Publications by authors named "Inger N Sierevelt"

100 Publications

Ten-year revision rates of contemporary total ankle arthroplasties equal 22%. A meta-analysis.

Foot Ankle Surg 2021 Jun 6. Epub 2021 Jun 6.

Department of Orthopedics, Xpert Orthopedics and Specialized Centre of Orthopedic Research and Education (SCORE), Laarderhoogtweg 12, 1101 EA Amsterdam, The Netherlands.

Background: The National Institute for Health and Care Excellence criterion for hip replacements is a (projected) revision rate of less than 5% after 10 years. No such criterion is available for ankle prostheses. The objective of the current study is to compare survival rates of contemporary primary ankle prostheses to the hip-benchmark.

Methods: The PRISMA methodology was used. Eligible for inclusion were clinical studies reporting revision rates of currently available primary total ankle prostheses. Data was extracted using preconstructed forms. The total and prosthesis-specific annual revision rate was calculated.

Results: Fifty-seven articles of eight different ankle prostheses were included (n = 5371), totaling 513 revisions at an average 4.6 years of follow-up. An annual revision rate of 2.2 was found (i.e. an expected revision rate of 22% at 10 years).

Conclusions: The expected 10-year revision rate of contemporary ankle prostheses is lower than the current benchmark for hip prostheses.
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http://dx.doi.org/10.1016/j.fas.2021.05.014DOI Listing
June 2021

Prospective Cohort Study to Investigate Factors Associated With Continued Immobilization of a Nondisplaced Scaphoid Waist Fracture.

J Hand Surg Am 2021 May 26. Epub 2021 May 26.

Department of Orthopedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia; Department of Orthopedic Surgery, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands.

Purpose: The decision to continue immobilization of a nondisplaced scaphoid waist fracture is often based on radiographic appearance (despite evidence that radiographs are unreliable and inaccurate for diagnosing scaphoid union 6-12 weeks after fracture) and fracture tenderness (even though it is influenced by cognitive biases on pain). This may result in unhelpful additional immobilization. We studied nondisplaced scaphoid waist fractures to determine the factors associated with (1) the surgeon's decision to continue cast or splint immobilization at the first visit when cast removal was being considered; (2) greater pain on examination; and (3) the surgeon's concern about radiographic consolidation.

Methods: We prospectively included 46 patients with a nondisplaced scaphoid waist fracture treated nonoperatively. At the first visit when cast removal was considered - after an average of 6 weeks of immobilization - patients rated pain during 4 examination maneuvers. The treating surgeon assessed union on radiographs and decided whether to continue or discontinue immobilization. Patients completed measures of the following: (1) the degree to which pain limits activities (Patient-Reported Outcome Measure Interactive System [PROMIS] Pain Interference Computer Adaptive Test [CAT], Pain Self-Efficacy Questionnaire-2); (2) symptoms of depression (PROMIS Depression CAT); and (3) upper extremity function (PROMIS Upper Extremity Function CAT). We used multivariable regression analysis to investigate the factors associated with each outcome.

Results: Perceived inadequate radiographic healing and greater symptoms of depression were independently associated with continued immobilization. Pain during the examination was not associated with continued immobilization. Patient age was associated with pain on examination. Shorter immobilization duration was the only factor associated with the surgeon's perception of inadequate radiographic consolidation.

Conclusions: Inadequate radiographic healing and greater symptoms of depression are associated with a surgeon's decision to continue cast or splint immobilization of a nondisplaced scaphoid waist fracture.

Clinical Relevance: Overreliance on radiographs and inadequate accounting for psychological distress may hinder the adoption of shorter immobilization times for nondisplaced waist fractures.
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http://dx.doi.org/10.1016/j.jhsa.2021.03.027DOI Listing
May 2021

Lower revision rates for cemented fixation in a long-term survival analysis of three different LCS designs.

Knee Surg Sports Traumatol Arthrosc 2021 May 2. Epub 2021 May 2.

SCORE Foundation, Specialized Center of Orthopedic Research and Education/Xpert Clinics Orthopedie, Laarderhoogtweg 12, 1101AE, Amsterdam, The Netherlands.

Background: In primary Total Knee Arthroplasty (TKA), it is still not clear if cemented or uncemented fixation has the best long-term survival. The Low Contact Stress (LCS) mobile-bearing (MB) knee system was introduced in 1977. The aim of this study is to investigate the long-term survival of this design with a minimum of 15-year follow-up.

Methods: A retrospective analysis was performed, with the primary endpoint for survival defined as revision. Cox regression analysis was performed to assess the association between type of fixation and the risk of revision, while correcting for potential confounders (diagnosis, design, age and sex).

Results: 1271 cases were included with inflammatory joint disease (IJD) (657 cases) and non-IJD (614 cases). TKAs were performed cemented in 522 cases and uncemented in 749 cases. A bicruciate retaining design was used in 180 cases, a rotating platform design in 174 cases and an anterior posterior glide posterior cruciate-retaining (PCR) design in 916 cases. Cumulative incidence of component revision at 15 years was 2.7% (95% CI 1.6; 4.5) for cemented and 10% (95% CI 8.1; 12.4) for uncemented TKA, respectively. The 20-year cumulative incidence was 2.9% (95% CI 1.7; 4.7) for cemented and 10.9% (95% CI 8.8; 13.4) for uncemented TKA, respectively. Age, non-IJD and PCR design were associated with a significantly higher risk of revision, regardless of the type of fixation.

Conclusion: Long-term survival for patients undergoing cemented or uncemented TKA using the LCS MB system revealed lower revision rates for cemented fixation. Revision risk was higher in younger, non-IJD patients who had the PCR design, regardless of the type of fixation. For the LCS MB TKA design, it is recommended to use cemented fixation.
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http://dx.doi.org/10.1007/s00167-021-06587-8DOI Listing
May 2021

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial.

BMC Musculoskelet Disord 2021 Apr 30;22(1):399. Epub 2021 Apr 30.

Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Background: For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking.

Methods: This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up.

Discussion: Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores.

Trial Registration: Registered at Netherlands Trial Register ( NL9072 ) on 25th of November 2020.
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http://dx.doi.org/10.1186/s12891-021-04280-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088019PMC
April 2021

Evaluation of the 'Spaarne soft tissue procedure' as a treatment for recurrent patellar dislocations: a four-in-one technique.

J Exp Orthop 2021 Apr 20;8(1):31. Epub 2021 Apr 20.

Department, of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, the Netherlands.

Purpose: The 'Spaarne soft tissue procedure', is a 4-in-1 soft tissue procedure that treats recurrent patellar dislocations in the young and active population. The procedure has not yet described elsewhere. The purpose of this study is to analyse the redislocation rate and to evaluate the postoperative knee function and patient satisfaction.

