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Journal articleZHOU T, Salman D, McGregor A, 2024,
Recent clinical practice guidelines for the management of low back pain: a global comparison
, BMC Musculoskeletal Disorders, Vol: 25, ISSN: 1471-2474BackgroundLow back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world.MethodsMEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.ResultsOur analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture.ConclusionsCurrent CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.
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Journal articleDavies A, Sabharwal S, Liddle AD, et al., 2024,
Revision rate in metal compared to ceramic humeral head total shoulder arthroplasty and hemiarthroplasty
, The Bone & Joint Journal, Vol: 106-B, Pages: 482-491, ISSN: 2049-4408AimsMetal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.MethodsNJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation.ResultsA total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure.ConclusionThe rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and a
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Journal articleHashim S, Jones G, 2024,
Revision anterior cruciate ligament reconstruction and medial unicompartmental knee replacement
, Journal of Orthopaedic Case Reports, Vol: 14, Pages: 121-125, ISSN: 2250-0685Failure of anterior cruciate ligament (ACL) reconstructive surgery often presents alongside progressive mono-compartment tibiofemoral arthrosis. A total knee arthroplasty (TKA) is the conventional treatment option for this scenario but is associated with high levels of dissatisfaction amongst this younger cohort. This case report outlines a 39-year-old male patient, who underwent revision anterior cruciate ligament reconstruction plus a medial unicompartmental knee replacement (UKA) as a single stage procedure. This is the first reported ACL revision with a simultaneous medial UKA and provides an alternative solution to a total knee arthroplasty in this younger cohort of patients.
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Journal articleClunie G, Roe J, Al-Yaghchi C, et al., 2024,
The voice and swallowing profile of adults with laryngotracheal stenosis before and after reconstructive surgery: a prospective, descriptive observational study
, Clinical Otolaryngology, Vol: 49, Pages: 324-330, ISSN: 1749-4478Objectives:Airway reconstruction for laryngo tracheal stenosis (LTS) improves dyspnoea. There is little evidence relating to impact upon voice and swallowing. We explored voice and swallowing outcomes in adults with LTS before and after reconstructive surgery.Design:Outcome measures were collected pre-reconstructive surgery, two-weeks post-surgery and up to 4-6 months post-surgery.Setting:Tertiary referral centre.Participants:With ethical approval, twenty consecutive adult (≥18 years) LTS patients undergoing airway reconstruction were prospectively recruited.Main outcome measures:These included physiological values (maximum phonation time (MPT) and fundamental frequency; penetration aspiration score, residue score), clinician-reported (GRBAS, functional oral intake score, 100ml Water Swallow Test) and patient-reported outcomes (Voice Handicap Index-10, Reflux Symptoms Index, Eating Assessment Tool, Dysphagia Handicap Index).Results:The observational study identified patient-reported and clinician-reported voice and swallow difficulties pre- and post-surgery; median and interquartile range are reported at each time point: Voice Handicap Index-10 23 (8-31); 20.5 (9-33.5), 24.5 (12.5-29); Dysphagia Handicap Index 9 (0-37); 13 (7-44); 15 (4-34); GRBAS grade 1(1-2); 2 (1-2.5); 2(1-2); 100ml Water Swallow Test volume score 16.7 (11.1-20); 14.3 (12.5-16.7); 16.7 (14.3-20.0); 100ml Water Swallow Test capacity score 16.3 ± 9.0; 11.0 ± 4.1; 12.5 ± 2.6.Conclusions:We present the first prospective data on voice and swallowing outcomes in adults with LTS before and after reconstructive surgery. The variability of the outcomes was higher than expected but importantly, for many the voice and swallow outcomes were not within normal limits before surgery. The clinical value of the study demonstrates the need for individual assessment and management of LTS patients’ voice and swallowing.
