Publications by authors named "Arthur de Gast"

37 Publications

The Effect of Functional Pelvic Tilt on the Three-Dimensional Acetabular Cup Orientation in Total Hip Arthroplasty Dislocations.

J Arthroplasty 2021 Jan 8. Epub 2021 Jan 8.

Department of Orthopedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, CA.

Background: Anterior and posterior pelvic tilt appears to play a role in total hip arthroplasty (THA) stability. When changing from the standing to the sitting position, the pelvis typically rotates posteriorly while the hips flex and this affects the femoro-acetabular positions. This case-control study compares changes in 3-D acetabular cup orientation during functional pelvic tilt between posterior THA dislocations vs stable THAs.

Methods: Standing and sitting 3-D cup orientation was compared between fifteen posterior dislocations vs 233 prospectively followed stable THAs. 3-D cup orientation was calculated using previously validated trigonometric algorithms on biplanar radiographs. Those algorithms combine the angles in the three anatomical planes (coronal inclination, transverse version, and sagittal ante-inclination) in the standing position with the change in sagittal pelvic tilt from standing to sitting to calculate the 3-D orientation in the sitting position.

Results: The standing cup orientation of the dislocated THAs was only characterized by a lower coronal inclination (P = .039). Compared with the controls, from standing to sitting, they showed less posterior pelvic tilt (P < .001). This led to a significant lower coronal inclination (P < .001) and sagittal ante-inclination (P < .001) in the sitting position but similar transverse version (P = .366).

Conclusions: Comparing posterior THA dislocations to stable THAs, there is a lower increase of all three orientation angles from standing to sitting. This leads to a decreased sitting coronal inclination and sagittal ante-inclination which may lead to an increased risk of impingement ensued by THA instability. By contrast, the transverse version was not significantly different in both positions. This confirms the importance of biplanar data on functional cup orientation.

Level Of Evidence: Diagnostic, Level III.
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http://dx.doi.org/10.1016/j.arth.2020.12.055DOI Listing
January 2021

Survivorship and Patient-Reported Outcomes of an Uncemented Vitamin E-Infused Monoblock Acetabular Cup: A Multicenter Prospective Cohort Study.

J Arthroplasty 2021 May 26;36(5):1700-1706. Epub 2020 Dec 26.

Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK.

Background: Addition of vitamin E to polyethylene is theorized to reduce the potential for oxidative wear in acetabular components. This paper presents a multicenter prospective cohort study that reports on outcomes from use of a Vitamin E-infused highly cross-linked polyethylene acetabular cup.

Methods: Patients were recruited across nine medical institutions. Clinical outcome measures recorded were the Harris Hip Score, visual analogue score for pain and satisfaction. Evidence of implant loosening or osteolysis was collected radiologically. Cup survival and reasons for revision in relevant cases were also recorded. Data collection was undertaken preoperatively, at 6-12 weeks, 6 months, 1 year, 2 years, and 5 years. A total of 675 patients were recruited, with 450 cases available at final review. Data regarding cup survival was available to 8 years and 9 months postoperatively.

Results: Improvements in both the Harris Hip Score and visual analogue score for pain and satisfaction were recorded at all time points, with these being maintained through the length of follow-up. In total, 89% of cups were implanted within the Lewinnek safe zone. A lucent line was identified in one case, with no evidence of acetabular osteolysis observed throughout the follow-up period. Cup survival was 98.9% at 8 years and 9 months. No revisions for aseptic loosening were observed.

Conclusions: The use of a vitamin E-infused polyethylene acetabular cup demonstrates reassuring patient-reported outcomes, radiological measures, and cup survival at medium to long-term follow-up.
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http://dx.doi.org/10.1016/j.arth.2020.12.032DOI Listing
May 2021

Wear and migration are not influenced by head size in a vitamin E-infused highly cross-linked polyethylene acetabular cup.

Orthop Traumatol Surg Res 2021 Feb 28;107(1):102644. Epub 2020 Dec 28.

Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern, Switzerland. Electronic address:

Background: Aseptic loosening and periprosthetic osteolysis are frequent complications in total hip arthroplasty requiring revision surgery. Highly cross-linked polyethylene (HXLPE) implants have improved wear resistance, permitting larger femoral heads. However, such implants may experience surface cracking, mechanical failure, and oxidative damage. Vitamin E-infused HXLPE (VEPE) implants were therefore developed to reduce oxidation without compromising mechanical strength. We addressed the following questions: (1) Does femoral head size affect the midterm annual polyethylene wear rates of VEPE acetabular cups? (2) Does femoral head size affect the midterm migration rates of VEPE acetabular cups? (3) Are clinical outcomes affected by femoral head size?

Hypothesis: Annual wear rate, migration rate, and clinical outcomes of VEPE acetabular cups are independent of femoral head size.

Patients And Methods: This was a prospective, multicentre, observational study of patients that underwent total hip arthroplasty. Hips were grouped according to the size of femoral head implanted (28 mm, 32 mm, and 36 mm). We determined annual wear rate and migration rate of VEPE acetabular cups using the Einzel-Bild-Röntgen-Analyse software. Clinically, we assessed the Harris Hip Score and visual analog score for pain and satisfaction.

Results: We followed 253 patients (267 hips) for a mean of 55.0±20.6 months in the 28 mm, 46.2±21.4 months in the 32 mm, and 43.8±22.6 months in the 36 mm group. The annual wear rate was 0.025 mm per year from 1 year to the last follow-up and remained similar between the groups (p>0.05). Also, mean two-dimensional migration rates did not exceed 0.05 mm from 2 years to the last follow-up and remained similar between the groups (p=0.355). Finally, clinical outcomes also did not differ between the groups (p>0.05). Two patients required revision surgery.

Discussion: Femoral head size did not influence midterm annual wear rate, migration rate, and clinical outcomes of VEPE acetabular cups. Furthermore, wear and cup migration rates were below the reported values leading to osteolysis and aseptic loosening. Nevertheless, studies with extended follow-up periods will be necessary to confirm these results in the long term.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.otsr.2020.03.030DOI Listing
February 2021

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

Orthop J Sports Med 2020 Oct 29;8(10):2325967120954392. Epub 2020 Oct 29.

Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.

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

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

Study Design: Randomized controlled trial; Level of evidence, 1.

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

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

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

Registration: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).
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http://dx.doi.org/10.1177/2325967120954392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607803PMC
October 2020

The Effect of Postural Pelvic Dynamics on the Three-dimensional Orientation of the Acetabular Cup in THA Is Patient Specific.

Clin Orthop Relat Res 2021 Mar;479(3):561-571

T. E. Snijders, A. de Gast, Clinical Orthopedic Research Center midden-Nederland, Diakonessenhuis, Zeist, the Netherlands.

Background: Sagittal pelvic dynamics mainly consist of the pelvis rotating anteriorly or posteriorly while the hips flexes, and this affects the femoroacetabular or THA configuration. Thus far, it is unknown how the acetabular cup of the THA in the individual patient reorients with changing sagittal pelvic dynamics.

Questions/purposes: The aim of this study was to validate a method that establishes the three-dimensional (3-D) acetabular cup orientation with changing sagittal pelvic dynamics and describe these changes during functional pelvic dynamics.

Methods: A novel trigonometric mathematical model, which was incorporated into an easy-to-use tool, was tested. The model connected sagittal tilt, transverse version, and coronal inclination of the acetabular cup during sagittal pelvic tilt. Furthermore, the effect of sagittal pelvic tilt on the 3-D reorientation of acetabular cups was simulated for cups with different initial positions. Twelve pelvic CT images of patients who underwent THA were taken and rotated around the hip axis to different degrees of anterior and posterior sagittal pelvic tilt (± 30°) to simulate functional pelvic tilt in various body positions. For each simulated pelvic tilt, the transverse version and coronal inclination of the cup were manually measured and compared with those measured in a mathematical model in which the 3-D cup positions were calculated. Next, this model was applied to different acetabular cup positions to simulate the effect of sagittal pelvic dynamics on the 3-D orientation of the acetabular cup in the coronal and transverse plane. After pelvic tilt was applied, the intraclass correlation coefficients of 108 measured and calculated coronal and transverse cup orientation angles were 0.963 and 0.990, respectively, validating the clinical use of the mathematical model.

Results: The changes in 3-D acetabular cup orientation by functional pelvic tilt differed substantially between cups with different initial positions; the change in transverse version was much more pronounced in cups with low coronal inclination (from 50° to -29°) during functional pelvic tilt than in cups with a normal coronal inclination (from 39° to -11°) or high coronal inclination (from 31° to 2°). However, changes in coronal inclination were more pronounced in acetabular cups with high transverse version.

Conclusion: Using a simple algorithm to determine the dynamic 3-D reorientation of the acetabular cup during functional sagittal pelvic tilt, we demonstrated that the 3-D effect of functional pelvic tilt is specific to the initial acetabular cup orientation and thus per THA patient.

Clinical Relevance: Future studies concerning THA (in)stability should not only include the initial acetabular cup orientation, but also they need to incorporate the effect of sagittal pelvic dynamics on the individual 3-D acetabular cup orientation. Clinicians can also use the developed tool, www.3d-hip.com, to calculate the acetabular cup's orientation in other instances, such as for patients with spinopelvic imbalance.
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http://dx.doi.org/10.1097/CORR.0000000000001489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899699PMC
March 2021

Unravelling the knee-hip-spine trilemma from the CHECK study.

Bone Joint J 2020 Sep;102-B(9):1261-1267

Department of Orthopedics, University Medical Center Utrecht, Utrecht, Netherlands.

Aims: The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting.

Methods: A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations.

Results: Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034).

Conclusion: High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b Cite this article: 2020;102-B(9):1261-1267.
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http://dx.doi.org/10.1302/0301-620X.102B9.BJJ-2019-1315.R2DOI Listing
September 2020

A vitamin E blended highly cross-linked polyethylene acetabular cup results in less wear: 6-year results of a randomized controlled trial in 199 patients.

Acta Orthop 2020 12 24;91(6):705-710. Epub 2020 Aug 24.

Clinical Orthopedic Research Center - mN, Zeist.

Background and purpose - Survivorship of total hip arthroplasty (THA) with the ultra-high molecular weight polyethylene (UHMWPE) monoblock cup has been limited due to periprosthetic osteolysis and aseptic loosening, secondary to wear of the UHMWPE. In response, a vitamin E blended highly cross-linked polyethylene (HXLPE) cup was developed. This study set out to compare the wear and clinical 6-year outcomes of vitamin E blended HXLPE with UHMWPE in an isoelastic monoblock cup in patients with hip osteoarthritis who underwent uncemented THA. The 2-year results have been reported previously. Patients and methods - For this randomized controlled trial 199 patients were included. 102 patients received the vitamin E blended HXLPE uncemented acetabular cup and 97 patients the uncemented UHMWPE monoblock cup. Clinical and radiographic parameters were obtained preoperatively, directly postoperatively, and at 3, 12, 24, and 72 months. Wear rates were compared using the femoral head penetration (FHP) rate. Results - 173 patients (87%) completed the 6-year follow-up. The mean NRS scores for rest pain, load pain, and patient satisfaction were 0.3 (SD 1), 0.6 (SD 1), and 8.6 (SD 1) respectively. The mean Harris Hip Score was 93 (SD 12). The FHP rate was lower in the vitamin E blended HXLPE cup (0.028 mm/year) compared with the UHMWPE cup (0.035 mm/year) (p = 0.002). No adverse reactions associated with the clinical application of vitamin E blended HXLPE were observed. 15 complications occurred, equally distributed between the two cups. The 6-year survival to revision rate was 98% for both cups. There was no aseptic loosening. Interpretation - This study shows the superior performance of the HXLPE blended with vitamin E acetabular cup with clinical and radiographic results similar to the UHMWPE acetabular cup.
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http://dx.doi.org/10.1080/17453674.2020.1807220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023918PMC
December 2020

Giant Seromal Cyst Development After Tourniquet Use During Total Knee Arthroplasty: A Case Report.

