Visible fluid motion on manipulation as the new threshold for intraoperatively determined knee arthroplasty component loosening: A Delphi study.

PURPOSE: There is a lack of a clear, uniform definition for intraoperatively assessed component loosening of a knee arthroplasty component, complicating the interpretation and interchangeability of results of diagnostic studies using an intraoperative observation as the reference test. The purpose of this study was to establish a consensus among specialised knee revision surgeons regarding the definition of intraoperatively determined loosening of total or unicondylar knee arthroplasty components. METHODS: Utilising the Delphi consensus method, an international panel of highly specialised knee revision surgeons was invited to participate in a three-round process. The initiation of the first round involved the exploration of possible criteria for intraoperatively determined loosening with open questions. The second round focused on rating these criteria importance on a five-point Likert scale. For the third round, criteria that reached consensus were summarised in consecutive definitions for intraoperatively determined loosening and proposed to the panel. Consensus was established when over 70% of participants agreed with a definition for intraoperatively determined loosening. RESULTS: The 34 responding panel members described in total 60 different criteria in the first round of which 34 criteria received consensus in the second round. Summarising these criteria resulted in four different definitions as minimal requirements for intraoperatively determined loosening. Eighty-eight percent of the panel members agreed on defining a component as loose if there is visible fluid motion at the interface observed during specific movements or when gently applying direct force. CONCLUSION: This study successfully established a consensus using a Delphi method among knee revision surgeons on the definition of intraoperatively determined component loosening. By agreeing on the visibility of fluid motion as new definition, this study provides a standardised reference for future diagnostic research. This definition will enhance the interpretability and interchangeability of future diagnostic studies evaluating knee arthroplasty component loosening. LEVEL OF EVIDENCE: Level V.

MRI and SPECT/CT demonstrate, with low certainty of evidence, the highest diagnostic accuracy for aseptic knee arthroplasty loosening: A systematic comparative diagnostic test review and meta-analysis.

PURPOSE: The purpose of this study was to evaluate and compare the diagnostic accuracy of modalities used to aid the diagnosis of aseptic knee arthroplasty loosening. METHODS: A comparative diagnostic test accuracy systematic review and meta-analysis was conducted following the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE and Cochrane databases were searched for original articles evaluating diagnostic modalities up to March 2024. Included studies compared the modality (index test) to the intraoperative finding as reference test. The QUADAS-C (Quality Assessment of Diagnostic Accuracy Studies-Comparative) tool was used to assess the quality of the included studies. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to evaluate the certainty of evidence. Level of evidence was evaluated using the Oxford Levels of Evidence tool. The primary outcome was the summary of diagnostic accuracy metrics for each modality as demonstrated by a summary receiver-operating characteristic (SROC) curve. RESULTS: The search yielded 467 articles. Of these, 14 articles were included. These 14 articles evaluated a total of five different diagnostic modalities: bone scintigraphy (three studies, 146 cases), 18-fluorodeoxyglucose positron emission tomography (two studies, 50 cases), single-photon emission computed tomography combined with computed tomography (SPECT/CT) (seven studies, 371 cases), radionuclide arthrogram (three studies, 196 cases) and magnetic resonance imaging (MRI) (one study, 116 cases). Nine studies exhibited a high risk of bias in patient selection, and all studies showed a high risk of bias related to the reference test. The majority of the included studies were classified as Level III evidence, leading to an overall low level of certainty in the evidence. The most accurate tests, as demonstrated by the SROC analysis, were MRI and SPECT/CT, with sensitivities ranging from 0.00 to 1.00 and 0.33 to 1.00 and specificities between 0.31-1.00 and 0.00-1.00, respectively. CONCLUSIONS: This review and meta-analysis evaluated available diagnostic modalities to aid the diagnosis of knee arthroplasty loosening and based on a low certainty of evidence suggests that MRI and SPECT/CT are currently the most accurate modalities available to aid the diagnosis of aseptic loosening of knee arthroplasty components. LEVEL OF EVIDENCE: Level III.

Non-invasive quantitative assessment of induced component displacement can safely and accurately diagnose tibial component loosening in patients: A prospective diagnostic study.

