Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics

PURPOSE

To investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures.

METHOD

A prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures.

RESULTS

Out of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors.

CONCLUSION

Maxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.

Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the 'C-Arm Rotational View (CARV)'

PURPOSE

Rotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined 'C-Arm Rotational View (CARV)', to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.

METHODS

A cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.

RESULTS

In total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p =  <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.

CONCLUSION

This study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined 'C-arm rotational view (CARV)' to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

Can CT-based gap and step-off displacement predict outcome after nonoperative treatment of acetabular fractures?

Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Methods

A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis.

Results

Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up.

Conclusion

Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process.

Both-Column Acetabular Fractures: Does Surgical Approach Vary Based on Using Virtual 3D Reconstructions?

Displacement of the anterior and posterior column complicates decision making for both-column acetabular fractures. We questioned whether pelvic surgeons agree on treatment strategy, and whether the use of virtual 3D reconstructions changes the treatment strategy of choice. A nationwide cross-sectional survey was performed in all pelvic trauma centers in the Netherlands. Twenty surgeons assessed 15 both-column fractures in 2D as well as 3D. Based on conventional imaging, surgical treatment was recommended in 89% of cases, and by adding 3D reconstructions this was 93% (p = 0.09). Surgical approach was recommended as anterior (65%), posterior (8%) or combined (27%) (poor level of agreement, κ = 0.05) based on conventional imaging. The approach changed in 37% (p = 0.006), with most changes between a combined and anterior approach (still poor level of agreement, κ = 0.13) by adding 3D reconstructions. Additionally, surgeons' level of confidence increased from good in 38% to good in 50% of cases. In conclusion, surgeons do not agree on the treatment strategy for both-column acetabular fractures. Additional information given by 3D reconstructions may change the chosen surgical approach and increase surgeons' confidence about their treatment decision. Therefore, virtual 3D reconstructions are helpful for assessing both-column fracture patterns and aid in the choice of treatment strategy.

Translation, Validity, and Reliability of the Dutch Anterior Cruciate Ligament-Quality of Life Questionnaire

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaire is a valid and reliable injury-specific instrument to assess the impact of an ACL rupture on the daily life of a patient.

Purpose

To translate the ACL-QoL into Dutch (ACL-QoL-NL) and to study its psychometric properties in patients with an ACL rupture.

Study Design

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

Methods

The original ACL-QoL questionnaire was translated from English to Dutch according to international guidelines. The study population consisted of 122 patients with a confirmed ACL rupture who completed the ACL-QoL-NL as well as 4 questionnaires: the International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, 36-item Short Form Health Survey, and Lysholm Knee Score. We determined the internal consistency, construct validity, and prevalence of floor and ceiling effects of the ACL-QoL-NL total score as well as its 5 subscales. To determine test-retest reliability, we analyzed the data of 68 patients who had a stable knee condition and who completed the ACL-QoL-NL a second time after a 2-week interval.

Results

The confirmatory factor analysis showed that the original structure of the ACL-QoL-NL was confirmed, except for 4 of 31 items. Internal consistency of the total scale and all 5 subscales was good. More than 75% of the predefined hypotheses on the correlations between the ACL-QoL-NL and the 4 questionnaires were met, indicating good construct validity. No significant floor or ceiling effects were observed. Test-retest reliability was good, and no systematic bias between test and retest was found. Standard error of measurement for the total score was 4.8 points out of 100, and the smallest detectable changes at the group and individual levels were 1.6 and 13.2 points, respectively.

Conclusion

The ACL-QoL-NL questionnaire was successfully translated from English to Dutch and demonstrated good internal consistency, validity, and reliability, with no presence of floor or ceiling effects.

Does 3D-assisted surgery of tibial plateau fractures improve surgical and patient outcome? A systematic review of 1074 patients

PURPOSE

The aim of this systematic review was to provide an overview of current applications of 3D technologies in surgical management of tibial plateau fractures and to assess whether 3D-assisted surgery results in improved clinical outcome as compared to surgery based on conventional imaging modalities.

METHODS

A literature search was performed in Pubmed and Embase for articles reporting on the use of 3D techniques in operative management of tibial plateau fractures. This systematic review was performed in concordance with the PRISMA-guidelines. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal. Differences in terms of operation time, blood loss, fluoroscopy frequency, intra-operative revision rates and patient-reported outcomes between 3D-assisted and conventional surgery were assessed. Data were pooled using the inverse variance weighting method in RevMan.

RESULTS

Twenty articles evaluating 948 patients treated with 3D-assisted surgery and 126 patients with conventional surgery were included. Five different concepts of 3D-assisted surgery were identified: '3D virtual visualization', '3D printed hand-held fracture models', 'Pre-contouring of osteosynthesis plates', '3D printed surgical guides', and 'Intra-operative 3D imaging'. 3D-assisted surgery resulted in reduced operation time (104.7 vs. 126.4 min; P < 0.01), less blood loss (241 ml vs. 306 ml; P < 0.01), decreased frequency of fluoroscopy (5.8 vs. 9.1 times; P < 0.01). No differences in functional outcome was found (Hospital for Special Surgery Knee-Rating Scale: 88.6 vs. 82.8; P = 0.23).

CONCLUSIONS

Five concepts of 3D-assisted surgical management of tibial plateau fractures emerged over the last decade. These include 3D virtual fracture visualization, 3D-printed hand-held fracture models for surgical planning, 3D-printed models for pre-contouring of osteosynthesis plates, 3D-printed surgical guides, and intra-operative 3D imaging. 3D-assisted surgery may have a positive effect on operation time, blood loss, and fluoroscopy frequency.

The effects of pelvic ring injuries on quality of life, physical, and mental health: results of a 2-year prospective cohort study

Purpose

Pelvic ring injuries are known to affect the patients’ daily life in terms of physical functioning and quality of life (QoL). Still, prospective studies on the patient’s perception over the first 2 years of rehabilitation are lacking. Therefore, patients cannot be properly informed about whether or when they will return to their pre-existing level of physical functioning and QoL.

Methods

A prospective longitudinal cohort study was performed over a 4-year period including all consecutive patients above 18 years who sustained a pelvic ring injury in a level 1 trauma center. Validated patient-reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D) at baseline (recalled pre-injury score), 6 weeks, 3 months, 6 months, 1 year and 2 years after the injury. It was assessed whether patients had fully recovered by comparing follow-up scores to baseline PROMs. Binary logistic regression analysis was used to identify independent predictors for patients who did not fully recover. Most experienced difficulties at 3 months and 1 year were identified by analyzing the highest reported scores on individual items of the SMFA.

Results

A total of 297 patients with a pelvic ring injury were identified of which 189 were eligible for follow-up and 154 (82%) responded. Median SMFA function score at 3 months, 1 and 2 years was 70, 78 and 88, respectively, compared to 96 out of 100 before the injury. Median SMFA bother score was 67, 79 and 88, respectively. Median EQ-5D score at 3 months, 1 and 2 years was 0.61, 0.81 and 0.85, respectively, compared to 1 (maximum achievable) before the injury. After 1 and 2 years of follow-up, 61% and 75% of the patients fully “recovered” in physical functioning and 52% and 71% fully recovered in terms of QoL. Female gender and high-energy trauma were independent predictors for not fully recovering after 1 year. After 3 months of follow-up, 54% of patients reported severe difficulties with recreational activities, whereas after 1 year, most experienced difficulties (31% of patients) concerned heavy house or yard work. Moreover, after 3 months and 1 year, 44% and 27% of patients reported feeling physically disabled.

