Anatomical shoulder replacements in young patients: A systematic review and meta-analysis.

Introduction: Increasing numbers of young patients receive shoulder replacements. Greater information on outcomes is needed to inform implant choice. The aim of this study was to investigate the survivorship and clinical effectiveness of hemiarthroplasty and anatomical total shoulder arthroplasty (TSA) in patients younger than 65 years. Method: A systematic review was performed of MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports. The primary outcomes were implant survival and change in perioperative shoulder scores. Results: Meta-analysis of implant survivorship was performed of six studies reporting on 416 patients. Implant survival was 86.1% (72.1,100) at 10 years for hemiarthroplasty and 82.3% (64.6,100) for TSA. 20 year survival was 80.0% for hemiarthroplasty (72.5,87.4) and 75.0% (56.9,93.1) for TSA. Ten studies were included in the meta-analysis of shoulder scores, multiple instruments were used. The standardised mean difference between pre-operative and post-operative shoulder scores was 2.15 (1.95, 2.35) for TSA at 4.2-4.9 years, and 2.72 (1.98,3.47) for hemiarthroplasty at 3.8-6 years. Conclusion: Over 80% of shoulder replacements last more than 10 years, and 75% last more than 20 years. Significant improvements in shoulder scores are shown at all time points.

Assessment of factual recall and higher-order cognitive domains in an open-book medical school examination.

Open-book examinations (OBEs) will likely become increasingly important assessment tools. We investigated how access to open-book resources affected questions testing factual recall, which might be easy to look-up, versus questions testing higher-order cognitive domains. Few studies have investigated OBEs using modern Internet resources or as summative assessments. We compared performance on an examination conducted as a traditional closed-book exam (CBE) in 2019 (N = 320) and a remote OBE with free access to Internet resources in 2020 (N = 337) due to COVID-19. This summative, end-of-year assessment focused on basic science for second-year medical students. We categorized questions by Bloom's taxonomy ('Remember', versus 'Understand/Apply'). We predicted higher performance on the OBE, driven by higher performance on 'Remember' questions. We used an item-centric analysis by using performance per item over all examinees as the outcome variable in logistic regression, with terms 'Open-Book, 'Bloom Category' and their interaction. Performance was higher on OBE questions than CBE questions (OR 2.2, 95% CI: 2.14-2.39), and higher on 'Remember' than 'Understand/Apply' questions (OR 1.13, 95% CI: 1.09-1.19). The difference in performance between 'Remember' and 'Understand/Apply' questions was greater in the OBE than the CBE ('Open-Book' * 'Bloom Category' interaction: OR 1.2, 95% CI: 1.19-1.37). Access to open-book resources had a greater effect on performance on factual recall questions than higher-order questions, though performance was higher in the OBE overall. OBE design must consider how searching for information affects performance, particularly on questions measuring different domains of knowledge.

The Salto total ankle arthroplasty - Clinical and radiological outcomes at five years.

BACKGROUND: Modern designs of total ankle arthroplasty (TAA) have the potential to treat symptomatic ankle OA without adversely affecting ankle biomechanics. We present the mid-term results of a modern, mobile-bearing TAA design. METHODS: TAA was performed in 50 consecutive patients (55 ankles) in an independent, prospective, single-centre series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of five years (range 2-10.5years). RESULTS: A total of three patients (four ankles) died and two (two ankles) were lost to follow-up. Three TAAs were revised for aseptic loosening (in two cases) or infection. Two further patients underwent reoperations, one for arthroscopic debridement of anterolateral synovitis and one for grafting of an asymptomatic tibial cyst. With all-cause revision as an endpoint, implant survival was 93.3% at five to ten years (95% CI 80.5%-97.8%). If reoperations are included this falls to 90.2% (95% CI 75.6%-96.3%) at five years. No other patient demonstrated radiographic evidence of loosening or subsidence. PROMs and satisfaction were excellent at latest follow-up. CONCLUSION: At five years, the outcomes for this design of TAA in this series were excellent, and were similar to those of previously published series from the designer centre.

Development and validation of a clinical prediction model for patient-reported pain and function after primary total knee replacement surgery.

