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National arthroplasty registries reveal a higher risk of revision for periprosthetic fracture and dislocation after total hip arthroplasty (THA) in patients with a femoral neck fracture compared to those with osteoarthritis (OA). Since these registries may con- tain confounding factors, we conducted a single center cohort study comparing survival and reason for failure between THA for an acute femoral neck fracture and OA using the same hip prosthesis after a minimum follow-up of 2 years. We retrospectively analyzed 2782 patients who had undergone THA with an Accolade TMZF stem and a Trident cup between March 2009 and September 2014. Primary diagnosis before THA was osteoarthritis (OA group : n=2610) or acute femoral fracture (Fracture group : n=172). Patients in both groups were operated on by the same hip surgeons. Effect of diagnosis on THA survival was analyzed using Cox-regression analysis. Chi-square tests were used to illustrate the different reasons for revision between the groups. Mean follow-up was 4.6 years (2-7.6). A total of 100 revisions were performed. The revision risk was comparable between the OA and Fracture group (HR=1.04, 95% CI :0.46-2.39). No differences were found between the OA and Fracture group with respect to the occurrence of periprosthetic fractures (0.8% vs. 0.6%, p=0.71) and revisions for dislocation (0.6% vs. 1.2%, p=0.38). We found no difference in outcome or reason for revision between THA for OA or femoral neck frac- ture. Using an implant with a proven ODEP rating and having experienced hip surgeons carry out the procedures may be more important than the primary diagnosis.

Background and purpose - Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. Patients and methods - A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned. Results - The questionnaire was completed by 175 patients, age 66 years (range 38-84), 57% female, BMI 29 (IQR 25-33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3-intra-articular injection-was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best. Interpretation - Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

The aim of this two-centre RCT was to compare pre- and post-operative radiological, clinical and functional outcomes between patient-specific instrumentation (PSI) and conventional instrumented (CI) unicompartmental knee arthroplasty (UKA). It was hypothesised that both alignment methods would have comparable post-operative radiological, clinical and functional outcomes. One hundred and twenty patients were included, and randomly allocated to the PSI or the CI group. Outcome measures were peri-operative outcomes (operation time, length of hospital stay and intra-operative changes of implant size) and post-operative radiological outcomes including the alignment of the tibial and femoral component in the sagittal and frontal plane and the hip–knee–ankle-axis (HKA-axis), rate of adverse events (AEs) and patient-reported outcome measures (PROMs) pre-operatively and at 3, 12 and 24 months post-operatively. There was a statistically significant difference (p

Background and purpose — Femoral neck fractures are commonly treated with cemented or uncemented hemiarthroplasties (HA). We evaluated differences in mortality and revision rates in this fragile patient group. Patients and methods — From January 1, 2007 until December 31, 2016, 22,356 HA procedures from the Dutch Arthroplasty Register (LROI) were included. For each HA, follow-up until death, revision, or end of follow-up (December 31, 2016) was determined. The crude revision rate was determined by competing risk analysis. Multivariable Cox regression analyses were performed to evaluate the effect of fixation method (cemented vs. uncemented) on death or revision. Age, sex, BMI, Orthopaedic Data Evaluation Panel (ODEP) rating, ASA grade, surgical approach, and previous surgery were included as potential confounders. Results — 1-year mortality rates did not differ between cemented and uncemented HA. 9-year mortality rates were 53% (95% CI 52–54) in cemented HA compared to 56% (CI 54–58) in uncemented HA. Multivariable Cox regression analysis showed similar mortality between cemented and uncemented HA (HR 1.0, CI 0.96–1.1). A statistically significantly lower 9-year revision rate of 3.1% (CI 2.7–3.6) in cemented HA compared with 5.1% (CI 4.2–6.2) in the uncemented HA was found with a lower hazard ratio for revision in cemented compared with uncemented HA (HR 0.56, CI 0.47–0.67). Interpretation — Long-term mortality rates did not differ between patients with a cemented or uncemented HA after an acute femoral neck fracture. Revision rates were lower in cemented compared with uncemented HA.

A considerable proportion of patients (19%) are dissatisfied after total knee arthroplasty (TKA). Possible factors contributing to this dissatisfaction are decreased posterior condylar offset (PCO) with subsequent joint line elevation, leading to mid-flexion instability. Secondly, the pre-disease mechanical alignment is changed into a neutral alignment. The Flexion First Balancer was developed to avoid these problems. This technique aims to maintain MCL isometry by restoring medial PCO and medial joint line to its pre-disease level. Also, to reconstruct the pre-disease mechanical alignment by adjusting the distal femoral angle. In this study we provide a detailed technical overview of the Flexion First Balancer technique.

Background: Especially in younger knee osteoarthritis patients, the ability to perform physical activity (PA) after knee arthroplasty (KA) is of paramount importance, given many patients’ wish to return to work and perform demanding leisure time activities. Goal Attainment Scaling (GAS) rehabilitation after KA may improve PA because it uses individualized activity goals. Therefore, our aim was to objectively quantify PA changes after KA and to compare GAS-based rehabilitation to standard rehabilitation. Methods: Data were obtained from the randomized controlled ACTION trial, which compares standard rehabilitation with GAS-based rehabilitation after total and unicompartmental KA in patients

Background and purpose — The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate. Patients and methods — During 2008–2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan–Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates. Results — The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1–3.0) and RA (HR = 2.0, CI 1.3–3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%). Interpretation — The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.

