Analysis of complications and revisions after spine surgery in 270 multiple myeloma patients with spinal involvement

BACKGROUND CONTEXT

Patients with multiple myeloma (MM) are at increased risk of infections and suffer from poor bone quality due to their disseminated malignant bone disease. Therefore, postoperative complications may occur following surgical treatment of MM lesions.

PURPOSE

In this study, we aimed to determine the incidence of postoperative complications and retreatments after spinal surgery in MM patients. Additionally, we sought to identify risk factors associated with complications and retreatments.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

In total, 270 patients with MM who received surgical treatment for spinal involvement between 2008 and 2021 were included.

OUTCOME MEASURES

The incidence of perioperative complications within 6 weeks and reoperations within 2.5 years and individual odds ratios for factors associated with these complications and reoperations.

METHODS

Data were collected through manual chart review. Hosmer and Lemeshow's purposeful regression method was used to identify risk factors for complications and reoperations.

RESULTS

The median age of our cohort was 65 years (SD = 10.8), and 58% were male (n = 57). Intraoperative complications were present in 24 patients (8.9%). The overall 6-week complication rate after surgery was 35% (n = 95). The following variables were independently associated with 6-week complications: higher Genant grading of a present vertebral fracture (OR 1.41; 95% CI 1.04-1.95; p = .031), receiving intramuscular or intravenous steroids within a week prior to surgery (OR 3.97; 95% CI 1.79-9.06; p = .001), decompression surgery without fusion (OR 6.53; 95% CI 1.30-36.86; p = .026), higher creatinine levels (OR 2.18; 95% CI 1.19-5.60; p = .014), and lower calcium levels (OR 0.58; 95% CI 0.37-0.88; p = .013). A secondary surgery was indicated for 53 patients (20%), of which 13 (4.8%) took place within two weeks after the initial surgery. We additionally discovered factors associated with retreatments, which are elucidated within the manuscript.

CONCLUSION

The goal of surgical treatment for MM bone disease is to enhance patient quality of life and reduce symptom burden. However, postoperative complication rates remain relatively high after spine surgery in patients with MM, likely attributable to both inherent characteristics of the disease and patient comorbidities. The risk for complications and secondary surgeries should be explored and a multidisciplinary approach is crucial.

Neurologic Outcomes After Radiation Therapy for Severe Spinal Cord Compression in Multiple Myeloma: A Study of 162 Patients

BACKGROUND

Bone destruction is the most frequent disease-defining clinical feature of multiple myeloma (MM), resulting in skeletal-related events such as back pain, pathological fractures, or neurologic compromise including epidural spinal cord compression (ESCC). Up to 24% of patients with MM will be affected by ESCC. Radiation therapy has been proven to be highly effective in pain relief in patients with MM. However, a critical knowledge gap remains with regard to neurologic outcomes in patients with high-grade ESCC treated with radiation.

METHODS

We retrospectively included 162 patients with MM and high-grade ESCC (grade 2 or 3) who underwent radiation therapy of the spine between January 2010 and July 2021. The primary outcome was the American Spinal Injury Association (ASIA) score after 12 to 24 months, or the last known ASIA score if the patient had had a repeat treatment or died. Multivariable logistic regression was used to assess factors associated with poor neurologic outcomes after radiation, defined as neurologic deterioration or lack of improvement.

RESULTS

After radiation therapy, 34 patients (21%) had no improvement in their impaired neurologic function and 27 (17%) deteriorated neurologically. Thirty-six patients (22%) underwent either surgery or repeat irradiation after the initial radiation therapy. There were 100 patients who were neurologically intact at baseline (ASIA score of E), of whom 16 (16%) had neurologic deterioration. Four variables were independently associated with poor neurologic outcomes: baseline ASIA (odds ratio [OR] = 6.50; 95% confidence interval [CI] = 2.70 to 17.38; p < 0.001), Eastern Cooperative Oncology Group (ECOG) performance status (OR = 6.19; 95% CI = 1.49 to 29.49; p = 0.015), number of levels affected by ESCC (OR = 4.02; 95% CI = 1.19 to 14.18; p = 0.026), and receiving steroids prior to radiation (OR = 4.42; 95% CI = 1.41 to 16.10; p = 0.015).

CONCLUSIONS

Our study showed that 38% of patients deteriorated or did not improve neurologically after radiation therapy for high-grade ESCC. The results highlight the need for multidisciplinary input and efforts in the treatment of high-grade ESCC in patients with MM. Future studies will help to improve patient selection for specific and standardized treatments and to clearly delineate which patients are likely to benefit from radiation therapy.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Neurological Outcomes and the Need for Retreatments Among Multiple Myeloma Patients With High-Grade Spinal Cord Compression: Radiotherapy vs Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Up to 30% of Multiple Myeloma (MM) patients are expected to experience Epidural Spinal Cord Compression (ESCC) during the course of their disease. To prevent irreversible neurological damage, timely diagnosis and treatment are important. However, debate remains regarding the optimal treatment regimen. The aim of this study was to investigate the neurological outcomes and frequency of retreatments for MM patients undergoing isolated radiotherapy and surgical interventions for high-grade (grade 2-3) ESCC.

METHODS

This study included patients with MM and high-grade ESCC treated with isolated radiotherapy or surgery. Pre- and post-treatment American Spinal Injury Association (ASIA) impairment scale and retreatment rate were compared between the 2 groups. Adjusted multivariable logistic regression was utilized to examine differences in neurologic compromise, pain, and retreatments.

RESULTS

A total of 247 patients were included (Radiotherapy: n = 154; Surgery: n = 93). After radiotherapy, 82 patients (53%) achieved full neurologic function (ASIA E) at the end of follow-up. Of the surgically treated patients, 67 (64%) achieved full neurologic function. In adjusted analyses, patients treated with surgery were less likely to experience neurologic deterioration within 2 years (OR = .15; 95%CI .05-.44; P = .001) and had less pain (OR = .29; 95%CI .11-.74; P = .010). Surgical treatment was not associated with an increased risk of retreatments (OR = .64; 95%CI .28-1.47; P = .29) or death (HR = .62, 95%CI .28-1.38; P = .24).

CONCLUSIONS

After adjusting for baseline differences, surgically treated patients with high-grade ESCC showed better neurologic outcomes compared to patients treated with radiotherapy. There were no differences in risk of retreatment or death.

Patient characteristics cannot predict the long-term effect of an intra-articular bupivacaine and corticosteroid injection in patients with femoroacetabular impingement: A retrospective cohort study

Background

To evaluate predictors for effect of an intra-articular (IA) bupivacaine and corticosteroid injection in patients with femoroacetabular impingement syndrome (FAIS).

Methods

All patients between 18 and 50 years old with FAIS who received an intra-articular (IA) bupivacaine and corticosteroid injection between 2016 and 2019 were eligible for this retrospective study. Two groups were made, the non-arthroscopy group (patients for whom conservative treatment with physiotherapy and an IA bupivacaine and corticosteroid injection was sufficient) and the arthroscopy group (patients who needed an arthroscopy because conservative treatment and an IA bupivacaine and corticosteroid injection failed). Multiple regression analysis was performed to analyse the effect of the IA corticosteroid injection and to predict arthroscopic intervention based on sex, age, body mass index, duration of complaints, alpha angle and abnormal bone morphology.

Results

In total 103 patients were included; 46 in the arthroscopy group and 57 in the non-arthroscopy group. The groups had similar baseline characteristics. A total of 37 (36%) patients had an effect of 3 months or longer from the IA corticosteroid injection; 31 (54%) were patients in the non-arthroscopy group versus 6 (13%) patients in the arthroscopy group (P < 0.001). Male sex seems to have an negative influence on the duration of the effect of the injection. None of the variables could significantly predict if a patient would undergo arthroscopic intervention (F(7,103) = 8.54, p = 0.3, R² = 0.11). The effect of the IA injection could not be predicted (p = 0.1; R² = 0.13).

Conclusion

There are no patient characteristics that predict who would and who would not benefit from the IA bupivacaine and corticosteroid injection in patients with FAIS and who would need an arthroscopic intervention within 1 year after the injection. Only male sex seems to have an negative influence on the duration of the effect of the injection.

The incidence of vertebral compression fractures and spinal instability in newly diagnosed multiple myeloma patients

Background

Multiple myeloma (MM) is a hematologic malignancy, characterized by clonal proliferation of plasma cells in the bone marrow. These plasma cell proliferations frequently result in scattered osteolytic bone lesions and extensive skeletal destruction. Myeloma bone lesions are frequently located in the spine, and are associated with debilitating bone pain and an increased rate of pathologic fractures and mortality. The aim of this study was to investigate the incidence of vertebral compression fractures (VCFs) and spinal instability in patients with MM.