JBJS Case Connect 2020 Jan-Mar;10(1):e0466

Clinical Orthopedic Research Center-mN, Zeist, the Netherlands.

Case: An 84-year old woman developed 2 large seromal cysts at the medial side of her right thigh, 4 months after total knee arthroplasty (TKA). The cysts were located at the place where the tourniquet, during surgery, had been applied. The diagnosis was confirmed with echography and magnetic resonance imaging. Both cysts were resected, and the patient recovered completely, after one relapse in which a lymphatic vessel was sutured.

Conclusion: Development of seromal cyst after tourniquet use during TKA is a rare but serious complication.
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http://dx.doi.org/10.2106/JBJS.CC.19.00466DOI Listing
January 2021

2-year results of an RCT of 2 uncemented isoelastic monoblock acetabular components: lower wear rate with vitamin E blended highly cross-linked polyethylene compared to ultra-high molecular weight polyethylene.

Acta Orthop 2020 06 26;91(3):254-259. Epub 2020 Feb 26.

Clinical Orthopedic Research Center-mN, Zeist, the Netherlands.

- The long-term survival of arthroplasty components may be limited by polyethylene wear-related problems such as periprosthetic osteolysis and aseptic loosening. Highly cross-linked polyethylene (HXLPE) blended with vitamin E was introduced to improve oxidative stability and to avoid long-term embrittlement. This study clinically compares the tribological behavior and clinical outcome of vitamin E blended HXLPE with ultra-high molecular weight polyethylene (UHMWPE) in an isoelastic monoblock cup for uncemented total hip arthroplasty. - In this randomized controlled trial (RCT), 199 patients were included: 102 patients received the vitamin E blended HXLPE cup, 97 patients the UHMWPE cup. Clinical and radiographic parameters were obtained preoperatively, directly postoperative and at 3, 12, and 24 months. Wear rates were compared using the mean linear femoral head penetration (FHP) rate. - 188 patients (94%) completed the 2-year follow-up. Mean patient satisfaction was higher in the vitamin E blended HXLPE group (8.9 [1]) than in in the control group (8.5 [2], p = 0.03). The Harris Hip Score (HHS) was higher in the vitamin E blended HXLPE group (95 [8]) than in the control group (92 [11], p = 0.3). The FHP rate was lower in the vitamin E blended HXLPE group: 0.046 mm/year compared with 0.056 mm/year in the control group (p = 0.05). No adverse reactions associated with the clinical application of vitamin E blended HXLPE were observed during follow-up, with an excellent 2-year survival to revision rate of 98% for both cups. - This study shows the superior performance of the HXLPE blended with vitamin E acetabular cup with lower linear femoral head penetration rates and better clinical results compared with the UHMWPE acetabular cup after 2 years.
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http://dx.doi.org/10.1080/17453674.2020.1730073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023900PMC
June 2020

How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study.

Br J Sports Med 2020 May 21;54(9):538-545. Epub 2019 Jun 21.

Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands.

Objectives: To examine whether physical therapy (PT) is cost-effective compared with arthroscopic partial meniscectomy (APM) in patients with a non-obstructive meniscal tear, we performed a full trial-based economic evaluation from a societal perspective. In a secondary analysis-this paper-we examined whether PT is non-inferior to APM.

Methods: We recruited patients aged 45-70 years with a non-obstructive meniscal tear in nine Dutch hospitals. Resource use was measured using web-based questionnaires. Measures of effectiveness included knee function using the International Knee Documentation Committee (IKDC) and quality-adjusted life-years (QALYs). Follow-up was 24 months. Uncertainty was assessed using bootstrapping techniques. The non-inferiority margins for societal costs, the IKDC and QALYs, were €670, 8 points and 0.057 points, respectively.

Results: We randomly assigned 321 patients to PT (n=162) or APM (n=159). PT was associated with significantly lower costs after 24 months compared with APM (-€1803; 95% CI -€3008 to -€838). The probability of PT being cost-effective compared with APM was 1.00 at a willingness to pay of €0/unit of effect for the IKDC (knee function) and QALYs (quality of life) and decreased with increasing values of willingness to pay. The probability that PT is non-inferior to APM was 0.97 for all non-inferiority margins for the IKDC and 0.89 for QALYs.

Conclusions: The probability of PT being cost-effective compared with APM was relatively high at reasonable values of willingness to pay for the IKDC and QALYs. Also, PT had a relatively high probability of being non-inferior to APM for both outcomes. This warrants further deimplementation of APM in patients with non-obstructive meniscal tears.

Trial Registration Numbers: NCT01850719 and NTR3908.
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http://dx.doi.org/10.1136/bjsports-2018-100065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212930PMC
May 2020

Restoring femoral offset and leg length; the potential of a short curved stem in total hip arthroplasty.

J Orthop 2019 Sep-Oct;16(5):396-399. Epub 2019 May 2.

Clinical Orthopedic Research Center - mN, Diakonessenhuis Zeist, Zeist, the Netherlands.

Background: Total hip arthroplasty (THA) is a very successful procedure in orthopedics. Still polyethylene wear and gait deficits are limiting the clinical success.It is important to reconstruct leg length (LL) and femoral offset (FO) anatomically in order to have the best possible result of a THA. Gait deficits can arise due to leg length discrepancy as well as changes in the abductor moment arm. In THA, LL and FO are strongly determined by the orientation, size and geometry of the femoral stem.

Methods: This radio-anatomical study used the data of a prospective cases series of 112 patients who underwent 126 primary THAs and had completed a 1-year follow-up examination. FO and LL were compared between the conventional straight stem in vivo and a computed simulated implantation of a short curved stem, using the pre- and postoperative pelvic radiographs of the same patients.

Results: In this simulation of the short curved stem statistically significantly restored native FO (p = 0.010) and LL (p = 0.000) better, compared to the conventional straight stem.