Purpose To define the longitudinal rotation axis around which individual vertebrae rotate, and to establish the various extra- and intravertebral rotation patterns in thoracic adolescent idiopathic scoliosis (AIS) patients, for better understanding of the 3D development of the rotational deformity. Methods Seventy high-resolution CT scans from an existing database of thoracic AIS patients (Cobb angle: 46°–109°) were included to determine the vertebral axial rotation, rotation radius, intravertebral axial rotation, and local mechanical torsion for each spinal level, using previously validated image processing techniques. Results For all levels, the longitudinal rotation axis, from which the vertebrae rotate away from the midline, was localized posterior to the spine. The axis became closer to the spine at the apex: apex, r = 11.5 ± 5.1 cm versus two levels above (radius = 15.8 ± 8.5 cm; p p p Conclusion In AIS, the vertebrae rotate away around an axis that is localized posterior to the spine. The distance between this axis and the spine is minimal at the apex and increases gradually to the neutral zones. The vertebral axial rotation is accompanied by smaller amounts of intravertebral rotation and local mechanical torsion, which increases toward the apical region. The altered morphology and alignment are important for a better understanding of the 3D pathoanatomical development of AIS and better therapeutic planning for bracing and surgical intervention. Graphic abstract These slides can be retrieved under Electronic Supplementary Material.

Intracellular cobalamin metabolism (ICM) defects can be present as autosomal recessive or X-linked disorders. Parenteral hydroxocobalamin (P-OHCbl) is the mainstay of therapy, but the optimal dose has not been determined. Despite early treatment, long-term complications may develop. We have analyzed the biochemical and clinical responses in five patients with early onset of different types of ICM defects (cblC: patients 1-3; cblA: patient 4; cblX: patient 5) following daily P-OHCbl dose intensification (DI). In patient 4, P-OHCbl was started at age 10 years and in patient 5 at age 5 years. OHCbl was formulated at either, 5, 25, or 50 mg/mL. P-OHCbl was intravenously or subcutaneously (SQ) delivered, subsequently by placement of a SQ injection port except in patient 4. In all patients, homocysteine and methylmalonic acid levels, demonstrated an excellent response to various P-OHCbl doses. After age 36 months, patients 1-3 had a close to normal neurological examination with lower range developmental quotient. In patient 3, moderate visual impairment was present. Patient 4, at age 10 years, had normal renal, visual and cognitive function. In cblX patient 5, epilepsy was better controlled. In conclusion, P-OHCbl-DI caused an excellent control of metabolites in all patients. In the three cblC patients, comparison with patients, usually harboring identical genotype and similar metabolic profile, was suggestive of a positive effect, in favor of clinical efficacy. With P-OHCbl-DI, CblA patient has been placed into a lower risk to develop renal and optic impairment. In cblX patient, lower P-OHCbl doses were administrated to improve tolerability., SCOPUS: ar.k, info:eu-repo/semantics/published

Purpose: It is not yet known if unicompartmental knee arthroplasty (UKA) patients are more likely to return to work sooner or have improved ability to work (i.e., workability) than total knee arthroplasty (TKA) patients. The following questions were addressed: patients were assessed to determine: (1) whether they returned to work sooner following UKA compared to TKA; (2) whether UKA patients had better WORQ function scores compared to TKA patients; and (3) if UKA patients have higher workability scores and greater satisfaction regarding workability than TKA patients. Methods: A multicenter retrospective cohort study was performed that included patients at least 2 years after having undergone either UKA or TKA surgery and on the condition that patients had been in work in the 2 years prior to surgery. Time period between stopping work and returning to work was assessed; the WORQ scores (0 = worst–100 = best) and the Work Ability Index (WAI = 0–10) and reported satisfaction with work ability. Results: UKA patients (n = 157, median 60 years, 51% male) were compared to TKA patients (n = 167, median 60 years, 49% male) (n.s.). Of the 157 UKA patients, 115 (73%) returned to work within 2 years compared to 121 (72%) of TKA patients (n.s.). More UKA patients return to work within 3 months (73% versus 48%) (p < 0.01). WORQ scores improved similarly in both groups. The WAI was also comparable between the groups. Dissatisfaction with workability was comparable (UKA 15% versus TKA 18% (n.s.). Conclusion: TKA and UKA patients have similar WORQ, WAI, and satisfaction scores. However, in this study population, UKA patients to return to work after surgery significantly sooner than TKA patients, which improves their quality of life and allows them to participate actively in society. This information can help health care providers and patients weigh-up the pros and cons and choose the best treatment and timing for patients in the working population. Level of evidence: III.

Introduction In this study, we describe the distribution of placenta delivery and the incidence of postpartum hemorrhage in both spontaneous placental delivery and manual removal of the placenta. Methods A retrospective study was performed of 7603 singleton vaginal deliveries of a gestational age over 32 weeks, registered between September 2011 and 2016. We calculated the incidence of postpartum hemorrhage (≥1000 mL blood loss) per 10-minute duration of the third stage. The odds ratio for developing postpartum hemorrhage was assessed, adjusted for risk factors. The incidence of postpartum hemorrhage was compared between women that did and did not receive manual removal of placenta. Results The median duration of the third stage was 10 minutes (interquartile range 7-16 minutes). The median amount of blood loss was 300 mL (200-400 mL). The overall incidence of postpartum hemorrhage was 8.5%. With every additional 10 minutes of third-stage duration, the risk of developing postpartum hemorrhage significantly increased. In a third stage longer than 60 minutes, the incidence of postpartum hemorrhage was 21.2% without manual removal of the placenta and 70.3% with manual removal. Conclusions The incidence of postpartum hemorrhage increases significantly from 10 to 19 minutes into the third stage. Women with the removal of the placenta had a significantly higher percentage of postpartum hemorrhage. The optimal timing for manual removal of the placenta should be investigated in a carefully designed randomized controlled trial to examine whether earlier manual removal of placenta lowers the incidence and limits the severity of postpartum hemorrhage.

