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Contains fulltext : 220918.pdf (Publisher’s version ) (Open Access) BACKGROUND: Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up. METHODS: A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction. RESULTS: There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up. CONCLUSION: Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non-device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.

Introduction In patients with recurrent patellar dislocations, a tibial tubercle osteotomy (TTO) can be indicated to correct patella alta or an increased trochlear groove–tibial tubercle distance. Several surgical techniques are described. Previous studies emphasize that detaching osteotomies results in devascularisation, which can lead to non-union and tibial shaft fractures. The aim of this study was to report the complication rates directly related to the surgical technique of a V-shaped TTO, where the tubercle is completely released from its periosteum using a step-cut osteotomy. Methods The retrospective case series comprised a large cohort of 263 knees with patella alta in 203 patients who underwent a V-shaped TTO, with or without additional realignment procedures, between March 2004 and October 2017. Data were obtained from available patient files. Complications were defined as minor or major. Results Thirteen major complications were registered (4.9%) including two tibial fractures (0.75%) and one non-union (0.37%). Five complications (1.9%) were defined as minor. Removal of the screws because of irritation or pain was seen in 22 cases (8.2%). Conclusion A V-shaped TTO is a safe procedure. The presumed higher risk for tibial fractures or pseudo-arthrosis could not be confirmed.

The FlexitSystem implant is a novel implant used in open wedge high tibial osteotomy. A clinical safety study was performed. Retrospectively 50 patients were analyzed who were treated with an open wedge high tibial osteotomy and the new FlexitSystem implant, with a minimal follow-up of one year. Complication rate, radiographic outcomes and implant removal were investigated. One patient underwent a revision surgery because of loss of correction and non-union. The complication rate was 10.0%. No other radiographic complications (screw breakage, implant failure) were found. In 24 patients (48%) the FlexitSystem implant was removed at a mean follow-up of 12.6 months (range 2.6 till 24.0 months). The mean reason was irritation of the implant. The FlexitSystem implant is a clinical safe and stable implant for an open wedge high tibial osteotomy, with a low complication rate. The rate of implant irritation requiring removal remained high.

Background Shortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy. Methods Thirty-six AO-OTA (Arbeitsgemeinschaft fur Osteosynthesefragen–Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment. Results On average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (P = .01). Conclusion This study reveals the influence the projection of the midshaft clavicular fracture has on the surgeon's decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.

Item does not contain fulltext BACKGROUND: Developmental dysplasia of the hip (DDH) is a common cause of secondary osteoarthritis (OA) in younger patients, and when end-stage OA develops, a THA can provide a solution. Different options have been developed to reconstruct these defects, one of which is impaction bone grafting combined with a cemented cup. To determine the true value of a specific technique, it is important to evaluate patients at a long-term followup. As there are no long-term studies, to our knowledge, on THA in patients with DDH using impaction bone grafting with a cemented cup, we present the results of this technique at a mean of 15 years in patients with previous DDH. QUESTIONS/PURPOSES: We wished to determine (1) the long-term probability of cup revision at a minimum followup of 15 years for cemented acetabular impaction bone grafting in patients with DDH; (2) the radiographic appearance of the bone graft and radiographic signs of implant loosening; and (3) the complications and pre- and postoperative Harris hip scores with cemented THA combined with impaction bone grafting in patients with previous DDH. METHODS: Between January 1984 and December 1995 we performed 28 acetabular impaction bone grafting procedures for secondary OA believed to be caused by DDH in 22 patients; four patients died before 15 years, leaving 24 hips in 18 patients for retrospective analysis at a minimum of 15 years (mean, 20 years; range, 16-29 years). The diagnosis of DDH was made according to preoperative radiographs and intraoperative findings. All grades of dysplasia were included; five patients had Crowe Group I, eight had Group II, nine had Group III, and two had Group IV DDH. No patients were lost to followup. In all cases the acetabular defects were combined cavitary and segmental. Owing to the high number of deaths, we performed a competing-risk analysis to determine the probability of cup revision surgery. RESULTS: The competing-risk analysis showed cumulative incidences at 15 and 20 years, with endpoint revision for any reason of 7% (95% CI, 0%-17%), whereas this was 4% (95% CI, 0%-11%) with endpoint revision of the cup for aseptic loosening. Three revision surgeries were performed. Two cup revisions were performed for aseptic loosening at 12 and 26 years. Another cup revision was performed owing to sciatic nerve problems at 2 years. A stable radiographic appearance of the graft was seen in 19 of the 25 unrevised hips. Four hips showed acetabular radiolucent lines and two showed acetabular osteolysis. None of the unrevised cups showed migration or radiographic failure. Postoperative complications included a pulmonary embolus and a superficial wound infection. The Harris hip score improved from 37 (range, 9-72) preoperatively to 83 (range, 42-99) at latest followup. CONCLUSIONS: Cemented primary THA with the use of impaction bone grafting shows satisfying long-term results in patients with previous DDH. For future research it is important to evaluate this technique in a larger cohort with a long-term followup. Other techniques also should be evaluated at long-term followup to be able to compare different techniques in this important and specific patient group. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Background The purpose of this study was to compare the mechanical stability of a relatively thin locking plate (FlexitSystem implant) with a relatively firm locking plate (TomoFix implant), both used for opening wedge high tibial osteotomy. Methods Seven fresh frozen paired human cadaveric tibiae were used. The opening wedge high tibial osteotomies in the left tibiae were fixated with the FlexitSystem implant and in the right tibiae with the TomoFix implant. The tibiae were CT-scanned to determine the bone mineral density. Axial loading was applied in a cyclic fashion for 50,000 cycles. We compared throughout the loading history the relative motions between the proximal and distal tibia using roentgen stereophotogrammetry analysis at set intervals. Also the strength of the reconstructions was compared using a displacement-controlled compressive test until failure. Results One pair (with the lowest bone mineral density) failed during the preparation of the osteotomy. The FlexitSystem implant displayed a similar stability compared to the TomoFix implant, with low translations (mean 2.16 ± 1.02 mm vs. 4.29 ± 5.66 mm) and rotations (mean 3.17 ± 2.04° vs. 4.30 ± 6.78°), which was not significant different. Although on average the FlexitSystem reconstructions were slightly stronger than the Tomofix reconstructions (mean 4867 ± 944 N vs. 4628 ± 1987 N), no significant (p = 0.71) differences between the two implants were found. Conclusion From a biomechanical point of view, the FlexitSystem implant is a suitable alternative to the TomoFix implant for a high tibial open wedge osteotomy.

