The journal of bone and joint surgery, Dec 1, 2012
ABSTRACT Hypermobility is an acknowledged risk factor for patellar instability. In this case cont... more ABSTRACT Hypermobility is an acknowledged risk factor for patellar instability. In this case control study the influence of hypermobility on clinical outcome following medial patellofemoral ligament (MPFL) reconstruction for patellar instability was studied. A total of 25 patients with hypermobility as determined by the Beighton criteria were assessed and compared with a control group of 50 patients who were matched for age, gender, indication for surgery and degree of trochlear dysplasia. The patients with hypermobility had a Beighton Score of ≥ 6; the control patients had a score of < 4. All patients underwent MPFL reconstruction performed using semitendinosus autograft and a standardised arthroscopically controlled technique. The mean age of the patients was 25 years (17 to 49) and the mean follow-up was 15 months (6 to 30). Patients with hypermobility had a significant improvement in function following surgery, with reasonable rates of satisfaction, perceived improvement, willingness to repeat and likelihood of recommendation. Functional improvements were significantly less than in control patients (p < 0.01). Joint hypermobility is not a contraindication to MPFL reconstruction although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery.
The journal of bone and joint surgery, Sep 1, 2012
We report a prospective analysis of clinical outcome in patients treated with medial patellofemor... more We report a prospective analysis of clinical outcome in patients treated with medial patellofemoral ligament (MPFL) reconstruction using an autologous semitendinosus graft. The technique includes superolateral portal arthroscopic assessment before and after graft placement to ensure correct graft tension and patellar tracking before fixation. Between October 2005 and October 2010, a total of 201 consecutive patients underwent 219 procedures. Follow-up is presented for 211 procedures in 193 patients with a mean age of 26 years (16 to 49), and mean follow-up of 16 months (6 to 42). Indications were atraumatic recurrent patellar dislocation in 141 patients, traumatic recurrent dislocation in 50, pain with subluxation in 14 and a single dislocation with persistent instability in six. There have been no recurrent dislocations/subluxations. There was a statistically significant improvement between available pre-and post-operative outcome scores for 193 patients (all p < 0.001). Female patients with a history of atraumatic recurrent dislocation and all patients with history of previous surgery had a significantly worse outcome (all p < 0.05). The indication for surgery, degree of dysplasia, associated patella alta, time from primary dislocation to surgery and evidence of associated cartilage damage at operation did not result in any significant difference in outcome. This series adds considerably to existing evidence that MPFL reconstruction is an effective surgical procedure for selected patients with patellofemoral instability.
The aim of this study was to describe the prevalence and patterns of neuropathic pain over one ye... more The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA). Methods Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey. Results Symptoms of neuropathic pain were common among patients reporting chronic pain at three months post-TKA, with half reporting neuropathic pain on painDETECT (191/363; 53%) and 74% (267/359) on DN4. Of those with neuropathic pain at three months, half continued to have symptoms over the next 12 months (148/262; 56%), one-quarter had improved (67/262; 26%), and for one-tenth their neuropathic symptoms fluctuated over time (24/262; 9%). However, a subgroup of participants reported new, late onset neuropathic symptoms (23/262; 9%). Prevalence of neuropathic symptoms was similar between the screening tools when the lower cutoff painDETECT score (≥ 13) was applied. Overall, mean neuropathic pain scores improved between three and 15 months after TKA. Conclusion Neuropathic pain is common in patients with chronic pain at three months after TKA. Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. Postoperative care should include screening, assessment, and treatment of neuropathic pain in patients with early chronic postoperative pain after TKA.
, et al. REST: a preoperative tailored sleep intervention for patients undergoing total knee repl... more , et al. REST: a preoperative tailored sleep intervention for patients undergoing total knee replacement-feasibility study for a randomised controlled trial. BMJ Open 2024;14:e078785.
