Orthopaedic Outpatient Clinic Research Articles

EFFICACY AND TOLERABILITY OF FLUPIRTINE MALEATE VERSUS DICLOFENAC IN MECHANICAL LOW BACK PAIN – A PROSPECTIVE COMPARATIVE STUDY

Objective: Low back pain (LBW) is one of the most common reasons for adults visiting orthopedic outpatient clinics in our country. The objective of the study was to compare the safety and efficacy of flupirtine, a selective neuronal potassium channel opener, with diclofenac, a widely used NSAIDs analgesic, in patients with mechanical LBW (MLBP). Methods: This prospective, open-labeled, and randomized comparative clinical study included 100 patients with MLBP for more than 6 weeks. Fifty patients received flupirtine 100 mg, and 50 patients received diclofenac 100 mg for 7 days. Follow-up was done on day 8 and day 30. Assessments of functional improvement by the Oswestry Disability Index (ODI), pain relief by the Visual Analog Scale (VAS), Numerical Rating Scale (NRS), and Pain Relief Rate (PRR) were recorded. Safety and tolerability were also assessed. Data were analyzed using the Chi-square and Paired student t-tests. Results: VAS, NRS, and ODI scores were assessed for each visit (0, 1, and 2), and PRR was assessed on visits 1 and 2. VAS (p<0.05), NRS (p<0.05) scores, and sustained effect after stoppage of the drug were found to be better in the flupirtine group compared to the diclofenac group. Flupirtine was well tolerated. More patients reported adverse events in diclofenac than in the flupirtine group. Conclusion: Flupirtine may have a superior sustained effect compared to diclofenac in MLBP.

Assessment of somatosensory profiles by quantitative sensory testing in children and adolescents with and without cerebral palsy and chronic pain

ObjectiveWe investigated differences in somatosensory profiles (SSPs) assessed by quantitative sensory testing in children and adolescents with cerebral palsy (CCP) with and without chronic pain and compared these differences to those in a group of typically developed children and adolescents (TDC) with and without chronic pain. MethodAll included subjects were consecutively recruited from and tested at the same outpatient orthopedic clinic by the same investigator. The subjects had their reaction times tested. The SSP consisted of the following tests: warmth (WDT), cool (CDT), mechanical (MDT), and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; wind-up ratio (WUR); dynamic mechanical allodynia (DMA) and cold pressor test (CPT) using a conditioned pain modulation (CPM) paradigm. ResultsWe included 25 CCP and 26 TDC. TDC without chronic pain served as controls. In TDC with chronic pain, WDT, HPT, HPT intensity, and PPT were higher than in controls. No differences in SSPs between CCP with and without chronic pain were observed. In CCP, the MDT, WDT, CDT, and HPT intensity were higher than in controls. CCP had longer reaction times than TDC. There were no differences regarding the remaining variables. DiscussionIn CCP, the SSPs were independent of pain status and findings on MR images. In all CCP the SSPs resembled TDC with chronic pain, compared to TDC without chronic pain. This suggests that CCP do not have the normal neuroplastic adaptive processes that activate and elicit functional changes in the central and peripheral nervous systems.

Outcomes of a Novel Spine Virtual Fracture Clinic in an Australian Tertiary Hospital.

This was a retrospective cohort study. To determine the proportion of referrals diverted by the SVFC from traditional outpatient clinic management. The consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges to the provision of quality care. Virtual fracture clinics for upper and lower limb fractures have reduced the burden on outpatient clinics through telephone-based management of these conditions. To date, no study describes the expansion of virtual care to the spine trauma population. A study of spine fractures referred to the RMH Department of Orthopaedic Surgery was conducted comparing outcomes prior to (January to December 2021) and following (July 2022 to November 2023) implementation of a spine virtual fracture clinic (SVFC). The primary aim of this study was to investigate the effects of a telephone-based SVFC on outpatient clinic activity, represented by the proportion of referrals discharged without requiring in-person clinic review. Secondary aims included appointment utilisation, lost to follow-up rates, duration of care, missed or mis-diagnoses, unplanned operations and complications. A total of 91.9% (n=666) referrals managed by the SVFC were discharged without in-person clinic attendance. Compared to outpatient clinic management (n=150 referrals), SVFC implementation was associated with reductions in the average number of consultations per referral (1.8 versus 2.4, P<0.001), appointments not attended (5% versus 13%, P<0.001), referrals lost to follow-up (0 versus 10.7%, P<0.001) and a shorter duration of care (median 48d versus 58d, P<0.001). A total of 65 patients (8.1%) were redirected to in-person clinics of which three underwent surgical intervention. No diagnostic errors, complications or adverse events were identified. This study demonstrates that a SVFC is an effective and safe alternative pathway to traditional hospital-based outpatient clinics with low-risk for any adverse outcomes.