Conclusions: Thus, the short curved stem restores FO and LL better, and could potentially prevent gait deficits.
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http://dx.doi.org/10.1016/j.jor.2019.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512581PMC
May 2019

Non-equivalent Results from Different Anteversion Measurements Methods for the Evaluation of the Acetabular Cup Orientation in Total Hip Arthroplasty.

Orthop Surg 2019 Apr 1;11(2):241-247. Epub 2019 Apr 1.

Clinical Orthopedic Research Center - mN, Diakonessenhuis Zeist, Zeist, the Netherlands.

Objective: To determine the comparability among 10 radiographic anteversion methods for acetabular cup orientation in total hip arthroplasty (THA) found in the literature and the "gold" standard of assessing the anteversion with CT.

Methods: This is a retrospective study that blindly compares 10 different conventional radiographic anteversion measurements with the "gold" standard, the measurement of anteversion on the transverse plane of the 3-D images made with CT. The patient archiving and communications system (PACS) was systematically searched for subjects that had undergone a CT angiogram of the abdomen and lower extremities, including the pelvis, had at least one THA in situ and had undergone anterior-posterior (AP) and cross-lateral pelvic radiography between January 2013 and August 2016 in the Diakonessenhuis Hospital Utrecht/Zeist, a non-academic institution. CT scans of patients (n = 16) were systematically collected. Three observers independently measured cup anteversion from radiographs, using a total of 10 different methods, and measured the "gold" standard on CT images. The outcomes of the 10 radiographic anteversion were compared in terms of linear correlation with the "gold" standard on CT images.

Results: The correlations of the radiographic measured anteversions with the "gold" standard measured on CT images were 0.528 for the method of Liaw, 0.556 for Wan, 0.562 for the cross-lateral method, 0.586 for Hassan, 0.594 for Dorr, 0.602 for Lewinnek, 0.624 for Widmer, 0.671 for the lateral CT, 0.747 for Ackland, and 0.771 for the method of Riten Pradham.

Conclusion: Anteversion measurement methods represent different projectional angles of the acetabular cup in different planes around different axes. Therefore, they differ from the "gold" standard and are not interchangeable, as is shown by this study. We consider the anatomical anteversion in the transverse plane rotating around the longitudinal axis as the "gold" standard and recommend avoiding using the term anteversion for other projectional angles in different planes.
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http://dx.doi.org/10.1111/os.12445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594505PMC
April 2019

Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial.

JAMA 2018 10;320(13):1328-1337

Department of Orthopedic Surgery, Joint Research, OLVG, Amsterdam, the Netherlands.

Importance: Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed in patients with meniscal tears.

Objective: To assess whether PT is noninferior to APM for improving patient-reported knee function in patients with meniscal tears.

Design, Setting, And Participants: Noninferiority, multicenter, randomized clinical trial conducted in 9 hospitals in the Netherlands. Participants were aged 45 to 70 years with nonobstructive meniscal tears (ie, no locking of the knee joint). Patients with knee instability, severe osteoarthritis, and body mass index greater than 35 were excluded. Recruitment took place between July 17, 2013, and November 4, 2015. Participants were followed up for 24 months (final participant follow-up, October 11, 2017).

Interventions: Three hundred twenty-one participants were randomly assigned to APM (n = 159) or a predefined PT protocol (n = 162). The PT protocol consisted of 16 sessions of exercise therapy over 8 weeks focused on coordination and closed kinetic chain strength exercises.

Main Outcomes And Measures: The primary outcome was change in patient-reported knee function on the International Knee Documentation Committee Subjective Knee Form (range, 0 to 100; from worse to best) from baseline over a 24-month follow-up period. The noninferiority margin was defined as a difference between treatment groups of 8 points and was assessed with a 1-sided α of .025. The primary analysis followed the intention-to-treat principle.

Results: Among 321 patients who were randomized (mean [SD] age, 58 [6.6] years; 161 women [50%]), 289 (90%) completed the trial (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the 24-month follow-up period, and 8 participants randomized to APM (5%) did not have APM. Over a 24-month follow-up period, knee function improved in the APM group by 26.2 points (from 44.8 to 71.5) and in the PT group by 20.4 points (from 46.5 to 67.7). The overall between-group difference was 3.6 points (97.5% CI, -∞ to 6.5; P value for noninferiority = .001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. Repeat surgery (3 in the APM group and 1 in the PT group) and additional outpatient visits for knee pain (6 in the APM group and 2 in the PT group) were the most frequent adverse events.

Conclusions And Relevance: Among patients with nonobstructive meniscal tears, PT was noninferior to APM for improving patient-reported knee function over a 24-month follow-up period. Based on these results, PT may be considered an alternative to surgery for patients with nonobstructive meniscal tears.

Trial Registration: ClinicalTrials.gov Identifier: NCT01850719.
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http://dx.doi.org/10.1001/jama.2018.13308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583004PMC
October 2018

Comparison of polyetheretherketone versus silicon nitride intervertebral spinal spacers in a caprine model.

J Biomed Mater Res B Appl Biomater 2019 04 9;107(3):688-699. Epub 2018 Aug 9.

Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands.

Polyetheretherketone (PEEK) is commonly used as a spinal spacer for intervertebral fusion surgery. Unfortunately, PEEK is bioinert and does not effectively osseointegrate into living bone. In contrast, comparable spacers made of silicon nitride (Si N ) possess a surface nanostructure and chemistry that encourage appositional bone healing. This observational study was designed to compare the outcomes of these two biomaterials when implanted as spacers in an adult caprine model. Lumbar interbody fusion surgeries were performed at two adjacent levels in eight adult goats using implants of PEEK and Si N . At six-months after surgery, the operative and adjacent spinal segments were extracted and measured for bone fusion, bone volume, bone-implant contact (BIC) and soft-tissue implant contact (SIC) ratios, and biodynamic stability. The null hypothesis was that no differences in these parameters would be apparent between the two groups. Fusion was observed in seven of eight implants in each group with greater bone formation in the Si N group (52.6%) versus PEEK (27.9%; p = 0.2). There were no significant differences in BIC ratios between PEEK and Si N , and the biodynamic stability of the two groups was also comparable. The results suggest that Si N spacers are not inferior to PEEK and they may be more effective in promoting arthrodesis. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000-000, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 688-699, 2019.
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http://dx.doi.org/10.1002/jbm.b.34162DOI Listing
April 2019

Lack of consensus on optimal acetabular cup orientation because of variation in assessment methods in total hip arthroplasty: a systematic review.

