Significance of tibial MRI findings of special forces recruits at the onset of their training

INTRODUCTION

MRI is commonly used to evaluate medial tibial stress syndrome (MTSS), based on grading assessments developed in civilian populations. When MTSS represents stress fracture, rest is required to allow for bone remodelling to occur. False positive evaluations can lead to unnecessary recruit attrition.

METHODS

Thirty randomly selected new recruits to a special forces training unit underwent MRI of their tibias using the T2-Dixon sequence at the onset of training. Evaluation was according to the Fredericson MTSS grading system. Prior to undergoing MRI, anthropomorphic measurements, a survey of sports history and an orthopaedic examination of subject tibias were performed. Orthopaedic follow-up was through 11 weeks of training.

RESULTS

Medial periosteal oedema without the presence of bone marrow oedema, corresponding to a grade 1 stress reaction, was present on MRI in 10 recruits (17 tibias). In only one case did the periosteal oedema include the posterior aspect of the medial cortex where medial tibial stress fractures usually occur. Tibial tenderness was present in seven tibias on examination done just prior to the MRI studies, but none were symptomatic and only one had periosteal oedema present on MRI, but without anatomical correlation between the site of the tenderness and the periosteal oedema. During subsequent training, five tibias in four recruits developed pain and tenderness. Two had periosteal oedema in their prior MRIs, but the location did not coincide anatomically with that of the tibial tenderness. The time from stopping sports before induction and the presence of periosteal oedema was not significant.

CONCLUSION

Periosteal oedema, one of the hallmarks used in MRI grading systems to evaluate MTSS, was found to have a 37.7% false positive rate for anatomically corresponding tibial tenderness at the time of the examination and during subsequent training, indicating the grading systems' low utility for the military.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory

OBJECTIVES

To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge.

DESIGN

Longitudinal qualitative study.

SETTING AND PARTICIPANTS

Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge.

METHOD

The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically.

RESULTS

Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress.

CONCLUSIONS AND IMPLICATIONS

The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Non-operative versus operative treatment of suprasyndesmotic ankle fractures: protocol for a prospective, multicentre, randomised controlled trial

INTRODUCTION

Surgery is widely recognised as the treatment of choice for suprasyndesmotic ankle fractures, because of the assumption that these injuries yield instability of the ankle joint. Stability assessment of ankle fractures using weightbearing radiographs is now used regularly to guide the treatment of transsyndesmotic and infrasyndesmotic ankle fractures. Patients with a congruent ankle joint on weightbearing radiographs can be treated non-operatively with excellent results. Weightbearing radiographs are, however, rarely performed on suprasyndesmotic fractures due to the assumed unstable nature of these fractures. If weightbearing radiographs can be used to identify suprasyndesmotic fractures suitable for non-operative treatment, we may save patients from the potential burdens of surgery.Our aim is to compare the efficacy of operative and non-operative treatment of patients with suprasyndesmotic ankle fractures that reduce on weightbearing radiographs.

METHODS AND ANALYSIS

A non-inferiority randomised controlled trial involving 120 patients will be conducted. A total of 120 patients with suprasyndesmotic ankle fractures with an initial radiographic medial clear space of <7 mm will be subjected to weightbearing radiographs. If the tibio-talar joint is completely reduced, we will randomise in a 1:1 ratio to either operative treatment including reduction and fixation of the syndesmosis or non-operative treatment with an orthosis. The primary study outcome is patient-reported ankle function and symptoms as measured by the Olerud-Molander Ankle Score at 2-year follow-up. Secondary outcomes include the Manchester-Oxford Foot Questionnaire, range of motion, radiographic results and rates of adverse events.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research South East, group A (permission number: 169307), has granted ethics approval. The results of this study will provide valuable insights for developing future diagnostic and treatment strategies for a common fracture type. The findings will be shared through publication in peer-reviewed journals and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT04615650.

Impact of different surgical and non-surgical interventions on health-related quality of life after thoracolumbar burst fractures without neurological deficit: protocol for a comprehensive systematic review with network meta-analysis

INTRODUCTION

There is no international consensus on how to treat thoracolumbar burst fractures (TLBFs) without neurological deficits. The planned systematic review with network meta-analyses (NMA) aims to compare the effects on treatment outcomes, focusing on midterm health-related quality of life (HRQoL).

METHODS AND ANALYSIS

We will conduct a comprehensive and systematic literature search, identifying studies comparing two or more treatment modalities. We will search MEDLINE, EMBASE, Google Scholar, Scopus and Web of Science from January 2000 until July 2023 for publications. We will include (randomised and non-randomised) controlled clinical trials assessing surgical and non-surgical treatment methods for adults with TLBF. Screening of references, data extraction and risk of bias (RoB) assessment will be done independently by two reviewers. We will extract relevant studies, participants and intervention characteristics. The RoB will be assessed using the revised Cochrane RoB V.2.0 tool for randomised trials and the Newcastle-Ottawa Scale for controlled trials. The OR for dichotomous data and standardised mean differences for continuous data will be presented with their respective 95% CIs. We will conduct a random-effects NMA to assess the treatments and determine the superiority of the therapeutic approaches. Our primary outcomes will be midterm (6 months to 2 years after injury) overall HRQoL and pain. Secondary outcomes will include radiological or clinical findings. We will present network graphs, forest plots and relative rankings on plotted rankograms corresponding to the treatment rank probabilities. The ranking results will be represented by the area under the cumulative ranking curve. Analyses will be performed in Stata V.16.1 and R. The quality of the evidence will be evaluated according to the Grading of Recommendations, Assessment, Development and Evaluations framework.

ETHICS AND DISSEMINATION

Ethical approval is not required. The research will be published in a peer-reviewed journal.

