2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

873 The Keystone Challenge- Volar Displaced Intra-Articular Distal Radius Fractures with Lunate Fossa Fragment

Aim

Volar displaced fractures of the distal radius are unstable and warrant operative management. A subset of patients with volar displaced fractures also has a separate lunate fossa fragment, a specific injury with greater instability that may precipitate carpal subluxation. We aim to review our long-term experience in the management of this complex injury, exploring surgical technique which may improve treatment.

Method

We retrospectively reviewed all volar displaced distal radius fixations between 2015 and 2020. Inclusion criteria: any displaced intra-articular volar distal radius fracture with lunate fragment involvement undergoing volar fixation and over 16 years of age. Exclusion criteria: shaft fractures, extra-articular fractures, open fractures, fractures fixed using k-wires or external fixation, revision surgery and patients without follow-up. We adapted our surgical approach in order to address this more complex fracture pattern, and all operations were performed by specialist hand surgeons.

Results

468 distal radius fractures were assessed, of which 29 (6%) cases included a lunate fossa fragment. 20 (69%) of patients were female, mean age was 59 years (SD 12.4). Mean length of stay was 5 hours and mean operative time was 96 mins (range 79-95). No patients had carpal subluxation, fracture fixation failure or return to theatre for any reason.

Conclusions

From our experience as a specialist orthopaedic institution, we recommend the extended FCR approach and intra-focal exposure to manage this complex injury. In particular, the lunate fossa fragment is the keystone which requires dedicated reduction prior to tackling the remaining fracture configuration.

42 An Analysis of Virtual Fracture Clinics in Orthopaedic Trauma in the UK During the Coronavirus Crisis

Aim

Virtual Fracture Clinics (VFC) are advocated by new Orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature. As well as recommendations on introducing a VFC service during the Coronavirus pandemic and into the future.

Method

A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify 9 relevant publications related to VFC.

Results

The Glasgow Model initiated in 2011 has become the benchmark. Clinical efficiency can be improved, reducing the number of ED referrals seen in VFC by 15%-28% and face to face consultations by 65%. 33-60% of patients may be discharged after review in the VFC. Some studies have shown no negative impact on the Emergency Department (ED), the time to discharge was not increased. Patients satisfaction ranges from 91%-97% using a VFC service, and there may be cost saving benefits annually from £67,385-£212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited, 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%).

Conclusions

We propose a pathway integrating the VFC model, whilst having Senior Orthopaedic decision makers available in ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice.

Heart rate variabilty changes during first week of acclimatization to 3500 m altitude in Indian military personnel

Acute exposure to hypobaric hypoxia induces the changes in autonomic control of heart rate. Due to emergencies or war like conditions, rapid deployment of Indian military personnel into high altitude frequently occurs. Rapid deployment to high altitude soldiers are at risk of developing high altitude sickness. The present study was conducted to evaluate the acute exposure to high altitude hypobaric hypoxia (3500 m altitude) on the autonomic nervous control of heart rate in Indian military personnel during first week of acclimatization Indices of heart rate variability (viz; R-R interval, total power, low frequency, high frequency, ratio of low to high frequency) and pulse arterial oxygen saturation were measured at sea level and 3500m altitude. Power spectrum of heart rate variability was quantified by low frequency (LF: 0.04-0.15 Hz) and high frequency (HF: 0.15-0.5 Hz) widths. The ratio of LF to HF was also assessed as an index of the sympathovagal balance. Mean R-R interval decreased significantly on day 2 on induction to altitude which tended to increase on day 5. Total power (TP) decreased high altitude and tended to recover within a week. Both HF and LF power showed decrement at 3500m in comparison to sea level. The ratio of LF to HF (LF/HF) at 3500m was significantly higher at 3500m. SpO2 values decreased significantly (P < 0.05) at high altitude on day-2 which increased on day-5. We conclude that autonomic control of the heart rate measured by heart rate variability was altered on acute induction to 3500m which showed a significant decrease in parasympathetic tone and increase in sympathetic tone, then acclimatization seems to be characterized by progressive shift toward a higher parasympathetic tone.

Conformational rigidity introduced by 2',5'-phosphodiester links in DNA

Conformational properties of 2',5'-linked 3'-deoxyribonucleotides have been compared with their natural isomer using CD spectroscopy. It is inferred from the salt induced titration curves that the 2',5'-linked-3'deoxyribonucleotides have rigid phosphodiester backbone.