Background: High tibial osteotomy (HTO) is increasingly used in young and physically active patients with knee osteoarthritis. These patients have high expectations, including return to sport (RTS). By retaining native knee structures, a return to highly knee-demanding activities seems possible. However, evidence on patient-related outcomes, including RTS, is sparse. Also, time to RTS has never been described. Furthermore, prognostic factors for RTS after HTO have never been investigated. These data may further justify HTO as a surgical alternative to knee arthroplasty. Purpose: To investigate the extent and timing of RTS after HTO in the largest cohort investigated for RTS to date and to identify prognostic factors for successful RTS. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients with HTO, operated on between 2012 and 2015, received a questionnaire. First, pre- and postoperative sports participation questions were asked. Also, time to RTS, sports level and frequency, impact level, the presymptomatic and postoperative Tegner activity score (1-10; higher is more active), and the postoperative Lysholm score (0-100; higher is better) were collected. Finally, prognostic factors for RTS were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph. Results: We included 340 eligible patients of whom 294 sufficiently completed the questionnaire. The mean follow-up was 3.7 years (± 1.0 years). Out of 256 patients participating in sports preoperatively, 210 patients (82%) returned to sport postoperatively, of whom 158 (75%) returned within 6 months. We observed a shift to participation in lower-impact activities, although 44% of reported sports activities at final follow-up were intermediate- or high-impact sports. The median Tegner score decreased from 5.0 (interquartile range [IQR], 4.0-6.0) presymptomatically to 4.0 (IQR, 3.0-4.0) at follow-up ( P < .001). The mean Lysholm score at follow-up was 68 (SD, ± 22). No significant differences were found between patients with varus or valgus osteoarthritis. The strongest prognostic factor for RTS was continued sports participation in the year before surgery (odds ratio, 2.81; 95% CI, 1.37-5.76). Conclusion: More than 8 of 10 patients returned to sport after HTO. Continued preoperative sports participation was associated with a successful RTS. Future studies need to identify additional prognostic factors.

An Author Correction to this article was published on 15 February 2019 An Author Correction to this article was published on 02 May 2019 We thank all individuals and families for their contribution. We thank Amaia Carrion Castillo and Else Eising for assistance with the WGS analysis of the index individual, and Sarah Graham and Elliot Sollis for cloning the wild-type CHD3 construct for immunofluorescence. This work was supported by the Netherlands Organization for Scientific Research (NWO) Gravitation Grant 24.001.006 to the Language in Interaction Consortium (L.S.B., S.E.F., and H.G.B.), the Max Planck Society (S.E.F.), the National Institute on Deafness and Other Communication Disorders Grant DC000496 (L.Sh.) and a core grant to the Waisman Center from the National Institute of Child Health and Human Development (Grant U54 HD090256) to L.Sh., the Canadian Institutes of Health Research Grants MOP-119595 and PJT-148830 to W.T.G. Individuals 11, 16, 24, and 28 were part of The DDD Study cohort. The DDD Study presents independent research commissioned by the Health Innovation Challenge Fund [Grant number HICF-1009-003], a parallel funding partnership between the Wellcome Trust and the Department of Health, and the Wellcome Trust Sanger Institute [Grant number WT098051]. The views expressed in this publication are those of the author(s) and not necessarily those of the Wellcome Trust or the Department of Health. The DDD study has UK Research Ethics Committee approval (10/H0305/83, granted by the Cambridge South REC, and GEN/284/12, granted by the Republic of Ireland REC). The research team acknowledges the support of the National Institute for Health Research, through the Comprehensive Clinical Research Network.

Background Context: One of the characteristics of reported observations in adolescent idiopathic scoliosis (AIS) is that the thoracic spine is longer anteriorly than posteriorly, more pronounced around the apex than the transitional zones. This reversal of the normal kyphotic anatomy of the thoracic spine is related to questions of etiopathogenesis of AIS. The changes in the anatomy of the anterior column have been described rather in detail; however, the role of the posterior spinal column and the laminae has so far not been elucidated. If the posterior column exhibits a longitudinal growth disturbance, it could act as a tether, leading to a more or less normal anterior column with a deformed and shorter posterior aspect of the spine. So far, it has remained unclear whether this anterior-posterior length discrepancy is the result of relative anterior lengthening or relative posterior shortening, and which tissues (bone, disc, intervertebral soft tissue) are involved. Purpose: The present study aimed to compare the discrepancy of the anterior-posterior length of the spinal column in the “true” midsagittal plane of each vertebra in patients with idiopathic scoliosis versus controls, using three-dimensional computed tomography (CT) scans. Study Design/Setting: This is a cross-sectional study. Patient Sample: The sample consisted of computed tomography scans of 80 patients with moderate to severe AIS (Cobb angle: 46°–109°) before scoliosis navigation surgery and 30 non-scoliotic age-matched controls. Outcome Measures: The height of the osseous and non-osseous structures from anterior to posterior in the “true” midsagittal plane has been determined: the anterior side of the vertebral body and disc, the posterior side of the vertebral body and disc, the lamina and interlaminar space and the spinous process and interspinous space, as well as the height ratios between the anterior column and posterior structures of the primary thoracic and lumbar AIS curves and corresponding levels in non-scoliotic controls. Methods: Semiautomatic software was used to reconstruct and measure the parameters in the true midsagittal plane of each vertebra and intervertebral structure that are rotated and tilted in a different way. Results: In AIS, the anterior height of the thoracic curve was 3.6±2.8% longer than the posterior height, 2.0±6.1% longer than the length along the laminae, and 8.7±7.1% longer than the length along the spinous processes, and this differed significantly from controls (−2.7±2.4%, −7.4±5.2%, and +0.7±7.8%; p

Summary Objective Knee Image Digital Analysis (KIDA) is standardized radiographic analysis software for measuring osteoarthritis (OA) characteristics. It was validated in mild OA, but used for severe OA as well. The current goal was to evaluate the performance of KIDA in severe OA. Design Of 103 patients, standardized radiographs were performed before and one and 2 years after treatment for severe OA. All radiographs were evaluated on subchondral bone density, joint space width (JSW), osteophytes, eminence height, and joint angle, twice within years by the same observer. Part of the radiographs were randomly selected for reevaluation twice within 1 month and evaluation by another observer. The intraclass correlation coefficient (ICC), smallest detectable difference (SDD) and coefficient of variation (CV) were calculated; the SDD and CV were compared to those in mild OA. The relation of severity with KIDA parameters and with observer differences was calculated with linear regression. Results Intra-observer ICCs were higher in the 98 severe radiographs reanalyzed within 1 month (all >0.8) than the 293 reanalyzed within years (all >0.5; most >0.8) and than inter-observer ICCs (all >0.7). SDDs and CVs were smaller when reanalyzed within a month and comparable to those in mild OA. Some parameters showed bias between readings. Severity showed significant relation with osteophytes and JSW parameters, and with the observer variation in these parameters (all P Conclusions KIDA is a well-performing tool also for severe OA. In order to decrease variability and SDDs, images should be analyzed in a limited time frame and randomized order.

