The weekend effect for hip fracture surgery

INTRODUCTION

Increased mortality rates have been reported for emergency admissions during weekends and outside office hours. Research on the weekend effect in hip fracture patients is however limited and demonstrates conflicting results. The aim of this study was to determine the effect of weekend admission and weekend surgery on 30-day and 1-year mortality following hip fracture surgery.

PATIENTS AND METHODS

All patients who underwent hip fracture surgery in our hospital between 2004 and 2015 were included in this retrospective study. Patient characteristics including age, gender, fracture type, American Society of Anesthesiologists (ASA) score, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI) and length of stay were collected. Information on admission and surgery date and time of day was recorded, as were in-hospital, 30-day and 1-year mortality. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day and 1-year mortality.

RESULTS

A total of 1803 patients were included, 546 patients (30.3%) were admitted during the weekend. Patient characteristics did not differ between weekday and weekend admissions. Surgical delay was less frequent in patients undergoing weekend surgery. Multivariable analysis demonstrated that older age, higher ASA score, higher NHFS and increased surgical delay were independently associated with 30-day mortality. One-year mortality was associated with age, gender, ASA score, CCI and surgical delay. Weekend admission and weekend surgery were not associated with increased 30-day or 1-year mortality.

CONCLUSIONS

There was no weekend effect for hip fracture patients in our study. These results indicate an adequate level of perioperative care outside weekday office hours within our health care system.

The dimensions of the tarsal sinus and canal in different foot positions and its clinical implications

This study presents a reference for the dimensions of the tarsal sinus and canal in healthy adults in different foot positions to facilitate understanding of the kinematics of the subtalar joint, the effect of an implant, and other clinical issues. In a 3D CT stress test on 20 subjects, the right foot was forced into a neutral and eight different extreme foot positions while CT scans were obtained. The bones were segmented in the neutral foot position. The kinematics of the bones in the extreme positions were determined relative to the neutral position. The dimensions of the tarsal sinus and canal were calculated by determining the radii of the maximal inscribed spheres at 20 equidistant locations along an axis in 3D surface models of the tali and calcanei in each foot position. The radii were small on the medial side and increased laterally. Medial from the middle, the radii were small and not significantly different among the various foot positions. At the lateral side, the dimensions were affected mainly by eversion or inversion and less by dorsiflexion or plantarflexion. The pattern was reproducible among subjects, but there were between-subject differences. The dimensions are mostly determined by rotation in the frontal plane. A pivot point was found medial from the middle. These data serve as a reference and model for predicting the effect of sinus implants and understanding such clinical problems as sinus tarsi syndrome. Between-subjects differences have to be taken into account. Clin. Anat. 30:1049-1057, 2017. © 2017 Wiley Periodicals, Inc.

Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review

BACKGROUND

The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm² in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs.

PURPOSE

To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes.

RESULTS

Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm² in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm², while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm². The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies.

CONCLUSION

An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm² in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

Low-dose dexamethasone during arthroplasty: What do we know about the risks?

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).

The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.

We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a ‘pro’ and ‘con’ discussion.

After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.

Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.

Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.

A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk–benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.

We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies.

Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

Overuse wrist injuries in young athletes: What do sports physicians consider important signals and functional limitations?

This study's objective was to collect items from experienced sports physicians, relating to the presence and severity of overuse wrist injuries in young athletes, for developing a measurement instrument for signals of overuse wrist injury. Seven Dutch elite sports physicians involved in guidance and treatment of young athletes in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) participated in a focus group. They discussed signals and limitations related to overuse wrist injuries in young athletes. Data were coded and categorised into signals and limitations with subcategories, using an inductive approach. Of the resulting 61 signals and limitations in nineteen (sub)categories, 20 were considered important, forming a comprehensive item set for identifying overuse wrist injury in young athletes. Signals such as pain, "click", crepitations, swelling and limited range of motion were marked useful for early identification of overuse wrist injury. Limitations in movement and performance were considered indicative of severe overuse injury but less relevant for initial injury identification. The focus group provided 17 important signals and 3 important limitations indicative of overuse wrist injury. These provide the basis for a valid measurement instrument for identifying overuse wrist injury in young athletes, with equal emphasis on pain and on other symptoms.

Expectations of younger patients concerning activities after knee arthroplasty: are we asking the right questions?

PURPOSE

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

METHODS

Focus groups were performed among osteoarthritis (OA) patients <65 years awaiting KA, in which they indicated what activities they expected to perform better in daily life, work and leisure time after KA. Additionally, 28 activities of daily life, 17 of work and 27 of leisure time were depicted from seven PROMS, which were rated on importance, frequency and bother. A total score, representing motivation for surgery, was also calculated.

