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OBJECTIVE: To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care.METHODS: Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA.RESULTS: 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036).CONCLUSION: Our multifaceted intervention did not improve SDM and ptDA uptake was low.PRACTICE IMPLICATIONS: In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Introduction: In cemented total hip arthroplasty (THA) various shapes and geometries of femoral implants are in use. Collarless, polished, and tapered (CPT) implants, and anatomically shaped (AS) implants are most commonly used. Due to their different design features, this might lead to different survival outcomes. In this register-based study, overall implant survival and short-term complications of CPT and AS cemented implants were evaluated. Methods: Data of the Dutch Arthroplasty Register (LROI) were used. Cemented femoral implants, which could be classified as CPT or AS were included in this study. Implants were excluded when no classification could be made or if implanted Results: 76,281 cemented THAs were included. At a mean of 5.1 years follow-up (SD 3.1, range 0–12 years), the overall survival of the AS implants was higher compared with the CPT implants, with a survival, of 99.2% and 99.0% respectively (log-rank; p Conclusions: Both designs show excellent overall survival rates at short-term follow-up. There is a higher overall survival of AS implants when compared with CPT implants. Revision for implant loosening, however, was statistically significantly higher in AS implants when compared with the CPT implants.

Background: This study aims to present an overview and critical appraisal of all previous studies comparing costs and outcomes of the different modes of fixation in total hip arthroplasty (THA). A secondary aim is to provide conclusions regarding the most cost-effective mode of implant fixation per gender and age-specific population in THA, based on high quality studies.Methods: A systematic search was conducted to identify cost-effectiveness analyses (CEAs) comparing different modes of implant fixation in THA. Analysis of results was done with solely CEAs that had a high methodological quality.Results: A total of 12 relevant studies were identified and presented, of which 5 were considered to have the methodological rigor for inclusion in the analysis of results. These studies found that either cemented or hybrid fixation was the most cost-effective implant fixation mode for most age- and gender-specific subgroups.Conclusion: Currently available well performed CEAs generally support the use of cemented and hybrid fixation for all age-groups relevant for THA and both genders. However, these findings were mainly based on a single database and depended on assumptions made in the studies' methodology. Issues discussed in this paper have to be considered and future work is needed.

Background: Outpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist.Patients and Methods: This retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs >= 1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis.Results: The complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS >= 1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS >= 1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m(2) (vs BMI

Background: Outpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA.Methods: A 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123).Results: Twenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables).Conclusion: One in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.

Background and purpose — Hip resurfacing arthroplasty (HRA) was designed for the highly active patient because of the various theoretical advantages compared with stemmed total hip arthroplasty (THA), but has shown high failure rates. Physical activity (PA) after arthroplasty is frequently determined with the use of questionnaires, which are known for their subjective nature, recall bias, and ceiling effect. These disadvantages are not applicable to physical activity monitoring (AM) using sensors. We compared objectively measured PA at long-term follow-up in a matched cohort of HRA and stemmed THA subjects. Patients and methods — We compared 2 groups of 16 patients (12 males) in each group, one having received unilateral HRA (median age 56 years at surgery) and a matched group having received unilateral stemmed THA with a small diameter femoral head (28 mm) on conventional polyethylene (median age 60 years at surgery) with osteoarthritis as indication for surgery, 10 years after surgery. Groups were matched by sex, age at surgery, and BMI. The daily habitual PA was measured over 4 consecutive days in daily living using a 3-axis accelerometer, gyroscope, and magnetometer. Both quantitative parameters (time standing, sitting, walking, number of steps, and sit–stand transfers) and qualitative parameters (walking cadence) were determined. Results — The AM was worn for a median 13 (11–16) hours per day. The median daily step count was 5,546 (2,274–9,966) for the HRA group and 4,583 (1,567–11,749) for the stemmed THA-group with 39 (21–74) versus 37 (24–62) daily sit–stand transfers respectively. The other PA parameters were also similar in both groups. Interpretation — We found similar median PA levels and also identical ranges. While short-term effects may exist, ageing and related behavioral adaptations or other effects seem to render the theoretical activity benefits from HRA irrelevant at longer follow-up.