Preoperative spinal education for lumbar spinal stenosis: A feasibility study.

Lumbar spinal stenosis (LSS) is a leading cause of chronic musculoskeletal pain among older adults. A common and costly intervention for the treatment of LSS is lumbar decompression with or without fusion (LSS surgery), which has mixed outcomes among patients. Prehabilitation is a strategy designed to optimize the consistency of positive surgical outcomes and promote patient self-efficacy, while attempting to mitigate postoperative complications. No efforts have investigated the prehabilitation strategies specifically for patients undergoing LSS surgery. To determine the feasibility of delivery and acceptability by participants of a novel prehabilitation intervention for patients undergoing LSS surgery. Feasibility study. Outpatient orthopedic clinic at an academic medical center. Patients at least 50 years of age, who were scheduled for LSS surgery between October 2020 and October 2021. PreOperative Spinal Education for Lumbar Spinal Stenosis (POSE-LSS), is a novel multimodal, education-focused, time-efficient prehabilitation program for patients undergoing LSS surgery. Participants received the following: (1) Educational booklet and video; (2) In-person physical therapy (PT) session; and (3) Telemedicine visit with a physiatrist. The primary outcomes of interest were feasibility and acceptability of intervention by participants. Key potential surgical outcomes were length of stay and discharge disposition. POSE-LSS was completed by all eligible participants enrolled (n = 15) indicating feasibility and acceptability. Potential effectiveness measures including length of stay and discharge disposition were positively associated with the POSE-LSS intervention. This study demonstrates that a novel prehabilitation intervention is feasible, acceptable, and appears positively associated with important short-term measures of postoperative recovery that may impact the trajectory of patient care following LSS surgery.

Enhancing the evaluation of physical function following orthopaedic trauma care: comparison of PROMIS Computerized Adaptive Testing and Short Musculoskeletal Function Assessment (SMFA)

OBJECTIVES: To compare measurement properties of Patient-Reported Outcomes Measurement Information System (PROMIS) (Physical Function (PF) and Pain Interference (PI)) computerized adaptive testing (CAT) to traditional Short Musculoskeletal Function Assessment (SMFA) (dysfunction index (DI) and bother index (BI)). To explore factors associated with PROMIS scores. METHODS: Design: Cross-sectional study. Setting: Level-I Trauma Center. Patient Selection Criteria: isolated upper/lower extremity fracture patients were recruited from the orthopaedic trauma outpatient clinic (October 1, 2021 to January 1, 2023). Outcome measures: Correlations (Pearson), reliability (Standard error (SE)(T score), efficiency (amount of information per item(1 – SE2/ Nitems)) and floor/ceiling effects were assessed. An r&gt;0.7 represented high correlation, SE≤2.2 represented sufficient reliability. Factors associated with worse PROMIS scores were also identified. RESULTS: In total, 202 patients completed PROMs at median 98 days follow-up. Correlations between PROMIS-PF and SMFA-DI, and PROMIS-PI and SMFA-BI were -0.84 and 0.65. Reliability was very high for both instruments (mean SE 2.0(PROMIS-PF), SE 2.1(PROMIS-PI) and SE 1.2(SMFA-DI), SE 1.8(SMFA-BI)). Relative efficiency for PROMIS-PF versus SMFA-DI, and PROMIS-PI versus SMFA-BI was 7.8(SD2.5), and 4.1(SD1.7), respectively. Neither PROMIS nor SMFA exhibited floor/ceiling effects. In the multivariable regression analyses, elevated levels of depression, among other factors, showed an (independent) association with worse PROMIS-PF and PROMIS-PI scores. CONCLUSIONS: PROMIS-PF and PROMIS-PI CATs showed a (high and moderate) correlation with SMFA and hence measure a comparable construct of physical function and discomfort. As CATs are much more efficient to administer, they present a compelling alternative to SMFA for evaluating impact of fracture treatment. The relation between symptoms of depression and PROMIS scores emphasizes the importance of psychosocial aspects of health in orthopaedic trauma patients. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Advanced Practice Physiotherapy in Canada: A Survey of Canadian Physiotherapists

