Operative or Nonoperative Treatment is Predicted Accurately for Patients Who Have Hip Complaints Consulting an Orthopedic Surgeon Using Machine Learning Algorithms Trained With Prehospital Acquired History-Taking Data.

BACKGROUND: Increasing numbers of patients suffering from hip osteoartritis will lead to increased orthopaedic health care consumption. Artificial intelligence might alleviate this problem, using Machine learning (ML) to optimize orthopaedic consultation workflow by predicting treatment strategy (non-operative or operative) prior to consultation. The purpose of this study was to assess ML accuracy in clinical practice, by comparing ML predictions to the outcome of clinical consultations. METHODS: In this prospective clinical cohort study, adult patients referred for hip complaints between January 20th to February 20th 2023 were included. Patients completed a computer-assisted history taking (CAHT) form and using these CAHT answers, a ML-algorithm predicted non-operative or operative treatment outcome prior to in-hospital consultation. During consultation, orthopaedic surgeons and physician assistants were blinded to the prediction in 90 and unblinded in 29 cases. Consultation outcome (non-operative or operative) was compared to ML treatment prediction for all cases, and for blinded and unblinded conditions separately. Analysis was done on 119 consultations. RESULTS: Overall treatment strategy prediction was correct in 101 cases (accuracy 85%, P < .0001). Non-operative treatment prediction (n = 71) was 97% correct versus 67% for operative treatment prediction (n = 48). Results from unblinded consultations (86.2% correct predictions,) were not statistically different from blinded consultations (84.4% correct, P > .05). CONCLUSIONS: Machine Learning algorithms can predict non-operative or operative treatment for patients with hip complaints with high accuracy. This could facilitate scheduling of non-operative patients with physician assistants, and operative patients with orthopaedic surgeons including direct access to pre-operative screening, thereby optimizing usage of health care resources.

A simplified, 2-question grading system for evaluating abstracts in orthopedic scientific meetings: a serial randomization study.

BACKGROUND AND PURPOSE: Efficient abstract scoring for congress presentation is important. Given the emergence of new study methodologies, a scoring system that accommodates all study designs is warranted. We aimed to assess the equivalence of a simplified, 2-question abstract grading system with a more complex currently used system in assessing abstracts submitted for orthopedic scientific meetings in a serial randomized study. METHODS: Dutch Orthopedic Association Scientific Committee (DOASC) members were randomized to grade abstracts using either the current grading system, which includes up to 7 scoring categories, or the new grading system, which consists of only 2 questions. Pearson correlation coefficient and mean abstract score with 95% confidence intervals (CI) were calculated. RESULTS: Analysis included the scoring of 195 abstracts by 12-14 DOASC members. The average score for an abstract using the current system was 60 points (CI 58-62), compared with 63 points (CI 62-64) using the new system. By using the new system, abstracts were scored higher by 3.3 points (CI 1.7-5.0). Pearson correlation was poor with coefficient 0.38 (P < 0.001). CONCLUSION: The simplified abstract grading system exhibited a poor correlation with the current scoring system, while the new system offers a more inclusive evaluation of varying study designs and is preferred by almost all DOASC members.

Quality of total hip arthroplasty health care based on four years of patient-reported outcomes in the Netherlands.

BACKGROUND: Joint arthroplasty registries have incorporated patient-reported outcomes (PROs) to evaluate outcomes from a patients' perspective to improve total hip arthroplasty (THA). To draw valid conclusions on PROs, a minimum response rate (RR) of 60% is advised. This study investigated (1) if the quality of THA health care based on PROs improved over the years in the Netherlands, (2) if RRs improved over the years, and (3) difference in PROs over the years in hospitals with RR ≥ 60% compared to RR < 60%. METHODS: Longitudinal study with publicly available datasets from 2016 to 2019. Primary outcome was increase/decrease in PRO change scores including 95%CI ranges over the years between preoperatively and 3 months postoperatively (pre-3 m), and 12 months postoperatively (pre-12 m). Improved quality of health care was arbitrary defined as when ≥ 3 of 4 included scores or ranges were statistically significant improved. Secondary outcome was increase/decrease in RRs over the years. Subgroups RR ≥ 60% and RR < 60% were compared. RESULTS: Hospitals (%) collecting THA PROs increased from 78 to 92%. EQ VAS change score increased over the years, and 95%CI ranges of EQ VAS, EQ-5D descriptive system and NRS pain during activity decreased over the years at pre-3 m (p < 0.05). All THA pre-12 m PRO change scores and 95%CI ranges remained equal (p > 0.05). Pre-3 m RR remained equal (around 43%, p = 0.107) and pre-12 m RR decreased 9% (49% to 40%, p = 0.008). Pre-3 m subgroup RR ≥ 60% was too small to analyse (5%). No difference was found between pre-12 m subgroups (RR ≥ 60% = 16%), p > 0.05). CONCLUSIONS: Quality of THA health care based on PROs seems equal in the Netherlands between 2016 and 2019. Although more hospitals participated in PRO collection, low RRs with large IQRs are observed and only 16% of the hospitals achieved the advised RR ≥ 60%. Multiple recommendations are provided to improve PRO collection and use.