Associations between future health expectations and patient satisfaction after lumbar spine surgery: a longitudinal observational study of 9929 lumbar spine surgery procedures

OBJECTIVE

This study aimed to investigate the associations between general health expectations and patient satisfaction with treatment for the two common spine surgery procedures diskectomy for lumbar disk herniation (LDH) and decompression for lumbar spinal stenosis (LSS).

DESIGN

Register study with prospectively collected preoperative and 1-year postoperative data.

SETTING

National outcome data from Swespine, the national Swedish spine register.

PARTICIPANTS

A total of 9929 patients, aged between 20 and 85 years, who were self-reported non-smokers, and were operated between 2007 and 2016 for one-level LSS without degenerative spondylolisthesis, or one-level LDH, were identified in the national Swedish spine register (Swespine). We used SF-36 items 11c and 11d to assess future health expectations and present health perceptions. Satisfaction with treatment was assessed using the Swespine satisfaction item.

INTERVENTIONS

One-level diskectomy for LDH or one-level decompression for LSS.

PRIMARY OUTCOME MEASURES

Satisfaction with treatment.

RESULTS

For LSS, the year 1 satisfaction ratio among patients with negative future health expectations preoperatively was 60% (95% CI 58% to 63%), while it was 75% (95% CI 73% to 76%) for patients with positive future health expectations preoperatively. The corresponding numbers for LDH were 73% (95% CI 71% to 75%) and 84% (95% CI 83% to 85%), respectively.

CONCLUSIONS

Patients operated for the common lumbar spine diseases LSS or LDH, with negative future general health expectations, were significantly less satisfied with treatment than patients with positive expectations with regard to future general health. These findings are important for patients, and for the surgeons who counsel them, when surgery is a treatment option for LSS or LDH.

Recurrence and return to duty following patellar instability events in military personnel

INTRODUCTION

Military service members experience patellar dislocations at a rate 10 times that of civilians. The purpose of this study was to determine the return to duty rate of active duty military personnel following first-time or recurrent patellar dislocation. Secondary goals were to identify patient variables and radiographic parameters associated with recurrent instability and requiring medical separation from military service.

METHODS

The Military Health System Data Repository was used to identify all active-duty military personnel who sustained a patellar dislocation between 2013 and 2018. Medical records were searched for patient variables including demographics, clinical findings, radiographic findings, treatment, adverse outcomes and military disposition. Patient variables associated with recurrent instability and undergoing medical separation were determined using univariate analysis and multivariate logistic regression. A total of 207 patients met inclusion and exclusion criteria.

RESULTS

Following patellar instability event, 30% of the cohort underwent surgical treatment. Fourteen per cent (29 of 207) underwent medical separation from military service. Regardless of treatment, 9% (18 of 207) experienced recurrent dislocation and 3% (6 of 207) experienced recurrent instability without dislocation. On multivariate analysis, none of the studied patient variables were associated with recurrent instability or medical separation.

CONCLUSIONS

Among military personnel, return to duty rates are similar to return to sport rates in civilians. This study demonstrates no difference in risk of recurrent instability or medical separation based on anatomical factors, which is useful during shared decision-making regarding treatment options and goals.

Women with limb loss: rationale, design and protocol for a national, exploratory needs assessment to evaluate the unique physical and psychosocial needs of women with limb loss

INTRODUCTION

There is a growing population of women with limb loss, yet limited research is available to provide evidentiary support for clinical decision-making in this demographic. As such, there is a critical gap in knowledge of evidence-based healthcare practices aimed to maximise the physical and psychosocial needs of women with limb loss. The objective of this study is to develop a comprehensive, survey-based needs assessment to determine the unique impact of limb loss on women, including physical and psychosocial needs.

METHODS AND ANALYSIS

A bank of existing limb loss-specific and non-limb loss-specific surveys were arranged around domains of general health, quality of life, prosthetic use and needs, psychosocial health and behaviours and body image. These surveys were supplemented with written items to ensure coverage of relevant domains. Written items were iteratively refined with a multidisciplinary expert panel. The interpretability of items and relevance to limb loss were then internally tested on a small group of rehabilitation, engineering and research professionals. A diverse sample of 12 individuals with various levels of limb loss piloted the instrument and participated in cognitive interviews. Items from existing surveys were evaluated for relevance and inclusion in the survey, but not solicited for content feedback. Pilot testing resulted in the removal of 13 items from an existing survey due to redundancy. Additionally, 13 written items were deleted, 42 written items were revised and 17 written items were added. The survey-based needs assessment has been crafted to comprehensively assess the wide spectrum of issues facing women with limb loss. The final version of the survey-based needs assessment included 15 subsections.

ETHICS AND DISSEMINATION

This study was approved by the Veterans Affairs Central Institutional Review Board. The results will be disseminated through national and international conferences, as well as through manuscripts in leading peer-reviewed journals.

TRIAL REGISTRATION NUMBER

No healthcare intervention on human participants was conducted.

Prognostic factors associated with failure of total elbow replacement: a protocol for a systematic review

INTRODUCTION

Total elbow replacement (TER) has higher failure rates requiring revision surgery compared with the replacement of other joints. Understanding the factors associated with failure is essential for informed decision-making between patients and clinicians, and for reducing the failure rate. This review aims to identify, describe and appraise the literature examining prognostic factors for failure of TER.