Background One of the more commonly used methods of determining the amount of shortening of the fractured clavicle is by comparing the length of the fractured side to the length of contralateral unfractured clavicle. A pre-existing natural asymmetry can make quantification of shortening using this method unreliable. The goal of this study is to assess the side-to-side variation in clavicle length in 100 uninjured, skeletally mature adults. Materials and methods To assess the side-to-side difference in clavicle length the length of both clavicles of 100 patients on thoracic computed tomography (CT) scans were measured. Patients without a history of pre-CT clavicular injury were included. The measurements were allocated into three groups based on the amount of asymmetry ( 10 mm). Dominant side and sex were analyzed to determine influence on the length of the clavicle. Results In 30 patients (30%), an asymmetry of 5 mm or more was found. 2% of the patients had a side-to-side difference of more than 10 mm. The absolute side-to-side length difference (LD) was 3.74 mm (95% CI 3.15–4.32; p

Contains fulltext : 170959.pdf (Publisher’s version ) (Open Access) Background and purpose - Very little has been published on the outcome of femoral cemented revisions using a third-generation cementing technique. We report the medium-term outcome of a consecutive series of patients treated in this way. Patients and methods - This study included 92 consecutive cemented femoral revisions performed in our department with a third-generation cementing technique and without instrumented bone impaction grafting between 1996 and 2007. The average age of the patients at revision was 66 (25-92) years. None of the patients were lost to follow-up. At review in December 2013, 55 patients were still alive and had a non-re-revised femoral revision component in situ after a mean follow-up of 11 (5-17) years. Results - The mean preoperative Harris hip score was 50, and improved to 73 at final follow-up. 2 patients died shortly after the revision surgery. 1 stem was re-revised for aseptic loosening; this was also the only case with radiolucent lines in all 7 Gruen zones. A femoral reoperation was performed in 19 hips during follow-up, and in 14 of these 19 reoperations the femoral component was re-revised. Survivorship at 10 years, with femoral re-revision for any reason as the endpoint, was 86% (95% CI: 77-92). However, excluding 8 patients with reinfections after septic index revisions and 1 with hematogenous spread of infection from the survival analysis, the adjusted survival for re-revision for any reason at 10 years was 92% (95% CI: 83-96). With re-revision for aseptic loosening as endpoint, the survival at 10 years was 99% (CI: 90-100). Interpretation - Femoral component revision with a third-generation cemented stem results in acceptable survival after medium-term follow-up. We recommend the use of this technique in femoral revisions with limited loss of bone stock.

Item does not contain fulltext BACKGROUND: The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far. QUESTIONS/PURPOSES: The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old. METHODS: During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate. RESULTS: The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%-95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%-100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised. CONCLUSIONS: IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Item does not contain fulltext BACKGROUND: Midshaft clavicle fractures are often associated with a certain degree of shortening. There is great variety in the imaging techniques and methods to quantify this shortening. This study aims to quantify the difference in measurements of shortening and length of fracture elements between 5 views of the fractured clavicle. Furthermore, the interobserver and intraobserver agreement between these views using a standardized method is evaluated. MATERIALS AND METHODS: Digitally reconstructed radiographs were created for 40 computed tomography datasets in the anteroposterior (AP), 15 degrees and 30 degrees craniocaudal, and 15 degrees and 30 degrees caudocranial views. A standardized method for measuring the length of fracture elements and the amount of shortening was used. Interobserver and intraobserver agreement for each of the 5 views was calculated. RESULTS: The interobserver and intraobserver agreement was excellent for all 5 views, with all intraclass correlation coefficient values greater than 0.75. The measured differences in relative and absolute shortening between views were statistically significant between the 30 degrees caudocranial view and all other views. The increase in median shortening measured between the commonly used 30 degrees caudocranial view (2.7 mm) and the AP view (8.5 mm) was 5.8 mm (P < .001). The relative median shortening between these views increased by 3.5% (P < .001). CONCLUSION: The length of fracture elements and the amount of shortening in the fractured clavicle can be reliably measured using a standardized method. The increase in absolute and relative shortening when comparing the caudocranial measurements with the AP and craniocaudal measurements may indicate that the AP and craniocaudal views provide a more accurate representation of the degree of shortening.

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [

Item does not contain fulltext PURPOSE: Patients suffering from post traumatic osteoarthritis of the acetabulum often require a total hip arthroplasty at a relatively young age. Long-term data outcome studies for this population are lacking. We report on the long-term outcome of 20 acetabular fractures in 20 patients treated with impaction bone grafting and a cemented cup after a mean follow-up of 18 years (range, 12-26 years). METHODS: The group consisted of 14 males (70 %) and six females (30 %) with an average age of 53.3 years (range, 35-75 years) at time of surgery. No patients were lost to follow-up. Four patients died and three patients underwent a revision; at review 13 patients were still living with their implant in situ. Survivorship analysis was performed at 20 years follow-up for three endpoints. RESULTS: Survival rate with endpoint revision for any reason at 20 years postoperative was 74.7 % (95 % confidence interval (CI), 40-91 %), 80.0 % (95 % CI, 41-95 %) for endpoint aseptic loosening, and 63.9 % (95 % CI 32-84 %) for endpoint radiographic failure. Three acetabular components were revised at 14.5, 15.3, and 16.7 years postoperative. Two cups failed for aseptic loosening and one cup failed due to septic loosening. The average postoperative Harris hip score was 82 (range, 56-100). CONCLUSION: Acetabular reconstruction with impaction bone grafting and the use of a cemented cup after acetabular fracture is an attractive technique with acceptable long-term results and a low complication and re-operation rate.

Item does not contain fulltext PURPOSE: The purpose of this study was to investigate whether nocturnal pain and pain at rest preoperatively influence the satisfaction in patients after joint arthroplasty. The second research question is whether subjective outcome (VAS/WOMAC) after hip (THA) or knee arthroplasty (TKA) differs in patients with or without nocturnal pain and pain at rest preoperatively compared to those who do not. METHODS: A consecutive group of 189 TKAs and 189 THAs was evaluated. The influence of pain at rest and nocturnal pain preoperatively on the outcome was evaluated by means of a one-way ANOVA. Outcome measurements used were WOMAC, VAS pain and VAS Satisfaction. RESULTS: The results show that satisfaction at follow up was not influenced by the presence of nocturnal pain or pain at rest preoperatively. The presence of nocturnal pain and pain at rest preoperatively did result in a poorer WOMAC pain score WOMAC physical impairment score and a higher VAS pain at rest and activity after surgery for both THA and TKA. CONCLUSION: The results show that the presence of pain at night and pain at rest in symptomatic osteoarthritic patients results in worse VAS and WOMAC scores, but with similar amounts of satisfaction at follow up. LEVEL OF EVIDENCE: II.

Item does not contain fulltext BACKGROUND: Tension-band wiring (TBW) has been accepted as the treatment of choice for displaced olecranon fractures. The aim of this study was to examine the effect of K-wire position on instability of the K-wires in relation to local complications and radiological and clinical long-term outcome. METHODS: We reviewed the early follow-up of 59 patients (mean age, 60 years) who underwent TBW osteosynthesis for displaced olecranon fractures. Follow-up information was available from medical records and radiographs. The main outcome measurements were proximal migration of the wires, gap, step, range of motion, and complications. Long-term follow-up included 21 patients (mean age, 58 years). Follow-up was available from a clinical visit and a radiograph. Visual Analogue Scale (VAS), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), EuroQol-5D (EQ-5D), and Broberg and Morrey osteoarthritis scores were obtained. RESULTS: Seventy-eight percent of the patients treated with intramedullary K-wires were found to have instability of K-wires, compared to 36% in the patients treated with transcortical K-wires. Patients with instability of the K-wires tend to develop osteoarthritis more often. There is a better functional outcome in patients where the osteosynthetic material is removed. CONCLUSION: Instability of K-wires after TBW is more common after intramedullary placement of the wires resulting in proximal migration of the K-wires and gap appearance. There was a tendency of more osteoarthritis in the group of patients where instability of K-wires was identified. We would recommend the use of transcortical placed wires, as well as to have a low threshold in removing the implants. 01 maart 2012

