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OBJECTIVE The Osteoarthritis Research Society International (OARSI) recommends assessment of physical function using a performance-based test of stair negotiation, but was unable to recommend any specific test. We assessed the reliability, validity, responsiveness, measurement error, and minimum important change (MIC) of the 6-step timed Stair Climb Test (SCT). METHODS We used pooled data from 397 participants with hip or knee osteoarthritis (54% women) from four clinical trials (86% retained at 12-week follow-up). Construct validity was assessed by testing six a priori hypotheses against other OARSI-recommended physical function measures. A self-reported Global Rating of Change scale was used to classify participants as worsened, improved and stable. Participants who worsened in physical function were excluded from all analyses. Responsiveness and MIC were assessed using multiple anchor-based and distribution-based approaches. Test-retest reliability, standard error of measurement (SEM) and smallest detectable change (SDC) were assessed on stable participants. RESULTS Five of six hypotheses (83%) for construct validity were met. Test-retest reliability was excellent (intraclass correlation coefficient2,1 : 0.83; 95% confidence interval: 0.71, 0.90). The SEM and SDC values were 0.44 and 1.21 seconds respectively. We did not find adequate support for responsiveness. The MIC values ranged from 0.78 to 1.95 seconds using different approaches (median=1.37 seconds). CONCLUSION The 6-step timed SCT adequately assesses the construct of physical function in individuals with hip or knee osteoarthritis with excellent 12-week test-retest reliability. However, support for its responsiveness was inadequate to recommend its use as an outcome measure in people with osteoarthritis for research and clinical practice.

Background There are a number of reports of polyethylene liner dissociation of third-generation modular acetabular components. This study compares our experience with 2 contemporary systems to determine whether this is an implant- or class-specific problem. Methods This is a single-center retrospective study of 961 primary total hip arthroplasties using 2 third-generation modular cementless acetabular shells: Pinnacle (535) and R3 (426) with a polyethylene liner. Details of all revisions were obtained from local databases and the New Zealand Joint Registry. Kaplan-Meier survival curves were calculated for all-cause revision, acetabular reoperation (including liner exchange), and liner dissociation. Results There were 17 revisions in group 1 (Pinnacle; DePuy Synthes): 17 for recurrent dislocation, 6 for liner dissociations (1.12%), 3 for femoral loosening, and one for deep infection. In group 2 (R3; Smith and Nephew), there were 4 revision procedures: one for infection, 2 for dislocation, and one femoral revision for periprosthetic fracture. There were significantly higher proportions revised in group 1 for all-cause revision, acetabular reoperation, and dissociation (P = .024 to 0.038). The 7-year survival for all-cause revision was 96.1% for Pinnacle and 99.0% for R3 (P = .022), and that in the acetabular reoperation group was 96.9% for Pinnacle and 99.3% for R3 (P = .035). Conclusions There was a higher revision rate for the Pinnacle acetabular component than for the R3 at 7 years. This was mainly due to polyethylene liner dissociation that can occur early or late. It appears to be a problem specific to the Pinnacle cup design rather than a feature of similar third-generation acetabular components.

Cardiopulmonary exercise testing is performed increasingly for cardiorespiratory fitness assessment and pre-operative risk stratification. Lower limb osteoarthritis is a common comorbidity in surgical patients, meaning traditional cycle ergometry-based cardiopulmonary exercise testing is difficult. The purpose of this study was to compare cardiopulmonary exercise testing variables and subjective responses in four different exercise modalities. In this crossover study, 15 patients with osteoarthritis scheduled for total hip or knee arthroplasty (mean (SD) age 68 (7) years; body mass index 31.4 (4.1) kg.m-2 ) completed cardiopulmonary exercise testing on a treadmill, elliptical cross-trainer, cycle and arm ergometer. Mean (SD) peak oxygen consumption was 20-30% greater on the lower limb modalities (treadmill 21.5 (4.6) (p < 0.001); elliptical cross-trainer (21.2 (4.1) (p < 0.001); and cycle ergometer (19.4 (4.2) ml.min-1 .kg-1 (p = 0.001), respectively) than on the arm ergometer (15.7 (3.7) ml.min-1 .kg-1 ). Anaerobic threshold was 25-50% greater on the lower limb modalities (treadmill 13.5 (3.1) (p < 0.001); elliptical cross-trainer 14.6 (3.0) (p < 0.001); and cycle ergometer 10.7 (2.9) (p = 0.003)) compared with the arm ergometer (8.4 (1.7) ml.min-1 .kg-1 ). The median (95%CI) difference between pre-exercise and peak-exercise pain scores was greater for tests on the treadmill (2.0 (0.0-5.0) (p = 0.001); elliptical cross-trainer (3.0 (2.0-4.0) (p = 0.001); and cycle ergometer (3.0 (1.0-5.0) (p = 0.001)), compared with the arm ergometer (0.0 (0.0-1.0) (p = 0.406)). Despite greater peak exercise pain, cardiopulmonary exercise testing modalities utilising the lower limbs affected by osteoarthritis elicited higher peak oxygen consumption and anaerobic threshold values compared with arm ergometry.