PURPOSE: Aseptic loosening often requires major, expensive and invasive revision surgery. Current diagnostic modalities merely show indirect signs of loosening. A recent proof of concept study proposed a non-invasive technique for the quantitative and visual assessment of implant movement as a diagnostic aid for tibial component loosening. The primary research question addressed is whether this novel diagnostic modality can safely and effectively aid the diagnosis of aseptic loosening. METHODS: This clinical study included patients suspected of aseptic total knee arthroplasty (TKA) loosening listed for revision surgery and asymptomatic patients. Safety was evaluated using a numerical rating scale (NRS) for discomfort and by registration of adverse events. Feasibility was assessed by recording the duration and ease of the procedure. Intra- and interrater reliability were evaluated. In symptomatic patients, diagnostic accuracy metrics were evaluated with intra-operative assessment as a reference test. RESULTS: In total, 34 symptomatic and 38 asymptomatic knees with a TKA were analysed. The median NRS for discomfort during loading was 6 (interquartile range [IQR]: 3.75-7.00) in symptomatic patients and 2 (IQR: 1.00-3.00) in asymptomatic patients. No adverse events were reported. The majority of users found the use of the loading device easy. The median time spent in the computed tomography room was 9 min (IQR: 8.00-11.00). Excellent to good intra- and interrater reliabilities were achieved. Diagnostic accuracy analysis resulted in a sensitivity of 0.91 (95% confidence interval [CI]: 0.72-0.97) and a specificity of 0.72 (95% CI: 0.43-0.90). CONCLUSIONS: The proposed diagnostic method is safe, feasible, reliable and accurate in aiding the diagnosis of aseptic tibial component loosening. LEVEL OF EVIDENCE: Level II.

Only Low Patients' Expectations Are Prognostic for Dissatisfaction With Performing Work-Related Knee-Straining Activities After Total Knee Arthroplasty: A Prospective Multicenter Cohort Study.

OBJECTIVE: To investigate whether preoperative expectations regarding performing work-related knee-straining activities were associated with being dissatisfied 6 months after total knee arthroplasty (TKA) among working patients, and, to identify prognostic factors for being dissatisfied with performing these work-related knee-straining activities. DESIGN: Multicenter prospective cohort study. SETTING: Orthopedic surgery departments of 7 hospitals in the Netherlands. PARTICIPANTS: A consecutive sample of 175 working patients who were on the waiting list for TKA (median age 59 years, 53% women) and intended to return to work (N=175). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Dissatisfaction with performing work-related knee-straining activities 6 months postoperative was measured using the Work Osteoarthritis or joint-Replacement Questionnaire (score range 0-100). The clinically relevant cut-off points for being satisfied and dissatisfied were ≥71 and ≤50, respectively. RESULTS: Thirty-three patients (19%) were dissatisfied with performing work-related knee-straining activities 6 months after TKA. Patients who expected to be dissatisfied preoperative had a 5.1 times higher odds (95% CI 1.7-15.5) of being dissatisfied 6 months postoperatively compared with patients who expected to be satisfied preoperative. Regression analyses revealed that only patients' expectations were prognostic for being dissatisfied 6 months postoperatively rather than age, pain level, or having a knee-straining job. CONCLUSIONS: Two in 10 working patients are dissatisfied with performing work-related knee-straining activities 6 months after TKA. Only preoperative patients' expectations appeared prognostic. Therefore, we should better prepare working patients with low expectations by managing their preoperative expectations and improving their performance of work-related knee-straining activities in rehabilitation.

Physical activity after revision knee arthroplasty including return to sport and work: a systematic review and meta-analysis including GRADE.

BACKGROUND: The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work. METHODS: A search was conducted in the databases Medline and Embase until February 24th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). RESULTS: Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234). CONCLUSIONS: The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low. LEVEL OF EVIDENCE: Level 3.

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

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.

Geometrical characteristics of the symptomatic and non-symptomatic ossa trigona.

