford, England.

Purpose: To determine whether a virtual reality (VR) arthroscopy simulator or benchtop (BT) arthroscopy simulator showed superiority as a training tool.

Methods: Arthroscopic novices were randomized to a training program on a BT or a VR knee arthroscopy simulator. The VR simulator provided user performance feedback. Individuals performed a diagnostic arthroscopy on both simulators before and after the training program. Performance was assessed using wireless objective motion analysis and a global rating scale.

Results: The groups (8 in the VR group, 9 in the BT group) were well matched at baseline across all parameters (P > .05). Training on each simulator resulted in significant performance improvements across all parameters (P < .05). BT training conferred a significant improvement in all parameters when trainees were reassessed on the VR simulator (P < .05). In contrast, VR training did not confer improvement in performance when trainees were reassessed on the BT simulator (P > .05). BT-trained subjects outperformed VR-trained subjects in all parameters during final assessments on the BT simulator (P < .05). There was no difference in objective performance between VR-trained and BT-trained subjects on final VR simulator wireless objective motion analysis assessment (P > .05).

Conclusions: Both simulators delivered improvements in arthroscopic skills. BT training led to skills that readily transferred to the VR simulator. Skills acquired after VR training did not transfer as readily to the BT simulator. Despite trainees receiving automated metric feedback from the VR simulator, the results suggest a greater gain in psychomotor skills for BT training. Further work is required to determine if this finding persists in the operating room.

Clinical Relevance: This study suggests that there are differences in skills acquired on different simulators and skills learnt on some simulators may be more transferable. Further work in identifying user feedback metrics that enhance learning is also required.
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http://dx.doi.org/10.1016/j.arthro.2016.10.021DOI Listing
May 2017