Conclusion

Pelvic ring injuries have a large impact on the patients’ daily life in the first 2 years of rehabilitation. Directly after the injury, physical functioning and QoL decrease strongly but then gradually improve over a 2-year period with about 75% of patients fully recovering. Female gender and high-energy trauma are shown to be independent predictors for not fully recovering. After 3 months, patients experience difficulties with both the physical and mental effects of the injury which continue to be present after 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01893-3.

Impact of the SARS-CoV-2 pandemic on trauma care: a nationwide observational study

Purpose

The SARS-CoV-2 pandemic severely disrupted society and the health care system. In addition to epidemiological changes, little is known about the pandemic’s effects on the trauma care chain. Therefore, in addition to epidemiology and aetiology, this study aims to describe the impact of the SARS-CoV-2 pandemic on prehospital times, resource use and outcome.

Methods

A multicentre observational cohort study based on the Dutch Nationwide Trauma Registry was performed. Characteristics, resource usage, and outcomes of trauma patients treated at all trauma-receiving hospitals during the first (W1, March 12 through May 11) and second waves (W2, May 12 through September 23), as well as the interbellum period in between (INT, September 23 through December 31), were compared with those treated from the same periods in 2018 and 2019.

Results

The trauma caseload was reduced by 20% during the W1 period and 11% during the W2 period. The median length of stay was significantly shortened for hip fracture and major trauma patients (ISS ≥ 16). A 33% and 66% increase in the prevalence of minor self-harm-related injuries was recorded during the W1 and W2 periods, respectively, and a 36% increase in violence-related injuries was recorded during the INT. Mortality was significantly higher in the W1 (2.9% vs. 2.2%) and W2 (3.2% vs. 2.7%) periods.

Conclusion

The imposed restrictions in response to the SARS-CoV-2 pandemic led to diminished numbers of acute trauma admissions in the Netherlands. The long-lasting pressing demand for resources, including ICU services, has negatively affected trauma care. Further caution is warranted regarding the increased incidence of injuries related to violence and self-harm.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01891-5.

Does 3D-Assisted Acetabular Fracture Surgery Improve Surgical Outcome and Physical Functioning?-A Systematic Review

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Does 3D-Assisted Operative Treatment of Pelvic Ring Injuries Improve Patient Outcome?-A Systematic Review of the Literature

Background: There has been an exponential growth in the use of advanced technologies for three-dimensional (3D) virtual pre- and intra-operative planning of pelvic ring injury surgery but potential benefits remain unclear. The purpose of this study was to evaluate differences in intra- and post-operative results between 3D and conventional (2D) surgery. Methods: A systematic review was performed including published studies between 1 January 2010 and 22 May 2020 on all available 3D techniques in pelvic ring injury surgery. Studies were assessed for their methodological quality according to the Modified McMaster Critical Review form. Differences in operation time, blood loss, fluoroscopy time, screw malposition rate, fracture reduction and functional outcome between 3D-assisted and conventional (2D) pelvic injury treatment were evaluated and a best-evidence synthesis was performed. Results: Eighteen studies fulfilled the inclusion criteria, evaluating a total of 988 patients. Overall quality was moderate. Regarding intra-operative results of 3D-assisted versus conventional surgery: The weighted mean operation time per screw was 43 min versus 52 min; for overall operation time 126 min versus 141 min; blood loss 275 ± 197 mL versus 549 ± 404 mL; fluoroscopy time 74 s versus 125 s and fluoroscopy frequency 29 ± 4 versus 63 ± 3. In terms of post-operative outcomes of 3D-assisted versus conventional surgery: weighted mean screw malposition rate was 8% versus 18%; quality of fracture reduction measured by the total excellent/good rate by Matta was 86% versus 82% and Majeed excellent/good rate 88% versus 83%. Conclusion: The 3D-assisted surgery technologies seem to have a positive effect on operation time, blood loss, fluoroscopy dose, time and frequency as well as accuracy of screw placement. No improvement in clinical outcome in terms of fracture reduction and functional outcome has been established so far. Due to a wide range of methodological quality and heterogeneity between the included studies, results should be interpreted with caution.

MRI Assessment of Muscle Damage After the Posterolateral Versus Direct Anterior Approach for THA (Polada Trial). A Randomized Controlled Trial

BACKGROUND

There is controversy in literature whether the direct anterior approach (DAA) results in less muscle damage compared with the posterolateral approach (PLA) for total hip arthroplasty. The aim of this randomized controlled trial was to assess muscle damage between these two approaches.

METHODS

Forty-six patients were included. Muscle atrophy, determined with the Goutallier classification, and muscle surface of twelve muscles were analyzed on magnetic resonance imaging images made preoperatively and one year postoperatively. Differences in component placement after DAA or PLA were assessed on radiographs. Harris hip scores and Hip disability and Osteoarthritis and Outcome Score were used as functional outcomes.

RESULTS

External rotator musculature was damaged in both approaches. After PLA, the obturator muscles showed significantly more atrophy and a decrease in muscle surface. After DAA, the tensor fascia latae showed an increased muscle atrophy and the psoas muscle showed a decreased muscle surface. An increase in muscle surface was seen for the rectus femoris, sartorius, and quadratus femoris after both approaches. The muscle surface of the gluteus medius and iliacus was also increased after PLA. No difference in muscle atrophy was found between the approaches for these muscles. The inclination angle of the cup in PLA was significantly higher. No differences were found in functional outcomes.

CONCLUSION

Different muscle groups were affected in the two approaches. After PLA, the external rotators were more affected, whereas the tensor fascia latae and psoas muscles were more affected after DAA.

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

OBJECTIVES

To assess the effectiveness of suprapatellar (SP)-nailing versus infrapatellar (IP)-nailing of tibia fractures in anterior knee pain, complications (retropatellar chondropathy, infection, and malalignment) and physical functioning and quality of life. A clinical question-driven and thorough systematic review of current literature is provided.

DATA SOURCE

PubMed and Embase databases were searched for studies published between 2010 and 2020 relating to SP and IP-nailing of tibia fractures. The study is performed in concordance with PRISMA-guidelines.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials, prospective and retrospective observational studies reporting on outcomes of interest.

DATA EXTRACTION

Data extraction was performed independently by 2 assessors. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal.

DATA SYNTHESIS

Continuous variables are presented as means with SD and dichotomous variables as frequency and percentages. The weighted mean, standardized weighted mean differences, and 95% confidence interval were calculated. A pooled analysis could not be performed because of differences in outcome measures, time-points, and heterogeneity.

RESULTS

Fourteen studies with 1447 patients were analyzed. The weighted incidence of anterior knee pain was 29% after SP-nailing and 39% after IP-nailing, without reported significance. There was a significant lower rate of malalignment after the SP-approach (4% vs. 26%) with small absolute differences in all planes. No substantial differences were observed in retropatellar chondropathy, infection, physical functioning, and quality of life.

CONCLUSIONS

This systematic review does not reveal superiority of either technique in any of the respective outcomes of interest. Definitive choice should depend on the surgeon's experience and available resources.

LEVEL OF EVIDENCE

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

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

INTRODUCTION

Hip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.

PATIENTS AND METHODS

A multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.

RESULTS

No differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).

DISCUSSION

Treatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.

CONCLUSIONS

Functional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

OBJECTIVE

to examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.

DESIGN

cross-sectional study.

SETTING

online survey platform.

PARTICIPANTS

119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.

MAIN OUTCOME MEASURES

A range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.

RESULTS

Psychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.

CONCLUSION

The current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.