Objective To investigate the effect of lab-based simulator training, on the ability of surgical t... more Objective To investigate the effect of lab-based simulator training, on the ability of surgical trainees to perform diagnostic knee arthroscopy. Method 20 orthopaedic SHOs with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training using a bench-top knee model. Learning curves were clearly demonstrated using motion analysis equipment to monitor performance. All 20 then spent an operating list with a blinded consultant trainer. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was assessed using the intra-operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PBA) protocol for diagnostic arthroscopy. Performance was further quantified with a ten point global rating assessment scale. Results Motion analysis demonstrated objective and significant improvement in performance during simulator training. In theatre the simulator-trained group performed significantly better than the untrained group. The simulator trainees were scored as OCAP competent on more than 70% of occasions, compared to less than 15% for the untrained group (p Conclusion Learning curves showing significantly improved performance at simulated diagnostic knee arthroscopy are clearly demonstrated using motion analysis assessment. Arthroscopic simulator training led to subsequent significant improvement in operating theatre performance as determined by OCAP and a global rating assessment scale. This demonstrates a degree of transfer validity from lab based arthroscopic simulator training using motion analysis assessment to the operating theatre. In addition OCAP PBAs appear to provide a useful framework for in theatre assessment; however questions are raised about the need for more objective assessment tools in order to truly distinguish between trainees varying levels of competence.
IntroductionTotal knee replacement (TKR) is a successful operation for many patients, however 15–... more IntroductionTotal knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics.We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR.MethodologyBetween 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4).ResultsAt three months post-operative, 53% reported neuropathic pain on painDETECT and 74% on DN4. Half (56%) remained in neuropathic pain over the twelve-month follow-up period, 26% reported improvement, and 9% reported new neuropathic symtpoms or fluctuated in and out of neuropathic pain (9%...
IntroductionThere is a need to develop approaches to reduce chronic pain after total knee replace... more IntroductionThere is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR.MethodologyREST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.Results57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an a...
IntroductionTotal knee replacement (TKR) aims to reduce pain and functional limitations. Despite ... more IntroductionTotal knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR.The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs).There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation.MethodologyTrial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were co...
For many people with advanced osteoarthritis, total knee replacement is an effective treatment to... more For many people with advanced osteoarthritis, total knee replacement is an effective treatment to relieve pain and improve function. However, 10–34% of people experience chronic postsurgical pain in the months and years after total knee replacement. The Support and Treatment After Replacement (STAR) randomised controlled trial (ISCRTN92545361) evaluated the clinical- and cost-effectiveness of a new multifaceted and personalised care pathway, compared with usual care, for people with pain at three months after total knee replacement. Our objective was to identify factors promoting or inhibiting its implementation, and to inform future training and wider implementation of the pathway. We conducted a prospective process evaluation using qualitative interviews with eight Extended Scope Practitioners and six Principal Investigators from seven trial sites who were involved in delivering the STAR care pathway during the trial. We used Normalization Process Theory as a theoretical framework...
Purpose Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than sati... more Purpose Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than satisfactory outcome in some patients. It was hypothesized that certain factors can be identified on radiological review that correlate with poor patient reported outcomes following PFA. Methods A retrospective cohort review of 369 patients undergoing PFA at our institution between 2005 and 2018 identified 43 “poor outcome” patients with an Oxford Knee Score (OKS) of less than 20 at 2 years follow up. These cases were matched by sex and age with 43 “good outcome” patients who had an OKS above 40 at 2 years post-op. Multiple radiological measurements were performed including anterior trochlea offset ratio (ATOR), component flexion/extension, component varus/valgus, component to bone width ratio and retinacular index. The OKS PROM was the primary outcome of the study. Stepwise logistic regression was performed to analyze the differences in radiological indices between the two groups. Results I...
Aims The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears... more Aims The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR. Methods We reviewed the data for a consecutive series of 88 patients (mean age 27.1 years (15 to 49); 65 male (74%) and 23 female (26%)) who underwent single-stage repair of a displaced BH meniscal tear (67 medial (76%) and 21 lateral (24%)) with concomitant hamstring autograft ACLR. The patient-reported outcome measures (PROMs) EuroQol visual analogue scale (EQ-VAS), EuroQol five-dimension health questionnaire (EQ-5D), Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC),...
BackgroundApproximately 20% of patients experience chronic pain after total knee replacement (TKR... more BackgroundApproximately 20% of patients experience chronic pain after total knee replacement (TKR). The impact of chronic pain after TKR on primary care services in the UK is currently unknown. The aim of this study was to compare primary care consultations and pain medicine prescriptions between patients with and without chronic pain after TKR. MethodsData from 5,055 patients who received TKR between 2009-2016 with anonymised linked data from the Clinical Practice Research Datalink Gold (CPRD) and English Hospital Episode Statistics (HES) Patient Reported Outcome Measures (PROMs) programme were analysed. The exposure time was from 10 years pre-operative to eight years post-operative. Patients with a score ≤14 on the Oxford Knee Score pain component scale at 6 months post-operative were classified as having chronic pain after TKR. Primary care consultations and prescribed pain medicines were quantified, and costs calculated based on national cost data. Results721 patients (14%) had ...