To develop and validate a clinical prediction model of patient-reported pain and function after undergoing total knee replacement (TKR). We used data of 1,649 patients from the Knee Arthroplasty Trial who received primary TKR across 34 centres in the UK. The external validation included 595 patients from Southampton University Hospital, and Nuffield Orthopaedic Centre (Oxford). The outcome was the Oxford Knee Score (OKS) 12-month after TKR. Pre-operative predictors including patient characteristics and clinical factors were considered. Bootstrap backward linear regression analysis was used. Low pre-operative OKS, living in poor areas, high body mass index, and patient-reported anxiety or depression were associated with worse outcome. The clinical factors associated with worse outcome were worse pre-operative physical status, presence of other conditions affecting mobility and previous knee arthroscopy. Presence of fixed flexion deformity and an absent or damaged pre-operative anterior cruciate ligament (compared with intact) were associated with better outcome. Discrimination and calibration statistics were satisfactory. External validation predicted 21.1% of the variance of outcome. This is the first clinical prediction model for predicting self-reported pain and function 12 months after TKR to be externally validated. It will help to inform to patients regarding expectations of the outcome after knee replacement surgery.

The effect of bearing surface on risk of periprosthetic joint infection in total hip arthroplasty: a systematic review and meta-analysis.

AIMS: Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Different bearing surface materials have different surface properties and it has been suggested that the choice of bearing surface may influence the risk of PJI after THA. The objective of this meta-analysis was to compare the rate of PJI between metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC) bearings. PATIENTS AND METHODS: Electronic databases (Medline, Embase, Cochrane library, Web of Science, and Cumulative Index of Nursing and Allied Health Literature) were searched for comparative randomized and observational studies that reported the incidence of PJI for different bearing surfaces. Two investigators independently reviewed studies for eligibility, evaluated risk of bias, and performed data extraction. Meta-analysis was performed using the Mantel-Haenzel method and random-effects model in accordance with methods of the Cochrane group. RESULTS: Our search strategy revealed 2272 studies, of which 17 met the inclusion criteria and were analyzed. These comprised 11 randomized controlled trials and six observational studies. The overall quality of included studies was high but the observational studies were at high risk of bias due to inadequate adjustment for confounding factors. The overall cumulative incidence of PJI across all studies was 0.78% (1514/193 378). For each bearing combination, the overall incidence was as follows: MoP 0.85% (1353/158 430); CoP 0.38% (67/17 489); and CoC 0.53% (94/17 459). The meta-analysis showed no significant difference between the three bearing combinations in terms of risk of PJI. CONCLUSION: On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. Future research, including basic science studies and large, adequately controlled registry studies, may be helpful in determining whether implant materials play a role in determining the risk of PJI following arthroplasty surgery. Cite this article: Bone Joint J 2018;100-B:134-42.

Bias and unicompartmental knee arthroplasty.

We recently published a paper comparing the incidence of adverse outcomes after unicompartmental and total knee arthroplasty (UKA and TKA). The conclusion of this study, which was in favour of UKA, was dismissed as "biased" in a review in Bone & Joint 360 Although this study is one of the least biased comparisons of UKA and TKA, this episode highlights the biases that exist both for and against UKA. In this review, we explore the different types of bias, particularly selection, reporting and measurement. We conclude that comparisons between UKA and TKA are open to bias. These biases can be so marked, particularly in comparisons based just on national registry data, that the conclusions can be misleading. For a fair comparison, data from randomised studies or well-matched, prospective observational cohort studies, which include registry data, are required, and multiple outcome measures should be used. The data of this type that already exist suggest that if UKA is used appropriately, compared with TKA, its advantages outweigh its disadvantages. Cite this article: Bone Joint J 2017;99-B:12-15.

Comparison of outcomes after UKA in patients with and without chondrocalcinosis: a matched cohort study.