No Difference in Recovery of Patient-Reported Outcome and Range of Motion between Cruciate Retaining and Posterior Stabilized Total Knee Arthroplasty: A Double-Blind Randomized Controlled Trial

Both from the perspective of the individual and from a socioeconomic point of view (e.g., return to work), it is important to have an insight into the potential differences in recovery between posterior cruciate ligament retaining (PCR) and posterior stabilized (PS) total knee arthroplasty (TKA) implants. The primary aim of this study was to compare the speed of recovery of patient-reported outcome between patients with a PCR and PS TKA during the first postoperative year. The secondary aim was to compare the effect on range of motion (ROM). In a randomized, double-blind, controlled, single-center trial, 120 adults diagnosed with osteoarthritis of the knee were randomized into either the PCR or PS group. Primary outcome was speed of recovery of patient-reported pain and function, measured with the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), with a follow-up of 1 year. Main secondary outcome measure was ROM. A generalized estimating equations (GEE) analysis was used to assess whether there was a difference over time between groups ("p-value for interaction"). Between 2008 and 2011, 59 participants received a PCR TKA (mean age, 70.3 years [SD = 7.7]; mean body mass index [BMI], 30.5 kg/m² [SD = 5.4]) and 55 participants a PS TKA (mean age, 73.5 years [SD = 7.0]; mean BMI, 29.2 kg/m² [SD = 4.4]). Six patients (two PCR and four PS) were excluded because of early drop-out, so 114 patients (95%) were available for analysis. In between group difference for total WOMAC score was -1.3 (95% confidence interval [CI]: -5.6 to 3.1); p-value for interaction was 0.698. For ROM, in between group difference was 1.1 (95% CI: -2.6 to 4.7); p-value for interaction was 0.379. These results demonstrated that there are no differences in speed of recovery of WOMAC or ROM during the first postoperative year after PCR or PS TKA.

Minimal important change in physical function in trauma patients: a study using the short musculoskeletal function assessment

Purpose

The Short Musculoskeletal Function Assessment (SMFA) questionnaire can be used to evaluate physical functioning in patients with traumatic injuries. It is not known what change in score reflects a meaningful change to patients. The aim was to determine minimal important change (MIC) values of the subscales (0–100) of the Dutch SMFA-NL in a sample of patients with a broad range of injuries.

Methods

Patients between 18 and 65 years of age completed the SMFA-NL and the Global Rating of Effect (GRE) questions at 6-week and 12-month post-injury. Anchor-based MIC values were calculated using univariable logistic regression analyses.

Results

A total of 225 patients were included (response rate 67%). The MIC value of the Upper Extremity Dysfunction (UED) subscale was 8 points, with a misclassification rate of 43%. The Lower Extremity Dysfunction subscale MIC value was 14 points, with a misclassification rate of 29%. The MIC value of the Problems with Daily Activities subscale was 25 points, with a misclassification rate of 33%. The MIC value of the Mental and Emotional Problems (MEP) subscale was 7 points, with a misclassification rate 37%.

Conclusion

MIC values of the SMFA-NL were determined. The MIC values aid interpreting whether a change in physical functioning can be considered clinically important. Due to the considerable rates of misclassification, the MIC values of the UED and MEP subscales should be used with caution.

The Achilles tendon Total Rupture Score is a responsive primary outcome measure: an evaluation of the Dutch version including minimally important change

PURPOSE

Aim of this study was to evaluate the responsiveness of the Dutch version of the Achilles tendon Total Rupture Score (ATRS-NL).

METHODS

Patients (N = 47) completed the ATRS-NL at 3 and 6 months after Achilles tendon rupture (ATR). Additionally, they filled out the Euroqol-5D-5L (EQ-5D-5L) and Global Rating of Change Score (GRoC). Effect sizes (ES) and standardized response means (SRM) were calculated. The anchor-based method for determining the minimally important change (MIC) was used. GRoC and improvement on the items mobility and usual activities on the EQ-5D-5L served as external criteria. The scores on these anchors were used to categorize patients' physical functioning as improved or unchanged between 3 and 6 months after ATR. Receiver operating curve (ROC) analysis was performed, with the calculation of the area under the ROC curve (AUC) and the estimation of MIC values using the optimal cut-off points.

RESULTS

There was a large change (ES: 1.58) and good responsiveness (SRM: 1.19) of the ATRS-NL between 3 and 6 months after ATR. Using ROC analysis, the MIC values ranged from 13.5 to 28.5 for reporting improvement on EQ-5D-5L mobility and GRoC, respectively. The AUC of improvement on mobility and improvement on GRoC were > 0.70.

CONCLUSION

The ATRS-NL showed good responsiveness in ATR patients between 3 and 6 months after injury. Use of this questionnaire is recommended in clinical follow-up and longitudinal research of ATR patients. MIC values of 13.5 and 28.5 are recommended to consider ATR patients as improved and greatly improved between 3 and 6 months after ATR.

LEVEL OF EVIDENCE

II.

Older polytrauma: Mortality and complications

INTRODUCTION

Older adults enduring a polytrauma have an increased mortality risk. Apart from age, the role of other predisposing factors on mortality are mainly described for the total polytrauma population. This study aimed to describe the mortality pattern of older polytrauma patients, its associated risk factors, and the role and etiology of in-hospital complications.

METHODS

An eight-year retrospective cohort was constructed from 380 polytrauma patients aged ≥65 in a Dutch level 1 trauma center and linked to the national trauma database (DTR). Demographics, injury characteristics, comorbidity, clinical characteristics, in-hospital mortality, mortality etiology and complications scored according to the Clavien-Dindo classification were analyzed. Primary outcome was the identification of risk factors associated with in-hospital mortality, followed by identification of in-hospital complications and their nature.

RESULTS

Overall in-hospital mortality was 36.3%, rising significantly with age. For patients aged ≥85 in-hospital mortality was 60.8%. Polytrauma patients aged ≥75 showed a peak of late-onset deaths one week following trauma. Age, a Glasgow coma score ≤8, coagulopathy, acidosis, injury severity score and the presence of a large subdural hematoma were significant risk factors influencing in-hospital mortality. Respiratory failure was the most prevalent severe and fatal complication. The proportion of fatal complications grew significantly with age (p < 0.01).

CONCLUSIONS

Age is strongly associated with in-hospital mortality in polytraumatized elderly. Coagulopathy, acidosis, a low Glasgow coma score, presence of a large subdural hematoma and injury severity score were independently of age associated with an increased mortality. Patients older than 75 years showed a unique trimodal distribution of mortality with a late onset one week following the initial trauma. Elderly were more susceptible for fatal complications. Respiratory failure was the most prevalent severe and fatal complication. Aggressive monitoring and treatment of the pulmonary status is therefore of utmost importance.

The development and internal validation of a model to predict functional recovery after trauma

Objective

To develop and internally validate the PROgnosis of functional recovery after Trauma (PRO-Trauma) prediction model.

Design

A prospective single-center longitudinal cohort study. Patients were assessed at 6 weeks and 12 months post-injury.

Methods

Patients that presented at the emergency department with an acute traumatic injury, were prompted for participation. Patients that completed the assessments at 6 weeks and 12 months post injury were included. Exclusion criteria: age < 18, age > 65, pathologic fractures, injuries that resulted in severe neurologic deficits. The predicted outcome, functional recovery, was defined as a Short Musculoskeletal Function Assessment (SMFA-NL) Problems with Daily Activities (PDA) subscale ≤ 12.2 points at 12 months post-injury (Dutch population norm). Predictors were: gender, age, living with partner, number of chronic health conditions, SMFA-NL PDA score 6 weeks post-injury, ICU admission, length of stay in hospital, injury severity score, occurrence of complications and treatment type. All predictors were obtained before 6 weeks post-injury. Missing data were multiply imputed. Predictor variables were selected using backward stepwise multivariable logistic regression. Hosmer-Lemeshow tests were used to evaluate calibration. Bootstrap resampling was used to internally validate the final model.