RESULTS

Data saturation was reached after six focus groups including 37 patients. Younger OA patients expect to perform better on 16 activities after KA, including high-impact leisure time activities. From the PROMs, daily life and work activities were rated high in both importance and motivation for surgery, but for leisure time activities importance varied highly between patients. All seven PROMs score activities of importance, but no single PROM incorporates all activities rated important.

CONCLUSION

Younger patients expect to perform better on many activities of daily life, work and leisure time after KA, and often at demanding levels. To measure outcomes of younger patients, we suggest using PROMs that include work and leisure time activities besides daily life activities, in which preferably scored activities can be individualized.

Osteoarthritis is associated with symptoms of common mental disorders among former elite athletes

PURPOSE

The primary aim was to establish the association between osteoarthritis (OA) and the occurrence and comorbidity of symptoms of common mental disorders (CMD: distress, anxiety/depression, sleep disturbance, adverse alcohol use) in a group of former elite athletes (rugby, football, ice hockey, Gaelic sports and cricket). A secondary aim was to explore this association in the subgroups of sports.

METHODS

Cross-sectional analysis was performed on the baseline questionnaires from five prospective cohort studies conducted between April 2014 and January 2016 in former elite athletes of rugby, football, ice hockey, Gaelic sports and cricket. The presence of OA (diagnosed by a medical professional) was examined with a single question, and symptoms of CMD were evaluated through multiple validated questionnaires (4DSQ, GHQ-12, PROMIS, AUDIT-C).

RESULTS

There was a significant association between OA and symptoms of distress (OR 1.7, 95 % CI 1.2-2.6), sleep disturbance (OR 1.6, 95 % CI 1.1-2.3), adverse alcohol use (OR 1.8, 95 % CI 1.2-2.6) and a comorbidity of symptoms of CMD (OR 1.5, 95 % CI 1.0-2.1) in former elite athletes.

CONCLUSION

OA might be a risk factor for developing symptoms of CMD in former elite athletes. The clinical relevance of this study is that an interdisciplinary approach to the clinical care and support of former elite athletes after their careers is advocated as the interaction between the physical and mental health issues occurring on the long term is complex. Monitoring OA among former elite athletes should be empowered while strategies to prevent symptoms worsening should be developed and implemented. The self-awareness, prevention and care of mental health problems that might occur after a professional sports career should also be addressed.

LEVEL OF EVIDENCE

Level III.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PURPOSE

To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.

METHODS

A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.

RESULTS

Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.).

CONCLUSIONS

Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Epidemiology of symptoms of common mental disorders among elite Gaelic athletes: a prospective cohort study

OBJECTIVE

Scientific knowledge about symptoms of common mental disorders among elite Gaelic athletes is lacking. Consequently, this study aimed to (i) determine the prevalence, comorbidity and 6-month incidence of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance, adverse alcohol use) among elite Gaelic athletes and (ii) evaluate their association with potential stressors (severe musculoskeletal injuries, surgeries, recent life events, career dissatisfaction).

METHODS

An observational prospective cohort study by means of questionnaires was conducted over six months among elite Gaelic athletes (N=204). Using validated questionnaires to assess symptoms of common mental disorders as well as several stressors, an electronic questionnaire was set up and distributed by the Gaelic Players' Association.

RESULTS

Prevalence ranged from 23% for adverse alcohol use to 48% for anxiety/depression. Around 24% of the participants reported at baseline two symptoms. Six-month incidence ranged from 11% for sleep disturbance to 21% for anxiety/depression. Severe musculoskeletal injury, surgery, recent life events and career dissatisfaction led to an increased risk for common mental disorders.

CONCLUSION

Our findings indicate that raising the self-awareness of all stakeholders in Gaelic sports about common mental disorders should be prioritized, as well as the evidence-based development and application of adequate preventive and supportive measures.

Validation of the PASSPORT V2 training environment for arthroscopic skills

PURPOSE

Virtual reality simulators used in the education of orthopaedic residents often lack realistic haptic feedback. To solve this, the (Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment) PASSPORT simulator was developed, which was subjected to fundamental changes: improved realism and user interface. The purpose was to demonstrate its face and construct validity.

METHODS

Thirty-one participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task, which was timed. Face validity, educational value and user-friendliness were determined with two representative exercises and by asking participants to fill out the questionnaire. A value of 7 or greater was considered sufficient.

RESULTS

Construct validity was demonstrated between experts and novices. Median task time for the fifth trial was 55 s (range 17-139 s) for the novices, 33 s (range 17-59 s) for the intermediates, and 26 s (range 14-52 s) for the experts. Median task times of three trials were not significantly different between the novices and intermediates, and none of the trials between intermediates and experts. Face validity, educational value and user-friendliness were perceived as sufficient (median >7). The presence of realistic tactile feedback was considered the biggest asset of the simulator.

