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Background: People post-hip fracture have reported experiences of fragmented care and poor discharge planning, therefore improvements in patient flow are required. This study reports the challenges people face during the discharge process and offers potential solutions for improving the transition from hospital to home from the perspectives of patients, carers, and health professionals., Methods: This was a qualitative study embedded within a multi-centre, feasibility randomised controlled trial (HIP HELPER). We undertook semi-structured interviews with 10 patient-carer dyads (10 people with hip fracture; 10 unpaid carers) and eight health professionals (four physiotherapists, two occupational therapists, one nurse and one physiotherapy researcher) between November 2021 and March 2022. Data were analysed using the principles of Framework Analysis., Results: Participants identified challenges in the transition from hospital to home post-hip fracture surgery: ineffective communication, disjointed systems, untimely services and 'it's more than just the hip'. Possible solutions and insights to facilitate this transition included the need for reassurance, collaborative planning, and individualisation., Conclusion: The transition from hospital to home following hip fracture surgery can be a challenging experience for patients, and for friends and family who support them as carers, making them feel vulnerable, frustrated and uncertain. Enabling a coordinated, collaborative approach to discharge planning and early recovery provision is considered a positive approach to improving NHS care., Trial Registration: ISRCTN13270387. Registered 29th October 2020., Competing Interests: Declarations Ethics approval and consent to participate North East—Newcastle & North Tyneside 1 Research Ethics Committee (20/NE/0213) Date: 14 October 2020. Written informed consent was obtained from all participants. Consent for publication Not required. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Despite contributing to significant morbidity in working-age adults, there is no consensus on the optimal treatment for prepatellar bursitis. Much of the existing literature combines prepatellar and olecranon bursitis. This systematic review aims to determine the optimal management of prepatellar bursitis., Study Design and Methods: A primary search of electronic published and unpublished literature databases from inception to November 2019 was completed. Articles over 25 years old, case reports with less than four patients, paediatric studies, and non-English language papers were excluded. Our primary outcome was recurrence after 1 year. Comparisons included endoscopic vs open bursectomy, duration of antibiotics. Methodological quality was assessed using the Institute of Health Economics and Revised Cochrane Risk of Bias scoring systems. Meta-analyses were conducted where appropriate., Results: In total 10 studies were included (N = 702). Endoscopic and open bursectomy showed no difference in recurrence after 1 year (OR 0.41, 95% CI 0.05-3.53, p = 0.67), and surgical complications (OR 1.44, 95% CI 0.34-6.08, p = 0.44). 80% endoscopically-treated patients were pain free after 1 year. Patients treated with antibiotics for less than 8 days were not significantly more prone to recurrence (2/17 vs 10/114, OR 0.66, 95% CI 0.13-3.29, p = 0.64) compared to 8 days plus at minimum 1 year post injury., Conclusions: Our study represents the largest cohort of patients evaluating management strategies for prepatellar bursitis, and includes data not previously published. Endoscopic bursectomy is non-inferior to open bursectomy, enabling a shorter hospital stay. It also offers a relatively low risk of post-operative pain. Endoscopic bursectomy is a viable option to treat both septic and aseptic prepatellar bursitis. Our small cohort suggests recurrence and hospital stay are not improved with antibiotic treatment exceeding 7 days for septic prepatellar bursitis., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aims: To establish the incidence and nature of injuries seen in patients following mobility scooter incidents., Methods: The Trauma Audit and Research Network (TARN) database was used to collect data concerning injuries associated with mobility scooters. The data was taken from incidents that occurred between February 2014 and November 2020. The data analysed included: patient demographics, injury mechanism and patterns and associated mortality rates., Results: 1,504 patients were identified of which 61.4% were male. The median age was 76.2 years (IQR 63.5-84.9). The median injury severity score (ISS) was 9 (IQR 9-17), with major trauma (ISS ≥16) being observed in 29.4% of patients. Injuries to the limb were most common, although injuries to the head were most severe. Vehicle collisions accounted for 65.4% of injuries and were most closely associated with the most severe incidents. The median length of stay in hospital was 12 days, excluding the patients who died. Overall, mortality following injury was 10.6%, but the mortality rate was 15.4% in those aged 75 years and over, and 24.2% in those sustaining severe trauma., Conclusion: As the population ages, injury characteristics of those with both major and non-major trauma changes. Mobility scooter use is prevalent amongst older people, and we provided a detailed analysis of injuries sustained with their use across a national database. The length of stay and the inherent resource use, because of admission following mobility scooter trauma, is considerable. These injuries particularly affect the 'most elderly' and carry a considerable mortality burden., Competing Interests: Declaration of Competing Interest None to declare, (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture., Introduction: To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital., Methods: We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death., Results: The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19-1.30) and 1.26 (95% CI 1.19-1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18-1.52) and 1.33 (95% CI 1.12-1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08-1.15) and 1.10 (95% CI 1.05-1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge., Conclusion: We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture., (© 2021. The Author(s).)

Introduction: Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis., Methods: Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360)., Results: The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low., Conclusions: There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings., (© 2021. The Author(s).)

Purpose: To determine the prevalence and change in neuropathic pain or pain catastrophizing before and 12 months following patellar stabilisation surgery for patellofemoral instability., Methods: We conducted a prospective clinical audit within a UK NHS orthopaedic surgical centre. Data from 84 patients with patellofemoral instability requiring stabilisation were analysed. Fifty percent (42/84) underwent MPFL reconstruction alone, and 16% (13/84) had both trochleoplasty and MPFL reconstruction. Neuropathic pain was assessed using painDETECT score. Pain catastrophizing was assessed using the Pain Catastrophizing Score. The Norwich Patellar Instability (NPI) Score and Kujala Patellofemoral Disorder Score were also routinely collected pre-operatively and one year post-operatively., Results: At 12 months post-operatively there was a statistically significant reduction in mean Pain Catastrophizing Scores (18.9-15.7; p < 0.02), but no change in mean painDETECT scores (7.3-7.8; p = 0.72). There was a statistically significant improvement in NPI scores (90.2-61.9; p < 0.01) and Kujala Patellofemoral Disorder Scores (48.7-58.1; p = 0.01). The prevalence of pain catastrophizing decreased from 31% pre-operatively to 24% post-operatively, whereas the prevalence of neuropathic pain remained consisted (10-11%)., Conclusions: Neuropathic pain and catastrophizing symptoms are not commonly reported and did not significantly change following patellofemoral stabilisation surgery. Whilst low, for those affected, there remains a need to intervene to improve outcomes following PFI surgery.

