Publications by authors named "Jón Karlsson"

390 Publications

Picking apart p values: common problems and points of confusion.

Knee Surg Sports Traumatol Arthrosc 2022 Aug 3. Epub 2022 Aug 3.

Department of Orthopedic Surgery & Sports Medicine, Hospital for Special Surgery, 535 East 70 th Street, New York, NY, 10021, USA.

Due to its frequent misuse, the p value has become a point of contention in the research community. In this editorial, we seek to clarify some of the common misconceptions about p values and the hazardous implications associated with misunderstanding this commonly used statistical concept. This article will discuss issues related to p value interpretation in addition to problems such as p-hacking and statistical fragility; we will also offer some thoughts on addressing these issues. The aim of this editorial is to provide clarity around the concept of statistical significance for those attempting to increase their statistical literacy in Orthopedic research.
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http://dx.doi.org/10.1007/s00167-022-07083-3DOI Listing
August 2022

Good results after treatment of  RAMP lesions in association with ACL reconstruction: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2022 Jul 23. Epub 2022 Jul 23.

Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Purpose: This study aimed to systematically evaluate the clinical, functional, and radiological outcomes, complications, and rate of return to sports among patients with RAMP lesion of the medial meniscus encountered during anterior cruciate ligament (ACL) reconstruction.

Methods: A systematic review was conducted based on the PRISMA guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "ACL" or "anterior cruciate ligament," and "RAMP lesion." The outcome measures extracted from the studies were the Short Form-12 (SF-12) in its mental and physical component (MCS and PCS), Lysholm score, Subjective IKDC, Marx Score, WOMAC Score, Tegner, Radiological changes, complications, failures and/or revision surgery, and rate of return to sports.

Results: The cohort of patients consisted of 1,243 participants with a mean age of 28.6 ± 2.6. The mean postoperative follow-up was 40.9 ± 6.3 months. A total of 1145 (92.1%) RAMP lesions were repaired with concomitant ACL reconstruction, while only 98 (7.9%) lesions were left untreated (or treated with abrasion only). The Lysholm score was used in 6 studies (in one only at final follow-up), with a significant improvement in all the studies (Lysholm 60.03 ± 6.12; Lysholm 89.9 ± 5.0). Eight studies out of nine reported Subjective IKDC score, and a significant improvement was noted in all cases (IKDC 56.2 ± 5.8. IKDC 84.9 ± 3.7). Of 18 (1.4%) complications reported, 15 (1.2%) were related to RAMP/ACL surgery, and of the remaining three (0.2%) two (0.2%) were hematomas and one (0.1%) a contralateral ACL lesion. Of the 106 (8.5%) revision surgeries required, 5 (0.4%) were in non-treated lesions [two (0.2%) ACL re-ruptures and three (0.2%) medial meniscus re-injury]. In treated patients, the revision occurred for the following reasons: 75 (6.0%) meniscectomy, 14 (1.1%) meniscal suture revisions, 11 (0.9%) ACL failures and one (0.1%) arthrolysis.

Conclusions: It is not yet clear if, in all cases of ACL reconstruction in which a medial meniscal RAMP lesion is encountered, the lesion needs to undergo surgical repair. Accordingly, it is recommended that in the repair of all unstable medial meniscal RAMP lesions during an ACL reconstruction in cases associated with a stable RAMP lesion, the surgeon may decide on repair based on the patient profile.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s00167-022-07067-3DOI Listing
July 2022

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

J ISAKOS 2022 Apr 13. Epub 2022 Apr 13.

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

Results: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

Conclusions: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.
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http://dx.doi.org/10.1016/j.jisako.2022.04.001DOI Listing
April 2022

ABC om Meniskskador.

Lakartidningen 2022 06 8;119. Epub 2022 Jun 8.

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June 2022

ABC om Meniskskador.

Lakartidningen 2022 06 8;119. Epub 2022 Jun 8.

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June 2022

Generalized joint hypermobility does not influence 1-year patient satisfaction or functional outcome after ACL reconstruction.

Knee Surg Sports Traumatol Arthrosc 2022 Jun 8. Epub 2022 Jun 8.

Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.