Patients and methods

Newly diagnosed patients with MM with computed tomography (CT) scans of the spine within three months of diagnosis were identified through an electronic patient database. Clinical baseline data were manually extracted from the patient charts. Fractured levels were graded on CT scans following the Genant grading system, and spinal instability was assessed through the Spinal Instability Neoplastic Score (SINS).

Results

A total of 385 patients with 6289 eligible vertebrae were eligible for inclusion. The mean age at diagnosis was 67 years, and 60% were male. At least one VCF was present in 180 patients (47%). A quarter of fractures were classified as severe. The incidence of fractures increased with more advanced disease stages, and men were more likely to have a fracture than women.

Conclusions

Our data show that 47% of MM patients present with one or more VCFs at the onset of their disease, of which 20% were classified as unstable, meaning a surgical consultation is recommended.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes

BACKGROUND

In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications.

METHODS

We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis.

RESULTS

Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications.

CONCLUSION

The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

The Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform Does Not Adequately Represent Physical Functioning in Patients Undergoing Total Hip Arthroplasty

OBJECTIVES

A frequently used patient-reported outcome measure for assessing physical functioning in patients with hip problems is the 5-item Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform (HOOS-PS). Nevertheless, its content validity (whether this instrument adequately reflects the construct of physical functioning) is unknown. This study aimed to assess the content validity of the HOOS-PS.

METHODS

A quantitative and qualitative research approach was used. Physical functioning was defined as the ability to perform activities that require physical actions, ranging from self-care to more complex activities that require a combination of skills, often within a social context. Patients (n = 51) and experts (n = 25) completed questionnaires regarding the relevance, comprehensiveness, and comprehensibility of the HOOS-PS. Semistructured interviews (n = 5) explored issues identified in the quantitative data in more depth. Thematic content analysis was conducted using a coding frame.

RESULTS

One of the 5 items was considered relevant to measure physical functioning. Comprehensiveness was considered insufficient by both patients and experts. Furthermore, comprehensibility was considered inadequate. Several items were found ambiguous or double barreled. Regarding interpretability, floor or ceiling effects were not found.

CONCLUSIONS

This study showed concerns about the content validity of the HOOS-PS: most items are considered not relevant, the HOOS-PS is considered not comprehensive, and several items are considered not comprehensible. These findings challenge the applicability of the HOOS-PS in clinical practice, research, value-based healthcare, and benchmarking.

Satisfaction, functional outcomes and predictors in hip arthroscopy: a cohort study

INTRODUCTION

Hip arthroscopy is not always successful, leading to high rates of total hip arthroplasty (THA) after arthroscopy. The aim of this study was to identify risk factors for THA, revision arthroscopy and low patient satisfaction and to compare outcomes of the different procedures of primary hip arthroscopy.

METHODS

A total of 91 primary hip arthroscopy procedures in 90 patients (66% female) were analysed. Data were gathered from patient files and a questionnaire was sent to patients including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), the EuroQol 5-dimension and questions about return to sports, satisfaction and pain before and after surgery. Using regression analyses, predictive factors for the outcomes were identified.

RESULTS

After a mean of 1.6 years, 4 patients (4%) underwent revision arthroscopy and 10 (11%) a THA. Of the responders (62%), 66% of the patients was satisfied to very satisfied about the surgery. Mean mHHS score was 75.3 (SE 1.9) and the mean WOMAC score was 81.0 (SE 2.8). Return to sports rate was 58%. A higher age was a significant predictor for lower satisfaction (p = 0.008) and a longer duration of symptoms was a significant predictor for worse mHHS outcome scores (p = 0.005).

CONCLUSION

A higher age is a predictor for a lower satisfaction and a longer duration of symptoms before surgery has a negative influence on functional outcome. No risk factors for THA or revision arthroscopy were found and there were no significant differences in outcome measurements between the performed surgeries.

Investigation of the efficacy and safety of ultrasound-standardized autologous blood injection as treatment for lateral epicondylitis

Background

There are various conservative treatment options for lateral epicondylitis (LE). The aim is to evaluate pain, daily functioning, and complications after ultrasound-standardized autologous blood injections in patients with LE.

Methods

For this prospective cohort study, consecutive patients (>18 years) diagnosed with LE were included. Autologous blood was injected using a medical device containing an injection disposable with 12 small needles (Instant Tennis Elbow Cure [ITEC]) device. Patient-Rated Tennis Elbow Evaluation (PRTEE), subjective elbow score (SES), palpation and provocation pain, satisfaction, and complications of treatment were measured at baseline and two months after treatment. Paired t-tests and Fisher’s exact tests were used for calculating the difference between pre- and post-treatment outcomes.

Results

Fifty-five elbows were analyzed. Mean time between pre- and post-treatment was 11.1 weeks (standard deviation [SD], 8.9 weeks). The mean PRTEE score decreased from 68.2 (SD, 15.7) before surgery to 53.2 (SD, 25.9; p<0.001) after. The mean SES improved from 36.9 (SD, 20.8) to 51.7 (SD, 27.4; p<0.001). Despite this improvement, only 44.7% of patients showed relevant clinical improvement in PRTEE, and 37.3% showed significant clinical improvement based on SES. Four patients reported a complication and the injection disposable failed three times.

Conclusions

Ultrasound-standardized autologous blood injection using the ITEC device is not an effective tool in reducing symptoms related to LE. This study showed that only half of all patients experienced a positive effect. In this heterogeneous cohort of patients, we showed no added value of ultrasound standardization.

Long-term quality of life outcome after spondylodiscitis treatment

BACKGROUND CONTEXT

Spondylodiscitis is the most common spinal infection of which the incidence has increased and the peak prevalence is between 50 and 70 years of age. Spondylodiscitis is often a complication of a distant infection. Early diagnosis can be challenging, and although improvements in diagnostic techniques and modern therapy have diminished the mortality of the disease, current literature about the outcome of spondylodiscitis is scarce.

PURPOSE

To evaluate the long-term clinical outcome of patients who suffered from spondylodiscitis.

STUDY DESIGN

A two-center cross-sectional study.

PATIENT SAMPLE

Patients with spondylodiscitis in two large teaching hospitals in the Netherlands between 2003 and 2017.

OUTCOME MEASURES

Visual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI) for function, and Short Form 36 (SF-36) for general quality of life of spondylodiscitis patients.

METHOD

Eligible patients were identified from electronic patient databases and completed multiple patient reported outcome measures after obtaining informed consent. General demographic and clinical information (age, sex, medical history) were extracted from the patient records. SF-36 domain scores of spondylodiscitis patients were compared with a nationwide population sample.

RESULTS

183 patients were treated for spondylodiscitis; additional questionnaires were received from 82 patients. After a median follow-up of 63 months, the overall mortality was 28%. The mean VAS for back pain was 3.5, and the mean ODI score was 22. In all SF-36 domains a significantly lower score was found in the spondylodiscitis group compared with a normative national Dutch cohort. There was a strong correlation between back pain and ODI scores (ρ=0.81, p<.05).

CONCLUSIONS

Our study confirms that spondylodiscitis is a disease causing a profound impact on back pain, function and quality of life. The results suggest that chronic back pain is a debilitating problem, as it has an extensive influence on daily activities and social and psychological well-being, causing significant disability.

Resident training does not influence the complication risk in total knee and hip arthroplasty

Background and purpose - Gaining experience in the surgery room during residency is an important part of learning the skills needed to perform arthroplasties. However, in practice, patients are often not fully comfortable with trainee involvement in their own surgery. Therefore, we investigated complications, revision rates, mortality, and operative time of orthopedic surgeons and residents as primary surgeon performing total knee arthroplasties (TKAs) or total hip arthroplasties (THAs).Patients and methods - In this multi-center retrospective cohort study, 3,098 TKAs and 4,027 THAs performed between 2007 and 2013 were analyzed. Complications, revisions, mortality, and operative time were compared for patients operated on by the orthopedic surgeon or a resident as primary surgeon. An additional analysis was performed to determine whether the complication risk was affected by the postgraduate year of the resident.Results - Orthopedic complication rates were similar (TKA: orthopedic surgeon: 10%, resident: 11%; THA: 9% and 8%), revision rates (TKA: 3% and 2%, THA: 3% and 2%), or mortality rates (TKA: 0.1% and 0.3%, THA: 0.2% and 0.3%). For both procedures a higher non-orthopedic complication rate was found in the resident group (TKA: 8% and 10%; p = 0.03, THA: 8% and 10%; p = 0.01) and a slightly longer operative time (TKA: mean difference 9.0 minutes (8%); THA: 11.3 minutes (11%)).Interpretation - Complications, revisions, and mortality were similar in TKAs or THAs performed by the resident as primary surgeon compared with surgeries performed by an orthopedic surgeon. This data can be used in teaching hospitals and may help to reassure patients.

Low rate of return to pre-injury level of sports after multi-ligament knee injury - Functional outcomes after MLKI

BACKGROUND

Multi-ligament knee injury (MLKI) is a rare but severe injury with potential devastating complications. The primary goal of this study was to investigate return to sports and work after MLKI. Secondary outcomes were patient reported outcome measures (PROMs), treatment, time between trauma, diagnosis and treatment, and neurovascular damage.

METHOD

A database search was performed to identify all patients with MLKI in our hospital (2010-2017). Pre-defined variables were collected from patient files and questionnaires. Multiple regression analysis was used to study the relationship between different variables and PROMs.

RESULTS

31 patients were included. The overall return to sports rate after a MLKI was 88.5%, but only 23.1% returned to their pre-injury level. 83.3% of the patients were able to return to work. Multiple regression analyses led to a significant prediction model for pain during rest (F(7,16) = 2.808, p = 0.041, R² = 0.355). Within this model, a higher age was a significant predictor for higher pain scores (p = 0.002). Age was also a significant (negative) predictor within the non-significant models for IKDC (p = 0.004) and Lysholm (p = 0.024). A delay between trauma and diagnosis of more than three months was seen in 32.3% of the patients.

CONCLUSIONS

This study showed a relatively high overall return to sports and work after MLKI, but less than a quarter returned to their pre-injury level of sports. An important finding was the substantial number of patients with a delay between trauma and diagnosis. This study contributes to more awareness and knowledge about MLKI among physicians, which is essential to reduce these delays.

Are the Roland Morris Disability Questionnaire and Oswestry Disability Index interchangeable in patients after lumbar spinal fusion?

BACKGROUND

Low back pain is a common health problem for which there are several treatment options. For optimizing clinical decision making, evaluation of treatments and research purposes it is important that health care professionals are able to evaluate the functional status of patients. Patient reported outcome measures (PROMs) are widely accepted and recommended. The Roland Morris Disability Questionnaire (RMDQ) and the Oswestry Disability Index (ODI) are the two mainly used condition-specific patient reported outcomes. Concerns regarding the content and structural validity and also the different scoring systems of these outcome measures makes comparison of treatment results difficult.

OBJECTIVE

Aim of this study was to determine if the RMDQ and ODI could be used exchangeable by assessing the correlation and comparing different measurement properties between the questionnaires.

METHODS

Clinical data from patients who participated in a multicenter RCT with 2 year follow-up after lumbar spinal fusion were used. Outcome measures were the RMDQ, ODI, Short Form 36 - Health Survey (SF-36), leg pain and back pain measured on a 0-100 mm visual analogue scale (VAS). Cronbach's alpha coefficients, Spearman correlation coefficients, multiple regression analysis and Bland-Altman plots were calculated.

RESULTS

three hundred and seventy-six completed questionnaires filled out by 87 patients were used. The ODI and RMDQ had both a good level of internal consistency. There was a very strong correlation between the RMDQ and the ODI (r= 0.87; p< 0.001), and between the VAS and both the ODI and RMDQ. However, the Bland-Altman plot indicated bad agreement between the ODI and RMDQ.

CONCLUSIONS

The RMDQ and ODI cannot be used interchangeably, nor is there a possibility of converting the score from one questionnaire to the other. However, leg pain and back pain seemed to be predictors for both the ODI and the RMDQ.

The normative Western Ontario Rotator Cuff Index values for age and sex

BACKGROUND

The Western Ontario Rotator Cuff Index (WORC) is a widely used disease-specific outcome tool developed for patients with rotator cuff injuries. The determination of age- and sex-adjusted normative WORC values enables us to determine whether a procedure is more beneficial in specific patient groups because the results can be compared with a matched standard. The purpose of this study was to determine normative WORC values and assess whether the WORC needs an adjusted score for age and sex.

METHODS

We included participants using an online data-capturing program. We collected the following variables: age, sex, presence of shoulder pathology, Subjective Shoulder Value, and WORC score. We defined the mean normative WORC score per age category and analyzed sex differences in WORC scores per age category and in all domains of the WORC score.

RESULTS

A total of 470 participants filled out the questionnaire. We excluded 44 participants because of pre-existing shoulder complaints or incomplete questionnaires. The mean total WORC score was 94% (standard deviation, 9%), and the mean total WORC score in every age and sex category was >90%. Of all participants, 85% scored between 91% and 100%; 63 participants (15%) scored 100%. The mean overall Subjective Shoulder Value was 98% (standard deviation, 6%). We found no statistically significant differences between sexes in the overall score, in the domain scores, and within the age categories.

CONCLUSION

We defined normative values for the WORC questionnaire in a random prospective cohort and found no difference in scores between sexes. The mean normative scores all were within the variance of the maximum, and the WORC score did not deteriorate with age. It seems that the results of this subjective questionnaire change with the participant's perspective. An adjusted WORC score for age and sex is not necessary. This information can serve as a basis for comparison with patients with shoulder disease.

Interchangeability of Diverse Analog Scales Used Within the Constant-Murley Score

Purpose

To assess the interchangeability of various existing answering scales within the subjective part of the Constant–Murley Score (CMS) and to determine the effect of the different answering scales on the inter- and intraobserver reliability.

Methods

In this prospective, single-center, cross-sectional trial, patients with shoulder problems were included from June to September 2018. Subjects recruited were 18 years or older, presented various shoulder complaints, e.g., diagnosis of osteoarthritis, subacromial pain syndrome, rotator cuff or biceps tendon problems, or frozen shoulder. An extended version of the CMS was prepared including the same questions multiple times but with varying answer scales. Six versions were made with random order of the questions. The answering scales were a verbal and paper based visual analog scale (VAS), smiley face scale, Numeric Rating Scale (NRS), and categories. Internal consistency of the various CMS, Spearman correlation coefficients, intraobserver, and interobserver agreement was assessed (ICC).

Results

In total, 93 patients were included. The total CMS using the paper-based VAS, smiley face score, and NRS were 46.9 ± 19.4, 45.2 ± 18.5, and 45.0 ± 18.7. Correlations of the total scores of the different versions varied from 0.98 to 0.99. CMS-category versus CMS-smiley face score and CMS-category versus CMS-NRS pain were significantly different (P = .02 and P = .01). Good internal consistency (0.76-0.79) and acceptable inter- and intraobserver reliability were found (ICC: 0.89-0.97, 0.98-0.99; P < .001).

Conclusions

The different answering scales for the subjective subscales within the CMS for pain, work, and recreational activity were not interchangeable on item level and significantly influenced the total CMS score. Differences were below the smallest detectable change and interpreted as not clinically relevant. Particularly on item level, data from different studies cannot be pooled and compared when different answering scales are being used. The inter- and intraobserver reliability were excellent.

Level of Evidence

Level I, prospective cross-sectional study.

Long-term (> 10 years) clinical outcomes of instrumented posterolateral fusion for spondylolisthesis

PURPOSE

Despite the rapid increase in instrumented spinal fusions for a variety of indications, most studies focus on short-term fusion rates. Long-term clinical outcomes are still scarce and inconclusive. This study investigated clinical outcomes > 10 years after single-level instrumented posterolateral spinal fusion for lumbar degenerative or isthmic spondylolisthesis with neurological symptoms.

METHODS

Cross-sectional long-term follow-up among the Dutch participants of an international multicenter randomized controlled trial comparing osteogenic protein-1 with autograft. Clinical outcomes were assessed using the Oswestry Disability Index (ODI), EQ-5D-3L and visual analogue scale (VAS) for leg and back pain, as well as questions on satisfaction with treatment and additional surgery.

RESULTS

The follow-up rate was 73% (41 patients). At mean 11.8 (range 10.1-13.7) years after surgery, a non-significant deterioration of clinical outcomes compared to 1-year follow-up was observed. The mean ODI was 20 ± 19, mean EQ-5D-3L index score 0.784 ± 0.251 and mean VAS for leg and back pain, respectively, 34 ± 33 and 31 ± 28. Multiple regression showed that diagnosis (degenerative vs. isthmic spondylolisthesis), graft type (OP-1 vs. autograft) and 1-year fusion status (fusion vs. no fusion) were not predictive for the ODI at long-term follow-up (p = 0.389). Satisfaction with treatment was excellent and over 70% of the patients reported lasting improvement in back and/or leg pain. No revision surgeries for non-union were reported.

CONCLUSION

This study showed favourable clinical outcomes > 10 years after instrumented posterolateral spinal fusion and supports spondylolisthesis with neurological symptoms as indication for fusion surgery.

Systematic review and meta-analysis of measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical Function Shortform (KOOS-PS)

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate all evidence on measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS).

DESIGN

This study was conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of PROMs. MEDLINE, EMBASE, The Cochrane Library, CINAHL and PsychINFO through February 2019 were searched. Eligible studies evaluated patients with hip or knee complaints and described a measurement property, interpretability, feasibility, or the development of either the HOOS-PS or KOOS-PS.

RESULTS

Twenty-three studies were included. For both questionnaires, the content validity was found inconsistent and the quality evidence was moderate for a sufficient reliability and high for an insufficient construct validity. The HOOS-PS had a high quality evidence of sufficient structural validity and internal consistency (pooled Cronbach's alpha 0.80; n = 3761) and low quality evidence of sufficient measurement error and indeterminate responsiveness. Concerning the KOOS-PS, the quality evidence was high for an insufficient responsiveness, moderate for an inconsistent structural validity and internal consistency and low for an inconsistent measurement error.

CONCLUSIONS

The inconsistent evidence for content validity implies that scores on the HOOS-PS and KOOS-PS may inadequately reflect physical functioning. Furthermore, there is evidence for insufficient construct validity and responsiveness in patients with knee osteoarthritis receiving conservative treatment. Using the HOOS-PS or KOOS-PS as outcome measurement instruments for comparing outcomes, measuring improvements or benchmarking in patients with hip or knee complaints or undergoing arthroplasty should only be done with great caution.

REVIEW REGISTRATION

PROSPERO number CRD42017069539.

Identifying predictive factors for vertebral collapse fractures in multiple myeloma patients

BACKGROUND CONTEXT

Vertebral compression fractures (VCFs) are a common complication for patients with multiple myeloma. These fractures are associated with significant morbidity and mortality due to severe back pain, spinal instability, increased risk of new fractures, neurologic dysfunction, and other physical symptoms.

PURPOSE

To identify risk factors associated with the development of VCFs which may help to predict them in future patients.

STUDY DESIGN

A retrospective multicenter cohort study.

PATIENT SAMPLE

Patients with multiple myeloma diagnosed between 2012 and 2018 and appropriate baseline- and follow-up imaging studies (>6 months after diagnosis) were included.

OUTCOME MEASURES

Individual odds ratios for each of the fifteen potential risk factors including patient factors and radiographical characteristics.

METHODS

Relevant clinical baseline data were extracted from the patient charts. Computed tomography (CT) scans were used to score all radiographic variables. VCFs were graded following the Genant grading system. General Linear Mixed Models were used to analyze risk factors associated with vertebral fractures.

RESULTS

A total of 143 patients with 1,605 eligible vertebrae were included in the study with a mean follow-up time of 25 months. Mean age at diagnosis was 65 years and 39% were female. Among 1,605 vertebrae, there were 192 (12%) VCFs (Genant grade 1 or higher) at the time of diagnosis and 111 (7%) occurred during follow-up. In a General Linear Mixed Model, significant predictors were gender (odds ratio [OR]=1.5), International Staging System stage 2 and 3 (OR=3.6 and OR=4.1 respectively), and back pain (OR=2.7). Furthermore, lower Hounsfield Unit score, lytic lesions and abnormal alignment were risk factors for (the development of) VCFs.

CONCLUSIONS

This study investigated both patient characteristics and vertebra-specific risk factors for VFCs in multiple myeloma patients. The factors found in this study might be useful for identifying patients at higher risk of VFCs to help clinical management to prevent vertebral collapse and the development of spinal deformities.

Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial

Background

It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears.

Purpose

To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m², locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method.

Results

After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale.

Conclusion

Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point.

Registration

NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Patient characteristics do not predict the change in physical functioning following arthroplasty measured by the HOOS-PS and KOOS-PS

Predicting personalized outcome after arthroplasty improves shared decision-making. The aim of this paper was to determine predictors of functional outcome measured by the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) or Knee injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS) in patients undergoing total hip (n = 79) or total knee arthroplasty (n = 90) respectively. Patients were assessed at baseline and following arthroplasty. A multiple regression analysis showed that the included variables predicted the change score in HOOS-PS limited (F (8,66) = 3.139, p = 0.005, adjusted R2 = 0.188) and the KOOS-PS not significantly (F (8,73) = 0.837, p = 0.573, adjusted R 2  = -0.016). Concluding, baseline characteristics cannot be used for personalized prediction using the KOOS-PS and HOOS-PS.

Validation of the Super Simple Hip score combined with the University of California, Los Angeles activity scale for younger patients

INTRODUCTION

Patient-reported outcome measures (PROMs) are used increasingly, but for young patients with hip complaints, traditional scoring systems have a ceiling effect that limits their usability. We developed and validated the Super Simple Hip (SUSHI) score, a PROM specifically targeted at younger patients with hip complaints. Although the SUSHI measured hip problems adequately, the responsiveness of its activity rating component was considered inadequate. Consequently, we replaced the activity rating component by the University of California, Los Angeles (UCLA) activity scale. The aim of this study was to validate the resulting new 10-item SUSHI-UCLA score.

METHODS

A prospective multicentre observational cohort study was performed. Patients between 18 and 59 years, who visited the Orthopaedic Department with hip complaints, completed the SUSHI-UCLA and hip osteoarthritis outcome score (HOOS) twice before their 1st appointment, and once 16 months after.

RESULTS

142 patients were included (mean age 49 years; SD 8.8). The SUSHI-UCLA score correlated well with the HOOS, both before and after treatment (Spearman's rho = 0.739 and 0.847, respectively, both p < 0.001). The responsiveness of both the SUSHI-UCLA score and the UCLA activity scale was high (standardised response mean = 2.51 and 1.35 respectively). The reproducibility was good (interclass correlation coefficient for agreement = 0.962). The minimal important change was 21.2. No significant floor or ceiling effect was observed.

CONCLUSION

The SUSHI-UCLA score is an adequate PROM to measure hip complaints in younger patients and includes a validated activity rating.

Non-inferiority and cost-effectiveness trial of isolated biceps tenotomy versus tenotomy with rotator cuff repair in patients with stage 2-3 Goutallier fatty degenerative cuff lesions (TenCuRe study): protocol of a multicentre randomised controlled trial

INTRODUCTION

For patients who are diagnosed with lesions of the rotator cuff that present advanced levels of fatty degeneration, arthroscopic repair of the rotator cuff remains controversial. This controversy can be attributed to the frequently reported high failure rate of the tendon fixation and the fact that it remains unclear why repair for these tears results in significant clinical improvement independent of the occurrence of such a re-tear. Recent publications have reported comparable clinical improvements when merely a tenotomy of the long head of the biceps tendon was performed and the rotator cuff tear was left untreated. These observations raise questions on the value of performing the more extensive cuff repairs in degenerative cuff tears. Even more, rehabilitation after an isolated tenotomy is much less cumbersome as compared with rehabilitation after rotator cuff repair and, therefore, might result in improved patient satisfaction. The goal of this trial is to study function and quality-of-life of patients undergoing arthroscopic biceps tenotomy with or without an additional cuff repair and to include an economic evaluation.

METHODS AND ANALYSIS

This multicentre randomised controlled non-inferiority trial, including an economic evaluation, is designed to compare the short-term and long-term outcome of patients who underwent an arthroscopic tenotomy of the long head of the biceps tendon with or without a cuff repair. We will include 172 patients with stage 2-3 Goutallier fatty infiltration cuff tears and with clinical symptoms of biceps pathology. Primary outcome is the rotator cuff specific quality-of-life (Western Ontario Rotator Cuff index) on the short term (6 months postoperatively). Secondary outcomes are quality-of-life 1, 2 and 5 year postoperatively and function (Constant-Murley score, glenohumeral range of motion), recovery status, pain (visual analogue scale), economic evaluation, satisfaction of treatment on the short-term and long-term and re-tear rate at 6 months determined with an ultrasound.

ETHICS AND DISSEMINATION

This trial has been approved by the Medical Research Ethics Committees United (MEC-U), Nieuwegein, the Netherlands (NL54313.100.15) and will be performed in accordance with the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results of this study will be reported in peer-reviewed journals and at (inter)national conferences. Furthermore, we will share our findings with the appropriate guideline committees.

TRIAL REGISTRATION NUMBER

The Dutch Trial Registry (NL4010).

Chlorhexidine 0.5%/70% Alcohol and Iodine 1%/70% Alcohol Both Reduce Bacterial Load in Clean Foot Surgery: A Randomized, Controlled Trial

No consensus exists regarding which cleansing technique, solution, and concentration should be used in orthopedic surgery. The aim of this randomized, controlled trial was to compare the effect of chlorhexidine 0.5%/70% alcohol with iodine 1%/70% alcohol on lowering positive cultures before elective foot surgery and to study any wound complications, infections and allergic reactions. Consecutive patients ≥18 years of age scheduled for a hallux valgus correction or arthrodesis of the first metatarsophalangeal joint were included. Swabs were taken from 2 sites before and twice after preparing the skin and were quantitatively and qualitatively analyzed. The study group consisted of 49 patients with a mean age of 52.3 ± 14.4 (range 22 to 75) years of whom 42 (86%) were female. No significant differences were observed for positive cultures between the chlorhexidine (73%, 2%, and 12%) and iodine (68%, 7%, and 9%) group at any time point. Coagulase-negative staphylococci were the most commonly isolated micro-organisms found after skin preparation. Occasionally, Bacillus spp and Corynebacterium spp were cultured. The complication rate 2 weeks postoperatively was 0% in the chlorhexidine group versus 8.7% (n = 2) in the iodine group (delayed wound healing; p = .215). The complication rate at 6 weeks postoperatively was, respectively, 3.8% (n = 1) versus 4.3% (n = 1; both showed swelling and redness; p > .999). There was no significant difference in postoperative wound problems or infection rates between the 2 skin preparation solutions. Chlorhexidine 0.5%/70% alcohol and iodine 1%/70% alcohol both decreased the amount of positive cultures in elective foot surgery.

The lateral femoral notch sign: a reliable diagnostic measurement in acute anterior cruciate ligament injury

PURPOSE

To describe the validity and inter- and intra-observer reliability of the lateral femoral notch sign (LFNS) as measured on conventional radiographs for diagnosing acute anterior cruciate ligament (ACL) injury.

METHODS

Patients (≤ 45 years) with a traumatic knee injury who underwent knee arthroscopy and had preoperative radiographs were retrospectively screened for this case-control study. Included patients were assigned to the ACL injury group (n = 65) or the control group (n = 53) based on the arthroscopic findings. All radiographs were evaluated for the presence, depth and location of the LFNS by four physicians who were blind to the conditions. To calculate intra-observer reliability, each observer re-assessed 25% of the radiographs at a 4-week interval.

RESULTS

The depth of the LFNS was significantly greater in ACL-injured patients than in controls [median 0.8 mm (0-3.1 mm) versus 0.0 mm (0-1.4 mm), respectively; p = 0.008]. The inter- and intra-observer reliabilities of the LFNS depth were 0.93 and 0.96, respectively. Secondary knee pathology (i.e., lateral meniscal injury) in ACL-injured patients was correlated with a deeper LFNS [median 1.1 mm (0-2.6 mm) versus 0.6 mm (0-3.1 mm), p = 0.012]. Using a cut-off value of 1 mm for the LFNS depth, a positive predictive value of 96% was found.

CONCLUSION

This was the first study to investigate the inter- and intra-observer agreement of the depth and location of the LFNS. The depth of the LFNS had a very high predictive value for ACL-injured patients and could be used in the emergency department without any additional cost. A depth of > 1.0 mm was a good predictor for ACL injury. Measuring the depth of the LFNS is a simple and clinically relevant tool for diagnosing ACL injury in the acute setting and should be used by clinicians in patients with acute knee trauma.

LEVEL OF EVIDENCE

Diagnostic study, level II.

Primary intra-articular epithelioid sarcoma of the knee: Unusual presentation of a rare entity

We report a case of a 60-year-old female with severe and progressive pain of her right knee. Physical therapy, pain medication, and arthroscopic debridement were unsuccessful. Finally, pathological examination revealed an intra-articular epithelioid sarcoma, a rare tumor in an atypical location. Patient died within 5 months after initial admission. Despite this unusual clinical course and presentation, we would like to share the valuable clinical lessons we learned from this case. Introduction of a coordinating physician in combination with a multidisciplinary treatment regarding optimal pain management should optimize treatment results in future patients.

A novel test for assessment of anterolateral rotatory instability of the knee: the tibial internal rotation test (TIR test)

Background

Rotational instability of the knee may persist after anterior cruciate ligament (ACL) reconstruction, which may be due to insufficiency of anterolateral stabilizing structures. However, no reliable diagnostic tool or physical examination test is available for identifying patients with anterolateral rotatory instability (ALRI). As shown in cadaveric studies, static internal rotation of the knee is increased in higher flexion angles of the knee after severing the anterolateral structures. This might also be the case in patients with an ACL-deficient knee and concomitant damage to the anterolateral structures. The objective of this study is to assess anterolateral rotatory instability of the knee during physical examination with a tibial internal rotation test.

Methods

ACL-injured knees of 52 patients were examined by two examiners and side-to-side differences were compared. Both lower legs were internally rotated by applying manual internal rotation torque to both feet in prone position with the knees in 30°, 60° and 90° of flexion. For quantification of the amount of rotation in degrees, a torque adapter on a booth was used. Intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the tibial internal rotation test.

Results

Tibial internal rotation is increased in 19.2% of the patients with ACL injury according to the tibial internal rotation test. Good intra-rater agreement was found for the tibial internal rotation test, κ_C = 0.63 (95%CI -0.02-1.28), p = 0.015. Fair inter-rater agreement was found, κ_F = 0.29 (95%CI 0.02–0.57), p = 0.038. Good rater-device agreement was found, κ_C = 0.62 (95%CI 0.15–1.10), p = 0.001.

Conclusion

The tibial internal rotation test shows increased tibial internal rotation in a small amount of patients with ACL injury. Even though no gold standard for assessment of increased tibial internal rotation of the knee is available yet, the test can be of additional value. It can be used for assessment of internal rotatory laxity of the knee as part of ALRI in addition to the pivot shift test. No clinical implications should yet be based on this test alone.

Electronic supplementary material

The online version of this article (10.1186/s40634-018-0141-9) contains supplementary material, which is available to authorized users.

Rater agreement reliability of the dial test in the ACL-deficient knee

Background

Posterolateral rotatory instability (PLRI) of the knee can easily be missed, because attention is paid to injury of the cruciate ligaments. If left untreated this clinical instability may persist after reconstruction of the cruciate ligaments and may put the graft at risk of failure. Even though the dial test is widely used to diagnose PLRI, no validity and reliability studies of the manual dial test are yet performed in patients. This study focuses on the reliability of the manual dial test by determining the rater agreement.

Methods

Two independent examiners performed the dial test in knees of 52 patients after knee distorsion with a suspicion on ACL rupture. The dial test was performed in prone position in 30°, 60° and 90° of flexion of the knees. ≥10° side-to-side difference was considered a positive dial test. For quantification of the amount of rotation in degrees, a measuring device was used with a standardized 6 Nm force, using a digital torque adapter on a booth. The intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the dial test.

Results

A positive dial test was found in 21.2% and 18.0% of the patients as assessed by a blinded examiner and orthopaedic surgeon respectively. Fair inter-rater agreement was found in 30° of flexion, κ_F = 0.29 (95% CI: 0.01 to 0.56), p = 0.044 and 90° of flexion, κ_F = 0.38 (95% CI: 0.10 to 0.66), p = 0.007. Almost perfect rater-device agreement was found in 30° of flexion, κ_C = 0.84 (95% CI: 0.52 to 1.15), p < 0.001. Moderate rater-device agreement was found in 30° and 90° combined, κ_C = 0.50 (95% CI: 0.13 to 0.86), p = 0.008. No significant intra-rater agreement was found.

Conclusions

Rater agreement reliability of the manual dial test is questionable. It has a fair inter-rater agreement in 30° and 90° of flexion.

Responsiveness and disease specificity of the Western Ontario Rotator Cuff index

The goal of this study was to determine the disease specificity and responsiveness of the Western Ontario Rotator Cuff Index (WORC). Responsiveness, two cut-off points of the minimal important change, the area under the curve, standard error of measurement, the minimal detectable change and the standardized response mean were determined. Patients undergoing a rotator cuff repair need to improve more than 35 points to be considered clinical importantly improved. The WORC is disease specific and has a high responsiveness in patients undergoing rotator cuff repair and patients with disease of the rotator cuff without rotator cuff tears.

Abduction Brace Versus Antirotation Sling After Arthroscopic Cuff Repair: The Effects on Pain and Function

PURPOSE

To study the effects on pain as the main outcome parameter and on function and cuff integrity as the secondary outcome parameters after arthroscopic rotator cuff repair in the short term comparing the abduction brace with an antirotation sling for postoperative shoulder immobilization.

METHODS

Eligible patients were between the ages of 18 and 75 years who were diagnosed with a traumatic or degenerative tear of the supraspinatus and/or infraspinatus tendon, confirmed by magnetic resonance imaging, for which an arthroscopic footprint repair was indicated and performed. Patients were randomly allocated to the antirotation sling or abduction brace group. Postoperative pain and use of analgesics were accurately registered up to 3 months after surgery using a patient diary. Follow-up examinations including the Constant-Murley score, Western Ontario Rotator Cuff index, and glenohumeral range of motion were scheduled 6 weeks, 3 and 6 months, and 1 year after surgery.

RESULTS

The average level of pain measured directly postoperation up to 1 year after surgery was not significant different between groups. Postoperatively, function scores and glenohumeral range of motion improved significantly for both groups; however, no differences were observed between groups. No retears were observed on ultrasonograph 3 months after surgery.

