While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR.
The aim of this study was to investigate surgeons’ reported change of treatment preference in response to the results and conclusion from a randomized controlled trial (RCT) and to study patterns of change between subspecialties and nationalities. Two questionnaires were developed through the Delphi process for this cross-sectional survey of surgical preference. The first questionnaire was sent out before the publication of a RCT and the second questionnaire was sent out after publication. The RCT investigated repair or non-repair of the pronator quadratus (PQ) muscle during volar locked plating of distal radial fractures (DRFs). Overall, 380 orthopaedic surgeons were invited to participate in the first questionnaire, of whom 115 replied. One hundred surgeons were invited to participate in the second questionnaire. The primary outcome was the proportion of surgeons for whom a treatment change was warranted, who then reported a change of treatment preference following the RCT. Secondary outcomes included the reasons for repair or non-repair, reasons for and against following the RCT results, and difference of preferred treatment of the PQ muscle between surgeons of different nationalities, qualifications, years of training, and number of procedures performed per year. Of the 100 surgeons invited for the second questionnaire, 74 replied. For the primary outcome, 6 of 32 surgeons (19%), who usually repaired the PQ muscle and therefore a change of treatment preference was warranted, reported a change of treatment preference based on the RCT publication. Of the secondary outcomes, restoring anatomy was the most common response for repairing the PQ muscle. The majority of the orthopaedic surgeons, where a change of treatment preference was warranted based on the results and conclusion of a RCT, did not report willingness to change their treatment preference.
In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery. A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals. Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes. Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events.
Obesity is associated with worse outcomes following total knee/hip arthroplasty (TKA/TKA). This study aimed to determine the feasibility of a dietitian-led low-inflammatory weight-loss program for people with obesity awaiting arthroplasty. Quasi-experimental pilot study enrolled people with obesity waitlisted for primary TKA/THA into ‘usual care’ (UC) or weight-loss (low-inflammatory diet) program (Diet). Recruitment occurred between July 2019 and February 2020 at Fairfield and Campbelltown Hospitals. Assessments at baseline, pre-surgery, time of surgery and 90-days following surgery included anthropometric measurements, patient-reported outcomes, serum biomarkers and 90-day postoperative complication rate. 97 people consented to the study (UC, n=47, mean age 67, BMI 37, TKA 79%; Diet, n=50, mean age 66, BMI 36, TKA 72%). Baseline characteristics indicated gross joint impairments and poor compliance with a low-inflammatory diet. Study feasibility criteria included recruitment rate (52%), proportion of diet patients that improved compliance to low-inflammatory diet by ≥10% (57%) and had ≥60% attendance of dietitian consultations (72%), proportion of patients who undertook serum biomarkers (55%). By presurgery assessments, the diet group had more patients who cancelled their surgery due to symptom improvement (4 vs 0), reduced waist-circumference measurements, increased compliance with the Low-Inflammatory diet and preservation of physical activity parameters. More usual care participants experienced at least one postoperative complication to 90-days (59% vs 47%) and were discharged to inpatient rehabilitation (21% vs 11%). There was no difference in weight change, physical function, and patient-reported outcome measures from pre-surgery to 90-days post-surgery, and length of hospital stay. Using pre-determined feasibility criteria, conducting a definitive trial is not feasible. However, intervention audit demonstrated high intervention fidelity. Pilot data suggest our program may promote weight loss but the clinical effects for most are modest. Further research utilising a stronger intervention may be required to assess the effectiveness of a pre-arthroplasty weight-loss intervention.
In this study we compare survivorship and patient reported outcome measures in robotically assisted versus conventional Total Hip Arthroplasty (THA). This paper investigates the hypothesis that implant survival and PROMS following THAs performed with robotic assistance were not different to outcomes following conventional THAs. Data included all patients undergoing THA for osteoarthritis between 19 April 2016 and 31 December 2020. Analysis of PROMS outcomes was restricted to those who had completed PROMS data preoperatively and at 6 months postoperatively. There were 157,647 procedures, including 3567 robotically assisted procedures, available for comparison of revision rates. 4557 procedures, including 130 robotically assisted procedures, had PROMS data available. The revision rate of primary THA performed with robotic assistance was not statistically different from THA performed by conventional methods (4 year cumulative percent revision 3.1% v 2.7%; HR = 1.05, p=0.67). The Oxford Hip Score, VAS for pain and the EQ-VAS score for overall health showed no statistically significant difference between the groups. The EQ-5D Utility Score showed an improved score (median score 1 v 0.88; OR = 1.58, p=0.007) for the robotically assisted group compared to the conventional group. Robotic assisted THA was not associated with significant improvement in early revision or joint-specific PROMs. The findings may have been biased, in either direction, by unmeasured patient, surgeon, hospital and prosthesis factors. The findings (including the difference in health-related quality of life) may have also been influenced by lack of blinding. Future research should include methods to minimise these biases.