Item does not contain fulltext INTRODUCTION: Patient satisfaction becomes more important in our modern health care system. The assessment of satisfaction is difficult because it is a multifactorial item for which no golden standard exists. One of the potential methods of measuring satisfaction is by using the well-known visual analogue scale (VAS). In this study, we validated VAS for satisfaction. PATIENT AND METHODS: In this prospective study, we studied 147 patients (153 hips). The construct validity was measured using the Spearman correlation test that compares the satisfaction VAS with the Harris hip score, pain VAS at rest and during activity, Oxford hip score, Short Form 36 and Western Ontario McMaster Universities Osteoarthritis Index. The reliability was tested using the intra-class coefficient. RESULTS: The Pearson correlation test showed correlations in the range of 0.40-0.80. The satisfaction VAS had a high correlation between the pain VAS and Oxford hip score, which could mean that pain is one of the most important factors in patient satisfaction. The intra-class coefficient was 0.95. CONCLUSIONS: There is a moderate to mark degree of correlation between the satisfaction VAS and the currently available subjective and objective scoring systems. The intra-class coefficient of 0.95 indicates an excellent test-retest reliability. The VAS satisfaction is a simple instrument to quantify the satisfaction of a patient after total hip arthroplasty. In this study, we showed that the satisfaction VAS has a good validity and reliability. 01 juni 2012

Background Internal fixation is one of the main options for treating displaced intracapsular hip fractures. However, controversy remains over which osteosynthesis is the best choice. Using a simulated displaced intracapsular hip fracture model, we compared the mechanical stability of three types of osteosynthesis: the sliding hip screw (SHS), three cannulated screws and the Targon ® FN. We also assessed whether bone mineral density (BMD) influenced the stability of the fixation. Methods Unstable/displaced intracapsular hip fractures were induced in a total of 12 pairs of fresh-frozen cadaver femora. Each fracture was fixed at random on the left or right side with an SHS or three cannulated screws (six bone pairs; study 1), or with an SHS or the Targon ® FN implant (six bone pairs; study 2). All femoral heads were exposed to cyclic combined axial and torque loads until failure. The failure mechanism, the maximal load-to-failure and the dual-energy X-ray absorptiometry (DEXA) values of the femoral heads were determined and their relationships were analysed. Results There was no significant difference in the maximal load-to-failure between the SHS and the three cannulated screws. The load-to-failure was significantly higher for the Targon ® FN than for the SHS. There was a high correlation between the bone mineral densities (BMDs) of the femoral heads and maximal load-to-failure in the Targon ® FN group only. Interpretation Basing the implant choice on preimplantation BMD measurements does not ensure the best biomechanical outcome. We found that the combination of a fixed-angle device and multiple sliding neck screws (Targon ® FN) enhances the mechanical strength of reconstructions in unstable/displaced intracapsular hip fractures.

Background and purpose In the reconstruction of unicondylar femoral bone defects with morselized bone grafts in revision total knee arthroplasty, a stem extension appears to be critical to obtain adequate mechanical stability. Whether stability is still assured by this reconstruction technique in bicondylar defects has not been assessed. The disadvantage of relatively stiff stem extensions is that bone resorption is promoted due to stress shielding. We therefore designed a stem that would permit axial sliding movements of the articulating part relative to the intramedullary stem.Methods This stem was used in the reconstruction with impaction bone grafting (IBG) of 5 synthetic distal femora with a bicondylar defect. A cyclically axial load was applied to the prosthetic condyles to assess the stability of the reconstruction. Radiostereometry was used to determine the migrations of the femoral component with a rigidly connected stem, a sliding stem, and no stem extension.Results We found a stable reconstruct...

Background and purpose The optimal treatment for isolated patellofemoral osteoarthritis is unclear at present. We systematically reviewed the highest level of available evidence on the nonoperative and operative treatment of isolated patellofemoral osteoarthritis to develop an evidenced-based discussion of treatment options.Methods A systematic computerized database search (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), and EMBASE) was performed in March 2009. The quality of the studies was assessed independently by two authors using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Results We extracted data from 44 articles. The best available evidence for treatment of isolated patellofemoral osteoarthritis is sparse and of generally low methodological quality. Nonoperative treatment using physiotherapy (GRADE: high quality, weak recommendation for use), taping (GRADE: moderate quality, weak recommendation fo...

Item does not contain fulltext The purpose of this study was to correlate the long-term survival of patellofemoral arthroplasty with primary diagnosis, age, sex, and body mass index. One hundred eighty-five consecutive Richards type II patellofemoral arthroplasties were performed in 161 patients with isolated patellofemoral osteoarthritis. Diagnoses included primary patellofemoral osteoarthritis, posttraumatic patellofemoral osteoarthritis, and patellofemoral osteoarthritis with a previous realignment procedure for patellar subluxation or trochlear dysplasia. Median time to follow-up was 13.3 (range, 2.0-30.6) years. Patellofemoral arthroplasty survival was 84% at 10 years and 69% at 20 years. Primary diagnosis, sex, or age at patellofemoral arthroplasty did not significantly affect the rate of revision (P=.35, P=.24, and P=.65, respectively). The rate of revision in obese patients (body mass index>30 kg/m2) was higher than that in nonobese patients (P=.02). 01 oktober 2010

Item does not contain fulltext Trochlear dysplasia is a predisposing factor for recurrent patellar instability. We evaluated the results of an anterior lateral femoral condyle open wedge osteotomy for treating patellar instability. A total of 16 consecutive patients (19 knees) with symptoms of recurrent patellar instability and trochlear dysplasia identified using a true lateral radiograph of the knee underwent an anterior lateral femoral osteotomy. Outcomes were documented at 2 years minimum follow-up using the Lysholm scale, the patellofemoral score, WOMAC score and standard conventional radiographs. In 17 knees, patients reported good improvement in stability (no dislocations) and most patients had a marked improvement in pain and functional scores at follow-up (mean follow-up 51 months). No serious complications occurred. Anterior femoral osteotomy of the lateral condyle appears to be a satisfactory and safe method for treating patients with patellofemoral joint instability caused by trochlea dysplasia. In selected cases this procedure can be used to correct trochlea dysplasia. In our opinion, the key to a successful treatment of patellofemoral instability is to successfully distinguish the anatomic deficiencies and to correct the anatomical abnormality.