CONCLUSION

Proper preparation for arthroscopic operations will increase the quality of real-life surgery and patients' safety. The PASSPORT simulator can assist in achieving this, as it showed construct and face validity, and its physical nature offered adequate haptic feedback during training. This indicates that PASSPORT has potential to evolve as a valuable training modality.

Effects of Pulsed Electromagnetic Fields on Return to Sports After Arthroscopic Debridement and Microfracture of Osteochondral Talar Defects: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

BACKGROUND

Osteochondral defects (OCDs) of the talus usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracture. Various possibilities have been suggested to improve the recovery process after debridement and microfracture. A potential solution to obtain this goal is the application of pulsed electromagnetic fields (PEMFs), which stimulate the repair process of bone and cartilage.

HYPOTHESIS

The use of PEMFs after arthroscopic debridement and microfracture of an OCD of the talus leads to earlier resumption of sports and an increased number of patients that resume sports.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 68 patients were randomized to receive either PEMFs (n = 36) or placebo (n = 32) after arthroscopic treatment of an OCD of the talus. The primary outcomes (ie, the number of patients who resumed sports and time to resumption of sports) were analyzed with Kaplan-Meier curves as well as Mann-Whitney U, chi-square, and log-rank tests. Secondary functional outcomes were assessed with questionnaires (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot and Ankle Outcome Score, EuroQol, and numeric rating scales for pain and satisfaction) at multiple time points up to 1-year follow-up. To assess bone repair, computed tomography scans were obtained at 2 weeks and 1 year postoperatively.

RESULTS

Almost all outcome measures improved significantly in both groups. The percentage of sport resumption (PEMF, 79%; placebo, 80%; P = .95) and median time to sport resumption (PEMF, 17 weeks; placebo, 16 weeks; P = .69) did not differ significantly between the treatment groups. Likewise, there were no significant between-group differences with regard to the secondary functional outcomes and the computed tomography results.

CONCLUSION

PEMF does not lead to a higher percentage of patients who resume sports or to earlier resumption of sports after arthroscopic debridement and microfracture of talar OCDs. Furthermore, no differences were found in bone repair between groups.

REGISTRATION

Netherlands Trial Register NTR1636.

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects

PURPOSE

The purpose of this study was to describe the short-term clinical outcome of a new arthroscopic fixation technique for primary osteochondral talar defects: lift, drill, fill and fix (LDFF).

METHODS

Seven patients underwent an arthroscopic LDFF surgery for osteochondral talar defects, the mean follow-up was 12 months (SD 0.6). Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS) and the numeric rating scales (NRS) of pain at rest and during walking. Remodelling and bone ingrowth after LDFF were analysed on weight-bearing radiographs during follow-up.

RESULTS

In all patients, LDFF led to an improvement of the AOFAS and NRS of pain. The AOFAS significantly improved from 63 to 99 (p < 0.001). The NRS of pain at rest significantly improved from 2.9 to 0.1 (p = 0.004), and pain with walking significantly improved from 7.6 to 0.1 (p < 0.001). On the final radiographs, five of seven patients showed remodelling and bone ingrowth after LDFF.

CONCLUSIONS

The LDFF of an osteochondral talar defect appears to be a promising arthroscopic treatment option for primary talar osteochondral defects. Although the clinical and radiological results of 1-year follow-up are encouraging, more patients and longer follow-up are needed to draw any firm conclusions and determine whether the results stand the test of time.

LEVEL OF EVIDENCE

Prospective case series. Therapeutic, Level IV.

Validity and reliability of a Dutch version of the Foot and Ankle Ability Measure

PURPOSE

The aim of the study was to develop a Dutch language version of the Foot and Ankle Ability Measure (FAAM) and evaluate its measurement properties according to the consensus-based standards for the selection of health measurement instruments (COSMIN) definitions.

METHODS

A forward-backward translation procedure was performed and subsequently the Dutch version of the FAAM was evaluated for its reliability and validity in 369 patients with a variety of foot and ankle complaints. The reliability was assessed by calculating the intraclass correlation coefficients (ICC, test-retest reliability), Cronbach's alpha (internal consistency), the standard error of measurement and the minimal detectable change (MDC). Additionally, this was done for athletes. The construct validity was assessed by the use of Spearman's correlation coefficient between FAAM domains and similar and contradictory domains of the Foot and Ankle Outcome Score, Short Form 36 and the Numeric Rating Scale for pain.

RESULTS

The ICC of the subscales ranged from 0.62 to 0.86. Cronbach's alpha's minimum was 0.97. At individual level, the MDC ranged from 23.9 to 44.7 and at group level from 2.77 to 4.32. In the subgroup of athletes, the reliability was higher. The hypothesized correlations of the construct validity were supported by an 80% confirmation rate.