CONCLUSIONS

In the short term, the level of pain, function, and quality of life were not significantly different between the use of an abduction brace and that of an antirotation sling after arthroscopic rotator cuff repair. Based on these findings, the abduction brace used in this study does not seem to be the solution for decreasing the pain experienced in the first postoperative weeks after arthroscopic rotator cuff repair, and both are recommendable.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial

INTRODUCTION

Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking.

METHODS AND ANALYSIS

A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events.

ETHICS AND DISSEMINATION

This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees.

TRIAL REGISTRATION NUMBER

NCT01850719.

Response shift of the Western Ontario Rotator Cuff index in patients undergoing arthroscopic rotator cuff repair

HYPOTHESIS

This study determined the response shift in patients undergoing rotator cuff repair using the Western Ontario Rotator Cuff index (WORC), a disease-specific quality of life questionnaire. We hypothesized there would be a response shift with a positive recalibration (overestimated their preoperative disability) on the WORC and increases over time.

METHODS

The study prospectively included 36 patients undergoing arthroscopic rotator cuff repair. At baseline, 3 months (T1), and 1 year (T2) after surgery the WORC, EuroQol (EQ)-5D-3L, and the patient's level of satisfaction after surgery were scored. To evaluate the response shift, patients also completed the WORC at 3 months (Pre-T1) and 1 year (Pre-T2) as how they perceived themselves to have been before surgery.

RESULTS

The result on Pre-T1 and Pre-T2 results revealed that patients retrospectively rated their overall WORC score comparable with the baseline WORC score (Pre-T0; T0 = 40.5 ± 18.4, Pre-T1 = 45.0 ± 22.7, Pre-T2 = 34.3 ± 21.3). No response shift was observed on all domains except a negative recalibrated response shift for emotional disability on T1 (P = .04).

CONCLUSIONS

No significant group-level response shift was observed using the WORC, except for the subdomain emotional disability at 3 months after arthroscopic rotator cuff repair. With the absence of any shift in patient's perception on the self-administered quality of life-related WORC questionnaire, this study suggests one could retrospectively reliably conduct group-level preoperative baseline information on quality of life up to 1 year after surgery.

Arthroscopic Partial Meniscectomy or Conservative Treatment for Nonobstructive Meniscal Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

To conduct a meta-analysis of randomized controlled trials comparing the outcome of arthroscopic partial meniscectomy (APM) with conservative treatment in adults with nonobstructive meniscal tears and to recommend a treatment of choice.

METHODS

We systematically searched the databases of MEDLINE, Excerpta Medica Database, Cochrane, the National Health Service Centre for Reviews and Dissemination, and Physiotherapy Evidence Database from inception to May 2, 2016. Two authors independently searched the literature and selected eligible studies. The meta-analyses used a random-effects model. The primary outcome was physical function, measured by knee-specific patient-reported outcomes. Secondary outcomes included knee pain, activity level, the progression of osteoarthritis, adverse events, general health, and quality of life.

RESULTS

We included 6 randomized controlled trials, with a total of 773 patients, of whom 378 were randomized to APM and 395 were randomized to the control treatment. After pooling the data of 5 studies, we found small significant differences in favor of the APM group for physical function at 2 to 3 months (mean difference [MD] = 3.31; 95% confidence interval [CI] = 0.69-5.93; P = .01; I(2) = 0% [Lysholm knee score]), and at 6 months (MD = 3.56; 95% CI = 0.24-6.88; P = .04; I(2) = 0% (Knee injury and Osteoarthritis Outcome Score [KOOS] and Western Ontario and McMaster Universities Osteoarthritis Index); standardized MD = 0.17; 95% CI = 0.01-0.32; P = .03; I(2) = 0% [Lysholm knee score, KOOS, and Western Ontario and McMaster Universities Osteoarthritis Index]). We also found small significant differences for pain at 6 months (MD = 3.56; 95% CI = 0.18-6.95; P = .04; I(2) = 0% [KOOS] and MD = 0.56; 95% CI = 0.28-0.83; P ≤ .0001; I(2) = 0% [visual analog scale and numeric rating scale]). We found no significant differences after 12 and 24 months.

CONCLUSIONS

We found small, although statistically significant, favorable results of APM up to 6 months for physical function and pain. However, we found no differences at longer follow-up.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis of Level I studies.

The Dutch version of the Forgotten Joint Score: test-retesting reliability and validation

The aim of this study was to translate the Forgotten Joint Score (FJS) into the Dutch language. This -questionnaire was tested for internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficients (ICC)). 159 patients were included in this study; 74 with a total hip arthroplasty (THA) and 85 with a total knee arthroplasty (TKA). The FJS showed a high internal consistency (Cronbach's alpha=0.957; ICC=0.943). The FJS showed a significant correlation (r=0.751) with the WOMAC and low ceiling effects (3.1%). This study proved the Dutch FJS to be highly discriminative in patients treated with a THA or TKA. This makes the FJS a reliable patient related outcome measurement, measuring a new dimension in arthroplasty: the ability to forget an artificial joint in everyday life.

Predictors of disease-specific quality of life after arthroscopic rotator cuff repair

PURPOSE

Disease-specific instruments of quality of life (QOL) are more sensitive to disease-specific changes. The purpose of this study is to identify prognostic factors for disease-specific QOL after all-arthroscopic rotator cuff (RC) repair using the Western Ontario Rotator Cuff Index (WORC).

METHODS

A total of 140 patients were evaluated after an RC repair with a mean follow-up of 22 ± 6.7 months. Evaluations included the WORC, EQ-5D and anchor questions. Preoperative patient demographics and radiologic characteristics were assessed to identify predictors of disease-specific QOL.

RESULTS

Most patients (81.4 %) were satisfied with their surgical result. Minor tear retraction (odds ratio [OR] 2.97, p = 0.030), male gender (OR 3.67, p = 0.003), no social benefits (OR 3.67, p = 0.042) and pre-surgical complaints for more than six months (OR 3.03, p = 0.021) were independent predictors for superior postoperative WORC score in multivariable analysis. None of these factors were predictive for a higher EQ-5D score.

CONCLUSION

These findings highlight the important impact of retraction on QOL after RC repair and underline the utility of disease-specific instruments. Future studies should focus on how these significant predictors can be used to improve decision making and to develop new treatment approaches.

Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty

Background

Patients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively. The purpose of this study was to assess the risk of thromboembolic events and bleeding-related complications after total hip and knee arthroplasty in patients requiring bridging therapy for anticoagulants.

Methods

A retrospective cohort study of all patients with primary total hip or total knee replacement in a 4-year period was performed. Outcome measures were blood loss, thromboembolic and bleeding-related complications and hospital stay.

Results

Bridged patients had more blood loss and higher complication rates than the control group. Most complications were bleeding-related, and there were no thromboembolic events. Seven of the 14 (50 %) total hip patients bridged with unfractioned heparin required reoperation (three patients with ischial neuropraxia due to hematoma). There were two bleeding-related deaths in total hip patients bridged with low-molecular-weight heparin. Mean hospital stay was significantly longer in unfractioned heparin bridging.

Conclusion

In this study, there was a significant increase in bleeding-related complications in total joint replacement with bridging therapy compared to prophylaxis. This risk was highest in patients with total hip arthroplasty. There were no thromboembolic events in bridged patients.

Prognostic factors for recovery after arthroscopic rotator cuff repair: a prognostic study

BACKGROUND

Studies concerning prognostic factors of recovery after arthroscopic rotator cuff repair mostly focus on tendon integrity or functional recovery as an outcome. Little is known about how they influence quality of life after surgery. We therefore tried to identify prognostic factors having an impact on quality of life after arthroscopic rotator cuff repair.

METHODS

This study included 30 patients who underwent arthroscopic rotator cuff repair. We assessed Western Ontario Rotator Cuff Index as primary outcome and RAND-36, Constant-Murley score, and a shoulder hindrance score as secondary outcomes. Patients were repeatedly measured: once preoperatively and 4 times postoperatively. Preoperative range of motion, obesity, fatty infiltration, and cuff retraction were preselected as prognostic factors.

RESULTS

Patients were significantly improved at 3 months and 6 months after arthroscopic rotator cuff repair. In multiple regression analysis, none of the preselected factors could be identified as a prognostic factor influencing quality of life after arthroscopic rotator cuff repair (measured with the Western Ontario Rotator Cuff Index). For the outcome variables RAND-36 (6 months, 1 year) and shoulder hindrance score (1 year), fatty infiltration Goutallier stages 1 and 2 and retraction grades II, III, and IV were significant predictors.

CONCLUSION

Although fatty infiltration and retraction grade predict the RAND-36 and shoulder hindrance score, this study could not support preoperative range of motion, obesity, fatty infiltration, or retraction of the cuff as a prognostic factor for quality of life after arthroscopic rotator cuff repair. This study shows that if selection of patients is done properly, these factors do not influence a successful outcome.

Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty

Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb. In total hip arthroplasty and total knee arthroplasty, the incidence ranges from 7% to 84%. In this study, the incidence and risk factors for postoperative urinary retention were described in a cohort of 376 men undergoing total hip arthroplasty. Postoperative urinary retention was defined as the inability to void after surgery for which single or indwelling catheterization was performed. Risk factors were identified using multivariate regression analysis. Following total hip arthroplasty, 150 (39.9%) of the 376 men developed urinary retention. Patient-controlled analgesia (odds ratio, 4.10; 95% confidence interval, 1.79-9.40), use of spinal anesthesia (odds ratio, 1.79; 95% confidence interval, 1.07-2.99), and age 70 years or older (odds ratio, 1.77; 95% confidence interval, 1.06-2.95) were independent risk factors for urinary retention. Potential risk factors that were not confirmed included body mass index, American Society of Anesthesiologists physical status (Class I-III), hypertension, diabetes mellitus, prostate pathology, smoking, average pain during the first 24 hours after surgery, and length of surgery. Two of the 150 patients with urinary retention (1.3%) for which a catheter has been inserted developed a urinary tract infection vs none of the patients without urinary retention. The risk of urinary retention after total hip arthroplasty is increased in men older than 70 years, those receiving spinal anesthesia, and those with patient-controlled analgesia postoperatively.

Reliability and Validity of the IKDC, KOOS, and WOMAC for Patients With Meniscal Injuries

BACKGROUND

Several patient-reported outcome measurements are used to measure functional outcome after treatment of meniscal injuries. However, for comparison of study results, there is a need for a uniform and standardized approach of measuring functional outcome. Selection of the instrument should be based on the quality of its measurement properties, and only the best instrument can be justified to be used.

PURPOSE

This study aimed to determine and compare the measurement properties of the Dutch-language versions of the International Knee Documentation Committee (IKDC) Subjective Knee Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) in a homogeneous group of patients with meniscal tears.

STUDY DESIGN

Cohort study (design); Level of evidence, 2.

METHODS

Patients on the waiting list for meniscal surgery and patients between 6 weeks and 6 months after meniscal surgery were included (n = 75). Patients were excluded if they received an arthroplasty or had surgery on the anterior cruciate ligament. Internal consistency (Cronbach alpha), test-retest reliability (intraclass correlation coefficient [ICC]), measurement error (SEM), smallest detectable difference (SDD), content validity, construct validity (factor analysis and hypothesis testing), and floor and ceiling effects were determined.

RESULTS

Results for the IKDC, KOOS dimensions, and WOMAC dimensions, respectively, were as follows: Cronbach alpha = .90, .72-.95, and .84-.95; ICC = 0.93, 0.84-0.89, and 0.77-0.89; SEM = 5.3, 7.0-12.6, and 7.3-12.2; SDD = 14.6, 19.4-35.0, and 20.2-33.9; hypotheses testing confirmation = 100%, 86%, and 85%. Floor effects within the SDD from the minimum score were found for the KOOS Sports/Recreation and Quality of Life dimensions. Ceiling effects within the SDD from the maximum score were found for the KOOS Activities of Daily Living and for all WOMAC dimensions.

CONCLUSION

The IKDC showed the best performance on all measurement properties, implying that the IKDC, rather than the KOOS or WOMAC, should be used to assess functional outcome in patients with meniscal tears.

The conceptually equivalent Dutch version of the Western Ontario Rotator Cuff Index (WORC)©

Background

The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff, originally developed in English. The purpose of this study was to cross-culturally adapt the WORC for use in the Dutch population and to evaluate reliability, agreement and floor and ceiling effects of this Dutch version in a population of patients with rotator cuff disease.

Methods

Reliability was tested by measuring the Cronbach’s alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Agreement was measured using the Standard Error of Measurement (SEM_agreement); and the smallest detectable change (SDC) was calculated based on the SEM. Pearson Correlations Coefficients were used to comparing the WORC with the RAND-36, the Constant Score and 11-point shoulder hindrance scale.

Results

Fifty-seven patients entered into this study of whom 50 were available for test-retest validation. The internal consistency of the Dutch WORC tested by Cronbach’s alpha was 0.95 for the total questionnaire. The ICC for the WORC is 0.91 with a 95% confidence interval of 0.85-0.95. Standard Error of Measurement was 6.0 points with a Smallest Detectable Change of 16.7 points on a 0-100 scale. Pearson Correlations Coefficients showed a significant positive correlation between the Dutch WORC and Constant Score (r = 0.60) and a strong reversed correlation with the shoulder hindrance scale (r = -0.75).

Conclusion

The Dutch WORC seems to be a reliable health-related quality of life questionnaire for patients with rotator cuff disorders.

Trial registration

NCT01532492.

Kinematics of a highly congruent mobile-bearing total knee prosthesis

PURPOSE

Limited or absent axial rotation of the mobile insert of total knee prostheses could lead to high contact stresses and stresses at the bone-implant interface, which in turn might lead to implant loosening. The aim of this study was to assess knee kinematics and muscle activation and their possible change over time in patients with a highly congruent, mobile-bearing total knee prosthesis.

METHODS

A prospective series of 11 rheumatoid arthritis patients was included to participate in this fluoroscopic and EMG study; only 7 patients completed the study. Kinematic evaluations took place 7 months, 1 and 2 years post-operatively. Repeated measurements ANOVA and linear mixed-effects model for longitudinal data were used to compare the differences between the follow-ups.

RESULTS

There are no significant changes in axial rotations between follow-up moments for the femoral component as well as the mobile insert. The insert remained mobile and followed the femoral component from 0° until approximately 60° of knee flexion. Diverging and reversed axial rotations and translations were seen during the dynamic motions.

CONCLUSIONS

Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years. Reversed and divergent axial rotations with increasing knee flexion indicate that as soon as the congruency decreases, the femoral component is no longer forced in a certain position by the insert and moves to a self-imposed position. At lower knee flexion angles, the femoral component might be obstructed by the highly congruent insert and therefore might not be able to move freely.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Integrated assessment techniques for linking kinematics, kinetics and muscle activation to early migration: a pilot study

The goal of this pilot study was to develop and test an integrated method to assess kinematics, kinetics and muscle activation of total knee prostheses during dynamic activities, by integrating fluoroscopic measurements with force plate, electromyography and external motion registration measurements. Subsequently, this multi-instrumental analysis was then used to assess the relationship between kinematics, kinetics and muscle activation and early migration of the tibial component of total knee prostheses. This pilot study showed that it is feasible to integrate fluoroscopic, kinematic and kinetic measurements and relate findings to early migration data. Results showed that there might be an association between deviant kinematics and early migration in patients with a highly congruent mobile-bearing total knee prosthesis. Patients that showed high levels of coactivation, diverging axial rotations of the insert and a deviant pivot point showed increased migration and might be at higher risk for tibial component loosening. In the future, to confirm our findings, the same integrated measurements have to be performed in larger patient groups and different prosthesis designs.

Kinematics and early migration in single-radius mobile- and fixed-bearing total knee prostheses

BACKGROUND

The mobile-bearing variant of a single-radius design is assumed to provide more freedom of motion compared to the fixed-bearing variant because the insert does not restrict the natural movements of the femoral component. This would reduce the contact stresses and wear which in turn may have a positive effect on the fixation of the prosthesis to the bone and thereby decreases the risk for loosening. The aim of this study was to evaluate early migration of the tibial component and kinematics of a mobile-bearing and fixed-bearing total knee prosthesis of the same single-radius design.

METHODS

Twenty Triathlon single-radius posterior-stabilized knee prostheses were implanted (9 mobile-bearing and 11 fixed-bearing). Fluoroscopy and roentgen stereophotogrammetric analysis (RSA) were performed 6 and 12 months post-operatively.

FINDINGS

The 1 year post-operative RSA results showed considerable early migrations in 3 out of 9 mobile-bearing patients and 1 out of 11 fixed-bearing patients. The range of knee flexion was the same for the mobile-bearing and fixed-bearing group. The mobile insert was following the femoral component during motion.

INTERPRETATION

Despite the mobile insert following the femoral component during motion, and therefore performing as intended, no kinematic advantages of the mobile-bearing total knee prosthesis were seen. The fixed-bearing knee performed as good as the mobile-bearing knee and maybe even slightly better based on less irregular kinematics and less early migrations.