Anteromedial osteoarthritis (AMOA) is a common wear pattern in primary osteoarthritic knees. In patients with bone-on-bone disease, the most appropriate surgical intervention is still a matter of debate. Knee arthroplasty is a well-accepted treatment to relieve symptoms and regain function. Unfortunately, satisfaction is limited, especially related to activities. A cross-sectional study was performed among patients treated with total knee arthroplasty (TKA) and unicondylar arthroplasty (UKA) to determine if the osteoarthritis wear pattern or type of prosthesis affects knee-specific function scores and satisfaction related to activities. All UKA patients (N = 100) were treated for AMOA. Based on radiological assessment of the wear pattern, TKA patients were divided into two groups: TKA for AMOA (N = 68) and true TKA (N = 99). The Knee injury and Osteoarthritis Outcomes Score (KOOS), new Knee Society score (KSS), anterior knee pain scale, visual analog scales (VASs) for satisfaction about activities, and net promoter score were collected. After 2 years' follow-up, the anterior knee pain scale and VAS satisfaction showed significantly better scores for patients treated with TKA for AMOA compared with the true TKA group. Also in the KOOS subscales, some differences were seen in favor of the TKA for AMOA group. The new KSS was not in favor of a specific wear pattern, but patients with AMOA treated with UKA performed better on the symptoms subscale compared with patients treated with TKA. In conclusion, patients treated with TKA for AMOA showed better knee-specific function scores and satisfaction scores compared with patients treated with TKA for other wear patterns, and only slight differences were found between both the AMOA groups (TKA for AMOA and UKA). Thus, the radiologic assessment of wear patterns might be useful to take into account the shared decision-making process, when discussing expectations, timing, and outcomes with knee osteoarthritis patients considering knee arthroplasty. When AMOA is present, it might be beneficial to choose UKA over TKA.

BACKGROUND: Knee arthroplasty (KA) is increasingly performed in relatively young, active patients. This heterogeneous patient population often has high expectations, including work resumption and performance of knee-demanding leisure-time activities. Goal attainment scaling (GAS) may personalize rehabilitation by using patient-specific, activity-oriented rehabilitation goals. Since unmet expectations are a leading cause of dissatisfaction after KA, personalized rehabilitation may improve patient satisfaction. We hypothesized that, compared with standard rehabilitation, GAS-based rehabilitation would result in younger, active patients having higher satisfaction regarding activities after KA. METHODS: We performed a single-center randomized controlled trial. Eligible patients were

Background and purpose — Partial knee replacement (PKR) survival rates vary a great deal among registries and cohort studies. These discrepancies can largely be attributed to inappropriate indications of the PKR and low thresholds for revision, but also to the PKR volume. This study used Dutch Arthroplasty Register data to analyze whether absolute PKR or proportional PKR hospital volume is associated with the risk of revision. Patients and methods — 18,134 PKRs were identified in the Dutch Arthroplasty Register from 2007 to 2016. For each year, hospitals were divided into 4 groups based on the quartiles for the absolute volume (< 22, 22–36, 36–58 and > 58 PKRs per year) and the proportional volume (< 8.5, 8.6–14.2, 14.3–25.8 and > 25.8% PKRs). Kaplan–Meier survival analysis was performed to determine survival rates. A multivariable Cox regression adjusted for age category, sex, ASA score, year of surgery, diagnosis, unicondylar side, and type of hospital was used to estimate hazard ratios (HR) for revision. Results and interpretation — Proportional PKR volume did not, but absolute PKR volume did influence the risk of revision. The adjusted HR for hospitals with an absolute volume of 22–36 PKRs per year was 1.04 (95% CI 0.91–1.20), 0.96 (CI 0.83–1.10) for the hospitals with 36–58 PKRs, and 0.74 (CI 0.62–0.89) for hospitals with more than 58 PKRs compared with hospitals that had fewer than 22 PKRs per year. So, patients treated with a PKR in a high absolute volume hospital have a lower risk of revision compared with those treated in a low absolute volume hospital.

Knee joint distraction (KJD) is a novel technique for relatively young knee osteoarthritis (OA) patients. With KJD, an external distraction device creates temporary total absence of contact between cartilage surfaces, which results in pain relief and possibly limits the progression of knee OA. Recently, KJD showed similar clinical outcomes compared with high tibial osteotomy (HTO). Yet, no comparative data exist regarding return to sport (RTS) and return to work (RTW) after KJD. Therefore, our aim was to compare RTS and RTW between KJD and HTO. We performed a cross-sectional follow-up study in patients

Introduction. Range of motion (ROM) is closely monitored before and after surgery for stiff elbow and during rehabilitation. Measurements in the home environment may be helpful to increase involvement and adherence of the patient. Therefore, our objective is to investigate the validity and inter- and intraobserver reliability of 3 alternative methods to assess the ROM by the patient in a home-based situation, in comparison to the universal goniometer (UG). We hypothesize that all 3 alternative methods will be valid alternatives and show a level of reliability equivalent to UG. Methods. Goniometric measurements of elbow flexion, extension, pronation and supination using photography, movie, and a smartphone application were obtained. The validity of these measurement methods was compared to UG. The interobserver and intraobserver reliability were calculated for all measurement methods. Results. Photography and movie based goniometry of the elbow showed good validity in flexion and extension. The interobserver and intraobserver reliability were found to be good to excellent for photo and movie but moderate to poor for UG and the smartphone application. Conclusions. Photo or movie based goniometry seems to be a useful option for initial and follow-up measurement of the elbow ROM, both in the outpatient clinic and in a home environment. Based on our study, the smartphone application we used is not recommended.

