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Introduction: Instability, loosening, and patellofemoral pain belong to the main causes for revision of total knee arthroplasty (TKA). Currently, the diagnostic pathway requires various diagnostic techniques such as x-rays, CT or SPECT-CT to reveal the original cause for the failed knee prosthesis, but increase radiation exposure and fail to show soft-tissue structures around TKA. There is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone, and TKA without radiation exposure. MRI is capable of visualising all the structures in the knee although it is still disturbed by susceptibility artefacts caused by the metal implant. Low-field MRI (0.25T) results in less metal artefacts and offers the ability to visualize the knee in weight-bearing condition. Therefore, the aim of this study is to investigate the possibilities of low field MRI to image, the patellofemoral joint and the prosthesis to evaluate the knee joint in patients with and without complaints after TKA. Method: Ten patients, eight satisfied and two unsatisfied with their primary TKA, (NexGen posterior stabilized, BiometZimmer) were included. The patients were scanned in sagittal, coronal, and transversal direction on a low field MRI scanner (G-scan Brio, 0.25T, Esaote SpA, Italy) in weight-bearing and non-weight-bearing conditions with T1, T2 and PD-weighted metal artefact reducing sequences (TE/TR 12–72/1160–7060, slice thickness 4.0mm, FOV 260×260×120m3, matrix size 224×216). Scans were analysed by two observers for: - Patellofemoral joint: Caton-Descamps index and Tibial Tuberosity-Trochlear Groove (TT-TG) distance. - Prosthesis malalignment: femoral component rotation using the posterior condylar angle (PCA) and tibial rotation using the Berger angle. Significance of differences in parameters between weight-bearing and non-weight-bearing were calculated with the Wilcoxon rank test. To assess the reliability the inter and intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC). The two unsatisfied patients underwent revision arthroplasty and intra-operative findings were compared with MRI findings. Results: In the satisfied group, a significant difference was found between TT-TG distance in non-weight-bearing and weight-bearing condition (p=0.018), with a good interrater reliability ICC=0.89. Furthermore, differences between weight-bearing and non-weight-bearing were found for the CD ratio, however, not significant (p=0.093), with a good interrater reliability ICC=0.89. The Berger angle could be measured with an excellent interrater reliability (ICC=0.94). The PCA was hard to assess with a poor interrater reliability (ICC=0.48). For one unsatisfied patient a deviation was found for tibial component rotation, according to the perioperative findings as, ‘malposition of the tibial component’. For the other unsatisfied patient revision surgery was performed due to aseptic loosening in which the MRI showed a notable amount of synovitis. Conclusion: It is possible to image the patellofemoral joint and knee prosthesis with low field MRI. Patellofemoral measurements and tibial component rotation measurements can reliably be performed. For the two patients with complaints MRI findings were consistent with intra-operative findings. Further research should focus on a larger group of patients with complaints after TKA to verify the diagnostic capacity of low field MRI for peri-prosthetic knee problems.

This case report describes a successful two-stage treatment in a 75-year-old male with a displaced neck of femur fracture, also suffering from an active chronic osteomyelitis of the ipsilateral calcaneus. In our case, a below-knee amputation was performed first, followed by total hip arthroplasty two weeks later. At 15-month follow-up, full recovery of the prefracture level of activities of daily living without significant impairment was obtained. Only a few cases of total hip arthroplasty in amputees have been published, but the indication for surgery was mainly traumatic or advanced osteoarthritis. Treating patients with this type of comorbidities is challenging; therapeutic dilemmas can be major. The management in cases like these requires a thorough evaluation and a clear surgical and medical treatment plan, preferably conducted by a multidisciplinary orthogeriatric team.

This report describes the possibilities of information and communication technology in healthcare. Attention is paid of how ICT can support the communication between health care professional mutually as well as the communication between professionals and patients. Besides this some barriers that hampers implementation in everyday healthcare practice are described.