Background: Despite growing awareness of the contribution of central pain mechanisms to knee oste... more Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice. Methods: A narrative review of original research papers was conducted by 9 clinicians and researchers from seven differente countries to reach agreement on clinically-relevant descriptors. Results: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behaviour of knee pain, presence of neuropathic-like or centrally-mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense. Conclusion: This article describes a set of clinically-relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies.
Background: Despite growing awareness of the contribution of central pain mechanisms to knee oste... more Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice. Methods: A narrative review of original research papers was conducted by 9 clinicians and researchers from seven differente countries to reach agreement on clinically-relevant descriptors. Results: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behaviour of knee pain, presence of neuropathic-like or centrally-mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense. Conclusion: This article describes a set of clinically-relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies.
Approximately 20% of people who have total knee replacement experience chronic pain afterwards, b... more Approximately 20% of people who have total knee replacement experience chronic pain afterwards, but there is little evidence about effective interventions for managing this type of pain. This article describes the systematic development and refinement of a complex intervention for people with chronic pain after knee replacement. The intervention is a care pathway involving an assessment clinic and onward referral, with telephone follow-up as required. In the design of this multistage study, we chose to focus on ensuring that the intervention was deliverable, implementable and acceptable. In line with the UK Medical Research Council's recommendations for comprehensive development of complex interventions, multiple phases of work were undertaken. Following on from initial development work to design the intervention, the draft intervention content was refined through consensus questionnaires with 22 health professionals and discussion at meetings with 18 healthcare professionals. T...
Introduction Although stabilisation of knee cartilage lesions (chondroplasty) may be performed wi... more Introduction Although stabilisation of knee cartilage lesions (chondroplasty) may be performed with an arthroscopic shaver, more recently, radiofrequency (RF) ablation has gained in popularity. However, their remain some concerns about the avoidance of thermal injury, chondrolysis, and osteonecrosis with the use of RF devices. Methods We reviewed the outcomes of 85 knee chondroplasties performed with a new RF ablation wand designed for knee chondroplasty. Lesion details and Chondropaenia Severity Score (CSS) were recorded for each patient. We evaluated the occurrence of adverse outcomes, post-operative complications, and the need for further surgery. Post-operative outcomes scores (Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS], and International Knee Documentation Committee [IKDC] subjective knee outcome) were recorded at a minimum of one-year follow-up. Results At the final mean follow-up of 27.5 months (range: 12-46.6 months), 12 (14%) knees had unde...
The Journal of Foot and Ankle Surgery Official Publication of the American College of Foot and Ankle Surgeons, Aug 28, 2013
The aim of the present study was to assess the reliability of commonly used intra-articular calca... more The aim of the present study was to assess the reliability of commonly used intra-articular calcaneal fracture classification systems and to compare them with the newer AO Integral Classification of Injuries (ICI) system. Forty computed tomography and radiographic images of 40 intra-articular calcaneal fractures were reviewed independently by 3 reviewers on 2 separate occasions and classified according to the Essex-Lopresti, Atkins, Zwipp and Tscherne, Sanders, and AO-ICI classification systems. The reviewers were unaware of the patients' identity and all aspects of clinical care. The data were analyzed using kappa (κ) statistics to assess the intra- and interobserver reliability. The κ values were calculated for Essex-Lopresti (κ = 0.85 intraobserver, κ = 0.78 interobserver), Atkins (κ = 0.42 intraobserver, κ = 0.73 interobserver), Zwipp and Tscherne (κ = 0.40 intraobserver, κ = 0.47 interobserver), Sanders (κ = 0.31 intraobserver, κ = 0.35 interobserver), and AO-ICI (κ = 0.41 intraobserver, κ = 0.33 interobserver). The AO-ICI classification system had levels of reproducibility similar to that of the Sanders classification, currently the most widely used system. The Essex-Lopresti classification demonstrated improved reliability compared with that reported in previous studies. This can be attributed to using sagittal computed tomography images, in addition to the originally described plain radiographs, for assessment. This improvement is relevant because of its accepted prognostic predictability.
