Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty

Background

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

Methods

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

Results

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Conclusions

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Survival rates of anatomically shaped and tapered slip cemented femoral implants: an analysis of 76,281 femoral implants of the Dutch arthroplasty register (LROI)

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 <100 times. Survival analyses were performed using Kaplan-Meier survival analysis and multivariable Cox-proportional hazard analysis.

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 < 0.001). Multivariable regression analysis revealed a higher rate for revision because of loosening of the AS implants (HR 2; CI, 1.4-3.1). AS implants had a lower rate for periprosthetic fractures compared with the CPT implants (HR 0.13; CI, 0.07-0.23).

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.

Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study

BACKGROUND

Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties.

METHODS

Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties.

RESULTS

A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision.

CONCLUSION

Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

Orthopaedic surgeons' perspective on the implementation of outpatient hip and knee arthroplasty - Results of a nationwide survey

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.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons

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.

Prosthetic hip-associated cobalt toxicity: a systematic review of case series and case reports

Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty. The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms. A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients. The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases). Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system. The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings. We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing. Level of Evidence: Level V, systematic review.

Age-Associated Changes in Proximal Femur Morphology Affect Femoral Component Sizing in Cementless Hip Arthroplasty

Background

In cementless hip arthroplasty, the femoral component should obtain firm fixation within the endosteal bone and achieve adequate reconstruction of hip joint biomechanics simultaneously. Previous anatomical studies described age-related changes of the proximal femoral canal, such as canal widening, which theoretically necessitates the use of larger stem sizes in elderly patients. This study examines a potential association between patients’ age at surgery and the implant size of a cementless femoral component.

Material and methods

A total of 13,423 primary hip arthroplasties with a single cementless stem registered in the Dutch Arthroplasty Register (LROI) were included. Patient characteristics (ie patients’ age, sex, height and weight at time of surgery) and femoral component size were derived. A one-way ANCOVA was used to compare the mean stem size between age groups, and multivariable linear regression analysis was used in order to investigate to which extent ageing impacted stem size.

Results

Each subsequent age- group (ten-year intervals) had a significantly larger mean stem size than the prior age- group. Multivariable linear regression analysis revealed that age is positively correlated with stem size and that this correlation is more prominent in females than in males (beta = .046, P < .001 and beta = .028, P < .001 respectively).

Interpretation

Implant size is positively correlated with age, in particular in females and independently from investigated anthropometric characteristics. The present study endorses that the femoral canal morphology is related to patients’ characteristics such as age and sex. The morphology will subsequently influence implant sizing and therefore may have biomechanical and clinical implications.

Implicit gender-career bias in postgraduate medical training still exists, mainly in residents and in females

BACKGROUND

More and more female residents enter postgraduate medical training (PGMT). Meanwhile, women are still underrepresented in academic medicine, in leadership positions and in most surgical specialties. This suggests that female residents' career development may still be negatively impacted by subtle, often unconscious stereotype associations regarding gender and career-ambition, called implicit gender-career bias. This study explored the existence and strength of implicit gender-career bias in doctors who currently work in PGMT, i.e. in attending physicians who act as clinical trainers and in their residents.

METHODS

We tested implicit gender-career bias in doctors working in PGMT by means of an online questionnaire and an online Implicit Association Test (IAT). We used standard IAT analysis to calculate participants' IAT D scores, which indicate the direction and strength of bias. Linear regression analyses were used to test whether the strength of bias was related to gender, position (resident or clinical trainer) or specialty (non-surgical or surgical specialty).

RESULTS

The mean IAT D score among 403 participants significantly differed from zero (D-score = 0.36 (SD = 0.39), indicating bias associating male with career and female with family. Stronger gender-career bias was found in women (β_female =0 .11; CI 0.02; 0.19; p = 0.01) and in residents (β_resident 0.12; CI 0.01; 0.23; p = 0.03).

CONCLUSIONS

This study may provide a solid basis for explicitly addressing implicit gender-career bias in PGMT. The general understanding in the medical field is that gender bias is strongest among male doctors' in male-dominated surgical specialties. Contrary to this view, this study demonstrated that the strongest bias is held by females themselves and by residents, independently of their specialty. Apparently, the influx of female doctors in the medical field has not yet reduced implicit gender-career bias in the next generation of doctors, i.e. in today's residents, and in females.

Cost-effectiveness analyses comparing cemented, cementless, hybrid and reverse hybrid fixation in total hip arthroplasty: a systematic overview and critical appraisal of the current evidence

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.

Quality, but not quantity of physical activity is associated with metal ion concentrations in unilateral hip resurfacing

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.

Patients with hip resurfacing arthroplasty are not physically more active than those with a stemmed total hip

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.

Metal ion concentrations after metal-on-metal hip arthroplasty are not correlated with habitual physical activity levels

INTRODUCTION

Metal-on-metal (MoM) hip arthroplasties have shown high clinical failure rates with many patients at risk for a revision and under surveillance for high metal ion concentrations. Implant wear releasing such ions is assumed to be a function of use, i.e. the patient's physical activity. This study aimed to assess whether habitual physical activity levels of MoM patients are correlated with metal ion concentrations and are higher in patients with high (at risk) than in patients with low (safe) metal ion concentrations.

METHODS

A cohort study was conducted of patients with any type of MoM hip prosthesis. Metal ion concentrations were determined using ICP-MS. Habitual physical activity of subjects was measured in daily living using an acceleration-based activity monitor. Outcome consisted of quantitative and qualitative activity parameters.

RESULTS

In total, 62 patients were included. Mean age at surgery was 60.8 ± 9.3 years and follow-up was 6.3 ± 1.4 years. Cobalt concentrations were highly elevated overall (112.4 ± 137.9 nmol/L) and significantly more in bilateral (184.8 ± 106.5 nmol/L) than in unilateral cases (87.8 ± 139.4 nmol/L). No correlations were found between physical activity parameters and metal ion concentrations. Subgroup analysis of patients with low versus high cobalt concentration showed no significant differences in habitual physical activity.