Introduction: Advanced practice physiotherapy (APP) represents an important development for the physiotherapy profession worldwide but few studies have documented these models in Canada and the physiotherapists working in such models. The objective of this study was to identify and describe Canadian physiotherapists in APP roles and their models of care (MoC) and identify barriers and facilitators of APP development in Canada. Methodology: An electronic survey was sent to Canadian physiotherapists with the collaboration of various professional organisations. The questionnaire included 37 questions about APP roles and MoC. Results: Fifty-seven physiotherapists identified themselves as APPs and completed the survey. Most practiced in private clinics (58.1%) or outpatient orthopaedic clinics (27.9%) and provided care to adults (95.3%) with orthopaedics disorders (86.0%). Most APPs were involved in first-contact and leading overall care (52.3%) or triage roles where they identify surgical candidates (68.2%). APPs mentioned their roles were established to improve care efficiency (82.1%) and were viewed positively by medical teams (76.9%) and patients (76.9%). Professional regulations (32.4%) and funding of roles and models (24.3%) were identified as barriers. Conclusions: Results of this study provide new original data regarding APP practice and MoC in Canada, acknowledging the various APP MoC and roles of respondents.

A Rare Case of Fungal Synovitis Presenting as Pigmented Villonodular Synovitis

Abstract Synovitis is a disorder that develops when the synovial tissue or joint lining becomes inflamed. The term pigmented villonodular synovitis (PVNS) refers to a form of tenosynovial giant cell neoplasm affecting the tendon and joint soft-tissue lining. We describe the rare case of a 37-year-old male presenting with complaints of swelling in the left knee following trauma. Patients have a limited range of motion. There is a previous history of an accident 1 year back for which he was operated. Recent magnetic resonance imaging (MRI) revealed anterior cruciate ligament and posterior cruciate ligament avulsion fracture. The clinical diagnosis and radiologic findings were in favor of PVNS. Histopathological examination revealed the presence of fungus. It was further confirmed by fungal culture, for which the patient was given antifungals and was further followed up in the orthopedics outpatient clinic. Thus, we diagnosed fungal synovitis in a patient who came with clinical presentation and MRI findings suggestive of PVNS.

Relation between Body Mass Index and Knee Osteoarthritis in Pre-Elderly to Elderly at Orthopedic Poly of Dr. Mohamad Soewandhie Regional Public Hospital Surabaya

Osteoarthritis is a degenerative joint disease characterized by painful joints, particularly prevalent in older individuals, attributed to mild inflammation resulting from bone-end friction. A study conducted in Surakarta revealed a 4.9-fold increase in osteoarthritis risk among individuals with a BMI &gt;25 compared to those with a BMI of 18.5-25.0. This research aims to investigate the association between knee osteoarthritis and BMI among elderly patients at the orthopedic outpatient clinic of Sesyapdhio Hospital, Surabaya. Using cross-sectional observational analysis, osteoarthritis patients were identified. The findings indicate a correlation between higher BMI and increased severity of osteoarthritis, contrasting with milder cases observed in individuals with normal BMI. Spearman's rank correlation review revealed a strong positive correlation (r=0.554) between BMI and osteoarthritis severity at Sexygandhio Hospital Surabaya. This study's unique contribution lies in its focused exploration of the relationship between BMI and osteoarthritis severity in elderly patients, offering insights into potential interventions tailored to BMI-specific risk profiles.

Achilles Tendon Stiffness in the Etiology of Sever Disease: A Shear Wave Elastography Study.