The journal of bone and joint surgery, Dec 1, 2012
ABSTRACT Hypermobility is an acknowledged risk factor for patellar instability. In this case cont... more ABSTRACT Hypermobility is an acknowledged risk factor for patellar instability. In this case control study the influence of hypermobility on clinical outcome following medial patellofemoral ligament (MPFL) reconstruction for patellar instability was studied. A total of 25 patients with hypermobility as determined by the Beighton criteria were assessed and compared with a control group of 50 patients who were matched for age, gender, indication for surgery and degree of trochlear dysplasia. The patients with hypermobility had a Beighton Score of ≥ 6; the control patients had a score of &lt; 4. All patients underwent MPFL reconstruction performed using semitendinosus autograft and a standardised arthroscopically controlled technique. The mean age of the patients was 25 years (17 to 49) and the mean follow-up was 15 months (6 to 30). Patients with hypermobility had a significant improvement in function following surgery, with reasonable rates of satisfaction, perceived improvement, willingness to repeat and likelihood of recommendation. Functional improvements were significantly less than in control patients (p &lt; 0.01). Joint hypermobility is not a contraindication to MPFL reconstruction although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery.
The journal of bone and joint surgery, Sep 1, 2012
We report a prospective analysis of clinical outcome in patients treated with medial patellofemor... more We report a prospective analysis of clinical outcome in patients treated with medial patellofemoral ligament (MPFL) reconstruction using an autologous semitendinosus graft. The technique includes superolateral portal arthroscopic assessment before and after graft placement to ensure correct graft tension and patellar tracking before fixation. Between October 2005 and October 2010, a total of 201 consecutive patients underwent 219 procedures. Follow-up is presented for 211 procedures in 193 patients with a mean age of 26 years (16 to 49), and mean follow-up of 16 months (6 to 42). Indications were atraumatic recurrent patellar dislocation in 141 patients, traumatic recurrent dislocation in 50, pain with subluxation in 14 and a single dislocation with persistent instability in six. There have been no recurrent dislocations/subluxations. There was a statistically significant improvement between available pre-and post-operative outcome scores for 193 patients (all p < 0.001). Female patients with a history of atraumatic recurrent dislocation and all patients with history of previous surgery had a significantly worse outcome (all p < 0.05). The indication for surgery, degree of dysplasia, associated patella alta, time from primary dislocation to surgery and evidence of associated cartilage damage at operation did not result in any significant difference in outcome. This series adds considerably to existing evidence that MPFL reconstruction is an effective surgical procedure for selected patients with patellofemoral instability.
The aim of this study was to describe the prevalence and patterns of neuropathic pain over one ye... more The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA). Methods Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey. Results Symptoms of neuropathic pain were common among patients reporting chronic pain at three months post-TKA, with half reporting neuropathic pain on painDETECT (191/363; 53%) and 74% (267/359) on DN4. Of those with neuropathic pain at three months, half continued to have symptoms over the next 12 months (148/262; 56%), one-quarter had improved (67/262; 26%), and for one-tenth their neuropathic symptoms fluctuated over time (24/262; 9%). However, a subgroup of participants reported new, late onset neuropathic symptoms (23/262; 9%). Prevalence of neuropathic symptoms was similar between the screening tools when the lower cutoff painDETECT score (≥ 13) was applied. Overall, mean neuropathic pain scores improved between three and 15 months after TKA. Conclusion Neuropathic pain is common in patients with chronic pain at three months after TKA. Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. Postoperative care should include screening, assessment, and treatment of neuropathic pain in patients with early chronic postoperative pain after TKA.
, et al. REST: a preoperative tailored sleep intervention for patients undergoing total knee repl... more , et al. REST: a preoperative tailored sleep intervention for patients undergoing total knee replacement-feasibility study for a randomised controlled trial. BMJ Open 2024;14:e078785.