PURPOSE: Chondrocalcinosis can be associated with an inflammatory arthritis and aggressive joint destruction. There is uncertainty as to whether chondrocalcinosis represents a contraindication to unicompartmental knee arthroplasty (UKA). This study reports the outcome of a consecutive series of patients with chondrocalcinosis and medial compartment osteoarthritis treated with UKA matched to controls. METHODS: Between 1998 and 2008, 88 patients with radiological chondrocalcinosis (R-CCK) and 67 patients with histological chondrocalcinosis (H-CCK) were treated for end-stage medial compartment arthritis with Oxford UKA. One-to-two matching was performed to controls, treated with UKA, but without evidence of chondrocalcinosis. Functional outcome and implant survival were assessed in each group. RESULTS: The mean follow-up was 10 years. The mean Oxford Knee Score (OKS) at final follow-up was 43, 41 and 41 in H-CCK, R-CCK and control groups (change from baseline OKS was 21, 18 and 15, respectively). The change was significantly higher in H-CCK than in control but was not significantly different in R-CCK. Ten-year survival was 96 % in R-CCK, 86 % in H-CCK and 98 % in controls. Although the survival in H-CCK was significantly worse than in control, only one failure was due to disease progression. CONCLUSION: The presence of R-CCK does not influence functional outcome or survival following UKA. Pre-operative radiological evidence of CCK should not be considered to be a contraindication to UKA. H-CCK is associated with significantly improved clinical outcomes but also a higher revision rate compared with controls. LEVEL OF EVIDENCE: Case control study, Level III.

Aetiology of lateral progression of arthritis following Oxford medial unicompartmental knee replacement: a case-control study.

PURPOSE: The aim of this case-control study is to assess for predictive factors that may determine development of lateral compartment progression after Oxford medial unicompartmental knee replacement. METHODS: Twenty-eight patients who were revised as a result of lateral osteoarthritis progression were matched to 52 alive and unrevised patients. Body mass index, intra-operative findings, postoperative leg alignment, meniscal bearing size and histological findings have been analysed. Radiological analysis was carried out on the immediate postoperative radiographs by two blinded observers to assess the severity of arthritis in the lateral compartment. The measurements of the components positions were converted into binary figures as to whether they were inside or outside the recommended limits for analysis. Conditional logistic regression was used to identify important predictors of progression, taking into account the case-control grouping. RESULTS: The results shows that the condition of the lateral compartment is a significant predictor for developing subsequent lateral compartment arthrosis (OR 2.627, p = 0.019). The study showed no relationship between progression of arthritis and component position (OR [0.5-1.18], p [0.21-1]). Nor have it demonstrated that BMI (OR 1.06, p = 0.61), postoperative leg alignment (OR 1.26, p = 0.636), meniscal bearing size (1.32, p = 0.307) or presence of chondrocalcinosis (OR 0.35, p = 0.36) have any association with lateral osteoarthritis progression. CONCLUSIONS: This study showed the importance of excluding radiographic evidence of lateral compartment osteoarthritis on the preoperative radiograph prior to medial unicompartmental knee replacement. We have not been able to show any relationship between progression of arthritis and component position. Level of proof Case-control study, level III.

Optimal usage of unicompartmental knee arthroplasty: a study of 41,986 cases from the National Joint Registry for England and Wales.

Unicompartmental knee arthroplasty (UKA) has advantages over total knee arthroplasty but national joint registries report a significantly higher revision rate for UKA. As a result, most surgeons are highly selective, offering UKA only to a small proportion (up to 5%) of patients requiring arthroplasty of the knee, and consequently performing few each year. However, surgeons with large UKA practices have the lowest rates of revision. The overall size of the practice is often beyond the surgeon's control, therefore case volume may only be increased by broadening the indications for surgery, and offering UKA to a greater proportion of patients requiring arthroplasty of the knee. The aim of this study was to determine the optimal UKA usage (defined as the percentage of knee arthroplasty practice comprised by UKA) to minimise the rate of revision in a sample of 41 986 records from the for National Joint Registry for England and Wales (NJR). UKA usage has a complex, non-linear relationship with the rate of revision. Acceptable results are achieved with the use of 20% or more. Optimal results are achieved with usage between 40% and 60%. Surgeons with the lowest usage (up to 5%) have the highest rates of revision. With optimal usage, using the most commonly used implant, five-year survival is 96% (95% confidence interval (CI) 94.9 to 96.0), compared with 90% (95% CI 88.4 to 91.6) with low usage (5%) previously considered ideal. The rate of revision of UKA is highest with low usage, implying the use of narrow, and perhaps inappropriate, indications. The widespread use of broad indications, using appropriate implants, would give patients the advantages of UKA, without the high rate of revision.