BACKGROUND Most public hospitals are receiving more referrals for first specialist assessment than they have capacity to see. Traditional priority categories are too broad for effective discrimination. In New Zealand (NZ) explicit prioritization is required by legislation and supported by the Medical Council of NZ. A new generic National Referral Prioritization tool (NRPT) has been developed which includes a patient impact on life score. This study reports its trial implementation in orthopaedic surgery in a single centre. METHODS Four months of referrals to the orthopaedic department were prioritized using the new NRPT and traditional clinical priority categories. Scores and acceptances were compared across conditions, surgeons and against the traditional categories. RESULTS The mean NRPT was 60.1 (range 23-99). The correlation with impact on life was 0.59. There was good consistency of scores between surgeons. The NRPT score was significantly different across clinical priority categories (urgent, semi-urgent, routine). A total of 305 referrals (49%) were accepted using the NRPT compared with 493 (79%) if the traditional tool had been used. Patients with foot and ankle, carpal tunnel syndrome and upper limb conditions had the lowest scores and were more likely to be declined. CONCLUSIONS The NRPT is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. It allows fine-tuning of a threshold score to balance acceptances and capacity.

Background: Evidence for the use of splints to reduce pain and improve function and quality of life in thumb carpometacarpal osteoarthritis (CMC OA) is sparse and poor despite recommendations by international guidelines.Objective: To outline the protocol for a study designed to determine the feasibility of conducting a fully powered pragmatic randomized controlled trial (RCT) comparing soft splint vs no splint for thumb CMC OA.Methods: The proposed pragmatic, assessor-blinded, and partial participant blinded parallel-group feasibility RCT will recruit 30 adults with thumb CMC OA and randomise to: splint intervention or usual care control. Randomization will be stratified by hand dominance. Primary feasibility outcomes are recruitment rate over a 4-month period, retention rate at 6 months, intervention acceptability, and rate of adverse events. Study costs, intervention fidelity, and clinical outcomes will also be evaluated. Measurements will be collected at baseline, 4 weeks, and 6 months post-initiation of treatment. This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618001639213.Major Findings: N/A.Conclusions: If shown to be effective, soft off-the shelf splints would be a good first-line non-pharmacological, non-surgical option for thumb CMC OA as prescribed by health professionals or accessed directly by patients. This feasibility study will inform a future, fully powered RCT as evaluated by success of the recruitment strategy; assessment time and acceptability; implementation and evaluation of ‘usual care’; and intervention procedures and adherence.

Aims To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem. Methods Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing. Results There were 61 revisions (9.7%; 0.82 revisions/100 observed component years, (OCYs)) in the all-cemented group and 18 (4.0%; 0.30/100 OCYs) in the hybrid group. The cumulative incidence of revision at 18 years was 12.1% for cemented and 5.2% for hybrids. There was a significantly greater risk of revision for all-cemented compared with hybrids (unadjusted sub-hazard ratio (SHR) 2.44; p = 0.001), and of revision for loosening, wear, or osteolysis (unadjusted SHR 3.77; p < 0.001). After adjustment, the increased risk of all-cause revision did not reach significance at age 70 years and above. The advantage for revision for loosening, wear, and osteolysis remained at all ages. Conclusion This study supports the use of uncemented acetabular fixation when used in combination with the Exeter stem with improved survivorship for revision for aseptic loosening, wear, and osteolysis at all ages and for all-cause revision in patients less than 70 years. Cite this article: Bone Joint J 2020;102-B(4):414–422

Between 2007 and 2018, 535 total hip arthroplasties using the uncemented Pinnacle acetabular component (DePuy Synthes, Warsaw, IN) and polyethylene liner were implanted in our unit. Of these, 6 patients presented acutely with liner polyethylene dissociation, giving a rate of liner dissociation of 1.11%. All dissociations were atraumatic. Failure occurred at mean 37 months (range 4.5 to 130 months). Radiologically, all acetabular components were within safe zone of abduction and mean anteversion was 10 degrees (range 2-20). In one case, there was posterior impingement against the femoral neck due to femoral malalignment. All patients underwent head and liner exchange with no repeat failures. Despite excellent long-term results, the frequency of dissociated polyethylene liners is a cause of concern with the Pinnacle acetabular component. Keywords: Pinnacle, Liner dissociation, Acetabular cup

Intravesicular application of Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is effective in the treatment of bladder cancer. However, systemic dissemination and subsequent infection of implants have been reported. We present a case of M. bovis infection of a total hip arthroplasty 5 years after BCG instillation for bladder cancer. He was treated with debridement, antibiotics, irrigation, and prosthesis retention with appropriate antituberculous therapy. At 4 years after surgery and 3 years after cessation of treatment, he has had no recurrence of infection with a good functional outcome. This case highlights the need to consider Mycobacteria infection in patients who have received intravesicular BCG. Debridement and retention of well-fixed implants can be successful in combination with appropriate antituberculous therapy. Keywords: Bacillus Calmette-Guérin, Total hip arthroplasty, Prosthetic joint infection, Mycobacterium bovis, DAIR

Background Despite increased use of uncemented and hybrid fixation, there is little evidence of their superiority over cemented implants. The aim of this study is to compare the long-term survivorship of cemented, hybrid and uncemented total hip arthroplasty (THA) at varying ages. Methods A total of 2156 hips (1315 cemented, 324 uncemented, and 517 hybrid) were performed in a single center between 1999 and 2005 with follow-up through to 2017. Registry and local databases were used to determine revision rates and cause. Unadjusted and adjusted competing risk survival analysis was performed. Results The cumulative incidence of all-cause revision at 18 years was cemented 10.9%, uncemented 8.9%, and hybrid 6.5%. Cemented fixation had a statistically significant higher risk of all-cause revision than hybrid in the adjusted model for all ages to 65 years (subhazard ratios [SHRs], 2.28-4.67) and a higher risk of revision for loosening, wear, or osteolysis at all ages (SHRs, 3.25-6.07). Uncemented fixation showed no advantage over hybrid fixation at any age, but did show advantages over cemented at younger ages (≤60 years) for all-cause revision (SHRs, 2.3-4.3). Conclusion Hybrid fixation with conventional polyethylene shows an advantage over cemented hips at all ages. Uncemented THA showed improved survival over cemented only at younger ages and no advantage over hybrid THA.

