Nonoperative management of patients with knee osteoarthritis (OA) through multidisciplinary programs may delay or reduce the need for total knee arthroplasty (TKA). However, avoidance of surgery may ...not represent success for the patient.
A cohort of 120 patients with knee OA managed with at least 6 months of supervised nonoperative treatment coordinated through the Joint Clinic were reviewed at 5 years. Outcomes including Oxford knee score (OKS), Short Form 12 (SF-12), and SF-6D and other measures including analgesia use, global change, and perception of need for surgery were collected and compared with those from the cohort who had undergone TKA.
Seventy (62.5%) surviving patients were still being managed nonoperatively. There was no significant change in any outcome score (OKS, SF-12 physical component score, SF-12 mental component score, SF-6D) (P = .26 to .84). Forty-two patients had undergone TKA with mean time to surgery 29.0 months (range, 9-69 months). In this group, the mean OKS fell from 17.9 at baseline to 10.3 (range, 3-21) preoperatively (P < .0001) and at 5 years there was a significant improvement from baseline in OKS, SF-12 physical component score, and SF-6D scores (P < .0001). All outcome scores and change in scores were significantly higher for the surgical group (all P < .001).
Although a high proportion of patients with knee OA have avoided surgery at 5 years, their outcomes show no improvement from baseline and are poorer than those who have undergone TKA. Avoidance of surgery should not necessarily be regarded as an indicator of success of nonoperative treatment for the patient.
The purpose of this study is to determine outcomes of a nonoperative treatment service for hip and knee osteoarthritis (OA), the “Joint Clinic,” at minimum 5-year follow-up, and investigate factors ...that may influence progression to joint replacement surgery.
This is an observational cohort study of 337 patients with hip (n = 151, 45%) or knee OA (n = 186, 55%) seen at the Joint Clinic, at 5-7 years of follow-up. Kaplan-Meier survival curves were used to determine survivorship of the affected joint and Cox regression used to determine factors associated with time to surgery.
At mean 6-year follow up, 188 (56%) patients had undergone or were awaiting total joint arthroplasty, 127 (38%) were still being managed nonoperatively, and 22 (7%) had died without having surgery. Patients with hip OA were more likely to have required surgery (111/151, 74%) than patients with knee OA (77/186, 41%) (chi-square = 33.6, P < .001). The 7-year surgery-free survival for hip OA was 23.7% and knee OA 55.9% (P < .001). Factors associated with increased likelihood of surgery were joint affected (hip, hazard ratio HR 2.80), Kellgren-Lawrence (KL) grade (KL 3, HR 2.02; KL 4, 4.79), and Oxford Hip/Knee Score (HR 1.34 for each 5 points worse at baseline).
More than 50% of the patients referred to secondary care with mild-moderate knee OA may not need surgery at 7 years. Patients with hip OA and those with severe radiographic changes are more likely to require surgery and should not be delayed if there is not an adequate response to conservative measures.
Background
Most public hospitals are receiving more referrals for first specialist assessment than they have capacity to see. Traditional priority categories are too broad for effective ...discrimination. In New Zealand (NZ) explicit prioritization is required by legislation and supported by the Medical Council of NZ. A new generic National Referral Prioritization tool (NRPT) has been developed which includes a patient impact on life score. This study reports its trial implementation in orthopaedic surgery in a single centre.
Methods
Four months of referrals to the orthopaedic department were prioritized using the new NRPT and traditional clinical priority categories. Scores and acceptances were compared across conditions, surgeons and against the traditional categories.
Results
The mean NRPT was 60.1 (range 23–99). The correlation with impact on life was 0.59. There was good consistency of scores between surgeons. The NRPT score was significantly different across clinical priority categories (urgent, semi‐urgent, routine). A total of 305 referrals (49%) were accepted using the NRPT compared with 493 (79%) if the traditional tool had been used. Patients with foot and ankle, carpal tunnel syndrome and upper limb conditions had the lowest scores and were more likely to be declined.