Results

A total of 246 patients were included, of which 104 (44%) showed functional recovery. The predictors in the final PRO-Trauma model were: living with partner, the number of chronic health conditions, SMFA-NL PDA subscale score at 6 weeks post-injury and length of stay in hospital. The apparent R² was 0.33 [0.33;0.34], the c-statistic was 0.79 [0.79;0.80]. Hosmer-Lemeshow test indicated good calibration (p = 0.92). Optimism-corrected R² was 0.28 [0.27;0.29] and the optimism-corrected Area Under the Curve was 0.77 [0.77;0.77].

Conclusion

The PRO-Trauma prediction model can be used to obtain valid predictions of attaining functional recovery after trauma at 12 months post-injury. The PRO-Trauma prediction model showed acceptable calibration and discrimination.

The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study

BACKGROUND

Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management.

METHODS

This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire.

DISCUSSION

This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management.

TRIAL REGISTRATION

Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.

Strict adherence to evidence-based protocol in choice of implants and surgical technique leads to fewer hip fracture reoperations

Background and purpose

Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation. Only part of the complications are surgery-related, however these, including reoperation may have the highest impact. Operative protocols are designed to treat all patients equally, according to evidence based guidelines. Aim of this study was to investigate the association between strict adherence to an operative protocol and postoperative complications, especially reoperations.

Materials and methods

A retrospective analyses of a prospective cohort. The cohort included all patients aged ≥60 treated for a hip fracture at University Medical Center Groningen between July 2009 and June 2013. The files of the patients were searched for complications, including reoperations. To evaluate adherence to the operative protocol all X-rays were retrospectively reviewed and the fracture type was reclassified. This retrospective fracture classification was compared with the treatment method used. Logistic regression analyses were used to assess whether patients that were not treated strictly according to the operative protocol have higher odds of developing a complication or of undergoing a reoperation.

Results

The study population consisted of 479 patients with a mean age of 78.4 (SD 9.5) years. Reoperation was performed in 11% of the patients during the follow-up period. The operative protocol was not followed strictly in 12% of the patients. When the operative protocol was not followed, the odds of having a reoperation was 2.41 times higher (p = 0.02). The overall complication rate was 75% and did not differ in both groups.

Conclusion

Strict adherence to an evidence-based operative protocol is of major importance toward preventing implant-related problems and reoperations

Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines

PURPOSE

This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands.

METHODS

A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer.

RESULTS

A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons.

CONCLUSION

This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed.

LEVEL OF EVIDENCE

Cross-sectional survey, Level V.

Structural Validity of the Short Musculoskeletal Function Assessment in Patients With Injuries

BACKGROUND

The Short Musculoskeletal Function Assessment (SMFA) is a widely used patient-reported outcome measure, originally having 2 elements of outcome: the function index and the bother index. In multiple studies, it has been argued that the SMFA should be scored using 3, 4, or 6 subscales instead. Therefore, there is inconsistency with the number of underlying dimensions of the SMFA.

OBJECTIVE

The aim of this study was to evaluate the structural validity of the various proposed subscale configurations of the SMFA in a broad range of Dutch patients with injuries.

DESIGN

This study used a prospective cohort design.

METHODS

Participants with injuries were asked to complete the Dutch SMFA (SMFA-NL) at 5 to 8 weeks postinjury. The structural validity of the 6 different factor structures that have been proposed in other studies was evaluated using confirmatory factor analyses. Internal consistency was analyzed using Cronbach alpha.

RESULTS

A total of 491 patients participated (response rate = 74%). A 4-factor structure showed an acceptable fit (root-mean-square error of approximation [RMSEA] = 0.070, comparative fit index = 0.973, Tucker-Lewis index = 0.971). Other models, including the original 2-index structure, showed insufficient structural validity in Dutch patients with injuries. The 4-factor structure showed sufficient discriminant validity and good internal consistency (Cronbach alpha ≥ 0.83).

LIMITATIONS

It is unclear whether conclusions are generalizable across different countries, people who are elderly, and people without injuries.

CONCLUSION

In a broad range of patients with injuries, the SMFA-NL may be best scored and interpreted using a 4-factor structure. Other factor structures showed insufficient structural validity.

Injury mechanisms, patterns and outcomes of older polytrauma patients-An analysis of the Dutch Trauma Registry

Background

Polytrauma patients nowadays tend to be older due to the growth of the elderly population and its improved mobility. The aim of this study was to compare demographics, injury patterns, injury mechanisms and outcomes between younger and older polytrauma patients.

Methods

Data from polytrauma (ISS≥16) patients between 2009 and 2014 were extracted from the Dutch trauma registry (DTR). Younger (Group A: ages 18–59) and older (Group B: ages ≥60) polytrauma patients were compared. Differences in injury severity, trauma mechanism (only data for the year 2014), vital signs, injury patterns, ICU characteristics and hospital mortality were analyzed.

Results

Data of 25,304 polytrauma patients were analyzed. The older patients represented 47.8% of the polytrauma population. Trauma mechanism in the older patients was more likely to be a bicycle accident (A: 17%; B: 21%) or a low-energy fall (A: 13%; B: 43%). Younger polytrauma patients were more likely to have the worst scores on the Glasgow coma scale (EMV = 3, A: 20%, B: 13%). However, serious head injuries were seen more often in the older patients (A: 53%; B: 69%). The hospital mortality was doubled for the older polytrauma patients (19.8% vs. 9.6%).

Conclusion

Elderly are involved more often in polytrauma. Although injury severity did not differ between groups, the older polytrauma patients were at a higher risk of dying than their younger counterparts despite sustaining less high-energy accidents.

Outcomes of operative and nonoperative treatment of 3- and 4-part proximal humeral fractures in elderly: a 10-year retrospective cohort study

Purpose

Despite a rising incidence in proximal humeral fractures, there is still no evidence for the best treatment option, especially for elderly patients. The aim of this retrospective cohort study was to evaluate health-related quality of life (HRQoL), functional outcome, pain and social participation in elderly patients, after operative and nonoperative treatment of displaced 3- and 4-part proximal humeral fractures.

Methods

150 patients aged ≥ 65, treated for a displaced 3- or 4-part proximal humeral fracture between 2004 and 2014, were invited to participate. Eventually 91 patients (61%) participated, of which 32 non-operatively treated patients were matched to 32 of the 59 operatively treated patients by propensity score matching. The EQ-5D, DASH, VAS for pain and WHODAS 2.0 Participation in Society domain were administered. Complications and reinterventions were registered.

Results

No significant difference was found between the two treatment groups in HRQoL (p = 0.43), function (p = 0.78) and pain (p = 0.19). A trend toward better social participation in the operative group (p = 0.09) was found. More complications and reinterventions occurred in the operative group than the nonoperative group, with 9 versus 5 complications (p = 0.37) and 8 versus 2 reinterventions (p = 0.08).

Conclusions

In this study, we found no evidence of a difference in HRQoL, functional outcome or pain 1–10 years after operative or nonoperative treatment in patients of 65 and older with a displaced 3- or 4-part humeral fracture. Operatively treated patients showed a trend toward better social participation but also higher reintervention rates.

Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review

OBJECTIVE

To determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR).

STUDY DESIGN

Systematic review.

DATA SOURCES

PubMed and EMBASE in November 2016.

ELIGIBILITY CRITERIA

Clinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included.

RESULTS

Fifty-six studies were included, most concerning the use of ultrasound (n=37) or MRI (n=18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r=0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. MRI examination was generally performed with 1.5Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r=0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%. Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive.

CONCLUSION

The adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities.

Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol

Introduction

Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO.

Materials and methods

This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners’ current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine.