Summary: Objectives: To combine cross-sectoral stakeholders’ preferences over interventions for knee osteoarthritis (OA) with guideline recommendations and evidence about interventions, and to investigate if these preferences differ by stakeholder group. Design: A survey based on multi-criteria decision analysis was implemented whereby the stakeholders revealed the relative importance, represented as weights, of eight criteria for choosing or recommending knee OA interventions. Using data from an OA clinical guideline, 15 recommended interventions were rated on the criteria and ranked by their total scores, calculated by summing the corresponding weights. Associations between the weights and stakeholder groups were explored using regression analysis. Results: Participants comprised 58 consumers with OA, 5 Māori health advocates, 79 healthcare providers, 24 policy-informants and 12 OA-researchers (N = 178; 63% female, [mean age±SD] 54 ± 13 years). Mean weights on the eight criteria, in decreasing order of importance, are: recommendation: 19.0%; quality of evidence: 17.7%; effectiveness: 15.0%; duration of effect: 13.2%; risk of serious harm: 12.8%; risk of mild/moderate side-effects: 9.4%; cost: 6.6%; and accessibility: 6.3%. For first-, second- and third-line OA interventions respectively, all land-based exercise (total score = 71.7%), NSAIDs (topical) (74.2%) and total joint replacement (74.3%) were ranked first. At all care phases, the recommended core interventions of weight management and self-management education ranked between 11th and 15th (48.0%–56.0%). Regression analysis identified only small differences in weights (≤5.7%; p

Background Total hip and knee arthroplasties (THA/TKA) are clinically effective but high cost procedures. The aim of this study is to perform a cost-effectiveness analysis of THA and TKA in the New Zealand (NZ) healthcare system. Methods Data were collected from 713 patients undergoing THA and 520 patients undergoing TKA at our local public hospital. SF-6D utility values were obtained from participants preoperatively and 1-year postoperatively, and deaths and any revision surgeries from patient records and the New Zealand Joint Registry at minimum 8-year follow-up. A continuous-time state-transition simulation model was used to estimate costs and health gains to 15 years. Quality-adjusted life years (QALYs), treatment costs, and incremental cost-effectiveness ratios (ICERs) were calculated to determine cost effectiveness. ICERs below NZ gross domestic product (GDP; NZ$60 600) and 0.5 times GDP per capita were considered “cost effective” and “highly cost effective” respectively. Results Cumulative health gains were 2.8 QALYs (THA) and 2.3 QALYs (TKA) over 15 years. Cost effectiveness improved from ICERs of NZ$74,400 (THA) and NZ$93,000 (TKA) at 1 year to NZ$6000 (THA) and NZ$7500 (TKA) at 15 years. THA and TKA were cost effective after 2 years and highly cost effective after 3 years. QALY gains and cost effectiveness were greater in patients with worse preoperative functional status and younger age. Conclusion THA and TKA are highly cost-effective procedures over longer term horizons. Although preoperative status and age were associated with cost effectiveness, both THA and TKA remained cost effective in patients with less severe preoperative scores and older ages.

Background The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA). Methods Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index. Results At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P Conclusions Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

Background There are relatively few 20-year results of uncemented acetabular components, and most of these are modular designs. This study reports the 20-year results of a monoblock press-fit acetabular component. Methods A total of 122 total hip arthroplasties (111 patients) using the Morscher cup were reviewed at a mean of 19.7 years. The average age at implantation was 57.3 years (range, 36-74 years), and 81 (66%) were men. Results Twenty-two patients (25 hips) had died. Seven hips were revised, including 5 acetabular revisions. Six patients (6 hips) declined to participate but were known not to have been revised. The mean Oxford hip score was 41.1 (range, 22-48), and the mean reduced Western Ontario and McMaster Universities Osteoarthritis Index score was 5.7/48 (range, 0-24). Eccentric wear was seen in 13 (15.7%) and major osteolysis in 14 (17%) of 82 surviving hips with radiographs. The all-cause revision rate was 0.32 per 100 observed component years (95% confidence interval [CI], 0.13-0.66). The 20-year Kaplan-Meier survival was 93.4% (CI, 86.6-96.8) for all-cause revisions, 95.5% (CI, 89.4-98.1) for any acetabular revision, and 97.1% (CI, 91.2-99.1) for acetabular aseptic loosening, wear, or osteolysis. Conclusion The Morscher acetabular component has continued to perform well at 20 years despite using conventional polyethylene with results that match or surpass other cementless acetabulae.