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Journal articleDavies A, Sabharwal S, Liddle AD, et al., 2024,
Revision rate in metal compared to ceramic humeral head total shoulder arthroplasty and hemiarthroplasty AN ANALYSIS OF DATA FROM THE NATIONAL JOINT REGISTRY
, BONE & JOINT JOURNAL, Vol: 106B, Pages: 482-491, ISSN: 2049-4394 -
Journal articleScott JW, Ng KCG, Liddle AD, et al., 2024,
Method for accurate removal of trabecular bone samples from a curved articulating surface of the distal femur
, CLINICAL BIOMECHANICS, Vol: 115, ISSN: 0268-0033 -
Journal articleWoodbridge H, McCarthy C, Jones M, et al., 2024,
Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study
, Critical Care (UK), Vol: 28, ISSN: 1364-8535BackgroundPhysical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.MethodsA three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.ResultsTwenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs
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Journal articleKeny SM, Bagaria V, Sahu D, et al., 2024,
Remote patient monitoring: A current concept update on the technology adoption in the realm of orthopedics
, Journal of Clinical Orthopaedics and Trauma, Vol: 51, ISSN: 0976-5662- Cite
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Journal articleHomer JJ, Winter SC, 2024,
Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition
, Journal of Laryngology and Otology, Vol: 138, Pages: S1-S224, ISSN: 0022-2151 -
Journal articleVivek K, Kamal R, Perera E, et al., 2024,
Vitamin D Deficiency Leads to Poorer Health Outcomes and Greater Length of Stay After Total Knee Arthroplasty and Supplementation Improves Outcomes
, JBJS REVIEWS, Vol: 12, ISSN: 2329-9185 -
Journal articleReynolds A, Doyle R, Boughton O, et al., 2024,
Dynamics of manual impaction instruments during total hip arthroplasty
, Bone & Joint Research, Vol: 13, Pages: 193-200, ISSN: 2046-3758AimsManual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.MethodsPosterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment.ResultsThe force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face.ConclusionThe direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training.
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Journal articleHuang F, Harris S, Zhou T, et al., 2024,
Which method for femoral component sizing when performing kinematic alignment TKA? An in silico study
, ORTHOPAEDICS & TRAUMATOLOGY-SURGERY & RESEARCH, Vol: 110, ISSN: 1877-0568 -
Journal articleSarai P, Luff C, Rohani-Shukla C, et al., 2024,
Characteristics of motor evoked potentials in patients with peripheral vascular disease
, PLoS One, Vol: 19, ISSN: 1932-6203With an aging population, it is common to encounter people diagnosed with peripheral vascular disease (PVD). Some will undergo surgeries during which the spinal cord may be compromised and intraoperative neuromonitoring with motor evoked potentials (MEPs) is employed to help mitigate paralysis. No data exist on characteristics of MEPs in older, PVD patients, which would be valuable for patients undergoing spinal cord at-risk surgery or participating in neurophysiological research. Transcranial magnetic stimulation, which can be delivered to the awake patient, was used to stimulate the motor cortex of 20 patients (mean (±SD)) age 63.2yrs (±11.5) with confirmed PVD, every 10 minutes for one hour with MEPs recorded from selected upper and lower limb muscles. Data were compared to that from 20 healthy volunteers recruited for a protocol development study (28yrs (±7.6)). MEPs did not differ between patient’s symptomatic and asymptomatic legs. MEP amplitudes were not different for a given muscle between patients and healthy participants. Except for vastus lateralis, disease severity did not correlate with MEP amplitude. There were no differences over time in the coefficient of variation of MEP amplitude at each time point for any muscle in patients or in healthy participants. Although latencies of MEPs were not different between patients and healthy participants for a given muscle, they were longer in older participants. The results obtained suggest PVD alone does not impact MEPs; there were no differences between more symptomatic and less symptomatic legs. Further, in general, disease severity did not corelate with MEP characteristics. With an aging population, more patients with PVD and cardiovascular risk factors will be participating in neurophysiological studies or undergoing surgery where spinal cord integrity is monitored. Our data show that MEPs from these patients can be easily evoked and interpreted.