Hip Int 2019 Jan 17;29(1):41-50. Epub 2018 May 17.

1 Clinical Orthopedic Research Centre - mN, Zeist, Utrecht, The Netherlands.

Introduction:: Dislocation is 1 of the main reasons for revision of total hip arthroplasty but dislocation rates have not changed in the past decades, compromising patients' well-being. Acetabular cup orientation plays a key role in implant stability and has been widely studied. This article investigates whether there is a consensus on optimal cup orientation, which is necessary when using a navigation system.

Methods:: A systematic search of the literature in the PubMed, Embase and Cochrane databases was performed (March 2017) to identify articles that investigated the direct relationship between cup orientation and dislocation, including a thorough evaluation of postoperative cup orientation assessment methods.

Results:: 28 relevant articles evaluating a direct relation between dislocation and cup orientation could not come to a consensus. The key reason is a lack of uniformity in the assessment of cup orientation. Cup orientation is assessed with different imaging modalities, different methodologies, different definitions for inclination and anteversion, several reference planes and distinct patient positions.

Conclusions:: All available studies lack uniformity in cup orientation assessment; therefore it is impossible to reach consensus on optimal cup orientation. Using navigation systems for placement of the cup is inevitably flawed when using different definitions in the preoperative planning, peroperative placement and postoperative evaluation. Further methodological development is required to assess cup orientation. Consequently, the postoperative assessment should be uniform, thus differentiating between anterior and posterior dislocation, use the same definitions for inclination and anteversion with the same reference plane and with the patient in the same position.
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http://dx.doi.org/10.1177/1120700018759306DOI Listing
January 2019

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

BMJ Open 2016 12 21;6(12):e014381. Epub 2016 Dec 21.

Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands.

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

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

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

Trial Registration Number: NCT01850719.
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http://dx.doi.org/10.1136/bmjopen-2016-014381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223724PMC
December 2016

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

Arthroscopy 2016 09 27;32(9):1855-1865.e4. Epub 2016 Jul 27.

Department of Orthopaedic Surgery, Joint Research, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands.

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

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

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

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

Level Of Evidence: Level I, systematic review and meta-analysis of Level I studies.
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http://dx.doi.org/10.1016/j.arthro.2016.05.036DOI Listing
September 2016

Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature.

Foot Ankle Surg 2016 Jun 28;22(2):73-7. Epub 2015 May 28.

Clinical Orthopedic Research Center Midden Nederland, Utrecht, The Netherlands; Department of Orthopedic Surgery, Diakonessenhuis Utrecht, The Netherlands.

Introduction: The objective of the present study was to review the current data on the long-term outcomes of posterior malleolar fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation.

Methods: The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2014 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of posterior malleolar fractures.

Results: Of 68 initially relevant studies, 19 met our inclusion criteria. A total of 886 fractures were identified in 885 patients. The mean sample size-weighted follow-up period was 3.7 years. Comparable results are achieved when comparing open reduction and internal fixation to conservative treatment for posterior malleolar fractures.

Discussion: Current consensus suggests posterior malleolar fragments comprising of >25% of the distal tibial plafond as seen on a true lateral radiograph and fragments with more than 2mm dislocation require open reduction and internal fixation of the fragment. The current consensus on treatment of posterior malleolar fractures is neither supported nor disapproved by the available evidence.
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http://dx.doi.org/10.1016/j.fas.2015.05.003DOI Listing
June 2016

Development of a Risk Stratification Model for Delayed Inpatient Recovery of Physical Activities in Patients Undergoing Total Hip Replacement.

J Orthop Sports Phys Ther 2016 03 26;46(3):135-43. Epub 2016 Jan 26.

Study Design: Prospective cohort design using data derived from usual care.

Background: It is important that patients are able to function independently as soon as possible after total hip replacement. However, the speed of regaining activities differs significantly.

Objectives: To develop a risk stratification model (RSM) to predict delayed inpatient recovery of physical activities in people who underwent total hip replacement surgery.

Methods: This study was performed in 2 routine orthopaedic settings: Diakonessenhuis Hospital (setting A) and Nij Smellinghe Hospital (setting B). Preoperative screening was performed for all consecutive patients. In-hospital recovery of activities was assessed with the Modified Iowa Level of Assistance Scale. Delayed inpatient recovery of activities was defined as greater than 5 days. The RSM, developed using logistic regression analysis and bootstrapping, was based on data from setting A (n = 154). External validation was performed on the data set from setting B (n = 271).

Results: Twenty-one percent of the patients in setting A had a delayed recovery of activities during their hospital stay. Multivariable logistic regression modeling yielded a preliminary RSM that included the following factors: male sex (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.2, 2.6), 70 or more years of age (OR = 1.2; 95% CI: 0.4, 3.4), body mass index of 25 kg/m(2) or greater (OR = 2.2; 95% CI: 0.7, 7.4), an American Society of Anesthesiologists score of 3 (OR = 1.2; 95% CI: 0.3, 4.4), a Charnley score of B or C (OR = 6.1; 95% CI: 2.2, 17.4), and a timed up-and-go score of 12.5 seconds or greater (OR = 3.1; 95% CI: 1.1, 9.0). The area under the receiver operating characteristic (ROC) curve was 0.82 (95% CI: 0.74, 0.90) and the Hosmer-Lemeshow test score was 3.57 (P>.05). External validation yielded an area under the ROC curve of 0.71 (95% CI: 0.61, 0.81).

