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Journal articleWoodbridge H, McCarthy C, Jones M, et al., 2024,
Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study
, Critical Care (UK), Vol: 28, ISSN: 1364-8535BackgroundPhysical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.MethodsA three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.ResultsTwenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs
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Journal articleKeny SM, Bagaria V, Sahu D, et al., 2024,
Remote patient monitoring: A current concept update on the technology adoption in the realm of orthopedics
, Journal of Clinical Orthopaedics and Trauma, Vol: 51, ISSN: 0976-5662- Cite
- Citations: 1
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Journal articleSarai P, Luff C, Rohani-Shukla C, et al., 2024,
Characteristics of motor evoked potentials in patients with peripheral vascular disease
, PLoS One, Vol: 19, ISSN: 1932-6203With an aging population, it is common to encounter people diagnosed with peripheral vascular disease (PVD). Some will undergo surgeries during which the spinal cord may be compromised and intraoperative neuromonitoring with motor evoked potentials (MEPs) is employed to help mitigate paralysis. No data exist on characteristics of MEPs in older, PVD patients, which would be valuable for patients undergoing spinal cord at-risk surgery or participating in neurophysiological research. Transcranial magnetic stimulation, which can be delivered to the awake patient, was used to stimulate the motor cortex of 20 patients (mean (±SD)) age 63.2yrs (±11.5) with confirmed PVD, every 10 minutes for one hour with MEPs recorded from selected upper and lower limb muscles. Data were compared to that from 20 healthy volunteers recruited for a protocol development study (28yrs (±7.6)). MEPs did not differ between patient’s symptomatic and asymptomatic legs. MEP amplitudes were not different for a given muscle between patients and healthy participants. Except for vastus lateralis, disease severity did not correlate with MEP amplitude. There were no differences over time in the coefficient of variation of MEP amplitude at each time point for any muscle in patients or in healthy participants. Although latencies of MEPs were not different between patients and healthy participants for a given muscle, they were longer in older participants. The results obtained suggest PVD alone does not impact MEPs; there were no differences between more symptomatic and less symptomatic legs. Further, in general, disease severity did not corelate with MEP characteristics. With an aging population, more patients with PVD and cardiovascular risk factors will be participating in neurophysiological studies or undergoing surgery where spinal cord integrity is monitored. Our data show that MEPs from these patients can be easily evoked and interpreted.
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Journal articleReynolds A, Doyle R, Boughton O, et al., 2024,
Dynamics of manual impaction instruments during total hip arthroplasty
, Bone & Joint Research, Vol: 13, Pages: 193-200, ISSN: 2046-3758AimsManual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.MethodsPosterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment.ResultsThe force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face.ConclusionThe direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training.
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Journal articleVivek K, Kamal R, Perera E, et al., 2024,
Vitamin D Deficiency Leads to Poorer Health Outcomes and Greater Length of Stay After Total Knee Arthroplasty and Supplementation Improves Outcomes
, JBJS REVIEWS, Vol: 12, ISSN: 2329-9185 -
Journal articleHuang F, Harris S, Zhou T, et al., 2024,
Which method for femoral component sizing when performing kinematic alignment TKA? An in silico study
, ORTHOPAEDICS & TRAUMATOLOGY-SURGERY & RESEARCH, Vol: 110, ISSN: 1877-0568 -
Book chapterRahman A, Liddle AD, Murray DW, 2024,
Results and registry data for unicompartmental knee replacements
, Unicompartmental Knee Arthroplasty A New Paradigm, Pages: 191-207There is good evidence that Unicompartmental Knee Replacement (UKR) has numerous advantages over Total Knee Replacement (TKR). UKR provides a faster recovery with a shorter hospital stay, fewer complications, lower re-admission rate and lower mortality. In addition, it provides better functional outcomes with more excellent results. UKR is also easier to revise than TKR, is less costly, and more effective over the patient's lifetime. The disadvantage of UKR is that it has a higher revision rate. One of the main reasons for this is that the threshold for revising a UKR is much lower than that for TKR because UKR are easier to revise, and the outcome of a revision is expected to be better. As a result, even though UKR have less poor outcomes than TKR, they have a higher revision rate. So, when deciding whether to do a UKR or TKR, surgeons should not just focus on the revision rate but instead should consider all factors important to patients. Registry data shows that most surgeons doing UKR do very small numbers, the most common being 1 or 2 per year. Surgeons doing small numbers have very high revision rates, and with increasing numbers the revision rate decreases. The only practical way surgeons can increase their UKR caseload is to increase the proportion of their primary knee replacements that are UKR, which is known as UKR usage. Surgeons with usage less than 20% tend to have a high revision rate so these surgeons should either stop doing UKR or do more. With mobile bearing UKR the revision rate decreases with increased usage up to 50%. The evidence-based indications for the mobile bearing UKR are satisfied in about 50% of patients needing knee replacement. Therefore, to achieve optimal results surgeons should adhere to the recommended indications. There are a few studies that report the 20-year results following UKR. The largest which included 683 knees, reported a 20-year survival of 91% (n=683) for a mobile bearing UKR. Three smaller studies of fixed bearing U