BACKGROUND: Posterior ankle impingement is strongly associated with the presence of an os trigonum, however, most patients with an os trigonum will never develop symptoms. It is hypothesized that the os trigonum is larger in the symptomatic ankle than in the non-symptomatic ankle, the distance between os trigonum and tibia is smaller and there are more degenerative changes in ankles with symptoms of posterior impingement. In this study the geometrical characteristics of the ipsilateral and contralateral os trigonum are compared in patients with a bilateral os trigonum and unilateral posterior impingement symptoms. METHODS: Patients with a bilateral os trigonum and unilateral posterior impingement complaints were included. Comparison between the symptomatic and asymptomatic ankles was done within each patient. From the CT-scan of each ankle, the tibia, fibula, calcaneus, talus and os trigonum were segmented and a geometric model was created. Based on these bone models, the volume of the os trigonum and talus, the size of the os trigonum, the distance between os trigonum and surrounding bones (talus, calcaneus, fibula and tibia) were calculated. In addition, the CT images were assessed for the type of os trigonum, the presence of cysts, irregular synchondrosis, calcifications and whether the os trigonum consisted of more than one fragment. RESULTS: A total of 22 patients were included in this study. In seventeen of the 22 patients, the symptomatic os trigonum was larger in comparison with the non-symptomatic side in terms of length (median Δ 2.4 mm, 8.9 versus 10.6 mm) and relative volume (median Δ 0.09%, 0.30 versus 0.45% of talar volume). Distances between the ossa trigona and surrounding bones were not statistically significantly different between both sides. Calcifications were more frequently found around the os trigonum in the symptomatic side (10 versus 3/22). CONCLUSIONS: The findings in this study support the hypothesis that symptomatic ossa trigona are larger in comparison with asymptomatic ossa trigona. Calcifications around the os trigonum were found more frequently in symptomatic than in non-symptomatic ossa trigona. LEVEL OF EVIDENCE: III.

Accuracy of Currently Available Methods in Quantifying Anterior Glenoid Bone Loss: Controversy Regarding Gold Standard-A Systematic Review.

PURPOSE: To determine the accuracy of glenoid bone loss-measuring methods and assess the influence of the imaging modality on the accuracy of the measurement methods. METHODS: A literature search was performed in the PubMed (MEDLINE), Embase, and Cochrane databases from 1994 to June 11, 2019. The guidelines and algorithm of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used. Included for analysis were articles reporting the accuracy of glenoid bone loss-measuring methods in patients with anterior shoulder instability by comparing an index test and a reference test. Furthermore, articles were included if anterior glenoid bone loss was quantified using a ruler during arthroscopy or by measurements on plain radiograph(s), computed tomography (CT) images, or magnetic resonance images in living humans. The risk of bias was determined using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: Twenty-one studies were included, showing 17 different methods. Three studies reported on the accuracy of methods performed on 3-dimensional CT. Two studies determined the accuracy of glenoid bone loss-measuring methods performed on radiography by comparing them with methods performed on 3-dimensional CT. Six studies determined the accuracy of methods performed using imaging modalities with an arthroscopic method as the reference. Eight studies reported on the influence of the imaging modality on the accuracy of the methods. There was no consensus regarding the gold standard. Because of the heterogeneity of the data, a quantitative analysis was not feasible. CONCLUSIONS: Consensus regarding the gold standard in measuring glenoid bone loss is lacking. The use of heterogeneous data and varying methods contributes to differences in the gold standard, and accuracy therefore cannot be determined. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Goal Setting and Achievement in Individualized Rehabilitation of Younger Total and Unicondylar Knee Arthroplasty Patients: A Cohort Study.

OBJECTIVE: To investigate activity goals, intensity and achievement of these activity goals in younger knee arthroplasty (KA) patients, and to identify the differences between total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA) patients. DESIGN: Prospective cohort study. SETTING: Department of orthopedic surgery and physical therapy practices. PARTICIPANTS: Patients (N=48) aged 65 years or younger who underwent KA. INTERVENTION: Rehabilitation with goal attainment scaling (GAS). MAIN OUTCOME MEASURES: GAS goals for daily life activity, work and leisure time, corresponding metabolic equivalent of task (MET) values, corrected MET values, and GAS scores at 3 and 6 months. RESULTS: The intensity levels of all 144 formulated activity goals were light in 16% of cases, moderate in 63%, and vigorous in 21%. Intensity levels did not differ between TKA and UKA patients. Following rehabilitation using GAS, 54% of daily life activity goals, 65% of work activity goals, and 46% of leisure time activity goals were attained after 3 months. After 6 months, 91% of daily life activity goals, 93% of work activity goals, and 89% of leisure time activity goals were attained. Goal attainment did not differ between MET intensity levels. Higher goal attainment was achieved in the UKA group (100%) compared with the TKA patients (82%) after 6 months (P<.001). CONCLUSIONS: Younger patients aim to perform many different activities of varying metabolic intensity levels following KA. After 6 months of rehabilitation using GAS, in these patients attain 91% of their preoperatively formulated activity goals, independent of the MET intensity level. After 6 months, UKA patients attain significantly more activity goals than TKA patients. GAS might be a useful objective outcome measure in evaluating clinical outcomes of individual KA patients.

Three Out of Ten Working Patients Expect No Clinical Improvement of Their Ability to Perform Work-Related Knee-Demanding Activities After Total Knee Arthroplasty: A Multicenter Study.