Background Osteoarthritis is the most common form of arthritis, principally affecting the older population. Highly prevalent, disabling diseases such as osteoarthritis strain the capacity of health systems, and can result in unmet need for services. The Joint Clinic was initiated to provide secondary care consultations and access to outpatient services for people with advanced hip or knee osteoarthritis, who were referred by their general practitioner for orthopaedic consultation but not offered an orthopaedic specialist appointment. Methods This longitudinal programme evaluation comprised four components: a proof-of-concept evaluation; an implementation evaluation; a process evaluation; and an outcomes evaluation. Interviews and surveys of general practitioners, staff, and patients were conducted pre- and post-implementation. Interviews were transcribed, and thematic analysis was completed. In addition, Joint Clinic patient visits and outcomes were reviewed. Results One hundred and eleven primary care physicians (GPs) and 66 patients were surveyed, and 28 semi-structured interviews of hospital staff and GPs were conducted. Proof of concept was satisfied. Interim and final implementation evaluations indicated adherence to the concept model, high levels of acceptance of and confidence in the programme and its staff, and timely completion within budget. Process evaluation revealed positive impacts of the programme and positive stakeholder perceptions, with some weaknesses in communication to the outer context of primary care. The Joint Clinic saw a total of 637 patient visits during 2 years of operation. Unmet need was reduced by 90%. Patient and referring physician satisfaction was high. Hospital management confirmed that the programme will continue. Conclusions This evaluation indicates that the Joint Clinic concept model is fit for purpose, functioned well within the organisation, and achieved its primary objective of reducing unmet need of secondary care consultation for those suffering advanced hip or knee osteoarthritis. Electronic supplementary material The online version of this article (10.1186/s12891-019-2702-1) contains supplementary material, which is available to authorized users.

There is increasing interest in scoring systems to prioritize patients for hip and knee arthroplasty. The purpose of this study was to determine the effectiveness of the New Zealand Orthopaedic Association (NZOA) score and compare it with patient-reported scores of patients listed for hip and knee arthroplasty.Over a 1-year period, all patients listed for primary hip and knee arthroplasty were scored by a prioritization nurse. The NZOA score, outcome, preoperative Oxford hip or knee score (OHKS) and reduced Western Ontario McMaster osteoarthritis index (WOMAC) score (RWS) were collected.Overall, 608 patients were listed for hip (319) or knee (289) arthroplasty. The mean scores for knees were all better than hips (P.001). On initial scoring, 324 patients (53%) were given certainty (mean NZOA, 80.5; OHKS, 10.0; RWS, 35.1), 90 (15%) given clinical over-ride (NZOA, 69.6; OHKS, 12.0; RWS, 33.2), and 194 (32%) returned to general practitioner (NZOA, 64; OHKS, 14.2; RWS, 30.8). Knees (38%) were more likely to be returned than hips (26%; P = .002). Fifty (26%) were re-referred during the study period (mean, 5 months) and given certainty or over-ride. The difference at final outcome between patients with certainty and clinical over-ride was NZOA, 10.3 points; Oxford, 1.6 points; and RWS, 1.4 points. The difference between clinical over-ride and returned to general practitioner was NZOA, 7.2; Oxford, 4.4; RWS, 5.3.The NZOA score is an effective tool for rationing for joint arthroplasty. Patients around the threshold score of 70 may not have a clinically important difference compared with those above threshold.

Purpose To describe the demographics, neurophysiological grading, and incidence of patients undergoing carpal tunnel decompression (CTD) for carpal tunnel syndrome (CTS) in a single region. Methods A retrospective review of 2,313 patients aged greater than 16 years who underwent 3,073 CTDs between January 2000 and August 2010. Crude annual and age- and sex-specific incidences were calculated for the study period. Nerve conduction study grades were recorded and compared with age and sex. Results Of the 2,313 patients 1,419 (61%) were female and 890 (39%) were male. Mean age at surgery was 56 years (range, 16–93 years). Females had a significantly higher CTD incidence compared with males (161 vs 108/100,000 person-years, respectively). The highest rates of CTD were seen in the 70- to 79-year age group for both men and women (307/100,000 person-years). Neurophysiological grade increased in severity with increasing age despite using an age-adjusted grading system, with higher grades in patients aged greater than 65 years. Conclusions This study suggests that carpal tunnel syndrome has the highest incidence in older people who tend to have more severe neurophysiological changes. Type of study/level of evidence Prognostic II.

Background: In countries with publicly funded health care, there is an increasing need for explicit rationing for total joint arthroplasty (TJA). The Oxford Hip and Knee Scores (OHS/OKS) have been used to set access thresholds for TJA despite not being developed for that purpose. The aim of this study was to determine whether preoperative OHS/OKS can aid rationing decisions by investigating the changes in general health-related quality of life after TJA. Methods: OHS/OKS, Short Form-12, and Short Form-6D (SF-6D) scores were collected preoperatively and at 1 year postoperatively in a cohort of patients undergoing total hip arthroplasty (THA; n = 713) and total knee arthroplasty (TKA; n = 520). The association between preoperative OHS/OKS and postoperative score and the change in OHS/OKS and SF-6D was investigated, adjusting for age and gender. Results: The mean Oxford scores improved from 13.9 to 40.7 (OHS) and 15.6 to 37.4 (OKS). The mean SF-6D improved after THA (0.53 to 0.80) and TKA (0.56 to 0.78) (all P < .0001). Poorer preoperative Oxford scores were associated with poorer postoperative OHS/OKS and SF-6D but larger improvements. For every 5 points lower preoperative OHS/OKS, the postoperative SF-6D score was worse by a margin of 0.019 (THA) and 0.023 (TKA). Conclusions: Preoperative OHS/OKS can help inform rationing decisions. A lower preoperative OHS/OKS will result in greater gains but a lower final outcome score in general health-related quality of life.