Mismatch in Capture of Periprosthetic Joint Infections Between the Dutch Arthroplasty Register (LROI) and a Detailed Regional Periprosthetic Joint Infection Registry.

BACKGROUND: National arthroplasty registries are important sources for periprosthetic joint infection (PJI) data and report an average incidence ranging from 0.5% to 2.0%. However, studies have shown that PJI incidence in national arthroplasty registries may be underestimated. Therefore, the incidence of PJI in the Dutch Arthroplasty Register (LROI) was evaluated. METHODS: We matched revisions due to infection within 90 days of index procedure in the LROI database (prospectively registered in 2014-2018) with acute PJI cases registered in a Regional Infection Cohort (RIC) and vice versa. The RIC comprised of 1 university hospital, 3 large orthopedic teaching hospitals and 4 general district hospitals, representing 11.3% of all Dutch arthroplasty procedures with a similar case mix. RESULTS: From the 352 acute PJIs in the RIC, 166 (47%) were registered in the LROI. Of the 186 confirmed PJI cases not registered in the LROI, 51% (n = 95) were a unregistered Debridement, Antibiotics, and Implant Retention procedure without component exchange. The remaining missing PJI cases (n = 91, 49%) were of administrative origin. The acute PJI incidence in the RIC was 1%, compared to a 0.6% incidence of revision <90 days due to infection from LROI data. CONCLUSION: Besides unregistered Debridement, Antibiotics, and Implant Retention procedures without component exchange, administrative errors are an important source of missing PJI data for the LROI, leading to underestimation of PJI incidence in the Netherlands. A national arthroplasty complication registry, linked to the LROI, might decrease the number of missing PJI cases. Although our study concerns Dutch data, it supports the scarce literature on PJI incidence obtained from national arthroplasty registries, which also reports an underestimation.

Machine learning algorithms trained with pre-hospital acquired history-taking data can accurately differentiate diagnoses in patients with hip complaints.

Background and purpose - Machine learning (ML) techniques are a form of artificial intelligence able to analyze big data. Analyzing the outcome of (digital) questionnaires, ML might recognize different patterns in answers that might relate to different types of pathology. With this study, we investigated the proof-of-principle of ML-based diagnosis in patients with hip complaints using a digital questionnaire and the Kellgren and Lawrence (KL) osteoarthritis score.Patients and methods - 548 patients (> 55 years old) scheduled for consultation of hip complaints were asked to participate in this study and fill in an online questionnaire. Our questionnaire consists of 27 questions related to general history-taking and validated patient-related outcome measures (Oxford Hip Score and a Numeric Rating Scale for pain). 336 fully completed questionnaires were related to their classified diagnosis (either hip osteoarthritis, bursitis or tendinitis, or other pathology). Different AI techniques were used to relate questionnaire outcome and hip diagnoses. Resulting area under the curve (AUC) and classification accuracy (CA) are reported to identify the best scoring AI model. The accuracy of different ML models was compared using questionnaire outcome with and without radiologic KL scores for degree of osteoarthritis.Results - The most accurate ML model for diagnosis of patients with hip complaints was the Random Forest model (AUC 82%, 95% CI 0.78-0.86; CA 69%, CI 0.64-0.74) and most accurate analysis with addition of KL scores was with a Support Vector Machine model (AUC 89%, CI 0.86-0.92; CA 83%, CI 0.79-0.87).Interpretation - Analysis of self-reported online questionnaires related to hip complaints can differentiate between basic hip pathologies. The addition of radiological scores for osteoarthritis further improves these outcomes.

What is the minimum response rate on patient-reported outcome measures needed to adequately evaluate total hip arthroplasties?