Purpose: The purpose of this study was to evaluate whether generalized joint hypermobility (GJH) influences postoperative results, including return to sport, patientreported outcomes, functional performance (hop tests), muscular strength, and the occurrence of ACL re-injury, in patients 1 year after anterior cruciate ligament (ACL) reconstruction.

Methods: Data was extracted from a regional rehabilitation-specific registry containing information on patients with ACL injury. Patients between the ages of 16-50 years previously undergoing ACL reconstruction with available 1 year follow-up data were eligible for inclusion. Generalized joint hypermobility was assessed using the Beighton score (BS). Patients were examined one year postoperatively in terms of return to sport, patient-reported outcome, hop tests, muscular strength and the occurrence of reinjury. For purpose of analysis, patients were allocated into two groups, depending on the existence of GJH. The KOOS subscale of sports and recreation was considered the primary outcome. Analyses were performed both dichotomously and by using adjusted logistic regression, to consider potential confounders.

Results: A total of 356 patients (41% males) were included, of which 76 (24% male) were categorized as having GJH. Patients with GJH had an inferior limb symmetry index preoperatively in terms of knee extension (mean 81.6 [SD 16.4] vs. 91.4 [SD 15.9], p = 0.02) and flexion strength (mean 91.9 vs. 99.1, p = 0.047) compared to patients without GJH. There was no difference between the groups in terms of the primary outcome, nor in any of the other postoperative outcomes. Nine patients (11.8%) in the group with GJH suffered ACL re-injury, compared with 13 patients (4.6%) in the control group (n.s.).

Conclusion: One year after ACL reconstruction the existence of GJH did not affect postoperative patient satisfaction, strength or functional outcome. No conclusive statements can be made regarding the influence of GJH on the risk of ACL re-injury in this particular study.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1007/s00167-022-07008-0DOI Listing
June 2022

Return to Sport for Professional and Subelite Ice Hockey Players After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome.

Orthop J Sports Med 2022 May 9;10(5):23259671221089984. Epub 2022 May 9.

Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Background: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain, which can prevent ice hockey players from sports participation. Hip arthroscopy is often performed to relieve pain and enable the player to return to sport (RTS) and return to performance (RTP).

Purpose: To determine the RTS and RTP rates for ice hockey players at the professional and subelite levels after hip arthroscopy for FAIS.

Study Design: Case series; Level of evidence, 4.

Methods: High-level ice hockey players who underwent hip arthroscopy for FAIS between 2011 and 2019 were identified using a local hip arthroscopy registry. The player's level was confirmed with ice hockey-specific web pages and was stratified as subelite or professional. Data on the players' careers were extracted from these web pages. Player position was divided into goalkeepers, defensemen, and forwards. Data on participation in games included the season before onset of symptoms, the season before surgery, and the first and second seasons after surgery. RTS was defined as returning to ice hockey after surgery, and RTP was considered as returning to the same league at a comparable level to before symptoms.

Results: A total of 80 ice hockey players were included. Comparing presymptom performance with the first season after surgery, the RTS rate was 72%, of which 94% of the players returned to the same or higher level of play. Comparing the presurgery season with the first season after surgery, the RTS rate was 78%. At the second season after surgery, 64% of players still played ice hockey, with a significantly higher return rate among professional players compared with subelite players (96% vs 69%; = .014). Overall, 85% goalkeepers, 74% forwards, and 60% defensemen returned to sport. Only 28% played at least the same number of games during the first season after surgery as they did during the presymptom season.

Conclusion: High-level ice hockey players who underwent hip arthroscopy for FAIS had a high RTS rate, in which the majority returned to the same league. However, only 28% played the same number of games the first season after surgery as they did at the presymptom level. Professional ice hockey players returned more frequently than players on the subelite level.
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http://dx.doi.org/10.1177/23259671221089984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9092588PMC
May 2022

Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

J ISAKOS 2022 04 14;7(2):62-66. Epub 2022 Jan 14.

Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%.

Results: A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT.

Conclusions: This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.
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http://dx.doi.org/10.1016/j.jisako.2021.12.001DOI Listing
April 2022

ABC om patellaluxationer.

Lakartidningen 2022 05 6;119. Epub 2022 May 6.