Sever disease is one of the most common causes of heel pain in growing children and adolescents. There is no consensus about etiology of Sever disease. The study comprised 41 participants aged 8 to 13 years who visited the orthopedic outpatient clinic: 17 patients with Sever disease and 24 asymptomatic children. The middle third segment of the body of the Achilles tendon and the calcaneal insertion zone were separately assessed. Five measuring points for the quantitative value of each point were randomly selected. The color scale used in the Young's modulus shows the lowest values in blue and the highest values in red. The mean values were used for the statistical analysis. Less elasticity was detected at the insertional site for the control group (4.02 kPa versus 3.65 kPa), the situation was reversed in the body of the Achilles tendon and the elasticity of the study group was less than that of the control group (241.0 kPa versus 260.5 kPa). However, no statistically significant difference was found between the groups. In conclusion, no difference was found in Achilles tendon elasticity between patients with Sever disease and healthy individuals in both the tendon body and the calcaneal insertionof the tendon. Achilles tendon elasticity has not been found to play a role in the etiology of Sever disease.

Frequency of Complications among Trauma Patients Treated by Traditional Bone Setters Presented to Orthopedics Department, Gujranwala Teaching Hospital Gujranwala.

Background: Traditional bone setters (TBS) are widely consulted for trauma care in developing regions, often leading to severe complications due to inadequate medical knowledge. This practice poses significant risks to patient safety and outcomes. Objective: The study aimed to evaluate the frequency and nature of complications encountered by trauma patients treated by traditional bone setters. Methods: This cross-sectional study was conducted in the Department of Orthopedics and Trauma Surgery at Gujranwala Teaching Hospital, Pakistan, from February 1st to April 31st. Ninety-seven patients who received care from TBS and subsequently presented at the Orthopedic outpatient clinic were included. Detailed data on demographics, injury type and site, TBS management techniques, and resulting complications were collected and analyzed using SPSS Version 20. Results: Among the 97 patients, 63 (64.95%) were female and 34 (35.05%) were male, with ages ranging from 3 to 70 years and a mean age of 33. TBS primarily used sticks and bandages for fracture management. The most common complications were malunion (42.27%), non-union (21%), and joint stiffness (17%). Conclusion: The high incidence of complications from TBS treatments significantly strains the Orthopedics department. Proposed solutions include integrating TBS into the healthcare system for improved training and regulation or implementing a complete ban on their malpractices.

Bilateral Elbow Dislocation Without Fracture After Minor Trauma in a Healthy Adult Man

The elbow is the second most frequently dislocated major joint in adults. Elbow dislocation is a common traumatic injury, occurring in approximately 20% of all joint dislocations. Falling onto an outstretched hand is the most prevalent cause of elbow dislocation. Simultaneous bilateral elbow dislocation is a rare presentation, and reports of similar injuries are very limited. A 21-year-old male patient was brought to the emergency department after landing on both hands with flexed elbows from a height of one meter while doing home decoration work. The posterolateral dislocations was detected in both elbows without a fracture on the plain radiographs. The patient's elbows were reduced under procedural sedation analgesia in the emergency department. The patient's splints were removed in the orthopedics outpatient clinic after a 2-week follow-up, and he had no complications. It should be noted that serious bilateral dislocations can occur even in minor traumas like this. Procedural sedation not only prevents the delay of the procedure and the occurrence of complications, especially during the treatment of such multiple dislocations, but also increases patient comfort.

Tackling efficiency in a high demand orthopaedic clinic.

Surgical outpatient clinics continuously face challenges in delivering efficient and effective care. An expanding population and chronic staff shortages makes sustainability critical. The primary objective of this study was to identify modifiable factors contributing to longer wait times in an orthopaedic outpatient clinic. A single-centre prospective observational cohort study was conducted at Western Australia's state trauma centre. Over a four-week period, clinicians completed forms identifying delays in clinic, and clinic numbers were captured through an electronic booking system. Data was analysed using SPSS v27. Face-to-face (FTF) and telehealth (TH) clinic volumes grew by 18.9% and 361.1% respectively between 2018 and 2022. For the study period, 754 forms were completed for attending clinic patients. This captured 42.4% and 96.8% of FTF and TH actual attendance. The average wait time for doctor consultation was 63.9 min. Wait times significantly reduced when x-rays were performed prior to clinic (P < 0.001), and when an unaccredited registrar held the on-call phone (P < 0.001). Trauma clinics ran overtime in 95% of cases compared to elective clinics in which 25% ran overtime. The golden staffing ratio was one doctor for 13 patients. TH experienced few delays related to technological fault. This study demonstrates that clinic volume continues to rise. It highlights the demand for adequate staffing and identifies several modifiable factors that influence clinic efficiency. It demonstrates the growth of TH as an alternative modality for outpatient surgical services and its potential for future expansion.

