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de Vos FH, Meuffels DE, Baart SJ, van Es EM, Reijman M. Externally validated treatment algorithm acceptably predicts nonoperative treatment success in patients with anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38738823 DOI: 10.1002/ksa.12247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 04/15/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture. METHODS Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression model and then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness-of-fit were assessed and externally validated by discrimination and calibration measures. RESULTS In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift test and the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58-0.81) and 0.68 (95% CI: 0.58-0.78). CONCLUSION This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Floris H de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Smees CJ, van Es EM, Tuijthof GJM, Colaris JW, de Graaff F, Vochteloo AJH. A comparison of 3-D CT and 2-D plain radiograph measurements of the wrist in extra-articular malunited fractures of the distal radius. J Hand Surg Eur Vol 2024; 49:546-553. [PMID: 37987680 PMCID: PMC11044515 DOI: 10.1177/17531934231213790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
Two-dimensional (2-D) plain radiographs may be insufficient for the evaluation of distal radial malunion, as it is a three-dimensional (3-D) deformity. This study introduced a 3-D measuring method that outputs radial inclination, ulnar variance, palmar tilt and axial rotation. To this end, a standardized and clearly defined coordinate system was constructed that allowed 3-D measurements closely resembling the conventional 2-D method in 35 patients. Mean differences between 3-D and 2-D measurements in affected wrists were 1.8° for radial inclination, 0.8 mm for ulnar variance and 3.7° for palmar tilt. In addition, inter- and intra-observer reproducibility of all 3-D and 2-D measurements were good or excellent (intraclass correlation coefficient >0.75), with 3-D reproducibility always better than 2-D. Axial rotation was present in all patients with a mean of 7.9° (SD 6.9). Although the differences between 2-D and 3-D measurements were small, 3-D evaluation enables the assessment of axial rotation and brings us closer to a routine 3-D evaluation of malunion.Level of evidence: III.
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Affiliation(s)
- Camiel J. Smees
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, The Netherlands
- Biomedical Device Design and Production Technology, University of Twente, Enschede, The Netherlands
| | - Eline M. van Es
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gabriëlle J. M. Tuijthof
- Biomedical Device Design and Production Technology, University of Twente, Enschede, The Netherlands
| | - Joost W. Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Feike de Graaff
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, The Netherlands
| | - Anne J. H. Vochteloo
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, The Netherlands
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Sleeswijk Visser TSO, Brul SL, O'Neill S, van Es EM, Eygendaal D, de Vos RJ. Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy. J Ultrasound Med 2024; 43:713-722. [PMID: 38140763 DOI: 10.1002/jum.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area. METHODS Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used. RESULTS The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good." CONCLUSION We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.
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Affiliation(s)
- Tjerk S O Sleeswijk Visser
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stefano L Brul
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Seth O'Neill
- Department of Life Sciences, School of Allied Health, University of Leicester, Leicester, UK
| | - Eline M van Es
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Schalleij JMCJ, van Schaardenburgh FE, Wörner E, Koenraadt-van Oost I, van Es EM, van Oirschot BAJA, Eygendaal D, The B. Smaller radioulnar window is associated with a distal biceps tendon rupture in patients with limited forearm rotation: a 3-dimensional computed tomography comparison study of proximal impingement caused by radial tuberosity hypertrophy-a single-center case series. J Shoulder Elbow Surg 2024; 33:373-380. [PMID: 37879599 DOI: 10.1016/j.jse.