Nonoperative management of patients with knee osteoarthritis (OA) through multidisciplinary programs may delay or reduce the need for total knee arthroplasty (TKA). However, avoidance of surgery may not represent success for the patient.A cohort of 120 patients with knee OA managed with at least 6 months of supervised nonoperative treatment coordinated through the Joint Clinic were reviewed at 5 years. Outcomes including Oxford knee score (OKS), Short Form 12 (SF-12), and SF-6D and other measures including analgesia use, global change, and perception of need for surgery were collected and compared with those from the cohort who had undergone TKA.Seventy (62.5%) surviving patients were still being managed nonoperatively. There was no significant change in any outcome score (OKS, SF-12 physical component score, SF-12 mental component score, SF-6D) (P = .26 to .84). Forty-two patients had undergone TKA with mean time to surgery 29.0 months (range, 9-69 months). In this group, the mean OKS fell from 17.9 at baseline to 10.3 (range, 3-21) preoperatively (P.0001) and at 5 years there was a significant improvement from baseline in OKS, SF-12 physical component score, and SF-6D scores (P.0001). All outcome scores and change in scores were significantly higher for the surgical group (all P.001).Although a high proportion of patients with knee OA have avoided surgery at 5 years, their outcomes show no improvement from baseline and are poorer than those who have undergone TKA. Avoidance of surgery should not necessarily be regarded as an indicator of success of nonoperative treatment for the patient.

Study Design Clinical measurement study; secondary analysis of randomized clinical trial data. Background A 12-item shortened version (ShortMAC) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a condition-specific, patient-reported osteoarthritis index, has been derived, published, and validated. The minimum important change (MIC) of the ShortMAC has not been reported or compared with the traditional 24-item WOMAC. Objectives To investigate the MIC of the 12-item ShortMAC and the traditional 24-item WOMAC across 3 levels of patient-perceived global change. Methods The Management of OsteoArthritis Trial cohort of 206 consecutive patients with knee or hip osteoarthritis was assessed at the initial visit and after 9 weeks of physical therapy (n = 155) or usual medical care (n = 51). The global rating of change instrument, assessed at the 9-week visit, provided the anchor. The MIC was calculated using receiver operating characteristic curve methodology for the ShortMAC and the traditional WOMAC, across 3 levels of patient-perceived change (small, medium, and large change) defined by the global rating of change. Results The MICs for the ShortMAC and traditional WOMAC (both transformed to a scale from 0 to 100) were 7.9 and 9.8 points for small change, 8.4 and 9.8 points for medium change, and 12.1 and 10.1 points for large change, respectively. The MICs of the pain and function subscales are also reported for small, medium, and large changes. Conclusion The lower point estimates for the MIC of the ShortMAC compared with that of the traditional WOMAC, using conventional definitions of MIC and half the number of items, indicate greater efficiency for use in clinical trials and reduced patient burden. J Orthop Sports Phys Ther 2018;48(2):81-86. Epub 21 Oct 2017. doi:10.2519/jospt.2018.7676.

The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing.Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS).With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS.This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing.Level II, prospective comparative study.

BACKGROUND Enhanced recovery after surgery (ERAS) programs or hip and knee replacements have had a significant effect on streamlining patient care with shorter stays, no increase in complications, and improved outcomes including reduced mortality. PURPOSE To compare outcomes following the introduction of an ERAS program for hip and knee replacements developed at our institution with a historical cohort of patients. METHODS ERAS protocols were developed at our institution for patients undergoing hip and knee joint replacements. Key aspects were changes in preadmission, a new education session, improved management of perioperative anemia, standardized anesthetic guidelines, day of surgery mobilization, and improved discharge planning. The results of the first 18 months (528 consecutive patients) were compared with those of a historical cohort of 507 patients from the 18 months prior to their introduction. RESULTS In the ERAS group, the mean age was 68.3 years for patients who underwent hip replacement and 70.4 years for patients who underwent knee replacement. Thirty-two percent of patients were ASA (American Society of Anesthesiologists) Grades III and IV. The average preoperative Oxford score was 11. The average length of stay (ALOS) fell from 5.6 to 4.3 days for patients who underwent hip replacement and from 5.7 to 4.8 days for patients who underwent knee replacement (p < .001). Ninety-six percent of patients were discharged home. The 30-day readmission rate increased from 3.2% to 5.5% (p = .065). Six-month Oxford knee scores were higher in the ERAS group (39.8 vs. 36.3, p = .03). There was no increase in mortality or early revision rate. CONCLUSIONS Substantial reductions in ALOS can be gained with the introduction of ERAS protocols, with high patient satisfaction and no increase in complications in a consecutive unselected group of public hospital patients. This requires a multidisciplinary approach and a strong clinical input.

Whether an occupation can cause carpal tunnel syndrome requiring carpal tunnel decompression (CTD) is contentious. We compared the demographics and incidence rates in lamb-freezing workers with the general population who had CTD. In the general population there were 1002 (63%) females and 583 (37%) males, mean age 48 years, and the rate of CTD was 1.36/1000 per annum. In lamb-freezing workers there were 225 males (mean age 38.4 years) and 60 females (mean age 44.6 years); most workers required CTD in their first three seasons. Compared with the general population, the incidence rate ratios in all freezing workers was 16.8; boners, 51.6; meat packers, 22.8; and slaughtermen, 5.4. All groups had a greater rate of CTD than the general population. This study suggests that carpal tunnel syndrome can be directly caused by an occupation.