While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR.
Emerging evidence has linked the long-term use of alendronate (fosamax) with subtrochanteric insufficiency fractures. However, findings to date have been anecdotal. The aims of this study were to determine the incidence of subtrochanteric insufficiency fractures and identify whether they were more prevalent following the introduction of alendronate in Australia. All patients that presented between January 2007 and February 2009 with low- energy subtrochanteric fracture were identified. Similar data were collected between January 1995 and February 1997 as this was immediately prior to introduction of alendronate in Australia. The radiographs were examined for failure due to pre- existing insufficiency fracture. Characteristic findings were a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. We also separately identified all patients that presented between 2007 and 2009 with a proximal femoral fracture and determined the proportion taking alendronate. One hundred and seventeen patients with low-energy subtrochanteric fracture were included. Seventy-nine patients presented between 2007 and 2009 and 38 presented between 1995 and 1997. Forty-one of the 79 (52%) patients were identified as having radiograph findings suggestive of underlying insufficiency fracture, whilst none were identified prior to the introduction of alendronate. Of the 41 patients with subtrochanteric insufficiency fracture, 40 (98%) had been taking alendronate and one had been taking risedronate. Twenty-nine of the 41 (71%) complained of prodromal pain in the affected femur. Eighteen of the 41 (44%) demonstrated subtrochanteric insufficiency changes on the contralateral side and 9 of 41 (22%) sustained spontaneous non-traumatic fracture during activities of daily living. Of the 38 patients without insufficiency changes, 12 (32%) had been taking alendronate. Alendronate use was therefore strongly suggestive of insufficiency fracture (sensitivity = 98%, specificity = 84%, PPV = 77%, NPV = 99%, LR+ = 6). The mean duration of alendronate use in those with insufficiency fracture was 7.1 years (95% CI, 6.6-7.6 years). The mean duration in those without was 3.2 years (95% CI, 2.6-3.8 years, P<0.0001). Three hundred and ninety eight patients presented with a low-energy proximal femur fracture between 2007 and 2009. Of these, only 52 (13%, P<0.0001) were taking alendronate. This is the largest study in the literature on subtrochanteric insufficiency fractures and alendronate therapy. Confirming recent reports, alendronate use was strongly suggestive of subtrochanteric insufficiency fracture. Our findings provide the most compelling evidence to date of the potential long-term sequelae of alendronate but more research is needed before definitive conclusions can be made.
Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function.
Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall. Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and intramedullary fixation (7%). Shoulder surgeons were more likely to operate (p<0.001). For an undisplaced Weber B lateral malleolus fracture, respondents selected plaster cast or boot (59%), lateral plating (31%), posterior plating (9%) and no splinting (2%). For a displaced Colles fracture in an older patient, respondents selected plating (47%), Kirschner wires (28%), cast/splint (23%) and external fixation (1%). Less experienced (p<0.001) and hand surgeons (p=0.024) were more likely to operate. For a two-part neck of humerus fracture in an older patient, respondents selected non-operative (74%), locking plate (14%), and hemiarthroplasty (7%). Shoulder surgeons were more likely to operate (p<0.001). Accounting for all answers in multiple regression modeling, it was found that more experienced surgeons (>15 years) were 25% less likely to operate (p=0.001). Overall, there was no difference among sub-specialties, or whether a surgeon participated in an on-call roster. Considerable practice variation exists among orthopaedic surgeons in the approach to common orthopaedic problems. Surgeons who identify with a sub-specialty are more likely to manage conditions in their area of interest operatively, and more experienced surgeons are less likely to recommend surgical management.