Background:Limited evidence exists on patient-relevant outcomes after high tibial osteotomy (HTO), including return to work (RTW). Furthermore, prognostic factors for RTW have never been described.Purpose:To investigate the extent and timing of RTW in the largest HTO cohort investigated for RTW to date and to identify prognostic factors for RTW after HTO.Study Design:Cohort study; Level of evidence, 3.Methods:Consecutive patients who underwent HTO between 2012 and 2015 were included. Patients received a questionnaire at a mean follow-up of 3.6 years. Questions were asked pre- and postoperatively regarding work status, job title, working hours, preoperative sick leave, employment status, and whether patients were their family’s breadwinner. The validated Work Rehabilitation Questionnaire (WORQ) was used to assess difficulty with knee-demanding activities. Prognostic factors for RTW were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph.Results:We identified 402 consecutive patients who underwent HTO, of whom 349 were included. Preoperatively, 299 patients worked, of whom 284 (95%) achieved RTW and 255 (90%) returned within 6 months. Patients reported significant postoperative improvements in performing knee-demanding activities. Being the family’s breadwinner was the strongest predictor of RTW (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.27-6.69). In contrast, preoperative sick leave was associated with lower odds of RTW (OR, 0.20; 95% CI, 0.08-0.46).Conclusion:After HTO, 95% of patients were able to RTW, of whom 9 of 10 returned within 6 months. Breadwinners were more likely to RTW, and patients with preoperative sick leave were less likely to RTW within 6 months. These findings may be used to improve preoperative counseling and expectation management and thereby enhance work-related outcomes after HTO.

Background Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking. Objectives Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW. Methods We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle–Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics. Results A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks. Conclusion A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process. Electronic supplementary material The online version of this article (10.1007/s40279-018-0924-2) contains supplementary material, which is available to authorized users.

Total knee arthroplasty (TKA) is a successful procedure, although up to 20% of patients remain dissatisfied. Preoperative identification of appropriate TKA candidates is essential for improving satisfaction. This study investigated if preoperative radiographic severity was associated with postoperative pain, function, and quality of life after TKA. We performed a cross-sectional cohort study including 327 TKA patients. Radiographic severity was determined by two independent radiologists using the Kellgren and Lawrence (KL) score. The Knee Injury and Osteoarthritis Outcome Score (KOOS), the New Knee Society Score (New KSS), and Anterior Knee Pain Score (AKPS) were collected. We evaluated the association between KL grade and patient-reported outcome measures (PROMs) with the use of regression analysis techniques. Out of 228 responders, 195 patients completed the questionnaire sufficiently. Forty-seven patients were classified as KL grades 1 to 2, and 144 patients were classified as KL grades 3 to 4. The inter-observer reliability between both radiologists was substantial (ϰ = 0.67). After adjusting for age, sex, and body mass index (BMI), the New KSS subscales symptoms and expectations, and the KOOS subscale quality of life were significantly higher in the KL grades 3 to 4 group. However, neither the remaining KOOS subscales and AKPS nor KOOS change scores differed between both groups. Thus, more severe osteoarthritis (OA) resulted in better outcomes after TKA, although this association was not observed for all PROMs. The use of new PROMs, such as the New KSS, could be more reliable because of lower ceiling effects than the KOOS. Investigating the value of additional methods to assess radiographic severity (such as semi-flexed knee radiographs and MRI) is imperative to reliably identify knee OA.

Background Post-traumatic deformities such as biceps tendon rupture or (peri-)articular fractures of the elbow are often related to a decrease in muscle strength. Postoperative evaluation of these deformities requires normative values of elbow strength. The purpose of this systematic review was to determine these normative values of isometric elbow strength in healthy adults resulting from studies evaluating this strength (i.e. flexion, extension, pronation and supination strength). Methods The databases of PubMed, EMBASE and Web of Sciences were searched and screened for studies involving the isometric elbow strength as measured in asymptomatic volunteers. The quality of the studies was assessed and studies of low quality were excluded. Results Nineteen studies met the inclusion criteria and were of sufficiently high quality to be included in the present review. In these studies, elbow strength was measured in a total of 1880 healthy volunteers. The experimental set-up and devices used to measure elbow strength varied between studies. Using some assumptions, a normative values table was assembled. Conclusions Large standard deviations of normative values in combination with different measurement devices used, as well as the different measurement positions of the subjects, demonstrated that there is no consensus about measuring the isometric elbow strength and therefore the normative values have to be interpreted with caution.

Purpose To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. Methods This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. Results The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, –∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. Conclusions Although statistically “inconclusive” regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. Level of Evidence Level I, randomized controlled trial and treatment study.

Introduction: Revision hip arthroplasty is associated with higher dislocation rates than primary hip arthroplasty. A dual-mobility cup (DMC) can reduce this risk. Another problem is destruction of the acetabulum, induced by aseptic loosening of the prosthesis. Bone impaction grafting (BIG) can be used to reconstruct these defects, but is usually performed with cemented all polyethylene cups. The purpose of this study is to evaluate midterm cup survival and dislocation rate for the combination of BIG and DMC. Methods: Between 2007 and 2013, 96 patients received 102 DMCs combined with BIG of the acetabulum during revision surgery. These data were first compared with a control group, consisting of 59 cases from the same hospital receiving a cemented all polyethylene cup combined with BIG. In addition, the control group was expanded with 41 cases operated on in 2007 in ‘an orthopaedic centre of excellence’, resulting in a ‘combined control group’ of 100 patients. Log-rank tests and chi-square tests were used to compare survival and dislocation rates, respectively. Results: Cumulative survival of the DMC was 95.8% (range 3 months-7 years). This was comparable to the survival in the control groups (96.5% and 94.7%). The dislocation rate of 2.9% (3/102) in the dual-mobility group was lower (p = 0.02) compared to the dislocation rate of 11.8% (7/59) in the control group, but not (p = 0.12) compared to 8% in the combined control group (8/100). Conclusions: This study shows that combining a DMC with BIG does not compromise outcome in terms of midterm survival of the cup.