Purpose.To review outcomes of 19 patients with tibial eminence fractures.Methods.Records of 10 female and 9 male patients with type II (n=3) and type III (n=16) displaced tibial intercondylar eminence fractures were reviewed. Nine of whom were skeletally immature aged 6 to 15 (mean, 12) years; the remaining 10 patients were aged 19 to 55 (mean, 32) years. 14 involved the left knee. All patients presented with a painful haemarthrosis and reduced range of movement.Results.The most common activity causing this injury was skiing (n=7, primarily in adult females [n=5]), followed by cycling or motocrossing (n=6) and falling or other sporting activities (n=6). The injury mechanisms entailed forced flexion with rotation (n=7), hyperextension with rotation (n=7, primarily in skeletally immature males [n=4]), and direct trauma (n=5, primarily in adult males [n=4]). Eight patients (60% of adults and 22% of children) had associated injuries of the knee, which commonly occurred after direct trauma. Two patients were treated in a cast or brace after closed or open reduction without fixation. Two patients underwent arthroscopic reduction and internal fixation, and 15 underwent open reduction and internal fixation (2 after failed arthroscopic reduction and 11 proceeded directly). Postoperatively, 7 patients had a positive Lachman test, but none complained of subjective instability. Ten patients had knee stiffness; all except one had been immobilised for 4 to 6 weeks. Seven patients had extension impingement; 6 of them had been treated with open reduction and internal fixation. Two patients underwent further surgery for debridement and screw removal at years 1 and 3. One patient developed arthrofibrosis and underwent arthrolysis at month 6, but knee stiffness remained. No patient underwent subsequent anterior cruciate ligament reconstruction.Conclusion.Tibial eminence fractures are as common in adults as in children. Female skiers are at higher risk. Stiffness is a more common complication than laxity. Early range-of-motion exercise may reduce stiffness and extension impingement.

Background:This study reports on the demographics of acute Achilles tendon rupture in our region and compares the results of a selective approach to operative and nonoperative treatment using an identical rehabilitation program with functional bracing.Materials and Methods:A consecutive series of 363 patients, aged 15 to 60 years, treated over 8.5 years by either open operative repair (143) or nonoperatively (220) were compared with respect to demographics, re-rupture rate, and major wound complication.Results:There was an almost equal number of males (159) and females (152) up to age 50 years but males comprised 73% of patients aged 51 to 60 years. Netball was the most common cause of injury and explains the relatively high incidence in females. In the 143 patients treated surgically there were two re-ruptures (1.4%) and two reop-erations for wound complications (1.4%). In the 220 patients treated nonoperatively there were 19 re-ruptures (8.6%), 13 of 113 males (11.5%) and six of 107 females (5.6%). There was a significantly lower re-rupture rate, and reoperation rate in the surgical group ( p < 0.05). In the nonoperative group there was a significantly lower rate of re-rupture in patients over 40 (six of 119) (4.1%) compared with those 40 years and under (13 of 99, 13.1%) and between females over 40 when compared with males 40 years and under.Conclusion:In our region there is a high incidence of Achilles tendon rupture among women due to netball and results in a younger age of injury than previously reported. Our results support surgery in patients less than 40 years, particularly males, if there are no contraindications. Functional bracing as part of nonoperative treatment can result in low re-rupture rates in patients over 40, especially in females. Level of Evidence: III, Retrospective Comparative Study

The purpose of this study is to compare the initial failure strengths of various interference screw devices used for tibial fixation of hamstring grafts in anterior cruciate ligament reconstruction and the effect of concentric or eccentric screw position. Quadrupled tendon grafts were harvested from freshly killed sheep. The grafts were then prepared and fixed in the distal femur using various devices (Intrafix (DePuy Mitek Raynham, MA, USA), RCI screw (Smith and Nephew Acufex, Mansfield, MA, USA), Wedge screw (Stryker Endoscopy, San Jose, CA, USA) in concentric position and Wedge screw in eccentric position with an interlock pin). The load required to cause mechanical failure of each construct was measured. The Intrafix device had a significantly greater mean strength to failure than all the other implants (mean 941 +/- 280 N) (P = 0.015 to P < 0.0001). The wedge screw inserted concentrically (737 +/- 134 N) had significantly greater initial failure strength than the wedge eccentric with interlock pin (458 +/- 266 N) (P = 0.03) and the RCI screw (464 +/- 107 N) (P = 0.00036). In this sheep model the Intrafix device with sheath inserted concentrically had significantly greater initial failure strength than the other interference screws. Concentric positioning of the wedge interference screw gave significantly greater initial failure strength of a quadruple tendon graft than eccentric positioning. The use of the Intrafix device or concentric positioning of an interference screw should result in increased initial fixation strength of hamstring grafts. This may allow more vigorous early rehabilitation and may result in less late graft laxity after anterior cruciate ligament reconstruction.

We studied sagittal laxity using the KT1000 arthrometer in 97 total knee arthroplasties (TKAs) in 83 patients using the porous-coated anatomic knee or Duracon TKA (Howmedica, Rutherford, NJ) with 5.4- to 9.9-year follow-up. Two differing tibial inserts were used: flat (group 1) and anteroposterior (AP) lipped (group 2). Greater posterior and total laxity at 75 degrees was seen in group 2 despite the AP-lipped insert. No differences were seen in functional outcome scores between groups. No significant relationship was seen between laxity and functional outcome. Knees with more than 10 mm of AP laxity at 75 degrees had significantly less flexion and lower Knee Society Scores than knees with 5 to 10 mm of AP laxity. We conclude that the optimal sagittal laxity in this cruciate-retaining TKA is between 5 and 10 mm, although this may not hold for posterior-stabilized designs.

Three boys with mild osteogenesis imperfecta (01) who sustained eight apophyseal avulsion fractures of the olecranon were compared with four normal boys with a unilateral apophyseal fracture. The children with OI were younger ( 1 1 years 7 months) than the normal children (14 years 3 months). All fractures were treated with tension band wiring (TBW). The contralateral elbow fractured 1 to 12 months later in the children with OI. Refractures occurred in two elbows, 6 to 16 months after the initial fracture and after TBW removal. One refracture presented late as a nonunion and was treated with bone grafting and plate fixation. None of the normal children experienced refracture after TBW removal. Good functional results and range of movement were achieved. Surgical treatment is recommended for all displaced fractures of the olecranon apophysis. There is a high risk of bilateral injury and a risk of refracture following removal of TBW in children with OI.

