Nuffield Orthopaedic Centre Research Articles

LONG-TERM FOLLOW-UP, REOPERATIONS, AND PATIENT-REPORTED OUTCOMES FOLLOWING REVISION SURGERY FOR FAILED TOTAL ANKLE ARTHROPLASTIES

IntroductionPrimary ankle arthroplasty (TAR) is increasingly used to treat end-stage ankle arthritis. Reported revision rates of TAR vary from 8.5% to 11.1% at 9 years. Revision surgery remains technically challenging with options ranging from simple joint debridement to tibio-talar-calcaneal fusion. The efficacy of these procedures remains unclear and there is no consensus on optimal revision options.MethodsA retrospective cohort study was performed of all patients undergoing surgery for a failed primary TAR at the Nuffield Orthopaedic Centre (2004–2021). TAR failure was determined by clinical assessment, serial radiographs and CT scans. Primary outcome measures included type and time of index surgery post TAR. Secondary outcomes included frequency of re-operations, post-operative complications, patient reported outcomes and union rate (for revision arthrodesis procedures).Results70 failed TARs in 69 patients (35M:34F, mean 65.7 years, s.d.=11.6) underwent re-operation a mean of 6.24 years (range 1–30) post primary. In total, 107 operations were performed including revision fusion (n=50), revision arthroplasty (n=14), bearing exchange (n=9) and joint clearance (n=9). The overall revision fusion union rate was 73.5% over a mean of 12.5 months (s.d.=7.6). 16/23 (69.6%) Tibio-Talo-Calcaneal and 9/12 (75%) ankle fusions (previous subtalar/triple fusion) using a hindfoot nail united over a mean 11.4 months (s.d.=6.0) and 15 months (s.d.=9.48) respectively. Only 64% of ankle fusions using screws alone united (mean=10.6 months, s.d.=8.14). The average post-operative MOXFQ score was 28.3 (s.d.=19.3). 73% said the operation improved their function and would recommend it to a friend/family member.ConclusionDespite low post-operative MOXFQ scores, over 70% of patients were satisfied with re-operation for a failed TAR. Over 26% of all TAR revision fusions fail to unite with the highest non-union rates observed post ankle arthrodesis with screws alone (36.4%).

Easier, quicker, safer: an enhanced instrument count procedure.

Andrea Szekretar, Theatre Scrub Team Leader and Advanced Scrub Practitioner, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust was runner up in the Innovation Award category of the BJN Awards 2021.

General Versus Regional Anaesthesia for Lower Limb Arthroplasty and Associated Patient Satisfaction Levels: A Prospective Service Evaluation in the Oxford University Hospitals.

IntroductionLower limb arthroplasty is performed under general anaesthesia (GA) or regional anaesthesia (RA). There is increasing evidence of the surgical and anaesthetic benefits of RA. National Institute for Health and Care Excellence (NICE) guidelines advise using either but highlight a lack of data comparing outcomes of RA and GA for these procedures. We conducted a service evaluation, prospectively analysing elective orthopaedic cases performed at the Nuffield Orthopaedic Centre, Oxford, UK from 19/11/2018 to 03/04/2019. We aimed to compare data on anaesthetic assessment, intra-operative parameters and patient satisfaction for RA and GA cases.MethodsWe selected elective patients, aged above 18, undergoing total hip, total knee or unilateral knee arthroplasties. Prospective quantitative and qualitative data were collected using two forms. Firstly, anaesthetists completed a case report recording demographic data, intra-operative details and reason for anaesthetic choice. Secondly a questionnaire gathered patient satisfaction data. This was analysed using descriptive statistics and presented in tables.ResultsData for 132 patients were collected over the service evaluation period. After exclusion, 99 patients were included for final analysis; 59 underwent GA and 40 had RA. GA was used predominantly due to patient preference (74.6%). RA was used primarily due to anaesthetic preference (75%); most commonly due to speed of list and duration of operation. Overall patients had low pain scores (0.3/10) and high pre-operative anxiety levels (4.6/10) regardless of anaesthetic.ConclusionOur results show high patient satisfaction with GA and RA for lower limb arthroplasty; however, pre-operative anxiety was common for both. Patient preference and comfort influenced choice of anaesthesia, highlighting the importance of pre-operative counselling and education to facilitate shared decision making, leading to favourable post-operative outcomes.

