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Background: Wound drainage after total knee or hip arthroplasty is a relatively frequent complication. It results in delayed mobilization, prolonged hospital stay, increased costs and is associated with an increased risk of infection. In this study, tissue adhesive was administered as an adjunct to skin closure with staples. Methods: From February 2017, in a cohort of 1000 consecutive patients receiving primary total hip, total knee (TKA) or unicondylar knee arthroplasty, tissue adhesive was administered after skin closure with staples. Patients were prospectively analyzed for increased duration of hospital admission due to wound drainage. This cohort was compared to a consecutive cohort of 1000 patients before February 2017, treated with the same perioperative protocol, except for administration of tissue adhesive for skin closure. Difference in number of patients requiring prolonged hospital stay due to wound drainage was assessed between the two cohorts. Besides, costs of tissue adhesive were compared to change in hospital admission costs to assess the cost-effectiveness. Results: The number of patients requiring prolonged hospital admission due to wound drainage was significantly reduced in the study group compared to the group not treated with tissue adhesive (39/990 patients vs. 68/961 patients, p = 0.002). The mean number of extra days of hospital admission due to wound drainage was also significantly lower in the tissue adhesive cohort (0.06 vs. 0.13 days). The mean number of extra days in hospital only proved to be significant in the TKA cohort. Total money saved by preventing prolonged hospital admission in general cohort amounted €19,610. Conclusion: This study proves that tissue adhesive as an adjunct to staples for wound closure after total knee arthroplasty reduces wound drainage and is cost effective. Besides, this could potentially lead to lower rates of periprosthetic joint infection. Therefore, the use of tissue adhesive in total knee arthroplasty would be recommended. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis. Methods: Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol. Results: The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18–7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions. Conclusion: Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers. Level of evidence: Level II. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group). Methods: All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016–June 2017) and after introduction of the intervention (July 2017–December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital. Results: 136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (β = − 0.15, P < 0.001) and by 0.19% per month for arthroscopy (β = − 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (β = − 0.74, P = 0.228) nor arthroscopy (β = 0.13, P = 0.688). Conclusions: The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Aim: N-3 fatty acids, especially eicosapentaenoic acid (EPA), may possess anticachectic properties. This trial compared a protein and energy dense supplement enriched with n-3 fatty acids and antioxidants (experimental: E) [...]

Purpose: The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors. Methods: A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis ("Arthrosis" versus "Meniscal lesion"), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy. Results: Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient–provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984–1.043)], diagnosis [OR 0.998 (95% CI 0.886–1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948–1.032)] were significantly associated with performing a potentially low value knee arthroscopy. Conclusions: In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Background: The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work., Methods: A search was conducted in the databases Medline and Embase until February 24 th , 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)., Results: Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234)., Conclusions: The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low., Level of Evidence: Level 3., (© 2023. The Author(s).)

Osteoarthritis of the knee is often accompanied by degeneration of the meniscus. Worldwide, the arthroscopic partial meniscectomy has been a standard of care for patients with knee pain in the presence a degenerative meniscal tear. However, in recent years, clinical studies have proven that a meniscectomy is not effective in the osteoarthritic knee. Physiotherapy is often as effective. The updated Dutch guidelines for meniscal tears therefore recommend an arthroscopic partial meniscectomy or fixation in case of a locked knee and for traumatic meniscal tears in younger patients. There also is an indication for a meniscectomy after failure of conservative treatment in case of a symptomatic meniscal tear in the absence of osteoarthritis.

Introduction: Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). Factors which could possibly contribute to this dissatisfaction are a decreased posterior condylar offset (PCO) and subsequent joint line elevation which leads to mid-flexion instability. The Flexion First Balancer (FFB) technique aims to adequately restore the medial PCO and thereby reconstruct the medial native joint line to its pre-disease height., Methods: A retrospective cohort of 59 patients operated using the FFB technique was analyzed and matched with a historic measured resection (MR) cohort of 59 patients. Groups were matched for age, gender, BMI and ASA classification. Joint line and PCO changes as well as patient reported outcome measurement scores (PROMs) were evaluated at one year [1.0 - 1.6] postoperatively., Results: Radiographic evaluation revealed no changes in joint line height in the FFB group, whereas an elevation in joint line was seen in the MR group (p = 0.002). The PCO increased after surgery in both group without any statistically significant differences. Evaluation of PROMs found no differences between the two groups for total OKS and KOOS scores, nor in re-operation or complication rates., Conclusion: The FFB technique seems to be a safe technique to use in TKA and reconstructs the pre-disease joint line in contrast to the MR technique. The clinical outcomes were comparable between both groups., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques., Level of Evidence: II.