DISCUSSION

No correlation was found between physical activity levels and metal ion concentrations. Implant use by normal habitual activities of daily living seems not to influence metal ion concentrations.

Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial

Background

Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS).

Methods

Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein–enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested.

Results

One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4–185 days) in the intervention group versus control 35.5 days (3–183 days; p_logrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68–1.41). Hospital LOS: 12.0 days (4–56 days) versus 11.0 days (3–115 days; p = .19; adjHR: 0.75; 95% CI: 0.53–1.06) and LOS in rehabilitation clinics: 19.5 days (0–174 days) versus 18.5 days (0–168 days; p = .82; adjHR: 1.04; 95% CI: 0.73–1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found.

Conclusions

Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals

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.

The association of leg length and offset reconstruction after total hip arthroplasty with clinical outcomes

BACKGROUND

Restoring native hip anatomy and biomechanics is important to create a well-functioning hip arthroplasty. This study investigated the association of hip offset and leg length after hip arthroplasty with clinical outcomes, including patient reported outcome measures, the Trendelenburg Test and gait analysis.

METHODS

In 77 patients undergoing primary hip arthroplasty for osteoarthritis (age mean = 65 SD = 11 years; BMI mean = 27 SD = 5 kg/m²), hip offset and leg length discrepancy were measured on anteroposterior radiographs. The Western Ontario & McMaster Universities Osteoarthritis Index, the Trendelenburg Test and gait were assessed preoperatively, and at 3 and 12 months postoperatively. An inertial measurement unit was used to derive biomechanical parameters, including spatiotemporal gait parameters and tilt angles of the pelvis. Relationships between radiographic and functional outcomes were investigated, and subgroups of patients with >15% decreased and increased femoral offset were analysed separately.

FINDINGS

Patient-reported function scores and clinical tests demonstrated a few significant, weak correlations with radiographic outcomes (Spearman's ρ range = 0.26-0.32; p < 0.05). Undercorrection of femoral offset was associated with lower patient-reported function scores and with more step irregularity as well as step asymmetry during gait. Postoperative leg length inequality was associated with increased frontal plane tilt angle of the pelvis during the Trendelenburg Test and increased sagittal plane motion of the pelvis during gait. Femoral offset subgroups demonstrated no significant differences for patient-reported function scores and outcomes of the Trendelenburg Test and gait analysis.

INTERPRETATION

Reduced hip offset and leg length discrepancy following hip arthroplasty seem to be marginally associated with worse clinical outcomes.

Experienced barriers in shared decision-making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons

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.

Performance on a Single-Legged Drop-Jump Landing Test Is Related to Increased Risk of Lateral Ankle Sprains Among Male Elite Soccer Players: A 3-Year Prospective Cohort Study

BACKGROUND

Soccer has a high injury rate, with lateral ankle sprains being a common injury. Therefore, an approach to prevent or at least reduce the occurrence is warranted. Injury prevention can be improved by identifying specific risk factors and individuals at risk.

PURPOSE

To assess drop-jump landing performance as a potential predictor of lateral ankle sprain within 3-year follow-up.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Single-legged drop-jump landing tests were performed by 190 elite soccer players. Based on ground-reaction forces, 6 outcome measures were calculated that aim to reflect the impact and stabilization phase. Lateral ankle sprains were registered during up to 3 years of follow-up. Following a z score correction for age, a multivariate regression analysis was performed.

RESULTS

During follow-up, 45 players (23.7%) suffered a primary lateral ankle sprain. Of those, 34 were regarded as severe (absence >7 days). Performance was related to increased risk of ankle sprain ( P = .005 for all sprains and P = .001 for severe sprains). Low mediolateral stability for the first 0.4 seconds after landing (a larger value indicates more force exerted in the mediolateral direction, resulting in rapid lateral stabilization) and high horizontal ground-reaction force between 3.0 and 5.0 seconds (a smaller value indicates less sway in the stabilization phase) were identified as risk factors. A player that scored 2 SD below average for both risk factors had a 4.4-times-higher chance of sustaining an ankle sprain than a player who scored average.

CONCLUSION

The current study showed that following a single-legged drop-jump landing, mediolateral force over 0 to 0.4 seconds and/or mean resultant horizontal ground-reaction force over 3 to 5 seconds has predictive value with regard to the occurrence of an ankle sprain among male elite soccer players within 3 years.

Effects of implementing time-variable postgraduate training programmes on the organization of teaching hospital departments

INTRODUCTION

As competency-based education has gained currency in postgraduate medical education, it is acknowledged that trainees, having individual learning curves, acquire the desired competencies at different paces. To accommodate their different learning needs, time-variable curricula have been introduced making training no longer time-bound. This paradigm has many consequences and will, predictably, impact the organization of teaching hospitals. The purpose of this study was to determine the effects of time-variable postgraduate education on the organization of teaching hospital departments.

METHODS

We undertook exploratory case studies into the effects of time-variable training on teaching departments' organization. We held semi-structured interviews with clinical teachers and managers from various hospital departments.

RESULTS

The analysis yielded six effects: (1) time-variable training requires flexible and individual planning, (2) learners must be active and engaged, (3) accelerated learning sometimes comes at the expense of clinical expertise, (4) fast-track training for gifted learners jeopardizes the continuity of care, (5) time-variable training demands more of supervisors, and hence, they need protected time for supervision, and (6) hospital boards should support time-variable training.

CONCLUSIONS

Implementing time-variable education affects various levels within healthcare organizations, including stakeholders not directly involved in medical education. These effects must be considered when implementing time-variable curricula.