P10 Rapid-access temporal artery ultrasound by vascular sonographers in suspected GCA: an audit during and after a training phase

Abstract Background Fast, same-day access ultrasound (US) of temporal (TA) and axillary (AxA) arteries has emerged as part of a gold standard of assessment for suspected giant cell arteritis (GCA). GCA is a rheumatological emergency but many rheumatology units lack expertise and capacity to provide such a service themselves. We audited US scanning for GCA by experienced vascular sonographers, but new to TA scanning, during and after a training phase. Methods Before the training audit a meeting between three vascular sonographers (LD, AO and MT), the radiology US Lead (KR) and an experienced rheumatologist sonographer (RK) took place to share the rationale, technique and evidence-base of TA/AXA scanning in suspected GCA. Early during the training period ad hoc co-scanning between technicians and RK/KR was performed and one technician attended the Vascular Scanning Unit at Nuffield Orthopaedic Centre in Oxford. Rheumatology medical staff was encouraged to refer all patients with suspected GCA to the Vascular US unit for scanning, with patients and clinicians being aware that the scan was for training purposes only. At the end of the training period, a sample review of images and reports was undertaken and diagnostic criteria and terminology rehearsed before service scanning commenced. Results Twenty-six subjects were scanned during the training period between July 2018 and May 2019: mean [range] 73 [53-89] years, 77% female. Of these 9 (35%) showed US changes reported as diagnostic of GCA in TAs, one equivocal and the remainder negative for GCA. Three of the 9 US-positive subjects underwent TA biopsy, which confirmed GCA in all cases. Of the 6 cases not undergoing biopsy, all were treated as GCA except one (3rd US training case, ESR 2). A total of 10 (38%) of all subjects underwent TA biopsy of which 7 showed a negative biopsy and negative TA US for GCA, thus resulting in a 100 % concordance of US and TA biopsy. In the first 4 months following the training phase, 23 subjects have been scanned for suspected GCA (mean [range] 69 [53-87] years, 65 % female): diagnostic, equivocal and negative changes for GCA were seen in 4, 2 and 17 subjects, respectively. No US-positive and 3 US-negative subjects underwent TA biopsy which showed negative histology for GCA in all three. Duration of steroid treatment before US and TA biopsy was a median 1 (IQR 0.75-4.0) and 6.5 (IQR 5.0-9.5) days, respectively, across both cohorts. Conclusion This audit suggests that experienced general vascular sonographers can achieve good proficiency in TA/AxA US for suspected GCA with excellent concordance with TA biopsy results to support a rapid-access clinical pathway for patients with suspected GCA. Furthermore, the audit suggests a reduction in biopsy rates in subjects whose US is positive for GCA. Disclosures L. Devonshire None. C. Koutsianas None. A. Ostrowski None. M. Trumper None. K. Randhawa None. R. Klocke None.

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

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

The failing medial compartment in the varus knee and its association with CAM deformity of the hip

BackgroundSince 2011, the knee service at the Nuffield Orthopaedic Centre has been offering a neutralising medial opening wedge high tibial osteotomy (HTO) to a specific group of patients with genu varum and early knee osteoarthritis. An observation was made concerning this group of patients and the presence of CAM deformity at the hip. The aim of this study is to establish whether or not any association exists between the OA phenotype shared by our HTO group and the incidence of CAM deformity at the hip. MethodsA cross-sectional study was designed to estimate the prevalence of CAM-type lesions across different groups of individuals. Our HTO group (n=30) was compared to a pre-arthroplasty group (n=20) and control group (n=20). A total of 70 subjects were identified across the different groups all of whom had long-leg radiographs (LLRs) available for analysis. LLRs were analysed using an in house developed Matlab®-based (Matlab R2009b; MathWorks) software package for hip measurements and MediCAD® (Hectec GmbH, Germany) for lower limb alignment measurements. ResultsThe HTO group had a significantly higher prevalence of CAM lesions (57%) than both the pre-arthroplasty (40%) and control (30%) groups. This difference was maintained when results were adjusted for potential confounding factors (age, gender and laterality). Across the groups, individuals with tibia vara were more likely to have CAM-deformity of the hip (p=0.021). ConclusionPatients with symptomatic early knee OA and varus deformity of the knee have a high prevalence of CAM deformity in the hip.