Mostly, patients with peri-pancreatic cancer (including pancreatic, ampullary and distal bile duct tumors) are diagnosed in a stage in which curative resection is not possible. The median survival rate of patients with non resectable peri-pancreatic cancer varies between 6 and 12 months. During this period palliative treatment is necessary, which should focus on major symptoms as obstructive jaundice, duodenal obstruction and pain. Controversy exists about how to provide optimal palliative treatment. Both surgical and non surgical palliative procedures relief obstructive jaundice. From early retrospective and prospective randomized studies it is known that in the early phase after treatment, more complications are found after surgical palliation, whereas in the late phase more complications are seen after endoscopic palliation. Because more recent studies clearly showed improved results after surgical palliation, current recommendations probably should be that patients with a suspected poor short-term survival (< 6 months) should be offered non surgical palliative therapy and those with a longer life expectancy may best be treated with bypass surgery. Unfortunately, valid criteria for estimating the remaining survival time are not available, except for the presence of metastases. The use of a prognostic score chart might assist in estimating the prognosis. Literature does not give sufficient information to make a well deliberated (evidence based) selection between the different types of surgical bypasses, but a choledochojejunostomy is generally preferred. After stenting, a correlation is found between survival and the development of duodenal obstruction, and between 9% and 21% of the patients who underwent a surgical biliary bypass without a prophylactic gastric bypass, will develop gastric outlet obstruction. Therefore, in patients with a relatively good prognosis it is recommended to perform routinely a double--biliary and gastric--bypass. Pain is a frequent symptom and is related with poor survival. Pain management aside from pain medication can be performed by means of a celiac plexus blockade or a thorascopic splanchnicectomy, and also radiotherapy seems to have a positive result on pain.

Aim: Survival after pancreaticoduodenectomy for periampullary tumours is limited. Over the last decade peri-operative management has improved and morbidity and mortality decreased. The aim of the study was to analyse recent survival data after pancreaticoduodenectomy and to determine factors that influence survival., Methods: From October 1992 to September 1998, 204 patients with a ductal adenocarcinoma in the pancreatic head (108), distal bile duct (32), and ampulla (64) who underwent standard pancreaticoduodenectomy, were analysed with regard to histology and tumour status. Survival was calculated by using the Kaplan-Meier method. Risk factors were identified in a univariate and multivariate analysis., Results: Median survival after resection for carcinoma of the pancreatic head, distal bile duct, and ampulla were 16, 25 and 24 months, respectively (P=0.008). In the univariate analysis vein resection, blood transfusion of more than four packed red cells, the presence of tumour positive resection margins, lymph-node metastases and poor tumour differentiation significantly decreased survival. In the multivariate analysis positive resection margins, lymph-node metastases, and poor tumour differentiation independently influenced survival., Conclusions: Resection margins, lymph-node status and tumour differentiation are independent prognostic factors. Survival after standard pancreaticoduodenectomy for periampullary tumours has not improved., (Copyright 2001 Harcourt Publishers Limited.)

Background: Resection of the portal/superior mesenteric vein (PV/SMV) during pancreatoduodenectomy (PD) is disputed. Although morbidity and mortality are acceptable, survival is limited after PV/SMV resection. In this study, we evaluate the effect of PV/SMV resection., Methods: Between 1992 and 1998, there were 215 consecutive patients who underwent PD for malignant disease. Thirty-four patients underwent a PV/SMV resection. Resection was only performed when minimal venous ingrowth was found perioperatively. Surgical techniques, perioperative parameters, and survival were analyzed., Results: The percentage of PV/SMV resections was 16%. Extensive (segment) resections were performed in 6 patients. The median blood loss was 1.8 L and resection margins were microscopically tumor free in 41% of the patients. The median hospital stay was 15 days, and mortality was 0%. Median survival after PV/SMV resection for pancreatic adenocarcinoma was 14 months., Conclusions: Limited PV/SMV resection for perioperatively encountered minimal venous ingrowth during PD can be performed safely without increased morbidity and mortality but also results in a high frequency of tumor-positive resection margins.