Thromboprophylaxis for venous thromboembolism (VTE) after elective arthroplasty remains controversial. Previous surveys have shown considerable variation amongst orthopaedic surgeons, and the topic is still being debated. Chest physicians recently advocated that randomised data demonstrating a risk reduction with long- established thromboprophylaxis have been ignored by orthopaedic surgeons. We present the current thromboprophylaxis practice amongst AOA members performing elective hip and knee replacements and discuss its rationale. All orthopaedic surgeons in the AOA were asked to complete a one page postal questionnaire asking for information regarding: whether they performed elective hip or knee arthroplasty, which methods of mechanical and/or chemical prophylaxis were routinely used, the time frame in ceasing thromboprophylaxis, the motive in using thromboprophylaxis, and whether thromboprophylaxis guidelines released by the AOA or RACS would be helpful in their orthopaedic practice. Responses from the survery are currently being collected and analysed. These results will be ready for presentation at the AOA conference. The results of the survey will be presented in addition to a discussion of the rationale behind current use of post-operative thromboprophylaxis for elective hip and knee arthroplasty and a need for clinical guidelines.
Patella fractures constitute 1% of all fractures and may disrupt the extensor mechanism of the knee. The mainstay of treatment for most patella fractures is operative fixation; however, patients with intact extensor mechanisms may be treated with splinting. We describe a series of patients with patella fractures managed non- operatively, without restricted weight bearing or splinting. A consecutive series of 21 patients presenting with a patella fracture to two metropolitan hospitals were included in this study. All patients had an intact extensor mechanism but no distinction was made on age or fracture type. All patients were treated non-operatively with analgesia, were allowed to fully weight-bear and were not splinted. A retrospective review of the case notes was performed and data was collected with phone interview. The main outcome measure was the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, which has a maximum (worst) possible score of 240, and which provides an aggregate score of pain, stiffness and function. Mean time at follow up was 24 months (range 5–49 months). WOMAC scores were excellent (mean=18 of possible maximum 240; range 0–84). Only one patient had a significant complication related to their fracture (deep venous thrombosis), which was detected during hospital admission. Most patients had returned to usual work (9/14). No patients required operative fixation. There was no association between adjusted WOMAC score and age, sex, compensation status, time of follow up, or whether the patient had a significant ipsilateral injury. Patients who had returned to work (p=0.02) or who had lower levels of education (p=0.03) had better WOMAC scores. Management of patella fractures with an intact extensor mechanism does not require restricted weight bearing or splinting.
Tibial shaft fractures have a high incidence of delayed and non-union, often requiring multiple procedures. Pulsed electromagnetic field (PEMF) stimulation is a safe and effective treatment for tibial non union but little is known about the efficacy of PEMF in preventing non-union in acute fractures. Between August 2005 and December 2008, eligible patients presenting at six major metropolitan hospitals with acute tibial shaft fractures (AO classification 4-2) were included. Participants were randomised by an independent allocation centre to identical active or inactive PEMF devices, both prescribed to be worn ten hours daily for twelve weeks. Baseline data were collected, and patients and surgeons were surveyed serially via post and/or phone at three, six and twelve months. Participants, data collectors and data analysts were blinded. The main outcome was any surgical intervention for delayed/non union. Data from 150 patients (76 active and 74 inactive) were available for analysis (12 month follow up 78%). There was no between-group difference in age, gender, mechanism of injury, open grade, smoking status, or compliance with the device (hours of use). Overall compliance was moderate (5.7 hours daily use). Fifteen of 76 (20%) of active device patients required surgery for delayed/non-union vs. 8 of 74 (11%) in the placebo group; odds ratio of surgery=2.03, p=0.13, 95% CI 0.80 to 5.12. An intention to treat analysis adjusted for open grade and hours the device was used showed an odds ratio of requiring surgery of 1.78 (p=0.24, 95% CI 0.68 to 4.64). A sub-group analysis of 80 compliant patients (defined a priori as a minimum average of six hours daily use) was performed. Nine of 35 (26%) patients with an active device required surgery for delayed/non-union vs. 3 of 45 (7%) in the placebo group; odds ratio of surgery=7.60 (p=0.017, 95% CI 1.43 to 40.24). Based on these unexpected initial results, PEMF stimulation does not prevent revision surgery for delayed/non-union in acute fractures of the tibial shaft.