The quality of bone surfaces may govern the use of model based fluoroscopy in the determination of joint laxity

The assessment of knee joint laxity is clinically important but its quantification remains elusive. Calibrated, low dosage fluoroscopy, combined with registered surfaces and controlled external loading may offer possible solutions for quantifying relative tibio-femoral motion without soft tissue artefact, even in native joints. The aim of this study was to determine the accuracy of registration using CT and MRI derived 3D bone models, as well as metallic implants, to 2D single-plane fluoroscopic datasets, to assess their suitability for examining knee joint laxity. Four cadaveric knees and one knee implant were positioned using a micromanipulator. After fluoroscopy, the accuracy of registering each surface to the 2D fluoroscopic images was determined by comparison against known translations from the micromanipulator measurements. Dynamic measurements were also performed to assess the relative tibio-femoral error. For CT and MRI derived 3D femur and tibia models during static testing, the in-plane error was 0.4 mm and 0.9 mm, and out-of-plane error 2.6 mm and 9.3 mm respectively. For metallic implants, the in-plane error was 0.2 mm and out-of-plane error 1.5 mm. The relative tibio-femoral error during dynamic measurements was 0.9 mm, 1.2 mm and 0.7 mm in-plane, and 3.9 mm, 10.4 mm and 2.5 mm out-of-plane for CT and MRI based models and metallic implants respectively. The rotational errors ranged from 0.5° to 1.9° for CT, 0.5-4.3° for MRI and 0.1-0.8° for metallic implants. The results of this study indicate that single-plane fluoroscopic analysis can provide accurate information in the investigation of knee joint laxity, but should be limited to static or quasi-static evaluations when assessing native bones, where possible. With this knowledge of registration accuracy, targeted approaches for the determination of tibio-femoral laxity could now determine objective in vivo measures for the identification of ligament reconstruction candidates as well as improve our understanding of the consequences of knee joint instability in TKA.

No differences in in vivo kinematics between six different types of knee prostheses

PURPOSE

The aim of this study was to compare a broad range of total knee prostheses with different design parameters to determine whether in vivo kinematics was consistently related to design. The hypothesis was that there are no clear recognizable differences in in vivo kinematics between different design parameters or prostheses.

METHODS

At two sites, data were collected by a single observer on 52 knees (49 subjects with rheumatoid arthritis or osteoarthritis). Six different total knee prostheses were used: multi-radius, single-radius, fixed-bearing, mobile-bearing, posterior-stabilized, cruciate retaining and cruciate sacrificing. Knee kinematics was recorded using fluoroscopy as the patients performed a step-up motion.

RESULTS

There was a significant effect of prosthetic design on all outcome parameters; however, post hoc tests showed that the NexGen group was responsible for 80% of the significant values. The range of knee flexion was much smaller in this group, resulting in smaller anterior-posterior translations and rotations.

CONCLUSION

Despite kinematics being generally consistent with the kinematics intended by their design, there were no clear recognizable differences in in vivo kinematics between different design parameters or prostheses. Hence, the differences in design parameters or prostheses are not distinct enough to have an effect on clinical outcome of patients.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

The Femoral Epicondylar Frame to track femoral rotation in optoelectronic gait analysis

Relative movement of skin markers to underlying bone limits a valid interpretation of axial femorotibial rotation in noninvasive optoelectronic gait analysis. A distal femoral clamp is a practical solution for thigh marker placement, however, existing devices are still susceptible to measurement errors at increased angles of knee flexion. We developed the Femoral Epicondylar Frame (FEF), which should result in less femoral rotational measurement error due to its anatomic fitting and controlled pressure adjustment. Seven subjects with a total knee replacement in situ, mean age 71 years, mean body mass index 28, were equipped with the frame mounted with a set of tantalum markers. Fluoroscopic data was collected during a step-up motion. A three-dimensional model fitting technique was used to compare the in vivo position and orientation of the frame and the femoral prosthesis component of the prosthesis. The frame rotational measurement error appeared to be linearly dependent on the knee flexion angle. When considering knee flexion angles lower than 40° of flexion, the highest measurement error was 3.3° on average, with an absolute extreme of 6.2°. It is concluded that the accuracy of the FEF is sufficient to evaluate axial knee rotation with optoelectronic gait analysis at group level in clinical studies.

Mobile bearing knee kinematics change over time. A fluoroscopic study in rheumatoid arthritis patients

BACKGROUND

In a previous fluoroscopy study the motion of a mobile bearing total knee prosthesis was evaluated. That study showed that the axial rotation of the insert was limited. Three possible explanations are given for the limited rotation: low conformity between the femoral component and insert, the fixed anterior position of the insert-tibia pivot point leading to impingement and fibrous tissue formation. While the effect of the conformity on the axial rotation will not change over time, the effect of impingement and fibrous tissue is likely to increase, and thereby further decreasing the axial rotation.

METHODS

In order to accurately assess changes in axial rotation over time in a mobile bearing total knee prosthesis rheumatoid arthritis patient group, patients were evaluated 8 months and 3 years postoperatively using fluoroscopy.

FINDINGS

In comparison with the 8 months evaluation, the rotation of the femoral component (range: -10.8 degrees to 2.8 degrees) and the insert (range: -5.9 degrees to 1.4 degrees) were further limited at 3 years (respectively, -5.9 degrees to 4.9 degrees and -2.8 degrees to 5.4 degrees). Patterns of axial rotation for the femoral component and insert varied considerably between the trials within patients while at the 8 months evaluation no significant difference within patients was observed.

INTERPRETATION

This study shows the importance of re-evaluating knee kinematics over time. The axial rotation of both the femoral component as the insert decreased over time, indicating a kinematic change caused by intrinsic factors. The decline in rotation of the insert could be explained by increased impingement and the formation of fibrous tissue.

Knee rotation during a weightbearing activity: influence of turning

Kinematic studies, in which mobile- and fixed-bearing total knee arthroplasty (TKA) were compared, showed controversial results with respect to axial femorotibial rotation. However, all studies focused only on straight ahead tasks, which may underestimate possible differences in freedom of rotation. The purpose of this study was to investigate the influence of turning on normal axial knee rotation. If large differences across tasks were to be found, this would support the use of this task in the evaluation of in-vivo TKA kinematics. In 15 healthy persons, crossover and sidestep turns were added to a standardized chair rise. Three-dimensional knee angles were recorded using an optoelectronic motion analysis system, and a noninvasive epicondylar frame was developed to track the femur. Compared to knee rotation during the straight ahead task, average peak tibial internal rotation increased during a crossover turn (p<0.001), as did peak external tibia rotation during a sidestep turn (p<0.001). The combined range of axial rotation for both turning tasks together was 20.9 degrees , versus 13.5 degrees for the straight ahead task (p<0.001). The turning maneuvers in this study induced a large range of axial knee rotation, so they could be important in studies comparing freedom of rotation in mobile- and fixed-bearing TKA.

Knee varus-valgus motion during gait--a measure of joint stability in patients with osteoarthritis?

OBJECTIVE

To determine the validity of varus-valgus motion as a measure of knee joint stability by establishing the relationship of varus-valgus motion with muscle strength, joint proprioception, joint laxity and skeletal alignment in patients with knee osteoarthritis (OA).

METHODS

Sixty-three patients with OA of the knee were tested. Varus-valgus motion was determined with a video-based optoelectronic gait analysis system. Muscle strength was measured using a computer-driven isokinetic dynamometer. Proprioceptive acuity was assessed by establishing the joint motion detection threshold in the anterior-posterior direction. Laxity was assessed using a device which measures the passive angular deviation of the knee in the frontal plane. Alignment was assessed using a goniometer. Regression analyses were performed to assess the relationship between varus-valgus motion, muscle strength, joint proprioception, joint laxity and skeletal alignment.

RESULT

Varus-valgus motion was not related to muscle strength, joint proprioception, joint laxity and skeletal alignment.

CONCLUSIONS

Knee joint stability cannot be measured as varus-valgus motion. Rather, a number of independent factors seem to contribute to the process of stabilization of the knee joint.

Complete 3D kinematics of upper extremity functional tasks

Upper extremity (UX) movement analysis by means of 3D kinematics has the potential to become an important clinical evaluation method. However, no standardized protocol for clinical application has yet been developed, that includes the whole upper limb. Standardization problems include the lack of a single representative function, the wide range of motion of joints and the complexity of the anatomical structures. A useful protocol would focus on the functional status of the arm and particularly the orientation of the hand. The aim of this work was to develop a standardized measurement method for unconstrained movement analysis of the UX that includes hand orientation, for a set of functional tasks for the UX and obtain normative values. Ten healthy subjects performed four representative activities of daily living (ADL). In addition, six standard active range of motion (ROM) tasks were executed. Joint angles of the wrist, elbow, shoulder and scapula were analyzed throughout each ADL task and minimum/maximum angles were determined from the ROM tasks. Characteristic trajectories were found for the ADL tasks, standard deviations were generally small and ROM results were consistent with the literature. The results of this study could form the normative basis for the development of a 'UX analysis report' equivalent to the 'gait analysis report' and would allow for future comparisons with pediatric and/or pathologic movement patterns.