Discrepancy and contradiction regarding fixation of hip stems with or without cement: survey among 765 hip arthroplasty specialists

INTRODUCTION

The growing use of cementless stems is associated with an increase in implant-related complications. This global survey study investigates which parameters orthopaedic surgeons currently consider for either cemented or cementless stem fixation in primary total hip arthroplasty (THA).

METHODS

A survey regarding current practice patterns was distributed among hip arthroplasty specialists. Key questions concerned: (i) frequency of using cemented/cementless stems; (ii) frequency of using parameters which influence a choice between both; (iii) usage of specific cut-off values for parameters.

RESULTS

507 (out of 765) respondents, having at least 5 years' experience and performing at least 50 cases a year, were selected for analysis. Respondents using both fixation techniques ( n = 413; 81%) use a cementless stem in 69% and a cemented stem in 31%. The choice is most frequently based on: (i) patient age; (ii) cortical thickness; (iii) femoral canal shape; (iv) bone mineral density; and (v) stem fit on preoperative templating. 57% using both fixation techniques do not use a specific cut-off value for age. 92% of the respondents that do use a cut-off value for age use exclusively cemented stems in patients being ⩾72.7 years (median 75; range 50-90 years). Considerable discrepancy and even contradictory responses were present regarding the other parameters and the use of specific cut-off values.

CONCLUSIONS

Current practice patterns regarding stem fixation in primary THA vary substantially among orthopaedic surgeons. Evidence-based guidelines are needed to define which parameters and threshold values support the best individual choice for hip stem fixation.

Current practice of orthopaedic surgical skills training raises performance of supervised residents in total knee arthroplasty to levels equal to those of orthopaedic surgeons

AIM

To investigate whether the current, generally accepted practice of orthopaedic surgical skills training can raise the performance of supervised residents to levels equal to those of experienced orthopaedic surgeons when it comes to clinical outcomes or implant position after total knee arthroplasty.

METHODS

In a retrospective analysis of primary total knee arthroplasty outcomes (minimum follow-up of 12 months) procedures were split into two groups: supervised orthopaedic residents as first surgeon (group R), and experienced senior orthopaedic surgeons as first surgeon (group S). Outcome data that were compared 1 year postoperatively were operation times, complications, revisions, Knee Society Scores (KSS) and radiological implant positions.

RESULTS

Of 642 included procedures, 220 were assigned to group R and 422 to group S. No statistically significant differences between the two groups were found in patient demographics. Operation time differed significantly (group R: 81.3 min vs. group S: 71.3 min (p = 0.000)). No statistically significant differences were found for complications (p = 0.659), revision rate (p = 0.722), femoral angle (p = 0.871), tibial angle (p = 0.804), femoral slope (p = 0.779), tibial slope (p = 0.765) and KSS (p = 0.148).

DISCUSSION AND CONCLUSION

Supervised residents needed 10 minutes extra operation time, but they provided the same quality of care in primary total knee arthroplasty as experienced orthopaedic surgeons concerning complication rates, revisions, implant position on radiographs and KSS. The currently used training procedure in which the supervising surgeon and the resident decide if the resident is ready to be first surgeon is safe for patients.

Flexible competency based medical education: More time efficient, higher costs

The financing of postgraduate medical education (PGME) becomes an important topic. PGME is costly, and in most western countries is partly paid by public funding. One of the models that can help to reduce costs is time-variable PGME. Moving to true outcome-based education can lead to more efficient training programs while maintaining educational quality. We analyzed the financial effects of time-variable PGME by identifying the educational activities of PGME programs and comparing the costs and revenues of these activities in gynecology training as an example. This resulted in a revenue-cost balance of PGME activities in gynecology. As gynecology consists of both surgical and non-surgical parts, this specialty is a good starting point for a training cost analysis that can be used for a more general discussion. Shortening PGME programs without losing educational quality appears to be possible with time-variable structures. However, shortening is only safely possible on those areas in which residents have already obtained the desired level of competence. This means that time can be gained at the expense of those educational activities in which residents generate the highest revenues. We therefore conclude that shorter education with the help of time-variable training schemes leads to overall higher costs at the hospital level.

Physical activity after outpatient surgery and enhanced recovery for total knee arthroplasty

PURPOSE AND HYPOTHESIS

The purpose of this study was to 'objectively' measure improvement of physical activity with the use of an activity monitor between patients who followed an enhanced recovery- or outpatient surgery pathway after total knee arthroplasty (TKA). It was hypothesized that both pathways will have comparable physical activity after TKA at 6-week follow-up.

METHODS

This prospective observational comparative case study was designed to investigate activity parameters (e.g. physical activity, number of steps, sit-stand transfers) of two different pathways after 6 weeks with the use of a non-invasive triaxial accelerometer activity monitor. This study included 20 patients with a mean age of 65.5 years (SD 6.1) undergoing TKA who were allocated to follow one of the two pathways: enhanced recovery (n = 10) or outpatient surgery (n = 10). Patients were monitored for 4 days pre-, 4 days during and 4 days after 5 weeks postoperatively. Patient-reported outcome measures (PROMs) and range of knee motion were obtained pre- and 6 weeks postoperatively.

RESULTS

The activity parameters recovered steeply during the first 4 postoperative days and continued to improve within both pathways (n.s.). Preoperative and during the first 4 days and 5 weeks postoperative, activity parameters were comparable (n.s.) between both pathways but did not reach preoperative levels of physical activity and range of motion (n.s.). PROMs improved within each pathway, and no difference between both pathways was observed (n.s.).

CONCLUSIONS

This study demonstrates that the early physical activity parameters of patients after TKA, following the outpatient surgery pathway, were similar to patients who followed the standard enhanced recovery pathway. The activity monitor is an added value for a more detailed and objective analysis of the physical performance in patients after TKA.