Purpose Three out of ten patients do not return to work after total knee arthroplasty (TKA). Patient expectations are suggested to play a key role. What are patients' expectations regarding the ability to perform work-related knee-demanding activities 6 months after TKA compared to their preoperative status? Methods A multi-center cross-sectional study was performed among 292 working patients listed for TKA. The Work Osteoarthritis or joint-Replacement Questionnaire (WORQ, range 0-100, minimal important difference 13) was used to assess the preoperatively experienced and expected ability to perform work-related knee-demanding activities 6 months postoperatively. Differences between the preoperative and expected WORQ scores were tested and the most difficult knee-demanding work-related activities were described. Results Two hundred thirty-six working patients (81%) completed the questionnaire. Patients' expected WORQ score (Median = 75, IQR 60-86) was significantly (p < 0.01) higher than their preoperative WORQ score (Median = 44, IQR 35-56). A clinical improvement in ability to perform work-related knee-demanding activities was expected by 72% of the patients, while 28% of the patients expected no clinical improvement or even worse ability to perform work-related knee-demanding activities 6 months after TKA. Of the patients, 34% expected severe difficulty in kneeling, 30% in crouching and 17% in clambering 6 months after TKA. Conclusions Most patients have high expectations, especially regarding activities involving deep knee flexion. Remarkably, three out of ten patients expect no clinical improvement or even a worse ability to perform work-related knee-demanding activities 6 months postoperatively compared to their preoperative status. Therefore, addressing patients expectations seems useful in order to assure realistic expectations regarding work activities.

A risk assessment model for chronic ankle instability: indications for early surgical treatment? An observational prospective cohort - study protocol.

BACKGROUND: Chronic ankle instability (CAI) is a common result of an ankle sprain. Even though early surgical treatment yields the best results, overall only professional athletes are eligible for acute surgical stabilization. Treating all patients with early surgical stabilization leads to a high amount of unnecessary invasive interventions, as not all patients progress to CAI. If patients at risk of developing CAI can be identified, treatment policies may be applied more effectively and efficiently. The purpose of this study is to develop a risk assessment model to identify patients at risk for CAI that should receive early surgical treatment. METHODS: In this observational prospective cohort, all patients aged sixteen years and older, reporting at the emergency department of one of the participating hospitals after sustaining a lateral ankle sprain, and filled out 1 out of 3 follow-up questionnaires and the 1 year follow-up are included. A lateral and anteroposterior radiograph is made. Patients are excluded if a fracture or other pathology is present. The included patients receive four questionnaires, including questions focusing on the sprain, treatment and complaints, the Foot and Ankle Outcome Score and the Cumberland Ankle Instability Tool. A total of eleven radiographic variables are assessed for inter- and intra-observer reliability. Additionally, four factors extracted from the questionnaires, will be evaluated for correlation with CAI. Significantly correlating factors (e.a. risk factors) will be implemented in a risk assessment model. For the final model, based on sixteen variables with a minimum of 20 events per variable and a prevalence of 30-40% after an initial sprain, a sample size of 2370 patients is needed to perform both internal and external model validation. DISCUSSION: This study will develop the first large scale model for the risk at CAI after an ankle sprain combining radiographic and patient characteristics. With this risk assessment model, patients at risk for CAI may be identified and properly informed on the treatment options. Patients identified as being at risk, may receive more adequate follow-up and become eligible for early surgical stabilization. This prevents patients from experiencing unnecessary long-lasting complaints, increasing the success rate of conservative and surgical treatment. TRIAL REGISTRATION: Retrospectively registered: NCT02955485 [Registration date: 3-11-2016]. NTR6139 [Registration date: 3-1-2017].

Expectations of younger patients concerning activities after knee arthroplasty: are we asking the right questions?

