Skin crease ‘bikini’ incision for the direct anterior approach in total hip arthroplasty

Aims

The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA).

Patients and Methods

A total of 964 patients (51% female; 59% longitudinal, 41% ‘bikini’) completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina ‘4P’ scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed.

Results

The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the ‘bikini’ group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the ‘bikini’ group (p = 0.911).

Conclusion

We found that a short oblique ‘bikini’ skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853–61.

Concurrent comparison of the measurement properties of generic and disease-specific questionnaires in obese inpatients

BACKGROUND

The concurrent comparison of questionnaires assessing health-related quality of life in the same population is necessary for better appreciating their performance and to select the best instrument for a given purpose (e.g. clinical trials and observational studies).

AIM

The aim of this study was to compare the measurement properties of two disease-specific and generic questionnaires: the Obesity-related Well-Being (ORWELL97), the Obesity-Related Disability test (TSD-OC), the EuroQoL, and the World Health Organization Quality of Life questionnaire.

MATERIALS/SUBJECTS

Two-hundreds and forty-nine obese inpatients [age 47 (standard deviation, SD 15) years, body mass index 44.4 (SD 5.2) kg/m(2), 69 % female] completed the four questionnaires before and after a 3-week multidisciplinary weight reduction program. Standard measurement properties were calculated and compared.

RESULTS

Intra-class correlation coefficient ranged from 0.73 to 0.90 for most of the instruments and subscales. The standard error of measurement ranged from 9 to 21 % for the generic instruments, and from 9 to 44 % for the specific questionnaires. Missing data and ceiling effects were found for TSD-OC. Responsiveness was similar for all the instruments. The correlations between the change scores of the instruments were small (<0.37).

CONCLUSIONS

It was not possible to identify a "best" instrument, but overall the ORWELL97 seems to show better measurement properties. The two specific instruments measured different constructs and they did not show a clear superior performance compared to the generic questionnaires.

Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement

OBJECTIVE

The aim of this study was to explore the role of expectations in relation to patient-rated global treatment outcome in patients undergoing hip preservation surgery for femoroacetabular impingement (FAI).

METHOD

Pre-operatively, 86 patients completed the Oxford Hip Score (OHS), a question about the motivation for undergoing surgery, and Likert-scales rating the improvement expected in various domains (pain, general function, sport, walking capacity, independence, social function, mental well-being). 12-months post-operatively, they rated the actual perceived improvement in each domain and the global outcome of surgery (GTO, 5-point Likert-scale: operation "helped a lot" through to "made things worse"), and completed the OHS again.

RESULTS

The most frequent "top reason" for surgery was "alleviation of pain", being indicated by 33% patients; 20% patients chose "fear of worsening", 16% "improvement in everyday activities", 11% "other therapies failed", 10% "improvement in sporting activities" and 10% other. The 12-month data revealed prior expectations had been overly optimistic in more than 50% patients for hip pain, sport, and general physical capacity, and in 33-45% patients for independence, mental well-being, and walking capacity. Multiple regression revealed significant (P<0.05) unique associations between GTO and "fulfilled expectations" for pain and sport (explaining 47% and 12% variance, respectively).

CONCLUSION

Expectations of surgery were overly optimistic. Having one's expectations fulfilled, especially in relation to pain, was important for a good outcome. The results emphasise the benefit of assessing patient-orientated outcome in routine practice and the factors that might influence it, such that realistic expectations can be established for patients prior to surgery.

The early outcome of surgical treatment for femoroacetabular impingement: success depends on how you measure it

OBJECTIVE

To evaluate the proportion of "successes" after surgery for femoroacetabular impingement (FAI) using different external criteria, "feeling better" and "feeling good", and to determine the corresponding cut-off scores indicating "success" for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (0-10-point response scale), Oxford Hip Score (OHS) and EuroQoL-5D (EQ-5D and EQ-VAS).

DESIGN

Prospective, observational study based in an orthopaedic hospital. Ninety-nine consecutive patients with FAI completed the questionnaires before and 6 months after surgery (arthroscopy or mini-open surgical dislocation). Patient-ratings of change in state ("feeling better") were assessed using a global treatment outcome (GTO) item. Acceptability of the current health state was assessed using the symptom-specific well-being (SSWB) item. Cut-off (threshold) scores for the different instruments indicating the minimal clinically important change (MCIC) and acceptable symptom state were calculated using Receiver Operating Characteristics (ROC) analyses.

RESULTS

Significant improvements in all scores (P < 0.001) were recorded 6 months after surgery. The proportion of good outcomes measured with GTO was 60%; 55% of patients reported having achieved an acceptable symptom state. The MCIC scores for improvement were ≥6 for the OHS (0-48 total score range), ≥15 for EQ-VAS, ≥0.16 for EQ-5D index, and ≥22 for the WOMAC-total score (0-100 total score range); absolute scores of ≥40, ≥80, ≥0.682 and ≤8, respectively, were associated with an acceptable symptom state.

CONCLUSIONS

The results show that feeling better does not always equate to feeling good, and that improvements in outcome scores, even large, do not necessarily indicate acceptability of the current state. The cut-off values may help in the interpretation of trial results and individual change-scores recorded in clinical practice.

The 12-item Oxford Knee Score: cross-cultural adaptation into German and assessment of its psychometric properties in patients with osteoarthritis of the knee

OBJECTIVE

To cross-culturally adapt and validate the Oxford Knee Score (OKS) for use in German-speaking patients with osteoarthritis of the knee.

METHODS

After the cross-cultural adaptation (OKS-D), the following metric properties of the questionnaire were assessed in 100 consecutive patients (mean age 66.5 years, 61 women) undergoing total knee replacement: feasibility (percentage of fully completed questionnaires), reliability (Intraclass Correlation Coefficients [ICC] and Bland and Altman's limits of agreement), and construct validity (correlation with the Western Ontario and McMaster Universities Index [WOMAC], Knee Society Score [KSS], Activities of Daily Living Scale [ADLS], and Short Form 12 [SF-12]), floor and ceiling effects, and internal consistency (Cronbach's Alpha, CA).

RESULTS

We received 91.9% fully completed questionnaires. Reliability of the OKS-D was excellent (ICC 0.91). Bland and Altman's limits of agreement revealed no significant bias (-0.2) and a random error of 6.2. Correlation coefficients with the other questionnaires ranged from -0.22 (SF-12 Mental Component Scale [MCS]) to -0.77 (ADLS). We observed no floor or ceiling effects. The CA was 0.83.

CONCLUSIONS

The German version of the OKS is a reliable and valid measure for the self-assessment of pain and function in German-speaking patients with osteoarthritis of the knee.

Sprint vs. interval training in football

The aim of this study was to compare the effects of high-intensity aerobic interval and repeated-sprint ability (RSA) training on aerobic and anaerobic physiological variables in male football players. Forty-two participants were randomly assigned to either the interval training group (ITG, 4 x 4 min running at 90 - 95 % of HRmax; n = 21) or repeated-sprint training group (RSG, 3 x 6 maximal shuttle sprints of 40 m; n = 21). The following outcomes were measured at baseline and after 7 weeks of training: maximum oxygen uptake, respiratory compensation point, football-specific endurance (Yo-Yo Intermittent Recovery Test, YYIRT), 10-m sprint time, jump height and power, and RSA. Significant group x time interaction was found for YYIRT (p = 0.003) with RSG showing greater improvement (from 1917 +/- 439 to 2455 +/- 488 m) than ITG (from 1846 +/- 329 to 2077 +/- 300 m). Similarly, a significant interaction was found in RSA mean time (p = 0.006) with only the RSG group showing an improvement after training (from 7.53 +/- 0.21 to 7.37 +/- 0.17 s). No other group x time interactions were found. Significant pre-post changes were found for absolute and relative maximum oxygen uptake and respiratory compensation point (p < 0.05). These findings suggest that the RSA training protocol used in this study can be an effective training strategy for inducing aerobic and football-specific training adaptations.

Variation in Top Level Soccer Match Performance

This study examined the influence of the opposing team, seasonal variations and the influence of first half activity on match performance in top-level soccer players. Physical performance measures were collected using the ProZone match analysis system from 20 professional soccer players from the same team and their opponents (n = 188) during a season. Match activities (standing, walking, jogging, running, high-speed running and sprinting), distances (total distance [TD], high-intensity running [HIR] and very high-intensity running [VHIR]) and other measures including involvement with the ball and peak running speed were collected. The influence of opponent team, the level of opposition, first half physical activities on second half activities, and playing position were analysed. The main finding was that TD (r = 0.62, p < 0.05), HIR (r = 0.51, p < 0.05), and VHIR (r = 0.65, p < 0.05) of the reference team was influenced by the activity profile of the opponent teams. The TD and HIR was higher against Best opponent teams compared to Worst opponent teams (p < 0.05), and the TD, HIR and VHIR travelled in the first half significantly influenced the distances covered in the second half. TD, HIR and VHIR were greater at the end of the season. These results may be used to interpret meaningful changes in match performance in top level soccer.

Effect of plyometric training on sand versus grass on muscle soreness and jumping and sprinting ability in soccer players

OBJECTIVE

The lower impact on the musculoskeletal system induced by plyometric exercise on sand compared to a firm surface might be useful to reduce the stress of intensified training periods or during rehabilitation from injury. The aim of this study was to compare the effects of plyometric training on sand versus a grass surface on muscle soreness, vertical jump height and sprinting ability.

DESIGN

Parallel two-group, randomised, longitudinal (pretest-post-test) study.

METHODS

After random allocation, 18 soccer players completed 4 weeks of plyometric training on grass (grass group) and 19 players on sand (sand group). Before and after plyometric training, 10 m and 20 m sprint time, squat jump (SJ), countermovement jump (CMJ), and eccentric utilization ratio (CMJ/SJ) were determined. Muscle soreness was measured using a Likert scale.

RESULTS

No training surface x time interactions were found for sprint time (p>0.87), whereas a trend was found for SJ (p = 0.08), with both groups showing similar improvements (p<0.001). On the other hand, the grass group improved their CMJ (p = 0.033) and CMJ/SJ (p = 0.005) significantly (p<0.001) more than players in the sand group. In contrast, players in the sand group experienced less muscle soreness than those in the grass group (p<0.001).

CONCLUSIONS

Plyometric training on sand improved both jumping and sprinting ability and induced less muscle soreness. A grass surface seems to be superior in enhancing CMJ performance while the sand surface showed a greater improvement in SJ. Therefore, plyometric training on different surfaces may be associated with different training-induced effects on some neuromuscular factors related to the efficiency of the stretch-shortening cycle.

Physiological and performance effects of generic versus specific aerobic training in soccer players

The aim of this study was to compare the effects of specific (small-sided games) vs. generic (running) aerobic interval training on physical fitness and objective measures of match performance in soccer. Forty junior players were randomly assigned to either generic (n=20) or specific (n=20) interval training consisting of 4 bouts of 4 min at 90-95 % of maximum heart rate with 3 min active rest periods, completed twice a week. The following outcomes were measured at baseline (Pre), after 4 weeks of pre-season training (Mid), and after a further 8 weeks of training during the regular season (Post): maximum oxygen uptake, lactate threshold (Tlac), running economy at Tlac, a soccer-specific endurance test (Ekblom's circuit), and indices of physical performance during soccer matches (total distance and time spent standing, walking, and at low- and high-intensity running speed). Training load, as quantified by heart rate and rating of perceived exertion, was recorded during all training sessions and was similar between groups. There were significant improvements in aerobic fitness and match performance in both groups of soccer players, especially in response to the first 4 weeks of pre-season training. However, no significant differences between specific and generic aerobic interval training were found in any of the measured variables including soccer specific tests. The results of this study showed that both small-sided games and running are equally effective modes of aerobic interval training in junior soccer players.

Validity of simple field tests as indicators of match-related physical performance in top-level professional soccer players

The aim of this study was to examine the construct validity of selected field tests as indicators of match-related physical performance. During the competitive season, eighteen professional soccer players (age 26.2 +/- 4.5 yrs, mass 80.8 +/- 7.8 kg, and height 181.9 +/- 3.7 cm) completed an incremental running field test to exhaustion, a vertical-jump and a repeated-sprint ability (RSA) test. Match physical performance was quantified during official matches using a video-computerized, semi-automatic, match analysis image recognition system, (ProZone, Leeds, UK). The selected measures of match physical performance were: total distance covered (TD), high intensity running (HIR: > 14.4 km . h (-1)), very high intensity running (VHIR:> 19.8 km . h (-1)), sprinting (> 25.2 km . h (-1)) and top running speed. Significant correlations were found between peak speed reached during the incremental field test and TD (r = 0.58, R (2) = 0.34; p < 0.05), HIR (r = 0.65, R (2) = 0.42; p < 0.01) and VHIR (r = 0.64, R (2) = 0.41; p < 0.01). Significant correlations were also found between RSA mean time and VHIR (r = - 0.60, R (2) = 0.36; p < 0.01) and sprinting distance (r = - 0.65, R (2) = 0.42; p < 0.01). Significant differences were found between the best and worst group as defined by the median split technique for peak speed (TD = 12 011 +/- 747 m vs. 10 712 +/- 669, HIR = 3192 +/- 482 m vs. 2314 +/- 347 m, and VHIR = 1014 +/- 120 vs. 779 +/- 122 m, respectively; p < 0.05) and RSA mean time (VHIR = 974 +/- 162 m vs. 819 +/- 144 m, and sprinting = 235 +/- 56 vs. 164 +/- 58 m, respectively; p < 0.05). In conclusion, this study gives empirical support to the construct validity of RSA and incremental running tests as measures of match-related physical performance in top-level professional soccer players.

Prediction of time to exhaustion from blood lactate response during submaximal exercise in competitive cyclists

The aim of this investigation was to develop and validate a new method to predict time to exhaustion (pTE) from blood lactate variables measured during a submaximal non-exhaustive constant workload cycling test in professional cyclists. A multiple regression equation to estimate pTE from blood lactate variables measured within the first 10 min of a submaximal test and TE was determined in 40 competitive cyclists. Predicted TE reliability [individual coefficient of variation (CV)] was calculated in eight amateur cyclists who repeated the proposed test three times. Seasonal variations of pTE were monitored in 12 professional cyclists. Validity of pTE was determined by the known-group difference method in 49 professional cyclists. The prediction equation was: log(n)TE = 4.2067 - 0.8221(log(n) B) - 0.2519(log(n) C), where B is the lactate concentration at the 10th minute of the constant workload test and C is the lactate slope calculated between the 5th and 10th minute (adjusted r (2) =0.83, root mean square error in cross validation=23.1%). Predicted TE CV was 11.7%. The pTE obtained at the beginning of the season and the best and worst tests performed during the competitive season, resulted 162, 224 and 103% higher than the basic period test, respectively (P<0.05). Predicted TE was the only parameter discriminating elite from subelite professional cyclists. In conclusion, this study demonstrates that pTE is a valid and practical alternative to incremental tests and direct measures of endurance capacity requiring exhaustive efforts for the evaluation of competitive cyclists.

Correlations between physiological variables and performance in high level cross country off road cyclists

OBJECTIVES

To examine the relations between maximal and submaximal indices of aerobic fitness and off road cycling performance in a homogeneous group of high level mountain bikers.

METHODS

12 internationally competitive mountain bikers completed the study. Maximum oxygen uptake (Vo(2max)), peak power output (PPO), power output (PO), and oxygen uptake (Vo(2)) at first (VT) and second (RCT) ventilatory thresholds were measured in the laboratory, and correlated with race time during a cross country circuit race.

RESULTS

The only physiological indices of aerobic fitness correlated with off road cycling performance were PO and Vo(2) at RCT when normalised to body mass (r = -0.63 and r = -0.66, respectively; p<0.05). VT, Vo(2max), and PPO were not correlated to performance in this homogeneous group of high level mountain bikers.

CONCLUSIONS

The results of this study suggest that submaximal indices of aerobic fitness such as PO and Vo(2) at RCT are more important determinants of off road cycling performance than maximal indices such as PPO and Vo(2max). This study confirms the importance of body mass for mountain biking performance. As aerobic fitness explained only 40% of the variance, other physiological and technical factors should be investigated, as they may be important determinants of cross country performance among elite mountain bikers.

Cardiovascular responses to aerobic step dance sessions with and without appendicular overload

AIM

Several studies showed that exercise intensity during aerobic step dance can be modified varying stepping rate, bench height and manipulating body mass using hand held or adding loads to the torso. The aim of this study was to determine the cardiovascular responses during aerobic step dance using an overload strategy not yet investigated: appendicular overload.

METHODS

Ten healthy and moderately trained women (mean+/-SD: age 27+/-3.4 years, height 167.8+/-4.6 cm, body mass 55.7+/-4.7 kg, body mass index 19.8+/-1.6, VO2max44.4+/-6.1 mLxkg-1xmin-1) performed an incremental treadmill test to determine VO2peak, the VO2-heart rate (HR) and rating of perceived exertion (RPE)-HR relationships. Within 1 week from the laboratory test, the subjects performed two identical aerobic step dance routines: one using a track suit with loads placed in pockets close to the legs and arms and another without overload.

RESULTS

The appendicular overload (10% of body mass) significantly increased the exercise intensity from 84.5% to 89.8% of HRmax corresponding to 68.9% and 78.3% of VO2peak, respectively (P<0.01). Similarly, RPE increased from 12.1 to 15.7 (P<0.001). The estimated VO2 and the caloric expenditure rose from 30.3 to 34.7 mLxkg-1xmin-1 and from 251 to 288 kcal, respectively.

CONCLUSION

This study shows that the use of appendicular overload significantly increases the energy cost of aerobic step session similarly to other overload strategies already reported in the literature.