LEVEL OF EVIDENCE

III.

Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck: a systematic review and meta-analysis of current generation hip stems

AIMS

Our aim was to prepare a systematic review and meta-analysis to compare the outcomes of cemented and cementless hemiarthroplasty of the hip, in elderly patients with a fracture of the femoral neck, to investigate the mortality, complications, length of stay in hospital, blood loss, operating time and functional results.

MATERIALS AND METHODS

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on randomised controlled trials (RCTs), studying current generation designs of stem only. The synthesis of results was done of pooled data, with a fixed effects or random effects model, based on heterogeneity.

RESULTS

A total of five RCTs including 950 patients (950 hips) were included. Cementless stems were found to be associated with more complications compared with cemented stems (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.12 to 2.31, p = 0.01), especially implant-related complications (OR 3.15, 95% CI 1.55 to 6.41, p = 0.002). The operating time was shorter for cementless stems (weighted mean difference -9.96 mins, 95%CI -12.93 to -6.98, p < 0.001). The data on functional outcomes could not be pooled. There was no statistically significant difference for any other outcome between the two methods of fixation.

CONCLUSION

In hemiarthroplasty of the hip using current generation stems, cemented stems result in fewer implant-related complications and similar mortality compared with cementless stems. Cite this article: Bone Joint J 2017;99-B:421-31.

Validation of a novel activity monitor in impaired, slow-walking, crutch-supported patients

BACKGROUND

A growing need in clinical practice of rehabilitation and orthopaedic medicine is for objective outcome tools to estimate physical activity. Current techniques show limited validity or are too demanding for routine clinical use. Accelerometer-based activity monitors (AMs) have shown promise for measuring physical activity in healthy people but lack validity in impaired patients.

OBJECTIVES

This study aimed to validate an accelerometer-based AM in impaired, slow-walking, crutch-supported patients after total joint arthroplasty (TJA).

METHODS

Shortly after TJA, patients who were safely mobilized with 2 crutches and 8 healthy participants completed a trial of different activities while wearing the AM on the lateral upper leg and being videotaped. Outcome variables (e.g., time walking, number of gait cycles, sit-stand-sit transfers) were compared to video recordings, and sensitivity, predictive value and mean percentage difference (MPD) values were calculated.

RESULTS

We included 40 patients (mean age: 65±9 years; mean BMI: 30±6kg/m²; male:female ratio: 18:22) and 8 healthy participants (mean age: 49±20 years; mean BMI: 23±0.7kg/m²; male:female ratio: 5:3). The AM showed excellent sensitivity (>95%) and predictive value (>95%) in identifying activities (e.g., walking, sitting, resting) and detecting the number of gait cycles and sit-stand-sit transfers (mean percentage difference: ±2%). Detection of number of steps ascending and descending stairs and cadence was more difficult but still showed good results (mean percentage difference: ±7%).

CONCLUSIONS

This is the first validation study to assess physical activity with an AM in impaired, slow-walking, crutch-supported patients. The AM was a valid tool for measuring physical activity in these patients. The tool may help in evaluating and optimizing rehabilitation programs for patients after TJA, those recovering from stroke or chronic impaired patients.

Dealing with the complex dynamics of teaching hospitals

Innovation and change in postgraduate medical education programs affects teaching hospital organizations, since medical education and clinical service are interrelated.Recent trends towards flexible, time-independent and individualized educational programs put pressure on this relationship. This pressure may lead to organizational uncertainty, unbalance and friction making it an important issue to analyze.The last decade was marked by a transition towards outcome-based postgraduate medical education. During this transition competency-based programs made their appearance. Although competency-based medical education has the potential to make medical education more efficient, the effects are still under debate. And while this debate continues, the field of medical education is already introducing next level innovations: flexible and individualized training programs. Major organizational change, like the transition to flexible education programs, can easily lead to friction and conflict in teaching hospital organizations.This article analyses the organizational impact of postgraduate medical education innovations, with a particular focus on flexible training and competency based medical education. The characteristics of teaching hospital organizations are compared with elements of innovation and complexity theory.With this comparison the article argues that teaching hospital organizations have complex characteristics and behave in a non-linear way. This perspective forms the basis for further discussion and analysis of this unexplored aspect of flexible and competency based education.

Adjustments in 2011 KSS increase the clinical suitability

The 2011 KSS is a valid clinical TKA questionnaire, but with a low completion rate (42%). Adjustments, focusing on optimizing scale features, are required to improve its clinical use. The low completion rates, non-optimal scale features, lacking rules or a combination of these factors where addressed, leading to the development of the adjusted 2011 KSS (2011 KSS-A). Four-hundred-ninety-nine primary TKA patients were addressed pre- and postoperative by mail. Clinimetric quality was evaluated. Seventy percent responded and 90% completed the scale. Internal consistency proved excellent with Cronbach's Alpha≥0.79 for all subscales. Strong correlations were found between the Functional Activity subscales and KOOS-PS (r=-0.63 to -0.87). All subscales improved significantly after intervention (r-range 14-33%, effect size 0.50-2.85). Postoperatively, ceiling effects were found in the subscales Symptoms (16%) and Walking & Standing (26%). Adjustments led to a shortened and simplified questionnaire while maintaining its clinimetric quality.

Assessment of physical function following total hip arthroplasty: Inertial sensor based gait analysis is supplementary to patient-reported outcome measures

BACKGROUND

Functional outcome assessment after total hip arthroplasty often involves subjective patient-reported outcome measures whereas analysis of gait is more objective. The study's aims were to compare subjective and objective functional outcomes after total hip arthroplasty between patients with low and high self-reported levels of pre-operative physical function.

METHODS

Patients undergoing total hip arthroplasty (n=36; m/f=18/18; mean age=63.9; SD=9.8 years; BMI=26.3; SD=3.5) were divided into a low and high function subgroup, and prospective measures of WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function score and gait were compared at baseline and 3 and 12 months post-operatively.