A 39-year-old man presented with knee pain and limited knee flexion. MRI showed a mucoid degeneration of the anterior cruciate ligament (celery stalk sign). This rare condition can be treated with arthroscopic debridement with volume reduction of the anterior cruciate ligament. In severe cases, anterior cruciate ligament resection could be considered.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Item does not contain fulltext PURPOSE: To prospectively evaluate the diagnostic performance of magnetic-resonance-arthrography (MRA) by experienced musculoskeletal radiologists in patients with traumatic-anterior-shoulder-instability (TASI), after feedback protocol execution. MATERIALS AND METHODS: Forty-five surgically confirmed MRA's were used to enhance personal feedback, to discuss differences in outcome between MRA assessment and surgical findings and to fine-tune definition interpretation agreement of 7 different TASI-related lesions, between experienced musculoskeletal radiologists and experienced orthopaedic shoulder surgeons. After execution of the feedback protocol 20 new, surgically confirmed, MRA's were assessed by 2 experienced musculoskeletal radiologists using a seven-lesion standardized scoring form. Kappa coefficients, sensitivity, specificity, and differences in percentage agreement or correct diagnosis (p-value, McNemar's test) were calculated per lesion and overall per 7 lesion types to assess whether diagnostic reproducibility and accuracy was improved. RESULTS: Per 7 lesion types, the overall kappa and percentage of agreement, between the 2 radiologists, were dramatically increased in comparison with our former study (k=0.81 versus k=0.48 and 90.7% versus 78.2%, respectively). The overall sensitivity of radiologist 1 increased from 45.9% to 87.8%, the overall sensitivity of radiologist 2 increased from 63.5% to 79.6% and the overall specificity of radiologist 2 increased from 80.1% to 85.7%. Furthermore, the overall percentage of correct diagnosis of both radiologist was also exceedingly higher (85.7% and 83.6%) compared to our former study (74.4% and 74.8%). CONCLUSION: The implementation of our feedback protocol dramatically improved the reproducibility and accuracy of high field MRA by experienced musculoskeletal radiologist in patients with traumatic anterior shoulder instability.

Syndesmotic disruption occurs in more than 10% of ankle fractures. Operative treatment with syndesmosis screw fixation has been successfully performed for decades and is considered the gold standard of treatment. Few studies have reported the long-term outcomes of syndesmosis injuries. This study investigated long-term patient-reported, radiographic, and functional outcomes of syndesmosis injuries treated with screw fixation and subsequent timed screw removal. A retrospective cohort study was carried out at a Level I trauma center. The study group included 43 patients who were treated for ankle fractures with associated syndesmotic disruptions between December 2001 and May 2011. The study included case file reviews, self-reported questionnaires, radiologic reviews, and clinical assessments. At 5.1 (±1.76) years after injury, 60% of participants had pain, 26% had degenerative changes, 51% had loss of tibiofibular overlap, and 33% showed medial clear space widening. Retained syndesmotic positions on radiographs were linked to better self-reported outcomes. There is an inversely proportional relation between age at the time of injury and satisfaction with the outcome of the ankle fracture as well as a directly proportional relation between age at the time of injury and pain compared with the preinjury state. Optimal restoration and preservation of the syndesmosis is crucial. Syndesmotic disruption is associated with poor long-term outcomes after ankle fracture. Greater age is a risk factor for chronic pain and dissatisfaction with the outcome of ankle fracture and syndesmosis injury. Therefore, patient education to facilitate realistic expectations about recovery is vital, especially in older patients. [ Orthopedics. 2015; 38(11):e1001–e1006.]

Contains fulltext : 154601.pdf (Publisher’s version ) (Open Access) PURPOSE: To evaluate the mid- to long-term results of the Richards' type II patellofemoral arthroplasty (PFA) in terms of functional scores, number and type of complications, patient satisfaction and survival. METHODS: We retrospectively studied patients that received a Richards' type II PFA at our institution between 1998 and 2007. Patients with a functioning PFA at the time of this study were evaluated. Outcomes included survival rates with endpoint loss of prosthesis, number and type of complications, Knee Society Scores (KSS) and Visual Analogue Scale (VAS) for pain. In addition, patients were asked how surgery influenced their original symptoms. RESULTS: Twenty-four patients (33 prostheses) were included. Follow-up ranged from 2.2 to 18.8 years with a mean of 9.7 years. Survival at 10 years was 73 % (95 % CI, 57-93 %). Median KSS score was 163 (range, 110-200). Median VAS Pain was 30 (range, 0-80) and VAS Satisfaction median was 90 (range, 50-100). Thirteen (62 %) PFAs were rated excellent, six (28 %) as good and two (10 %) as fair. Twelve (36 %) of the cases required further surgery within 4 years after implantation. Seven of these (21 %) were converted to TKA after a mean time of 5.5 years, five out of seven were converted because of ongoing tibiofemoral osteoarthritis (TFOA). CONCLUSIONS: We found a rate of 21 % (7/33) conversion of the Richards' II PFA to TKA after a mean of 5.5 years; 71 % (5/7) of cases were because of TFOA. We strongly advise not to use PFA if there is any sign of joint disease in other compartments than patellofemoral.

Contains fulltext : 154727.pdf (Publisher’s version ) (Open Access) PURPOSE: It is often a difficult decision whether it is safe to perform revision hip surgery in a patient of 80 years and older. Therefore we evaluated the results of cemented revisions in these elderly patients. METHODS: Clinical data, radiographs and complications of 49 consecutive cup and/or stem revisions in 48 patients were prospectively collected. The average age of the patients at surgery was 84 years (range, 80-92). We performed Kaplan-Meier (KM) analysis and also a competing risk (CR) analysis because in this series the presence of a competing event (i.e. death) prevents the occurrence of endpoint rerevision. RESULTS: Twenty-nine patients (30 hips) died without rerevision during follow-up and their data was included. The average follow-up of the 16 surviving patients was eight years (range, six to 13). Six re-operations were performed, of which three were re-revisions. Eight-year survivorship was 91.6 % (95 % confidence interval (CI) 76-97 %) for endpoint re-revision for any reason. With the CR analysis we calculated that due to the increasing number of competing events, the KM analysis overestimates the failure rate with 32 % for this endpoint. The average Harris hip score improved from 49 to 74. Mortality within three months after surgery was 6 %. One postoperative fracture occurred and six hips dislocated. CONCLUSION: Cemented revisions can provide satisfying results in patient of 80 years and older with acceptable survivorship and complication rates.

Item does not contain fulltext BACKGROUND: We compared the diagnostic reproducibility and accuracy of musculoskeletal radiologists with orthopaedic shoulder surgeons in 2 large medical centers in assessing magnetic resonance arthrograms (MRAs) of patients with traumatic anterior shoulder instability. METHODS: Forty-five surgically confirmed MRAs were assessed by 4 radiologists, 4 orthopaedic surgeons, 2 radiologic teams, and 2 orthopaedic teams. During MRA assessment and surgery, the same 7-lesion scoring form was used. kappa Coefficients, sensitivity, specificity, and differences in percentage of agreement or correct diagnosis (P < .05, McNemar test) were calculated per lesion and overall per the 7 lesion types. RESULTS: The overall kappa between the individual radiologists (kappa = 0.51, kappa = 0.46) and orthopaedic surgeons (kappa = 0.46, kappa = 0.41) was moderate. Although the overall percentage of agreement between the radiologists was slightly higher than that between the orthopaedic surgeons in both centers (80.0% vs 77.5% and 75.2% vs 73.7%), there was no significant difference. In each medical center, however, the most experienced orthopaedic surgeon was exceedingly more accurate than both radiologists per the 7 lesion types (81.9% vs 72.4%/74.6% and 76.5% vs 67.3%/73.7%). In 3 of 4 cases, this difference was significant. Overall accuracy improvement through consensus assessment was merely established for the weakest member of each team. CONCLUSION: Experienced orthopaedic surgeons are more accurate than radiologists in assessing traumatic anterior shoulder instability-related lesions on MRA. In case of diagnosis disagreement, these orthopaedic surgeons should base their treatment decision on their own MRA interpretation.