'The Sister' in the early days of the NHS.

All the readers of this journal will have read and heard about the ward and operating theatre sisters in 'the old days'. What were they really like, and what was it like to work with them in the hospitals of those far-off times? I entered the old Radcliffe Infirmary Oxford in the summer of 1945, just as World War II was drawing to a close, as a 19 year old student to start my clinical training. I then qualified in July 1948, the very month the NHS came into being, and started my surgical career as house surgeon. The Radcliffe was the only acute hospital in the town and dealt with all emergency admissions. In addition, we worked at the Churchill Hospital, then a hutted hospital, erected during the War to deal with Canadian military casualties and now handed over for civilian use. Elective orthopaedics was carried out at the Wingfield Morris Hospital, later the Nuffield Orthopaedic Centre. The patients here were mostly children with bone and joint tuberculosis or poliomyelitis. The Slade Isolation Hospital dealt with the infectious fevers; I was admitted there twice as a student, with first chicken pox and then measles, both caught from my patients!

Complications of minimally invasive calcaneal osteotomy versus open osteotomy.

Calcaneal osteotomy is an established technique for correcting hindfoot deformity. Patients traditionally receive an osteotomy through the open lateral approach to the calcaneus. To reduce the rate of wound complications associated with a direct open lateral approach, a minimally invasive surgical (MIS) technique has been adopted. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. We hypothesized that the new MIS calcaneal osteotomy would be a safe alternative to open calcaneal osteotomy while obtaining the same displacement. The safety of the new MIS technique was investigated with a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre from 2008 to 2014. The primary outcome measure was 30 day postoperative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates, and calcaneal displacement. Eighty-one patients underwent calcaneal osteotomy as part of their corrective surgery, 50 in the Open approach group and 31 in MIS group. The average age was 47.7 years (range 16-77) for the Open group and 50.1 (range 21-77) in the MIS group. A mean calcaneal displacement of 9.4 mm (SD = 1.16, 8 to 11 mm) and 10.2 mm (SD = 1.06, 8 to 13 mm) was achieved through the MIS and Open approaches, respectively. There were significantly fewer wound complications in the MIS group (6.45%) compared to the Open group (28%, P = .022). The MIS group was associated with significantly lower rate of wound infection (3% versus 20%, P = .044). Three patients in the Open group experienced sural peripheral neuropathy. The average length of stay was 3.8 days following MIS and 4.3 days following open calcaneal osteotomy. Nonunion occurred in only 1 patient in the MIS group and none in the open group. MIS calcaneal osteotomy was found to be a safe technique. It was technically as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications. Level III, comparative study.

Picture quiz: Musculoskeletal imaging

Musculoskeletal imagingPicture quiz: Musculoskeletal imagingA Daghir and J TehA DaghirDepartment of Radiology, Nuffield Orthopaedic Centre, Oxford, UKSearch for more papers by this author and J TehDepartment of Radiology, Nuffield Orthopaedic Centre, Oxford, UKSearch for more papers by this authorPublished Online:3 Apr 2014https://doi.org/10.1259/img.20120021SectionsPDF/EPUBFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About Previous article Next article FiguresReferencesRelatedDetails Volume 23, Issue 1December 2014 2014 The British Institute of Radiology History Published onlineApril 03,2014 Metrics Download PDF

AB0093 Angiopoietin-Like 4 is Over–Expressed in Rheumatoid Arthritis: A Potential Role in Pathological Bone Resorption

BackgroundIn contrast to normal synovial tissue, rheumatoid synovium is hypoxic, and expresses the hypoxia-inducible transcription factors HIF-1α and HIF-2α, which allow the transcription of genes involved in angiogenesis, inflammation, apoptosis...