FINDINGS

WOMAC function scores significantly improved in both low and high function subgroups at 3 months post-operatively whereas gait parameters only improved in patients with a low pre-operative function. Between 3 and 12 months post-operatively, WOMAC function scores had not significantly further improved whereas several gait parameters significantly improved in the low function group. WOMAC function scores and gait parameters were only moderately correlated (Spearman's r=0.33-0.51).

INTERPRETATION

In a cohort of patients undergoing total hip arthroplasty, pre-operative differences in mean WOMAC function scores and gait parameters between low and high function subgroups disappeared by 3 months post-operatively. Gait parameters only improved significantly during the first 3 post-operative months in patients with a low pre-operative function, highlighting the importance of investigating relative changes rather than the absolute changes and the need to consider patients with high and low functions separately.

Validity of an inertial measurement unit to assess pelvic orientation angles during gait, sit-stand transfers and step-up transfers: Comparison with an optoelectronic motion capture system

An inertial measurement unit (IMU) allows kinematic evaluation of human motion with fewer operational constraints than a gold standard optoelectronic motion capture (MOCAP) system. The study's aim was to compare IMU and MOCAP measurements of dynamic pelvic orientation angles during different activities of daily life (ADL): gait, sit-to-stand (STS) transfers and block step-up (BS) transfers. A single IMU was attached onto the lower back in seventeen healthy participants (8F/9 M, age 19-31 years; BMI < 25) and optical skin markers were attached onto anatomical pelvic landmarks for MOCAP measurements. Comparisons between IMU and MOCAP by Bland-Altman plots demonstrated that measurements were between 2SD of the absolute difference and Pearson's correlation coefficients were between 0.85 and 0.94. Frontal plane pelvic angle estimations achieved a RMSE in the range of [2.7°-4.5°] and sagittal plane measurements achieved a RMSE in the range of [2.7°-8.9°] which were both lowest in gait. Waveform peak detection times demonstrated ICCs between 0.96 and 1.00. These results are in accordance to other studies comparing IMU and MOCAP measurements with different applications and suggest that an IMU is a valid tool to measure dynamic pelvic angles during various activities of daily life which could be applied to monitor rehabilitation in a wide variety of musculoskeletal disorders.

Patient-reported outcome measures versus inertial performance-based outcome measures: A prospective study in patients undergoing primary total knee arthroplasty

BACKGROUND

Outcome assessment of total knee arthroplasty (TKA) by subjective patient reported outcome measures (PROMs) may not fully capture the functional (dis-)abilities of relevance. Objective performance-based outcome measures could provide distinct information. An ambulant inertial measurement unit (IMU) allows kinematic assessment of physical performance and could potentially be used for routine follow-up.

AIM

To investigate the responsiveness of IMU measures in patients following TKA and compare outcomes with conventional PROMs.

METHODS

Patients with end stage knee OA (n=20, m/f=7/13; age=67.4 standard deviation 7.7 years) were measured preoperatively and one year postoperatively. IMU measures were derived during gait, sit-stand transfers and block step-up transfers. PROMs were assessed by using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society Score (KSS). Responsiveness was calculated by the effect size, correlations were calculated with Spearman's rho correlation coefficient.

RESULTS

One year after TKA, patients performed significantly better at gait, sit-to-stand transfers and block step-up transfers. Measures of time and kinematic IMU measures demonstrated significant improvements postoperatively for each performance-based test. The largest improvement was found in block step-up transfers (effect size=0.56-1.20). WOMAC function score and KSS function score demonstrated moderate correlations (Spearman's rho=0.45-0.74) with some of the physical performance-based measures pre- and postoperatively.

CONCLUSION

To characterize the changes in physical function after TKA, PROMs could be supplemented by performance-based measures, assessing function during different activities and allowing kinematic characterization with an ambulant IMU.

The Morphology of the Proximal Femoral Canal Continues to Change in the Very Elderly: Implications for Total Hip Arthroplasty

A shape mismatch between cementless stems and the femoral canal of very elderly patients could partly explain the inferior performance of cementless compared to cemented stems in this age group. Influences of age and gender on canal morphology were investigated by measuring coronal/sagittal dimensions on CT-scans of subjects ≥80 years old (n = 117) and subjects < 80 years old (n = 51). Absolute canal dimensions like width were larger in octogenarians than in younger subjects. These differences were larger in the sagittal plane than in the coronal plane (P < 0.001). Canal flaring changed asymmetrically with increased medial and less lateral flaring in octogenarians. Age-related changes were mainly observed in females and should be taken into consideration for implant design, selection and implantation in octogenarians.

Accelerometer-based Physical Activity Monitoring in Patients with Knee Osteoarthritis: Objective and Ambulatory Assessment of Actual Physical Activity During Daily Life Circumstances

Background:

It is important to assess physical activity objectively during daily life circumstances, to understand the association between physical activity and diseases and to determine the effectiveness of interventions. Accelerometer-based physical activity monitoring seems a promising method and could potentially capture all four FITT (i.e. Frequency, Intensity, Time, Type) components of physical activity considered by the World Health Organization (WHO).

Aim:

To assess the four FITT components of physical activity with an accelerometer during daily life circumstances and compare with self-reported levels of physical activity in patients with knee osteoarthritis (OA) and a healthy control group.

Methods:

Patients (n=30) with end-stage knee OA and age-matched healthy subjects (n=30) were measured. An ambulant tri-axial accelerometer was placed onto the lateral side of the upper leg. Physical activity was measured during four consecutive days. Using algorithm-based peak detection methods in Matlab, parameters covering the four FITT components were assessed. Self-reported physical activity was assessed using the Short questionnaire to assess health enhancing physical activity (SQUASH).