We present a case in which the radial artery was found running within the carpal tunnel at the time of routine carpal tunnel decompression. It appears to be an anomalous superficial palmar branch of the radial artery that is substituting for the normal radial artery.

Background: Closed tibialis anterior tendon rupture is an uncommon condition typically occurring in the middle aged to elderly patient. Diagnosis may be delayed due to unfamiliarity with the problem by the treating physician. Materials and Methods: We treated seven patients (4 males aged 54 to 80; 3 females aged 43 to 82) with this problem. Four patients had a history of systemic corticosteroid use and one had had a local steroid injection. Four of the seven patients were managed with direct operative repair and one with a non-anatomical repair to the talar neck. Two patients were managed nonoperatively of whom one subsequently required late surgical reconstruction. Patients were reviewed clinically and completed a Foot and Ankle Outcome Score (FAOS). Followup ranged from 12 months to 12 years. Results: In the operative group four patients had no functional limitations from the injury and one had mild ankle weakness. One in the nonoperative group required salvage surgery four years after rupture. At followup the mean FAOS was 85 (range, 64 to 98) in the operative group and 52 (range, 28 to 75) in the nonoperative group. Conclusion: A ruptured tibialis anterior tendon is a rare condition. There is an association with systemic steroid use as well as local steroid injection. Early diagnosis allows operative repair by various techniques leading to predictably good results. Our experience supports operative repair even in the elderly patient. Level of Evidence: IV, Retrospective Case Series

We reviewed the results at nine to 13 years of 125 total hip replacements in 113 patients using the monoblock uncemented Morscher press-fit acetabular component. The mean age at the time of operation was 56.9 years (36 to 74). The mean clinical follow-up was 11 years (9.7 to 13.5) and the mean radiological follow-up was 9.4 years (7.7 to 13.1). Three hips were revised, one immediately for instability, one for excessive wear and one for deep infection. No revisions were required for aseptic loosening. A total of eight hips (7.0%) had osteolytic lesions greater than 1 cm, in four around the acetabular component (3.5%). One required bone grafting behind a well-fixed implant. The mean wear rate was 0.11 mm/year (0.06 to 0.78) and was significantly higher in components with a steeper abduction angle. Kaplan-Meier survival curves at 13 years showed survival of 96.8% (95% confidence interval 90.2 to 99.0) for revision for any cause and of 95.7% (95% confidence interval 88.6 to 98.4) for any acetabular re-operation.

We describe 7 cases of synovitis or arthritis occurring after commencement of alendronate for treatment of osteoporosis. These were cases from our practice or notified to the New Zealand Pharmacovigilance Centre, Dunedin, New Zealand. There was no evidence of rheumatoid arthritis, pyrophosphate arthropathy, or seronegative arthritis in any patient. Symptoms recurred on rechallenge in 5 of the cases. We conclude alendronate should be considered as a possible cause of synovitis or polyarthritis in patients treated with it in the absence of any other pathology.

Background: Trochanteric bursitis or greater trochanter pain syndrome (GTPS) is a frequent cause of lateral hip pain. This article reports our experience with a new method of Z-lengthening of the iliotibial band for refractory GTPS. Methods: Fifteen patients (17 hips) were diagnosed with GTPS unresponsive to conservative treatment including steroid injection. Fourteen patients were women. The average age was 60 years and average duration of symptoms was 4.7 years. Results: At the mean follow up of 47 months following Z-lengthening, eight patients reported excellent results with complete resolution of symptoms, eight had good results with symptoms improved and one had a poor result. One patient required secondary repair of a tear in the tendon of gluteus minimus, with a subsequent excellent result. The mean Harris Hip Score improved from 46 to 82. Conclusion: We recommend this technique in patients with refractory GTPS. Associated tears of gluteus medius or minimus should be identified and repaired at the time of surgery.

The purposes of this study were to determine the interobserver and intraobserver reliability of ultrasound measurements in unstable neonatal hips treated with the Pavlik harness and to determine whether ultrasound measurements correlate with radiological outcome at 6 months. Sixty-four babies treated from birth with the Pavlik harness for neonatal hip instability were scanned at 2 and 6 weeks. The alpha and beta angles of Graf, the combined (H) angle of Hosny, and the femoral head coverage (FHC) were measured by 3 observers and remeasured by each observer on a minimum of 50 scans. From 248 scans, 792 sets of measurements were made. Hips were categorized as normal, abnormal, or borderline for each parameter; and interobserver and intraobserver repeatability coefficients and Kappa values were calculated. The alpha angle had the smallest interobserver range (17 degrees), the H angle range was 21 degrees, and the beta angle 28 degrees. Kappa values were best for the FHC and beta angle (0.66-0.8). The mean acetabular index (AI) of all hips at 6 months was 26 degrees (SD, 4.9). The AI was 30 degrees or greater in 24 hips (18 babies) despite prolonged splintage in 9 hips (6 babies). A stepwise linear regression analysis showed that the FHC at 6 weeks was predictive of AI at 6 months (regression coefficient -0.27; 95% confidence interval -0.42 to -0.12; P

We report on seven developmental hip dislocations in five babies (age 6-22 months) in whom ultrasound had demonstrated reduced and stable hips. Four hips in three babies had been diagnosed as having clinical instability (Barlow positive) at birth, which had stabilized by the time of the scan (16-45 days). Femoral head coverage ranged from 36 to 56%. One hip had minimal sonographic laxity on stress examination. Hips that are reduced and stable sonographically at 2-6 weeks of age can subsequently dislocate. Any child with instability at birth should be reviewed with a pelvic radiograph at 4-6 months, even if an ultrasound scan appears to be normal.