Methods: Twenty-seven patients (34 knees) underwent the four-in-one SST-procedure. The 4-step technique required a minor change in 2010, including the use of a smaller strip of the patellar tendon for transposition. After a median follow-up of 10.4 years, the redislocation rate was evaluated as the primary outcome measure. Secondary outcome measures were functional outcome (IKDC, Kujala, Lysholm and Tegner activity scale) and Numeric Rating Scales for satisfaction and pain.

Results: Redislocation occurred in 8 cases (23.5%) and subluxation occurred in 13 cases (38.2%) post-surgery. A significant higher number of redislocations and subluxations were seen before 2010 (p = 0.04, p = 0.03). The median postoperative IKDC, Lysholm and Kujala scores for the total group were 54, 76 and 81 respectively. Pre- and postoperative Tegner activity scale were both level 3. Median NRS scores during rest, walking and sports were 1, 3 and 5 respectively. Satisfaction with the procedure was reported as 'excellent' or 'good' by 79% of the patients.

Conclusion: Despite the high overall redislocation rate and increased pain scores, the SST-procedure shows to be a safe procedure in patients with recurrent patellar dislocations based on the cases after 2010. Mid- and long-term results show moderate to good functional outcomes and satisfaction.

Level Of Evidence: Therapeutic retrospective cohort study, LEVEL III.
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http://dx.doi.org/10.1186/s40634-021-00349-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058128PMC
April 2021

The influence of hydroxyapatite coating on continuous migration of a Zweymuller-type hip stem: a double-blinded randomised RSA trial with 5-year follow-up.

Hip Int 2021 Apr 12:11207000211006782. Epub 2021 Apr 12.

Xpert Clinics, Orthopaedic Surgery, Amsterdam, The Netherlands.

Background And Purpose: Adding hydroxyapatite to a stem to enhance ingrowth is a matter of debate, even less is known about the long-term effect on stability by adding hydroxyapatite (HA). Continuous migration in the first 2-5 years is an indicator of failed osteointegration or pending failure, enhancing the risk of loosening within 10 years after initial surgery. We performed a double-blinded randomised RSA trial with 5-year follow-up, to compare and analyse migration characteristics of the hydroxyapatite uncoated (HA-) and hydroxyapatite coated (HA+) Zweymuller-type hip stem.

Patients And Methods: In this single-centre prospective randomised controlled trial 51 patients were randomised to receive either a HA- or a HA+ Zweymuller-type hip stem during total hip replacement. After 5 years, 35 patients were still eligible for follow-up evaluation. The migration pattern was measured by use of radio stereometric analysis (RSA) images up to 2 years to evaluate short-term migration, additionally RSA images were obtained 5 years postoperatively to assess late-term and continuous migration. Furthermore, the improvement of clinical outcome was analysed by HSS and HOOS ADL and pain subscales preoperative and after 5 years.

Results: After initial settling of the implant, no significant migration occurred up to 5 years post-surgery for HA+ as well as HA- prostheses. Continuous migration within the 2-5 years' time interval was not observed for both HA+ nor the HA- group in all directions ( 0.05). No significant difference between both groups was observed ( 0.10). In both groups the HHS and HOOS improved significantly at 5 years compared to baseline for both groups. Improvement was not altered by the hydroxyapatite coating. No significant difference between both groups was observed ( 0.58).

Conclusions: Addition of a hydroxyapatite coating did not influence the migration 5 years postoperatively for the Zweymuller-type hip stem.Clinical Trial Protocol number: NL 23524.048.08.
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http://dx.doi.org/10.1177/11207000211006782DOI Listing
April 2021

Capsular closure versus unrepaired interportal capsulotomy after hip arthroscopy in patients with femoroacetabular impingement, results of a patient-blinded randomised controlled trial.

Hip Int 2021 Apr 12:11207000211005762. Epub 2021 Apr 12.

Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopaedic Surgery Clinic, Amsterdam, The Netherlands.

Background: Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy.

Purpose: To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS).

Materials And Methods: All eligible patients with femoroacetabular impingement who opt for hip arthroscopy ( = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively.

Results: Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery ( = 0.67). Both groups significantly improved after surgery ( < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport ( = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains (  0.05).

Conclusions: The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy.

Trial Registration: This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.
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http://dx.doi.org/10.1177/11207000211005762DOI Listing
April 2021

Radiographic assessment of calcifying tendinitis of the rotator cuff : an inter- and intraobserver study.

Acta Orthop Belg 2020 Sep;86(3):525-531

The radiographic appearance of calcific tendinitis of the rotator cuff varies according to the stage of the disease. We compared currently used classification systems in a large group of observers to identify the most reliable classification system. Thirty-seven orthopaedic surgeons evaluated shoulder radiographs of 25 patients to classify the stage of the calcific tendinitis according to the classifications by (1) Gärtner and (2) Molé on a Web-based study platform. Inter and intraobserver agreement among observers was measured using the Siegel and Castellan multirater κ. Both classification systems had fair interobserver agreement : κ was 0.25 for the Molé classification and 0.34 for the Gärtner classification. The Gärtner classification was significantly more reliable than the Molé classification. Currently there is no radiographic classification that can serve the purpose of guiding the treatment in a reliable way.
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September 2020

Results of stemless shoulder arthroplasty: a systematic review and meta-analysis.

EFORT Open Rev 2021 Jan 4;6(1):35-49. Epub 2021 Jan 4.

Spaarne Gasthuis, Hoofddorp, The Netherlands.

Stemless shoulder arthroplasty relies solely on cementless metaphyseal fixation and is designed to avoid stem-related problem such as intraoperative fractures, loosening, stress shielding or stress-risers for periprosthetic fractures.Many designs are currently on the market, although only six anatomic and two reverse arthroplasty designs have results published with a minimum of two-year follow-up.Compared to stemmed designs, clinical outcome is equally good using stemless designs in the short and medium-term follow-up, which is also the case for overall complication and revision rates.Intraoperative fracture rate is lower in stemless compared to stemmed designs, most likely due to the absence of intramedullary preparation and of the implantation of a stem.Radiologic abnormalities around the humeral implant are less frequent compared to stemmed implants, possibly related to the closer resemblance to native anatomy.Between stemless implants, several significant differences were found in terms of clinical outcome, complication and revision rates, although the level of evidence is low with high study heterogeneity; therefore, firm conclusions could not be drawn.There is a need for well-designed long-term randomized trials with sufficient power in order to assess the superiority of stemless over conventional arthroplasty, and of one design over another. Cite this article: 2021;6:35-49. DOI: 10.1302/2058-5241.6.200067.
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http://dx.doi.org/10.1302/2058-5241.6.200067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845565PMC
January 2021

Ceramic-on-ceramic ceramic-on-polyethylene, a comparative study with 10-year follow-up.

World J Orthop 2021 Jan 18;12(1):14-23. Epub 2021 Jan 18.

Department of Orthopedic Surgery, Xpert Orthopedie Amsterdam/SCORE (Specialized Center of Orthopedic Research and Education), Amsterdam 1101EA, The Netherlands.

Background: In press-fit total hip arthroplasty (THA) ceramic-on-ceramic (CoC) bearings are a potential for overcoming the wear that is seen in ceramic-on-polyethylene (CoPE) bearings, and can lead to wear-induced osteolysis, resulting in loosening of the implant. However, CoC bearings show disadvantages as well, such as squeaking sounds and being more fragile, which can cause ceramic head or liner fracture. Because comparative long-term studies are limited, the objective of this study was to determine the long-term difference in wear, identify potential predictive factors for wear, investigate radiological findings such as osteolysis, and evaluate clinical functioning and complications between these bearings.

Aim: To determine 10-year differences in wear, predictive factors for wear, and investigate radiological findings and clinical functioning between CoC and CoPE.

Methods: This observational prospective single-center cohort study with a 10-year follow-up includes a documented series of elective THAs. Primary outcome was wear measured by anteroposterior (AP) radiographs. Secondary outcomes were potential predictive factors for wear, complications during follow-up, Harris hip score (HHS), and radiological findings such as presence of radiolucency, osteolysis, atrophy, and hypertrophy around the cup. Due to the absence of wear in the CoC group, stratified analysis to identify risk factors for wear was only performed in the CoPE group by use of univariate linear regression analysis. HHS was expressed as a change from baseline and the association with bearing type was assessed by use of multivariate linear regression analysis, adjusted for potential confounders.

Results: A total of 17 CoPE (63.0%) and 25 CoC (73.5%) cases were available for follow-up and showed a linear wear of respectively 0.130 mm/year (range 0.010; 0.350) and 0.000 mm/year (range 0.000; 0.005), which was significant ( < 0.001) between both groups. Wear always occurred in the cranial direction. Cup inclination was the only predictive factor for polyethylene (PE) wear. No dislocations, ceramic head, or liner fractures were seen. The HHS showed a mean change from baseline of 37.1 points (SD 18.5) in the CoPE group and 43.9 (SD 17.0) in the CoC group. This crude difference of 6.8 (range -5.2; 18.7) in favor of the CoC group was not significant ( = 0.26) and was not significant when adjusted for age, gender, and diagnosis either ( = 0.99). No significant differences in complications and radiological findings were seen between groups.

Conclusion: CoC bearing shows lower wear rates compared to CoPE at 10-year follow-up with cup inclination as a predictive factor for wear and no differences in complications, HHS, and radiological findings.
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http://dx.doi.org/10.5312/wjo.v12.i1.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814309PMC
January 2021

What is the role of cemented fixation in total knee arthroplasty? The two-year results of a randomized RSA controlled trial.

Bone Joint J 2021 Jan;103-B(1):98-104

SCORE Foundation, Specialized Center of Orthopedic Research and Education/Xpert Clinics Orthopedie, Amsterdam, The Netherlands.

Aims: For many designs of total knee arthroplasty (TKA) it remains unclear whether cemented or uncemented fixation provides optimal long-term survival. The main limitation in most studies is a retrospective or non-comparative study design. The same is true for comparative trials looking only at the survival rate as extensive sample sizes are needed to detect true differences in fixation and durability. Studies using radiostereometric analysis (RSA) techniques have shown to be highly predictive in detecting late occurring aseptic loosening at an early stage. To investigate the difference in predicted long-term survival between cemented, uncemented, and hybrid fixation of TKA, we performed a randomized controlled trial using RSA.

Methods: A total of 105 patients were randomized into three groups (cemented, uncemented, and hybrid fixation of the ACS Mobile Bearing (ACS MB) knee system, implantcast). RSA examinations were performed on the first day after surgery and at scheduled follow-up visits at three months, six months, one year, and two years postoperatively. Patient-reported outcome measures (PROMs) were obtained preoperatively and after two years follow-up. Patients and follow-up investigators were blinded for the result of randomization.

Results: RSA secondary stabilization did not show a significant difference between the three types of fixation. A maximum total point motion of less than 0.2 mm in the second postoperative year was shown in each group, which suggests stabilization of the implant. At 24 months after surgery, PROMs significantly improved compared to baseline in all treatment groups. No significant difference was observed between the three groups.

Conclusion: Secondary stabilization measurements in this study demonstrated no significant difference between the groups. In all groups migration stabilized after initial settling of the implant. For this implant the long-term outcome is not expected to be influenced by the type of fixation to the bone. Cite this article: 2021;103-B(1):98-104.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-0788.R1DOI Listing
January 2021

The Impact of Minimally Invasive Treatment for Rotator Cuff Calcific Tendinitis on Self-Reported Work Ability and Sick Leave.

Arthrosc Sports Med Rehabil 2020 Dec 5;2(6):e821-e827. Epub 2020 Oct 5.

Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp.

Purpose: To examine the impact of rotator cuff calcific tendinitis on patients' self-reported work ability and sick leave, to compare work ability and sick leave with shoulder function after minimally invasive treatment, and to assess which prognostic factors influence the change in work ability.

Methods: A prospective cohort was analyzed in this study. The primary outcome measure was the single-question work ability score (0-10 points). Secondary outcome measures were quality and quantity of work, sick leave, functional outcome, and radiographic resorption. Potential predictive factors (treatment method, age, sex, resorption of the calcific deposit, physical work load, and work status) were tested in a statistical model. Follow-up was at 6 months and 1 year.

Results: The study cohort consisted of 67 patients. The mean age was 49.6 ± 6.4 years and 45 (67%) were female. Physical workload was categorized as light (58%), medium (24%), and heavy (18%). Work ability score improved from a mean of 6.1 ± 2.8 to 8.5 ± 2.0 points after 1 year. Treatment with minimally invasive treatment techniques was associated with a reduction in partial or full-time sick leave from 28% to 6%. The mean days of sick leave a month declined from 3.3 to 0.8 days. Functional disability was greater in patients with partial or full-time sick leave. The physical workload turned out to be the most important patient associated factor predicting change in work ability.

Conclusions: This study supports the hypothesis that rotator cuff calcific tendinitis has a significant impact on work ability and sick leave. Minimally invasive treatment resulted in a clinically relevant improvement in work ability score and decline in sick leave. In particular, patients with medium and high physically demanding work for the shoulder benefit from minimally invasive treatment to improve their work ability.

Level Of Evidence: Level II, prospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2020.07.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754604PMC
December 2020

Is obesity associated with short-term revision after total knee arthroplasty? An analysis of 121,819 primary procedures from the Dutch Arthroplasty Register.

Knee 2020 Dec 18;27(6):1899-1906. Epub 2020 Nov 18.

Department of Orthopedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.