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May 2022

Like, share and follow: The KSSTA and JEO social media.

Knee Surg Sports Traumatol Arthrosc 2022 07 21;30(7):2195-2199. Epub 2022 Apr 21.

Department for Orthopaedics, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.

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http://dx.doi.org/10.1007/s00167-022-06977-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9206600PMC
July 2022

Disappointment and frustration, but long-term satisfaction: patient experiences undergoing treatment for a chronic Achilles tendon rupture-a qualitative study.

J Orthop Surg Res 2022 Apr 9;17(1):217. Epub 2022 Apr 9.

Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Background: Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as "chronic", and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture.

Methods: To evaluate patients' experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4-6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman.

Results: The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) "The injury", where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) "The diagnosis", where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) "The treatment", where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) "The outcomes", where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged.

Conclusions: An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.
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http://dx.doi.org/10.1186/s13018-022-03103-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8994186PMC
April 2022

Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques.

Knee Surg Sports Traumatol Arthrosc 2022 Jul 9;30(7):2477-2484. Epub 2022 Apr 9.

Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80, Gothenburg, Sweden.

Purpose: Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps.

Method: Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work.

Results: The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side.

Conclusion: The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-022-06943-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9206609PMC
July 2022

Greater proportion of patients report an acceptable symptom state after ACL reconstruction compared with non-surgical treatment: a 10-year follow-up from the Swedish National Knee Ligament Registry.

Br J Sports Med 2022 Aug 8;56(15):862-869. Epub 2022 Apr 8.

Sahlgrenska Sports Medicine Center, Gothenburg, Sweden

Objectives: To compare the proportion of patients with anterior cruciate ligament (ACL) injury reporting an acceptable symptom state, between non-surgical and surgical treatment during a 10-year follow-up.

Methods: Data were extracted from the Swedish National Knee Ligament Registry. Exceeding the Patient Acceptable Symptom State (PASS) for the Knee injury and Osteoarthritis Outcome Score (KOOS) was the primary outcome. The PASS and KOOS (aggregated KOOS without the activities of daily living (ADL) subscale) were compared cross-sectionally at baseline and 1, 2, 5 and 10 years after ACL injury, where patients treated non-surgically were matched with the maximum number of patients with ACL reconstruction for age, sex and activity at injury.

Results: The non-surgical group consisted of 982 patients, who were each matched against 9 patients treated with ACL reconstruction (n=8,838). A greater proportion of patients treated with ACL reconstruction exceeded the PASS in KOOS pain, ADL, sports and recreation, and quality of life compared with patients treated non-surgically at all follow-ups. With respect to quality of life, significantly more patients undergoing ACL reconstruction achieved a PASS compared with patients receiving non-surgical treatment at all follow-ups except at baseline, with differences ranging between 11% and 25%; 1 year -25.4 (-29.1; -21.7), 2 years -16.9 (-21.2; -12.5), 5 years -11.0 (-16.9; -5.1) and 10 years -24.8 (-36.0; -13.6). The ACL-reconstructed group also reported statistically greater KOOS at all follow-ups.

Conclusion: A greater proportion of patients treated with ACL reconstruction report acceptable knee function, including higher quality of life than patients treated non-surgically at cross-sectional follow-ups up to 10 years after the treatment of an ACL injury.
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http://dx.doi.org/10.1136/bjsports-2021-105115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9304118PMC
August 2022

Integration of polyurethane meniscus scaffold during ACL revision is not reliable at 5 years despite favourable clinical outcome.

Knee Surg Sports Traumatol Arthrosc 2022 Mar 26. Epub 2022 Mar 26.

3B's Research Group, I3Bs-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, 4805-017, Guimarães, Portugal.

Purpose: The aim of this study was to evaluate the clinical outcome at 5-year follow-up of a one-step procedure combining anterior cruciate ligament (ACL) reconstruction and partial meniscus replacement using a polyurethane scaffold for the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy. Moreover, the implanted scaffolds have been evaluated by MRI protocol in terms of morphology, volume, and signal intensity.