AB0059 Chromatin Modifying Mechanisms in Macrophages Differ between Healthy Controls and Patients Wih Rheumatoid Arthritis

BackgroundMacrophages are central players in the pathogenesis of rheumatoid arthritis, and targeted inhibition of their principal cytokine products, TNFα and IL-6, are effective treatments. However, a significant proportion of patients...

SAT0193 Utility of Ultrasound in the Nuffield Orthopaedic Centre Emergency Rheumatology Clinic: Survey of Clinical Effectiveness

BackgroundThe aim of the survey was to evaluate the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases seen in the Nuffield Orthopaedic Hospital emergency rheumatology clinic.ObjectivesPrimary:...

98. Modification of a Validated Patient-Reported Experience Measure Tool for Rheumatoid Arthritis for Use in Other Rheumatic Conditions: Results of a Pilot Study

1National Rheumatoid Arthritis Society, Maidenhead, Berkshire, United Kingdom; 2Rheumatology, Nuffield Orthopaedic Centre, Oxford, United Kingdom; 3School of Health and Rehabilitation, Keele University, Keele, United Kingdom; 4Health Service Research Unit, Keele University, Keele, United Kingdom; 5ismedica ltd, Staffordshire, United Kingdom; 6Roche Products Ltd, Welwyn Garden City, United Kingdom, 7Royal Lancaster Infirmary, Lancaster, United Kingdom; 8Clinical Sciences, University of Liverpool, Liverpool, United Kingdom.

131. Utility of Ultrasound in the Nuffield Orthopaedic Centre Emergency Rheumatology Clinic: Survey of Clinical Effectiveness

131. Utility of Ultrasound in the Nuffield Orthopaedic Centre Emergency Rheumatology Clinic: Survey of Clinical Effectiveness

Do psychological factors predict response to intra-articular steroid therapy in knee osteoarthritis?

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S381 the Nuffield Orthopaedic Centre (Oxford) between 2010–2012. LoS data was highly skewed and underwent natural log transformation. Linear regression methods were used to assess the association between TUG and LoS after adjustment for age, gender and BMI. To assess whether the association between preoperative TUG and postoperative LoS was consistent across operation type an interaction between these two variables was also included. Table 1 Mean values of baseline characteristics in sample population (n 1⁄4 534).

A4.9 Angiopoietin-like 4 is over–expressed in rheumatoid arthritis: a potential role in pathological bone resorption

Background and ObjectivesIn contrast to normal synovial tissue, rheumatoid synovium is hypoxic, and expresses the hypoxia-inducible transcription factors HIF-1α and HIF-2α which allow the transcription of genes involved in angiogenesis,...

Ischiofemoral Impingement: A Retrospective Analysis of Cases in a Specialist Orthopaedic Centre over a Four-Year Period

Ischiofemoral impingement is a recently identified cause of chronic hip pain, the pathophysiology and clinical features of which are poorly understood. To determine the clinical significance of MRI findings of ischiofemoral impingement. Retrospective search for cases of ischiofemoral impingement in the Nuffield Orthopaedic Centre, Oxford, over a 4 year period, and review of medical notes to identify correlation between clinical and MRI features. Sixteen hips in 13 patients with MRI signs of ischiofemoral impingement were identified. All patients were females with a median age of 36 years (range 17-80 years). In six patients the symptoms corresponded to the side of the quadratus femoris abnormality and narrowed ischiofemoral distance. In two patients the symptoms were on the same side as the abnormality but were more consistent with back pain and sciatica. In five patients the symptoms were not anatomically related to the abnormality. Abnormalities identified; seven patients had muscle oedema (six unilateral, one bilateral) and six had muscle wasting (four unilateral, two bilateral). Of the patients with quadratus femoris oedema, two had gluteus medius enthesopathy and one had hamstring enthesopathy. Two patients presented with a chronic loud clunking of the hip on walking. Ischiofemoral impingement on MRI is seen in patients with pain localised to the ipsilateral buttock and in patients with symptoms unrelated to the abnormality. The condition may be associated with wasting or oedema of the quadratus femoris muscle on MRI and may occur secondary to injury in other muscles controlling movement of the hip such as the hamstrings and gluteus medius. Ischiofemoral impingement is a cause of a clunking hip.