Background: The prevalence of obesity is increasing. The association with knee osteoarthritis is well documented, resulting in the population requesting total knee arthroplasty (TKA) for invalidating symptoms to be heavier in nature. The purpose of the current analysis was to assess the association between preoperative body mass index (BMI) and short-term revision rate after TKA. The secondary aim was to investigate the influence of implant fixation method on the association between BMI and survivorship.

Methods: This is a retrospective analysis of prospectively collected registry data (Dutch Arthroplasty Register; LROI). All primary TKA procedures in patients >18 years of age with registered BMI were selected (n = 121,819). Non-obese patients (BMI 18-25) were compared with overweight (BMI 25-30) and class I-III obese (BMI >30, >35, >40) patients. Crude all-cause revision rates were calculated using competing risk analysis. Adjusted hazard ratios (HRs) were determined with Cox multivariable regression analyses for all-cause, septic and aseptic revision and secondary patellar resurfacing.

Results: Revision rates were 3.3% for non-obese patients, 3.5% for overweight patients, 3.7% for class I obese patients, 3.6% for class II obese patients and 3.7% for class III obese patients. Class III obese patients had a significant higher risk for septic revision compared with non-obese patients (HR 1.53, 95% confidence interval (CI) 1.06-2.22). Class I obese patients had a higher risk for secondary patellar resurfacing (HR 1.52, 95% CI 1.12-2.08). All-cause and aseptic revision rates were similar between BMI groups.

Conclusions: Obesity appeared to be associated with some short-term revision risks after TKA, but was not associated with an overall increase in revision rate.
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http://dx.doi.org/10.1016/j.knee.2020.09.020DOI Listing
December 2020

What Are the Frequency, Related Mortality, and Factors Associated with Bone Cement Implantation Syndrome in Arthroplasty Surgery?

Clin Orthop Relat Res 2021 04;479(4):755-763

R. Rassir, M. Schuiling, I. N. Sierevelt, C. W. P. van der Hoeven, P. A. Nolte, Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.

Background: Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and the loss of consciousness during cemented arthroplasty; it may result in death. Its incidence has only been explored for hemiarthroplasty and THA after fracture or cancer. To our knowledge, there are no studies that comprehensively explore and compare the incidence of BCIS in other arthroplasty procedures.

Questions/purposes: (1) To report the incidence of BCIS in TKA, unicondylar knee arthroplasty, hip hemiarthroplasty, THA, shoulder arthroplasty, TKA, and revision THA and TKA; (2) to determine whether severe BCIS is associated with an increased risk of death within 30 days of surgery; and (3) to identify factors associated with the development of severe BCIS.

Methods: All patients undergoing cemented arthroplasty for any reason (TKA [11% cemented, 766 of 7293], unicondylar knee arthroplasty [100% cemented, 562 procedures], hip hemiarthroplasty for femur fractures [100% cemented, 969 procedures], THA [8% cemented, 683 of 8447], shoulder arthroplasty [84% cemented, 185 of 219], and revision arthroplasty of the hip and knee [36% cemented, 240 of 660]) between January 2008 and August 2019 were considered for inclusion in the current retrospective observational study. Fixation choice was dependent on surgeon preference (THA and TKA), prosthesis design (shoulder arthroplasty), or bone quality (revision arthroplasty). The following procedures were excluded because of insufficient data: < 1% (1 of 766) of TKAs, 1% (4 of 562) of unicondylar knee arthroplasties, 6% (54 of 969) of hip hemiarthroplasties, 1% (6 of 683) of THAs, 6% (12 of 185) of shoulder arthroplasties, and 14% (34 of 240) of revision procedures. This resulted in a final inclusion of 3294 procedures (765 TKAs [23%], 558 unicondylar knee arthroplasties [17%], 915 hip hemiarthroplasties [28%], 677 THA [21%], 173 shoulder arthroplasties [5%], and 206 revision arthroplasties [6%]), of which 28% (930 of 3294) had an emergent indication for surgery. Of the patients, 68% (2240 of 3294) were females, with a mean age of 75 ± 11 years. All anesthetic records were extracted from our hospital's database, and the severity of BCIS was retrospectively scored (Grade 0 [no BCIS], Grade 1 [O2% < 94% or fall in systolic blood pressure of 20% to 40%], Grade 2 [O2% < 88% or fall in systolic blood pressure of > 40%], and Grade 3 [cardiovascular collapse requiring CPR]). Procedures were dichotomized into no or moderate BCIS (Grades 0 and 1) and severe BCIS (Grades 2 and 3). The adjusted 30-day mortality of patients with severe BCIS was assessed with a multivariate Cox regression analysis. A multivariate logistic regression analysis was performed to identify factors associated with the development of severe BCIS.

Results: BCIS occurred in 26% (845 of 3294) of arthoplasty procedures. The incidence was 31% (282 of 915) in hip hemiarthroplasty, 28% (210 of 765) in TKA, 24% (165 of 677) in THA, 23% (47 of 206) in revision arthroplasty, 20% (113 of 558) in unicondylar knee arthroplasty, and 16% (28 of 173) in shoulder arthroplasty. Patients with severe BCIS were more likely (hazard ratio 3.46 [95% confidence interval 2.07 to 5.77]; p < 0.001) to die within 30 days of the index procedure than were patients with less severe or no BCIS. Factors independently associated with the development of severe BCIS were age older than 75 years (odds ratio 1.57 [95% CI 1.09 to 2.27]; p = 0.02), American Society of Anesthesiologists Class III or IV (OR 1.58 [95% CI 1.09 to 2.30]; p = 0.02), and renal impairment (OR 3.32 [95% CI 1.45 to 7.46]; p = 0.004).

Conclusion: BCIS is common during cemented arthroplasty; severe BCIS is uncommon, but it is associated with an increased risk of death within 30 days of surgery. Medically complex patients undergoing hip hemiarthroplasty may be at particular risk. Patients at high risk for severe BCIS (renal impairment, ASA III/IV, and age older than 75 years) should be identified and preventive measures such as medullary lavage before cementation, femoral venting, and avoidance of excessive pressurization of implants should be taken to reduce the likelihood and consequences of BCIS. Because of the increased risk of periprosthetic fractures in uncemented hip stems, factors associated with the development of BCIS should be weighed against the risk factors for sustaining periprosthetic fractures (poor bone quality, female sex) to balance the risks of fixation method against those of BCIS for each patient.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083844PMC
April 2021

Quantifying the minimal and substantial clinical benefit of the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff.

JSES Int 2020 Sep 6;4(3):606-611. Epub 2020 Jun 6.

Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.

Background: To aid the interpretation of clinical outcome scores, it is important to determine the measurement properties. The aim of this study was to establish the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score in patients with long-lasting rotator cuff calcific tendinitis treated with high-energy extracorporeal shockwave therapy and ultrasound guided needling. The secondary purpose was to assess the responsiveness of both questionnaires and to identify variables associated with achieving the MCID and SCB.