Contains fulltext : 47792.pdf (Publisher’s version ) (Closed access) Nail-patella syndrome (NPS) is characterized by developmental defects of dorsal limb structures, nephropathy, and glaucoma and is caused by heterozygous mutations in the LIM homeodomain transcription factor LMX1B. In order to identify possible genotype-phenotype correlations, we performed LMX1B mutation analysis and comprehensive investigations of limb, renal, ocular, and audiological characteristics in 106 subjects from 32 NPS families. Remarkable phenotypic variability at the individual, intrafamilial, and interfamilial level was observed for different NPS manifestations. Quantitative urinanalysis revealed proteinuria in 21.3% of individuals. Microalbuminuria was detected in 21.7% of subjects without overt proteinuria. Interestingly, nephropathy appeared significantly more frequent in females. A significant association was established between the presence of clinically relevant renal involvement in an NPS patient and a positive family history of nephropathy. We identified normal-tension glaucoma (NTG) and sensorineural hearing impairment as new symptoms associated with NPS. Sequencing of LMX1B revealed 18 different mutations, including six novel variants, in 28 families. Individuals with an LMX1B mutation located in the homeodomain showed significantly more frequent and higher values of proteinuria compared to subjects carrying mutations in the LIM domains. No clear genotype-phenotype association was apparent for extrarenal manifestations. This is the first study indicating that family history of nephropathy and mutation location might be important in precipitating individual risks for developing NPS renal disease. We suggest that the NPS phenotype is broader than previously described and that NTG and hearing impairment are part of NPS. Further studies on modifier factors are needed to understand the mechanisms underlying phenotypic heterogeneity.

Contains fulltext : 170074.pdf (Publisher’s version ) (Open Access) BACKGROUND: Patient-Reported Outcome (PRO) measurement is a method for measuring perceptions of patients on their health and quality of life. The aim of this paper is to present the results of PRO measurements in total hip and knee replacement as routinely collected during 20 years of surgery in a university hospital setting. METHODS: Data of consecutive patients between 1993 and 2014 were collected. Health outcomes were measured pre-surgery and at 3, 6, and 12 months post-surgery. Outcomes for hip replacement were measured with the Harris Hip Score (HHS) and Oxford Hip Score (OHS). Outcomes for knee replacement were measured with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Knee Society Score (KSS). A Visual Analog Scale (VAS) for pain was used. Absolute and relative Minimal Clinically Important Differences (MCID) were estimated. Generalized estimating equation analysis was used for estimating mean outcomes. Trends over time were analyzed. RESULTS: The database contained 2,089 patients with hip replacement, and 704 patients with knee replacement. Mean HHS and OHS scores in primary hip replacement at 12 months post-surgery were 86.7 (SD: 14.5) and 41.1 (SD: 7.5) respectively. Improvements on the HHS based on absolute MCID was lower for revisions compared to primary hip replacements, with 72.4% and 87.0% respectively. Mean WOMAC and KSS scores in knee replacement at 12 months post-surgery were 21.5 (SD: 18.2) and 67.0 (SD: 26.4) respectively. Improvements based on absolute MCID were lowest for the KSS (62.6%) and highest for VAS pain (85.6%). Trend analysis showed a difference in 1 out of 24 comparisons in hip replacement and in 2 out of 9 comparisons in knee replacement. CONCLUSIONS: The functional status of a large cohort of patients significantly improved after hip and knee replacement based on routine data collection. Our study shows the feasibility of the routine collection of PRO data in patients with total hip and knee replacement. The use of PRO data provides opportunities for continuous quality improvement.

The medial patellofemoral complex, consisting of the medial patellofemoral ligament (MPFL) and the medial patellotibial ligament, is the main passive stabiliser of the patellofemoral joint. Since it has been shown that rupture of the MPFL is the main pathological consequence of patellar dislocation and biomechanical studies have demonstrated that the MPFL is the main restraint against lateral patellar displacement, reconstruction of the MPFL has become a widespread technique for restoration of patellofemoral stability.

Although indomethacin is effective in preventing heterotopic ossification (HO) after total hip arthroplasty (THA) when used for 8 to 14 days, side effects are frequently observed. We conducted a prospective, nonrandomized pilot study of prophylaxis for HO in THA using indomethacin for 3 days. We used a 2-stage design for phase 2 clinical data, based on earlier studies in our department. Our study group consisted of 19 patients, of whom 14 (74%) developed HO; 7 (37%) showed grade I, 4 (21%) grade II, and 3 (15.8%) grade III according to the Brooker classification. We compared these results with 2 historic control groups; one group received indomethacin for 7 days, and the other group received no prophylaxis. We did not see any reduction of the ossification relative to the group that received no prophylaxis. Indomethacin for 3 days seems not to be sufficient to prevent HO.