Incidence on cost and duration of therapy for potential infections in post-operative traumatic wounds with prosthetic devices, previously treated and untreated with antibacterial gels at San Giuliano hospital ASLNaples 2 north

IntroductionBacterial infections associated with implanted biomaterials represent the most significant complication in orthopedics, constituting the leading cause of failure in primary hip and knee prostheses. Prevention of infections associated with implanted biomaterials should simultaneously focus on at least two objectives: inhibition of biofilm formation and minimization of suppression of the local immune response. Some technologies proposed for this purpose in clinical practice have already demonstrated strong evidence of antibacterial efficacy, safety, and resistance. The time is ripe for further development and experimentation of these technologies in a clinical setting.Materials and MethodsThe study involved observing wounds in the 6 months following treatments (Follow Up). The aim was to evaluate the cost-benefit aspects in patients treated with defensive antibacterial gels during orthopedic interventions for prostheses and/or synthesis at the San Giuliano Hospital, ASL Napoli 2 North. The goal was to assess the effectiveness of the treatment applied to patients undergoing orthopedic interventions for prostheses and/or orthopedic synthesis. The wounds of treated and untreated patients were compared six months post-surgery, along with the costs incurred by the National Health Service (NHS) and the respective benefits obtained for treated and untreated patients. The observational and retrospective study spanned six months and involved a cohort of 60 patients from the orthopedic department and outpatient clinic of San Giuliano Hospital, ASL Napoli 2, undergoing post-traumatic interventions. The cohort was divided into two groups: Group A (gA) included 30 operated patients whose wounds or devices used were treated with decontamination gels to prevent infections, while Group B (gB) consisted of 30 patients operated on but not treated with any such device. The study involved a six-month observation of the two groups, evaluating the possible occurrence of infections, their duration (until complete healing, including any complications), and the average cost of therapy required for treatment (monitoring the use of drugs, supplies, and devices). A scale of values was then set up based on the average cost incurred and the average duration of treatment for each of the 4 levels of the scale.ResultsAt the end of the period, 30 patients from Group A and 30 from Group B were observed. Within Group A, 2 patients reported infections, placing them in the first two levels of the scale. In Group B, 8 patients required treatment for infections, placing them at different levels of the scale based on the treatment received and its associated cost. The economic impact is high and varies depending on the breadth of usage indications, such as applying the device alone or as a carrier in association with antibiotics for all subjects undergoing primary and revision arthroplasty or osteosynthesis surgical procedures, or only for a fraction of them (e.g., patients at risk of infections, subjects undergoing prosthesis re-implantation, osteosynthesis of traumatic exposed fractures, etc.).ConclusionsManaging an infection that develops after an orthopedic intervention for prostheses and/or synthesis leads patients to seek long term medical check-ups and specialized nursing assistance. The total costs for treating the 10 infected patients show that the overall expenditure for the 8 in Group B is much higher than that for the total of 2 in Group A, both because of the fivefold increase in numbers and the milder and more treatable nature of infections in the two patients in Group A. Even when considering the costs related to the use of antibacterial gels on wounds or prosthetic devices/osteosynthesis, the economic savings are significant considering the cost of pharmacological treatments for infections and their potential complications.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial

BackgroundDespite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT.MethodsThe Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic “add-on” trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes).ResultsThe average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82).ConclusionsIn patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function.Trial registrationThe trial is registered on ClinicalTrials.gov: NCT 03353272 (27/11/2017).

THE EFFECT OF TIME AND SEX ON POST-ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PSYCHOLOGICAL PATIENT REPORTED OUTCOME MEASURE SCORES.

