Aim: To audit the accuracy and efficacy of injections for subacromial impingement administered by our medical staff and specialist role physiotherapist. Methods: 49 patients presenting to the outpatient clinic with subacromial impingement agreed to take part in the study. They were allocated according to date of referral to either the consultant, the physiotherapist or registrar grade for injection via an anterior approach into the subacromial bursa. The therapeutic injection contained a specified volume of radiocontrast as well as depomedrone and lignocaine. Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast. Results: Accuracy rates of 67% through an anterior approach were obtained by both the consultant and the physiotherapist. At registrar level 48% accuracy was achieved. Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections. Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%. Conclusions: In our practice, the specialist physiotherapist already has an established role in administering therapeutic subacromial injections. Our audit demonstrates acceptable and equal accuracy to the consultant which we feel justifies this particular part of their role. However, at registrar grade the level of accuracy is reduced and most likely reflects inexperience, as over time accuracy improved. Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder

The Specialist Sarcoma Physiotherapist aims to ensure that patients with sarcoma receive a coordinated and seamless rehabilitation programme, when and where they need it, to enable them to achieve maximum function and quality of life. The National Institute of Clinical Excellence (NICE) Sarcoma guidelines (NICE 2006), recommend that all patients should have their care supervised by, or in conjunction with a sarcoma Multidisciplinary team (MDT). The role of the specialised physiotherapist on the MDT enables rehabilitation to be provided in a timely and coordinated way (NICE 2006). Sarcoma and its treatment can have a major effect on the quality of patients’ lives. Treatment often involves extensive surgery, coupled with chemotherapy and/or radiotherapy. Rehabilitation of patients with sarcoma is highly specialised. A Specialist Sarcoma Physiotherapy team was set up at The Christie and Manchester Royal Infirmary in 1998. All patients who need it, can access expert rehabilitation and advice. The physiotherapist is a core member of the MDT, attends clinics, MDT meetings and offers seamless rehabilitation to in-patients and out-patients undergoing treatment (surgery, radiotherapy and chemotherapy) for bone or soft tissue sarcoma. The physiotherapist must have an in-depth understanding of all aspects of sarcoma: treatment modalities, functional and psycho-social issues, and impact of disease progression, etc. Rehabilitation is often intensive and may take months and sometimes years. The physiotherapist will spend many hours with the patient and develops a close relationship where practical as well as emotional advice and counselling become part of the treatment. In the event of metastatic disease, the physiotherapist continues to offer support and helps to maximize independence and function even in the end stages of the disease. Access to specialist advice and rehabilitation helps the patient maximise the benefits of treatment, and aims to improve physical, social and emotional outcomes both during and following treatment

We report a prospective study of the feasibility of employing specially trained physiotherapists to screen neonates for congenital dislocation of the hip. During ten years 42,241 babies were screened, using clinical tests; 255 were diagnosed and treated by a Pavlik harness. In the same period 13 children presented late with congenital dislocation of the hip which had not been detected by the screening programme

Aims. To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation. Methods. We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional. Results. Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating). Conclusion. In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation. Cite this article: Bone Jt Open 2022;3(9):701–709

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries. Cite this article: Bone Joint J 2023;105-B(7):723–728

Aims. Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes. Methods. A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale (‘not important’ to ‘critically important’). A consensus meeting was held to finalize the CMS. Results. Overall, 14 distinct measurements were identified in the systematic review, with Reimer’s migration percentage being the most frequently reported. These measurements were presented over the two rounds of the Delphi process, along with two additional measurements that were suggested by participants. Ultimately, two measurements, Reimer’s migration percentage and femoral head-shaft angle, were included in the CMS. Conclusion. This use of a minimum standardized set of measurements has the potential to encourage uniformity across hip surveillance programmes, and may streamline the development of tools, such as artificial intelligence systems to automate the analysis in surveillance programmes. This core set should be the minimum requirement in clinical studies, allowing clinicians to add to this as needed, which will facilitate comparisons to be drawn between studies and future meta-analyses. Cite this article: Bone Jt Open 2023;4(11):825–831