With the increase in sports participation an equal increase in sports-related injuries has been observed. Over the last few decades injuries of the knee joint have played a major role, due to many popular knee pivoting sports including soccer, skiing and basketball. Treatment options for anterior cruciate ligament (ACL) injuries have dramatically changed over the last 50 years, as described by Chambat et al. [1], which is the first invited paper in this special issue. Especially for younger orthopaedic surgeons who mainly learn to treat ACL insufficiency by arthroscopic means the development of our thoughts about the surgical treatment of this particular ruptured ligament, e.g. by the change from outside to inside the joint, from augmentation to reconstruction of the ligament itself, has been an interesting journey. Moreover, sometimes older techniques may be of considerable value in certain severe instabilities, to aid attainment of optimal stability. I refer to the articles by Vadala et al. [2] and Dejour et al. [3] who both use an extra-articular augmentation to increase the stability. Maybe this will become a new trend in the coming years. Another issue is the graft to use for ACL reconstruction. There has been a shift from bone-patellar tendon-bone towards the hamstrings in recent years. In some countries, for example The Netherlands, the hamstring tendons are practically exclusively used nowadays. This shift is not based on sound scientific evidence that hamstrings perform better, actually several meta-analyses show they perform more or less equally well, but may be partly industry driven. This trend is also seen in the international survey performed by Chechik at al. [4] in this issue. Interestingly this shift is not clearly seen among the members of the ACL Study Group. The ACL Study Group was organised around 28 years ago by a small group of orthopaedic surgeons with a common interest in the ligament. Today the group has about 180 dedicated knee surgeons as members from all over the world who meet every two years to exchange information. Every two years the members fill out a questionnaire concerning their methods of treatment. The 2012 results show that the hamstrings are used in 56 % and bone-patellar tendon-bone in 35 % of the reconstructions. Since the use of hamstrings has become quite popular as a graft and we all know that the quality of a single semitendinous tendon sometimes is questionable, the question arises whether it is harmful to also harvest the gracilis tendon from the same side. In an elegant study Barenius at al. [5] give us the answers. And what about patellar tendinitis after ACL surgery with the patellar tendon? Or without any surgery? Although I have the impression that this was an issue during the past few years when we used bone blocks of at least 25 mm in length; since that has changed to bone blocks with a maximum of 15 mm (personal experience) this complication hardly ever occurs. Since it seems to be more related to open chain exercises it is seen in different patients with or without surgery and with hamstrings or patellar tendon. The use of a double bundle for ACL reconstructions is another example of a change in surgical technique to increase the final result in stability of the knee joint. Although the idea of a double bundle sounds attractive, based on the multi-ligamentous tissue of the original ACL, the main benefit of this new technique has been the awareness of the fact that an anatomical reconstruction of the ACL within the femoral footprint is not the same as an isometric reconstruction as performed for years by many surgeons. Increased stability by this new technique, however, can only be proven by comparison of double-bundle vs anatomical single-bundle reconstruction. The isometric reconstructions should not be included in such a comparison of course. By carefully reading the latest meta-analysis by Li et al. [6] and the review of Suomalainen et al. [7], it is clear that no important differences were found. Also, using new techniques such as computer navigation in a comparative study did not show significant differences with regard to one technique [8]. Therefore, for now the question whether double-bundle reconstruction will be the gold standard for the coming years remains. Interesting in this view is the very conservative view of the members of the ACL Study Group: Only 15 % of the members routinely performed double-bundle reconstructions in 2012 and 85 % felt that double-bundle reconstructions did not perform better! Of course there will be indications when the technique of a double-bundle reconstruction instead of a single-bundle reconstruction should be considered. Therefore, in this issue we focus on indications and contraindications for both techniques in a paper from the Pittsburgh group [9]. It is interesting to read how—in time—indications are set and changed today in comparison to a couple of years ago. Since it is clear that there remains a broad indication to use single-bundle grafts for ACL reconstruction a renewed focus on anatomical placement and the surgical technique to reach this anatomical footprint is valuable. We have known for several years that it is impossible to properly reach the femoral footprint through the tibial tunnel; therefore, techniques have been developed using an extra medial portal, retrograde drilling of the tunnel and double-incision techniques. I invited Marcus Arnold and co-workers [10] to describe their surgical double-incision technique with bone-patellar tendon-bone as a graft and Charlie Brown and colleagues [11] to cover the issue of the medial portal technique. Both have described and beautifully illustrated the pearls of these surgical procedures. And what about long-term results? We know that with a good position of the ACL graft, this graft will survive for a long time. However, up till now we are not able to prevent arthritis of the knee joint, probably due to the fact that we are not yet able to mimic the original ACL closely enough. The two papers in this issue with ten years follow-up, both from Germany [12, 13], show a significant number with established arthritis. This reminds us of the indication for surgery which should in general include the restoration of knee stability, the prevention of meniscal damage but no prevention of arthritis. And what about the possibilities for return to sport after the reconstruction? After reading the article by Julian Feller from Australia [14], I have the feeling we should also be more reluctant about sports participation at a high level. We also know from all long-term follow-up studies the importance of retaining the menisci. Sometimes retention of the meniscus is not possible, or a meniscus has been taken out already. What about synthetic replacement? How far are we today? In a review paper by Vrancken et al. [15] we are informed of the current possibilities, results and drawbacks. We are all more interested in success than failure, including complications. Sometimes the failure is established easily by physical examination and X-rays which show a definitively incorrect position of bone tunnels. Sometimes it is more subtle. Michael Hirschmann and co-workers [16] studied the value of single photon emission computed tomography/computed tomography (SPECT/CT), a rather new modality in medicine, in relation to graft orientation. In my view this modality might open up new ways of detecting fine abnormalities which may elucidate persistent complaints in patients. The use of allografts and synthetics is limited in many countries. However, they are still in use and it was decided also in this issue to pay attention to these ways of reconstruction of the ACL. Although it is often stated that the re-rupture rate is higher in allograft reconstructions, (I hear numbers in the range of 10 % at congresses) Hu et al. [17] could not establish this in their meta-analysis of prospective studies. Are the more negative aspects of these allografts maybe not published? A systematic review about synthetics is included concerning the ligament augmentation and reconstruction system (LARS) [18]. An important warning looking at the results is the fact that only nine papers could be found and that all papers showed a poor methodological quality. Also included is the study from Struewer et al. [19] who showed the findings of second-look arthroscopies (more than 30 % synovial reactions) after reconstruction with the LARS. After studying both papers I suppose the individual orthopaedic surgeon will draw his/her own conclusions and know which graft sources to use or not to use. At the end of this special issue we included the paper of Boutefnouchet et al. [20]. This paper was selected because of the excellent results this group has with an arthroscopic technique of posterior cruciate ligament reconstruction. I hope and expect that all articles in this issue will be valuable and that this issue will serve as a reference for the coming years in the treatment variability of knee injuries.

Purpose : The role of MR imaging in grading medial collateral ligament (MCL) injury of the knee in comparison to other grading methods (clinical findings and instrumental measurement) is hardly documented in the literature. The purpose of this study is to compare the results of MR imaging in grading acute MCL injuries to the results of a clinical grading by an instrumented valgus-varus laxity tester (VVLT). Materials and methods : Twenty-one patients clinically suspected of acute MCL injury were tested by VVLT, a well documented and instrumented test-device. All patients subsequently underwent MR imaging of the knee. MCL injury was graded independently by VVLT and MR imaging using a classification method with reference to Petermann. Results: Ninteen patients had corresponding grading results by VVLT and MR imaging (kappa, 0.83; S.E., 0.10); 14 patients had a Grade I, four a Grade II and two patients had a Grade III MR imaged MCL injury. Associated lesions were also depicted on MR imaging (bone contusion ( n = 3), ACL disruption ( n = 2) and medial meniscal rupture ( n = 1)). Conclusions : This study shows a very high degree of agreement between the results in grading acute MCL injuries with MR imaging and an instrumented valgus-varus laxity tester (VVLT). MR imaging depicted important, clinically undetected, additional lesions which can determine the treatment of MCL injury.

Contains fulltext : 95878.pdf (Publisher’s version ) (Open Access) PURPOSE: The aim of this study was to evaluate subsidence tendency, surface congruency, chondrocyte survival and plug incorporation after osteochondral transplantation in an animal model. The potential benefit of precise seating of the transplanted osteochondral plug on the recipient subchondral host bone ('bottoming') on these parameters was assessed in particular. METHODS: In 18 goats, two osteochondral autografts were harvested from the trochlea of the ipsilateral knee joint and inserted press-fit in a standardized articular cartilage defect in the medial femoral condyle. In half of the goats, the transplanted plugs were matched exactly to the depth of the recipient hole (bottomed plugs; n = 9), whereas in the other half of the goats, a gap of 2 mm was left between the plugs and the recipient bottom (unbottomed plugs; n = 9). After 6 weeks, all transplants were evaluated on gross morphology, subsidence, histology, and chondrocyte vitality. RESULTS: The macroscopic morphology scored significantly higher for surface congruency in bottomed plugs as compared to unbottomed reconstructions (P = 0.04). However, no differences in histological subsidence scoring between bottomed and unbottomed plugs were found. The transplanted articular cartilage of both bottomed and unbottomed plugs was vital. Only at the edges some matrix destaining, chondrocyte death and cluster formation was observed. At the subchondral bone level, active remodeling occurred, whereas integration at the cartilaginous surface of the osteochondral plugs failed to occur. Subchondral cysts were found in both groups. CONCLUSIONS: In this animal model, subsidence tendency was significantly lower after 'bottomed' versus 'unbottomed' osteochondral transplants on gross appearance, whereas for histological scoring no significant differences were encountered. Since the clinical outcome may be negatively influenced by subsidence, the use of 'bottomed' grafts is recommended for osteochondral transplantation in patients.