CONCLUSION

The Dutch version of the FAAM met adequate measurement properties, although the reliability is not optimal. The FAAM-Sport subscale is more useful in athletes and the FAAM-Sport % seems not to contribute. In athletes with various foot and ankle symptoms, the FAAM can be used for functional assessment and follow-up at group level. For the general population, the FAAM is less appropriate.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Evaluation of the Dutch version of the Foot and Ankle Outcome Score (FAOS): Responsiveness and Minimally Important Change

PURPOSE

The aim of this study was to evaluate the responsiveness of the Foot and Ankle Outcome Score (FAOS) and provide data on the Minimally Important Change (MIC) in patients 1 year after hindfoot and ankle surgery.

METHODS

Prospective pre-operative and 1 year post-operative FAOS scores were collected from 145 patients. A patient's global assessment and a longitudinal derived Function Change Score were used as external anchors. To assess responsiveness, effect sizes (ES) and Standardized Response Means (SRM) were calculated and hypotheses on their magnitudes were formulated. Additional ROC curve analysis was performed, and the Area Under the Curve (AUC) was calculated as a measure of responsiveness. MIC values were estimated using two different methods: (1) the mean change method and (2) the optimal cut-off point of the ROC curve.

RESULTS

Responsiveness was supported by confirmation of 84% of the hypothesized ES and SRM and almost all AUCs exceeding 0.70. MIC values ranged from 7 (symptoms) to 38 (sport) points. They varied between calculation methods and were negatively associated with baseline values. A considerable amount of MIC values did not exceed the smallest detectable change limit, indicating that the FAOS is more suitable at group level than for longitudinally following individual patients.

CONCLUSIONS

The FAOS demonstrated good responsiveness in patients 1 year after hindfoot and ankle surgery. Due to their wide variation, MIC estimates derived in this study should be interpreted with caution. However, these estimates can be of value to facilitate sample size calculation in future studies.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

M. J. Kerkhoffs G. Injuries, Matches Missed and the Influence of Minimum Medical Standards in the A-League Professional Football: A 5-Year Prospective Study

BACKGROUND

Epidemiological data on the occurrence of time-loss injuries over several A-League seasons remains lacking, while the effect of the mandatory implementation of 'Minimum Medical Standards' as a part of the collective bargaining agreement (CBA) needs to be explored.

OBJECTIVES

To explore the 5 year evolution of hamstring, groin, knee, ankle and total time-loss injuries among professional footballers in the A-League; to evaluate the consequences of these time-loss injuries in terms of total matches missed and costs incurred; and to explore whether the mandatory implementation of 'Minimum Medical Standards' in the A-League had led to a decrease in the occurrence of total time-loss injuries and total matches missed.

PATIENTS AND METHODS

An observational prospective study has been carried out since 2008. Data were collected weekly during the seasons 2008 - 2009 to 2012 - 2013 through official match previews/reviews, official media releases, official websites and/or self-reports by players. Total and specific (hamstring, groin, knee and ankle) numbers of time-loss injuries and matches missed were obtained for each season and the related financial costs calculated.

RESULTS

The total number of time-loss injuries and matches missed rose from 129 and 506 respectively in 2008 - 2009 to 202 and 1110 in 2010 - 2011. Following the introduction of 'Minimum Medical Standards', both categories decreased (significantly for matches missed). These time-loss injuries and matches missed led to high costs of up to AUD$ 37,317,029.29 (2012 - 2013 season). The same trend was found for knee injuries, while hamstring and ankle injuries remained almost the same. However, time-loss due to groin injuries increased despite the introduction of "Minimum Medical Standards".

CONCLUSIONS

The introduction of "Minimum Medical Standards" in the A-League had a favorable effect on the number of total, hamstring, knee and ankle injuries and on the number of matches missed due to these injuries, but not on the number of groin injuries. The costs related to time-loss injuries and related matches missed remained high.

Return to Sports and Physical Activity After Total and Unicondylar Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.

OBJECTIVES

Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.

METHODS

PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) 'arthroplasty', 'sports' and 'recovery of function', the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.

RESULTS

Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89% after TKA and from 75 to >100% after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1-4.6 after UKA and 0.2-1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.

CONCLUSIONS

Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.

Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review

PURPOSE

The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures.

METHODS

A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included.

RESULTS

Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5% at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022).

CONCLUSIONS

Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Rehabilitation after surgical treatment of peroneal tendon tears and ruptures

PURPOSE

The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures.

METHODS

A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies.

RESULTS

In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options.

CONCLUSION

Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation.

LEVEL OF EVIDENCE

Systematic Review, Level IV.