Aims. This Delphi study assessed the challenges of diagnosing soft-tissue knee injuries (STKIs) in acute settings among orthopaedic healthcare stakeholders. Methods. This modified e-Delphi study consisted of three rounds and involved 32 orthopaedic healthcare stakeholders, including physiotherapists, emergency nurse practitioners, sports medicine physicians, radiologists, orthopaedic registrars, and orthopaedic consultants. The perceived importance of diagnostic components relevant to STKIs included patient and external risk factors, clinical signs and symptoms, special clinical tests, and diagnostic imaging methods. Each round required scoring and ranking various items on a ten-point Likert scale. The items were refined as each round progressed. The study produced rankings of perceived importance across the various diagnostic components. Results. In Round 1, the study revealed widespread variability in stakeholder opinions on diagnostic components of STKIs. Round 2 identified patterns in the perceived importance of specific items within each diagnostic component. Round 3 produced rankings of perceived item importance within each diagnostic component. Noteworthy findings include the challenges associated with accurate and readily available diagnostic methods in acute care settings, the consistent acknowledgment of the importance of adopting a patient-centred approach to diagnosis, and the transition from divergent to convergent opinions between Rounds 2 and 3. Conclusion. This study highlights the potential for a paradigm shift in acute STKI diagnosis, where variability in the understanding of STKI diagnostic components may be addressed by establishing a uniform, evidence-based framework for evaluating these injuries. Cite this article: Bone Jt Open 2024;5(11):984–991

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction

Aims. This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery. Methods. This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion. A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920

Aims. To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV). Methods. A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities. Results. In total, 39 OMTs were included from the systematic review. Two additional OMTs were identified from the interviews and questionnaires, and four were added after round one Delphi. Overall, 22 OMTs reached ‘consensus in’ during the Delphi and two reached ‘consensus out’; 21 OMTs reached ‘no consensus’ and were included in the final consensus meeting. In all, 21 participants attended the consensus meeting, including a wide diversity of clubfoot practitioners, parent/patient representative, and an independent chair. A total of 21 outcomes were discussed and voted upon; six were voted ‘in’ and 15 were voted ‘out’. The final COS document includes nine OMTs and two existing outcome scores with a total of 31 outcome parameters to be collected after a minimum follow-up of five years. It incorporates static and dynamic clinical findings, patient-reported outcome measures, and a definition of CTEV relapse. Conclusion. We have defined a minimum set of outcomes to draw comparisons between centres and studies in the treatment of CTEV. With the use of these outcomes, we hope to allow more meaningful research and a better clinical management of CTEV. Cite this article: Bone Jt Open 2022;3(1):98–106

Satisfactory military orthopaedic service provision in the UK suffers significantly from a lack of basic resources, notably overall consultant numbers and host trust support. The waiting time to see an appropriate consultant (uniformed or contracted) can be as long as nine months. Many of these referrals from the primary care sector do not, in fact, need to see a consultant. Appropriately trained individuals such as; GP’s with special interests, Nurse Practitioners and Extended Scope Practitioners may all have a role to play in patient management. Military Physiotherapists are uniquely qualified to deal with these referrals. They can provide military input, advice on grading, order appropriate investigations (including MRI scans and X-rays) and give guidance on further management and arrange follow-on treatment. Although popular in spinal assessment clinics, we are unaware of this facility being formally used in a general military orthopaedic setting. We have now reviewed the results of our first 100 patients. The average waiting time to first appointment was 2 weeks. 75 patients were dealt with solely by the screening clinic. 21 MRI scans, were ordered. Only 25 patients required review by the orthopaedic team. 7 patients required surgery. Our conclusion is that such clinics represent a clinically beneficial and cost-effective screening tool at the primary/secondary care interface. A high patient satisfaction at the short waiting times and outcomes was also noted.