Can pain and function be distinguished in the Oxford Knee Score in a meaningful way? An exploratory and confirmatory factor analysis

The purpose of this paper was to examine if pain and functioning can be distinguished in the Oxford Knee Score (OKS) in a meaningful way. This was done by (1) conducting exploratory factor analysis to explore the factorial structure of the OKS and (2) conducting confirmatory factor analysis to examine whether a two-factor solution is superior to a one-factor solution. Secondary data analysis of four independent datasets containing OKS scores on 161,973 patients was performed. Four independent datasets contained data on: (1) 156, 788 patients from the NHS HES/PROMS dataset, (2) 2,405 consecutive patients from the South West London Elective Operating Centre, (3) 2,353 patients enrolled in the Knee Arthroplasty Trial and (4) 427 consecutive patients listed for knee replacement surgery at the Nuffield Orthopaedic Centre in Oxford. Factor extraction methods suggested that, depending on the method employed, both one- and two-factor solutions are meaningful. Overall and in each data set some cross-loading occurred and item loadings were consistent across two factors. On confirmatory factor analysis, both one- and two-factor models had acceptable fit indices. This allowed the creation of the 'OKS pain component' and the 'OKS functional component' subscales. Factor analysis confirmed the original conceptual basis of the OKS but offered an option to perform additional analyses using pain and functional subscales. Further research should focus on providing further evidence on construct validity and responsiveness of the newly derived subscales.

Specific guidelines for the treatment of diabetic foot infections 2011

VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA VU University Medical Centre, Amsterdam, The Netherlands Nuffield Orthopaedic Centre, Oxford, UK Gustave Dron Hospital, Tourcoing, France IWGDF, Heemstede, The Netherlands University of Manitoba, Winnipeg, MB, Canada University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA University Medical Centre, Ljubljana, Slovenia Nottingham University Hospitals NHS Trust, Nottingham, UK

F653 PHYSIOTHERAPISTS EXPERIENCES OF ACTIVITY PACING WITH PEOPLE WITH CHRONIC PAIN

European Journal of Pain SupplementsVolume 5, Issue S1 p. 184-184 F653 PHYSIOTHERAPISTS EXPERIENCES OF ACTIVITY PACING WITH PEOPLE WITH CHRONIC PAIN C. Scott-Dempster, C. Scott-Dempster Physiotherapy DepartmentSearch for more papers by this authorF. Toye, F. Toye Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, OxfordSearch for more papers by this authorJ. Truman, J. Truman Department of Health Sciences, University of Southampton, SouthamptonSearch for more papers by this authorK. Barker, K. Barker Musculoskeletal Division, Nuffield Orthopaedic Centre NHS Trust, Oxford, UKSearch for more papers by this author C. Scott-Dempster, C. Scott-Dempster Physiotherapy DepartmentSearch for more papers by this authorF. Toye, F. Toye Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, OxfordSearch for more papers by this authorJ. Truman, J. Truman Department of Health Sciences, University of Southampton, SouthamptonSearch for more papers by this authorK. Barker, K. Barker Musculoskeletal Division, Nuffield Orthopaedic Centre NHS Trust, Oxford, UKSearch for more papers by this author First published: 30 January 2012 https://doi.org/10.1016/S1754-3207(11)70633-2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume5, IssueS1September 2011Pages 184-184 RelatedInformation