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND It has been suggested that hypertrophy of the radial tuberosity may result in impingement leading to either a lesion of the distal biceps tendon or rotational impairment. Two previous studies on hypertrophy of the radial tuberosity had contradictory results and did not examine the distance between the radius and ulna: the radioulnar window. Therefore, this comparative cohort study aimed to investigate the radioulnar window in healthy subjects and compare it with that in subjects with either nontraumatic-onset rotational impairment of the forearm or nontraumatic-onset distal biceps tendon ruptures with rotational impairment of the forearm by use of dynamic 3-dimensional computed tomography measurements to attain a comprehensive understanding of the underlying etiology of distal biceps tendon ruptures. We hypothesized that a smaller radioulnar window would increase the risk of having a nontraumatic-onset distal biceps tendon rupture and/or rotational impairment compared with healthy individuals. METHODS This study measured the distance between the radius and ulna at the level of the radial tuberosity using entire-forearm computed tomography scans of 15 patients at the Amphia Hospital between 2019 and 2022. Measurements of healthy subjects were compared with those of subjects who had nontraumatic-onset rotational impairment of the forearm and subjects who had a nontraumatic-onset distal biceps tendon rupture with rotational impairment of the forearm. The Wilcoxon signed rank test was used for individual comparisons, and the Mann-Whitney U test was used for group comparisons. RESULTS A significant difference was found between the radioulnar window in the forearms of the subjects with a distal biceps tendon rupture (mean, 1.6 mm; standard deviation 0.2 mm) and the radioulnar window in the forearms of the healthy subjects (mean, 4.8 mm; standard deviation, 1.4 mm; P = .018). A trend toward smaller radioulnar windows in the rotational impairment groups was also observed, although it was not significant (P > .05). CONCLUSIONS The radioulnar window in the forearms of the subjects with a distal biceps tendon rupture with rotational impairment was significantly smaller than that in the forearms of the healthy subjects. Therefore, patients with a smaller radioulnar window have a higher risk of rupturing the distal biceps tendon. Nontraumatic-onset rotational impairment of the forearm may also be caused by a similar mechanism. Future studies are needed to further evaluate these findings.
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Affiliation(s)
- Jill M C J Schalleij
- Faculty of Health, Medicine and Lifestyle, Maastricht University, Maastricht, The Netherlands.
| | | | - Elisabeth Wörner
- Department of Orthopaedics, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Bertram The
- Department of Orthopaedics, Amphia Hospital, Breda, The Netherlands
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Kuiper RJA, Colaris JW, Stockmans F, van Es EM, Viergever MA, Seevinck PR, Weinans H, Sakkers RJB. Impact of bone and cartilage segmentation from CT and MRI on both bone forearm osteotomy planning. Int J Comput Assist Radiol Surg 2023; 18:2307-2318. [PMID: 37219804 PMCID: PMC10632286 DOI: 10.1007/s11548-023-02929-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION The use of MRI scans for pre-operative surgical planning of forearm osteotomies provides additional information of joint cartilage and soft tissue structures and reduces radiation exposure in comparison with the use of CT scans. In this study, we investigated whether using 3D information obtained from MRI with and without cartilage information leads to a different outcome of pre-operative planning. METHODS Bilateral CT and MRI scans of the forearms of 10 adolescent and young adult patients with a unilateral bone deformation were acquired in a prospective study. The bones were segmented from CT and MRI, and cartilage only from MRI. The deformed bones were virtually reconstructed, by registering the joint ends to the healthy contralateral side. An optimal osteotomy plane was determined that minimized the distance between the resulting fragments. This process was performed in threefold: using the CT and MRI bone segmentations, and the MRI cartilage segmentations. RESULTS Comparison of bone segmentation from MRI and CT scan resulted in a 0.95 ± 0.02 Dice Similarity Coefficient and 0.42 ± 0.07 mm Mean Absolute Surface Distance. All realignment parameters showed excellent reliability across the different segmentations. However, the mean differences in translational realignment between CT and MRI bone segmentations (4.5 ± 2.1 mm) and between MRI bone and MRI bone and cartilage segmentations (2.8 ± 2.1 mm) were shown to be clinically and statistically significant. A significant positive correlation was found between the translational realignment and the relative amount of cartilage. CONCLUSION This study indicates that although bone realignment remained largely similar when using MRI with and without cartilage information compared to using CT, the small differences in segmentation could induce statistically and clinically significant differences in the osteotomy planning. We also showed that endochondral cartilage might be a non-negligible factor when planning osteotomies for young patients.
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Affiliation(s)
- Ruurd J A Kuiper
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Joost W Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Filip Stockmans
- Muscles & Movement, Department of Development and Regeneration, KU Leuven Campus Kulak, Kortrijk, Belgium
| | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter R Seevinck
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Harrie Weinans
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ralph J B Sakkers
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Es EM, Stockmans F, Colaris JW. Corrective Osteotomy in a Patient With Congenital Absence of Pronation Based on Three-Dimensional Statistical Shape Modeling. Hand (N Y) 2023:15589447231209343. [PMID: 37946500 DOI: 10.1177/15589447231209343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
We present a new indication of a three-dimensional statistical shape model (SSM): a patient with bilateral impaired forearm rotation due to a congenital variance in bone shape. A corrective osteotomy was planned and performed to best match the SSM created by computed tomography (CT) scans of 18 peers. Postoperatively, pronation increased by 70°, and the patient was pain-free. A CT scan showed accurate correction of the deformity and union of all osteotomies. This technique offers opportunities for patients with bilateral nontraumatic osseous forearm pathology.
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Affiliation(s)
- Eline M van Es
- Department of Orthopedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Filip Stockmans
- Department of Development and Regeneration, University of Leuven, Campus Kortrijk, Belgium
| | - Joost W Colaris
- Department of Orthopedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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van der Graaff SJA, Reijman M, Meuffels DE, Koopmanschap MA, Eijgenraam SM, van Es EM, Hofstee DJ, Auw Yang KG, Noorduyn JCA, van Arkel ERA, van den Brand ICJB, Janssen RPA, Liu WY, Bierma-Zeinstra SMA. Cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in patients aged under 45 years. Bone Joint J 2023; 105-B:1177-1183. [PMID: 37909164 DOI: 10.1302/0301-620x.105b11.bjj-2023-0107.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Aims The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears. Methods We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective. Results A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit. Conclusion Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy.
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Affiliation(s)
- Sabine J A van der Graaff
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Marc A Koopmanschap
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| | - Susanne M Eijgenraam
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Dirk J Hofstee
- Department of Orthopaedics, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Kiem G Auw Yang
- Department of Orthopaedics, St. Antonius Hospital, Utrecht, Netherlands
| | - Julia C A Noorduyn
- Department of Orthopaedic Surgery, OLVG, Amsterdam, Netherlands
- Department of Human Movement Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - Ewoud R A van Arkel
- Department of Orthopaedics, Haaglanden Medical Centre, Den Haag, Netherlands
| | | | - Rob P A Janssen
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Centre, Eindhoven, Netherlands
- Department of Biomechanical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, Netherlands
| | - Wai-Yan Liu
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Centre, Eindhoven, Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven, Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
- Department of General Practice, Erasmus MC University Medical Centre, Rotterdam, Netherlands
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Koper MC, Spek RWA, Reijman M, van Es EM, Baart SJ, Verhaar JAN, Bos PK. Are serum cobalt and chromium levels predictors for patient-reported outcome measures in the ASR hip resurfacing arthroplasty? Bone Joint J 2023; 105-B:775-782. [PMID: 37394959 DOI: 10.1302/0301-620x.105b7.bjj-2022-1359.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Aims The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate. Methods A total of 62 patients with an ASR-HRA were included and monitored yearly postoperatively. At follow-up, serum Co and Cr levels were measured and the HHS and the HOOS were scored. In addition, preoperative patient and implant variables and the need for revision surgery were recorded. We used a linear mixed model to relate the serum Co and Cr levels to different patient-reported outcome measures (PROMs). For the survival analyses we used the Kaplan-Meier and Cox regression model. Results We found that an increase of one part per billion (ppb) in serum Co and Cr levels correlated significantly with worsening of the HHS in the following year. This significant correlation was also true for the HOOS-Pain and HOOS-quality of life sub scores. The overall ten-year survival rate in our cohort was 65% (95% confidence interval (CI) 52.5 to 77.6). Cox regression analysis showed a significant hazard ratio (HR) of 1.08 (95% CI 1.01 to 1.15; p = 0.028) for serum Co level. No significance was found with sex or inclination angle. Conclusion This study shows that increasing serum Co and Cr levels measured in patients with an ASR-HRA are predictive for deterioration in HHS and HOOS subscales in the following year. Increasing serum Co and Cr should forewarn both surgeon and patient that there is a heightened risk of failure. Continued and regular review of patients with an ASR-HRA implant by measurement of serum Co/Cr levels and PROMs remains essential.
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Affiliation(s)
- Maarten C Koper
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Reinier W A Spek
- Department of Trauma and Orthopedic Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Max Reijman
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Eline M van Es
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - P K Bos
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, the Netherlands
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Abstract
The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient's activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.
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Affiliation(s)
- Mark F Siemensma
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Anna E van der Windt
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Eline M van Es
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Joost W Colaris
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Erasmus MC, University Medical Center Rotterdam, Department of Orthopaedics and Sports Medicine, 3000 CA, Rotterdam, The Netherlands
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van der Graaff SJA, Reijman M, van Es EM, Bierma-Zeinstra SMA, Verhaar JAN, Meuffels DE. Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial. Br J Sports Med 2023; 57:78-82. [PMID: 36137731 DOI: 10.1136/bjsports-2021-105235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up. METHODS We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon. RESULTS At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period. CONCLUSION Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period. TRIAL REGISTRATION NUMBER NL 2618.
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Affiliation(s)
| | - Max Reijman
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Eline M van Es
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Jan A N Verhaar
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Duncan E Meuffels
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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van der Graaff SJA, Eijgenraam SM, Meuffels DE, van Es EM, Verhaar JAN, Hofstee DJ, Auw Yang KG, Noorduyn JCA, van Arkel ERA, van den Brand ICJB, Janssen RPA, Liu WY, Bierma-Zeinstra SMA, Reijman M. Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial. Br J Sports Med 2022; 56:bjsports-2021-105059. [PMID: 35676079 PMCID: PMC9304087 DOI: 10.1136/bjsports-2021-105059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To compare outcomes from arthroscopic partial meniscectomy versus physical therapy in young patients with traumatic meniscal tears. METHODS We conducted a multicentre, open-labelled, randomised controlled trial in patients aged 18-45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomised to arthroscopic partial meniscectomy or standardised physical therapy with an optional delayed arthroscopic partial meniscectomy after 3-month follow-up. The primary outcome was the International Knee Documentation Committee (IKDC) score (best 100, worst 0) at 24 months, which measures patients' perception of symptoms, knee function and ability to participate in sports activities. RESULTS Between 2014 and 2018, 100 patients were included (mean age 35.1 (SD 8.1), 76% male, 34 competitive or elite athletes). Forty-nine were randomised to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during the follow-up period. In both groups, improvement in IKDC scores was clinically relevant during follow-up compared with baseline scores. At 24 months mean (95% CI) IKDC scores were 78 (71 to 84) out of 100 points in the arthroscopic partial meniscectomy group and 78 (71 to 84) in the physical therapy group with a between group difference of 0.1 (95% CI -7.6 to 7.7) points out of 100. CONCLUSIONS In this trial involving young patients with isolated traumatic meniscal tears, early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up. TRIAL REGISTRATION https://www.trialregister.nl/trials.
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Affiliation(s)
| | - Susanne M Eijgenraam
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Duncan E Meuffels
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Eline M van Es
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Jan A N Verhaar
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Dirk Jan Hofstee
- Orthopaedics, Noordwest Hospital Group, Alkmaar, The Netherlands
| | | | | | | | | | - Rob P A Janssen
- Orthopaedic Surgery, Maxima Medical Centre, Eindhoven, The Netherlands
- Department of Biomechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Wai-Yan Liu
- Orthopaedic Surgery, Maxima Medical Centre, Eindhoven, The Netherlands
- Orthopaedic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Max Reijman
- Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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12
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van Es EM, Colaris JW, Stockmans F. Three-dimensional statistical shape modelling for corrective osteotomy in bilateral malunited forearm fracture. J Hand Surg Eur Vol 2022; 47:535-537. [PMID: 35078391 DOI: 10.1177/17531934221074896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Joost W Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Filip Stockmans
- Department of Development and Regeneration, University of Leuven Campus Kortrijk, Kortrijk, Belgium
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13
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van der Graaff SJA, Meuffels DE, Bierma-Zeinstra SMA, van Es EM, Verhaar JAN, Eggerding V, Reijman M. Why, When, and in Which Patients Nonoperative Treatment of Anterior Cruciate Ligament Injury Fails: An Exploratory Analysis of the COMPARE Trial. Am J Sports Med 2022; 50:645-651. [PMID: 35048733 DOI: 10.1177/03635465211068532] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment strategy for patients with an anterior cruciate ligament (ACL) rupture is still under debate. Different determinants of the need for a reconstruction have not been thoroughly investigated before. PURPOSE To investigate why, when, and which patients with an ACL rupture who initially started with rehabilitation therapy required reconstructive surgery. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS In the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation (COMPARE) trial, 167 patients with an ACL rupture were randomized to early ACL reconstruction or rehabilitation therapy plus optional delayed ACL reconstruction. We conducted an exploratory analysis of a subgroup of 82 patients from this trial who were randomized to rehabilitation therapy plus optional delayed ACL reconstruction. The reasons for surgery were registered for the patients who underwent a delayed ACL reconstruction. For these patients, we used the International Knee Documentation Committee (IKDC) subjective knee form, Numeric Rating Scale for pain, and instability question from the Lysholm questionnaire before surgery. To determine between-group differences between the nonoperative treatment and delayed ACL reconstruction group, IKDC and pain scores during follow-up were determined using mixed models and adjusted for sex, age, and body mass index. RESULTS During the 2-year follow-up of the trial, 41 of the 82 patients received a delayed ACL reconstruction after a median time of 6.4 months after inclusion (interquartile range, 3.9-10.3 months). Most reconstructions occurred between 3 and 6 months after inclusion (n = 17; 41.5%). Ninety percent of the patients (n = 37) reported knee instability concerns as a reason for surgery at the moment of planning surgery. Of these patients, 18 had an IKDC score ≤60, 29 had a pain score of ≥3, and 33 patients had knee instability concerns according to the Lysholm questionnaire before surgery. During follow-up, IKDC scores were lower and pain scores were higher in the delayed reconstruction group compared with the nonoperative treatment group. Patients in the delayed reconstruction group had a significantly younger age (27.4 vs 35.3 years; P = .001) and higher preinjury activity level compared with patients in the nonoperative treatment group. CONCLUSION Patients who experienced instability concerns, had pain during activity, and had a low perception of their knee function had unsuccessful nonoperative treatment. Most patients received a delayed ACL reconstruction after 3 to 6 months of rehabilitation therapy. At baseline, patients who required reconstructive surgery had a younger age and higher preinjury activity level compared with patients who did not undergo reconstruction.
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Affiliation(s)
- Sabine J A van der Graaff
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Eline M van Es
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Vincent Eggerding
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Abstract
Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III.
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Affiliation(s)
- Kasper C. Roth
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands,Kasper C. Roth, Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Postbus 2040, 3000 CA Rotterdam, The Netherlands.
| | - Eline M. van Es
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gerald A. Kraan
- Department of Orthopaedics, Reinier HAGA Orthopaedic Centre, Zoetermeer, The Netherlands
| | - Jan A. N. Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Joost W. Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Sleeswijk Visser TSO, van Es EM, Meuffels DE, Verhaar JAN, de Vos RJ. Standardized pain mapping for diagnosing Achilles tendinopathy. J Sci Med Sport 2021; 25:204-208. [PMID: 34753666 DOI: 10.1016/j.jsams.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/19/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy. DESIGN Cross-sectional study. METHODS Eligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy. RESULTS 110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78-0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54-0.79). CONCLUSIONS There is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.
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Affiliation(s)
- Tjerk S O Sleeswijk Visser
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, the Netherlands; Leiden University Medical Center, the Netherlands
| | - Eline M van Es
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, the Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, the Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center, the Netherlands.
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van Yperen DT, Reijman M, van Es EM, Bierma-Zeinstra SMA, Meuffels DE. Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes. Am J Sports Med 2018; 46:1129-1136. [PMID: 29438635 DOI: 10.1177/0363546517751683] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An anterior cruciate ligament (ACL) rupture has major consequences at midterm follow-up, with an increasing chance of developing an old knee in a young patient. The long-term (≥20 years) effects of the operative and nonoperative treatment of ACL ruptures are still unclear. PURPOSE To compare the long-term treatment outcomes of operative versus nonoperative treatment of ACL ruptures in high-level athletes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Fifty patients with an ACL rupture were eligible for participation, and they were treated either nonoperatively (n = 25) in 1992, consisting of structured rehabilitation and lifestyle adjustments, or operatively (n = 25) between 1994 and 1996 with an arthroscopic transtibial bone-patellar tendon-bone technique. The patients in the nonoperative group were drawn from those who responded well to 3 months of nonoperative treatment, whereas the patients in the operative group were drawn from those who had persistent instability after 3 months of nonoperative treatment. Both groups were pair-matched and assessed at 10- and 20-year follow-up regarding radiological knee osteoarthritis, functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner, Knee injury and Osteoarthritis Outcome Score), meniscal status, and knee stability (KT-1000 arthrometer, pivot-shift test, Lachman test, 1-legged hop test). RESULTS All 50 patients (100%) were included in the current study for follow-up. After 20 years, we found knee osteoarthritis in 80% of the operative group compared with 68% of the nonoperative group ( P = .508). There was no difference between groups regarding functional outcomes and meniscectomy performed. The median IKDC subjective score was 81.6 (interquartile range [IQR], 59.8-89.1) for the operative group and 78.2 (IQR, 61.5-92.0) for the nonoperative group ( P = .679). Regarding the IKDC objective score, 21 patients (84%) in the operative group had a normal or near normal score (A and B) compared with 5 patients (20%) in the nonoperative group ( P < .001). The pivot-shift test finding was negative in 17 patients (68%) versus 3 patients (13%) for the operative and nonoperative groups, respectively ( P < .001), and the Lachman test finding was negative in 12 patients (48%) versus 1 patient (4%), respectively ( P = .002). CONCLUSION In this retrospective pair-matched follow-up study, we found that after 20-year follow-up, there was no difference in knee osteoarthritis between operative versus nonoperative treatment when treatment was allocated on the basis of a patient's response to 3 months of nonoperative treatment. Although knee stability was better in the operative group, it did not result in better subjective and objective functional outcomes.
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Affiliation(s)
- Daan T van Yperen
- Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eline M van Es
- Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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van Es EM, Meeuwsen T, Smeets B, Daanen HA. Finger Temperatures In Hypoxia And Normoxia In A Neutral And Cold Environment. Med Sci Sports Exerc 2009. [DOI: 10.1249/01.mss.0000355278.25245.7c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hendriksen IJ, Simons M, van Es EM, van Mechelen W. Electrical Assisted Cycling: Energy Expenditure, Heart Rate and Power Output. Med Sci Sports Exerc 2008. [DOI: 10.1249/01.mss.0000322309.48696.dc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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van der Loo H, van Es EM. Effects Of High-intensity Exercise On The ROM Training Device On Muscular Strength And Body Composition. Med Sci Sports Exerc 2007. [DOI: 10.1249/01.mss.0000274175.90807.d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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van Es EM, van der Loo H. High-intensity Exercise On The ROM Training Device Improves VO2max And Endurance Capacity In Untrained Adults. Med Sci Sports Exerc 2007. [DOI: 10.1249/01.mss.0000274364.81369.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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