Conclusion: We demonstrated that the risk for delayed recovery of activities during the hospital stay can be predicted by using preoperative data. Level of Evidence Prognosis, level 1b.
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http://dx.doi.org/10.2519/jospt.2016.6124DOI Listing
March 2016

An uncemented iso-elastic monoblock acetabular component: preliminary results.

J Arthroplasty 2015 Apr 27;30(4):615-21. Epub 2014 Nov 27.

Clinical Orthopedic Research Center-midden Nederland (CORC-mN) Department of Orthopedics, Diakonessenhuis Hospital, Utrecht, The Netherlands.

Little is known about the clinical application of highly cross-linked polyethylene (HXLPE) blended with vitamin E. This study evaluates an uncemented iso-elastic monoblock cup with vitamin E blended HXLPE. 112 patients were followed up for 2years. 95.5% completed the follow-up. The mean VAS score for patient satisfaction was 8.8 and the mean Harris Hip Score was 94.2. In 7 cases initial gaps behind the cup were observed, which disappeared completely during follow-up in 6 cases. The mean femoral head penetration rate was 0.055mm/year. No adverse reactions or abnormal mechanical behavior was observed with the short term use of vitamin E blended HXLPE. This study shows the promising performance of this cup and confirms the potential of vitamin E blended HXLPE.
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http://dx.doi.org/10.1016/j.arth.2014.11.017DOI Listing
April 2015

Poor intermediate-term survival of the uncemented Optan anatomically adapted femoral component.

Acta Orthop 2014 Aug 23;85(4):363-7. Epub 2014 Jun 23.

Clinical Orthopaedic Research Center - midden Nederland (CORC-mN) , Department of Orthopaedics, Diakonessenhuis Hospital Utrecht/Zeist, Utrecht , the Netherlands .

Purpose: We evaluated the 5-year survival of the uncemented Optan anatomically adapted femoral stem, with revision for aseptic loosening as the endpoint.

Methods: Between January 2004 and March 2007, 432 total hip arthroplasties (THAs) were performed in 432 patients. After follow-up for a mean time of 5 years, the patients were evaluated using the WOMAC questionnaire and plain radiography. Patients who were unable to attend the follow-up visit were contacted by telephone to determine whether they had had any revision surgery of their THA.

Results: Within 5 years, 39 patients (9%) had died of unrelated causes and 63 patients (15%) had been lost to follow-up. Of the remaining cohort, 224 patients (68%) had full follow-up while 88 patients (27%) were evaluated with WOMAC only and 18 patients (5%) were evaluated with radiography only. The mean WOMAC score of all evaluated patients was 21 (10-100). At 5-year follow-up, there were 26 stem revisions reported (6%), 14 hips (3%) showed aseptic loosening, and 12 hips (3%) had had a periprosthetic femoral fracture. The 5-year survival to revision for any reason was 94%. Worst-case analysis yielded a 5-year survival of 79%.

Interpretation: The 5-year survival for aseptic loosening of the Optan anatomically adapted femoral component was disappointing. Radiographic evaluation showed evidence of proximal radiolucencies and distal cortical bone hypertrophy, which we attribute to insufficient proximal bone in-growth and increased load transfer at the tip of the stem. We do not recommend the use of the Optan femoral stem.
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http://dx.doi.org/10.3109/17453674.2014.934185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4105766PMC
August 2014

Edge loading does not increase wear rates of ceramic-on-ceramic and metal-on-polyethylene articulations.

J Biomed Mater Res B Appl Biomater 2014 Nov 21;102(8):1627-38. Epub 2014 Mar 21.

Department of Orthopedics, Clinical Orthopedic Research Center (CORC-mN), Diakonessenhuis Utrecht/Zeist, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands.

The mal-positioning of total hip arthroplasty components can result in edge loading conditions. Purpose of this study was to determine if the wear rate of ceramic-on-ceramic and metal-on-polyethylene increases under edge loading conditions. The literature was reviewed to determine which of the commonly used hip bearings is the most forgiving to implant mal-orientation. Two 28-mm ceramic-on-ceramic articulations were tested in vitro: pure alumina (PAL) ceramic versus the new alumina-toughened zirconia (ATZ). Two 28-mm metal-on-polyethylene articulations were tested in vitro: conventional ultrahigh molecular weight polyethylene (UHMWPE) versus highly crosslinked polyethylene (HXLPE) stabilized with vitamin E. All bearings were tested at standard and at highest possible inclination angles. Hip simulator tests were run for five million cycles based on N = 3 tests per condition. The average wear rate of ATZ-on-ATZ is 0.024 mm(3) /Mcycles at 45° and 0.018 mm(3) /Mcycles at 65°. Wear rate of PAL-on-PAL is between 0.02 and 0.03 mm(3) /Mcycles at 45°, as well as 65°. The wear rate of UHMWPE was 31 ± 1 mm(3) /Mcycles at an inclination angle of 45° and 26 ± 1 mm(3) /Mcycles at 80°. The wear rate of vitamin E stabilized HXLPE was 5.9 ± 0.2 mm(3) /Mcycles at 45° and 5.8 ± 0.2 mm(3) /Mcycles at 80°. Edge loading does not increase the wear rate of ceramic-on-ceramic and metal-on-polyethylene articulations. The newest biomaterials showed markedly lower wear rates compared with their conventional counterparts. ATZ-on-ATZ showed the lowest wear rate of all tested pairings, but the vitamin E stabilized HXLPE seems to be the most forgiving material when it comes to implant mal-orientation.
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http://dx.doi.org/10.1002/jbm.b.33147DOI Listing
November 2014

The SNAP trial: a double blind multi-center randomized controlled trial of a silicon nitride versus a PEEK cage in transforaminal lumbar interbody fusion in patients with symptomatic degenerative lumbar disc disorders: study protocol.

BMC Musculoskelet Disord 2014 Feb 25;15:57. Epub 2014 Feb 25.

Clinical Orthopaedic Research Center-midden Nederland (CORC-mN), Department of Orthopaedics, Diakonessenhuis, Utrecht/Zeist, The Netherlands.