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Book chapterRahman A, Liddle AD, Murray DW, 2024,
Results and registry data for unicompartmental knee replacements
, Unicompartmental Knee Arthroplasty A New Paradigm, Pages: 191-207There is good evidence that Unicompartmental Knee Replacement (UKR) has numerous advantages over Total Knee Replacement (TKR). UKR provides a faster recovery with a shorter hospital stay, fewer complications, lower re-admission rate and lower mortality. In addition, it provides better functional outcomes with more excellent results. UKR is also easier to revise than TKR, is less costly, and more effective over the patient's lifetime. The disadvantage of UKR is that it has a higher revision rate. One of the main reasons for this is that the threshold for revising a UKR is much lower than that for TKR because UKR are easier to revise, and the outcome of a revision is expected to be better. As a result, even though UKR have less poor outcomes than TKR, they have a higher revision rate. So, when deciding whether to do a UKR or TKR, surgeons should not just focus on the revision rate but instead should consider all factors important to patients. Registry data shows that most surgeons doing UKR do very small numbers, the most common being 1 or 2 per year. Surgeons doing small numbers have very high revision rates, and with increasing numbers the revision rate decreases. The only practical way surgeons can increase their UKR caseload is to increase the proportion of their primary knee replacements that are UKR, which is known as UKR usage. Surgeons with usage less than 20% tend to have a high revision rate so these surgeons should either stop doing UKR or do more. With mobile bearing UKR the revision rate decreases with increased usage up to 50%. The evidence-based indications for the mobile bearing UKR are satisfied in about 50% of patients needing knee replacement. Therefore, to achieve optimal results surgeons should adhere to the recommended indications. There are a few studies that report the 20-year results following UKR. The largest which included 683 knees, reported a 20-year survival of 91% (n=683) for a mobile bearing UKR. Three smaller studies of fixed bearing U
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Journal articleStoddart J, Garner A, Tuncer M, et al., 2024,
Load transfer in bone after partial, multi-compartmental, and total knee arthroplasty
, Frontiers in Bioengineering and Biotechnology, Vol: 12, ISSN: 2296-4185Introduction: Arthroplasty-associated bone loss remains a clinical problem: stiff metallic implants disrupt load transfer to bone and hence its remodeling stimulus. The aim of this research was to analyze how load transfer to bone is affected by different forms of knee arthroplasty: isolated partial knee arthroplasty (PKA), compartmental arthroplasty (CPKA, two or more PKAs in the same knee) and total knee arthroplasty (TKA). Methods: An experimentally validated subject-specific finite element model was analyzed native, and with medial unicondylar, lateral unicondylar, patellofemoral, biunicondylar, medial bicompartmental, lateral bicompartmental, tricompartmental and total knee arthroplasty. Three load cases were simulated for each: gait, stair ascent and sit-to-stand. Strain shielding and overstraining were calculated from the differences between the native and implanted states. Results: For gait, the TKA femoral component led to mean strain shielding (30%) more than three times higher than PKA (4% to 7%) and CPKA (5% to 8%). Overstraining was predicted in the proximal tibia (TKA 21%, PKA/CPKA 0 to 6%). The variance in the distribution for TKA was an order of magnitude greater than for PKA/CPKA indicating less physiological load transfer. Only the TKA-implanted femur was sensitive to load case: for stair ascent and gait, almost the entire distal femur was strain-shielded, whereas during sit-to-stand the posterior femoral condyles were overstrained. Discussion: TKA requires more bone resection than PKA and CPKA. These finite element analyses suggest that a longer-term benefit for bone is probable as partial and multicompartmental knee procedures lead to more natural load transfer compared to TKA. High-flexion activity following TKA may be protective of posterior condyle bone resorption, which may help explain why bone loss affects some patients more than others. The male and female intact bone models are included as supplementary material.