Results

There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis.

Conclusions

The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.

Tibial component with and without stem extension in a trabecular metal cone construct

PURPOSE

The purpose of this study was to investigate stability and strain distribution of a tibial plateau reconstruction with a trabecular metal cone while the tibial component is implanted with and without a stem, and whether prosthetic stability was influenced by bone mineral density. Trabecular metal cones are designed to fill up major bone defects in total knee arthroplasty. Tibial components can be implanted in combination with a stem, but it is unclear whether this is necessary after reconstruction with a trabecular metal cone. Implanting a stem can give extra stability, but may have negative side effects.

METHODS

Tibial revision arthroplasties with trabecular metal cones were performed after reconstruction of a 2B bone defect according to the Anderson Orthopedic Research Institute classification. Components were implanted in seven pairs of cadaveric tibiae; one tibia of each pair was implanted with stem and the other without. All specimens were loaded to one bodyweight alternating between the medial and lateral tibial component. Implant-bone micro-motions, bone strains, bone mineral density and correlations were measured and/or calculated.

RESULTS

Tibial components without a stem showed only more varus tilt [difference in median 0.14° (P < 0.05)], but this was not considered clinically relevant. Strain distribution did not differ. Bone mineral density only had an effect on the anterior/posterior tilt [ρ: -0.72 (P < 0.01)].

CONCLUSION

Tibial components, with or without a stem, which are implanted after reconstruction of major bone defects using trabecular metal cones produce very similar biomechanical conditions in terms of stability and strain distribution. If in vivo studies confirm that a stem extension is not mandatory, orthopaedic surgeons can decide not to implant a stem.

LEVEL OF EVIDENCE

II.

Do CAS measurements correlate with EOS 3D alignment measurements in primary TKA?

PURPOSE

Objective of this study was to compare intraoperative computer-assisted surgery (CAS) alignment measurements during total knee arthroplasty (TKA) with pre- and postoperative coronal alignment measurements using EOS 3D reconstructions.

METHODS

In a prospective study, 56 TKAs using imageless CAS were performed and coronal alignment measurements were recorded twice: before bone cuts were made and after implantation of the prosthesis. Pre- and postoperative coronal alignment measurements were performed using EOS 3D reconstructions. Thanks to the EOS radiostereography system, measurement errors due to malpositioning and deformity during acquisition are eliminated. CAS measurements were compared with EOS 3D reconstructions. Varus/valgus angle (VV), mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were measured.

RESULTS

Significantly different VV angles were measured pre- and postoperatively with CAS compared to EOS. For preoperative measurements, mLDFA did not differ significantly, but a significantly larger mMPTA in valgus was measured with CAS.

CONCLUSION

Results of this study indicate that differences in alignment measurements between CAS measurements and pre- and postoperative EOS 3D are due mainly to the difference between weight-bearing and non-weight-bearing position and potential errors in validity and reliability of the CAS system. EOS 3D measurements overestimate VV angle in lower limbs with substantial mechanical axis deviation. For lower limbs with minor mechanical axis deviation as well as for mMPTA measurements, CAS measures more valgus than EOS. Eventually the results of this study are of clinical relevance, since it raises concerns regarding the validity and reliability of CAS systems in TKA.

LEVEL OF EVIDENCE

IIb.

[E-bikers are more often seriously injured in bicycle accidents: results from the Groningen bicycle accident database]

OBJECTIVE

Analysing injury types, injury severity and mortality in victims of accidents with electric bicycles in comparison with conventional bicycles.

DESIGN

Prospective cohort study.

METHOD

Data of patients treated at the Accident & Emergency Department of the University Medical Center Groningen after a bicycle accident are being entered in a database since 2014. We have analysed this database for accidents with electric bicycles (e-bikes) and conventional bicycles occurring among adult patients for the period of July 2014 to May 2016. 'Propensity score matching' was used to match e-bikers to conventional cyclists, based on age, gender and the presence of comorbidities.

RESULTS

107 of the 475 included victims were riding an e-bike. Average age of e-bikers and conventional cyclists was 65 years and 39 years respectively. Comorbidity was more common in e-bikers. E-bikers were injured significantly more severely than conventional cyclists. They had more severe injuries of the head and face, and upper and lower extremities. E-bikers were also admitted to the hospital more often, and for longer periods, and they underwent surgery more often. Mortality was the same. Propensity score matching revealed that e-bikers had multiple severe injuries (ISS > 15) twice as often as conventional cyclists, that they had more severe head injuries and were admitted for longer periods than conventional cyclists.

CONCLUSION

E-bikers who had a bicycle accident had more severe injuries, more frequently had multiple injuries and had more severe head injuries than conventional cyclists. This resulted in a greater need for care. Preventive measures such as riding lessons and helmet use should be encouraged. Care providers should pay extra attention to the possibility of severe injuries when a patient had a bicycle accident with an e-bike.

The design of a randomised controlled trial to evaluate the (cost-) effectiveness of the posterolateral versus the direct anterior approach for THA (POLADA - trial)

Background

Total hip arthroplasty (THA) is one of the most successful orthopaedic procedures. Because of the increasing number of THAs, a growing demand for faster recovery and a greater emphasis on cost-effectiveness, minimally invasive THAs have been introduced in the last decades. The direct anterior approach is a minimally invasive, tissue-sparing approach in which intermuscular planes are used. Theoretically, this approach should result in a faster recovery of physical functioning and higher health-related quality of life.

Methods/design

A randomised controlled trial will be performed. Patients will be randomly allocated to undergo THA by means of the anterior or posterolateral approach. Both the intervention and control group will consist of two subgroups: 1) patients with a good bone stock who will receive an uncemented femoral stem, and 2) patients with a poor bone stock who will receive a cemented femoral stem. Patients between 18 and 90 years with primary or secondary osteoarthritis will be included. Physical functioning and health-related quality of life will be assessed by means of questionnaires. Additionally, performance based tests will be performed to objectively assess the physical functioning. Cost-effectiveness will be assessed by obtaining data on medical costs in and outside the hospital and other nonmedical costs. Measurements will take place preoperatively, two and six weeks, three months and one year postoperatively.

Discussion

There is some evidence that the anterior approach results in reduced tissue damage and faster recovery in the direct postoperative period, compared to the posterolateral approach. However, there is still a lack of well-designed studies that have confirmed the better outcomes and cost-effectiveness of the anterior approach. Therefore, the purpose of this study is to assess the physical functioning, health related quality of life and the cost-effectiveness of the anterior approach, compared to the conventional posterolateral approach.

Trial registration

Netherlands Trial Registry, number 5343 (registration date April 12, 2015)

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1322-2) contains supplementary material, which is available to authorized users.

Pseudotumour incidence, cobalt levels and clinical outcome after large head metal-on-metal and conventional metal-on-polyethylene total hip arthroplasty: mid-term results of a randomised controlled trial

We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation. From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (sd) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, sd 5) were recruited after a mean follow-up of 50 months (36 to 64). The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without. Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA.

Cross-Cultural Adaptation and Validation of the Dutch Version of the Hip and Groin Outcome Score (HAGOS-NL)

Background

Valid and reliable questionnaires to assess hip and groin pain are lacking. The Hip and Groin Outcome Score (HAGOS) is a valid and reliable self-reported measure to assess symptoms, activity limitations, participation restrictions and quality of life of persons with hip and/or groin complaints. The purpose of this study was to translate and cross-culturally adapt the HAGOS into Dutch (HAGOS-NL), and to evaluate its internal consistency, validity and reliability.

Methods

Translation and cross-cultural adaption of the Dutch version of the HAGOS (HAGOS-NL) was performed according to international guidelines. The study population consisted of 178 adult patients who had undergone groin hernia repair surgery in the previous year. All respondents filled in the HAGOS-NL, the SF-36, and the SMFA-NL for determining construct validity of the HAGOS-NL. To determine reliability, 81 respondents filled in the HAGOS-NL after a time interval of two weeks.

Results

Factor analysis confirmed the original six-factor solution of the HAGOS. Internal consistency was good for all the subscales of the HAGOS-NL. High correlations were observed between the HAGOS-NL and the SF-36 and SMFA-NL, indicating good construct validity. The HAGOS-NL showed high reliability, except for the subscale Participation in Physical Activities which was moderate.

Conclusions

The HAGOS was successfully translated and cross-culturally adapted from English into Dutch (HAGOS-NL). This study shows that the HAGOS-NL is a valid and reliable instrument for the assessment of functional status and health-related quality of life in patients with groin complaints.

The Validity of a New Low-Dose Stereoradiography System to Perform 2D and 3D Knee Prosthetic Alignment Measurements

Introduction

The EOS stereoradiography system has shown to provide reliable varus/valgus (VV) measurements of the lower limb in 2D (VV2D) and 3D (VV3D) after total knee arthroplasty (TKA). Validity of these measurements has not been investigated yet, therefore the purpose of this study was to determine validity of EOS VV2D and VV3D.

Methods

EOS images were made of a lower limb phantom containing a knee prosthesis, while varying VV angle from 15° varus to 15° valgus and flexion angle from 0° to 20°, and changing rotation from 20° internal to 20° external rotation. Differences between the actual VV position of the lower limb phantom and its position as measured on EOS 2D and 3D images were investigated.

Results

Rotation, flexion or VV angle alone had no major impact on VV2D or VV3D. Combination of VV angle and rotation with full extension did not show major differences in VV2D measurements either. Combination of flexion and rotation with a neutral VV angle showed variation of up to 7.4° for VV2D; maximum variation for VV3D was only 1.5°. A combination of the three variables showed an even greater distortion of VV2D, while VV3D stayed relatively constant. Maximum measurement difference between preset VV angle and VV2D was 9.8°, while the difference with VV3D was only 1.9°. The largest differences between the preset VV angle and VV2D were found when installing the leg in extreme angles, for example 15° valgus, 20° flexion and 20° internal rotation.

Conclusions

After TKA, EOS VV3D were more valid than VV2D, indicating that 3D measurements compensate for malpositioning during acquisition. Caution is warranted when measuring VV angle on a conventional radiograph of a knee with a flexion contracture, varus or valgus angle and/or rotation of the knee joint during acquisition.

Short Musculoskeletal Function Assessment: normative data of the Dutch population

BACKGROUND

The Short Musculoskeletal Function Assessment (SMFA) is widely used in both research and clinical practice. Despite its frequent use, normative data of the SMFA have remained limited. Aim of this study was to gather normative data for the Dutch SMFA (SMFA-NL).

METHODS

The SMFA-NL consists of two indices (function index and bother index) and four subscales (upper extremity dysfunction, lower extremity dysfunction, mental and emotional problems, and problems with daily activities). A total of 900 patients were invited to fill in the SMFA-NL. Six age groups (18-24, 25-34, 35-44, 45-54, 55-64, and 65-75 years) were constructed. Analysis of variance, t tests, and regression analyses were used to assess age and gender effects.

RESULTS

The response rate was 97 %. There was a significant difference between men and women in scores on all indices and subscales (range p < 0.001 to p = 0.002), except for the upper extremity dysfunction subscale (p = 0.06). A significant interaction effect was found between gender and age for the upper extremity dysfunction subscale; a larger decrease in score with increasing age was observed for women, compared with men. Significant differences were found between age groups for the bother index (p < 0.001), lower extremity dysfunction subscale (p = 0.001), and the problems with daily activities subscale (p = 0.002).

CONCLUSION

Significant differences in SMFA-NL scores were found between men and women and between different age groups. These SMFA-NL normative data provide an opportunity of benchmarking health status of participants with musculoskeletal disorders or injuries against their age- and gender-matched peers in the Dutch population.

Secondary patellar resurfacing following total knee arthroplasty : A cohort study in fifty eight knees with a mean follow-up of thirty one months

PURPOSE

If anterior knee pain (AKP) emerges or persists following total knee arthroplasty (TKA), secondary patellar resurfacing (SPR) may offer relief of AKP. The purpose of our study was to evaluate the mid-term clinical outcomes after secondary patellar resurfacing for persistent AKP. Secondary objectives were to correlate surgical outcomes with clinical and radiological parameters including 99 m-technetium bone scintigraphy.

METHODS

In this study, 57 patients (58 knees, 51 women and 6 men) with a mean age of 70 years at the time of SPR were included. Patients were asked about their satisfaction regarding the outcome of the procedure. Patellar position was assessed by axial radiographs, and we reassessed the preoperatively performed bone scintigraphy.

RESULTS

After a median follow-up of 31 (6-76) months, 42 patients (43 knees) were satisfied and 15 were dissatisfied regarding the outcome of the procedure. Dissatisfied patients had more often a shorter time interval between TKA and SPR, patellar tilt on axial radiographs, and a 'hot' bone scan.

CONCLUSION

In patients with persistent AKP following TKR, secondary resurfacing leads to patient satisfaction in a relatively large number of patients. Better results were seen in patients without tilting of the patella. The added value of a bone scan as an indicator to perform SPR is not clarified in the present study.

Patellar resurfacing in posterior cruciate ligament retaining total knee arthroplasty (PATRES): design of a randomized controlled clinical trial

BACKGROUND

Anterior knee pain may occur after total knee arthroplasty (TKA). Patellar resurfacing, which is considered to lower the incidence of anterior knee pain after TKA, remains controversial. In the present study clinical and radiological outcomes after TKA performed on patients with clinical and radiological signs of femorotibial and patellofemoral osteoarthritis (OA) with and without patellar resurfacing will be compared.

METHODS/DESIGN

Fifty patients will be included in a randomized controlled trial. Patients scheduled for TKA with clinical and radiological signs of femorotibial and patellofemoral OA will be included. Arthritis of the patellofemoral joint was determined based on the preoperative Baldini and Merchant X-ray views, which is assessed by the orthopaedic surgeon who treats the patient. Exclusion criteria are rheumatoid arthritis, history of patellar fracture, tuberosity transposition, high tibial osteotomy (HTO), hip arthroplasty and posterior cruciate ligament insufficiency. Patients will be randomized to undergo TKA either with or without patellar resurfacing. Outcomes will be assessed preoperatively, at 6 weeks and at 6, 12, 18 and 24 months postoperatively. Primary outcome measure is the patellofemoral scoring system according to Baldini. Secondary outcome measures are the Knee Society clinical rating system (KSS) and the Knee Osteoarthritis Outcome Scale (KOOS) scores. Conventional weight-bearing radiographs, and views according to Baldini will be used to asses component loosening, wear, and patellofemoral problems including fracture or loosening of resurfaced patellae, subluxation and wear of non-resurfaced patellae.

DISCUSSION

There is no consensus regarding patellar resurfacing during primary TKA. Current prospective studies fail to determine any differences in clinical outcome among patients after TKA with or without patellar resurfacing. This randomized controlled trial has been designed to determine the effectiveness of patellar resurfacing during TKA in patients undergoing TKA who have clinical and radiological signs of tibiofemoral and patellofemoral OA, using a specific patellofemoral outcome measurement.

TRIAL REGISTRATION

Netherlands Trial Registry NTR3108.

Does imageless computer-assisted TKA lead to improved rotational alignment or fewer outliers? A systematic review

BACKGROUND

Computer-assisted surgery (CAS) has been developed to enhance prosthetic alignment during primary TKAs. Imageless CAS improves coronal and sagittal alignment compared with conventional TKA. However, the effect of imageless CAS on rotational alignment remains unclear.

QUESTIONS/PURPOSES

We conducted a systematic and qualitative review of the current literature regarding the effectiveness of imageless CAS during TKA on (1) rotational alignment of the femoral and tibial components and tibiofemoral mismatch in terms of deviation from neutral rotation, and (2) the number of femoral and tibial rotational outliers.

METHODS

Data sources included PubMed, MEDLINE, and EMBASE. Study selection, data extraction, and methodologic quality assessment were conducted independently by two reviewers. Standardized mean difference with 95% CI was calculated for continuous variables (rotational alignment of the femoral or tibial component and tibiofemoral mismatch). To compare the number of outliers for femoral and tibial component rotation, the odds ratio and 95% CI were calculated. The literature search produced 657 potentially relevant studies, 17 of which met the inclusion criteria. One study was considered as having high methodologic quality, 15 studies had medium, and one study had low quality.

RESULTS

Conflicting evidence was found for all outcome measures except for tibiofemoral mismatch. Moderate evidence was found that imageless CAS had no influence on postoperative tibiofemoral mismatch. The measurement protocol for measuring tibial rotation varied among the studies and in only one of the studies was the sample size calculation based on one of the outcome measures used in our systematic review.

CONCLUSIONS

More studies of high methodologic quality and with a sample size calculation based on the outcome measures will be helpful to assess whether an imageless CAS TKA improves femoral and tibial rotational alignment and tibiofemoral mismatch or decreases the number of femoral and tibial rotational outliers. To statistically analyze the results of different studies, the same measurement protocol should be used among the studies.

Chevron versus Mitchell osteotomy in hallux valgus surgery: a comparative study

Good clinical results have been reported for chevron and Mitchell osteotomies in mild hallux valgus (HV). The primary aim of the present study was to compare first metatarsal shortening after chevron and Mitchell osteotomies in HV. The secondary outcome measures were the degree of valgus correction, metatarsalgia, and patient satisfaction. A total of 84 patients were included in the present study and were treated from 2005 to 2007; 42 patients were in each group. The outcome measurements-first metatarsal length, HV angle, 1-2 intermetatarsal angle, satisfaction, and metatarsalgia-were taken preoperatively and at follow-up. The Mitchell osteotomy resulted in a significantly larger decrease in the first metatarsal length. No significant difference in transfer metatarsalgia was found. Approximately 30% of patients were mildly or not satisfied after HV surgery. Mitchell osteotomy leads to a larger decrease in the first metatarsal length. Patients with metatarsalgia performed poorly, and no significant differences in metatarsalgia were found. Preventing postoperative metatarsalgia is important for a successful outcome after HV surgery.

Assessment of prosthesis alignment after revision total knee arthroplasty using EOS 2D and 3D imaging: a reliability study

Introduction

A new low-dose X-ray device, called EOS, has been introduced for determining lower-limb alignment in 2D and 3D. Reliability has not yet been assessed when using EOS on lower limbs containing a knee prosthesis. Therefore purpose of this study was to determine intraobserver and interobserver reliability of EOS 2D and 3D knee prosthesis alignment measurements after revision total knee arthroplasty (rTKA).

Methods

Forty anteroposterior and lateral images of 37 rTKA patients were included. Two observers independently performed measurements on these images twice. Varus/valgus angles were measured in 2D (VV2D) and 3D (VV3D). Intraclass correlation coefficients and the Bland and Altman method were used to determine reliability. T-tests were used to test potential differences.

Results

Intraobserver and interobserver reliability were excellent for VV2D and VV3D. No significant difference or bias between the first and second measurements or the two observers was found. A significant mean and absolute difference of respectively 1.00° and 1.61° existed between 2D and 3D measurements.

Conclusions

EOS provides reliable varus/valgus measurements in 2D and 3D for the alignment of the knee joint with a knee prosthesis. However, significant differences exist between varus/valgus measurements in 2D and 3D.

Evaluation of the effect of a comprehensive multidisciplinary care pathway for hip fractures: design of a controlled study

Background

Hip fractures constitute an economic burden on healthcare resources. Most persons with a hip fracture undergo surgery. As morbidity and mortality rates are high, perioperative care leaves room for improvement. Improvement can be achieved if it is organized in comprehensive care pathways, but the effectiveness of these pathways is not yet clear. Hence the objective of this study is to compare the clinical effectiveness of a comprehensive care pathway with care as usual on self-reported limitations in Activities of Daily Living.

Methods/Design

A controlled trial will be conducted in which the comprehensive care pathway of University Medical Center Groningen will be compared with care as usual in two other, nonacademic, hospitals. In this trial, propensity scores will be used to adjust for differences at baseline between the intervention and control group. Propensity scores can be used in intervention studies where a classical randomized controlled trial is not feasible. Patients aged 60 years and older will be included. The hypothesis is that 15% more patients at University Medical Center Groningen compared with patients in the care-as-usual condition will have recovered at least as well at 6 months follow-up to pre-fracture levels for Activities of Daily Living.

Discussion

This study will yield new knowledge with respect to the clinical effectiveness of a comprehensive care pathway for the treatment of hip fractures. This is relevant because of the growing incidence of hip fractures and the consequent massive burden on the healthcare system. Additionally, this study will contribute to the growing knowledge of the application of propensity scores, a relatively novel statistical technique to simulate a randomized controlled trial in studies where it is not possible or difficult to execute this kind of design.

Trial registration

Nederlands Trial Register NTR3171

Reliability and validity of the Dutch version of the Foot and Ankle Outcome Score (FAOS)

BACKGROUND

The Foot and Ankle Outcome Score (FAOS) is a patient-reported questionnaire measuring symptoms and functional limitations of the foot and ankle. Aim is to translate and culturally adapt the Dutch version of the FAOS and to investigate internal consistency, validity, repeatability and responsiveness.

METHODS

According to the Cross Cultural Adaptation of Self-Report Measures guideline, the FAOS was translated into Dutch. Eighty-nine patients who had undergone an ankle arthroscopy, ankle arthrodesis, ankle ligament reconstruction or hallux valgus correction completed the FAOS, FFI, WOMAC and SF-36 questionnaires and were included in the validity study. Sixty-five of them completed the FAOS a second time to determine repeatability. Responsiveness was analysed in an additional 15 patients who were being treated for foot or ankle problems.

RESULTS

Internal consistency of the FAOS is high (Cronbach's alphas varying between 0.90 and 0.96). Repeatability can be considered good, with ICC's ranging from 0.90 to 0.96. Construct validity can be classified as good with moderate-to-high correlations between the FAOS subscales and subscales of the FFI (0.55 to 0.90), WOMAC (0.57 to 0.92) and SF-36 subscales physical functioning, pain, social functioning and role-physical (0.33 to 0.81). Low standard response means were found for responsiveness (0.0 to 0.4).

CONCLUSIONS

The results of this study show that the Dutch version of the FAOS is a reliable and valid questionnaire to assess symptoms and functional limitations of the foot and ankle.