METHODS AND ANALYSIS

This systematic review will be conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Electronic literature searches will be conducted using Medline, EMBASE, PubMed and Cochrane. The search strategy will be broad, including a combination of subject headings (MESH) and free text search. This search will be supplemented with a screening of reference lists of the included studies and relevant reviews. Two independent reviewers will screen all search results in two stages (title and abstract, and full text) based on the Population, Index prognostic factor, Comparator prognostic factor, Outcome, Time and Setting criteria. The types of evidence included will be randomised trials, non-randomised trials, prospective and retrospective cohort studies, registry studies and case-control studies. If the literature lacks enough studies, then case series with 50 or more TERs will be considered for inclusion. Data extraction and risk of bias assessment for included studies will be performed by two independent reviewers using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies for Prognostic Factors and Quality In Prognostic Studies tools.Meta-analyses of prognostic estimates for each factor will be undertaken for studies that are deemed to be sufficiently robust and comparable. Several challenges are likely to arise due to heterogeneity between studies, therefore, subgroup and sensitivity analyses will be performed to account for the differences between studies. Heterogeneity will be assessed using Q and I2 statistics. If I2>40% then pooled estimates will not be reported. When quantitative synthesis is not possible, a narrative synthesis will be undertaken. The quality of the evidence for each prognostic factor will be assessed using the Grades of Recommendation Assessment, Development and Evaluation tool.

PROSPERO REGISTRATION NUMBER

CRD42023384756.

Prediction of knee joint pain in Tai Chi practitioners: a cross-sectional machine learning approach

OBJECTIVE

To build a supervised machine learning-based classifier, which can accurately predict whether Tai Chi practitioners may experience knee pain after years of exercise.

DESIGN

A prospective approach was used. Data were collected using face-to-face through a self-designed questionnaire.

SETTING

Single centre in Shanghai, China.

PARTICIPANTS

A total of 1750 Tai Chi practitioners with a course of Tai Chi exercise over 5 years were randomly selected.

MEASURES

All participants were measured by a questionnaire survey including personal information, Tai Chi exercise pattern and Irrgang Knee Outcome Survey Activities of Daily Living Scale. The validity of the questionnaire was analysed by logical analysis and test, and the reliability of this questionnaire was mainly tested by a re-test method. Dataset 1 was established by whether the participant had knee pain, and dataset 2 by whether the participant's knee pain affected daily living function. Then both datasets were randomly assigned to a training and validating dataset and a test dataset in a ratio of 7:3. Six machine learning algorithms were selected and trained by our dataset. The area under the receiver operating characteristic curve was used to evaluate the performance of the trained models, which determined the best prediction model.

RESULTS

A total of 1703 practitioners completed the questionnaire and 47 were eliminated for lack of information. The total reliability of the scale is 0.94 and the KMO (Kaiser-Meyer-Olkin measure of sampling adequacy) value of the scale validity was 0.949 (>0.7). The CatBoost algorithm-based machine-learning model achieved the best predictive performance in distinguishing practitioners with different degrees of knee pain after Tai Chi practice. 'Having knee pain before Tai Chi practice', 'knee joint warm-up' and 'duration of each exercise' are the top three factors associated with pain after Tai Chi exercise in the model. 'Having knee pain before Tai Chi practice', 'Having Instructor' and 'Duration of each exercise' were most relevant to whether pain interfered with daily life in the model.

CONCLUSION

CatBoost-based machine learning classifier accurately predicts knee pain symptoms after practicing Tai Chi. This study provides an essential reference for practicing Tai Chi scientifically to avoid knee pain.

Osteoarthritis in the UK Armed Forces: a review of its impact, treatment and future research

Within the UK Armed Forces, musculoskeletal injuries account for over half of all medical downgrades and discharges. Data from other Armed Forces show that osteoarthritis (OA), more common in military personnel, is likely to contribute to this, both in its primary form and following injury (post-traumatic OA, PTOA), which typically presents in the third or fourth decade. OA is not a progressive 'wear and tear' disease, as previously thought, but a heterogenous condition with multiple aetiologies and modulators, including joint damage, abnormal morphology, altered biomechanics, genetics, low-grade inflammation and dysregulated metabolism. Currently, clinical diagnosis, based on symptomatic or radiological criteria, is followed by supportive measures, including education, exercise, analgesia, potentially surgical intervention, with a particular focus on exercise rehabilitation within the UK military. Developments in OA have led to a new paradigm of organ failure, with an emphasis on early diagnosis and risk stratification, prevention strategies (primary, secondary and tertiary) and improved aetiological classification using genotypes and phenotypes to guide management, with the introduction of biological markers (biomarkers) potentially having a role in all these areas. In the UK Armed Forces, there are multiple research studies focused on OA risk factors, epidemiology, biomarkers and effectiveness of different interventions. This review aims to highlight OA, especially PTOA, as an important diagnosis to consider in serving personnel, outline current and future management options, and detail current research trends within the Defence Medical Services.

Relationship between shoulder abduction strength and rotator cuff tear in elderly women: a general population study

OBJECTIVES

To investigate the effect of age-related rotator cuff tears on shoulder strength in a general population cohort.

DESIGN

Cross sectional observational study.

SETTING

This study was set in an outpatient clinic setting in Chingford, North East London, and was a component of the 20 year visit of the Chingford 1000 women cohort.

PARTICIPANTS

Individuals were part of the Chingford 1000 women cohort, a 20-year-old longitudinal population study. This cohort has been extensively characterised as representative of the population of the UK. At the 20 year visit, 446 attended for shoulder assessment and were aged between 64 and 87.

PRIMARY AND SECONDARY OUTCOME MEASURES

Isometric shoulder abduction strength measured using a Nottingham Mecmesin Myometer and the presence of rotator cuff pathology, determined via ultrasound examination (GE voluson i portable ultrasound machine with a 10-16MHz linear probe). Shoulders were classified into normal, abnormal tendon/partial tear, full-thickness tears (>0 and ≤2.5 cm) and full-thickness tears (>2.5 cm). Symptoms were defined using the Oxford Shoulder Score, where an abnormal score was defined as symptomatic.