Introduction: Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR., Materials and Methods: A primary search of electronic databases, grey literature, and trial registries was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Outcome measures were grouped into short (< 6 months), medium (6-12 months), and long term (> 12 months). Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials., Results: All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p < 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at 2 weeks [65.98 (SD = 14.51) versus 47.35 (SD = 14.48) p = 0.000], 4 weeks [88.20 (SD = 15.11) versus 57.65 (SD = 14.80) p = 0.000], and 6 months [105.33 (SD = 12.34) versus 85.53 (SD = 14.77) p = 0.000] post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme [TSK - 14.30 (SD = 0.80) versus - 2.10 (SD = 0.80) p < 0.001], an outpatient cognitive behavioural therapy (CBT) programme [TSK 27.76 (SD = 4.56) versus 36.54 (SD = 3.58)], and video-based psychological treatment [TSK 24 (SD = 5) versus 29 (SD = 5) p < 0.01]., Conclusions: Kinesiophobia negatively affects functional outcomes up until 1 year post-operatively, while active ROM is reduced up to 6 months post-procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

Background: Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability., Methods: This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; 'Personalised Knee Therapy' (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use., Results: We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months., Conclusion: This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability., Trial Registration: The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). http://www.isrctn.com/ISRCTN14950321., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Aims: To investigate the incidence and pattern of injury in patients with a diagnosis of a fall from a stairlift., Methods: Data was analysed from the Trauma Audit and Research Network (TARN) database from 2000 to 2018 for those recorded suffering stairlift related injuries between the ages of 40-100 years. Patient demographics, injury mechanism and pattern, mortality rate and height of fall were analysed., Results: 1069 patients were identified in the initial search with 651 having an eligible mechanism of injury. The mean age was 82 (range 41.4-100.1) years. The most common site of injury was the limbs (49.2%) with the most severe injuries to the head (mean AIS 3.1). The mean ISS was 12.5 (Range 1-75). There was no relationship between height of fall and ISS (r s 0.054 p = 0.4). Individuals were 78% more likely to have an ISS score of 15 or more if they had a head injury, (OR: 0.12; 95% CI: 0.06-0.24) and 79% more likely to have sustained an injury to the thorax (OR: 0.21; 95% CI: 0.11-0.41). Injury to the head was 95% more likely in individuals with an ISS score greater than 25 points or more (OR: 0.05; 95% CI: 0.01-0.16) and 69% more likely for those who sustain injury to the thorax. Individuals with an ISS score of 25 points or more were 18 times more likely to have sustained injury getting off their stair lift compared to any other method of falling from their stair lift. Mortality was associated with injuries to the thorax in those aged 70 years or below, injuries to the face, spine and limb for those aged 71-85 years and with head injury in those over 85 years. The overall mortality rate was 15.7%., Conclusion: Falls from stairlifts commonly result in limb injuries and most severe injuries are sustained to the head. When patients fall getting off from astairlift, have injuries to their head or thorax they have a higher ISS. The overall mortality is 15.7%. Given the increasing use of stairlifts in our ageing population, strategies should be considered to make these safer., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020. Published by Elsevier Ltd.)

Background: Patellar dislocations account for two percent of all knee injuries with a 17% chance of re-dislocation. There are few validated scores specific to instability. One of these is the Norwich Patellar Instability Score. There has been limited assessment of the validity, floor-ceiling effect and responsiveness of the Norwich Patellar Instability (NPI) Score from an independent centre. The purpose of this paper is to address this limitation., Methods: Data from 90 patients referred to a tertiary referral patellofemoral clinic were analysed. All routinely completed data including NPI Score, Kujala Patellofemoral Disorder Score, and demographic outcomes during appointments, up to 36 months following initial clinical assessment was analysed. Convergent validity was assessed by correlating outcomes of the Kujala Patellofemoral Disorder Score to the NPI Score. Effect size (ES) was determined between baseline to 12-month and 12 to 36-month assessments to determine responsiveness. Floor-ceiling effect was evaluated at baseline, 12-month and 12 to 36-month follow-up., Results: NPI Score demonstrated good convergent validity to the Kujala Patellofemoral Disorder Score (p < .001; 95% confidence interval (CI): -0.71 to -0.52). NPI Score demonstrated good responsiveness to change both between baseline to 12 months (ES: 0.43; 95% CI: 0.42 to 0.10) and 12 to 36 months (ES: 0.67; 95% CI: 0.60 to 0.15). Whilst the NPI Score did not demonstrate a ceiling effect, there was moderate risk of a floor-effect where 13% of the cohort reported the lowest levels of NPI scores., Conclusions: The NPI Score is a valid and responsive outcome for people with recurrent patellar dislocation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To determine the relationship between falls and deficits in specific cognitive domains in older adults., Design: An analysis of the English Longitudinal Study of Ageing (ELSA) cohort., Setting: United Kingdom community-based., Participants: 5197 community-dwelling older adults recruited to a prospective longitudinal cohort study., Measurements: Data on the occurrence of falls and number of falls, which occurred during a 12-month follow-up period, were assessed against the specific cognitive domains of memory, numeracy skills, and executive function. Binomial logistic regression was performed to evaluate the association between each cognitive domain and the dichotomous outcome of falls in the preceding 12 months using unadjusted and adjusted models., Results: Of the 5197 participants included in the analysis, 1308 (25%) reported a fall in the preceding 12 months. There was no significant association between the occurrence of a fall and specific forms of cognitive dysfunction after adjusting for self-reported hearing, self-reported eyesight, and functional performance. After adjustment, only orientation (odds ratio [OR]: 0.80; 95% confidence intervals [CI]: 0.65-0.98, p = 0.03) and verbal fluency (adjusted OR: 0.98; 95% CI: 0.96-1.00; p = 0.05) remained significant for predicting recurrent falls., Conclusions: The cognitive phenotype rather than cognitive impairment per se may predict future falls in those presenting with more than one fall.