Objective To investigate the effect of lab-based simulator training, on the ability of surgical t... more Objective To investigate the effect of lab-based simulator training, on the ability of surgical trainees to perform diagnostic knee arthroscopy. Method 20 orthopaedic SHOs with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training using a bench-top knee model. Learning curves were clearly demonstrated using motion analysis equipment to monitor performance. All 20 then spent an operating list with a blinded consultant trainer. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was assessed using the intra-operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PBA) protocol for diagnostic arthroscopy. Performance was further quantified with a ten point global rating assessment scale. Results Motion analysis demonstrated objective and significant improvement in performance during simulator training. In theatre the simulator-trained group performed significantly better than the untrained group. The simulator trainees were scored as OCAP competent on more than 70% of occasions, compared to less than 15% for the untrained group (p Conclusion Learning curves showing significantly improved performance at simulated diagnostic knee arthroscopy are clearly demonstrated using motion analysis assessment. Arthroscopic simulator training led to subsequent significant improvement in operating theatre performance as determined by OCAP and a global rating assessment scale. This demonstrates a degree of transfer validity from lab based arthroscopic simulator training using motion analysis assessment to the operating theatre. In addition OCAP PBAs appear to provide a useful framework for in theatre assessment; however questions are raised about the need for more objective assessment tools in order to truly distinguish between trainees varying levels of competence.
IntroductionTotal knee replacement (TKR) is a successful operation for many patients, however 15–... more IntroductionTotal knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics.We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR.MethodologyBetween 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4).ResultsAt three months post-operative, 53% reported neuropathic pain on painDETECT and 74% on DN4. Half (56%) remained in neuropathic pain over the twelve-month follow-up period, 26% reported improvement, and 9% reported new neuropathic symtpoms or fluctuated in and out of neuropathic pain (9%...
IntroductionThere is a need to develop approaches to reduce chronic pain after total knee replace... more IntroductionThere is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR.MethodologyREST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.Results57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an a...
IntroductionTotal knee replacement (TKR) aims to reduce pain and functional limitations. Despite ... more IntroductionTotal knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR.The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs).There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation.MethodologyTrial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were co...
For many people with advanced osteoarthritis, total knee replacement is an effective treatment to... more For many people with advanced osteoarthritis, total knee replacement is an effective treatment to relieve pain and improve function. However, 10–34% of people experience chronic postsurgical pain in the months and years after total knee replacement. The Support and Treatment After Replacement (STAR) randomised controlled trial (ISCRTN92545361) evaluated the clinical- and cost-effectiveness of a new multifaceted and personalised care pathway, compared with usual care, for people with pain at three months after total knee replacement. Our objective was to identify factors promoting or inhibiting its implementation, and to inform future training and wider implementation of the pathway. We conducted a prospective process evaluation using qualitative interviews with eight Extended Scope Practitioners and six Principal Investigators from seven trial sites who were involved in delivering the STAR care pathway during the trial. We used Normalization Process Theory as a theoretical framework...
Purpose Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than sati... more Purpose Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than satisfactory outcome in some patients. It was hypothesized that certain factors can be identified on radiological review that correlate with poor patient reported outcomes following PFA. Methods A retrospective cohort review of 369 patients undergoing PFA at our institution between 2005 and 2018 identified 43 “poor outcome” patients with an Oxford Knee Score (OKS) of less than 20 at 2 years follow up. These cases were matched by sex and age with 43 “good outcome” patients who had an OKS above 40 at 2 years post-op. Multiple radiological measurements were performed including anterior trochlea offset ratio (ATOR), component flexion/extension, component varus/valgus, component to bone width ratio and retinacular index. The OKS PROM was the primary outcome of the study. Stepwise logistic regression was performed to analyze the differences in radiological indices between the two groups. Results I...
Aims The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears... more Aims The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR. Methods We reviewed the data for a consecutive series of 88 patients (mean age 27.1 years (15 to 49); 65 male (74%) and 23 female (26%)) who underwent single-stage repair of a displaced BH meniscal tear (67 medial (76%) and 21 lateral (24%)) with concomitant hamstring autograft ACLR. The patient-reported outcome measures (PROMs) EuroQol visual analogue scale (EQ-VAS), EuroQol five-dimension health questionnaire (EQ-5D), Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC),...
BackgroundApproximately 20% of patients experience chronic pain after total knee replacement (TKR... more BackgroundApproximately 20% of patients experience chronic pain after total knee replacement (TKR). The impact of chronic pain after TKR on primary care services in the UK is currently unknown. The aim of this study was to compare primary care consultations and pain medicine prescriptions between patients with and without chronic pain after TKR. MethodsData from 5,055 patients who received TKR between 2009-2016 with anonymised linked data from the Clinical Practice Research Datalink Gold (CPRD) and English Hospital Episode Statistics (HES) Patient Reported Outcome Measures (PROMs) programme were analysed. The exposure time was from 10 years pre-operative to eight years post-operative. Patients with a score ≤14 on the Oxford Knee Score pain component scale at 6 months post-operative were classified as having chronic pain after TKR. Primary care consultations and prescribed pain medicines were quantified, and costs calculated based on national cost data. Results721 patients (14%) had ...