Conclusions
The NRPT is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. It allows fine‐tuning of a threshold score to balance acceptances and capacity.
The National Referral Prioritization tool is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. In future, it may allow comparison between specialities and other hospitals.
Critically ill patients have considerable oxidative stress. Glutamine and antioxidant supplementation may offer therapeutic benefit, although current data are conflicting.
In this blinded 2-by-2 ...factorial trial, we randomly assigned 1223 critically ill adults in 40 intensive care units (ICUs) in Canada, the United States, and Europe who had multiorgan failure and were receiving mechanical ventilation to receive supplements of glutamine, antioxidants, both, or placebo. Supplements were started within 24 hours after admission to the ICU and were provided both intravenously and enterally. The primary outcome was 28-day mortality. Because of the interim-analysis plan, a P value of less than 0.044 at the final analysis was considered to indicate statistical significance.
There was a trend toward increased mortality at 28 days among patients who received glutamine as compared with those who did not receive glutamine (32.4% vs. 27.2%; adjusted odds ratio, 1.28; 95% confidence interval CI, 1.00 to 1.64; P=0.05). In-hospital mortality and mortality at 6 months were significantly higher among those who received glutamine than among those who did not. Glutamine had no effect on rates of organ failure or infectious complications. Antioxidants had no effect on 28-day mortality (30.8%, vs. 28.8% with no antioxidants; adjusted odds ratio, 1.09; 95% CI, 0.86 to 1.40; P=0.48) or any other secondary end point. There were no differences among the groups with respect to serious adverse events (P=0.83).
Early provision of glutamine or antioxidants did not improve clinical outcomes, and glutamine was associated with an increase in mortality among critically ill patients with multiorgan failure. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00133978.).
Summary
Cardiopulmonary exercise testing is performed increasingly for cardiorespiratory fitness assessment and pre‐operative risk stratification. Lower limb osteoarthritis is a common comorbidity in ...surgical patients, meaning traditional cycle ergometry‐based cardiopulmonary exercise testing is difficult. The purpose of this study was to compare cardiopulmonary exercise testing variables and subjective responses in four different exercise modalities. In this crossover study, 15 patients with osteoarthritis scheduled for total hip or knee arthroplasty (mean (SD) age 68 (7) years; body mass index 31.4 (4.1) kg.m‐2) completed cardiopulmonary exercise testing on a treadmill, elliptical cross‐trainer, cycle and arm ergometer. Mean (SD) peak oxygen consumption was 20‐30% greater on the lower limb modalities (treadmill 21.5 (4.6) (p < 0.001); elliptical cross‐trainer (21.2 (4.1) (p < 0.001); and cycle ergometer (19.4 (4.2) ml.min−1.kg−1 (p = 0.001), respectively) than on the arm ergometer (15.7 (3.7) ml.min‐1.kg‐1). Anaerobic threshold was 25‐50% greater on the lower limb modalities (treadmill 13.5 (3.1) (p < 0.001); elliptical cross‐trainer 14.6 (3.0) (p < 0.001); and cycle ergometer 10.7 (2.9) (p = 0.003)) compared with the arm ergometer (8.4 (1.7) ml.min−1.kg−1). The median (95%CI) difference between pre‐exercise and peak‐exercise pain scores was greater for tests on the treadmill (2.0 (0.0‐5.0) (p = 0.001); elliptical cross‐trainer (3.0 (2.0‐4.0) (p = 0.001); and cycle ergometer (3.0 (1.0‐5.0) (p = 0.001)), compared with the arm ergometer (0.0 (0.0‐1.0) (p = 0.406)). Despite greater peak exercise pain, cardiopulmonary exercise testing modalities utilising the lower limbs affected by osteoarthritis elicited higher peak oxygen consumption and anaerobic threshold values compared with arm ergometry.
Objective
The Osteoarthritis Research Society International (OARSI) recommends assessment of physical function using a performance‐based test of stair negotiation but was unable to recommend any ...specific test. We assessed the reliability, validity, responsiveness, measurement error, and minimum important change (MIC) of the 6‐step timed Stair Climb Test (SCT).