Methods: Twenty patients with symptomatic knee laxity after failed ACL reconstruction and partial medial meniscectomy underwent ACL revision combined with polyurethane-based meniscal scaffold implant. Clinical assessment at 2- and 5-year follow-ups included VAS, Tegner Activity Score, International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm Score. MRI evaluation of the scaffold was performed according to the Genovese scale with quantification of the scaffold's volume at 1- and 5-year follow-ups.

Results: All scores revealed clinical improvement as compared with the preoperative values at the 2- and 5-year follow-ups. However, a slight, but significant reduction of scores was observed between 2 and 5 years. Concerning the MRI assessment, a significant reduction of the scaffold's volume was observed between 1 and 5 years. Genovese Morphology classification at 5 years included two complete resorptions (Type 3) and all the remaining patients had irregular morphology (Type 2). With regard to the Genovese Signal at the 5-year follow-up, three were classified as markedly hyperintense (Type 1), 15 as slightly hyperintense (Type 2), and two as isointense (Type 1).

Conclusion: Simultaneous ACL reconstruction and partial meniscus replacement using a polyurethane scaffold provides favourable clinical outcomes in the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy at 5 years. However, MRI evaluation suggests that integration of the scaffold is not consistent.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s00167-022-06946-zDOI Listing
March 2022

[Treatment and diagnosis of overuse injury in the Achilles tendon].

Lakartidningen 2022 03 15;119. Epub 2022 Mar 15.

med dr, leg fysioterapeut, sahlgrenska akademin.

Achilles tendinopathy is a common overuse injury, especially among runners. It should be divided into midportion Achilles tendinopathy and insertional Achilles tendinopathy, as the treatments are different. Achilles tendinopathy is a clinical diagnosis, which includes a combination of pain, swelling and stiffness. If pain is located 2-6 cm above the insertion to the calcaneus, it is considered a midportion tendinopathy. Pain located more distally, close to the insertion, is defined as insertional tendinopathy. Both midportion and insertional Achilles tendinopathies are primarily treated with physiotherapy during three to six months. Exercise has the highest level of evidence and is more successful in midportion Achilles tendinopathy. Insertional tendinopathy more often requires surgical treatment, with removal of bony exostosis and chronically inflamed bursa.
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March 2022

Brace cast following surgical treatment of distal radial fracture: a prospective randomised study comparing quality of recovery.

F1000Res 2021 4;10:336. Epub 2021 May 4.

Department of Anaesthesia & Intensive Care, Institute of Clinical Science, Karolinska Institute, Danderyd University Hospital, Stockholm, 182 88, Sweden.

: Immobilisation following surgical treatment of distal radial fractures (DRF) is traditionally performed with a dorsal cast splint. There is an interest in changing the rigid cast to a removable brace. This can reduce the risk for cast-corrections, complications and improve recovery of function. The aim of the study was to compare quality of recovery (QoR) between brace and traditional cast for immobilisation during the first postoperative week. 60 patients with American Society of Anesthesiologists (ASA) physical status 1-3, scheduled for surgical treatment of DRF under a supraclavicular block (SCB) in a day-surgery setting were randomised into two groups of immobilisation post-surgery; brace (n=30) traditional cast (n=30). Study objectives were: differences in self-assessed QoR using the QoR-15 questionnaire, postoperative oral oxycodone consumption, perioperative time events and unplanned healthcare contacts one week postoperatively. : 54 patients, 46 females/eight males were included in the analysis; 27 with brace and 27 with traditional cast. QoR-15 median scores improved significantly from baseline/preoperative to day 7 (brace p=0.001, cast p=0.001) with no differences between the two groups. The only difference found was that patients in the brace group had significantly worse pain score 24-hours post-surgery (p=0.022). No significant differences were seen in total median oxycodone consumption the first three postoperative days. No differences were found in perioperative events or unplanned healthcare contacts. : Brace appears to be a feasible option to traditional cast for immobilisation following surgical treatment of DRF. The early QoR was similar in both groups apart from more pain in the brace group the first 24 postoperative hours.
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http://dx.doi.org/10.12688/f1000research.52046.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8837810.2PMC
April 2022

Surgical treatment of chronic Achilles tendon rupture results in improved gait biomechanics.

J Orthop Surg Res 2022 Feb 2;17(1):67. Epub 2022 Feb 2.

Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Background: Chronic Achilles tendon rupture is associated with persistent weakness at push-off with the affected foot and poor balance, resulting in significant alterations to normal gait. Surgical repair is the most common treatment for improving gait in patients with a Chronic Achilles tendon rupture, but, to date, the outcomes have not been quantified in the literature.

Methods: A total of 23 patients with a Chronic Achilles tendon rupture (mean age 61 ± 15 years) underwent three-dimensional gait analysis according to a standardized protocol using an optical tracking system. Data of spatiotemporal, kinematic and kinetic variables were collected preoperatively and one year postoperatively. In addition, the postoperative gait biomechanics were compared with the gait biomechanics of a control group consisting of 70 healthy individuals (mean age 49 ± 20 years). The prospectively collected data were analyzed by an independent t test.

Results: Postoperatively, increments were found in gait speed (mean difference - 0.12 m/s), stride length (- 0.12 m), peak ankle moment (- 0.64 Nm/kg), peak ankle power (- 1.38 W/kg), peak knee power (- 0.36 m) and reduced step width (0.01 m), compared with preoperative gait biomechanics (p < 0.014). Compared with the control group, patients with a Chronic Achilles tendon rupture exhibited slower postoperative gait speed (mean difference 0.24 m/s), wider step width (- 0.02 m), shorter stride length (0.16 m), longer relative stance phase (- 2.15%), lower peak knee flexion (17.03 degrees), greater peak knee extension (2.58 degrees), lower peak ankle moment (0.35 Nm/kg), peak ankle power (1.22 W/kg) and peak knee power (1.62 W/kg), (p < 0.010).

Conclusion: Surgical intervention and postoperative rehabilitation can be an effective treatment for alterations in gait after a Chronic rupture of the Achilles tendon. However, at one year postoperatively, patients still exhibit impairments in spatiotemporal variables and knee and ankle power compared with healthy controls.
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http://dx.doi.org/10.1186/s13018-022-02948-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8812178PMC
February 2022

Superior Outcome of Early ACL Reconstruction versus Initial Non-reconstructive Treatment With Late Crossover to Surgery: A Study From the Swedish National Knee Ligament Registry.

Am J Sports Med 2022 03 2;50(4):896-903. Epub 2022 Feb 2.

Sahlgrenska Sports Medicine Center, Gothenburg, Sweden.

Background: Although comparable clinical and functional outcomes have been reported after nonsurgical and surgical anterior cruciate ligament (ACL) treatment, few studies have investigated the effects of early versus late ACL reconstruction with initial rehabilitation.

Purpose: To determine patient-reported knee function in patients who initially undergo nonreconstructive treatment after an ACL injury but who later choose to undergo ACL reconstruction as compared with (1) patients undergoing ACL reconstruction close to the index injury and (2) patients treated nonreconstructively at 1 to 10 years of follow-up.

Study Design: Cohort study; Level of evidence, 2.

Methods: Results from the Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted from the Swedish National Knee Ligament Registry for patients treated with nonreconstruction, early ACL reconstruction, and initial nonreconstruction but subsequent ACL reconstruction (crossover group). The KOOS (a mean of 4 KOOS subscales) was analyzed cross-sectionally at baseline and at the 1-, 2-, 5-, and 10-year follow-ups. Additionally, the Patient Acceptable Symptom State (PASS) was applied to all KOOS subscales from baseline to the 10-year follow-up.

Results: A total of 1,074 crossover, 484 nonreconstruction, and 20,352 early ACL reconstruction cases were included. The crossover group reported lower KOOS values than the group undergoing early ACL reconstruction at baseline and at all follow-ups (mean difference [95% CI]): baseline, -6.5 (-8.0 to -5.0); 1 year, -9.3 (-10.9 to -7.7); 2 years, -4.8 (-6.3 to -3.2); 5 years, -6.1 (-8.8 to -3.4); and 10 years, -10.9 (-16.3 to -5.2). Additionally, a smaller proportion of the crossover cohort achieved a PASS on KOOS subscales at baseline and through the 1-, 2-, 5-, and 10-year follow-ups as compared with the early ACL reconstruction cohort. No differences were observed between crossover and nonreconstruction cases on either the KOOS or the PASS at any follow-up.