Results:

Knee OA patients demonstrated fewer walking bouts (154 ±79 versus 215 ±65 resp.; p=0.002), step counts (4402 ±2960 steps/day versus 6943 ±2581 steps/day; p=0.001) and sit-to-stand (STS) transfers (37 ±14 versus 44 ±12; p=0.031) compared to controls. Knee OA patients demonstrated more time sitting (65 ±15% versus 57 ±10% resp.; p=0.029), less time walking (8 ±4% versus 11 ±4% resp.; p=0.014) and lower walking cadence (87 ±11steps/min versus 99 ± 8steps/min resp.; p<0.001). Accelerometer-based parameters of physical activity were moderately-strong (Pearsons’s r= 0.28-0.49) correlated to self-reported SQUASH scores.

Conclusion:

A single ambulant accelerometer-based physical activity monitor feasibly captures the four FITT components of physical activity and provides more insight into the actual physical activity behavior and limitations of knee OA patients in their daily life.

Clinimetric quality of the new 2011 Knee Society score: high validity, low completion rate

BACKGROUND

The demands of the younger and more active current total knee arthroplasty (TKA) patients are not in line with the current outcome assessments. Therefore, new questionnaires are developed or adjusted, as with the popular 1989 Knee Society Score (KSS). This study is the first to investigate the clinimetric parameters of the patient-reported outcome measurement (PROM) part of the 2011 KSS.

METHODS

Four-hundred-fifteen primary Dutch TKA patients were scored using the PROM part of the 2011 KSS. The scale is subdivided into an Objective (not evaluated), Satisfaction, Expectation and Function subscales. Clinimetric quality was evaluated by response and completion rate, test-retest reliability (n=29, intraclass correlation coefficient), internal consistency (n=172, Cronbach's alpha), construct validity (Pearson's correlations with 1989 KSS (n=75) and KOOS-PS (n=139)) and responsiveness (n=20, paired-samples t-test, effect sizes and floor and ceiling effects).

RESULTS

A response rate of 96% and completion rate of 43% were found. Reliability and internal consistency proved excellent with ICCs≥0.79 and Cronbach's alpha≥0.76 for all subscales. Strong correlations were found between the Function subscales of the 2011 KSS and KOOS-PS (r=-0.60 to -0.83). All subscales improved significantly after intervention, with exception of Walking & Standing and Discretionary Activities. 23% reached the maximum score postoperatively in Walking & Standing, indicating a ceiling effect.

CONCLUSIONS

The 2011 KSS is a reliable, internal consistent, construct valid and responsive questionnaire to assess the outcome of the Dutch TKA patients. Optimizations (e.g. shortening the scale, simplified design) are recommended to increase the disappointing completion rate.

CLINICAL RELEVANCE

The 2011 KSS is a reliable, internal consistent, construct valid and responsive questionnaire to assess the outcome of the Dutch TKA patients.

Quantification of 18F-Fluoride Kinetics: Evaluation of Simplified Methods

(18)F-fluoride PET is a promising noninvasive method for measuring bone metabolism and bone blood flow. The purpose of this study was to assess the performance of various clinically useful simplified methods by comparing them with full kinetic analysis. In addition, the validity of deriving bone blood flow from K1 of (18)F-fluoride was investigated using (15)O-H2O as a reference.

METHODS

Twenty-two adults (mean age ± SD, 44.8 ± 25.2 y), including 16 patients scheduled for bone surgery and 6 healthy volunteers, were studied. All patients underwent dynamic (15)O-H2O and (18)F-fluoride scans before surgery. Ten of these patients had serial PET measurements before and at 2 time points after local bone surgery. During all PET scans, arterial blood was monitored continuously. (18)F-fluoride data were analyzed using nonlinear regression (NLR) and several simplified methods (Patlak and standardized uptake value [SUV]). SUV was evaluated for different time intervals after injection and after normalizing to body weight, lean body mass, and body surface area, and simplified measurements were compared with NLR results. In addition, changes in SUV and Patlak-derived fluoride influx rate (Ki) after surgery were compared with corresponding changes in NLR-derived Ki. Finally, (18)F-fluoride K1 was compared with bone blood flow derived from (15)O-H2O data, using the standard single-tissue-compartment model.

RESULTS

K1 of (18)F-fluoride correlated with measured blood flow, but the correlation coefficient was relatively low (r = 0.35, P < 0.001). NLR resulted in a mean Ki of 0.0160 ± 0.0122, whereas Patlak analysis, for the interval 10-60 min after injection, resulted in an almost-identical mean Ki of 0.0161 ± 0.0117. The Patlak-derived Ki, for 10-60 min after injection, showed a high correlation with the NLR-derived Ki (r = 0.976). The highest correlation between Ki and lean body mass-normalized SUV was found for the interval 50-60 min (r = 0.958). Finally, changes in SUV correlated significantly with those in Ki (r = 0.97).

CONCLUSION

The present data support the use of both Patlak and SUV for assessing fluoride kinetics in humans. However, (18)F-fluoride PET has only limited accuracy in monitoring bone blood flow.

A pilot study of a practice management training module for medical residents

BACKGROUND

In 2005 a competency based curriculum was introduced in the Dutch postgraduate medical training programs. While the manager's role is one of the seven key competencies, there is still no formal management course in most postgraduate curricula. Based on a needs assessment we conducted, several themes were identified as important for a possible management training program. We present the results of the pilot training we performed to investigate two of these themes.

METHODS

The topics "knowledge of the healthcare system" and "time management" were developed from the list of suggested management training themes. Fourteen residents participated in the training and twenty-four residents served as control. The training consisted of two sessions of four hours with a homework assignment in between. 50 True/false-questions were given as pre- and post-test to both the test and control groups to assess the level of acquired knowledge among the test group as well as the impact of the intervention. We also performed a qualitative evaluation using evaluation forms and in-depth interviews.