Little is known about the influence of physical activity (PA) on metal ion concentrations in subjects with metal-on-metal hip arthroplasty. Implant wear is thought to be a function of use and thus of patient activity levels. It is hypothesized that daily habitual PA of patients with hip resurfacing arthroplasty (HRA) is associated with metal ion concentrations. Therefore a study was conducted in patients with a unilateral HRA at 10-years follow-up. Blood metal ion concentrations were determined. An acceleration-based activity monitor was used to measure PA in daily life. The cohort consisted of 12 males (75%) and 4 females (25%) with a median age at surgery of 55.5 +/- 9.7 years [43.0-67.9] and a median follow-up of 9.9 +/- 1.0 years [9.1-10.9]. The median cobalt and chromium ion concentrations were 25 +/- 13 and 38 +/- 28 nmol/L. A significant association between sit-stand transfers and high-intensity peaks with cobalt ion concentrations were found. Regarding PA and metal ion concentrations as a proxy of wear in HRA, specific activities like transfers or qualitative aspects of activity behavior like intensity, seem to matter more than the quantity of low-intensity activities like walking or cycling. This suggests that patients may safely engage in such activities to achieve important general health benefits and quality of life.

Background/objective: The ongoing pandemic of non-communicable diseases, with systemic arterial hypertension at the forefront, mandates urgent attention to the aetiopathogenic mechanism rather than continuing to rely on suppressive drug therapies. Lifestyle interventions (such as diet, sleep and exercise) may have substantial impact on blood pressure control in hypertension. However this may not be evident in clinical trials of lifestyle intervention if the blood pressure was previously controlled by drugs. We therefore sought to develop an alternative method of measuring the impact of lifestyle intervention, rather than rely on blood pressure measurement alone. Methods: The open trial of a personalized food avoidance dietary approach to stop hypertension was approved by the UNTH ethics committee. The Antihypertensive Drug Treatment Requirement (ADTR) score was calculated as the total number of defined unitary dosages of antihypertensive drugs times adherence +/- 0.1 accordingly for each mm Hg that average systolic pressure either exceeds 120 mm Hg (AOBP or home BP, whichever higher) or goes below 100 mm Hg Hg (AOBP or home BP, whichever lower). The dietary compliance score was based on the frequency of major/ minor dietary indiscretion (as per the PFADASH guidelines) i.e. less than (= GOOD) or more than (= POOR) once a month/ once a fortnight, respectively. Normality of data distribution was assessed by computing Shapiro-Wilk statistics. Cronbach's alpha reliability coefficient was used to assess internal consistency of ADTR measurements. Results: Bi-quarterly Shapiro – Wilk statistics for AdhRx scores and ADTR scores showed more than 80% likelihood of being normally distributed at 5% significance level (i.e. 13 out of 16 data sets tested). Cronbach's alpha reliability coefficient was 0.980. This confirmed consistency of the ADTR measurement scale. For three study participants who improved to Good compliance (after dietary counseling) and four participants who failed to improve, Good compliance was associated with lower ADTR scores, but the differences between Good (mean ADTR of 1.07+0.82) and Poor (3.81+3.15) were not statistically significant (p = 0.210). For the three study participants who transited from Poor to Good compliance (in response to counseling), there was a high degree of negative correlation (i.e. decline of drug requirement) which was statistically significant in two of them (p

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators’ initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Introduction In shared decision‐making (SDM), physicians encourage the patient to participate in the care process. The theory of planned behaviour describes that behaviour is dependent on intention. In its turn, intention is explained by attitude, subjective norm and perceived behavioural control. In orthopaedics, little is known about current SDM behaviour and how to promote it.The aim of the present study was to gain insight into the SDM behaviour of orthopaedic residents and supervisors by measuring levels of intention, attitudes, subjective norms and perceived behavioural control. Furthermore, we aimed to determine the predictors of intention for SDM. Methods A questionnaire survey study was conducted among orthopaedic surgeons and residents working in the care of hip and knee osteoarthritis, to determine their intentions, attitudes, subjective norms and perceived behavioural control regarding SDM. Results Of the 385 physicians approached, 71 residents and 64 orthopaedic surgeons participated. Residents and the supervisors alike had positive intentions regarding SDM. Intention for SDM behaviour was explained by attitude, subjective norm and perceived behavioural control, with perceived behavioural control having the strongest association. In residents, the intention to engage in SDM was more hampered by a lower level of perceived behavioural control than in surgeons. Conclusions Physicians are willing to perform SDM and consider SDM as favourable in the orthopaedic clinic. The implementation of SDM is mainly hampered by experienced barriers that they cannot control. These findings underline the importance of incorporating SDM in the curriculum of postgraduates. Possibilities for efficient SDM implementation should be explored, to overcome perceived barriers.