Background: clinical trials test the effectiveness or efficacy of treatments. It is important that researchers evaluate interventions with the most meaningful outcome measures. The 2014 hip fracture core outcome set recommended that mortality, mobility, pain, activities of daily living and health-related quality of life (HRQOL) should be assessed in all trials of patient with hip fracture. The purpose of this analysis was to determine the uptake of these recommendation., Methods: all trials registered from 1997 to 2018 recruiting participants following hip fracture were identified from the ClinicalTrials.gov trials registry. The frequency of each core domain adopted annually were assessed., Results: 311 trials were identified and analysed. On analysing trial registries for years which presented a minimum of 10 registrations, full core outcome set adoption ranged from 0% (2017; 2018) to 24% (2009). Mortality and mobility were the most consistently reported domains (mortality: 27% (2017) to 56% (2011); mobility: 36% (2015) to 60% (2004)). In contrast, pain and HRQOL were least reported (pain: 14% (2017) to 61% (2015); HRQOL: 10% (2010) to 11% (2008)). There was no clear change in core outcome domain set adoption following the publication of Hayward et al.'s (2014) core outcome set., Conclusions: there has been limited adoption of the hip fracture core outcome set from its publication in 2014. Further consideration to improve implementation is required to improved uptake., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To assess reliability and discriminative validity of cartilage compositional magnetic resonance imaging (MRI) in knee osteoarthritis (OA)., Design: The study was carried out per PRISMA recommendations. We searched MEDLINE and EMBASE (1974 - present) for eligible studies. We performed qualitative synthesis of reliability data. Where data from at least two discrimination studies were available, we estimated pooled standardized mean difference (SMD) between subjects with and without OA. Discrimination analyses compared controls and subjects with mild OA (Kellgren-Lawrence (KL) grade 1-2), severe OA (KL grade 3-4) and OA not otherwise specified (NOS) where not possible to stratify. We assessed quality of the evidence using Quality Appraisal of Diagnostic Reliability (QAREL) and Quality Assessment of Diagnostic Accuracy (QUADAS-2) tools., Results: Fifty-eight studies were included in the reliability analysis and 26 studies were included in the discrimination analysis, with data from a total of 2,007 knees. Intra-observer, inter-observer and test-retest reliability of compositional techniques were excellent with most intraclass correlation coefficients >0.8 and coefficients of variation <10%. T1rho and T2 relaxometry were significant discriminators between subjects with mild OA and controls, and between subjects with OA (NOS) and controls (P < 0.001). T1rho showed best discrimination for mild OA (SMD [95% CI] = 0.73 [0.40 to 1.06], P < 0.001) and OA (NOS) (0.60 [0.41 to 0.80], P < 0.001). Quality of evidence was moderate for both parts of the review., Conclusions: Cartilage compositional MRI techniques are reliable and, in the case of T1rho and T2 relaxometry, can discriminate between subjects with OA and controls., (Copyright © 2018 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Evidence-based practice is a foundation to clinical excellence. However there remains little evidence on the characteristics of authors who contribute to the evidence-base and whether these have changed over time. The purpose of this study was to explore these characteristics by undertaking a bibliometric analysis to explore publication and authorship characteristics in a leading sub-speciality orthopaedic journal (The Knee) over a 20-year period., Methods: All articles published in The Knee in 1996, 2006 and 2016 were identified. For each article, data collected included: highest academic award; profession; gender; continent of first and last author; total number of authors; the level of evidence; and funding source. We analysed temporal changes in these variables using appropriate statistical models., Results: A total of 413 papers were analysed. Between 1996 to 2016 there has been a significant increase in the overall number of authors, the number of paper submitted from Asia, the proportion of Level 1 or 2 tiered evidence, the proportion of people with Bachelor or Master-level degrees as their highest level of educational award and the proportion of non-medically qualified authors (P<0.001). From 2006 to 2016 there was a significant increase in the proportion of articles whose first author was female (P=0.03), but no significant change in the number of females as last author (P=0.43)., Conclusion: The findings indicate that there have been changes in publication and authorship characteristics in this sub-speciality orthopaedic journal during the past 20years. This provides encouraging indication of greater diversification and internationalisation of orthopaedic research., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To determine whether physical activity measured using the Physical Activity Scale for the Elderly (PASE), changes during the initial 24 months post-total hip (THR) or knee replacement (TKR), and how this compares to a matched non-arthroplasty cohort., Design: Case-controlled study analysis of a prospectively collected dataset., Setting: USA community-based., Participants: 116 people post-THR, 105 people post-TKR compared to 663 people who had not undergone THR or TKR, or had hip or knee osteoarthritis. Cohorts were age-, gender- and BMI-matched., Main Outcome Measures: Physical activity assessed using the 12-item PASE at 12 and 24 months post operatively., Results: There was no significant difference in total PASE score between pre-operative to 12 months (mean: 136 vs 135 points; p=0.860) or 24 months following THR (mean: 136 vs 132 points; p=0.950). Whilst there was no significant difference in total PASE score from pre-operative to 12 months post-TKR (126 vs 121 points; p=0.930), by 24 months people following TKR reported significantly greater physical activity (126 vs 142 points; p=0.040). There was no statistically significant difference in physical activity between the normative matched and THR (p≥0.140) or TKR (p≥0.060) cohorts at 12 or 24 months post joint replacement., Conclusions: Physical activity is not appreciably different to pre-operative levels at 12 or 24 months post-THR, but was greater at 24 months following TKR. Health promotion strategies are needed to encourage greater physical activity participation following joint replacement, and particularly targeting those who undergo THR., (Copyright © 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

To systematically review the evidence to determine the clinical outcomes and the important methodological quality features of interventional studies on adults with non-inflammatory multi-joint pain (MJP). Systematic search of published and unpublished literature using the databases: AMED, CINAHL, MEDLINE, EMBASE, psycINFO, SPORTDiscus, PEDro, OpenGrey, the EU Clinical Trials Register, World Health Organization International Clinical Trial Registry Platform, ClinicalTrials.gov and the ISRCTN registry (search: inception to 19th October 2017). All papers reporting the clinical outcomes of non-pharmacological interventions for people with non-inflammatory MJP were included. Studies were critically appraised using the Downs and Black Critical Appraisal and the TIDieR reporting checklists. Data were analysed using a Best Evidence Synthesis approach. From 3824 citations, four papers satisfied the eligibility criteria. Three studies reported outcomes from multidisciplinary rehabilitation programmes and one study reported the findings of a spa therapy intervention. All interventions significantly improved pain, function and quality of life in the short-term. There was limited reporting of measures for absenteeism, presenteeism and psychosocial outcomes. The evidence was 'weak', and due to a lack of controlled trials, there is limited evidence to ascertain treatment effectiveness. Design consideration for future trials surround improved reporting of participant characteristics, interventions and the standardisation of core outcome measures. There is insufficient high-quality trial data to determine the effectiveness of treatments for non-inflammatory MJP. Given the significant health burden which this condition presents on both individuals and wider society, developing and testing interventions and accurately reporting these, should be a research priority. Registration PROSPERO (CRD42013005888).

Objectives: Although osteoarthritis (OA) is a common condition in older adults, the role of OA in increasing cardiovascular disease (CVD) incidence is still debated. The aim of this study was to investigate the association between OA and the onset of CVD in a large database of American adults., Design: Longitudinal., Setting: Community-dwelling., Participants: People with OA or at high risk of OA., Measurements: Osteoarthritis was defined as the presence of OA of the hand, knee, hip, back/neck or of other sites. CVD was defined as self-reported presence of heart attack, heart failure, stroke and other cerebral atherosclerotic conditions, and peripheral artery disease., Results: A total 4,265 persons without CVD (mean age=60.8 years, females=59.2%) at baseline were analyzed (1,775 with OA versus 2,490 without). Over a mean of 8.2 years, according to an adjusted Cox's regression analysis for 11 potential baseline confounders, study participants with OA of any joint had a significantly higher risk of developing CVD compared to those without OA (Hazard ratio (HR): =1.27; 95% CI: 1.03-1.56). The presence of hand OA was associated with a higher risk of developing CVD (HR=1.31; 95%CI: 1.01-1.68) with respect to those who had no OA. Knee, hip and back/neck OA did not, instead, increase the risk of developing CVD. The association between OA and CVD was significant in the women, but not in the men., Conclusions: OA, in particular, when it affects the hand and in women, was associated with a higher risk of developing CVD., Competing Interests: The Authors declare that there is no conflict of interest.