Methods: A prospective cohort of 80 patients with rotator cuff calcific tendinitis was analyzed. Two anchor-based methods were used to calculate the MCID and SCB. Effect sizes and standardized response means were calculated to assess the responsiveness. Additional univariate logistic regression analyses were performed to identify factors associated with the achievement of the MCID and SCB.

Results: For the Constant-Murley score, we found an MCID and SCB of 9.8 and 19.9, respectively, based on the mean change method and 5.5 and 10.5, respectively, based on receiver operating characteristic analysis. For the Disabilities of the Arm, Shoulder and Hand score, we found an MCID and SCB of -8.2 and -19.6, respectively, with the former and -11.7 and -12.5, respectively, with the latter. The responsiveness of both outcome measures was good, with large effect sizes and standardized response means. The radiographic resorption after 6 weeks and after 6 months appeared to be the most important positive predictor for achieving the MCID and SCB after 6 months.

Conclusion: This study established the MCID, SCB, and responsiveness for patients with long-lasting rotator cuff calcific tendinitis who were treated with minimally invasive treatment options. With this information, physicians can distinguish between a statistically significant difference and a clinically relevant benefit. Successful radiographic resorption after 6 weeks and after 6 months was associated with achieving clinically significant improvement after treatment.
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http://dx.doi.org/10.1016/j.jseint.2020.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479032PMC
September 2020

Treatment type may influence degree of post-dislocation shoulder osteoarthritis: a systematic review and meta-analysis.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 16. Epub 2020 Sep 16.

Department of Orthopedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Purpose: Age at primary dislocation, recurrence, and glenoid bone loss are associated with development of osteoarthritis (OA). However, an overview of OA following traumatic anterior shoulder instability is lacking and it is unclear to what degree type of surgery is associated with development of OA in comparison to non-operative treatment. The aim of this study was to determine the degree of OA at long-term follow-up after non-operative and operative treatments for patients with anterior shoulder instability. Surgery is indicated when patients experience recurrence and this is associated with OA; therefore, it was hypothesized that shoulders show a higher proportion or degree of OA following operative treatment compared to non-operative treatment.

Methods: A literature search was performed in the PubMed/Medline, EMBASE, and Cochrane databases. Articles reporting the degree of OA that was assessed with the Samilson-Prieto or Buscayret OA classification method after non-operative and operative treatment for anterior shoulder instability with a minimum of 5 years follow-up were included.

Results: Thirty-six articles met the eligibility criteria of which 1 reported the degree of OA for non-operative treatment and 35 reported the degree of OA for 9 different operative procedures. A total of 1832 patients (1854 shoulders) were included. OA proportions of non-operative and operative treatments are similar at any point of follow-up. The Latarjet procedure showed a lower degree of OA compared to non-operative treatment and the other operative procedures, except for the Bristow procedure and Rockwood capsular shift. The meta-analyses showed comparable development of OA over time among the treatment options. An increase in OA proportion was observed when comparing the injured to the contralateral shoulder. However, a difference between the operative subgroups was observed in neither analysis.

Conclusion: Non-operative and operative treatments show similar OA proportions at any point of follow-up. The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data. Operative treatment according to the Latarjet procedure results in a lower degree of OA compared to other treatments, including non-operative treatment.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-06263-3DOI Listing
September 2020

Correction to: Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 4. Epub 2020 Sep 4.

Amsterdam UMC, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, The Netherlands.

The original article can be found online.
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http://dx.doi.org/10.1007/s00167-020-06248-2DOI Listing
September 2020

High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis.

Knee Surg Sports Traumatol Arthrosc 2021 May 25;29(5):1494-1501. Epub 2020 Jul 25.

Department of Orthopedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands.

Purpose: The primary objective of this study was to determine the degree of patient satisfaction at a minimum of 5 years of follow-up after endoscopic calcaneoplasty. The secondary objectives were to assess functional outcome measures, pain scores, analysis of bone removal, reformation of exostosis at follow-up and correlation of the size of the exostosis and recurrent or persisting complaints.

Methods: This study evaluated patients who underwent endoscopic calcaneoplasty, between January 1st 2000 and December 31st 2010, for the diagnosis of retrocalcaneal bursitis. The evaluation consisted of PROMs (patient-reported outcome measures), a questionnaire and a visit to the outpatient clinic for physical examination and a standard lateral weight-bearing radiograph of the ankle. Patient satisfaction, functional outcomes and pain scores were measured by use of a numeric rating scale (NRS). Size of the posterosuperior calcaneal exostosis was measured on a standard lateral weight-bearing radiograph using parallel pitch lines (PPL) and the Fowler-Philip angle (PFA).

Results: The response rate was 28 out of 55 (51%) and the median time to follow-up was 101(IQR 88.5-131.8) months. The median satisfaction score for treatment results was 8.5 out of 10 (IQR 6-10). FAOS symptoms 84.5 (IQR 58.0-96.4), FAOS pain 90.3 (IQR 45.1-100.0), FAOS ADL 94.9 (IQR 58.1-100.0), FAOS sport 90.0 (IQR 36.3-100.0) and FAOS QOL 71.9 (IQR 37.5-93.8) and median AOFAS was 100 (IQR 89-100). The median PLL difference between before operation and 2 weeks after the operation was - 4 mm (IQR-6 and -1) and the median PLL difference between 2 weeks after the operation and at follow-up was 1 mm (0-2). The median PFA was 65 (63-69) at baseline, 66.5 (60.8-70.3) 2 weeks after the operation and 64 (60.8-65.3) at follow-up.

Conclusion: Despite the limited response rate, this study shows high patient satisfaction and good long-term functional outcome in patients affected by retrocalcaneal bursitis who underwent endoscopic calcaneoplasty.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s00167-020-06167-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8038992PMC
May 2021

No clinical difference between TiN-coated versus uncoated cementless CoCrMo mobile-bearing total knee arthroplasty; 10-year follow-up of a randomized controlled trial.

Knee Surg Sports Traumatol Arthrosc 2021 Mar 4;29(3):750-756. Epub 2020 May 4.

Department of Orthopaedic Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.

Purpose: Improvement of biomechanical properties of cobalt-chromium-molybdenum (CoCrMo) implant surface and reduction of adhesive wear is achieved by titanium-nitride (TiN) coating in vitro. Less pain, higher postoperative outcome scores and a lower revision rate after TKA with a TiN-coated CoCrMo TKA compared with uncoated CoCrMo TKA after 10-year follow-up was hypothesized.

Methods: In a double-blinded RCT, 101 patients received a cementless mobile-bearing CoCrMo TKA, either TiN-coated or uncoated. The primary outcome measure was the visual analogue scale (VAS) score for pain and secondary outcome measures were the Knee Society Score (KSS), Oxford Knee Score (OKS), revision rate and adverse events. Patients were assessed at 6 weeks, 6 months, 1 year, 5 years and 10 years, postoperatively.