Item does not contain fulltext BACKGROUND: Since its introduction, there has been controversy about the use of locking plates in the treatment of proximal humeral fractures. Have they really improved the functional outcome after a proximal humeral fracture or should nonsurgical treatment have a more prominent role? In order to evaluate our hypothesis that nonsurgical treatment for proximal humerus fractures should be the first choice of treatment, a matched controlled cohort study was conducted to compare the midterm (>1 year) functional and radiologic outcome of a group of patients treated with a locking plate and a matched group of patients treated nonsurgically. Complications in each group of patients were evaluated. MATERIALS AND METHODS: Through direct matching, 17 patients (1 bilateral fracture) treated with a locking plate were matched to 18 patients treated nonsurgically. Medical records and radiographs were reviewed retrospectively to obtain relevant patient related data and fracture type according to Neer classification (i.e. 2-, 3- and 4-part fractures). At the time of clinical follow-up, EQ-5D, American Shoulder and Elbow Surgeons (ASES) score, visual analog pain (VAS) pain and VAS satisfaction scores were completed. Active range of motion was tested. New radiographs were made to evaluate fracture healing, complications and, in the locking plate group, the position of the plate and screws. RESULTS: No significant differences were found in the characteristics of the patient groups. A significant difference in range of motion was found in favor of the nonsurgically treated patients. Results of ASES and patient satisfaction scores were also tending toward nonsurgical treatment. Furthermore, the complication rate was higher with locking plate treatment. Patients treated with a locking plate needed significantly more additional treatment on their injured shoulder (P = 0.005). DISCUSSION: This study's main limitation was the fact that the choice of initial fracture management was based on clinical judgement, as well as patient's fitness for surgery and therefore not randomized. By matching for fracture type this bias was largely overcome. Surgical treatment had a higher complication rate, requiring more additional treatment, which was often related to the initial surgery. Improving surgical technique could possibly lead to better outcomes for the surgically treated patients. In addition to the more favorable outcomes, nonsurgical treatment is also a more cost effective treatment. CONCLUSION: Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures.

The bone mineral density (BMD) of the distal femur decreases by 16-36% within one year after total knee arthroplasty (TKA) because of the femoral component's stress-shielding effect. The aim of this prospective study was to determine the quantitative change from the baseline BMD in the distal femur 1 year after patellofemoral arthroplasty using dual-energy X-ray absorptiometry (DXA)., Journal Article, info:eu-repo/semantics/published

Item does not contain fulltext In a randomised clinical trial in 50 patients with symptomatic osteoarthritis of the medial compartment of the knee, the clinical results of high tibial osteotomy (HTO) according to the open wedge osteotomy (OWO) and closed wedge osteotomy (CWO) were compared. In both groups locked plate fixation was used. Clinical and radiological assessments were performed preoperatively and after one year. Postoperative hip-knee-ankle (HKA) correction angles were monitored on standing leg X-rays. The effect of HTO on collateral laxity of the knee was measured with a specially designed varus-valgus device. The WOMAC osteoarthritis index, the modified knee society score (KS) and visual analogue scales (VAS) were used to assess symptoms of osteoarthritis, function, pain and patient satisfaction. At one-year follow-up we found accurate corrections in both groups and the planned correction angles were achieved. No loss of correction was observed. Furthermore, the medial collateral laxity and the patellar height significantly decreased after OWO. Significant improvements of WOMAC and KS scores were found in both groups. All patients had significantly less pain and were very satisfied with the results. Surgery time was significantly longer in the CWO group, and complications were more frequent in this group. Both techniques led to good and comparable clinical results. The choice of whether to perform an open or a closed wedge osteotomy may be based on preoperative patellar height or concomitant collateral laxity. 01 februari 2010

Background Varus thrust of the knee is a dynamic increase of an often preexisting varus angle and it is suspected to be a major reason for failure of anterior cruciate ligament reconstructions. However, it is not known if a direct relationship exists between varus thrust and forces in the anterior cruciate ligament. Hypothesis Forces in the anterior cruciate ligament increase with increasing varus alignment, and consequently an anterior cruciate ligament deficiency in a varus-aligned leg leads to more lateral tibiofemoral joint opening. Study Design Controlled laboratory study. Methods Six human cadaver legs were axially loaded with 3 different weightbearing lines—a neutral weightbearing line, a weightbearing line that passes through the middle of the medial tibial plateau (50% varus), and a line passing the edge of the medial tibial plateau (100% varus)—that were used to create a varus moment. The resulting lateral tibiofemoral joint opening and corresponding anterior cruciate ligament tension were measured. The tests were repeated with and without the anterior cruciate ligament in place. Results In the neutral aligned legs, there was no apparent lateral joint opening, and no anterior cruciate ligament tension change was noted. The lateral joint opening increased when the weightbearing line increased from 0% to 50% to 100%. The lateral joint opening was significantly higher in 10° of knee flexion compared with knee extension. In the 100% varus weightbearing line, the anterior cruciate ligament tension was significantly higher (53.9 N) compared with neutral (31 N) or the 50% weightbearing line (37.9 N). A thrust could only be observed in the 100% weightbearing line tests. In the absence of an anterior cruciate ligament, there was more lateral joint opening, although this was only significant in the 100% weightbearing line. Conclusion There is a direct relationship between varus alignment and anterior cruciate ligament tension. In the absence of an anterior cruciate ligament, the amount of lateral opening tends to increase. With increasing lateral opening, a thrust can sometimes be experimentally observed. Clinical Relevance A varus alignment in an anterior cruciate ligament—deficient knee does not necessarily lead to a varus thrust and therefore does not always need operative varus alignment correction. However, in an unstable anterior cruciate ligament—deficient knee with a varus thrust, it might be safer to perform a high valgus tibial osteotomy to minimize the risk of an anterior cruciate ligament reconstruction failure.

Background and purpose The long-term outcome of patellofemoral arthroplasty is related to progression of femorotibial osteoarthritis with need for conversion to total knee arthroplasty. We investigated whether prior patellofemoral arthroplasty compromises the results of total knee arthroplasty. Methods 13 patients who had had 14 Richards type II patellofemoral arthroplasties converted to total knee arthroplasty because of femorotibial osteoarthritis, were individually matched to a control group of 13 patients with 14 primary total knee arthroplasties. The mean follow-up times for the patients and the control group were 5.7 (2–13) years and 5.2 (2–13) years, respectively. Clinical outcome was assessed using Knee Society score (KSS), WOMAC score, range of motion, and complications. Results KSS and WOMAC scores were similar in the two groups (KSS in patient and control groups: 82 and 86 (p = 0.6); KSS function: 76 and 88 (p = 0.5); WOMAC score: 33 and 21 (p = 0.1)). Within 6 months after conversion, 3 knees had to be manipulated under anesthesia for limited motion. No patients in the control group required manipulation under anesthesia. Interpretation Patellofemoral arthroplasty appears not to have a negative effect on the outcome of later total knee arthroplasty.