© 2017 The Association of University Radiologists Rationale and Objectives Radiology expertise is dependent on the use of efficient search strategies. The aim of this study is to investigate the effect of teaching search strategies on trainee's accuracy in detecting lung nodules at computed tomography. Materials and Methods Two search strategies, “scanning” and “drilling,” were tested with a randomized crossover design. Nineteen junior radiology residents were randomized into two groups. Both groups first completed a baseline lung nodule detection test allowing a free search strategy, followed by a test after scanning instruction and drilling instruction or vice versa. True positive (TP) and false positive (FP) scores and scroll behavior were registered. A mixed-design analysis of variance was applied to compare the three search conditions. Results Search strategy instruction had a significant effect on scroll behavior, F(1.3) = 54.2, P < 0.001; TP score, F(2) = 16.1, P < 0.001; and FP score, F(1.3) = 15.3, P < 0.001. Scanning instruction resulted in significantly lower TP scores than drilling instruction (M = 10.7, SD = 5.0 versus M = 16.3, SD = 5.3), t(18) = 4.78, P < 0.001; or free search (M = 15.3, SD = 4.6), t(18) = 4.44, P < 0.001. TP scores for drilling did not significantly differ from free search. FP scores for drilling (M = 7.3, SD = 5.6) were significantly lower than for free search (M = 12.5, SD = 7.8), t(18) = 4.86, P < 0.001. Conclusions Teaching a drilling strategy is preferable to teaching a scanning strategy for finding lung nodules.

Background and purpose - Radiostereometric analysis (RSA) is an accurate method for measurement of early migration of implants. Since a relation has been shown between early migration and future loosening of total knee and hip prostheses, RSA plays an important role in the development and evaluation of prostheses. However, there have been few RSA studies of the upper limb, and the value of RSA of the upper limb is not yet clear. We therefore performed a systematic review to investigate the accuracy and precision of RSA of the upper limb. Patients and methods - PRISMA guidelines were followed and the protocol for this review was published online at PROSPERO under registration number CRD42016042014. A systematic search of the literature was performed in the databases Embase, Medline, Cochrane, Web of Science, Scopus, Cinahl, and Google Scholar on April 25, 2015 based on the keywords radiostereometric analysis, shoulder prosthesis, elbow prosthesis, wrist prosthesis, trapeziometacarpal joint prosthesis, humerus, ulna, radius, carpus. Articles concerning RSA for the analysis of early migration of prostheses of the upper limb were included. Quality assessment was performed using the MINORS score, Downs and Black checklist, and the ISO RSA Results - 23 studies were included. Precision values were in the 0.06-0.88 mm and 0.05-10.7° range for the shoulder, the 0.05-0.34 mm and 0.16-0.76° range for the elbow, and the 0.16-1.83 mm and 11-124° range for the TMC joint. Accuracy data from marker- and model-based RSA were not reported in the studies included. Interpretation - RSA is a highly precise method for measurement of early migration of orthopedic implants in the upper limb. However, the precision of rotation measurement is poor in some components. Challenges with RSA in the upper limb include the symmetrical shape of prostheses and the limited size of surrounding bone, leading to over-projection of the markers by the prosthesis. We recommend higher adherence to RSA guidelines and encourage investigators to publish long-term follow-up RSA studies.

Background Knee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce. Objectives Our aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW. Methods We systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled. Results We included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders. Conclusion Eight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload. Electronic supplementary material The online version of this article (doi:10.1007/s40279-017-0726-y) contains supplementary material, which is available to authorized users.

Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) are common sexual transmitted infections (STI). However, most STI screening programmes do not include routinely detection of these pathogens. Consequently, epidemiological data about MG and TV in the general population is lacking. The current study aims to give insight into the prevalence of both infections, thereby guiding decisions whether testing for these pathogens should be included routinely.Between February 2013 and August 2015, all samples sent to the laboratory of Diakonessenhuis Utrecht for STI testing (i.e. testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)) were additionally examined for the presence of MG and TV by means of a laboratory-developed RT-PCR. Samples were collected by our hospital or by regional general practitioners.A total of 5628 PCR's were evaluated. In 7.5%, one or more STI were detected. CT was found in 5% and MG was positive in 1.9%. NG was detected in 0.5% and TV was detected in 0.6% of the samples. CT was found more often in primary care than in hospital setting (9.7% vs. 3.0%, p .05). The same was shown for NG (1.1% vs. 0.2%, p .05). More men than women were positive for CT (11.2% vs. 3.8%, p .05) and NG (1.4% vs. 0.3%, p .05).MG is more prevalent than NG and TV in a regional Dutch population. Furthermore, TV is equally common as NG. Based on our prevalence data, including MG and TV in STI testing protocols should be considered in the future.

Purpose In recent years, duration of hospitalisation after knee arthroplasty has decreased and fast track and outpatient surgery protocols have been developed. Studies have shown that outpatient surgery is feasible, safe, and cost effective. However, the psychological well-being of patients undergoing outpatient surgery has never been described before. The purpose of this study was to investigate how patients experience outpatient surgery for unicompartmental knee arthroplasty (UKA), examining levels of anxiety and depression, satisfaction, and pain. It was hypothesized that the same-day discharge following UKA would not result in higher levels of anxiety and depression, compared to the standard fast-track surgery. Methods This case-controlled study included 20 patients undergoing UKA in an outpatient surgery setting and 20 patients undergoing the standard fast-track procedure. The Hospital Anxiety and Depression Scale (HADS, 0–42, lower is better) and numeric rating scales (NRS, 0–10) for pain and satisfaction were collected preoperatively, on the day of surgery, on the first, second, and seventh postoperative days and after 6 and 12 weeks. The Oxford Knee Score (OKS), the KOOS, EuroQoL-5D, and Net Promoter Score (NPS) were collected preoperatively and 3 months postoperatively. Results 90% of patients in the outpatient surgery group were discharged on the day of surgery. At the first postoperative day, the median HADS score was significantly lower in the outpatient surgery group compared to the fast-track group (3 vs. 8, p = 0.02), the median NRS satisfaction score was significantly higher in the outpatient surgery group (8 vs. 5, p = 0.03), and no differences existed between both groups for the NRS pain scores. At 3 month follow-up, no significant differences in improvement scores existed between both groups for the HADS, the NRS scores, and for the OKS, KOOS, EuroQoL-5D, and NPS. Conclusion The results of this study emphasize the feasibility of an outpatient surgery pathway in carefully selected UKA patients. The outpatient surgery pathway is safe, and clinical outcome, including levels of anxiety and depression, satisfaction, and pain, was similar in outpatient surgery patients compared to the standard fast-track patients. Level of evidence Case-control study, Level III.