RESULTS

446 women (891 shoulders) aged 71 (range 65-84) were included in the study. Age, the presence of pain and the non-dominant arm were demonstrated to reduce strength. Rotator cuff tears and pathology had no isolated effect on shoulder strength in those aged under 70. However, in the over 70s full-thickness tears>0 and ≤2.5 cm, and >2.5 cm had mean reductions of 6.3 and 12.7 N, respectively (p<0.001).

CONCLUSION

Rotator cuff tears of all sizes in those aged under 70 were not associated with a loss of shoulder strength. In those aged over 70, strength was reduced by 30% with small and 40% with large full thickness tears. Loss in strength was associated a loss of ability to perform activities of daily living but only for large tears.

Timing of adverse events in patients undergoing acute and elective hip arthroplasty surgery: a multicentre cohort study using the Global Trigger Tool

OBJECTIVE

To explore timing in relation to all types of adverse events (AEs), severity and preventability for patients undergoing acute and elective hip arthroplasty.

DESIGN

A multicentre cohort study using retrospective record review with Global Trigger Tool methodology in combination with data from several registers.

SETTING

24 hospitals in 4 major regions of Sweden.

PARTICIPANTS

Patients ≥18 years, undergoing acute or elective total or hemiarthroplasty of the hip, were eligible for inclusion. Reviews of weighted samples of 1998 randomly selected patient records were carried out using Global Trigger Tool methodology. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country.

RESULTS

The cohort consisted of 667 acute and 1331 elective patients. Most AEs occurred perioperatively and postoperatively (n=2093, 99.1%) and after discharge (n=1142, 54.1%). The median time from the day of surgery to the occurrence of AE was 8 days. The median days for different AE types ranged from 0 to 24.5 for acute and 0 to 71 for elective patients and peaked during different time periods. 40.2% of the AEs, both major and minor, occurred within postoperative days 0-5 and 86.9% of the AEs occurred within 30 days. Most of the AEs were deemed to be of major severity (n=1370, 65.5%) or preventable (n=1591, 76%).

CONCLUSIONS

A wide variability was found regarding the timing of different AEs with the majority occurring within 30 days. The timing and preventability varied regarding the severity. Most of the AEs were deemed to be preventable and/or of major severity. To increase patient safety for patients undergoing hip arthroplasty surgery, a better understanding of the multifaceted nature of the timing of AEs in relation to the occurrence of differing AEs is needed.

Clinical characteristics of locomotive syndrome categorised by the 25-question Geriatric Locomotive Function Scale: a systematic review

OBJECTIVES

The purpose of this study was to compile the currently available evidence on the clinical characteristics of the locomotive syndrome (LS) categorised by the 25-question Geriatric Locomotive Function Scale (GLFS-25) and clarify its clinical usefulness for assessing mobility function.

DESIGN

Systematic review.

DATA SOURCES

The PubMed and Google Scholar were searched for the relevant studies on 20 March 2022.

ELIGIBILITY CRITERIA

We included relevant peer-reviewed articles, available in English language, on clinical LS characteristics categorised with the GLFS-25.

DATA EXTRACTION AND SYNTHESIS

Pooled ORs or mean differences (MDs) of the LS groups were calculated and compared with the non-LS groups for each clinical characteristic.

RESULTS

In total, 27 studies that involve 13 281 participants (LS, n=3385; non-LS, n=9896) were examined in this analysis. Older age (MD 4.71; 95% (CI) 3.97 to 5.44; p<0.00001), female gender (OR 1.54; 95% CI 1.38 to 1.71; p<0.00001), higher body mass index (MD 0.78; 95% CI 0.57 to 0.99; p<0.00001), osteoporosis (OR 1.68; 95% CI 1.32 to 2.13; p<0.0001), depression (OR 3.14; 95% CI 1.81 to 5.44; p<0.0001), lower lumbar lordosis angle (MD -7.91; 95% CI -10.08 to -5.74; p<0.00001), higher spinal inclination angle (MD 2.70; 95% CI 1.76 to 3.65; p<0.00001), lower grip strength (MD -4.04; 95% CI -5.25 to -2.83; p<0.00001), lower back muscle strength (MD -15.32; 95% CI -23.83 to -6.81; p=0.0004), lower maximum stride (MD -19.36; 95% CI -23.25 to -15.47; p<0.00001), higher timed up-and-go (MD 1.36; 95% CI 0.92 to 1.79; p<0.00001), lower one-leg standing time (MD -19.13; 95% CI -23.29 to -14.97; p<0.0001) and slower normal gait speed (MD -0.20; 95% CI -0.22 to -0.18; p<0.0001) were found to be associated with LS. No significant differences were noted in other clinical characteristics between the two groups.

CONCLUSIONS

GLFS-25 is clinically useful for assessing mobility function according to the evidence available on the clinical characteristics of LS categorised by the GLFS-25 questionnaire items until.

Effects of microcurrent therapy in promoting function and pain management of knee osteoarthritis: a systematic review and meta-analysis protocol

INTRODUCTION

Microcurrent therapy (MCT) is a rising conservative treatment for patients with knee osteoarthritis (OA). Considering its potential benefits and convenience, MCT's application in those individuals with knee OA is capacious. However, no plausible clinical evidence has proved its unequivocal advantages in treating knee OA conservatively. The purpose of this study is to determine whether MCT is helpful in pain management and promoting function of knee OA and is safe in the treatment of knee OA in adult patients.

METHODS AND ANALYSIS

We will search through MEDLINE, Embase, Cochrane Library, Web of Science and Google Scholar from inception to 15 March 2023. Original studies will include randomised controlled trials of patients treated with MCT. Two authors will independently screen, select studies, extract data and perform risk of bias assessment. Data consistently reported across studies will be pooled using random-effects meta-analysis. Heterogeneity will be evaluated using Cochrane's Q statistic and quantified using I² statistics. Graphical and formal statistical tests will be used to assess for publication bias.