Conclusion: A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction.
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http://dx.doi.org/10.1177/03635465211069995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8980451PMC
March 2022

More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume.

Knee Surg Sports Traumatol Arthrosc 2022 Jun 29;30(6):2014-2019. Epub 2022 Jan 29.

Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA.

Purpose: Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability. Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons.

Methods: A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume). Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6 mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior-anterior (PA) and proximal-distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers.

Results: A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01).

Conclusion: Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-022-06875-xDOI Listing
June 2022

Freddie H Fu: a true friend of ESSKA.

Knee Surg Sports Traumatol Arthrosc 2022 01;30(1):1-2

Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA.

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http://dx.doi.org/10.1007/s00167-021-06827-xDOI Listing
January 2022

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

Foot Ankle Int 2022 03 5;43(3):448-452. Epub 2022 Jan 5.

Background: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

Methods: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

Results: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

Conclusion: These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

Level Of Evidence: Level V, mechanism-based reasoning.
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http://dx.doi.org/10.1177/10711007211049169DOI Listing
March 2022

Current trends in the anterior cruciate ligament part 1: biology and biomechanics.

Knee Surg Sports Traumatol Arthrosc 2022 Jan 20;30(1):20-33. Epub 2021 Dec 20.

The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.

A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.
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http://dx.doi.org/10.1007/s00167-021-06826-yDOI Listing
January 2022

Correction to: The ankle cartilage cascade: incremental cartilage damage in the ankle joint.

Knee Surg Sports Traumatol Arthrosc 2022 Aug;30(8):2881

Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00167-021-06817-zDOI Listing
August 2022

Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation.

Knee Surg Sports Traumatol Arthrosc 2022 Jan 5;30(1):34-51. Epub 2021 Dec 5.

The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.

Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.
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http://dx.doi.org/10.1007/s00167-021-06825-zDOI Listing
January 2022

Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study.

BMC Anesthesiol 2021 11 9;21(1):273. Epub 2021 Nov 9.

Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.

Background: Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control.

Methods: Patients (n = 90) with ASA physical status 1-3 were prospectively randomised to receive; SCB with mepivacine 1%, 25-30 ml (n = 30), SCB with ropivacaine 0.5%, 25-30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups.

Results: The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3-3.3) and 2.7 (IQR 1.3-4.2) (p = 0.017) and OEC 30 mg (IQR 10-80) and 85 mg (IQR 45-125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%).

Conclusions: The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution.

Trial Registration: NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).
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http://dx.doi.org/10.1186/s12871-021-01499-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8577027PMC
November 2021

Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry.

Orthop J Sports Med 2021 Oct 12;9(10):23259671211038893. Epub 2021 Oct 12.

Gothenburg Sports Trauma Research Center, Gothenburg, Sweden.

Background: Previous studies have identified young age as a risk factor for anterior cruciate ligament (ACL) revision. However, few studies have looked separately at pediatric patients and adolescents with regard to outcomes after ACL reconstruction.

Purpose: To determine whether patient age at ACL reconstruction affects the risk of undergoing revision surgery in young patients.

Study Design: Cohort study; Level of evidence, 3.

Methods: This study was based on data from the Swedish National Knee Ligament Registry. Patients aged 5 to 35 years who underwent a primary ACL reconstruction with a hamstring tendon autograft between January 1, 2005, and December 31, 2015, were included. The cohort was stratified into different age groups of pediatric patients, adolescents, and young adults to estimate patients with open, recently closed, and closed epiphyses, respectively. The primary endpoint was ACL revision. A multivariable Cox regression model was used to assess the ACL revision rate. The results were expressed as hazard ratios (HRs) and 95% CIs.

Results: A total of 36,274 ACL reconstructions were registered during the study period. Of these, 2848 patients were included in the study: 47 pediatric patients (mean age, 13.6 years; range, 9-15 years), 522 adolescents (mean age, 17.4; range, 14-19 years), and 2279 young adults (mean age, 27.0; range, 20-35 years). A total of 31 patients (1.1%) underwent ACL revision within 2 years (0 pediatric patients, 9 adolescents [1.7%], and 22 young adults [1.0%]) and a total of 53 patients (2.6%) underwent ACL revision within 5 years (2 pediatric patients [6.9%], 15 adolescents [3.9%], and 36 young adults [2.2%]). The adolescent age group had a 1.91 times higher rate of ACL revision compared with the young adults (HR = 1.91 [95% CI, 1.13-3.21]; = .015). There were no differences in revision rates between the pediatric age group and the young adults (HR = 2.93 [95% CI, 0.88-9.79]; = .081).