OBJECTIVES To assess the learning curve of the direct superior approach (DSA) for total hip arthroplasty (THA) and to compare surgical, clinical, and radiological results with a matched control group using the mini posterior approach (MPA). METHODS A prospective cohort study was performed from October 2016 to May 2017 including our first 52 patients undergoing THA using the DSA. Patients with primary osteoarthritis or osteonecrosis and a body mass index (BMI)

Purpose Distal femoral osteotomy (DFO) is a well-accepted procedure for the treatment of femoral deformities and associated symptoms including osteoarthritis, especially in younger and physically active patients in whom knee arthroplasty is undesirable. Still, there is an apparent need for evidence on relevant patient outcomes, including return to sport (RTS) and work (RTW), to further justify the use of knee osteotomy instead of surgical alternatives. Therefore, the purpose of the present study was to investigate the extent and timing of patients’ RTS and RTW after DFO. Methods This monocentre, retrospective cohort study included consecutive DFO patients, operated between 2012 and 2015. Out of 126 eligible patients (18–70 years, 63% female), all patients responded, and 100 patients completed the questionnaire. Median follow-up was 3.4 years (range 1.5–5.2). The predominant indication for surgery was symptomatic unicompartmental osteoarthritis and valgus or varus leg alignment caused by a femoral deformity. The primary outcome measure was the percentage of RTS and RTW. Secondary outcome measures included time to RTS/RTW, sports level and frequency, the median pre-symptomatic and postoperative Tegner activity score (1–10, higher is more active) and the postoperative Lysholm score (0–100, higher is better). Results Out of 84 patients participating in sports preoperatively, 65 patients (77%) returned to sport postoperatively. Forty-six patients (71%) returned to sports within 6 months. Postoperative participation in high-impact sports was possible though less frequent compared to preoperative participation. Out of 80 patients working preoperatively, 73 (91%) returned to work postoperatively, of whom 59 patients (77%) returned within 6 months. The median pre-symptomatic Tegner activity score [4.0 (range 0–10)] was significantly higher (p

Introduction Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). Factors which could possibly contribute to this dissatisfaction are a decreased posterior condylar offset (PCO) and subsequent joint line elevation which leads to mid-flexion instability. The Flexion First Balancer (FFB) technique aims to adequately restore the medial PCO and thereby reconstruct the medial native joint line to its pre-disease height. Methods A retrospective cohort of 59 patients operated using the FFB technique was analyzed and matched with a historic measured resection (MR) cohort of 59 patients. Groups were matched for age, gender, BMI and ASA classification. Joint line and PCO changes as well as patient reported outcome measurement scores (PROMs) were evaluated at one year [1.0 – 1.6] postoperatively. Results Radiographic evaluation revealed no changes in joint line height in the FFB group, whereas an elevation in joint line was seen in the MR group (p = 0.002). The PCO increased after surgery in both group without any statistically significant differences. Evaluation of PROMs found no differences between the two groups for total OKS and KOOS scores, nor in re-operation or complication rates. Conclusion The FFB technique seems to be a safe technique to use in TKA and reconstructs the pre-disease joint line in contrast to the MR technique. The clinical outcomes were comparable between both groups.

Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). However, the diagnosis remains a challenge for clinicians. In 2011, the muscoskeletal infection society (MSIS) criteria provided a consensus which has been updated in 2013, but these criteria are complex and contain tests that are time-consuming. The same is applicable to the pro-Implant guidelines. Therefore, a simpler diagnostic test is desirable. The value of neutrophil gelatinase-associated lipocalin (NGAL), leucocyte esterase (LE) levels, and the white blood cell (WBC) count in synovial fluid to diagnose PJI after TKA was evaluated. In a retrospective cohort study, we analyzed 89 synovial fluid samples from 86 patients with suspected PJI after TKA. Thirteen and 23 of those samples were classified as PJI according to the MSIS and pro-Implant criteria, respectively. Subsequently, NGAL, LE levels, and the WBC count were determined, the former one using an immunoassay. Using either the MSIS or pro-Implant criteria as the golden standard for PJI, sensitivity and specificity of those markers were determined with ROC curves, and medians were compared with Mann–Whitney U and Pearson Chi-square tests. When applying the MSIS criteria, NGAL revealed 92% sensitivity and 83% specificity. WBC count showed similar sensitivity (92%) and specificity (84%), whereas sensitivity and specificity for LE were 39% and 88% respectively. When applying the pro-Implant criteria, sensitivity was 95% and specificity was 95% for NGAL. Sensitivity and specificity for WBC count were 100% and 97% and for LE 39% and 92% respectively. NGAL and WBC count in synovial fluid has high accuracy in the diagnosis of PJI after TKA and should seriously be considered as part of PJI diagnostics. Leucocyte esterase can serve as rule-in criterion peroperatively. These conclusions are independent of which criteria set was used as golden standard.