Unicompartmental knee arthroplasty: is the glass half full or half empty?

There is a large amount of evidence available about the relative merits of unicompartmental and total knee arthroplasty (UKA and TKA). Based on the same evidence, different people draw different conclusions and as a result, there is great variability in the usage of UKA. The revision rate of UKA is much higher than TKA and so some surgeons conclude that UKA should not be performed. Other surgeons believe that the main reason for the high revision rate is that UKA is easy to revise and, therefore, the threshold for revision is low. They also believe that UKA has many advantages over TKA such as a faster recovery, lower morbidity and mortality and better function. They therefore conclude that UKA should be undertaken whenever appropriate. The solution to this argument is to minimise the revision rate of UKA, thereby addressing the main disadvantage of UKA. The evidence suggests that this will be achieved if surgeons use UKA for at least 20% of their knee arthroplasties and use implants that are appropriate for these broad indications.

Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales.

Whether to use total or unicompartmental knee replacement (TKA/UKA) for end-stage knee osteoarthritis remains controversial. Although UKA results in a faster recovery, lower rates of morbidity and mortality and fewer complications, the long-term revision rate is substantially higher than that for TKA. The effect of each intervention on patient-reported outcome remains unclear. The aim of this study was to determine whether six-month patient-reported outcome measures (PROMs) are better in patients after TKA or UKA, using data from a large national joint registry (NJR). We carried out a propensity score-matched cohort study which compared six-month PROMs after TKA and UKA in patients enrolled in the NJR for England and Wales, and the English national PROM collection programme. A total of 3519 UKA patients were matched to 10 557 TKAs. The mean six-month PROMs favoured UKA: the Oxford Knee Score was 37.7 (95% confidence interval (CI) 37.4 to 38.0) for UKA and 36.1 (95% CI 35.9 to 36.3) for TKA; the mean EuroQol EQ-5D index was 0.772 (95% CI 0.764 to 0.780) for UKA and 0.751 (95% CI 0.747 to 0.756) for TKA. UKA patients were more likely to achieve excellent results (odds ratio (OR) 1.59, 95% CI 1.47 to 1.72, p < 0.001) and to be highly satisfied (OR 1.27, 95% CI 1.17 to 1.39, p < 0.001), and were less likely to report complications than those who had undergone TKA. UKA gives better early patient-reported outcomes than TKA; these differences are most marked for the very best outcomes. Complications and readmission are more likely after TKA. Although the data presented reflect the short-term outcome, they suggest that the high revision rate for UKA may not be because of poorer clinical outcomes. These factors should inform decision-making in patients eligible for either procedure.

Determinants of revision and functional outcome following unicompartmental knee replacement.

OBJECTIVE: Unicompartmental Knee Replacement (UKR) has important advantages over total knee replacement (TKR) but has a higher revision rate. Outcomes vary between centres, suggesting that risk factors for revision may be modifiable with changes to patient selection or operative technique. The objective of this study was to determine factors affecting revision, patient-reported outcome and satisfaction following UKR. METHOD: 25,982 cases from three national databases were analysed. Multilevel multivariable regression models were used to examine the effect of patient and surgical factors on implant survival, patient-reported outcome and satisfaction at 6 months and 8 years following UKR. RESULTS: Of the 25,982 cases, 3862 (14.9%) had pre-operative and 6-month Oxford Knee Scores (OKS). Eight-year survival was 89.1% (95% confidence intervals (CI) 88.3-89.9). OKS increased from 21.9 (SD 7.6) to 37.5 (SD 9.5). Age (Hazard ratio (HR) 0.96 (95% CI 0.96-0.97) per year), male gender (HR 0.86 (95% CI 0.76-0.96)), unit size (HR 0.92 (95% CI 0.86-0.97) per case up to 40 cases/year) and operating surgeon grade (HR 0.78 (95% CI 0.67-0.91) if consultant) predicted improved implant survival. Older patients (≥ 75 years), and those with lower deprivation levels had superior OKS and satisfaction (adjusted mean difference 0.14 (95% CI 0.09-0.20) points per year of age and 0.93 (95% CI 0.60-1.27) per quintile of deprivation). Ethnicity, anxiety and co-morbidities also affected patient-reported outcome. CONCLUSIONS: This study has identified important predictors of revision and patient-reported outcome following UKR. Older patients, who are least likely to be offered UKR, may derive the greatest benefits. Improved understanding of these factors may improve the long-term outcomes of UKR.