The purpose of this thesis was to investigate the role of modern anterior cruciate ligament (ACL) suture repair (ACLSR) in the treatment of ACL ruptures (ACL#). We (1) performed a systematic review of the literature (SR) to critically appraise, summarize, and compare recent literature on outcomes of ACLSR; (2) in the human cadaveric knee, compared the biomechanical properties of two augmented and one historical non-augmented ACLSR techniques after cyclic loading, across the arc of knee flexion; (3) performed a randomized clinical trial (RCT) with two- and five-year follow-up on outcomes of DA ACLSR compared to ACLR; and (4) investigated whether the preoperative magnetic resonance imaging (MRI) scan could have predicted specific morphological ACL# characteristics in patients that underwent arthroscopic ACLSR in our RCT. In the SR, we found that the amount of high-quality evidence for ACLSR is poor. This made it difficult to establish the role of ACLSR in the treatment of ACL#s. In the biomechanical study, we found that only DA resulted in restoration of anterior tibial translation values similar to those for the intact ACL, and lower than those for the ruptured ACL directly post-operation and after cyclic loading, across the arc of flexion of the knee. Furthermore, we found that the targeted isometric tunnel placement for the augmentation braid was not attained. This could lead to length-change in the tunnels’ distance across the arc of flexion of the knee, which can only be compensated by DA. In the RCT, we found that, in contrast to the result for non-inferiority of ACLSR compared to ACLR at two-year follow-up, the results at five-year follow-up were inconclusive. However, there were no statistically significant differences in any of the outcome measures between ACLSR compared to ACLR. Finally, we found that the assessment of specific ACL# characteristics of the preoperative MRI was not opportune, meaning that final assessment of a patient’s eligibility for ACLSR based on ACL# characteristics should be made at the time of (and not prior to) surgery. This PhD shows that (1) there may be no difference in the outcome between modern ACLSR and ACLR; and (2) augmentation of the ACLSR with a strong, small- diameter braid positioned parallel to the ACL and shielding the ACL from (some) stress during healing may be one of the important pillars for the success of ACLSR.

In orthopaedic surgery, often orthopaedic hardware (e.g. suture anchors, prosthesis, osteosynthesis material) made of metal alloys is implanted. Before the implantation of orthopaedic hardware, magnetic resonance imaging (MRI) is the imaging modality of choice for imaging musculoskeletal structures. After implantation of orthopaedic hardware, MRI is disturbed by susceptibility artefacts due to the metal implants, which reduce the diagnostic value. Lowering the main magnetic field should reduce the size and prominence of susceptibility artefacts. In clinical practice MRI is performed in supine condition; however, given that during the day our limbs are in weight-bearing position, it seems relevant to image them in similar weight-bearing conditions. Low-field MRI offers the possibility for imaging in upright weight-bearing position. Therefore, this thesis first investigates the diagnostic properties of MRI near orthopaedic hardware. Second, it explores the added value of weight-bearing low-field MRI after the most frequently performed joint procedure, the total knee arthroplasty (TKA). Based on this thesis is concluded that MRI is a useful imaging modality after surgery in which orthopaedic hardware (titanium suture anchors, TKA, or other) is implanted. Although the added value of weight-bearing MRI could not be proven, high-field MRI performs as well as low-field MRI in imaging several pathologies and can be considered as an addition to the current diagnostic arsenal. High-field MRI excels in image quality, low-field in usability at low cost.

Chronic pain is considered a major public health problem. In addition to the physical and emotional burden that chronic pain brings, it gives rise to significant health care costs. Although conventional rehabilitation programs are effective, the use of telerehabilitation, providing remote care via communication technologies, is expected to offer several advantages over conventional clinic-based rehabilitation because it affords patients to rehabilitate within their own social environment. This can facilitate the care delivery process, increase access of care and improve patients' well-being and quality of life. However, despite the great potential of telerehabilitation, its intended benefits will only be realized when these treatments are accepted and used by patients as fully fledged alternatives to conventional care. Therefore, an understanding of patients' reasons for accepting or refusing relerehabilitation is crucial. The aim of this thesis is to identify drivers and barriers related to patients' acceptance of exercise-based telerehabilitation for chronic pain. This will provide more insight into strategies that may improve telerehabilitation design and as such may facilitate the uptake of prospective telerehabilitation services.

Despite the huge potential of telemedicine services (increasing accessibility of care, increasing quality of care and lowering of healthcare costs), its implementation in daily clinical practice is very limited and most services fade away after a project or pilot phase. The aim of this thesis has been to contribute to knowledge concerning the added value of telemedicine services for physical rehabilitation. For this, two state of the art evaluation studies of telemedicine services for physical rehabilitation (chapter 2 and 3) have been performed and in addition, the actual use of these telemedicine services and its association between actual use and clinical benefit have been addressed (chapter 5 and 6). Results of this thesis show that telemedicine services have potential to comply with the increased demand of care in the field of rehabilitation and other fields. To provide concrete guidelines to other researchers active in the field of evaluation of telemedicine services the “DeChant” framework [4] is refined into a new stage approach framework focusing on four different aspects 1] evaluation objective, 2] evaluation context, 3] evaluation design and 4] evaluation endpoints. Actual use is an aspect that is hugely underexposed given that it is significantly related to clinical outcome and the measure that reflects real adoption of telemedicine by its end users. In addition, based on the knowledge that actual use of telemedicine decreases over time, it is important that new tools and techniques will be developed that improve actual use. It is hypothesized that this can be realized on one hand by enhancing technologies, such as using ambulant technology that allows objective monitoring and feedback and gaming technology but also by addressing implementation strategies such as implementation intentions.