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Journal articleStoddart J, Garner A, Tuncer M, et al., 2024,
Load transfer in bone after partial, multi-compartmental, and total knee arthroplasty
, Frontiers in Bioengineering and Biotechnology, Vol: 12, ISSN: 2296-4185Introduction: Arthroplasty-associated bone loss remains a clinical problem: stiff metallic implants disrupt load transfer to bone and hence its remodeling stimulus. The aim of this research was to analyze how load transfer to bone is affected by different forms of knee arthroplasty: isolated partial knee arthroplasty (PKA), compartmental arthroplasty (CPKA, two or more PKAs in the same knee) and total knee arthroplasty (TKA). Methods: An experimentally validated subject-specific finite element model was analyzed native, and with medial unicondylar, lateral unicondylar, patellofemoral, biunicondylar, medial bicompartmental, lateral bicompartmental, tricompartmental and total knee arthroplasty. Three load cases were simulated for each: gait, stair ascent and sit-to-stand. Strain shielding and overstraining were calculated from the differences between the native and implanted states. Results: For gait, the TKA femoral component led to mean strain shielding (30%) more than three times higher than PKA (4% to 7%) and CPKA (5% to 8%). Overstraining was predicted in the proximal tibia (TKA 21%, PKA/CPKA 0 to 6%). The variance in the distribution for TKA was an order of magnitude greater than for PKA/CPKA indicating less physiological load transfer. Only the TKA-implanted femur was sensitive to load case: for stair ascent and gait, almost the entire distal femur was strain-shielded, whereas during sit-to-stand the posterior femoral condyles were overstrained. Discussion: TKA requires more bone resection than PKA and CPKA. These finite element analyses suggest that a longer-term benefit for bone is probable as partial and multicompartmental knee procedures lead to more natural load transfer compared to TKA. High-flexion activity following TKA may be protective of posterior condyle bone resorption, which may help explain why bone loss affects some patients more than others. The male and female intact bone models are included as supplementary material.
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Journal articleKarunaseelan K, Nasser R, Cobb J, et al., 2024,
Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach: a biomechanical study
, The Bone & Joint Journal, Vol: 106, ISSN: 2049-4408Aims:Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA.Methods:Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators.Results:Following initial exposure, the ischiofemoral ligament (7 to 8 o’clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o’clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%).Conclusion:Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.
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Conference paperKarunaseelan KJ, Nasser R, Jeffers JRT, et al., 2024,
Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach
, Annual Meeting of the International-Hip-Society, Publisher: BRITISH EDITORIAL SOC BONE & JOINT SURGERY, Pages: 59-66, ISSN: 2049-4394 -
Journal articleZhao Y, Coppola A, Karamchandani U, et al., 2024,
Artificial intelligence applied to magnetic resonance imaging reliably detects the presence, but not the location, of meniscus tears: a systematic review and meta-analysis
, EUROPEAN RADIOLOGY, ISSN: 0938-7994 -
Conference paperPlumb W, Casale G, Bottle A, et al., 2024,
Clinical pathway clustering using surrogate likelihoods and replayability validation
, Winter Simulation Conference 2023, Publisher: ACM / IEEE, Pages: 1220-1231Modelling clinical pathways from Electronic Health Records (EHRs) can optimize resources and improvepatient care, but current methods for generating pathway models using clustering have limitations includingscalability and fidelity of the clusters. We propose a novel pathway modelling approach using MaximumLikelihood (ML) data clustering on Markov chain representations of clinical pathways. Our method iscalibrated to produce clusters with low inter-cluster variability across the pathways. We use machine learningwith Stochastic Radial Basis Functions (SRBF) kernels for surrogate optimization to handle non-convexityand propose an incremental optimization method to improve scalability. We also define a methodologybased on novel replayability scores to help analysts compare the fidelity of alternative clustering results.Results show that our ML method produces clusters that have higher fidelity in terms of replayability scoresthan k-means based clustering and in capturing queueing contention, which is important for bottleneckidentification in healthcare.