Introduction: Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator., Materials and Methods: A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5)., Results: Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important., Conclusion: We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To determine the prevalence and change in social isolation and loneliness in people before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in England., Design: The English Longitudinal Study of Ageing (ELSA) dataset, a prospective study of community-dwelling older adults, was used to identify people who had undergone primary THA or TKA because of osteoarthritis. Social isolation was assessed using the ELSA Social Isolation Index. Loneliness was evaluated using the Revised University of California, Los Angeles (UCLA) Loneliness Scale. The prevalence of social isolation and loneliness were calculated and multilevel modelling was performed to assess the potential change of these measures before arthroplasty, within a two-year operative-recovery phase and a following two-year follow-up., Results: The sample consisted of 393 people following THA and TKA. The prevalence of social isolation and loneliness changed from 16.9% to 18.8% pre-operative to 21.8% and 18.9% at the final post-operative follow-up respectively. This was not a statistically significant change for either measure (P = 0.15; P = 0.74). There was a significant difference in social isolation at the recovery phase compared to the pre-operative phase (P = 0.01), where people following arthroplasty reported an increase in social isolation (16.9-21.4%). There was no significant difference between the assessment phases in respect to UCLA Loneliness Scale score (P ≥ 0.74)., Conclusions: Given the negative physical and psychological consequences which social isolation and loneliness can have on individuals following THA or TKA, clinicians should be mindful of this health challenge for this population. The reported prevalence of social isolation and loneliness suggests this is an important issue., (Copyright © 2017 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery., Methods: Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach., Results: A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium., Conclusion: Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objectives: To explore the musculoskeletal health of retired professional ballet dancers in the United Kingdom (UK)., Design: Online national survey., Participants: Retired professional ballet dancers living in the UK., Methods: The survey explored: what musculoskeletal injuries or diseases are experienced by retired professional ballet dancers; which anatomical regions were affected by musculoskeletal injuries or diseases in retired professional ballet dancers; whether ballet dancers were forced to retire from professional ballet due to musculoskeletal injuries or disease., Results: Forty-six retired ballet dancers responded. Thirty-six percent (n = 17) of respondents reported retiring from ballet due to musculoskeletal injury. The median age when respondents retired from professional ballet was 29 years. The most common issues that caused people to retire were hip and back pain (25%; n = 9 respectively), followed by hamstring injuries, ankle injuries, cervical spine injuries, and anterior knee pain (13% respectively; n = 5). Ninety-one percent (n = 42) reported experiencing muscle and joint pain post-retirement., Conclusions: Musculoskeletal pain and disease was a problem for respondents in this study. Further investigation is needed to define the problem, so management can be examined. Comparing performance and training regimes to injury rates in professional dancers, and then following these cohorts into retirement, would increase knowledge on this population., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aims: Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients., Methods: A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality., Results: From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups., Conclusion: For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160-6., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Introduction: Falls are a major challenge for older people and are a significant source of mortality and morbidity. There has been uncertainty as to whether people with total hip (THA) or knee (TKA) arthroplasty have a greater risk of falls and associated fractures. This analysis was to explore this question with a large community dataset., Materials and Methods: Data from all people enroled onto the US Osteoarthritis Initiative programme who had undergone a THA (n = 104) or TKA (n = 165), within a 12-month period, were compared to those who had not undergone an arthroplasty (n = 4631). Data were collected on: the number of participants who reported a fall within a 12-month period; the frequency of falls in this period; and whether a fracture was sustained during this period. Odd ratios were calculated for the probability of experiencing a fall or fracture between the groups., Results: There was no statistical difference in falls between people following THA (OR 0.90; 95 % CI 0.58-1.41) or TKA (OR 0.95; 0.67-1.35) compared to a non-arthroplasty cohort. Whilst there was no statistical difference in fracture risk between people following TKA compared to non-arthroplasty individuals (OR 1.25; 95 % CI 0.57-2.70), those who underwent THA had a 65 % lower chance of experiencing a fracture in the initial 12 post-operative months compared to the non-THA cohort (OR 0.35; 95 % CI 0.19-0.65; p < 0.01)., Conclusions: There appears a lower chance of experiencing a fracture for people following THA compared to those who have not.

Background: Total hip replacement (THR) is one of the most common orthopaedic procedures in the United Kingdom (UK). Historically, people following THR have been provided with hip precautions and equipment such as: raised toilet seats and furniture rises, in order to reduce the risks of dislocation post-operation. The purpose of this study was to determine current practices in the provision of these interventions in the UK for people following primary THR., Methods: A 27-question, self-administered online survey was developed and distributed to UK physiotherapists and occupational therapists involved in the management of people following primary THR (target respondents). The survey included questions regarding the current practices in the provision of equipment and hip precautions for THR patients, and physiotherapist's and occupational therapist's attitudes towards these practices. The survey was disseminated through print and web-based/social media channels., Results: 170 health professionals (87 physiotherapists and 83 occupational therapists), responded to the survey. Commonly prescribed equipment in respondent's health trusts were raised toilet seats (95 %), toilet frames and rails (88 %), furniture raises (79 %), helping hands/grabbers (77 %), perching stools (75 %) and long-handled shoe horns (75 %). Hip precautions were routinely prescribed by 97 % of respondents. Hip precautions were most frequently taught in a pre-operative group (52 % of respondents). Similarly equipment was most frequently provided pre-operatively (61 % respondents), and most commonly by occupational therapists (74 % respondents). There was variability in the advice provided on the duration of hip precautions and equipment from up to 6 weeks post-operatively to life-time usage., Conclusions: Current practice on hip precautions and provision of equipment is not full representative of clinician's perceptions of best care after THR. Future research is warranted to determine whether and to whom hip precautions and equipment should be prescribed post-THR as opposed to the current 'blanket' provision of equipment and movement restriction provided in UK practice.

Whilst analgesics and medications have demonstrated efficacy for people with osteoarthritis, their effectiveness is dependent on adherence. This has previously been reported as particularly low in this population. The purpose of this meta-ethnography was to explore possible perceptions for this. A systematic review of published and unpublished literature was undertaken. All qualitative studies assessing the attitudes or perceptions of people with osteoarthritis towards medication adherence were eligible. Study quality was assessed using the Critical Appraisal Skills Programme qualitative tool. Analysis was undertaken using a meta-ethnography approach, distilling to a third-order construct and developing a line of argument. From 881 citations, five studies met the eligibility criteria. The meta-ethnography generated a model where medication adherence for people with osteoarthritis is perceived as a balance between the willingness and preference to take medications with the alterative being toleration of symptoms. Motivators to influence this 'balance' may fluctuate and change over time but include: severity of symptoms, education and understanding of osteoarthritis and current medications, or general health which may raise issues for poly-pharmacy as other medications are added or substituted into the patient's formulary. Medicine adherence in people with osteoarthritis is complex, involving motivators which will fluctuate in impact on individuals at different points along the disease progression. Awareness of each motivator may better inform clinicians as to what education, support or change in prescription practice should be adopted to ensure that medicine adherence is individualised to better promote long-term behaviour change.