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Journal articleKarunaseelan K, Nasser R, Cobb J, et al., 2024,
Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach: a biomechanical study
, The Bone & Joint Journal, Vol: 106, ISSN: 2049-4408Aims:Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA.Methods:Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators.Results:Following initial exposure, the ischiofemoral ligament (7 to 8 o’clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o’clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%).Conclusion:Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.
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Conference paperKarunaseelan KJ, Nasser R, Jeffers JRT, et al., 2024,
Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach
, Annual Meeting of the International-Hip-Society, Publisher: BRITISH EDITORIAL SOC BONE & JOINT SURGERY, Pages: 59-66, ISSN: 2049-4394 -
Journal articleZhao Y, Coppola A, Karamchandani U, et al., 2024,
Artificial intelligence applied to magnetic resonance imaging reliably detects the presence, but not the location, of meniscus tears: a systematic review and meta-analysis
, EUROPEAN RADIOLOGY, ISSN: 0938-7994 -
Conference paperPlumb W, Casale G, Bottle A, et al., 2024,
Clinical pathway clustering using surrogate likelihoods and replayability validation
, Winter Simulation Conference 2023, Publisher: ACM / IEEE, Pages: 1220-1231Modelling clinical pathways from Electronic Health Records (EHRs) can optimize resources and improvepatient care, but current methods for generating pathway models using clustering have limitations includingscalability and fidelity of the clusters. We propose a novel pathway modelling approach using MaximumLikelihood (ML) data clustering on Markov chain representations of clinical pathways. Our method iscalibrated to produce clusters with low inter-cluster variability across the pathways. We use machine learningwith Stochastic Radial Basis Functions (SRBF) kernels for surrogate optimization to handle non-convexityand propose an incremental optimization method to improve scalability. We also define a methodologybased on novel replayability scores to help analysts compare the fidelity of alternative clustering results.Results show that our ML method produces clusters that have higher fidelity in terms of replayability scoresthan k-means based clustering and in capturing queueing contention, which is important for bottleneckidentification in healthcare.
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Journal articleChang G, Moiteiro Manteigas H, Strutton PH, et al., 2024,
An evaluation of a healthy participant laboratory model of epidural hyperthermia: a physiological study
, International Journal of Obstetric Anesthesia, Vol: 57, ISSN: 0959-289XBACKGROUND: Hyperthermia complicates 21% of cases of intrapartum epidural analgesia, but the mechanism is unclear. One hypothesis is that blockade of cholinergic sympathetic nerves prevents active vasodilation and sweating, thus limiting heat loss. Because labour increases heat production, this could create a situation in which heat production exceeds loss, causing body temperature to rise. This physiological study tested a novel laboratory model of epidural-related hyperthermia, using exercise to simulate the increased heat production of labour and surface insulation to simulate the effect of epidural analgesia. METHODS: Twelve healthy non-pregnant participants (six female) cycled an ergometer for two hours at 20 Watts (W) on two occasions: once with surface insulation (intervention) and once without (control). Core temperature, skin temperature (eight sites), and heat loss (eight sites) were recorded. Mean body temperature and heat production were calculated. Values are mean (SD). RESULTS: Exercise increased heat production on both visits (intervention 38 (18) W; control 37 (31) W; P = 0.94). Total heat loss was less on the intervention visit (intervention 115 (19) W; control 129 (23) W; P = 0.002). Core temperature increased on both visits (intervention 0.21 (0.37)°C; control 0.19 (0.27)°C; P < 0.001). The increase in mean body temperature was greater on the intervention visit (intervention 0.47 (0.41)°C; control 0.25 (0.19)°C; P = 0.007). CONCLUSIONS: This laboratory model predicts that labour epidural analgesia limits heat loss by >14 W. Once the model is validated, it could be used to test the efficacy of potential interventions to prevent and treat epidural-related maternal hyperthermia.
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