It is fascinating for both the patient and the surgeon to predict the outcome of a TKA at an early stage. Satisfaction after TKA is primarily determined by the preoperative expectations of the patient. The purpose of this study was to investigate if the peri-operative expectations of the surgeon predicted the outcome of a TKA. A prospective study of 53 primary TKAs was performed. Preoperatively, the surgeon described the assessment of the difficulty of the TKA on a VAS. Immediately postoperative, the surgeon gave his satisfaction VAS about the procedure. After 1 year the surgeon’s satisfaction VAS, the patient’s satisfaction VAS and the KSCRS were determined. The Spearman’s correlation coefficients between the preoperative difficulty assessment, the immediate postoperative satisfaction and the outcome measurements after 1 year were all very poor (−0.01 to 0.23). The outcome of a TKA depends on multiple factors. Both the surgeon’s preoperative assessment of the difficulty and the surgeon’s immediate postoperative satisfaction do not independently predict the outcome of a TKA.

The aim of this study was to compare the preoperative patients' expectations with their postoperative satisfaction after arthroplasties of the hip and knee, using a visual analogue scale. The comparison was made in a group of 44 patients after 44 primary knee and hip joint arthroplasties. A visual analogue scale (VAS) was used for the assessment of expectation and satisfaction. The mean preoperative expectation VAS was 14.8 (SD: 14.3). The mean patient satisfaction at time of follow up was 13.0 (SD : 21.1). We found no agreement in the preoperative patient's expectation satisfaction versus postoperative satisfaction (p = 0.66). Moreover in our study, the patients expected to be less satisfied than they actually were at follow-up, which is shown with the Bland and Altman method. It appears that patients are not capable of predicting the outcome of the joint arthroplasty, which could be influenced by negative preoperative information on complications and risks. Pain and functional disability are probably the most important factors for the patients' satisfaction after arthroplasty surgery.

Contains fulltext : 70643.pdf (Publisher’s version ) (Open Access) Osteochondral transplantation is a successful treatment for full-thickness cartilage defects, which without treatment would lead to early osteoarthritis. Restoration of surface congruency and stability of the reconstruction may be jeopardized by early mobilization. To investigate the biomechanical effectiveness of osteochondral transplantation, we performed a standardized osteochondral transplantation in eight intact human cadaver knees, using three cylindrical plugs on a full-thickness cartilage defect, bottomed on one condyle, unbottomed on the contralateral condyle. Surface pressure measurements with Tekscan pressure transducers were performed after five conditions. In the presence of a defect the border contact pressure of the articular cartilage defect significantly increased to 192% as compared to the initially intact joint surface. This was partially restored with osteochondral transplantation (mosaicplasty), as the rim stress subsequently decreased to 135% of the preoperative value. Following weight bearing motion two out of eight unbottomed mosaicplasties showed subsidence of the plugs according to Tekscan measurements. This study demonstrates that a three-plug mosaicplasty is effective in restoring the increased border contact pressure of a cartilage defect, which may postpone the development of early osteoarthritis. Unbottomed mosaicplasties may be more susceptible for subsidence below flush level after (unintended) weight bearing motion.

Contains fulltext : 52317.pdf (Publisher’s version ) (Open Access) BACKGROUND: Although indomethacin is effective in preventing heterotopic ossification (HO) after primary total hip arthroplasty, side effects are frequently observed. In the last decade a new class of drugs--the COX-2 selective nonsteroidal anti-inflammatory drugs--has been developed. To investigate the effect of these COX-2 selective NSAIDs on heterotopic ossification (HO) after primary total hip arthroplasty (THA), we conducted a randomized controlled trial using either indomethacin or rofecoxib for 7 days. METHODS: 186 patients received either indomethacin 3 times daily, or rofecoxib twice, and 1 placebo, daily for 7 days. HO was graded according to the 1-year postoperative radiographs according to the Brooker classification. RESULTS: 12 of the 186 patients included discontinued their medication before the end of the trial due to side effects. The remaining 174 patients were included in the analysis. In the indomethacin group (n = 89), 77 patients (87%) showed no HO, 9 showed HO of grade 1 and 3 showed HO of grade 2 according to the Brooker classification. In the rofecoxib group (n = 85) 73 patients (86%) showed no ossification, 9 showed grade 1, and 3 showed grade 2. INTERPRETATION: The prophylactic effect of rofecoxib for 7 days in preventing heterotopic ossification after primary total hip arthroplasty is comparable to the effect of indomethacin given for 7 days. These results indicate that the development of HO follows a COX-2 pathway.

Contains fulltext : 53392.pdf (Publisher’s version ) (Closed access) INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) prevent heterotopic ossification but gastrointestinal complaints are frequently. Selective cyclooxygenase-2 (COX-2) inhibiting NSAID produce less gastrointestinal side effects. PATIENTS AND METHODS: A prospective two-stage study design for phase 2 clinical trials with 42 patients was used to determine if rofecoxib (a COX-2 inhibitor) 50 mg oral for 7 days prevents heterotopic ossification. A cemented primary THA was inserted for osteoarthroses. After 6 months heterotopic bone formation was assessed on AP radiographs using the Brooker classification. RESULTS: No heterotopic ossification was found in 81% of the patients, 19% of the patients had Brooker grade 1 ossification. CONCLUSION: Using a two-stage study design for phase 2 clinical trials, a 7-day treatment of a COX-2 inhibitor (rofecoxib) prevents effectively the formation of heterotopic ossification after cemented primary total hip arthroplasty.

Contains fulltext : 52759.pdf (Publisher’s version ) (Open Access) BACKGROUND AND PURPOSE: Wire pre-tension in the Ilizarov frame is considered to be important in order to reduce movements that can impair fracture healing. Wires will eventually lose part of their pre-tension, however. In order to gain more insight into the need for wire pre-tension, we investigated: (1) the amount of pre-ten-sion loss, (2) the relationship between pre-tension loss and bolt-tightening torque, (3) the cause of a possible loss of pre-tension, and (4) the effect of pre-tension on cyclic micromotions and total displacement of the bone segments. METHODS: 3 Ilizarov configurations, with various wire pre-tensions and bolt-tightening torques, were tested 3 times with an MTS machine. For each wire, slippage and tensions were measured for the duration of the whole experiment. RESULTS: A loss of wire pre-tension (up to 75%) due to slippage was found. Higher bolt-tightening torques significantly reduced the amount of pre-tension loss. Furthermore, a higher wire pre-tension reduced the maximal axial displacement of the bone fragment. There was, however, least cyclic axial micromotion when no wire pre-tension was present -- probably due to the lack of wire recoil. INTERPRETATION: Wires in an experimental Ilizarov external fixator lose pre-tension within a limited period of time, and probably also in the clinical setting. This does not seem to lead to increased cyclic axial micromotions of the bone fragements. However, the question remains as to how excessive axial displacement of the bone fragment and other loading configurations will affect the process of fracture healing in a patient.