PURPOSE: Indications for total and unicondylar knee arthroplasty (KA) have expanded to younger patients, in which Patient-Reported Outcome Measures (PROMs) often show ceiling effects. This might be due to higher expectations. Our aims were to explore expectations of younger patients concerning activities in daily life, work and leisure time after KA and to assess to what extent PROMs meet and evaluate these activities of importance. METHODS: Focus groups were performed among osteoarthritis (OA) patients <65 years awaiting KA, in which they indicated what activities they expected to perform better in daily life, work and leisure time after KA. Additionally, 28 activities of daily life, 17 of work and 27 of leisure time were depicted from seven PROMS, which were rated on importance, frequency and bother. A total score, representing motivation for surgery, was also calculated. RESULTS: Data saturation was reached after six focus groups including 37 patients. Younger OA patients expect to perform better on 16 activities after KA, including high-impact leisure time activities. From the PROMs, daily life and work activities were rated high in both importance and motivation for surgery, but for leisure time activities importance varied highly between patients. All seven PROMs score activities of importance, but no single PROM incorporates all activities rated important. CONCLUSION: Younger patients expect to perform better on many activities of daily life, work and leisure time after KA, and often at demanding levels. To measure outcomes of younger patients, we suggest using PROMs that include work and leisure time activities besides daily life activities, in which preferably scored activities can be individualized.

Which patients do not return to work after total knee arthroplasty?

Total knee arthroplasty (TKA) is increasingly being performed among working patients suffering from knee osteoarthritis. Two out of ten patients do not return to work (RTW) after TKA. Little evidence is available about these patients to guide clinicians. Therefore, this study investigates patients' characteristics associated with no RTW. A multicenter retrospective cohort study was performed among working patients having undergone a primary TKA during 2005-2010. The following preoperative characteristics were assessed: age at surgery, sex, comorbidity, body mass index (BMI), preoperative sick-leave duration, patient-reported work-relatedness of knee symptoms, and physical job demands. In addition, the Knee injury and Osteoarthritis Outcome Scores (KOOS) after TKA were assessed. Backward stepwise logistic regression analyses were performed to predict no RTW. Seven hundred and sixty-four patients were approached, and 558 patients (73 %) responded. One hundred and sixty-seven met the inclusion criteria and 46 did not RTW. A preoperative sick-leave duration >2 weeks (OR 12.5, 90 % CI 5.0-31.5) was most strongly associated with no RTW. Other associations found were: female sex (OR 3.2, 90 % CI 1.3-8.2), BMI ≥ 30 (OR 2.8, 90 % CI 1.1-7.1), patient-reported work-relatedness of knee symptoms (OR 5.3, 90 % CI 2.0-14.1), and a physically knee-demanding job (OR 3.3, 90 % CI 1.2-8.9). Age and KOOS were not associated with no RTW. Especially obese female workers, with a preoperative sick-leave duration >2 weeks, who perform knee-demanding work and indicate that their knee symptoms are work-related have a high chance for no RTW after TKA. These results stress the importance of a more timely referral for work-directed care of patients at risk for no RTW after TKA.

Does Goal Attainment Scaling improve satisfaction regarding performance of activities of younger knee arthroplasty patients? Study protocol of the randomized controlled ACTION trial.

BACKGROUND: Knee arthroplasty is being increasingly performed, and also more often in a younger patient population (<65 years of age). Up to 20 % of patients remain dissatisfied after knee arthroplasty, despite the apparent technical success of the operation. Recent studies suggest that the fulfilment of patients' expectations plays an important role in achieving satisfaction. Thus, addressing preoperative expectations more explicitly might improve patient satisfaction. The primary aim of the present study is to investigate the effect of a multidisciplinary, goal attained and individualized rehabilitation on satisfaction of activities of younger patients (<65 years) after knee arthroplasty. METHODS/DESIGN: A single-centre randomized controlled trial will be conducted. In total, 120 patients (<65 years of age) with knee osteoarthritis who will undergo knee arthroplasty, will be randomly allocated to either goal attainment scaling rehabilitation or usual care rehabilitation. Goal attainment scaling rehabilitation includes drafting individually set rehabilitation goals preoperatively and measuring progress of rehabilitation on a six-point scale (-3 to +2). The primary outcome is patient satisfaction concerning activities in daily life, work and leisure time, including sports. Secondary outcome measures include KOOS, OKS, SQUASH and WORQ questionnaires and activity objectively measured with the Activ8® activity monitor. DISCUSSION: The findings of this study will help to elucidate whether goal attainment scaling is an effective rehabilitation method for achieving higher levels of patient satisfaction, with a focus on activities, in younger patients after knee arthroplasty. TRIAL REGISTRATION: This trial is since June 15(th) 2015 registered at the Dutch Trial Register: NTR5251 .

Identification of the superficial peroneal nerve: Anatomical study with surgical implications.