Comparison of gait in patients following a computer-navigated minimally invasive anterior approach and a conventional posterolateral approach for total hip arthroplasty: a randomized controlled trial

Minimally invasive total hip arthroplasty (MIS THA) aims at minimizing damage to muscles and tendons to accelerate postoperative recovery. Computer navigation allows a precise prosthesis alignment without complete visualization of the bony landmarks during MIS THA. A randomized controlled trial (RCT) was conducted to determine the effectiveness of a computer-navigated MIS anterior approach for THA compared to a conventional posterolateral THA technique on the restoration of physical functioning during recovery following surgery. Thirty-five patients underwent computer-navigated MIS THA via the anterior approach, and 40 patients underwent conventional THA using the conventional posterolateral approach. Gait analysis was performed preoperatively, 6 weeks, and 3 and 6 months postoperatively using a body-fixed-sensor based gait analysis system. Walking speed, step length, cadence, and frontal plane angular movements of the pelvis and thorax were assessed. The same data were obtained from 30 healthy subjects. No differences were found in the recovery of spatiotemporal parameters or in angular movements of the pelvis and thorax following the computer-navigated MIS anterior approach or the conventional posterolateral approach. Although gait improved after surgery, small differences in several spatiotemporal parameters and angular movements of the trunk remained at 6 months postoperatively between both patient groups and healthy subjects.

After total knee arthroplasty, many people are not active enough to maintain their health and fitness: an observational study

QUESTIONS

What proportion of people after total knee arthroplasty adheres to the physical activity regimen recommended for maintenance of health (moderate intensity physical activity for at least 30min on 5 days/week)? What proportion adheres to the activity regimen recommended to improve fitness (vigorous intensity physical activity for at least 20min on 3 days/week)? What factors are associated with adherence to these recommendations?

DESIGN

An observational study.

PARTICIPANTS

830 adults who underwent a total knee arthroplasty between 2002 and 2006 at University Medical Center Gronigen or Martini Hospital Gronigen, the Netherlands.

OUTCOME MEASURES

The Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) was used to measure the physical activity behaviour of the participants. These data were analysed as adherence to each recommendation.

RESULTS

The health recommendation was adhered to by 51% of the participants. The fitness recommendation was adhered to by 53% of participants. Almost half (46%) of the participants fulfilled both recommendations, and 42% did not fulfil either recommendation. Males and more educated participants had higher odds of meeting the health, fitness, and both recommendations. Respondents living with family had higher odds of meeting the fitness recommendation.

CONCLUSION

After total knee arthroplasty, 42% of people are not active enough to maintain their health and fitness. Physiotherapists should encourage people with a total knee arthroplasty to undertake the recommended exercise regimens to maintain health and fitness, with particular attention to those people with characteristics known to be associated with poor adherence to the recommendations.

The influence of overweight/obesity on patient-perceived physical functioning and health-related quality of life after primary total hip arthroplasty

Background

Overweight/obesity in patients after total hip arthroplasty (THA) is a growing problem and is associated with postoperative complications and a negative effect on functional outcome. The objective of this study is to determine to what extent overweight/obesity is associated with physical functioning and health-related quality of life 1 year after primary THA.

Methods

A retrospective analysis of prospectively collected data from 653 patients who had undergone a primary THA was conducted. Physical functioning, health-related quality of life, body mass index (BMI), comorbidity, and postoperative complications were assessed by means of a questionnaire and from medical records. To determine to what extent overweight/obesity is associated with physical functioning and health-related quality of life after THA, a structural equation model (SEM) analysis was conducted.

Results

The association of BMI corrected for age, gender, complications, and comorbidity with physical functioning is −0.63. This means that an increase in 1 kg/m² BMI leads to a reduction of 0.63 points in the physical functioning score as measured with the Western Ontario and McMaster Universities Osteoarthritis Index (100-point scale). The prevalence of complications or comorbidity leads to a reduction of, respectively, 5.63 and 7.25 (one or two comorbidities) and 14.50 points in the case of more than two comorbidities on the physical functioning score. The same pattern is observed for health-related quality of life.

Conclusions

The influence of overweight/obesity on physical functioning and health-related quality of life is low. The impact of complications and comorbidity is considerable. Refusing a patient a THA solely on the basis of overweight or obesity does not seem justified.

Cross-cultural adaptation of the Dutch Short Musculoskeletal Function Assessment questionnaire (SMFA-NL): internal consistency, validity, repeatability and responsiveness

The purpose of this study was to translate and culturally adapt the Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SMFA-NL) and to investigate the internal consistency, validity, repeatability and responsiveness of the translated version. The original SMFA was first translated and culturally adapted from English into Dutch according to a standardised procedure and subsequently tested for clinimetric quality. The study population consisted of 162 patients treated for various musculoskeletal injuries or disorders at the departments of Orthopedics and Traumatology. All respondents filled in the SMFA-NL and the SF-36 and a region-specific questionnaire. To determine repeatability, 87 respondents filled in the SMFA-NL for a second time after a time interval of three to four weeks. To determine responsiveness, 29 respondents who were treated for their injury within three months before the first assessment filled in the SMFA-NL for a second time after two to three months. The following analyses were performed to evaluate clinimetric quality of the SMFA-NL: factor analysis and Cronbach's alpha (internal consistency), floor and ceiling effects, Spearman's Rho (construct validity), intraclass correlation coefficients and the Bland & Altman method (repeatability), and standardised response means (SRM) (responsiveness). Factor analysis demonstrated four subscales of the SMFA-NL. Both the newly identified subscales of the SMFA-NL and the conventional subscales of the SMFA showed good internal consistency. No floor and some ceiling effects were found. Construct validity was good, as high correlations were found between the subscales of the SMFA-NL and the respective subscales of the SF-36 and the region-specific questionnaires. Repeatability of the SMFA-NL subscales was high, with no systematic bias between first and second assessment. Responsiveness of the SMFA-NL was moderate, as small to moderate SRMs were found. We successfully translated and culturally adapted a Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SFMA-NL). This study shows that the SMFA-NL is a valid, reliable and moderately responsive method for the assessment of functional status of patients who have a broad range of musculoskeletal disorders. Furthermore, it will allow for comparison between different patient groups as well as for cross-cultural comparisons.

Subjects with hip osteoarthritis show distinctive patterns of trunk movements during gait-a body-fixed-sensor based analysis

Background

Compensatory trunk movements during gait, such as a Duchenne limp, are observed frequently in subjects with osteoarthritis of the hip, yet angular trunk movements are seldom included in clinical gait assessments. Hence, the objective of this study was to quantify compensatory trunk movements during gait in subjects with hip osteoarthritis, outside a gait laboratory, using a body-fixed-sensor based gait analysis. Frontal plane angular movements of the pelvis and thorax and spatiotemporal parameters of persons who showed a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp.

Methods

A Body-fixed-sensor based gait analysis approach was used. Two body-fixed sensors were positioned at the dorsal side of the pelvis and on the upper thorax. Peak-to-peak frontal plane range of motion (ROM) and spatiotemporal parameters (walking speed, step length and cadence) of persons with a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp. Participants were instructed to walk at a self-selected low, preferred and high speed along a hospital corridor. Generalized estimating equations (GEE) analyses were used to assess group differences between persons with a Duchenne limp, without a Duchenne limp and healthy subjects.

Results

Persons with a Duchenne limp showed a significantly larger thoracic ROM during walking compared to healthy subjects and to persons without a Duchenne limp. In both groups of persons with hip osteoarthritis, pelvic ROM was lower than in healthy subjects. This difference however only reached significance in persons without a Duchenne limp. The ratio of thoracic ROM relative to pelvic ROM revealed distinct differences in trunk movement patterns. Persons with hip osteoarthritis walked at a significantly lower speed compared to healthy subjects. No differences in step length and cadence were found between patients and healthy subjects, after correction for differences in walking speed.

Conclusions

Distinctive patterns of frontal plane angular trunk movements during gait could be objectively quantified in healthy subjects and in persons with hip osteoarthritis using a body-fixed-sensor based gait analysis approach. Therefore, frontal plane angular trunk movements should be included in clinical gait assessments of persons with hip osteoarthritis.