Aims: The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck., Patients and Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant systematic review, using the PubMed, EMBASE and Cochrane libraries databases. A meta-analysis was performed where possible, and a narrative synthesis when a meta-analysis was not possible., Results: Our analyses revealed a significantly increased risk of complications including deep infection, early dislocation and peri-prosthetic fracture with salvage THA when compared with primary THA for an intracapsular fracture of the femoral neck (overall risk ratio of 3.15). Functional outcomes assessment using EuroQoL (EQ)-5D were not significantly different (p = 0.3)., Conclusion: Salvage THA carries a significantly higher risk of complications than primary THA for intracapsular fractured neck of femur. Current literature is still lacking well designed studies to provide a full answer to the question., Take Home Message: Salvage THA is associated with more complications than primary THA for intracapsular neck of femur fractures., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: Smoking and alcohol consumption has a negative effect on overall health. Limited evidence has been presented as to how these health behaviours may change between pre- and postoperative intervals in the initial 12 months post-arthroplasty. The purpose of this study was to address this uncertainty., Hypothesis: Smoking and alcohol consumption differs between pre- and post-THA/TKA and it differs between non-arthroplasty cohorts., Materials and Methods: Data from the Osteoarthritis Initiative (OAI), a population-based observational study in the USA, were gathered. In total, data from 287 people who had undergone THA or TKA from baseline to month 48 OAI follow-up assessments were analysed. Data on this cohort were compared to 287 age- and gender-matched people with osteoarthritis. Mean change from pre- to post-arthroplasty, and differences between arthroplasty and non-arthroplasty participants for smoking and alcohol consumption were assessed descriptively and through Wilcoxin-matched pairs test and Student t-tests (as appropriate)., Results: The lifetime prevalence of smoking was high for people who received THA (99%) and TKA (96%). Prevalence of current smoking significantly decreased from 5 to 3% across the THA and TKA cohort in the initial 12 months post-arthroplasty (P<0.05). Similarly, there was a statistically significant decrease in weekly alcohol consumption post-arthroplasty for people who underwent THA and TKA (P<0.01), although the mean difference was only by 0.9 alcoholic drinks. The only statistically significant difference in smoking and alcohol consumption for arthroplasty to non-arthroplasty participants was in weekly alcohol consumption, which was higher by 0.3 drinks in the non-arthroplasty cohort (P=0.04)., Conclusions: Smoking and alcohol consumption decreased in the initial 12 months post-THA and TKA. This was not significantly different to an age- and gender-matched non-arthroplasty cohort. Whilst this is positive, a small group of patients still present with unhealthy lifestyle choices in relation to these behaviours post-arthroplasty., Level of Evidence: Level III - prospective case control study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Implant malposition in total knee arthroplasty (TKA) often results in unsatisfactory outcomes. Rotational malalignment leads to impaired patellar tracking, stability and joint biomechanics. Patient-specific instrumentation aims to improve three-dimensional implant positioning while reducing overall costs of instrumentation., Methods: A PRISMA compliant search of all relevant literature between 2000 and 2014 was performed. The primary outcome of interest was deviation from a neutral femoral and tibial axial alignment of patient-specific instrumentation (PSI) vs conventional instrumentation. Femoral rotation was measured with reference to the transepicondylar axis. Tibial rotation was reported with reference to the anterior tibial tuberosity and a "best fit" with the anterior tibial cortex., Results: Six randomised studies met the inclusion criteria reporting on a total of 444 knees. Computed tomography (CT) based PSI systems were used exclusively in three studies, and two further studies in association with magnetic resonance imaging (MRI). MRI was used exclusively in one study. Mean femoral rotation in the conventional group was: -1.7 to 1.6° (vs -1.7 to 1° in the PSI group). Meta-analysis demonstrated a significant treatment effect favouring PSI with increased accuracy in "three-degree outliers" with femoral rotation: Z=2.07, P=0.04. A single study reported tibial rotational outcomes with no significant difference demonstrated in conventional instrumentation vs PSI., Conclusions: This Level 1 meta-analysis demonstrates favourable femoral rotational alignment outcomes in PSI knee arthroplasty. Only limited data is available for tibial rotational outcomes. Further studies with standardised "gold-standard" measurement criteria are required to clarify tibial rotational outcomes in PSI TKA., Level of Evidence: 1., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: This paper assessed the validity, internal consistency, responsiveness and floor-ceiling effects of the Norwich Patellar Instability (NPI) Score for a cohort of conservatively managed people following first-time patellar dislocation (FTPD)., Methods: Fifty patients were recruited, providing 130 completed datasets over 12 months. The NPI Score, Lysholm Knee Score, Tegner Level of Activity Score and isometric knee extension strength were assessed at baseline, six weeks, six and 12 months post-injury., Results: There was high convergent validity with a statistically significant correlation between the NPI Score and the Lysholm Knee Score (p<0.001), Tegner Level of Activity Score (p<0.001) and isometric knee extension strength (p<0.002). Principal component analysis revealed that the NPI Score demonstrated good concurrent validity with four components account for 70.4% of the variability. Whilst the NPI Score demonstrated a flooring-effect for 13 of the 19 items, no ceiling effect was reported. There was high internal consistency with a Cronbach Alpha value of 0.93 (95% CI: 0.91 to 0.93). The NPI Score was responsive to change over the 12 months period with an effect size of 1.04 from baseline to 12 months post-injury., Conclusions: The NPI Score is a valid tool to assess patellar instability symptoms in people conservatively managed following FTPD., Level of Evidence: Level II., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objectives: To review the association between patellofemoral joint (PFJ) imaging features and patellofemoral pain (PFP)., Design: A systematic review of the literature from AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro, EMBASE and SPORTDiscus was undertaken from their inception to September 2014. Studies were eligible if they used magnetic resonance imaging (MRI), computed tomography (CT), ultrasound (US) or X-ray (XR) to compare PFJ features between a PFP group and an asymptomatic control group in people <45 years of age. A pooled meta-analysis was conducted and data was interpreted using a best evidence synthesis., Results: Forty studies (all moderate to high quality) describing 1043 people with PFP and 839 controls were included. Two features were deemed to have a large standardised mean difference (SMD) based on meta-analysis: an increased MRI bisect offset at 0° knee flexion under load (0.99; 95% CI: 0.49, 1.49) and an increased CT congruence angle at 15° knee flexion, both under load (1.40 95% CI: 0.04, 2.76) and without load (1.24; 95% CI: 0.37, 2.12). A medium SMD was identified for MRI patella tilt and patellofemoral contact area. Limited evidence was found to support the association of other imaging features with PFP. A sensitivity analysis showed an increase in the SMD for patella bisect offset at 0° knee flexion (1.91; 95% CI: 1.31, 2.52) and patella tilt at 0° knee flexion (0.99; 95% CI: 0.47, 1.52) under full weight bearing., Conclusion: Certain PFJ imaging features were associated with PFP. Future interventional strategies may be targeted at these features., Prospero Registration Number: CRD 42014009503., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: We aimed to define whether distal vastus medialis (VM) muscle strengthening improves functional outcomes compared to general quadriceps muscle strengthening following first-time patellar dislocation (FTPD)., Methods: Fifty patients post-FTPD were randomised to either a general quadriceps exercise or rehabilitation programme (n=25) or a specific-VM exercise and rehabilitation regime (n=25). The primary outcome was the Lysholm knee score, and secondary outcomes included the Tegner Level of Activity score, the Norwich Patellar Instability (NPI) score, and isometric knee extension strength at various knee flexion ranges of motion. Outcomes were assessed at baseline, six weeks, six months and 12months., Results: There were statistically significant differences in functional outcome and activity levels with the Lysholm knee score and Tegner Level of Activity score at 12months in the general quadriceps exercise group compared to the VM group (p=0.05; 95% confidence interval (CI): -14.0 to 0.0/p=0.04; 95% CI: -3.0 to 0.0). This did not reach a clinically important difference. There was no statistically significant difference between the groups for the NPI score and isometric strength at any follow-up interval. The trial experienced substantial participant attrition (52% at 12months)., Conclusions: Whilst there was a statistical difference in the Lysholm knee score and Tegner Level of Activity score between general quadriceps and VM exercise groups at 12months, this may not have necessarily been clinically important. This trial highlights that participant recruitment and retention are challenges which should be considered when designing future trials in this population., Level of Evidence: Therapeutic study, Level I., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Aim: A systematic review and meta-analysis of clinical studies assessing alignment outcomes in patient-specific instrumented (PSI) knee arthroplasty was conducted., Materials and Methods: PRISMA compliant data was extracted from literature databases up to January 2014., Results: Twenty-six studies met the inclusion criteria, reporting a total of 1792 knees. Twenty-three studies reported alignment outcomes in the coronal plane, 11 in the sagittal plane. In all but three series, MRI was the preoperative imaging modality. Range of mean postoperative alignment (hip-knee-ankle [HKA] angle) was 176.5 to 181.70. The proportion of three degrees of outliers showed an overall mean of 18.6%. In total, fifteen studies compared alignment outcomes between standard and PSI. From these, four studies showed significantly higher accuracy of coronal plane alignment with PSI (HKA angle). Meta-analysis of seven high-quality comparative studies demonstrated no significant increased accuracy in postoperative mechanical axis (HKA angle) with PSI. Subgroup meta-analysis of both femoral and tibial rotation was not feasible due to a low number of inclusive high-quality series., Conclusions: PSI knee arthroplasty is shown not to confer increased accuracy in reconstituting the postoperative mechanical axis. Further studies are required to demonstrate both clinical and radiological alignment outcomes in PSI knee arthroplasty with focus upon tibial and femoral rotation., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Anterior knee pain (AKP) encompasses a range of pathologies. As a result, there are a number of therapeutic options used to treat AKP. The non-operative treatments have been analysed in a number of randomised controlled trials and systematic reviews. There is however a scarcity of such publications covering the surgical management of AKP. There are no systematic reviews that have investigated surgical interventions for AKP due to pathology of the infrapatellar fat pad (IFP). The aims of this study were to review the literature systematically, to establish which surgical procedures have been used to treat IFP disease and to determine their efficacy., Methods: The review was conducted in accordance with the PRISMA reporting guidelines. A search of the literature was performed on 1st January 2014 using multiple databases including CENTRAL, MEDLINE, EMBASE, PubMed, and Google Scholar. The quality of the studies was assessed using Oxford Evidence-Based Medicine Levels of Evidence guidelines and the GRADE approach., Results: Twenty-four eligible studies were found and included. The critical appraisal identified that the current evidence-base has low methodology quality. The clinical findings indicated that there is a positive trend towards the surgical management of IFP disease for AKP symptoms. Excision of IFP tumours and resection of the IFP in Hoffa's disease can lead to improvements in symptoms and function., Conclusions: Truly robust evidence to support the surgical management of IFP pathology requires randomised controlled trials; however the expenses involved to design such trials means that they are unlikely to be undertaken for this uncommon disorder. Consequently well-designed and well-reported case series need to be undertaken to improve our current understanding that includes recording quantitative measures such as range of knee motion, VAS Pain scores and a validated scoring system., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Primary Objective: To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury., Research Design: A retrospective case note review assessed total rehabilitation unit admission., Methods and Procedures: Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge., Main Outcomes and Results: A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = -6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36-68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002-0.35)., Conclusions: There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.