Results: 68 patients (67%) were available for 10-year follow-up. No difference was found in any of the assessed outcome measures with a mean decrease in VAS score (31.6 ± 22.9) and a mean increase in OKS (10.9 ± 8.4), KSS (29.3 ± 31.4), KSSK (26.4 ± 18.2) and KSSF (4.1 ± 22.9). Overall revision rate was 7% (coated 6% vs uncoated 8%) without additional revision procedures between 5 and 10-year follow-up.

Conclusions: The in vitro potential benefits of TiN coating did not result in better clinical outcome when compared to an uncoated cementless TKA. Pain, functional outcome and revision rates were comparable after 10-year follow-up. TiN-coated cementless TKA provides comparable good long-term results, similar to uncoated cementless CoCrMo TKA.

Level Of Evidence: Level 1, Therapeutic Study NETHERLANDS TRIAL REGISTER: NL2887/NTR3033.
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http://dx.doi.org/10.1007/s00167-020-05997-4DOI Listing
March 2021

A Comprehensive Evaluation of Lateral Unicompartmental Knee Arthroplasty Short to Mid-Term Survivorship, and the Effect of Patient and Implant Characteristics: An Analysis of Data From the Dutch Arthroplasty Register.

J Arthroplasty 2020 07 18;35(7):1813-1818. Epub 2020 Feb 18.

Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.

Background: The rarity of lateral unicompartmental knee arthroplasty (UKA) results in a lack of large cohort studies and understanding. The aim of this study is to comprehensively evaluate survivorship of lateral UKA with registry data and compare this to medial UKA.

Methods: Lateral (n = 537) and medial UKAs (n = 19,295) in 2007-2017 were selected from the Dutch Arthroplasty Register. Survival analyses were performed with revision for any reason as primary endpoint. Adjustments were made for patient and implant characteristics. Stratified analyses according to patient and implant characteristics were performed. Reasons and type of revision were grouped according to laterality and bearing design.

Results: The 5-year revision rate was 12.9% for lateral UKA and 9.3% for medial UKA. Multivariable regression analyses showed no significant increased risk for revision for lateral UKA (hazard ratio 0.87, 95% confidence interval 0.66-1.15). Stratified analyses showed that the effect of patient characteristics on revision was comparable between lateral and medial UKA; however, the use of mobile-bearing design for lateral UKA was associated with increased revision rate. Progression of osteoarthritis was the main reason for revision on both sides accompanied by tibia component loosening for medial UKA. Reasons and type of revision varied depending on bearing design.

Conclusion: Similar survivorship of lateral and medial UKA was reported. Specifically, there is a notable risk for revision when using mobile-bearing designs for lateral UKA. Failure modes and type of revision depends on laterality and bearing design. These findings emphasize that surgical challenges related to anatomy and kinematics of the lateral and medial knee compartment need to be considered.
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http://dx.doi.org/10.1016/j.arth.2020.02.027DOI Listing
July 2020

Implant survival in uncemented total hip arthroplasty for displaced intracapsular femoral neck fractures: outcomes of 115 patients in a single center.

Eur J Orthop Surg Traumatol 2020 Jul 7;30(5):885-893. Epub 2020 Mar 7.

Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands.

Introduction: There remains disagreement about the use of cemented or uncemented total hip arthroplasty (THA) for patients with a displaced intracapsular femoral neck fracture (FNF). The aim of this study was to assess implant survival, mortality, and postoperative complication rates of uncemented THA for a displaced intracapsular FNF in a single center.

Patients And Methods: A cohort of 115 patients who received uncemented THAs for a displaced intracapsular FNF was retrospectively examined for implant survival in terms of revision and any reoperation, mortality, and postoperative complications.

Results: The one- and five-year implant survival was 99.1% (95% confidence interval (CI) 97.3-100.9) and 97.8% (95% CI 94.7-100.9) for revision and 93.6% (95% CI 88.9-98.3) and 90.0% (95% CI 83.3-96.7) for any reoperation, respectively. Impaired mobility was significantly associated with lower implant survival (p = 0.01). The one, three, and 12 month mortality rates were 2.8% (95% CI 0-5.9), 3.7% (95% CI 0.2-7.2), and 5.6% (95% CI 1.3-9.9), respectively. Postoperative complication rate was 10% with 5% intra-operative fractures.

Conclusions: Contrary to earlier reports of results of uncemented THA for displaced FNF, the results of this study were comparable with those reported in the literature for cemented THA in displaced FNF with respect to implant survival, mortality, and complication rates. This indicates that uncemented THA could be a viable option for these patients. In future, the additional literature with a prospective design is needed to support and reinforce our conclusion.
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http://dx.doi.org/10.1007/s00590-020-02652-zDOI Listing
July 2020

Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial.

Arthroscopy 2020 07 28;36(7):1823-1833.e1. Epub 2020 Feb 28.

Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.

Purpose: To compare clinical and radiographic outcomes after treatment with standardized high-energy extracorporeal shock wave therapy (ESWT) and ultrasound-guided needling (UGN) in patients with symptomatic calcific tendinitis of the rotator cuff who were nonresponsive to conservative treatment.

Methods: The study was designed as a randomized controlled trial. The ESWT group received ESWT (2000 pulses, energy flux density 0.35 mJ/mm) in 4 sessions with 1-week intervals. UGN was combined with a corticosteroid ultrasound-guided subacromial bursa injection. Shoulder function was assessed at standardized follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant Murley Score (CMS), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and visual analog scale for pain and satisfaction. The size, location, and morphology of the deposits were evaluated on radiographs. The a priori sample size calculation computed that 44 participants randomized in each treatment group was required to achieve a power of 80%.

Results: Eighty-two patients were treated (56 female, 65%; mean age 52.1 ± 9 years) with a mean baseline CMS of 66.8 ± 12 and mean calcification size of 15.1 ± 4.7 mm. One patient was lost to follow-up. At 1-year follow-up, the UGN group showed similar results as the ESWT group with regard to the change from baseline CMS (20.9 vs 15.7; P = .23), Disabilities of the Arm, Shoulder, and Hand questionnaire (-20.1 vs -20.7; P = .78), and visual analog scale for pain (-3.9 and -2.6; P = .12). The mean calcification size decreased by 13 ± 3.9 mm in the UGN group and 6.7 ± 8.2 mm in the ESWT group (
Conclusions: This RCT compares the clinical and radiographic results of UGN and high-energy ESWT in the treatment of calcific tendinitis of the rotator cuff. Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. However, UGN is more effective in eliminating the calcific deposit, and the amount of additional treatments was greater in the ESWT group.

Level Of Evidence: II, randomized controlled trial.
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http://dx.doi.org/10.1016/j.arthro.2020.02.027DOI Listing
July 2020

The migration pattern and initial stability of the Optimys short stem in total hip arthroplasty: a prospective 2-year follow-up study of 33 patients with RSA.