Valgus subsidence of the tibial component in cementless Oxford unicompartmental knee replacement.

The cementless Oxford unicompartmental knee replacement has been demonstrated to have superior fixation on radiographs and a similar early complication rate compared with the cemented version. However, a small number of cases have come to our attention where, after an apparently successful procedure, the tibial component subsides into a valgus position with an increased posterior slope, before becoming well-fixed. We present the clinical and radiological findings of these six patients and describe their natural history and the likely causes. Two underwent revision in the early post-operative period, and in four the implant stabilised and became well-fixed radiologically with a good functional outcome. This situation appears to be avoidable by minor modifications to the operative technique, and it appears that it can be treated conservatively in most patients.

Improved fixation in cementless unicompartmental knee replacement: five-year results of a randomized controlled trial.

BACKGROUND: When used for appropriate indications, unicompartmental knee replacement is associated with fewer complications, faster recovery, and better function than total knee replacement. However, joint registries demonstrate a higher revision rate for unicompartmental knee replacement. Currently, most unicompartmental knee replacements are cemented; common reasons for revision include aseptic loosening and pain. These problems could potentially be addressed by using cementless implants, with coatings designed to improve fixation. The objectives of this study were to compare the quality of fixation as well as clinical outcomes of cemented and cementless unicompartmental knee replacements at five years of follow-up. METHODS: A randomized controlled trial was established with sixty-three knees (sixty-two patients) receiving either cemented (thirty-two patients) or cementless Oxford unicompartmental knee replacements (thirty patients). Fixation was assessed with fluoroscopic radiographs aligned to the bone-implant interface at one and five years. Outcome scores, including the Oxford Knee Score, Knee Society objective and functional scores, and Tegner Activity Score, were collected preoperatively and at six months and one, two, and five years postoperatively. At each postoperative time point, these were recorded as absolute scores and change from the preoperative score. RESULTS: Four patients died during the study period. There were no revisions. Mean operative time was nine minutes shorter in the cementless group (p = 0.049). At five years, there was no significant difference in any outcome measure except the Knee Society functional score and the change in the Knee Society functional score, which were significantly better in the cementless group (p = 0.003 for both). There were significantly more tibial radiolucencies in the cemented group (twenty of thirty knees versus two of twenty-seven knees; p < 0.001). There were nine complete radiolucencies in the cemented group and none in the cementless group (p = 0.01). CONCLUSIONS: Cementless fixation provides improved fixation at five years compared with cemented fixation in mobile-bearing unicompartmental knee replacements, maintaining equivalent or superior clinical outcomes with a shorter operative time and no increase in complications. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for authors for a complete description of levels of evidence.

Cementless fixation in Oxford unicompartmental knee replacement: a multicentre study of 1000 knees.