Background: The purpose of this study was to determine the diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis., Methods: An electronic search of databases registering published (MEDLINE, EMBASE, CINAHL, AMED, Cochrane Library, ScienceDirect) and unpublished literature was conducted to January 2013. All diagnostic accuracy studies that compared the accuracy of ultrasound (index test) with a reference standard for lateral epicondylitis were included. The methodological quality of each of the studies was appraised using the QUADAS tool. When appropriate, the pooled sensitivity and specificity analysis was conducted., Results: Ten studies investigating 711 participants and 1077 elbows were included in this review. Ultrasound had variable sensitivity and specificity (sensitivity: 64%-100%; specificity: 36%-100%). The available literature had modest methodological quality, and was limited in terms of sample sizes and blinding between index and reference test results., Conclusions: There is evidence to support the use of ultrasound in the detection of lateral epicondylitis. However, its accuracy appears to be highly dependent on numerous variables, such as operator experience, equipment and stage of pathology. Judgement should be used when considering the benefit of ultrasound for use in clinical practice. Further research assessing variables such a transducer frequency independently is specifically warranted., Level of Evidence: Level II., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Aims: The purpose of this study was to determine the optimal clinical and cost-effective strategy for managing people following ACL rupture., Methods: A systematic review of the published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, psycINFO and the Cochrane Library) and unpublished literature (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) was conducted on April 2013. All randomised and non-randomised controlled trials evaluating clinical or health economic outcomes of isolated ligament reconstruction versus non-surgical management following ACL rupture were included. Methodological quality was assessed using the PEDro appraisal tool. When appropriate, meta-analysis was conducted to pool data., Results: From a total of 943 citations, sixteen studies met the eligibility criteria. These included 1397 participants, 825 who received ACL reconstruction versus 592 who were managed non-surgically. The methodological quality of the literature was poor. The findings indicated that whilst reconstructed ACL offers significantly greater objective tibiofemoral stability (p<0.001), there appears limited evidence to suggest a superiority between reconstruction versus non-surgical management in functional outcomes. There was a small difference between the management strategies in respect to the development of osteoarthritis during the initial 20 years following index management strategy (Odds Ratio 1.56; p=0.05)., Conclusions: The current literature is insufficient to base clinical decision-making with respect to treatment opinions for people following ACL rupture. Whilst based on a poor evidence, the current evidence would indicate that people following ACL rupture should receive non-operative interventions before surgical intervention is considered., (© 2013.)