Background: Polyetheretherketone (PEEK) cages have been widely used in the treatment of lumbar degenerative disc disorders, and show good clinical results. Still, complications such as subsidence and migration of the cage are frequently seen. A lack of osteointegration and fibrous tissues surrounding PEEK cages are held responsible. Ceramic implants made of silicon nitride show better biocompatible and osteoconductive qualities, and therefore are expected to lower complication rates and allow for better fusion.Purpose of this study is to show that fusion with the silicon nitride cage produces non-inferior results in outcome of the Roland Morris Disability Questionnaire at all follow-up time points as compared to the same procedure with PEEK cages.

Methods/design: This study is designed as a double blind multi-center randomized controlled trial with repeated measures analysis. 100 patients (18-75 years) presenting with symptomatic lumbar degenerative disorders unresponsive to at least 6 months of conservative treatment are included. Patients will be randomly assigned to a PEEK cage or a silicon nitride cage, and will undergo a transforaminal lumbar interbody fusion with pedicle screw fixation. Primary outcome measure is the functional improvement measured by the Roland Morris Disability Questionnaire. Secondary outcome parameters are the VAS leg, VAS back, SF-36, Likert scale, neurological outcome and radiographic assessment of fusion. After 1 year the fusion rate will be measured by radiograms and CT. Follow-up will be continued for 2 years. Patients and clinical observers who will perform the follow-up visits will be blinded for type of cage used during follow-up. Analyses of radiograms and CT will be performed independently by two experienced radiologists.

Discussion: In this study a PEEK cage will be compared with a silicon nitride cage in the treatment of symptomatic degenerative lumbar disc disorders. To our knowledge, this is the first randomized controlled trial in which the silicon nitride cage is compared with the PEEK cage in patients with symptomatic degenerative lumbar disc disorders.

Trial Registration: NCT01557829.
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http://dx.doi.org/10.1186/1471-2474-15-57DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937453PMC
February 2014

[Arthroscopic meniscectomy: does it make sense in patients older than 45?].

Ned Tijdschr Geneeskd 2013 ;157(3):A6865

Onze Lieve Vrouwe Gasthuis, afd. Orthopedische chirurgie, Amsterdam.

Meniscus surgery is the most commonly performed surgical procedure in orthopaedics. Almost two-thirds of the patients are over 45 years old. It is not known, however, whether a torn meniscus in older patients is the primary cause of knee pain, or whether the pain is caused by an ongoing degenerative process. Until 2013, there were hardly any studies comparing the efficacy of meniscus surgery with that of a non-surgical approach in this group of patients. This has recently changed with the publication of two randomized controlled studies comparing arthroscopic meniscectomy with conservative therapy. The studies showed that meniscectomy had no added value to physical therapy. This commentary briefly discusses these studies and discloses the lack of current knowledge on the aspect of cost-effectiveness of these treatments.
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October 2014

Polyetheretherketone (PEEK) cages in cervical applications: a systematic review.

Spine J 2015 Jun 27;15(6):1446-60. Epub 2013 Dec 27.

Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.

Background Context: Polyetheretherketone (PEEK) cages have been widely used during the past decade in patients with degenerative disorders of the cervical spine. Their radiolucency and low elastic modulus make them attractive attributes for spinal fusion compared with titanium and bone graft. Still, limitations are seen such as pseudoarthrosis, subsidence, and migration of the cages. Limited evidence on the clinical outcome of PEEK cages is found in the literature other than noncomparative cohort studies with only a few randomized controlled trials.

Purpose: To assess the clinical and radiographic outcome of PEEK cages in the treatment of degenerative disc disorders and/or spondylolisthesis in the cervical spine.

Study Design: Systematic review of all randomized controlled trials and prospective and retrospective nonrandomized comparative studies with a minimum follow-up of 6 months and all noncomparative cohort studies with a long-term follow-up of more than 5 years.

Outcome Measures: The primary outcome variable was clinical performance. Secondary outcome variables consisted of radiographic scores.

Methods: The MEDLINE, EMBASE, and Cochrane Library databases were searched according to the Preferred Reporting Items of Systematic reviews and Meta-Analyses statement and Meta-analysis Of Observational Studies in Epidemiology guidelines. No conflict of interest reported. No funding received.

Results: A total of 223 studies were identified, of which 10 studies were included. These comprised two randomized controlled trials, five prospective comparative trials, and three retrospective comparative trials.

Conclusions: Minimal evidence for better clinical and radiographic outcome is found for PEEK cages compared with bone grafts in the cervical spine. No differences were found between PEEK, titanium, and carbon fiber cages. Future studies are needed to improve methodology to minimize bias. Publication of lumbar interbody fusion studies needs to be promoted because differences in clinical and/or radiographic scores are more likely to be demonstrated in this part of the spine.
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http://dx.doi.org/10.1016/j.spinee.2013.08.030DOI Listing
June 2015

Do monoblock cups improve survivorship, decrease wear, or reduce osteolysis in uncemented total hip arthroplasty?

Clin Orthop Relat Res 2013 Nov 3;471(11):3572-80. Epub 2013 Aug 3.

Clinical Orthopedic Research Center-midden Nederland (CORC-mN), Department of Orthopaedics, Diakonessenhuis Hospital, PO Box 80250, 3508 TG, Utrecht, The Netherlands,

Background: Monoblock acetabular components used in uncemented total hip arthroplasty (THA) have certain mechanical characteristics that potentially reduce acetabular osteolysis and polyethylene wear. However, the degree to which they achieve this goal is not well documented.

Questions/purposes: The purpose of this study was to use a systematic review of controlled trials to test the hypothesis that monoblock cups have superior (1) polyethylene wear rate; (2) frequency of cup migration; (3) frequency of acetabular osteolysis; and (4) frequency of aseptic loosening compared with modular components used in uncemented THA.