RESULTS

All fourteen residents completed the training. Six residents in the control group were lost to follow up. The pre- and post-test showed improvement among the participating residents in comparison to the residents from the control group, but this improvement was not significant. The qualitative assessment showed that all residents evaluated the training positively and experienced it as a useful addition to their training in becoming a medical specialist.

CONCLUSION

Our training was evaluated positively and considered to be valuable. This study supports the need for mandatory medical management training as part of the postgraduate medical curriculum. Our training could be an example of how to teach two important themes in the broad area of medical management education.

Objective outcome evaluation using inertial sensors in subacromial impingement syndrome: a five-year follow-up study

Shoulder-related dysfunction is the second most common musculoskeletal disorder and is an increasing burden on health-care systems. Commonly used clinical questionnaires suffer from subjectivity, pain dominance and a ceiling effect. Objective functional measurement has been identified as a relevant issue in clinical rehabilitation. Inertia based motion analysis (IMA) is a new generation of objective outcome assessment tool; it can produce objective movement parameters while being fast, cheap and easy to operate. In this prospective study, an inertial sensor comprising a three-dimensional accelerometer and gyroscope is attached at the humerus to measure shoulder movements during two motion tasks in patients with subacromial impingement syndrome at baseline and at five-year after treatment. One hundred healthy subjects served as healthy reference database and 15 patients were measured pre- and post-treatment. IMA was better able to detect improvement in shoulder movements compared to the clinical questionnaires (Disability of Arm, Shoulder and Hand (DASH) and Simple Shoulder Test (SST); p < 0.05) and was hardly correlated with the clinical questionnaires (Pearson R = 0.39). It may therefore add an objective functional dimension to outcome assessment. The fast assessment (t < 5 min) of a simple motion test makes it suitable for routine clinical follow-up.

Inertia based functional scoring of the shoulder in clinical practice

Shoulder-related dysfunction is the second most common musculoskeletal disorder and is responsible for an increasing burden on health-care systems. Commonly used clinical outcome scores suffer from subjectivity, pain dominance and a ceiling effect. Objective functional measurement has been identified as a relevant issue in clinical rehabilitation. In recognition of this goal simple techniques for routine clinical application have been investigated with some success. Inertia based motion analysis (IMA) is a new generation of objective outcome assessment tool; it can produce objective movement parameters while being fast, cheap and easy to operate. This study investigates if a simple IMA shoulder test is suitable as a functional outcome measure for routine clinical follow-up. We measured 100 healthy subjects and 50 patients with confirmed unilateral shoulder pathology. Two motion tasks were performed on both shoulders and two simple motion parameters based on angular rate and acceleration were calculated. Patients were also assessed by the disability of arm, shoulder and hand (DASH) and the simple shoulder test. IMA produced high intra- (ICC = 0.94) and inter-assessor reliability (ICC = 0.90). Asymmetry was >3 times higher in patients than in healthy controls (p < 0.01). Healthy and pathological subjects could be distinguished with high diagnostic sensitivity (>84.0%) and specificity (>81.0%). There was a weak correlation between the IMA shoulder score and the clinical questionnaires (Pearson R < 0.25), as it may add an objective functional dimension to outcome assessment. The fast assessment (t < 5 min) of a simple motion task makes it workable for routine clinical follow-up. The IMA shoulder test adds objective information on functional capacity to the clinical scores and may help the physician in his decision-making, follow-up of treatment, effect of training and possibly lead to the development of new therapeutic interventions.

The influence of age, muscle strength and speed of information processing on recovery responses to external perturbations in gait

Dynamic imbalance caused by external perturbations to gait can successfully be counteracted by adequate recovery responses. The current study investigated how the recovery response is moderated by age, walking speed, muscle strength and speed of information processing. The gait pattern of 50 young and 45 elderly subjects was repeatedly perturbed at 20% and 80% of the first half of the swing phase using the Timed Rapid impact Perturbation (TRiP) set-up. Recovery responses were identified using 2D cameras. Muscular factors (dynamometer) and speed of information processing parameters (computer-based reaction time task) were determined. The stronger, faster reacting and faster walking young subjects recovered more often by an elevating strategy than elderly subjects. Twenty three per cent of the differences in recovery responses were explained by a combination of walking speed (B=-13.85), reaction time (B=-0.82), maximum extension strength (B=0.01) and rate of extension moment development (B=0.19). The recovery response that subjects employed when gait was perturbed by the TRiP set-up was modified by several factors; the individual contribution of walking speed, muscle strength and speed of information processing was small. Insight into remaining modifying factors is needed to assist and optimise fall prevention programmes.

Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial

Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective.

INTRODUCTION

Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective.

METHODS

Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively.

RESULTS

Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years.

CONCLUSION

Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.

Accelerometry-based gait analysis, an additional objective approach to screen subjects at risk for falling

This study investigated whether the Tinetti scale, as a subjective measure for fall risk, is associated with objectively measured gait characteristics. It is studied whether gait parameters are different for groups that are stratified for fall risk using the Tinetti scale. Moreover, the discriminative power of gait parameters to classify elderly according to the Tinetti scale is investigated. Gait of 50 elderly with a Tinneti>24 and 50 elderly with a Tinetti≤24 was analyzed using acceleration-based gait analysis. Validated algorithms were used to derive spatio-temporal gait parameters, harmonic ratio, inter-stride amplitude variability and root mean square (RMS) from the accelerometer data. Clear differences in gait were found between the groups. All gait parameters correlated with the Tinetti scale (r-range: 0.20-0.73). Only walking speed, step length and RMS showed moderate to strong correlations and high discriminative power to classify elderly according to the Tinetti scale. It is concluded that subtle gait changes that have previously been related to fall risk are not captured by the subjective assessment. It is therefore worthwhile to include objective gait assessment in fall risk screening.