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Journal articleDe Mori A, Heyraud A, Tallia F, et al., 2024,
Ovine mesenchymal stem cell chondrogenesis on a novel 3D-printed hybrid scaffold in vitro
, Bioengineering, Vol: 11, ISSN: 2306-5354This study evaluated the use of silica/poly(tetrahydrofuran)/poly(ε-caprolactone) (SiO2/PTHF/PCL-diCOOH) 3D-printed scaffolds, with channel sizes of either 200 (SC-200) or 500 (SC-500) µm, as biomaterials to support the chondrogenesis of sheep bone marrow stem cells (oBMSC), under in vitro conditions. The objective was to validate the potential use of SiO2/PTHF/PCL-diCOOH for prospective in vivo ovine studies. The behaviour of oBMSC, with and without the use of exogenous growth factors, on SiO2/PTHF/PCL-diCOOH scaffolds was investigated by analysing cell attachment, viability, proliferation, morphology, expression of chondrogenic genes (RT-qPCR), deposition of aggrecan, collagen II, and collagen I (immunohistochemistry), and quantification of sulphated glycosaminoglycans (GAGs). The results showed that all the scaffolds supported cell attachment and proliferation with upregulation of chondrogenic markers and the deposition of a cartilage extracellular matrix (collagen II and aggrecan). Notably, SC-200 showed superior performance in terms of cartilage gene expression. These findings demonstrated that SiO2/PTHF/PCL-diCOOH with 200 µm pore size are optimal for promoting chondrogenic differentiation of oBMSC, even without the use of growth factors.
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Journal articleChang G, Moiteiro Manteigas H, Strutton PH, et al., 2024,
An evaluation of a healthy participant laboratory model of epidural hyperthermia: a physiological study
, International Journal of Obstetric Anesthesia, Vol: 57, ISSN: 0959-289XBACKGROUND: Hyperthermia complicates 21% of cases of intrapartum epidural analgesia, but the mechanism is unclear. One hypothesis is that blockade of cholinergic sympathetic nerves prevents active vasodilation and sweating, thus limiting heat loss. Because labour increases heat production, this could create a situation in which heat production exceeds loss, causing body temperature to rise. This physiological study tested a novel laboratory model of epidural-related hyperthermia, using exercise to simulate the increased heat production of labour and surface insulation to simulate the effect of epidural analgesia. METHODS: Twelve healthy non-pregnant participants (six female) cycled an ergometer for two hours at 20 Watts (W) on two occasions: once with surface insulation (intervention) and once without (control). Core temperature, skin temperature (eight sites), and heat loss (eight sites) were recorded. Mean body temperature and heat production were calculated. Values are mean (SD). RESULTS: Exercise increased heat production on both visits (intervention 38 (18) W; control 37 (31) W; P = 0.94). Total heat loss was less on the intervention visit (intervention 115 (19) W; control 129 (23) W; P = 0.002). Core temperature increased on both visits (intervention 0.21 (0.37)°C; control 0.19 (0.27)°C; P < 0.001). The increase in mean body temperature was greater on the intervention visit (intervention 0.47 (0.41)°C; control 0.25 (0.19)°C; P = 0.007). CONCLUSIONS: This laboratory model predicts that labour epidural analgesia limits heat loss by >14 W. Once the model is validated, it could be used to test the efficacy of potential interventions to prevent and treat epidural-related maternal hyperthermia.
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Journal articleZhou T, Salman D, Mcgregor A, 2024,
mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis
, JMIR MHEALTH AND UHEALTH, Vol: 12, ISSN: 2291-5222 -
Journal articleBoyles RH, Alexander CM, Belsi A, et al., 2024,
Are clinical prediction rules used in spinal cord injury care? A survey of practice
, Topics in Spinal Cord Injury Rehabilitation, Vol: 30, Pages: 45-58, ISSN: 1082-0744BACKGROUND: Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice. OBJECTIVES: To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom. METHODS: An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients. RESULTS: One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future. CONCLUSION: The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.