Low scores on psychological patient reported outcomes measures (PROMs), including the anterior cruciate ligament-return to sport after injury (ACL-RSI) and injury-psychological readiness to return to sport (I-PRRS), after anterior cruciate ligament (ACL) reconstruction (ACLR) have been associated with a maladaptive psychological response to injury and poor prognosis. The purpose of this study was to assess the effect of time post-ACLR and sex on ACL-RSI and I-PRRS scores and generate normative reference curves. It was hypothesized that males would demonstrate higher ACL-RSI and I-PRRS scores than females in the first 1-year post-ACLR. Case series. Outpatient sports medicine and orthopedic clinic. 507 patients post-primary ACLR 12-to-30-years-old with 796 ACL-RSI or I-PRRS scores one or more times between 0- and 1-year post-ACLR (age at ACLR: 17.9 ± 3.0 y). An honest broker provided anonymous data from our institution's knee injury clinical database. Generalized additive models for location, scale, and shape and generalized least squares analyses were used to assess the effect of time post-ACLR and sex on ACL-RSI and I-PRRS scores. ACL-RSI and I-PRRS scores increased over time post-ACLR, and males had higher scores compared to females up until approximately five months post-ACLR with scores converging thereafter. Males report higher ACL-RSI and I-PRRS scores compared to females in the initial stages of rehabilitation, but scores converge between sexes at times associated with return to play following ACLR. Normative reference curves can be used to objectively appraise patients' ACL-RSI and I-PRRS scores at any time point post-ACLR. This may lead to timely identification of patients with scores or changes in scores over time post-ACLR associated with a maladaptive psychological response to injury and a poor prognosis and optimized ACLR outcomes.

Evaluation of Chêneau brace in the treatment of thoracic and lumbar adolescent idiopathic scoliosis with apical vertebral rotation.

Adolescent idiopathic scoliosis (AIS) is a common structural disorder of the spine in adolescents, often associated with structural deformities in both coronal and axial positions. Apical vertex rotation (AVR) is one of the main indicators of axial deformity in patients with scoliosis. Currently, there are few studies on the impact of AVR in the treatment of AIS. This study examined the influence of different AVR on AIS after brace treatment. Data were collected from 106 AIS participants aged 11-16 years from the orthopedic outpatient clinic of the Second Hospital of Lanzhou University. Two orthopaedic professionals measured the Cobb angle, AVR and spinal mid-line offset before and after brace treatment, and descriptive and linear correlation analyses were used to determine the correlation between AVR and AIS measured parameters. (1) In AIS volunteers with the same AVR, the treatment effect of AIS with lumbar predominant curvature was higher than that of AIS with thoracic predominant curvature. The treatment effect tended to decrease with increasing AVR. (2) Spinal mid-line deviation was associated with AVR. For patients with AIS with I and II degrees of AVR, the treatment effect of spinal mid-line offset after bracing is better. For AIS patients with AVR III degrees and above, the degree of correction of spinal mid-line offset decreases with the continuous correction of Cobb angle. The efficacy of AIS was found to be related to the severity of AVR. The efficacy of AIS with predominantly lumbar curvature was significantly higher than that of AIS with predominantly thoracic curvature. The efficacy of treatment of mid-line spinal deviation also decreased with increasing AVR.

Investigation of Reaction Time, Proprioception, and Shaped Pathway Walking Performance in Older Patients with Total Knee Arthroplasty