Objective: To perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes., Summary Background Data: Hospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account., Methods: In part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death., Results: Between the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications. The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year., Conclusions: The overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the single-center outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.

Controversy exists about the indication for a palliative pancreatoduodenectomy. A palliative resection for patients with a pancreatic carcinoma can be performed safely nowadays with low mortality and acceptable morbidity in centers with experience. The early results in terms of mortality and morbidity are not different from resections with curative intent or even after bypass surgery. The procedure seems effective for controlling symptoms of the disease, and the quality of life after a palliative resection is acceptable and not worse than after bypass surgery. It is, however, still doubtful whether the incidence of symptom recurrence, such as jaundice, obstruction, and pain, is lower after resection than after bypass surgery. The longer survival after palliative resection could also be due to patient selection and postoperative treatment. There are no randomized trials to prove the superiority of palliative resection over bypass surgery. The safety of pancreatic resection for cancer has already changed the policy in centers with experience, and surgeons are more willing to perform a resection because the results are better or at least the same as after bypass surgery. There are, however, no results to confirm that a palliative resection should be performed routinely or to justify resection as a debulking procedure.

Most patients with bilio-pancreatic malignancy are no candidate for curative resection and will need palliative treatment. Palliation in these patients is focussed on relief symptoms such as obstructive jaundice, duodenal obstruction and pain. It has been suggested that non surgical treatment (stenting) is the optimal palliation for patients with short survival and surgical bypass for those surviving more than 6 months. Unfortunately valid criteria for estimating survival are not available except for metastases. A prognostic score chart to predict survival probabilities for 3,6 and 9 months after diagnosis has been developed. The use of this prognostic score chart may help clinicians to select optimal palliative treatment for individual patients. Surgical biliary drainage can be performed by a simple cholecystoenterostomy; a choledochoduodenostomy or a choledocho/hepaticojejunostomy with Roux-Y jejunal limb reconstruction. The present data available in the literature do not give sufficient guidance to make a well deliberated selection between the different types of bypass surgery but choledochojejunostomy is generally preferred. Gastroentero-stomy is performed routinely during the biliary bypass procedure in our institution because gastric outlet obstruction has been described between 9-21% of the patients who underwent only a surgical biliary bypass but there is still controversy. Recently it was also suggested that there is an indication to perform palliative resections. No results are available to justify resections as a debulking procedure.

High-affinity binding sites for the pancreatic beta-cell hormone amylin have been reported in the kidney, and it has been postulated that these sites may be involved in the genesis of hypertension. In the present study, we have used in vivo injection of 125I-amylin and in vitro autoradiographic techniques to assess renal amylin binding in both a genetic and a surgically induced model of hypertension. In the spontaneously hypertensive rat (SHR) at 6 weeks of age, before the rise in systolic blood pressure, there was a 36% increase in density of amylin binding compared with their normotensive counterpart, the Wistar-Kyoto rat (WKY). In SHR, there was a further increase in the density of amylin binding (to 53% greater) as the systolic blood pressure rose between 6 and 12 weeks of age. Histological examination of kidneys from SHR at 12 weeks of age revealed staining for a brush border glycoprotein, normally restricted to the proximal tubules, extending from the urinary pole into half of the epithelial lining of the glomerular capsule. In contrast to WKY, these cells also bound 125I-amylin with high density in SHR. In a rat model of renal ablation and hypertension, systolic blood pressure correlated with the density of 125I-amylin binding in the renal cortex (r=.54, P=.003, n=28). The changes in amylin binding reported here suggest a possible role for this peptide and/or activation of its receptor in the genesis as well as the maintenance of hypertension.