Conclusion: Adolescents had almost twice the rate of revision ACL reconstruction compared with young adults.
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http://dx.doi.org/10.1177/23259671211038893DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8516395PMC
October 2021

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture.

Knee Surg Sports Traumatol Arthrosc 2022 Mar 18;30(3):1109-1117. Epub 2021 Oct 18.

The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.

Purpose: Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions.

Methods: From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture.

Results: Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043).

Conclusions: The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.
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http://dx.doi.org/10.1007/s00167-021-06767-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8901518PMC
March 2022

Patterns of traumatic outdoor rock-climbing injuries in Sweden between 2008 and 2019.

J Exp Orthop 2021 Oct 9;8(1):89. Epub 2021 Oct 9.

Orthopaedic department, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Purpose: Injury prevalence patterns for climbers have been presented in several papers but results are heterogenous largely due to a mix of included climbing disciplines and injury mechanisms. This study describes the distribution and pattern of acute traumatic climbing injuries sustained during outdoor climbing in Sweden.

Methods: Patients that experienced a climbing related traumatic injury during outdoor climbing between 2008 and 2019 and who submitted a self-reported questionnaire to the Swedish Climbing Association were included in the study. Medical records were retrieved, and the International Climbing and Mountaineering Federation injury classification system was used for injury presentation.

Results: Thirty-eight patients were included in the study. Seven (18%) injuries occurred during traditional climbing, 13 (34%) during sport climbing and 9 (24%) during bouldering. Varying with climbing discipline, 84-100% injuries were caused by falls. Injuries of the foot and ankle accounted for 72-100% of the injuries. Fractures were the most common injury (60%) followed by sprains (17%) and contusions (10%).

Conclusions: Traumatic injuries sustained during outdoor climbing in Sweden were predominantly caused by falls and affected the lower extremities in all major outdoor climbing disciplines. Rope management errors as a cause of injury were common in sport climbing and in activity surrounding the climbing, indicating there is room for injury-preventing measures.
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http://dx.doi.org/10.1186/s40634-021-00407-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502181PMC
October 2021

Learning to interact with new technology: Health care workers' experiences of using a monitoring system for assessing hand hygiene - a grounded theory study.

Am J Infect Control 2022 06 2;50(6):651-656. Epub 2021 Oct 2.

The Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.

Background: Recently, innovative technologies for hand hygiene (HH) monitoring have been developed to improve HH adherence in health care. This study explored health care workers' experiences of using an electronic monitoring system to assess HH adherence.

Methods: An electronic monitoring system with digital feedback was installed on a surgical ward and interviews with health care workers using the system (n = 17) were conducted.  The data were analyzed according to grounded theory by Strauss and Corbin.

Results: Health care workers' experiences were expressed in terms of having trust in the monitoring system, requesting system functionality and ease of use and becoming aware of one's own performance. This resulted in the core category of learning to interact with new technology, summarized as the main strategy when using an electronic monitoring system in clinical settings. The system with digital feedback improved the awareness of HH and individual feedback was preferable to group feedback.

Conclusions: Being involved in using and managing a technical innovation for assessing HH adherence in health care is a process of formulating a strategy for learning to interact with new technology. The importance of inviting health care workers to participate in the co-design of technical innovations is crucial, as it creates both trust in the innovation per se and trust in the process of learning how to use it.
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http://dx.doi.org/10.1016/j.ajic.2021.09.023DOI Listing
June 2022

The ankle cartilage cascade: incremental cartilage damage in the ankle joint.

Knee Surg Sports Traumatol Arthrosc 2021 Nov 5;29(11):3503-3507. Epub 2021 Oct 5.

Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Level of evidence Editorial, Level V.
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http://dx.doi.org/10.1007/s00167-021-06755-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8514360PMC
November 2021
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