PURPOSE: To prevent iatrogenic damage to the superficial peroneal nerve during ankle arthroscopy, it needs to be identified. The purpose of the present study was to determine which clinical test identified the superficial peroneal nerve most frequently and which determinants negatively affected the identification. METHODS: A total of 198 ankles (99 volunteers) were examined for identification of the superficial peroneal nerve. Race, gender, body mass index (BMI), shoe size and frequency of physical activity were collected. RESULTS: The best method to identify the superficial peroneal nerve was the maximal combined ankle plantar flexion and inversion test. In this position, the nerve was identified in 57% of the ankles by palpation. BMI was the only independently influential factor in the identification of the superficial peroneal nerve. CONCLUSION: Since in nearly six out of the ten ankles the superficial peroneal nerve can be identified, it is advised to assess its anatomy prior to portal placement. A higher BMI negatively influences the identification of the superficial peroneal nerve. LEVEL OF EVIDENCE: Diagnostic study, Level III.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).

Dynamic in vivo evaluation of radiocarpal contact after a 4-corner arthrodesis.

PURPOSE: To understand the mechanisms that preserve joint integrity after 4-corner arthrodesis (FCA). METHODS: We investigated the long-term changes of the radiolunate articulation after an FCA for different motions of the wrist in a cross-sectional study that included wrists of 10 healthy participants and both operated and nonoperated wrists of 8 individuals who had undergone FCA on 1 side. The average postoperative follow-up period of the FCA group was 5.7 years. The radiolunate articulation was assessed from dynamic 3-dimensional distance maps during wrist motion. Contact surface area, centroid position of the articular area, and distance between radiolunate articular surfaces were measured and compared between healthy subjects and operated and nonoperated wrists of FCA patients. RESULTS: The total radiolunate articulation area was larger in patients with FCA. The average radiolunate joint space thickness was preserved in the operated FCA wrists. The centroid of the articulation area was shifted radially and dorsally in FCA wrists. CONCLUSIONS: Changes of the motion pattern of the lunate during radioulnar deviation and flexion-extension of the wrist after FCA can explain the shift of the centroid radially and dorsally. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Early experience with the Vanguard complete total knee system: 2-7 years of follow-up and risk factors for revision.

A cross-sectional study in two hospitals was performed on 807 patients with a primary Vanguard (Biomet) total knee Arthroplasty (TKA). The research questions addressed were (1) what are the two- and six year survival rates of the Vanguard, (2) what are the clinical outcome scores, (3) what are the findings at revision and (4) what are predictors for revision? The mean age at time of surgery was 67.0 (SD 10.0). The mean follow-up was 3.6 years (95% CI 3.56-3.73). At two years the survival was 97.2% for all-reasons (767 patients remaining) and 99%, for prosthesis-related-reasons (777 remaining). At six years this was 96.5% (40 remaining) and 98.6% (41 remaining). The mean clinical results (84% response on KOOS, Oxford and NRS) were good. A previous osteotomy was a risk factor for revision (hazard ratio 5.1, P=0.001). This early experience with the Vanguard shows a good survival with no adverse outcomes related to the implant and therefore further use of the implant is justified.

Total knee arthroplasty and the unforeseen impact on return to work: a cross-sectional multicenter survey.

The number of patients receiving a TKA during working life is increasing but little is known about the impact of TKA on patients' reintegration into the workplace. In this cross-sectional survey it was found that 173 of 480 responders worked within 2 years prior to surgery. Sixty-three percent of the working patients stopped within two weeks prior to surgery and 102 patients returned within 6 months. One third never returned to work. Activities that most improved were operating foot pedals, operating vehicles, standing and walking on level terrain. Activities that least improved were kneeling, crouching and clambering. Fifty patients scored 5 or less on the Work Ability Index. Thirty patients were dissatisfied. TKA significantly, but unequally, reduces difficulties in carrying out knee-burdening work activities.

A reliable, valid and responsive questionnaire to score the impact of knee complaints on work following total knee arthroplasty: the WORQ.

The Work, Osteoarthritis or joint-Replacement Questionnaire (WORQ) was developed to assess physical difficulty experienced in work before or following total knee arthroplasty (TKA). Thirteen questions were designed. The WORQ was tested for internal consistency by factor analysis, internal reliability (Crohnbach's α), and construct validity. A test-retest reproducibility was performed for analyzing standard error of measurement (SEM agreement), reliability (ICC) and smallest detectable change (SDC) in individuals and groups. Lastly responsiveness (standardized response means [SRM]), floor and ceiling effects and interpretability (minimal important change [MIC]) were analyzed. It is shown that the WORQ is a reliable, valid and responsive questionnaire that can be used to evaluate the impact of knee complaints following TKA on patients' ability to work.