Aims. Patients undergoing limb reconstruction surgery often face a challenging and lengthy process to complete their treatment journey. The majority of existing outcome measures do not adequately capture the patient-reported outcomes relevant to this patient group in a single measure. Following a previous systematic review, the Stanmore Limb Reconstruction Score (SLRS) was designed with the intent to address this need for an effective instrument to measure patient-reported outcomes in limb reconstruction patients. We aim to assess the face validity of this score in a pilot study. Methods. The SLRS was designed following structured interviews with several groups including patients who have undergone limb reconstruction surgery, limb reconstruction surgeons, specialist nurses, and physiotherapists. This has subsequently undergone further adjustment for language and clarity. The score was then trialled on ten patients who had undergone limb reconstruction surgery, with subsequent structured questioning to understand the perceived suitability of the score. Results. Ten patients completed the score and the subsequent structured interview. Considering the tool as a whole, 100% of respondents felt the score to be comprehensible, relevant, and comprehensive regarding the areas that were important to a patient undergoing limb reconstruction surgery. For individual questions, on a five-point Likert scale, importance/relevance was reported as a mean of 4.78 (4.3 to 5.0), with ability to understand rated as 4.92 (4.7 to 5.0) suggesting high levels of relevance and comprehension. Flesch-Kincaid reading grade level was calculated as 5.2 (10 to 11 years old). Conclusion. The current SLRS has been shown to have acceptable scores from a patient sample regarding relevance, comprehensibility, and comprehensiveness. This suggests face validity, however further testing required and is ongoing in a larger cohort of patients to determine the reliability, responsiveness, precision, and criterion validity of the score in this patient group. Cite this article: Bone Jt Open 2021;2(9):705–709

Introduction: The Oxford Knee Score (OKS) is commonly used in the assessment of outcome for knee arthroplasty. All patients having knee arthroplasty at our institution undergo OKS at both nurse led pre-assessment and admission physiotherapy visit, a period of 10 to 30 days pre-operatively. At both instances, the scoring form is left with the patient and collected at the end of the visit.

Anecdotal evidence from our centre suggested that patients attending for arthroplasty surgery were scoring differently at each visit.

The aim of this study is to establish if there is a significant difference OKS at pre-assessment visit and on admission to the ward.

Statistical Method: A pilot study was carried out. A power calculation revealed a requirement for 44 patients to enter the study. The resultant probability was 90 percent that the study would detect a difference at a two sided 5.0 percent significance level, if the minimum clinical difference is 3 points. This is based on the standard deviation of the difference in the response variables of 6. A clinical difference of 3 is drawn from previous studies investigating the use of the OKS.

44 patients undergoing arthroplasty surgery had their OKS for both visits retrospectively analysed.

The mean of the totals of both visits was analysed and found to conform to normality and hence was further investigated by a paired samples t test.

Comparison of individual scoring revealed a violation of normality and hence was further analysed using a Wilcoxon Signed Ranks Test.

Results: A statistically significant result at the 5% level was observed t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI).

Analysis of the individual scoring at both intervals revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units. No significant difference was seen when time between assessments was analysed.

Conclusion: This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed.

This work supports earlier studies that pre-operative assessment using the OKS is robust to variance in the pre-operative scoring window.

All patients undergoing knee arthroplasty at our institution complete Oxford Knee Scoring (OKS) at nurse-led pre-assessment and again at an admission physiotherapy visit on the ward which may be up to 2 months later.

The aim of this study is to establish the extended reproducibility of the OKS by statistical analysis of scores taken at these intervals.

44 patients were required to achieve a 90 % probability to detect a difference at a two-sided 5 % significance level with a minimum clinical difference of 3 points, a cut off used in previous works regarding the use of OKS.

Both the overall population means and the differences between individual questions were analysed by a paired samples t test and a Wilcoxon Signed Ranks Test respectively.

Mean interval between attendance for pre-assessment and admission visit was 16 days (7–60).

A statistically significant result at the 5% level was observed for the t test t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI).

Analysis of difference between individual questions revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units.

This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed.

The original validation of the OKS was obtained using test-retest reproducibility over a 24 hour period. This work shows that the OKS is robust to violations in reproducibility at duration much greater than this and for practical purposes is valid if taken at any point during the pre-admission phase of care.

Aims

Perthes’ disease is an idiopathic avascular necrosis of the developing femoral head, often causing deformity that impairs physical function. Current treatments aim to optimize the joint reaction force across the hip by enhancing congruency between the acetabulum and femoral head. Despite a century of research, there is no consensus regarding the optimal treatment. The aim of this study was to describe the experiences of children, their families, and clinicians when considering the treatment of Perthes’ disease.

Aims

Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app).

Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

Aims

The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model.

Aims

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

Aims

An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise.