BackgroundA structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.MethodsApplying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.ResultsThirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.ConclusionThe consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Background Patellofemoral pain is highly prevalent across the lifespan, and a significant proportion of people report unfavourable outcomes years after diagnosis. Previous research has implicated patellofemoral joint loading during gait in patellofemoral pain and its sequelae, patellofemoral osteoarthritis. Biomechanical foot-based interventions (e.g., footwear, insoles, orthotics, taping or bracing) can alter patellofemoral joint loads by reducing motions at the foot that increase compression between the patella and underlying femur via coupling mechanisms, making them a promising treatment option. This systematic review will summarise the evidence about the effect of biomechanical foot-based interventions on patellofemoral joint loads during gait in adults with and without patellofemoral pain and osteoarthritis. Methods MEDLINE (Ovid), the Cumulative Index to Nursing and Allied Health Literature CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), SPORTdiscus (EBSCO) and Embase (Ovid) will be searched. Our search strategy will include terms related to ‘patellofemoral joint’, ‘loads’ and ‘biomechanical foot-based interventions’. We will include studies published in the English language that assess the effect of biomechanical foot-based interventions on patellofemoral joint loads, quantified by patellofemoral joint pressure, patellofemoral joint reaction force and/or knee flexion moment. Two reviewers will independently screen titles and abstracts, complete full-text reviews, and extract data from included studies. Two reviewers will assess study quality using the Revised Cochrane Risk of Bias (RoB 2) tool or the Cochrane Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I) tool. We will provide a synthesis of the included studies’ characteristics and results. If three or more studies are sufficiently similar in population and intervention, we will pool the data to conduct a meta-analysis and report findings as standardised mean differences with 95% confidence intervals. If a meta-analysis cannot be performed, we will conduct a narrative synthesis of the results and produce forest plots for individual studies. Discussion This protocol outlines the methods of a systematic review that will determine the effect of biomechanical foot-based interventions on patellofemoral joint loads. Our findings will inform clinical practice by identifying biomechanical foot-based interventions that reduce or increase patellofemoral joint loads, which may aid the treatment of adults with patellofemoral pain and osteoarthritis. Trial registration Registered with PROSPERO on the 4th of May 2022 (CRD42022315207).

ObjectiveTo evaluate the effects of biomechanical foot-based interventions (eg, footwear, insoles, taping and bracing on the foot) on patellofemoral loads during walking, running or walking and running combined in adults with and without patellofemoral pain or osteoarthritis.DesignSystematic review with meta-analysis.Data sourcesMEDLINE, CINAHL, SPORTdiscus, Embase and CENTRAL.Eligibility criteria for selecting studiesEnglish-language studies that assessed effects of biomechanical foot-based interventions on peak patellofemoral joint loads, quantified by patellofemoral joint pressure, reaction force or knee flexion moment during gait, in people with or without patellofemoral pain or osteoarthritis.ResultsWe identified 22 footwear and 11 insole studies (participant n=578). Pooled analyses indicated low-certainty evidence that minimalist footwear leads to a small reduction in peak patellofemoral joint loads compared with conventional footwear during running only (standardised mean difference (SMD) (95% CI) = −0.40 (–0.68 to –0.11)). Low-certainty evidence indicated that medial support insoles do not alter patellofemoral joint loads during walking (SMD (95% CI) = −0.08 (–0.42 to 0.27)) or running (SMD (95% CI) = 0.11 (–0.17 to 0.39)). Very low-certainty evidence indicated rocker-soled shoes have no effect on patellofemoral joint loads during walking and running combined (SMD (95% CI) = 0.37) (−0.06 to 0.79)).ConclusionMinimalist footwear may reduce peak patellofemoral joint loads slightly compared with conventional footwear during running only. Medial support insoles may not alter patellofemoral joint loads during walking or running and the evidence is very uncertain about the effect of rocker-soled shoes during walking and running combined. Clinicians aiming to reduce patellofemoral joint loads during running in people with patellofemoral pain or osteoarthritis may consider minimalist footwear.

Objective To systematically review the literature to determine whether external ankle supports influence ankle biomechanics in chronic ankle instability (CAI) participants during sports-related tasks. Data Sources A literature search of MEDLINE, SPORTDiscus, and CINAHL databases was conducted in November 2021. Study Selection Included studies were randomised cross-over or parallel-group controlled trials with CAI participants using external ankle supports, compared to no support, assessing ankle biomechanics during landing, running, or change of direction. Data Extraction Two authors independently conducted study identification, data extraction, risk of bias (RoB2), and quality of evidence (GRADE) assessments. Meta-analysis using random-effects was used to compare between-group mean differences (MD) with 95% confidence intervals (CI). GRADE recommendations were used to determine the certainty of findings. Data Synthesis Thirteen studies of low to moderate risk of bias were included. During landing, very low-grade evidence indicate external ankle supports reduce frontal plane excursion (MD [95% CI] −1.83° [−2.97, −0.69], p=0.002), plantarflexion ground contact angle (−3.86° (−6.18, −1.54), p=0.001), sagittal plane excursion (−3.45° [−5.00, −1.90], p<0.001), but not inversion ground contact angle (−1.00° [−3.59, 1.59], p=0.45). During running, very low to low-grade evidence indicate external ankle supports reduce sagittal plane excursion (−5.21° [−8.59, −1.83], p=0.003), but not inversion ground contact angle (0.32° [−2.11, 1.47], p=0.73), frontal plane excursion (−1.31° [−3.24, 0.63], p=0.19), or plantarflexion ground contact angle (−0.12° [−3.54, 3.29], p=0.94). There were insufficient studies investigating changes of direction. Conclusion There is low to very low-grade evidence that external ankle supports reduce frontal plane excursion but not inversion ground contact angle in CAI participants during landing. Limiting frontal plane excursion may reduce ankle sprain risk. Frontal plane ankle kinematics were not influenced by external ankle supports during running. Sagittal plane reductions were observed with external ankle supports during landing and running, but its influence on ankle sprain risk is undetermined.

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