ETHICS AND DISSEMINATION

Ethical approval will not be needed for this study as the data will be extracted from already published studies. The results of this review will be published in a peer-reviewed journal and presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42022319828.

Developing a best practice framework for musculoskeletal outpatient physiotherapy delegation: the MOPeD mixed-methods research study protocol

INTRODUCTION

Physiotherapy assistants/support workers are an important part of the physiotherapy workforce in the UK. Many of them work in National Health Service (NHS) physiotherapy outpatient services treating patients with musculoskeletal (MSK) conditions. In many services, they take responsibility, under professional supervision, for types of clinical work traditionally undertaken by physiotherapists such as leading exercise classes and treating individual patients. Nevertheless, their role(s) are relatively undefined and as such, there is considerable variation in the duties and tasks they undertake. This study aims to design a framework of 'best practice' in delegation to guide the work of clinicians in NHS physiotherapy MSK services and facilitate standardisation of practice to ensure that patients receive safe and effective treatment by the most appropriate person.

METHODS AND ANALYSIS

This mixed-methods study will be conducted in four stages. In stage 1, a focused ethnography in two MSK outpatient physiotherapy services will explore how the current use of delegation is informed by the culture within the clinical setting as well as views, attitudes about, and experiences of, delegation among clinicians, managers and patients. In stage 2a, nominal group technique will be used with three separate groups (physiotherapists/physiotherapy assistants/support workers, managers) to reach a consensus about what components should be included in a best practice framework of delegation. In stage 2b, a discrete choice experiment will elicit patients' preferences between care from physiotherapists and physiotherapy assistants/support workers within MSK physiotherapy services. In the final stage, the results of all previous stages will be triangulated to inform the development of a best practice delegation framework for future testing and use within NHS MSK outpatient physiotherapy services.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the South West-Frenchay Research Ethics Committee. The findings will be disseminated in peer-reviewed journals, conference presentations, the lay press and social media.

Implementation of the national Getting it Right First Time orthopaedic programme in England: a qualitative case study analysis

OBJECTIVE

To describe the implementation and impact of the Getting it Right First Time (GIRFT) national orthopaedic improvement programme at the level of individual National Health Service (NHS) Trusts.

DESIGN

Qualitative case studies conducted at six NHS Trusts, as part of a mixed-methods evaluation of GIRFT.

SETTING

NHS elective orthopaedic surgery in England.

PARTICIPANTS

59 NHS staff.

INTERVENTION

Improvement bundle, including bespoke routine performance data and improvement recommendations for each organisation, delivered via 'deep-dive' visits to NHS Trusts by a senior orthopaedic clinician.

RESULTS

Although all case study sites had made improvements to care, very few of these were reportedly a direct consequence of GIRFT. A range of factors, operating at three different levels, influenced their ability to implement GIRFT recommendations: at the level of the orthopaedic team (micro-eg, how individuals perceived the intervention); the wider Trust (meso-eg, competition for theatre/bed space) and the health economy more broadly (macro-eg, requirements to form local networks). Some sites used GIRFT evidence to support arguments for change which helped cement and formalise existing plans. However, where GIRFT measures were not a Trust priority because of more immediate demands-for example, financial and bed pressures-it was less likely to influence change.

CONCLUSION

Dynamic relationships between the different contextual factors, within and between the three levels, can impact the effectiveness of a large-scale improvement intervention and may account for variations in implementation outcomes in different settings. When designing an intervention, those leading future improvement programmes should consider how it sits in relation to these three contextual levels and the interactions that may occur between them.

Postsurgery paths and outcomes for hip fracture patients (POST-OP HIP PATHS): a population-based retrospective cohort study protocol

INTRODUCTION

Hip fracture patients receive varying levels of support posthip fracture surgery and often experience significant disability and increased risk of mortality. Best practice guidelines recommend that all hip fracture patients receive active rehabilitation following their acute care stay, with rehabilitation beginning no later than 6 days following surgery. Nevertheless, patients frequently experience gaps in care including delays and variation in rehabilitation services they receive. We aim to understand the factors that drive these practice variations for older adults following hip fracture surgery, and their impact on patient outcomes.

METHODS AND ANALYSIS

We will conduct a retrospective population-based cohort study using routinely collected health administrative data housed at ICES. The study population will include all individuals with a unilateral hip fracture aged 50 and older who underwent surgical repair in Ontario, Canada between 1 January 2015 and 31 December 2018. We will use unadjusted and multilevel, multivariable adjusted regression models to identify predictors of rehabilitation setting, time to rehabilitation and length of rehabilitation, with predictors prespecified including patient sociodemographics, baseline health and characteristics of the acute (surgical) episode. We will examine outcomes after rehabilitation, including place of care/residence at 6 and 12 months postrehabilitation, as well as other short-term and long-term outcomes.

ETHICS AND DISSEMINATION

The use of the data in this project is authorised under section 45 of Ontario's Personal Health Information Protection Act and does not require review by a Research Ethics Board. Results will be disseminated through conference presentations and in peer-reviewed journals.

Additional operation rates after surgery for degenerative spine diseases: minimum 10 years follow-up of 4705 patients in the national Swedish spine register

OBJECTIVES

To identify rates of additional operation after the index operation for degenerative lumbar spine diseases.

DESIGN

Retrospective register study.

SETTING

National outcome data from Swespine, the National Swedish spine register.

PARTICIPANTS

A total of 4705 patients who underwent one-level surgery for degenerative disk disease (DDD) or lumbar spinal stenosis (LSS) with or without degenerative spondylolisthesis (DS) between 1 January 2007 and 31 December 2010 were followed from 1 January 2007 to 31 December 2020 to record all cases of additional lumbar spine operations.

INTERVENTIONS

One-level spinal decompression and/or posterolateral fusion for degenerative spine diseases.

PRIMARY OUTCOME MEASURES

Number of additional operations.

RESULTS

Additional operations were more common at adjacent levels for patients with LSS with DS treated with decompression and fusion whereas additional operations were more evenly distributed between the index level and the adjacent levels for DDD treated with fusion and LSS with and without DS treated with decompression only. For patients younger than 60 years, treated with decompression and fusion for LSS with DS, the additional operations were evenly distributed between the index level and the adjacent levels.

CONCLUSIONS

There are different patterns of additional operations following the index procedure after surgery for degenerative spine diseases. Rigidity across previously mobile segments is not the only important factor in the development of adjacent segment disease (ASD) after spinal fusion, also the underlying disease and age may play parts in ASD development. The findings of this study can be used in the shared decision-making process when surgery is a treatment option for patients with degenerative lumbar spine diseases as the first operation may be the start of a series of additional spinal operations for other degenerative spinal conditions, either at the index level or at other spinal levels.

Study protocol for a randomised placebo controlled trial of platelet-rich plasma injection to prevent post-traumatic knee osteoarthritis after anterior cruciate ligament reconstruction

INTRODUCTION

The elevated cytokine levels in patients suffering from anterior cruciate ligament (ACL) rupture may lead to acute post-traumatic arthritis (APTA) and post-traumatic osteoarthritis (PTOA). Due to its chondrogenerative and anti-inflammatory effect, platelet-rich plasma (PRP) therapy is expected to show a positive outcome in APTA and PTOA. The proposed trial aims to quantitatively measure the efficacy of PRP injection in arresting post-traumatic cartilage degeneration among patients after ACL reconstruction.

METHODS AND ANALYSIS

This will be a single-blind, randomised, prospective, controlled clinical trial designed following the Consolidated Standards of Reporting Trials guidelines. After ACL reconstruction, 80 patients will be randomised to receive either leucocyte-poor PRP injection after joint aspiration or a placebo control group receiving only joint aspiration. Participants (age 20-49 years) will be those who have undergone ACL reconstruction within the past 2 weeks with a body mass index<35 and Kellgren Lawrence osteoarthritis grade<2. The primary outcome will include MRI-T2 values of knee cartilage at 6 months. The secondary outcomes will include pain assessment by Visual Analogue Scale, Knee injury and Osteoarthritis Outcome Score, blood and urine test, physical findings, measurements for muscle strength and joint stability.

ETHICS AND DISSEMINATION

The study was approved by The Independent Ethics Committee for Clinical Trials of the Japanese Association for the Promotion of State-of-the-Art Medicine. Results of the trial and each of the outcomes will be shared via conferences and publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

jRCTb030200391.

Effectiveness of subacromial injections in rotator cuff lesions: systematic review and meta-analysis protocol

INTRODUCTION

Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder.

METHODS AND ANALYSIS

Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software.

ETHICS AND DISSEMINATION

Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events.

PROSPERO REGISTRATION NUMBER

CRD42020199292.

Clinical effectiveness of tenotomy versus tenodesis for long head of biceps pathology: a systematic review and meta-analysis

OBJECTIVES

The comparative clinical effectiveness of common surgical techniques to address long head of biceps (LHB) pathology is unclear. We synthesised the evidence to compare the clinical effectiveness of tenotomy versus tenodesis.

DESIGN

A systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation approach.

DATA SOURCES

EMBASE, Medline, PsycINFO and the Cochrane Library of randomised controlled trials were searched through 31 October 2021.

ELIGIBILITY CRITERIA

We included randomised controlled trials, reporting patient reported outcome measures, comparing LHB tenotomy with tenodesis for LHB pathology, with or without concomitant rotator cuff pathology. Studies including patients treated for superior labral anterior-posterior tears were excluded. No language limits were employed. All publications from database inception to 31 October 2021 were included.

DATA EXTRACTION AND SYNTHESIS

Screening was performed by two authors independently. A third author reviewed the article, where consensus for inclusion was required. Data were extracted by two authors. Data were synthesised using RevMan. Inverse variance statistics and a random effects model were used.

RESULTS

860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included. Pooled analysis of patient-reported functional outcome measures data demonstrated comparable outcomes (n=10 studies; 403 tenotomy vs 416 tenodesis; standardised mean difference (SMD): 0.14, 95% CI -0.04 to 0.32, p=0.13). There was no significant difference for pain (Visual Analogue Scale) (n=8 studies; 345 tenotomy vs 350 tenodesis; MD: -0.11, 95% CI -0.28 to 0.06, p=0.21). Tenodesis resulted in a lower rate of Popeye deformity (n=10 studies; 401 tenotomy vs 410 tenodesis; OR: 0.29, 95% CI 0.19 to 0.45, p<0.00001). Tenotomy demonstrated shorter operative time (n=4 studies; 204 tenotomy vs 201 tenodesis; MD 15.2, 95% CI 1.06 to 29.36, p<0.00001).

CONCLUSIONS

Aside from a lower rate of cosmetic deformity, tenodesis yielded no significant clinical benefit to tenotomy for addressing LHB pathology.

PROSPERO REGISTRATION NUMBER

CRD42020198658.

Dual mobility versus conventional total hip arthroplasty in femoral neck fractures (DISTINCT): protocol for a registry-nested, open-label, cluster-randomised crossover trial

INTRODUCTION

Hip fractures treated with total hip arthroplasty (THA) are at high risk of prosthesis instability, and dislocation is the most common indication for revision surgery. This study aims to determine whether dual mobility THA implants reduce the risk of dislocation compared with conventional THA in patients with hip fracture suitable to be treated with THA.

METHODS AND ANALYSIS

This is a cluster-randomised, crossover, open-label trial nested within the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The clusters will comprise hospitals that perform at least 12 THAs for hip fracture per annum. All adults age ≥50 years who meet the Australian and New Zealand Hip Fracture Registry guidelines for THA will be included. The intervention will be dual mobility THA and the comparator will be conventional THA. Each hospital will be allocated to two consecutive periods, one of dual mobility THA and the other of conventional THA in random order, aiming for an average of 16 patients eligible for the primary analysis per group (32 total per site), allowing different recruitment totals between sites. Data will be collected through the AOANJRR and linked with patient-level discharge data acquired through government agencies. The primary outcome is dislocation within 1 year. Secondary outcomes include revision surgery for dislocation and all-cause, complications and mortality at 1, 2 and 5 years. If dual mobility THA is found to be superior, a cost-effectiveness analysis will be conducted. The study will aim to recruit 1536 patients from at least 48 hospitals over 3 years.

ETHICS AND DISSEMINATION

Ethics approval has been granted (Sydney Local Health District - Royal Prince Alfred Hospital Zone (approval X20-0162 and 2020/ETH00680) and site-specific approvals). Participant recruitment is via an opt-out consent process as both treatments are considered accepted, standard practice. The trial is endorsed by the Australia and New Zealand Musculoskeletal Clinical Trials Network.

TRIAL REGISTRATION NUMBER

ACTRN12621000069853.

Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden

OBJECTIVES

Superficial surgical site infection (SSSI) may increase the risk of serious complications such as periprosthetic joint infection (PJI). This study aims to identify patient-related risk factors associated with SSSI and investigate their correlation with the progression of PJI.

DESIGN

In this retrospective study, 1191 elective hip and knee prostheses were included. Patients were interviewed 3-5 months after surgery to answer questions about the postoperative period. Patient records were reviewed to determine whether there had been any documentation of wound-healing difficulties or whether antibiotics were prescribed to treat an infection related to arthroplasty surgery.

SETTING

Uppsala University Hospital, patients treated between November 2008 and December 2012.

PARTICIPANTS

The study population comprised 433 knees and 758 hips.

OUTCOME MEASURES

We studied patient-related risk factors (joint, age, sex, the American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking, diabetes and rheumatic disease) to determine whether they were associated with (1) SSSI and (2) the progress from SSSI to PJI.

RESULTS

84 (7%) patients of the total cohort developed SSSI. This infection progressed to a PJI in 24 (29%) of the patients. Factors with increased adjusted risk ratios (aRRs) for SSSIs were knee surgery (1.7; 95% CI: 1.1 to 2.7), age≥65 years (1.7; 95% CI: 1.1 to 2.8), BMI≥30 (1.9; 95% CI: 1.0 to 3.4) and ASA classification≥3 (1.7; 95% CI: 1.0 to 2.9). ASA classification≥3 was the only factor showing a significant progression from SSSI to PJI (aRR=3.3; 95% CI: 1.0 to 10.3).

CONCLUSIONS

The risk of progressing from an SSSI to a PJI is high. Older patients, patients with obesity, and those with a high ASA classification considered for elective total knee arthroplasty seem to have an increased risk of developing SSSI. Patients with a high ASA classification seem to have an increased risk of progressing from SSSI to PJI.

Development and training of a machine learning algorithm to identify patients at risk for recurrence following an arthroscopic Bankart repair (CLEARER): protocol for a retrospective, multicentre, cohort study

INTRODUCTION

Shoulder instability is a common injury, with a reported incidence of 23.9 per 100 000 person-years. There is still an ongoing debate on the most effective treatment strategy. Non-operative treatment has recurrence rates of up to 60%, whereas operative treatments such as the Bankart repair and bone block procedures show lower recurrence rates (16% and 2%, respectively) but higher complication rates (<2% and up to 30%, respectively). Methods to determine risk of recurrence have been developed; however, patient-specific decision-making tools are still lacking. Artificial intelligence and machine learning algorithms use self-learning complex models that can be used to make patient-specific decision-making tools. The aim of the current study is to develop and train a machine learning algorithm to create a prediction model to be used in clinical practice-as an online prediction tool-to estimate recurrence rates following a Bankart repair.

METHODS AND ANALYSIS

This is a multicentre retrospective cohort study. Patients with traumatic anterior shoulder dislocations that were treated with an arthroscopic Bankart repair without remplissage will be included. This study includes two parts. Part 1, collecting all potential factors influencing the recurrence rate following an arthroscopic Bankart repair in patients using multicentre data, aiming to include data from >1000 patients worldwide. Part 2, the multicentre data will be re-evaluated (and where applicable complemented) using machine learning algorithms to predict outcomes. Recurrence will be the primary outcome measure.

ETHICS AND DISSEMINATION

For safe multicentre data exchange and analysis, our Machine Learning Consortium adhered to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. No Institutional Review Board is required for this study.

Prospective double-blind randomised controlled trial protocol comparing bone marrow aspirate concentrate intra-articular injection combined with subchondral injection versus intra-articular injection alone for the treatment of symptomatic knee osteoarthritis

INTRODUCTION

Subchondral and intra-articular injections of bone marrow aspirate concentrate (BMAC) showed promising results for knee osteoarthritis (OA) patients. To date, there is no evidence to demonstrate whether the combination of these treatments provides higher benefits than the intra-articular injection alone.

METHODS AND ANALYSIS

Eighty-six patients with symptomatic knee OA (aged between 40 and 70 years) are randomised to BMAC intra-articular injection combined with subchondral BMAC injection or BMAC intra-articular injection alone in a ratio of 1:1. The primary outcome is the total Western Ontario and McMaster Universities Osteoarthritis Index, the secondary outcomes are the International Knee Documentation Committee Subjective and Objective Knee Evaluation Form, the Tegner activity scale, the EuroQol-Visual Analogue Scale, and the health questionnaire European Quality of Life Five Dimension score. Additional CT and MRI evaluations are performed at the baseline assessment and at the final 12-month follow-up. The hypothesis is that the combined injections provide higher knee pain and function improvement compared with BMAC intra-articular injection alone. The primary analysis follows an intention to treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Emilia Wide Area Ethical Committee of the Emilia-Romagna Region (CE-AVEC), Bologna, Italy. Written informed consent is obtained from all the participants. Findings of this study will be disseminated through peer-reviewed publications and conference presentations.

PROTOCOL VERSION

Version 1 (14 May 2018).

TRIAL REGISTRATION NUMBER

NCT03876795.

Neuromuscular and structural tendon adaptations after 6 weeks of either concentric or eccentric exercise in individuals with non-insertional Achilles tendinopathy: protocol for a randomised controlled trial

INTRODUCTION

There is limited evidence on the neural strategies employed by the central nervous system to control muscle force in the presence of non-insertional Achilles tendinopathy (NIAT). Additionally, the neuromuscular mechanisms by which exercise may help to resolve tendon pain remain unclear.

OBJECTIVE

This study aims to first establish changes in the gastrocnemius-soleus motor unit firing properties after applying a training protocol of 6 weeks based on either controlled eccentric or concentric contractions in individuals with NIAT. Second, we want to determine changes in the level of pain and function and mechanical and structural properties of the Achilles tendon after applying the same training protocol. Additionally, we want to compare these variables at baseline between individuals with NIAT and asymptomatic controls.

METHODS AND ANALYSIS

A total of 26 individuals with chronic (>3 months) NIAT and 13 healthy controls will participate in the study. Individuals with NIAT will be randomised to perform eccentric or concentric training for 6 weeks. Motor unit firing properties of the medial gastrocnemius, lateral gastrocnemius and soleus muscles will be assessed using high-density surface electromyography, as well as Achilles tendon length, cross-sectional area, thickness and stiffness using B-mode ultrasonography and shear wave elastography. Moreover, participants will complete a battery of questionnaires to document their level of pain and function.

ETHICS AND DISSEMINATION

Ethical approval (ERN-20-0604A) for the study was obtained from the Science, Technology, Engineering and Mathematics Ethical Review Committee of the University of Birmingham. The results of the study will be published in peer-review journals.

TRIAL REGISTRATION NUMBER

ISRCTN46462385.

BioFACTS: biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome - protocol for a prospective multinational, multicentre study involving patients with tibial fractures

INTRODUCTION

The ischaemic pain of acute compartment syndrome (ACS) can be difficult to discriminate from the pain linked to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is based on clinical findings and performed at a low level of suspicion. Biomarkers of muscle cell damage may help to identify and monitor patients at risk, similar to current routines for patients with acute myocardial infarction. This study will test the hypothesis that biomarkers of muscle cell damage can predict ACS in patients with tibial fractures.

METHODS AND ANALYSIS

Patients aged 15-65 years who have suffered a tibial fracture will be included. Plasma (P)-myoglobin and P-creatine phosphokinase will be analysed at 6-hourly intervals after admission to the hospital (for 48 hours) and-if applicable-after surgical fixation or fasciotomy (for 24 hours). In addition, if ACS is suspected at any other point in time, blood samples will be collected at 6-hourly intervals. An independent expert panel will assess the study data and will classify those patients who had undergone fasciotomy into those with ACS and those without ACS. All primary comparisons will be performed between fracture patients with and without ACS. The area under the receiver operator characteristics curves will be used to identify the success of the biomarkers in discriminating between fracture patients who develop ACS and those who do not. Logistic regression analyses will be used to assess the discriminative abilities of the biomarkers to predict ACS corrected for prespecified covariates.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethical Review Boards in Linköping (2017/514-31) and Helsinki/Uusimaa (HUS/2500/2000). The BioFACTS study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology recommendations.

TRIAL REGISTRATION NUMBER

NCT04674592.

Protocol for the CONNECT project: a mixed methods study investigating patient preferences for communication technology use in orthopaedic rehabilitation consultations

INTRODUCTION

Technology has been placed at the centre of global health policy and has been cited as having the potential to increase efficiency and remove geographical boundaries for patients to access care. Communication technology may support patients with orthopaedic problems, which is one of the leading causes of disability worldwide. There are several examples of technology being used in clinical research, although uptake in practice remains low. An understanding of patient preferences will support the design of a communication technology supported treatment pathway for patients undergoing orthopaedic rehabilitation.

METHODS AND ANALYSIS

This mixed methods project will be conducted in four phases. In phase I, a systematic review of qualitative studies reporting communication technology use for orthopaedic rehabilitation will be conducted to devise a taxonomy of tasks patients' face when using these technologies to access their care. In phase II, qualitative interviews will investigate how the work of being a patient changes during face-to-face and communication technology consultations and how these changes influence preference. In phase III, a discrete choice experiment will investigate the factors that influence preferences for the use of communication technology for orthopaedic rehabilitation consultations. Phase IV will be a practical application of these results. We will design a 'minimally disruptive' communication technology supported pathway for patients undergoing orthopaedic rehabilitation.

ETHICS AND DISSEMINATION

The design of a pathway and underpinning patient preference will assist in understanding factors that might influence technology implementation for clinical care. This study requires ethical approval for phases II, III and IV. Approvals have been received for phase II (approval received on 4 December 2016 from the South Central-Oxford C Research Ethics Committee (IRAS ID: 255172, REC Reference 18/SC/0663)) and phase III (approval received on 18 October 2019 from the London-Hampstead Research Ethics Committee (IRAS ID: 248064, REC Reference 19/LO/1586)) and will be sought for phase IV. All participants will provide informed written consent prior to being enrolled onto the study.

PROSPERO REGISTRATION NUMBER

CRD42018100896.