Methods: A systematic search was conducted in the Medline, Embase, and Cochrane electronic databases to assemble all controlled trials comparing monoblock with modular uncemented acetabular components in primary THA. Included studies were considered "best evidence" if the quality score was either ≥ 50% on the Cochrane Back Review Group checklist or ≥ 75% the Newcastle-Ottawa quality assessment scale. A total of seven publications met our inclusion criteria.

Results: Best evidence analysis showed no difference in polyethylene wear rate, the frequency of cup migration, and aseptic loosening between monoblock and modular acetabular components. No convincing evidence was found for the claim that lower frequencies of acetabular osteolysis are observed with the use of monoblock cups compared with modular uncemented cups.

Conclusions: The purported benefits of monoblock cups were not substantiated by this systematic review of controlled studies in that polyethylene wear rates and frequencies of cup failure and acetabular osteolysis were similar to those observed with modular implants. Other factors should therefore drive implant selection in cementless THA.
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http://dx.doi.org/10.1007/s11999-013-3144-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792292PMC
November 2013

Excellent survivorship of the Morscher monoblock cup with a 28-mm Metasul-on-Metasul bearing at a mean of 5-year follow-up.

J Arthroplasty 2014 Feb 12;29(2):405-9. Epub 2013 Jun 12.

Clinical Orthopedic Research Center (CORC-mN), Department of Orthopedics, Diakonessenhuis Hospital Utrecht/Zeist, Utrecht, the Netherlands.

The Morscher monoblock cup is designed for optimal osteointegration and holds the potential for excellent long-term survival. The Metasul-on-Metasul bearing was introduced to eliminate wear-induced periprosthetic osteolysis. This study reviews 137 Morscher cups with a 28-mm Metasul-on-Metasul bearing used in primary THA at 5.1years (3.2-6.6) after implantation. One hundred thirty-seven cups were implanted in 119 patients. Three patients (2.2%) had died of unrelated causes, and 10 patients (8.0%) were lost to follow-up. The mean Harris Hip score was 89.8 and the mean WOMAC sum score was 18.5. No cases of acetabular osteolysis were found. The 5-year cup survival rate was 98.5%. The Morscher cup with a 28-mm Metasul-on-Metasul bearing used in uncemented THA showed no acetabular osteolysis and promising survivorship at intermediate-term follow-up.
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http://dx.doi.org/10.1016/j.arth.2013.05.005DOI Listing
February 2014

Role of the long head of the biceps brachii muscle in axial humeral rotation control.

Clin Anat 2012 Sep 22;25(6):737-45. Epub 2011 Nov 22.

Clinical Orthopedic Research Center-mN, Diakonessenhuis Hospital, Utrecht/Zeist, Utrecht, The Netherlands.

This anatomical and biomechanical study focuses on the specific influence of the long head of biceps brachii muscle in controlling axial humeral rotation. The tendon of the long head of the biceps brachii (biceps tendon) is shown to either facilitate or restrict axial humeral rotation. Its effect on axial humeral rotation is strongly related to firstly the amount of biceps tendon load, secondly glenohumeral scapular plane elevation, and thirdly the rotatory position of the humerus. At 0° glenohumeral elevation, biceps tendon load caused an increase of internal humeral rotation, from 0° at 2.25 N biceps tendon load to 23° at 82.25 N. Under 45° glenohumeral elevation, biceps tendon load can restrict and facilitate as well internal and external axial humeral rotation, increasing the rotatory range of motion. Above 45° glenohumeral elevation biceps tendon load restricts internal and external axial humeral rotation, increasing actively joint stability by increasing torsional rigidity. These findings on the function of the biceps tendon could have consequences for the clinical interpretation. In the elevated arm position, extreme rotation loads the long head of the biceps tendon and may turn out to biceps or bicepslabrum complex injuries.
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http://dx.doi.org/10.1002/ca.22001DOI Listing
September 2012

[Scientific output of orthopaedic hospitals in the Netherlands: not all hospitals meet the requirements of the Dutch orthopaedic residency programme].

Ned Tijdschr Geneeskd 2011 ;155(18):A2915

Diakonessenhuis Utrecht, afd. Orthopedie, Utrecht, the Netherlands.

Objective: To evaluate the feasibility of the requirements for scientific participation in the Dutch orthopaedic residency programme by assessing the numbers of articles published by orthopaedic teaching hospitals.

Design: Descriptive.

Method: All 29 orthopaedic teaching hospitals in the Netherlands were asked to draw up a list of articles published from 2004 to 2009. The publications were subdivided into papers indexed in PubMed and papers published in the Nederlands Tijdschrift voor Orthopedie (NTvO, Netherlands Journal of Orthopaedics) and the Nederlands Tijdschrift voor Traumatologie (NTvT, Netherlands Journal of Traumatology).

Results: There was an overall response rate of 72% (21/29). For the 8 non-responders a search of PubMed and the NTvO-NTvT journal databases was used to compile a list of their publications. The university teaching hospitals (n = 8) published 1150 articles, 1118 of which were indexed in PubMed, 19 published in the NTvO and 13 in the NTvT. Peripheral teaching hospitals (n = 21) published 689 articles: 590 indexed in PubMed, 77 published in the NTvO and 22 in the NTvT. In the peripheral teaching hospitals there was a positive correlation between the number of orthopaedic surgeons and PhD students and the number of published articles.

Conclusion: Of the 29 teaching hospitals, 9 (31%) did not meet the requirements for publication specified in the Dutch orthopaedic residency programme guidelines. The number of published articles is related to the numbers of orthopaedic surgeons and PhD students in peripheral teaching hospitals. The requirements for the minimum number of publications could therefore be revised to reflect the proportion of orthopaedic surgeons in each teaching hospital. The introduction of a weighting factor that accounts for the quality of the publications would also result in a more balanced assessment.
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September 2011

Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial.

BMC Med 2011 Jan 24;9. Epub 2011 Jan 24.

Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Background: Shoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain.

Methods: A single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group.

Results: Compared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2).

Conclusions: The results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain.

Trial Registration Number: ISRCTN: ISRCTN75722066.
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http://dx.doi.org/10.1186/1741-7015-9-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039607PMC
January 2011