The Cementless Oxford Unicompartmental Knee Replacement (OUKR) was developed to address problems related to cementation, and has been demonstrated in a randomised study to have similar clinical outcomes with fewer radiolucencies than observed with the cemented device. However, before its widespread use it is necessary to clarify contraindications and assess the complications. This requires a larger study than any previously published. We present a prospective multicentre series of 1000 cementless OUKRs in 881 patients at a minimum follow-up of one year. All patients had radiological assessment aligned to the bone-implant interfaces and clinical scores. Analysis was performed at a mean of 38.2 months (19 to 88) following surgery. A total of 17 patients died (comprising 19 knees (1.9%)), none as a result of surgery; there were no tibial or femoral loosenings. A total of 19 knees (1.9%) had significant implant-related complications or required revision. Implant survival at six years was 97.2%, and there was a partial radiolucency at the bone-implant interface in 72 knees (8.9%), with no complete radiolucencies. There was no significant increase in complication rate compared with cemented fixation (p = 0.87), and no specific contraindications to cementless fixation were identified. Cementless OUKR appears to be safe and reproducible in patients with end-stage anteromedial osteoarthritis of the knee, with radiological evidence of improved fixation compared with previous reports using cemented fixation.

Preoperative pain location is a poor predictor of outcome after Oxford unicompartmental knee arthroplasty at 1 and 5 years.

PURPOSE: Indications for unicompartmental knee arthroplasty (UKA) vary between units. Some authors have suggested, and many surgeons believe, that medial UKA should only be performed in patients who localise their pain to the medial joint line. This is despite research showing a poor correlation between patient-reported location of pain and radiological or operative findings in osteoarthritis. The aim of this study is to determine the effect of patient-reported preoperative pain location and functional outcome of UKA at 1 and 5 years. METHODS: Preoperative pain location data were collected for 406 knees (380 patients) undergoing Oxford medial UKA. Oxford Knee Score, American Knee Society Scores and Tegner activity scale were recorded preoperatively and at follow-up; 272/406 (67 %) had pure medial pain, 25/406 (6 %) had pure anterior knee pain, and 109/406 (27 %) had mixed or generalised pain. None had pure lateral pain. The primary outcome interval is 1 year; 132/406 patients had attained 5 years by the time of analysis, and their 5-year data are presented. RESULTS: At 1 and 5 years, each group had improved significantly by each measure [mean ΔOKS 15.6 (SD 8.9) at year 1, 16.3 (9.3) at year 5]. There was no difference between the groups, nor between patients with and without anterior knee pain or isolated medial pain. CONCLUSIONS: No correlation is demonstrated between preoperative pain location and outcome. We conclude that localised medial pain should not be a prerequisite to UKA and that it may be performed in patients with generalised or anterior knee pain.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children.

We present the results of 17 children of Tanner stage 1 or 2 who underwent reconstruction of the anterior cruciate ligament between 1999 and 2006 using a transphyseal procedure, employing an ipsilateral four-strand hamstring graft. The mean age of the children was 12.1 years (9.5 to 14). The mean follow-up was 44 months (25 to 100). Survival of the graft, the functional outcome and complications were recorded. There was one re-rupture following another injury. Of the remaining patients, all had good or excellent results and a normal International Knee Documentation Committee score. The mean post-operative Lysholm score was 97.5 (SD 2.6) and the mean Tegner activity scale was 7.9 (SD 1.4). One patient had a mild valgus deformity which caused no functional disturbance. No other abnormality or discrepancy of leg length was seen. Measurements with a KT1000 arthrometer showed no significant difference between the normal and the operated legs. In this small series, transphyseal reconstruction of the anterior cruciate ligament appeared to be safe in these young children.

Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices.

Chronic pelvic pain is a common and disabling condition affecting women of childbearing age. A specific diagnosis for the condition is often difficult, and referred pain from the abdominal viscera, neurogenic and psychogenic factors have all been implicated, as have pelvic conditions such as endometriosis, pelvic inflammatory disease and ovarian cysts; no diagnosis is made in 60% of patients. Pelvic congestion syndrome (PCS), the presence of varices of the pelvic veins, has been shown to be the underlying aetiology in a significant proportion of patients with chronic pelvic pain; the development of these varices is caused by a combination of endocrine and mechanical factors. Given the positional nature of these varices, they are rarely diagnosed with conventional methods such as B-mode ultrasound and diagnostic laparoscopy. Diagnosis is best made with selective ovarian venography, although newer, non-invasive methods such as magnetic resonance imaging and duplex ultrasound are increasingly gaining favour. Pelvic varices are eminently treatable, either using ovarian suppression or by the ligation or embolization of the pelvic veins.