Methods
We used pooled data from 397 participants with hip or knee osteoarthritis (54% women) from 4 clinical trials (86% retained at 12‐week follow‐up). Construct validity was assessed by testing 6 a priori hypotheses against other OARSI‐recommended physical function measures. A self‐reported Global Rating of Change scale was used to classify participants as worsened, improved, and stable. Participants who worsened in physical function were excluded from all analyses. Responsiveness and MIC were assessed using multiple anchor‐based and distribution‐based approaches. Test–retest reliability, standard error of measurement (SEM), and smallest detectable change (SDC) were assessed on stable participants.
Results
Five of 6 hypotheses (83%) for construct validity were met. Test–retest reliability was excellent (intraclass correlation coefficient2,1 0.83; 95% confidence interval 0.71–0.90). The SEM and SDC values were 0.44 and 1.21 seconds, respectively. We did not find adequate support for responsiveness. The MIC values ranged from 0.78 to 1.95 seconds using different approaches (median 1.37 seconds).
Conclusion
The 6‐step timed SCT adequately assesses the construct of physical function in individuals with hip or knee osteoarthritis with excellent 12‐week test–retest reliability. However, support for its responsiveness was inadequate to recommend its use as an outcome measure in people with osteoarthritis for research and clinical practice.
To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem.
Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and ...either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing.
There were 61 revisions (9.7%; 0.82 revisions/100 observed component years, (OCYs)) in the all-cemented group and 18 (4.0%; 0.30/100 OCYs) in the hybrid group. The cumulative incidence of revision at 18 years was 12.1% for cemented and 5.2% for hybrids. There was a significantly greater risk of revision for all-cemented compared with hybrids (unadjusted sub-hazard ratio (SHR) 2.44; p = 0.001), and of revision for loosening, wear, or osteolysis (unadjusted SHR 3.77; p < 0.001). After adjustment, the increased risk of all-cause revision did not reach significance at age 70 years and above. The advantage for revision for loosening, wear, and osteolysis remained at all ages.
This study supports the use of uncemented acetabular fixation when used in combination with the Exeter stem with improved survivorship for revision for aseptic loosening, wear, and osteolysis at all ages and for all-cause revision in patients less than 70 years. Cite this article:
2020;102-B(4):414-422.
Background:
The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of ...functional bracing.
Methods:
Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution’s physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS).
Results:
With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated (P = 0.30) or between patients younger and older than 40 years at time of injury (P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = −0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = −0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS.
Conclusions:
This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing.
Level of Evidence:
Level II, prospective comparative study.
Despite increased use of uncemented and hybrid fixation, there is little evidence of their superiority over cemented implants. The aim of this study is to compare the long-term survivorship of ...cemented, hybrid and uncemented total hip arthroplasty (THA) at varying ages.
A total of 2156 hips (1315 cemented, 324 uncemented, and 517 hybrid) were performed in a single center between 1999 and 2005 with follow-up through to 2017. Registry and local databases were used to determine revision rates and cause. Unadjusted and adjusted competing risk survival analysis was performed.
The cumulative incidence of all-cause revision at 18 years was cemented 10.9%, uncemented 8.9%, and hybrid 6.5%. Cemented fixation had a statistically significant higher risk of all-cause revision than hybrid in the adjusted model for all ages to 65 years (subhazard ratios SHRs, 2.28-4.67) and a higher risk of revision for loosening, wear, or osteolysis at all ages (SHRs, 3.25-6.07). Uncemented fixation showed no advantage over hybrid fixation at any age, but did show advantages over cemented at younger ages (≤60 years) for all-cause revision (SHRs, 2.3-4.3).
Hybrid fixation with conventional polyethylene shows an advantage over cemented hips at all ages. Uncemented THA showed improved survival over cemented only at younger ages and no advantage over hybrid THA.
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