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Journal articleDavies AR, Sabharwal S, Liddle AD, et al., 2024,
The risk of revision is higher following shoulder hemiarthroplasty compared with total shoulder arthroplasty for osteoarthritis: a matched cohort study of 11,556 patients from the National Joint Registry, UK
, Acta Orthopaedica, Vol: 95, Pages: 73-85, ISSN: 0001-6470BACKGROUND AND PURPOSE: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are used in the management of osteoarthritis of the glenohumeral joint. We aimed to determine whether TSA or HA resulted in a lower risk of adverse outcomes in patients of all ages with osteoarthritis and an intact rotator cuff and in a subgroup of patients aged 60 years or younger. PATIENTS AND METHODS: Shoulder arthroplasties recorded in the National Joint Registry, UK, between April 1, 2012 and June 30, 2021, were linked to Hospital Episode Statistics in England. Elective TSAs and HAs were matched on propensity scores based on 11 variables. The primary outcome was all-cause revision. Secondary outcomes were combined revision/non-revision reoperations, 30-day inpatient complications, 1-year mortality, and length of stay. 95% confidence intervals (CI) were reported. RESULTS: 11,556 shoulder arthroplasties were included: 7,641 TSAs, 3,915 HAs. At 8 years 95% (CI 94-96) of TSAs and 91% (CI 90-92) of HAs remained unrevised. The hazard ratio (HR) varied across follow-up: 4-year HR 2.7 (CI 1.9-3.5), 8-year HR 2.0 (CI 0.5-3.5). Rotator cuff insufficiency was the most common revision indication. In patients aged 60 years or younger prosthesis survival at 8 years was 92% (CI 89-94) following TSA and 84% (CI 80-87) following HA. CONCLUSION: The risk of revision was higher following HA in patients with osteoarthritis and an intact rotator cuff. Patients aged 60 years and younger had a higher risk of revision following HA.
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Journal articlevan Helden JFL, Alexander E, Cabral HV, et al., 2023,
Home-based arm cycling exercise improves trunk control in persons with incomplete spinal cord injury: an observational study
, Scientific Reports, Vol: 13, ISSN: 2045-2322Arm cycling is used for cardiorespiratory rehabilitation but its therapeutic effects on the neural control of the trunk after spinal cord injury (SCI) remain unclear. We investigated the effects of single session of arm cycling on corticospinal excitability, and the feasibility of home-based arm cycling exercise training on volitional control of the erector spinae (ES) in individuals with incomplete SCI. Using transcranial magnetic stimulation, we assessed motor evoked potentials (MEPs) in the ES before and after 30 min of arm cycling in 15 individuals with SCI and 15 able-bodied controls (Experiment 1). Both groups showed increased ES MEP size after the arm cycling. The participants with SCI subsequently underwent a 6-week home-based arm cycling exercise training (Experiment 2). MEP amplitudes and activity of the ES, and movements of the trunk during reaching, self-initiated rapid shoulder flexion, and predicted external perturbation tasks were measured. After the training, individuals with SCI reached further and improved trajectory of the trunk during the rapid shoulder flexion task, accompanied by increased ES activity and MEP amplitudes. Exercise adherence was excellent. We demonstrate preserved corticospinal drive after a single arm cycling session and the effects of home-based arm cycling exercise training on trunk function in individuals with SCI.
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Journal articleEdwards TC, Soussi D, Gupta S, et al., 2023,
Collaborative team training in virtual reality is superior to individual learning for performing complex open surgery: a randomised controlled trial
, Annals of Surgery, Vol: 278, Pages: 850-857, ISSN: 0003-4932Objective: To assess if multiplayer virtual reality (VR) training was superior to single player training for acquisition of both technical and non-technical skills in learning complex surgery.Summary Background Data: Superior team-work in the operating room (OR) is associated with improved technical performance and clinical outcomes. VR can successfully train OR staff individually, however VR team training has yet to be investigated.Method: Forty participants were randomised to individual or team VR training. Individually-trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five VR training sessions over 6-weeks. Subsequently, they underwent a real-life assessment in which they performed Anterior Approach Total Hip Arthroplasty (AA-THA) surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together and individually-trained participants were randomly paired up. Videos were marked by two blinded assessors recording the NOTSS, NOTECHS II and SPLINTS scores. Secondary outcomes were procedure time and number of technical errors.Results: Teams outperformed individually-trained participants for non-technical skills in the real-world assessment (NOTSS 13.1±1.5 vs 10.6±1.6, P=0.002, NOTECHS-II score 51.7±5.5 vs 42.3±5.6, P=0.001 and SPLINTS 10±1.2 vs 7.9±1.6, P=0.004). They completed the assessment 28.1% faster (27.2 minutes±5.5 vs 41.8 ±8.9, P<0.001), and made fewer than half the number of technical errors (10.4±6.1 vs 22.6±5.4, P<0.001).Conclusions: Multiplayer training leads to faster surgery with fewer technical errors and the development of superior non-technical skills.
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Journal articleVella-Baldacchino M, Webb J, Selvarajah B, et al., 2023,
Should we recommend patellofemoral arthroplasties to patients?
, BONE & JOINT OPEN, Vol: 4, Pages: 948-956, ISSN: 2633-1462
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