Background: This study firstly aimed to determine whether proprioception deficits, as measured by joint position sense (JPS), occur in people following recurrent patellar dislocations. Secondly, to determine whether JPS changes following medial patellofemoral ligament reconstruction (MPFL) reconstruction for patellar instability., Methods: Thirty people following recurrent patellar dislocation were recruited. Pre-operative JPS was assessed using the passive angle reproduction test. Through this, an assessor moved a participant's limb to a target position. This was returned to neutral, before finally moving the limb again, whilst requiring the participant to indicate when they thought the target angle was reached. The actual angular error (AAE) was calculated as the difference between the perceived angle and target angle. Clinical outcomes included the Kujala Patellofemoral Disorder Score, the International Knee Documentation Committee (IKDC) form, pain, knee motion, extensor muscle strength and frequency of patellar dislocation. Outcomes were assessed pre-operative, 6 weeks, 3 and 12 months., Results: Mean AAE was 2.2° (inner range) to 3.9° (mid-range); this was not clinically significant. There was no statistically significant difference between the baseline-and-6 week, 6 week-and-3 month or baseline-and-12 month AAE measures (p=0.38 to 1.00). There was a statistically significant improvement in functional outcomes as measured by the Kujala score, IKDC form, reduced pain and increased extension strength from baseline to 12 months (p<0.01)., Conclusions: Following recurrent patellar dislocation, patients exhibit minimal deficits in JPS. Whilst MPFL reconstruction significantly improved clinical and functional outcomes for this population, this operation did not significantly alter JPS during the first post-operative year., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objectives: To review and synthesize the existing literature on the experience of living with a diagnosis of hip and/or knee osteoarthritis (OA)., Method: A systematic review was undertaken using meta-ethnography. A search of both published (AMED, CINAHL, EMBASE, PsychINFO, SportsDisc, MEDLINE, Cochrane Clinical Trials Registry, PubMed) and unpublished/trial registry databases [World Health Organization (WHO) International Clinical Trials Registry Platform, Current Controlled Trials, the United States National Institute of Health Trials Registry, National Institute for Health Research (NIHR) Clinical Research Portfolio Database] was undertaken from their inception to 5 June 2013., Results: Thirty-two studies formed the meta-ethnography of the lived experiences of people with OA. In total, 1643 people with OA were sampled, the majority diagnosed with knee OA. The evidence base was weak to moderate in quality. The majority of studies indicated that people viewed living with OA negatively. Four key factors influenced their attitudes to the condition: the severity of their symptoms; the impact of these symptoms on their functional capability; their attitude towards understanding their disease; and their perceptions of other people's beliefs towards their disease., Conclusions: The current literature suggests that greater knowledge of the pathology of OA, management of symptoms, promotion of functional activity for patients and their family/friends networks, and understanding to better inform OA patient's role in society are all important elements that affect a person's attitude to OA. By better understanding these factors during future consultations, clinicians may forge stronger relationships with their patients to more effectively manage this long-term disabling condition.

Aim: Patellar instability is a complex, multi-factorial disorder. Radiological assessment is regarded as an important part of the management of this population. The purpose of this study was to determine the intra- and inter-rater reliability of common radiological measurements used to evaluate patellar instability., Methods and Materials: One hundred and fifty X-rays from 51 individuals were reviewed by five reviewers, two orthopaedic trainees, a radiological trainee, a consultant radiologist and an orthopaedic physiotherapist. Radiological measurements assessed included patellar shape, sulcus angle, congruence angle, lateral patellofemoral angle, lateral patellar displacement (LPD), lateral displacement measurement (LDM), boss height, and patellar height ratios. All assessors were provided with a summary document outlining the method of assessing each measurement. No further formal teaching was provided. Bland-Altman analyses were adopted to assess intra- and inter-rater reliability., Results: The results indicated generally low measurement error on intra-rater reliability assessment, particularly for LPD, LDM and boss height measurements. Whilst the inter-rater reliability between assessors indicated a low mean difference for assessments of patellar height measurements, patellar angle, lateral patellar dislocation and lateral displacement, wide 95% limits of agreement for all measurements indicated poor precision., Conclusion: Many of the standard measurements used to assess the patellofemoral joint on plain radiographs have poor precision. Intra-rater reliability may be related to experience but it seems likely that to achieve good inter-rater reliability, specific training may be required to calibrate observers. More formal training in the technique of radiological measurement for those who were inexperienced might have improved the inter-rater reliability., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The purpose of this study was to evaluate the diagnostic test accuracy of X-ray arthrography in the detection of TFCC tear. Both published and unpublished databases were searched from their inception to August 2010. All studies comparing the diagnostic accuracy of X-ray arthrography (index test) to arthroscopy (reference standard) for patients with suspected TFCC tears were included in this review. Twelve studies assessing 430 patients (430 wrists) satisfied the eligibility criteria and were included. X-ray arthrography presented with a pooled sensitivity of 76.2% and specificity of 92.5% for the detection of complete TFCC tear. The triple-compartment injection X-ray arthrography was superior to the single-compartment injection technique. To conclude, the diagnostic test accuracy of X-ray arthrography is limited. Neither the single- nor the triple-compartment injection arthrography method is acceptable, given their reported low sensitivities. Further evaluation of the diagnostic test accuracy of Magnetic Resonance Arthrography and Magnetic Resonance Imaging is therefore warranted.

Background/hypothesis: To report the analysis of the initial rehabilitation results of the Norwich Enhanced Recovery Programme (NERP), regime with increased post-operative physiotherapy input following total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed under spinal anaesthetic with wound catheter infiltration., Materials and Methods: A secondary analysis of a service improvement programme was undertaken from an acute National Health Service Hospital in the United Kingdom. Ninety-five patients listed for THA (n=67) or TKA (n=28) were reviewed during the first six post-operative weeks. All received an enhanced post-operative programme including commencement of mobilisation four hours post-operatively and physiotherapy interventions a minimum of twice daily during hospital admission. The primary outcome measure was the Iowa Level of Assistance Score at discharge. Secondary outcomes included length of hospital stay (LOS), visual analogue scale pain at discharge and complications during the initial six post-operative weeks., Results: The NERP is a successful rehabilitation regime for patients following THA and TKA, facilitating early safe discharge (mean LOS=3.5 days) with minimal complications. Patients who commenced mobilisation on the day of the operation reported significantly reduced pain score (p=0.02) and length of stay (p<0.01) compared to those who did not. Thirty-four percent of patients were discharged with rollator frames., Conclusions: Whilst the early results of the NERP allow patients who have undergone THA or TKA surgery a short hospital length of stay, its demand on out-reach physiotherapy suggests that the availability of such community services is imperative to ensure the appropriate progression of rehabilitation., Level of Evidence: Level IV - retrospective series., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library database and the PEDro database, in addition to unpublished literature databases was conducted to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies. The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme tool. The results indicated that there is no statistically significant difference in recurrent injury between the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament injury (p = 0.68). The addition of proprioceptive training demonstrated a significant reduction in subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop the rigour of the evidence-base and to determine the optimal proprioceptive training programme following ankle ligament injury with different populations., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: Radiological measurement scores are used by orthopaedic physiotherapists in triage and surveillance of patients with degenerative changes of the tibiofemoral and patellofemoral joints. The purpose of this study was to estimate the intra- and inter-observer reliability of a radiological measurement score to assess patellofemoral joint osteoarthritis, the Jones Patellofemoral Osteoarthritis Score (JPOS), with an orthopaedic physiotherapist and three grades of junior surgeons/doctors., Methods: A total of 390 skyline X-rays of the patellofemoral joint were reviewed on 2 occasions, 4 weeks apart, by an orthopaedic physiotherapist, 2 orthopaedic surgeons, and an orthopaedic doctor. Intra- and inter-observer reliability of the JPOS was calculated using a weighted kappa analysis., Results: The results indicated that while there was good overall intra-observer agreement for this measurement score for all assessors, inter-observer reliability was generally poor between the orthopaedic physiotherapist and the orthopaedic surgeons/doctor., Conclusion: Our findings call into question the use of the JPOS by orthopaedic physiotherapists working in triage or orthopaedic surveillance programmes with other orthopaedic clinicians.