This is a case in which an anomalous tendon of the palmaris profundus was found running on the anterior surface of the median nerve, dividing the nerve into 2 branches at the wrist bilaterally. Excision of the tendon at the time of re-exploration of the carpal tunnel resulted in complete relief of carpal tunnel symptoms.

We report a long-term follow-up of a female patient with a multifocal extremity desmoid tumour. She had 3 local recurrences after excision and developed a second unresectable pelvic tumour that has remained unchanged in size for 14 years since starting tamoxifen treatment.

This article reports the results of a neonatal hip screening program comprising clinical screening and targeted ultrasound performed by orthopaedic surgeons. Over 7 years, from 1995 to 2001, there were 15,397 live births in the authors' region. Seven hundred thirty-three babies (4.8% of births) were referred for hip ultrasound: 80% for risk factors and 20% for instability. Eighty-three babies (5.4/1,000) were splinted in a Pavlik harness. Three of these subsequently required surgery (1.9/1,000). Ten patients (0.65/1000) presented with hip dislocation after 12 weeks of age, nine of whom required open or closed reduction (0.56/1,000). From 1978 to 1985, when neonatal pediatricians clinically screened all babies, 18 babies presented late from 13,707 births (1.3/1000). Since the introduction of orthopaedic screening and targeted ultrasound, there has been a significant reduction in late diagnosis in the authors' institution.

Alendronic acid (Fosamax, Merck) is a potent oral bisphosphonate licensed for prevention (5 mg daily) and treatment of postmenopausal osteoporosis (70 mg weekly or 10 mg daily).1 A 69 year old woman had been treated for osteoporosis with disodium etidronate (Didronel, Procter & Gamble) for four years. She had a history of asthma but was not taking prednisolone. She started taking 70 mg alendronic acid a week but within …

Study Design. An experimental model to assess radiation exposure during lumbar pedicle screw insertion. Objectives. To measure skin (patient) and scatter (surgeon) doses of radiation during lumbar spine fluoroscopy to assess safety of the procedure for both the surgeon and patient and determine best practice. Summary of Background Data. Fluoroscopy assists with accuracy of pedicle screw placement, yet the optimal technique of C-arm use and risk to both patient and operating room staff from radiation exposure are unknown. Methods. Entry- and scatter-dose recordings were made using a digital dosimeter while screening an anthropomorphic phantom prone on a radiolucent operating table. The source was positioned both superiorly and inferiorly with the height varied in the latter orientation to create a working space under the C-arm. The senior author fluoroscopy records were reviewed in 140 consecutive cases. Results. In a series of 140 patients who underwent pedicle screw fixation, the fluoroscopy time was 1.4 minutes per case or 0.33 minutes per screw. In the source-superior position, the effective dose received by the patient was approximately 2.3 mSv per case. In the source-inferior position with a working space of 300 mm, the effective dose was 6.8 mSv. Scatter dose to the surgeon was higher in the source-superior position but was still less than 10% of recommended limits for the hand, thyroid, and eyes. Conclusions. The source-superior position is the preferred position for pedicle screw screening if a working space is required. Patient exposure is minimized, and surgeon dose is well within current recommendations.

We have developed a computerised system for the storage, retrieval and analysis of the workload of a hand clinic. In a study of 800 patients we have found it superior to a punched card system collecting similar information. The computer system functioned reliably and achieved its user specification. It should prove a useful tool in helping a surgeon in matters of audit, research and disease or accident prevention but its long term performance in this regard requires evaluation.

An audit of 43 breast cancer patients, considered to be of high operative risk and treated only with Tamoxifen was performed. All cases were potentially operable. Good outcome was obtained in only one-third of patients. Salvage surgery had no operative mortality.

Purpose. To review the subjective and functional results of basal thumb metacarpal osteotomy for the treatment of trapeziometacarpal osteoarthritis. Methods. Between July 1993 and November 1998, 35 thumb osteotomies without internal fixation were performed on 33 patients in the Christchurch Hospital, New Zealand. Records of 28 thumbs (13 right and 15 left) of 26 patients (17 women and 9 men) were available for review. Patients were reviewed using strength testing and the Michigan Hand Outcomes Questionnaire. Results. The mean age of the 26 patients was 54 years (range, 30–69 years). Of the 28 thumbs, 22 (21 patients) had good or excellent results, 2 fair, one poor. The remaining 3 thumbs (3 patients) required further revision and were classified as failures. The mean follow-up period of the 25 thumbs (24 patients) not requiring revision was 34 months (range, 12–73 months). Good thumb motion was present in all hands with no trapeziometacarpal instability seen. Compared with the normative data, the strengths of key pinch, pulp pinch, and tripod pinch of our patients were significantly lower (22–32% lower), but not the grip strength. Michigan Hand Outcomes Questionnaire scores increased 28 (range, 1–56) points after surgery, with significant improvement especially in pain (+44 points), activities of daily living (one-handed tasks, +41 points), and satisfaction (+35 points). Conclusion. Basal thumb metacarpal osteotomy is a straightforward, conservative procedure that should be considered for grades II and III trapeziometacarpal osteoarthritis.