Hip Int 2020 Jan 23:1120700020901844. Epub 2020 Jan 23.

Specialized Centre of Othopedic Research & Education (SCORE) and Xpert Orthopedie, Amsterdam, Netherlands.

Background And Purpose: The consensus that bone stock preservation and optimal restoration of offset and leg length is important in total hip arthroplasty is now widespread, especially for young and active patients. Short stems seem promising in this aspect, though implant stability is still of concern. This study looked at the migration pattern of the Optimys short stem through RSA analysis.

Patients And Methods: 40 patients were included. RSA images were made directly postoperatively (within 5 days), at 6 weeks and at 3, 6, 12 and 24 months. Double examinations were made for precision measurement. HOOS and pain scores were obtained preoperatively and at 2 years. 4 patients were excluded due to protocol violation and 1 patient was excluded for RSA analysis with a CN number >110. 2 patients were lost to follow-up after 3 and 6 months (  1 lost,   1 deep infection, respectively).

Results: Mean age was 60 years with a mean BMI of 27. RSA analysis of 34 patients showed a significant initial median proximodistal translation (subsidence) of 0.21 mm (IQR 0.64-0.06) and anteversion-retroversion rotation of 0.59° (IQR 0.01-1.34) at 6 weeks, after which the stem stabilises and showed no further significant movement. Median migration in other directions was small. 4 patients had an initial subsidence of >2 mm, all showed secondary stabilisation. HOOS outcomes were satisfactory, with the domain symptoms and pain showing a median score of 95/100 at 2 years.

Conclusions: After initial migration the Optimys achieves secondary stabilisation, suggesting low risk on long-term aseptic loosening.

Clinical Trials Registration: NL47055.048.13.
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http://dx.doi.org/10.1177/1120700020901844DOI Listing
January 2020

Overstuffing in resurfacing hemiarthroplasty is a potential risk for failure.

J Orthop Surg Res 2019 Dec 30;14(1):474. Epub 2019 Dec 30.

Spaarne Hospital, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands.

Purpose: Literature describes the concern of an overstuffed shoulder joint after a resurfacing humeral head implant (RHHI). The purpose of this study was to evaluate inter-observer variability of (1) the critical shoulder angle (CSA), (2) the length of the gleno-humeral offset (LGHO), and (3) the anatomic center of rotation (COR) in a patient population operated with a Global Conservative Anatomic Prosthesis (CAP) RHHI. The measurements were compared between the revision and non-revision groups to find predictive indicators for failure.

Methods: Pre- and postoperative radiographs were retrieved from 48 patients who underwent RHHI from 2007 to 2009 using a Global CAP hemiarthroplasty for end-stage osteoarthritis. This cohort consisted of 36 females (12 men) with a mean age of 77 years (SD 7.5). Two musculoskeletal radiologist and two specialized shoulder orthopedic surgeons measured the CSA, LGHO, and COR of all patients.

Results: The inter-observer reliability showed excellent reliability for the CSA, LGHO, and the COR, varying between 0.91 and 0.98. The mean COR of the non-revision group was 4.9 mm (SD 2.5) compared to mean COR of the revision group, 8 mm (SD 2.2) (p < 0.01). The COR is the predictor of failure (OR 1.90 (95%Cl 1.19-3.02)) with a cut of point of 5.8 mm. The mean CSA was 29.8° (SD 3.9) There was no significant difference between the revision and non-revision groups (p = 0.34). The mean LGHO was 2.6 mm (SD 3.3) post-surgery. The mean LGHO of the revision group was 3.9 (SD 1.7) (p = 0.04) post-surgery. Despite the difference in mean LGHO, this is not a predictor for failure.

Conclusion: The CSA, LGHO, and COR can be used on radiographs and have a high inter-observer agreement. In contrast with the CSA and LGHO, we found a correlation between clinical failure and revision surgery in case of a deviation of the COR greater than 5 mm.

Trial Registration: Institutional review board, number: ACLU 2016.0054, Ethical Committee number: CBP M1330348. Registered 7 November 2006.
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http://dx.doi.org/10.1186/s13018-019-1522-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936124PMC
December 2019

Influence of Preoperative Tibiotalar Alignment in the Coronal Plane on the Survival of Total Ankle Replacement: A Systematic Review.

Foot Ankle Int 2020 02 8;41(2):160-169. Epub 2019 Nov 8.

Specialized Center of Orthopaedic Research & Education (SCORE), Department of Orthopaedic Surgery, Xpert Orthopedie, Amsterdam, the Netherlands.

Background: It remains controversial whether significant preoperative tibiotalar varus and valgus deformity should be contraindications for total ankle replacement (TAR). The primary aim of this systematic review was to analyze the influence of preoperative tibiotalar varus and valgus alignment on the survival of TAR.

Methods: The databases MEDLINE and Embase were searched from onset through September 2018. Two authors performed study selection and data extraction using a predefined data extraction tool. Implant survival in the alignment groups was reported as "revisions per 100 component years." Additional procedures, complications, and revisions were also reported. Assessment of the methodological quality was performed using the Newcastle-Ottawa Scale (NOS).

Results: In total, 17 studies were considered eligible, in which a total of 1692 TARs were included from 1627 patients. The weighted mean follow-up was 52.4 (range, 1-147) months. The neutral alignment group included 711 TARs, the varus group included 545 TARs, and the valgus group included 332 TARs. Total revisions were 52, 37, and 36 in the preoperative tibiotalar neutral, varus, and valgus alignment groups, respectively. Revisions per 100 observed component years were 1.6, 1.7, and 2.5 in the preoperative tibiotalar neutral, varus, and valgus alignment groups, respectively. A total of 129 complications and 447 additional procedures were reported in 601 TARs.

Conclusion: There was a strong indication that preoperative varus alignment in the coronal plane had a comparable implant survival to neutral alignment. Preoperative valgus alignment demonstrated a more negative influence on implant survival.

Level Of Evidence: Level III, systematic review.
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http://dx.doi.org/10.1177/1071100719886817DOI Listing
February 2020

There is no difference in postoperative pain, function and complications in patients with chondrocalcinosis in the outcome of total knee arthroplasty for end-stage osteoarthritis.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 24;28(9):2970-2979. Epub 2019 Sep 24.

Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, The Netherlands.

Purpose: Chondrocalcinosis is the radiographic appearance of calcium crystals in cartilage and other soft tissue. It is suggested that preoperative chondrocalcinosis predicts a worse outcome after total knee arthroplasty and it is unclear if chondrocalcinosis leads to more postoperative complications. This study aimed to compare function, pain, postoperative complications, postoperative signs of acute arthritis and revision rates between patients with and without chondrocalcinosis undergoing total knee arthroplasty for osteoarthritis.