IntroductionPregnant women faced with complications of pregnancy often require long-term hospital admission for maternal and/or fetal monitoring. Antenatal admissions cause a burden to patients as well as hospital resources and costs. A telemonitoring platform connected to wireless cardiotocography (CTG) and automated blood pressure (BP) devices can be used for telemonitoring in pregnancy. Home telemonitoring might improve autonomy and reduce admissions and thus costs. The aim of this study is to compare the effects on patient safety, satisfaction and cost-effectiveness ofhospital care versustelemonitoring (HOTEL) as an obstetric care strategy in high-risk pregnancies requiring daily monitoring.Methods and analysisThe HOTEL trial is an ongoing multicentre randomised controlled clinical trial with a non-inferiority design. Eligible pregnant women are >26+0 weeks of singleton gestation requiring monitoring because of pre-eclampsia (hypertension with proteinuria), fetal growth restriction, preterm rupture of membranes without contractions, recurrent reduced fetal movements or an intrauterine fetal death in a previous pregnancy.Randomisation takes place between traditional hospitalisation (planned n=208) versus telemonitoring (planned n=208) until delivery. Telemonitoring at home is facilitated with Sense4Baby CTG devices, Microlife BP monitor and daily telephone calls with an obstetric healthcare professional as well as weekly hospital visits.Primary outcome is a composite of adverse perinatal outcome, defined as perinatal mortality, 5 min Apgar Ethics and disseminationThe study protocol was approved by the Ethics Committee of the Utrecht University Medical Center and the boards of all six participating centres. Trial results will be submitted to peer-reviewed journals.Trial registration numberNTR6076.

Purpose: Total knee arthroplasty (TKA) is widely used as a treatment for knee osteoarthritis. However, still up to 20% of the patients are dissatisfied. Joint line elevation after TKA might be a contributing factor as it alters knee kinematics. The aim of this study was to investigate the effect of joint line elevation on outcome. Methods: A systematic review of the literature was performed to select studies that reported on joint line alterations after primary or revision TKA and outcome. Studies with comparable outcome parameters were included in a correlation analysis. Results: In total, 396 studies were identified, of which 27 met the inclusion criteria. 8 studies could be included in the correlation analysis. Mean joint line elevation after primary TKA was 3.0 mm and after revision TKA this was 3.6 mm. A statistically significant negative correlation was found between joint line elevation and the postoperative Knee Society Score (KSS) function score (ρ = − 0.496, p < 0.001). In a pooled analysis, the maintained joint line revision TKA group had statistically significant better postoperative KSS total scores compared to an elevated joint line group (p < 0.001). Conclusion: In this systematic review, a negative correlation between joint line elevation and outcome was found. Furthermore, revision TKAs with a maintained joint line have statistically significant better postoperative KSS scores compared to an elevated joint line group. To achieve optimal outcome after TKA, restoration of the joint line is one of the parameters that should be pursued and introduced elevation should not exceed 4 mm. Level of evidence: IV.

Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure. A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups. Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used. The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0–348 months; median, 14 months). Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01). Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design.Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099

In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved. A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in ‘Visual Analogue Scale’). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment. When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy. This study is registered in the Trial Register ( www.trialregister.nl ) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569

Introduction: Surgeon volume of hip arthroplasties is of importance with regard to complication and revision rates in total hip arthroplasty. For hip hemiarthroplasty, the effect of surgeon volume on outcome is far less studied. We analyzed the outcome of hip hemiarthroplasties performed by orthopedic surgeons in a retrospective cohort in different volume categories, focusing on early survival of the prosthesis and complications. Methods: Between March 2009 and January 2014, 752 hemiarthroplasties were performed for intracapsular femoral neck fracture by 27 orthopedic surgeons in a large Dutch teaching hospital. Surgeons were divided into four groups, a resident group and three groups based on the number of total hip arthroplasties and hemiarthroplasties performed per year: a low-volume (< 10 arthroplasties per year), moderate-volume (10–35 arthroplasties per year), and high-volume groups (> 35 arthroplasties per year). Outcome measures were stem survival using a competing risk analysis, complication rates, and mortality. Chi-square tests were used to compare complication rates and mortality between groups. Results: Patients were followed for a minimum of 2 years or until revision or death. Overall 60% of the patients included had died at time of follow-up. We found comparable stem survival rates in the low-volume group (n = 48), moderate-volume group (n = 201), high-volume group (n = 446), and resident group (n = 57). There were no significant differences between the groups with regard to dislocation rate, incidence of periprosthetic fracture, infection, and mortality. Conclusion: Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. Hemiarthroplasty can safely be performed by both experienced hip surgeons and low-volume surgeons.

The current study used theories on expertise development (the holistic model of image perception and the information reduction hypothesis) as a starting point to identify and explore potentially relevant process measures to monitor and evaluate expertise development in radiology residency training. It is the first to examine expertise development in volumetric image interpretation (i.e., CT scans) within radiology residents using scroll data collected longitudinally over five years of residency training. Consistent with the holistic model of image perception, the percentage of time spent on full runs, i.e. scrolling through more than 50% of the CT-scan slices (global search), decreased within residents over residency training years. Furthermore, the percentage of time spent on question-relevant areas in the CT scans increased within residents over residency training years, consistent with the information reduction hypothesis. Second, we examined if scroll patterns can predict diagnostic accuracy. The percentage of time spent on full runs and the percentage of time spent on question-relevant areas did not predict diagnostic accuracy. Thus, although scroll patterns over training years are consistent with visual expertise theories, they could not be used as predictors of diagnostic accuracy in the current study. Therefore, the relation between scroll patterns and performance needs to be further examined, before process measures can be used to monitor and evaluate expertise development in radiology residency training.

Purpose Indications for total and unicondylar knee arthroplasty (KA) have expanded to younger patients, in which Patient-Reported Outcome Measures (PROMs) often show ceiling effects. This might be due to higher expectations. Our aims were to explore expectations of younger patients concerning activities in daily life, work and leisure time after KA and to assess to what extent PROMs meet and evaluate these activities of importance. Methods Focus groups were performed among osteoarthritis (OA) patients

Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE. Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported. Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular. Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way