The importance to including objective functional outcomes in the clinical follow up of total knee arthroplasty patients

In clinical practice, it is increasingly important to assess patients' daily functionality routinely and objectively. Acceleration-based gait analysis (AGA) has shown to be reliable and technically suitable for routine clinical use outside the laboratory. This study investigated the suitability of AGA for measuring function in orthopaedic patients with symptomatic gonarthrosis listed for total knee arthroplasty (TKA) by investigating (a) the ability of AGA to distinguish patients from healthy subjects, (b) the sensitivity to gait changes of AGA in assessing recovery following total knee arthroplasty in a subpopulation, and (c) correlations between AGA parameters and clinical scales. Gait was assessed using AGA in 24 patients with symptomatic gonarthrosis listed for TKA, and in 24 healthy subjects. AGA parameters (e.g. speed, asymmetry) and clinical scales (e.g. KSS) were used to monitor progress in 12 patients 3 months after TKA. The Mann-Whitney-U test, Receiver Operating Characteristic (ROC) curves, repeated measurement ANOVA and Pearson correlations were performed. AGA differentiated pathological from healthy gait. The area under the ROC curve, sensitivity and specificity values were high for speed, step frequency and step length. Different recovery profiles were found, with clinical scales showing faster recovery rates. None or only weak correlations were found between AGA and clinical scores. AGA was found to be of clinical relevance in identifying and monitoring patients with symptomatic gonarthrosis in orthopaedic practice, providing objective and additional information about function beyond clinical scales. This, together with the fact that AGA can be applied routinely, suggests the suitability of AGA for use in rehabilitation programs.

Correlation of Technetium-99m scintigraphy, progressive acetabular osteolysis and acetabular component loosening in total hip arthroplasty

In total hip arthroplasty (THA) Technetium scintigraphy can help to diagnose a loose implant by detecting elevated osteoblastic activity. It has been used for timing the revision of cemented implants. In uncemented cups progressive radiological acetabular osteolysis can be present before loosening accurs, but it is probably unwise to await cup loosening before embarking on revision. We explored the possible relationship between such osteolysis and positive findings on technetium scintigraphy, to see if the technique could predict the need for revision. Between 1990 and 1996 500 hydroxyapatite-coated hip prostheses were implanted (follow-up range: 9-15 years), and technetium scintigraphy and plain radiography were performed annually postoperatively. 32 cups were revised for progressive acetabular osteolysis. We compared the introperative findings at revision with the pre-operative scintigraphic and radiographic results. The sensitivity and specificity for diagnosing progressive acetabular osteolysis by technetium scintigraphy were 34% and 0% respectively. The sensitivity and specificity of the technique for detecting loosening were 38% and 73% respectively. The sensitivity and specificity of technetium scintigraphy for detection of a either loosening or progressive acetabular osteolysis are worse than reported for plain radiography. Despite negative scintigraphy, there may be progressive bone loss at a critical level. Scintigraphy has no additional value to plain radiography as a reliable indicator for timing cup revision in the process of progressive acetabular osteolysis.

Towards unobtrusive in vivo monitoring of patients prone to falling

Falling is a serious health problem for many elderly. To investigate whether the higher fall incidence in elderly is due to a higher probability of experiencing near falls in daily life, it is necessary to evaluate the stumble incidence of elderly in daily life. Accelerometers are already frequently used for in vivo activity monitoring. The current study investigates whether an ambulant and unobtrusive accelerometer can identify stumbles from treadmill walking using a wavelet based detection approach. Seventy nine healthy subjects walked on a treadmill with a triaxial accelerometer attached at the level of the sacrum. Stumbles were induced using a specially designed braking system (The TRiP). The TRiP evoked 30 stumbles at different phases of the swing phase. A wavelet-based detection algorithm is used to isolate the stumbles from treadmill walking, with a specificity of 99.9% and a sensitivity of 98.4%.

Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable

PURPOSE

In total knee arthroplasty, tissue-sparing techniques are considered more important, as functional gain could become more advantageous when early mobilization is commenced. The parapatellar approach is most often used, whereas the subvastus approach is a suitable alternative. Presently, it is unknown, according to true objective measurements, which of the two is most advantageous.

METHODS

In this prospective randomized double-blind, short-term trial measurements (KSS, WOMAC, PDI, VAS, ability to perform) were obtained at day 1, day 3, 1 week, 6 weeks, and 3 months.

RESULTS

The subvastus group (n=20) showed only significantly less extension lag direct postoperative (P=0.04) compared with the parapatellar group (n=20). Other scores were not significantly different. The Dynaport®knee test, an objective performance-based tool, could not demonstrate significant differences. A blunt anatomical dissection was carried out in both observational and histological to support findings. A dense innervation of the distal vastus medialis was found. This is at risk employing the subvastus approach. Both approaches harm the suprapatellar bursa. The vastus medialis sheath must be detached distally to open the knee joint. No true separate vastus medialis obliquus could be identified.

CONCLUSION

Comparable to literature, only mild advantage employing the subvastus approach was found, but only early postoperative and not objectively. As this approach is also not suitable in every case, we will continue to use the parapatellar approach.

Juxta-articular myxoma of the knee in a 5-year-old boy: a case report and review of the literature (2009: 12b)

Juxta-articular myxoma (JAM) is a relatively rare variant of myxoma that occurs in the vicinity of large joints. It is composed of fibroblast-like cells that produce an excessive amount of glycosaminoglycans rich in hyaluronic acid. The peak incidence is between the 3rd and 5th decades of life. In this report we describe an extremely rare case of JAM in the knee of a 5-year-old child. The clinical presentation, radiological features and histopathologic findings are described, and the relevant literature is reviewed.