Background: Despite growing awareness of the contribution of central pain mechanisms to knee oste... more Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice. Methods: A narrative review of original research papers was conducted by 9 clinicians and researchers from seven differente countries to reach agreement on clinically-relevant descriptors. Results: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behaviour of knee pain, presence of neuropathic-like or centrally-mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense. Conclusion: This article describes a set of clinically-relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies.
Background: Despite growing awareness of the contribution of central pain mechanisms to knee oste... more Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice. Methods: A narrative review of original research papers was conducted by 9 clinicians and researchers from seven differente countries to reach agreement on clinically-relevant descriptors. Results: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behaviour of knee pain, presence of neuropathic-like or centrally-mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense. Conclusion: This article describes a set of clinically-relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies.
Approximately 20% of people who have total knee replacement experience chronic pain afterwards, b... more Approximately 20% of people who have total knee replacement experience chronic pain afterwards, but there is little evidence about effective interventions for managing this type of pain. This article describes the systematic development and refinement of a complex intervention for people with chronic pain after knee replacement. The intervention is a care pathway involving an assessment clinic and onward referral, with telephone follow-up as required. In the design of this multistage study, we chose to focus on ensuring that the intervention was deliverable, implementable and acceptable. In line with the UK Medical Research Council's recommendations for comprehensive development of complex interventions, multiple phases of work were undertaken. Following on from initial development work to design the intervention, the draft intervention content was refined through consensus questionnaires with 22 health professionals and discussion at meetings with 18 healthcare professionals. T...
Introduction Although stabilisation of knee cartilage lesions (chondroplasty) may be performed wi... more Introduction Although stabilisation of knee cartilage lesions (chondroplasty) may be performed with an arthroscopic shaver, more recently, radiofrequency (RF) ablation has gained in popularity. However, their remain some concerns about the avoidance of thermal injury, chondrolysis, and osteonecrosis with the use of RF devices. Methods We reviewed the outcomes of 85 knee chondroplasties performed with a new RF ablation wand designed for knee chondroplasty. Lesion details and Chondropaenia Severity Score (CSS) were recorded for each patient. We evaluated the occurrence of adverse outcomes, post-operative complications, and the need for further surgery. Post-operative outcomes scores (Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS], and International Knee Documentation Committee [IKDC] subjective knee outcome) were recorded at a minimum of one-year follow-up. Results At the final mean follow-up of 27.5 months (range: 12-46.6 months), 12 (14%) knees had unde...
The Journal of Foot and Ankle Surgery Official Publication of the American College of Foot and Ankle Surgeons, Aug 28, 2013
The aim of the present study was to assess the reliability of commonly used intra-articular calca... more The aim of the present study was to assess the reliability of commonly used intra-articular calcaneal fracture classification systems and to compare them with the newer AO Integral Classification of Injuries (ICI) system. Forty computed tomography and radiographic images of 40 intra-articular calcaneal fractures were reviewed independently by 3 reviewers on 2 separate occasions and classified according to the Essex-Lopresti, Atkins, Zwipp and Tscherne, Sanders, and AO-ICI classification systems. The reviewers were unaware of the patients' identity and all aspects of clinical care. The data were analyzed using kappa (κ) statistics to assess the intra- and interobserver reliability. The κ values were calculated for Essex-Lopresti (κ = 0.85 intraobserver, κ = 0.78 interobserver), Atkins (κ = 0.42 intraobserver, κ = 0.73 interobserver), Zwipp and Tscherne (κ = 0.40 intraobserver, κ = 0.47 interobserver), Sanders (κ = 0.31 intraobserver, κ = 0.35 interobserver), and AO-ICI (κ = 0.41 intraobserver, κ = 0.33 interobserver). The AO-ICI classification system had levels of reproducibility similar to that of the Sanders classification, currently the most widely used system. The Essex-Lopresti classification demonstrated improved reliability compared with that reported in previous studies. This can be attributed to using sagittal computed tomography images, in addition to the originally described plain radiographs, for assessment. This improvement is relevant because of its accepted prognostic predictability.
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Papers by Nick Howells