Methods: In this retrospective cohort study performed in 2017, 408 knees in 392 patients (16 bilateral total knee arthroplasties) were included. None of the patients received additional synovectomy. PROMs were evaluated after 1 year (n = 294) and 5 years (n = 308). The follow-up for clinical data was 5 years (n = 408). The range of final follow-up was 57-84 months. All preoperative radiographs were scored for chondrocalcinosis and Oxford Knee Score, Knee Society Score and Algofunctional Index were used to assess outcome. All clinical records were screened for postoperative complications (excessive wound discharge, infection, loosening, PAO, stiffness), arthritis after surgery and reoperation or revision for any reason.

Results: Sixty-three knees (15.4%) showed signs of chondrocalcinosis. Male gender, higher age and lower BMI were risk factors for chondrocalcinosis. No difference was found in Oxford Knee Score, Knee Society Score and Algofunctional Index, nor in postoperative complications, postoperative signs of acute arthritis and revision rate.

Conclusion: Patients with and without chondrocalcinosis have the same outcome after total knee arthroplasty related to pain, functionality, complications, arthritis and revision after surgery for end-stage osteoarthritis. Chondrocalcinosis is not a contraindication for total knee arthroplasty and additional synovectomy is unnecessary.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-019-05725-7DOI Listing
September 2020

Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature.

Knee Surg Sports Traumatol Arthrosc 2020 Jun 5;28(6):1946-1957. Epub 2019 Sep 5.

Amsterdam UMC, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, The Netherlands.

Purpose: To assess the outcomes of the various techniques of primary repair of proximal anterior cruciate ligament (ACL) tears in the recent literature using a systematic review with meta-analysis.

Methods: PRISMA guidelines were followed. All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears using primary repair, repair with static (suture) augmentation and dynamic augmentation between January 2014 and July 2019 in PubMed, Embase and Cochrane were identified and included. Primary outcomes were failure rates and reoperation rates, and secondary outcomes were patient-reported outcome scores.

Results: A total of 13 studies and 1,101 patients (mean age 31 years, mean follow-up 2.1 years, 60% male) were included. Nearly all studies were retrospective studies without a control group and only one randomized study was identified. Grade of recommendation for primary repair was weak. There were 9 out of 74 failures following primary repair (10%), 6 out of 69 following repair with static augmentation (7%) and 106 out of 958 following dynamic augmentation (11%). Repair with dynamic augmentation had more reoperations (99; 10%), and more hardware removal (255; 29%) compared to the other procedures. All functional outcome scores were > 85% of maximum scores.

Conclusions: This systematic review with meta-analysis found that the different techniques of primary repair are safe with failure rates of 7-11%, no complications and functional outcome scores of > 85% of maximum scores. There was a high risk of bias and follow-up was short with 2.1 years. Prospective studies comparing the outcomes to ACL reconstruction with sufficient follow-up are needed prior to widespread implementation.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-019-05697-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253375PMC
June 2020

Incidence, Predictors, and Fracture Mapping of (Occult) Posterior Malleolar Fractures Associated With Tibial Shaft Fractures.

J Orthop Trauma 2019 Dec;33(12):e452-e458

Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia.

Objectives: To (1) evaluate the incidence of posterior malleolar fractures (PMFs) in patients with tibial shaft fractures (TSFs) using advanced imaging; (2) identify predictors for patients at risk of an (occult) PMF; and (3) describe PMF characteristics to guide "malleolus-first" fixation.

Design: Retrospective diagnostic imaging study.

Setting: Level-I trauma center.

Patients: One hundred sixty-four patients treated with intramedullary nailing for TSFs who underwent low-dose postoperative computed tomography (CT) scans to assess (mal)rotational alignment.

Intervention: Analysis of advanced imaging for the presence of PMFs. Univariate and multivariate analyses to identify predictors. Qualitative analysis of PMFs by fracture mapping.

Main Outcome Measures: (1) Incidence of PMFs in patients with TSFs as diagnosed on post-op CT scans; (2) independent predictors for the presence of PMFs; and (3) PMF patterns.

Results: One in five patients with a TSF has an associated PMF (22%), increasing to one-in-two in patients with simple spiral fractures (56%). In 25% of patients, these fractures were occult. Univariate analysis identified simple spiral and distal third TSFs, proximal third and spiral fibula fractures, and low-energy trauma as predictors for PMFs. Multivariate analysis demonstrated that distal third and simple spiral TSFs were the only independent predictors. Haraguchi type I is the pattern specific to PMFs associated with TSF.

Conclusions: Half of patients presenting with a simple spiral TSF have an associated PMF. In one in four patients, these are occult. Additional preoperative CT scan imaging may be considered in patients presenting with simple spiral distal third TSFs, despite negative lateral radiographs, so that PMFs can be identified and managed with "malleolus-first" fixation.

Level Of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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December 2019

Quantification of Postoperative Posterior Malleolar Fragment Reduction Using 3-Dimensional Computed Tomography (Q3DCT) Determines Outcome in a Prospective Pilot Study of Patients With Rotational Type Ankle Fractures.

J Orthop Trauma 2019 Aug;33(8):404-410

Department of Orthopadic Surgery, Royal Adelaide Hospital, Adelaide, Australia.

Objective: To correlate Q3DCT measurements of residual step-off, gap, and 3D multidirectional displacement of postoperative posterior malleolar fracture fragment reduction in patients with rotational type ankle fractures, with patients' clinical outcome using standardized patient- and physician-based outcome measures.

Design: Prospective cohort study.

Setting: Level-I Trauma Center.

Patients: Thirty-one patients with ankle fractures including a posterior malleolar fracture (OTA/AO type 44) were included.

Intervention: All patients underwent open reduction internal fixation of their ankle fracture, of which 18 patients (58%) had direct fixation of the posterior malleolar fragment. Decision of (direct) fixation of the posterior malleolar fragment was not standardized and guided by surgeons' preference.

Main Outcome Measurements: Quality of postoperative reduction was quantified using Q3DCT: posterior fragment size (% of joint surface), residual step-off (mm), postoperative gaps (mm), and overall multidirectional displacement were quantified. Foot and Ankle Outcome Score pain and symptoms subscales and quality of life (Short Form-36) at 1 year postoperatively were included as the main outcome measures.

Results: Step-off (mean 0.6 mm, range 0.0-2.7, SD 0.8) showed a significant correlation with worse Foot and Ankle Outcome Score pain and symptoms subscales. Residual fracture gap (mean 12.6 mm, range 0.0-68.8, SD 19.5) and 3D multidirectional displacement (mean 0.96 mm, range 0.0-2.8, SD 0.8) showed no correlation.

Conclusions: In patients with rotational type ankle fractures involving a posterior malleolar fracture, contemporary Q3DCT measurements of posterior fragment size and residual intra-articular step-off-but not gap-show significant correlation with patient-reported pain and symptoms.

Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001486DOI Listing
August 2019