High tibial osteotomy (HTO) has been advocated for the treatment of isolated medial compartment osteoarthritis of the knee. Debate remains over the superiority of performing a medial opening-wedge or lateral closing-wedge HTO. The purpose of this study was to compare the clinical and radiological outcomes, and complications of patients following opening-wedge compared to closing-wedge HTO. A systematic review was undertaken of published and unpublished literature databases from their inception to May 2010. Twelve papers reporting nine clinical trials were found to be suitable for meta-analysis comparing 324 opening-wedge HTOs to 318 closing-wedge HTOs. There was no difference in the incidence of infection, deep vein thrombosis, peroneal nerve palsy, non-union or revision to knee arthroplasty (p>0.05). There was however a significantly greater posterior tibial slope and mean angle of correction, reduced patellar height and hip-knee-ankle angle following opening-wedge HTO (p<0.05). No significant difference was found for any clinical outcome including pain, functional score or complications (p>0.05)., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Background: This study assessed the clinical and radiological outcomes of different non-surgical interventions, surgical versus non-surgical interventions, and different surgical interventions used in the management of proximal fifth metatarsal fractures., Methods: A systematic review of published and unpublished literature was undertaken., Results: Six studies, assessing 330 patients and 333 fractures of the proximal fifth metatarsal were reviewed. Four studies assessed outcomes following tuberosity fractures, whilst 2 studies recruited patients following proximal diaphyseal or Jones fractures. The findings suggested that bandage is superior to below knee cast immobilisation for patient-reported functional and pain scores, with no difference in fracture union or re-fracture, and a shorter duration to return to work. There was no significant difference in complication rates or functional outcomes for patients managed in a plaster slipper compared to a bandage post-injury. When comparing surgical and non-surgical management, intramedullary screw fixation results in a shorter time to fracture union, reduced complication rates and earlier return to pre-injury activities compared to non-surgical cast immobilisation. However, the evidence-base is limited in it size and presented with a number of methodological limitations., Conclusions: Further well-conducted randomised controlled trials are required to determine the optimal management strategy for the different types of proximal fifth metatarsal fractures., (Copyright © 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Aim: To determine the diagnostic accuracy of ultrasound to detect partial and complete thickness rotator cuff tears based on all available clinical trials., Materials and Methods: An electronic search of databases registering published and unpublished literature was conducted. All diagnostic accuracy studies that directly compared the accuracy of ultrasound (the index test) to either arthroscopic or open surgical findings (the reference test) for rotator cuff tear were included. The methodological quality of each included study was assessed using the QUADAS form. When appropriate, pooled sensitivity and specificity analysis was conducted, with an assessment of the summary receiver operating characteristic (ROC) curve for each analysis., Results: Sixty-two studies assessing 6007 patients and 6066 shoulders were included. Ultrasonography had good sensitivity and specificity for the assessment of partial thickness (sensitivity 0.84; specificity 0.89), and full-thickness rotator cuff tears (sensitivity 0.96; specificity 0.93). However, the literature poorly described population characteristics, assessor blinding, and was based on limited sample sizes. The literature assessing transducer frequency was particularly small in size., Conclusion: Ultrasonography is an appropriate radiological technique for the assessment of rotator cuff tears with an acceptable sensitivity and specificity. The diagnostic test accuracy of ultrasound is superior for the detection of full-thickness compared to partial-thickness cuff tears. Further study assessing the effect of transducer frequency is warranted., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Purpose: Venous thromboembolic disease following skeletal polytrauma is a major issue for trauma surgeons, but there is no consensus of opinion regarding the optimal form of prophylaxis. The purpose of this paper was to compare the incidence of venous thromboembolic events (VTE) after major skeletal trauma managed with different prophylactic methods and their combinations., Methods: A search of AMED, CINAHL, Cochrane Library, EMBASE and MEDLINE databases was performed from their inception to July 2010. A search of unpublished literature databases was undertaken. All randomised controlled trials assessing the incidence of VTE events between two or more forms of thromboprophylaxis for patient following major skeletal trauma were included. Two reviewers independently identified all eligible articles, extracted the data, and critically appraised all included publications using the Critical Appraisal Skills Programme tool., Results: A total of 11 papers were identified. The findings of this study suggest that low molecular weight heparin (LMWH) may be superior to low dose heparin (LDH), and that LMWH should be used in addition to mechanical prophylaxis measures in patients following major skeletal trauma. There is limited evidence for the use of electrostimulation. There appeared to be no significant difference between the use of LDH compared to calf compression devices. However, the evidence-base was insufficient in both size and methodological quality., Conclusions: There is currently insufficient research to be able to inform trauma surgeons as to the optimal method of thromboprophylaxis for patients following major skeletal trauma.

Health surveys using questionnaires facilitate the acquisition of information on the knowledge, behaviour, attitudes, perceptions and clinical history of a selected population. Their internal and external validities are threatened by poor design and low response rates. Numerous studies have investigated survey design and administration but care should be taken when generalising findings in different clinical and cultural settings. The current evidence-base suggests that no single mode of survey administration, such as postal, electronic or telephone, is superior to another. Whilst there is no evidence of an ideal response rate relationship to survey validity, response rates can be enhanced by including monetary incentives, providing a time cue, and repeat contact with non-responders. Unlike other modes of experimental data collection, few guidelines currently exist for survey and questionnaire design and response rate should not be considered a direct measure of a survey's quality., (Copyright © 2010 Elsevier B.V. All rights reserved.)

The Oxford unicompartmental knee replacement gives good results in patients with symptomatic osteoarthritis of the medial compartment. Previous studies have suggested that the presence of radiolucent lines (RLLs) does not reflect a poor outcome in such patients. However, the reliability and validity of this assessment have not been determined. Our aim was to assess the intra- and interobserver reliability and the sensitivity and specificity of the assessment of RLLs around both tibial and femoral components using standard radiographs. Two reviewers assessed the radiographs of 45 patients who had loosening of the tibial or femoral component confirmed at revision surgery and compared them with those of a series of 45 asymptomatic patients matched for age and gender. The results suggested that, using standard radiographs, tibial RLLs were 63.6% sensitive and 94.4% specific and femoral RLLs 63.9% sensitive and 72.7% specific for loosening. Overall intra- and interobserver reliability was highly variable, but zonal analysis showed that lucency at the tip of the femoral peg was significantly associated with loosening of the femoral component. Fluoroscopically guided radiographs may improve the zonal reliability of the assessment of RLLs, but further independent and comparative studies are required. In the meantime, the innocence of the physiological RLLs detected by standard radiographs should be viewed with caution.

There has been debate about the role of unicompartmental knee replacement in the presence of radiologically identifiable degenerative changes of the patellofemoral joint. We studied 195 knees in 163 patients in whom an Oxford unicompartmental knee replacement had been performed for medial osteoarthritis between January 2004 and July 2007. The mean age of the patients was 66 years (51 to 93). The degree of degenerative change of the patellofemoral joint was assessed using Jones' criteria. Functional outcome was assessed at a mean of 3.4 years (2 to 7) post-operatively, using the Oxford knee score and the Short-form 12 score. Degenerative changes of the patellofemoral joint were seen pre-operatively in 125 knees (64%) on the skyline radiographs. There was no statistically significant difference in the Oxford knee or Short-form 12 scores between those patients who had patellofemoral osteoarthritis pre-operatively and those who did not (p = 0.22 and 0.54, respectively). These results support the opinion expressed at the designer's hospital that degenerative changes of the patellofemoral joint in isolation should not be considered to be a contraindication to medial Oxford unicompartmental knee replacement.