ObjectivesThe existing literature on total knee arthroplasty (TKA) does not provide clear data on step reaction time and proprioception and gait in shaped pathways. This study investigated the relationship between proprioception and reaction time with walking performance in shaped pathways in older patients undergoing TKA. DesignA cross-sectional observational study. Setting and ParticipantsAn orthopedic outpatient clinic with 103 older patients with TKA after a minimum of 6 months after surgery. MethodsParticipants were evaluated with Figure-of-8 Walk Test (F8WT), L Test, Tinnetti Gait Test (TGT), proprioception measurement with an app-based inclinometer, and step reaction time (SRT) test. The same assessor carried out all evaluations. ResultsF8WT showed a strong correlation with SRT-right, SRT-left, and Tinetti Gait Test (TGT), respectively (r1 = 0.628, r2 = 0.619, r3 = −0.615, P < .01). In addition, F8WT was moderately correlated with Right Leg Proprioception Test (RLPT) and Left Leg Proprioception Test (LLPT), respectively (r1 = 0.487, r2 = 0.439, P < .01). There was a moderate correlation between L Test with RLRT, LLRT, and TGT, respectively (r1 = 0.597, r2 = 0.584, r3 = −0.542, P < .01). Besides, there was a weak positive correlation between L Test with RLPT and LLPT, respectively (r1 = 0.394, r2 = 0.335, P < .01). A regression model showed that the L test was related to RLRT, LLRT, and TGT (R2 = 0.432, P < .001). The higher ability of the L test was weakly associated with higher levels of TGT (standardized β = −0.28, P = .0012). Besides, regression analysis also proved that F8WT was related to RLRT, LLRT, and TGT (R2 = 0.522, P < .001). The most highly associated parameter was LLRT (standardized β = 0.958, P = .003). Conclusions and ImplicationsGait in shaped pathways is associated with proprioception, reaction time, and balance ability in older patients with TKA. Therefore, proprioception, reaction time, and balance should be considered to improve the shaped pathway walking performance of patients after bilateral, right, or left TKA surgery.

Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 2024;47(3):141-146.].

Companions' contributions to information gathering in Chinese outpatient clinical interaction.

Patients are commonly accompanied to visit clinicians in Chinese outpatient clinics. Although there has been extensive research on the roles of companions in asymmetric interactions within medical settings, there is a paucity of conversation analytic studies that examine the active participation and contributions of companions on an equal footing in medical consultations. How companions on an equal footing participate and contribute in Chinese outpatient clinical consultations remains under-explored. By employing video recordings of three-party consultations in the Chinese orthopaedic outpatient clinic as the data and adopting conversation analysis as the method, this study investigated how companions participated in and contributed to the information-gathering activity and how their contributions were interactionally negotiated and managed by clinicians and adult patients over sequences of interaction. We showed that companions negotiated epistemic rights in reporting and repairing the information about medical problems in the patients' epistemic domain and displayed different levels of encroachment on patients' epistemic rights by endorsing patients' responses, repairing the information in patients' responses, and offering information directly to clinicians. Companions also exerted deontic authority and shaped the trajectory of the consultations by hindering or facilitating the progressivity of the interaction. We argued that companions' contributions to the information-gathering activity might reflect the family-centred model of the doctor-patient relationship in the Chinese orthopaedic outpatient clinic. Clinicians are suggested to open up opportunities for companions' participation and contributions while respecting patients' rights, especially when there is a collision of knowledge claims between patients and their companions.

Companion responses to diagnosis in Chinese outpatient clinical interaction

Patients regularly attend clinical consultations with companions in Chinese outpatient clinics. Despite companions' significant influence on clinical consultations, how companions respond to diagnosis and their contributions to the activity of diagnosis in Chinese outpatient clinical interaction remain under-researched. The present study, by adopting the method of conversation analysis, investigated clinicians' diagnostic deliveries and companions' subsequent responses in Chinese outpatient clinical interaction. The data for this study consisted of 79 video recordings of clinical consultations in the Chinese orthopedic outpatient clinic, approximately lasting 12 h and involving three male clinicians, 79 patients (37 male/42 female), and 91 companions (51 male/40 female). Three basic categories of companion responses to diagnosis were identified: minimal verbal responses, embodied responses, and extended responses. It was demonstrated that these distinct responses allowed companions to challenge clinicians' medical authority in the activity of diagnosis by delivering their own diagnostic judgments, resisting clinicians' diagnoses, and orienting to clinicians' accounts for their diagnostic statements and reasoning, thus displaying companion agency in the Chinese outpatient clinical decision-making and indicating a transition from a paternalistic model to a family-centered model of the doctor-patient relationship in the Chinese orthopedic outpatient interaction. This study furthers current knowledge of companion involvement across healthcare contexts and contributes to raising clinicians' awareness of the significance of companions’ contributions in Chinese outpatient clinical interaction.