BACKGROUND: Unknown is which response rate on patient-reported outcome measures (PROMs) is needed to both obtain an accurate outcome and ensure generalizability in evaluating total hip arthroplasty (THA) procedures. Without an evidence based minimum response rate (MRR) on THA PROMs, it is possible that hospitals report invalid patient-reported outcomes (PROs) due to a too low response rate. Alternatively, hospitals may invest too much in achieving an unnecessary high response rate. The aim of this study is to gain an insight into the MRR on PROMs needed to adequately evaluate THA procedures from a clinical perspective. METHODS: Retrospective study on prospective collected data of primary, elective THA procedures was performed. MRR was investigated for each PROM (NRS pain at rest, NRS pain during activity, EQ-5D-3L, HOOS-PS, anchor function, OHS, anchor pain and NRS satisfaction) separately to calculate the primary outcome: MRR for the THA PROMs set. MRR on a PROM needed to have (condition 1.) similar PRO change score (3 month score minus preoperative score) including confidence interval, (condition 2.) maintaining the influence of each change score predictor and (condition 3.) equal distribution of each predictor, as those of a 100% PROM response rate group. Per PROM, a 100%-group was identified with all patients having the PRO change score. Randomly assessed groups of 90% till 10% response rate (in total 90 groups) were compared with the 100%-group. Linear mixed model analyses and linear regressions were executed. RESULTS: The MRR for the THA PROMs set was 100% (range: 70-100% per PROM). The first condition resulted in a MRR of 60%, the second condition in a MRR of 100% and the third condition in a MRR of 10%. CONCLUSIONS: A 100% response rate on PROMs is needed in order to adequately evaluate THA procedures from a clinical perspective. All stakeholders using THA PROs should be aware that 100% of the THA patients should respond on both preoperative and 3 month postoperative PROMs. For now, taking the first step in improving evaluation of THA for quality control by achieving at least two of the three conditions of MRR, advised is to require a response rate on PROMs of 60% as the lower limit.

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.

Percutaneous Cervical Nucleoplasty vs. Pulsed Radio Frequency of the Dorsal Root Ganglion in Patients with Contained Cervical Disk Herniation; A Prospective, Randomized Controlled Trial.

BACKGROUND: Cervical neck pain is often caused by cervical disk pathology and may cause severe symptoms and disability. Surgeons and patients are increasingly aware of postsurgery-related complications. This stimulated the clinical usage of minimally invasive treatments such as percutaneous nucleoplasty (PCN) and pulsed radio frequency (PRF). However, scientific evidence on both treatments is limited. OBJECTIVE: Our objective was to evaluate the efficacy of PCN compared to PRF in patients with contained cervical disk herniation. METHODS: A prospective randomized clinical trial was conducted including 34 patients with radicular pain due to a single contained cervical disk herniation who were treated with either PCN or PRF. Demographic data were collected, and the Medical Outcomes Study 12-Item Short Form (SF-12) Health Survey, visual analog scale (VAS), and the Neck Disability Index (NDI) were completed 1, 2, and 3 months after treatment. Treatment satisfaction and complications were recorded. RESULTS: In the PCN group (n = 17, mean age 52.4 years, 10 female/7 male), patients were treated at C5 to C6 (8 cases) or C6 to C7 (9 cases). In the PRF group (n = 17, mean age 49.5 years, 8 female/9 male), patients were treated at C3 to C4 (1 case), C5 to C6 (10 cases), or C6 to C7 (6 cases). At 3 months, mean pain VAS improved significantly from baseline in the PCN group (mean improvement: 43.4 points) and in the PRF group (34.0 points). However, improvement in 1 group was not superior compared to the other group (P = 0.48). No serious complications were reported. CONCLUSION: Within 3 months, both PCN and PRF show significant pain improvement in patients with contained cervical disk herniation, but none is superior to the other. Both treatment options appear to be effective and safe in regular clinical practice.

Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature.

OBJECTIVE: A systematic literature review and meta-analysis on the effectiveness of lifestyle restrictions and precautions to prevent dislocation after total hip arthroplasty. DATA SOURCES: MEDLINE and the Cochrane Library were searched in February 2015, with additional hand searching of systematic reviews and reference lists. REVIEW METHODS: This review was conducted in accordance with the PRISMA statement for reporting systematic reviews and meta-analysis. PubMed and the Cochrane Library were searched from their start date through to February 2015. Randomized controlled trials and comparative case series in English, Dutch or German language were included. Only primary total hip arthroplasty procedures managed with different postoperative restrictions and precautions protocols were included. Primary outcome was the total hip arthroplasty dislocation rate, secondary outcomes were patient functioning, return to activities of daily living and patient satisfaction. RESULTS: A total of 119 eligible articles were identified, six were included: three randomized controlled trials, one retrospective matched cohort study, one retrospective and one prospective cohort study, describing 1122 procedures (restrictions group: n = 528; no restrictions group: n = 594). Both the standard posterior and anterolateral surgical approaches were included. There were eight dislocations (1.5%) in the restricted group, vs. six dislocations (1.0%) in the unrestricted group. Patients in the unrestricted group resumed activities significantly faster and were more satisfied with their pace of recovery. CONCLUSION: A more liberal lifestyle restrictions and precautions protocol will not lead to worse dislocation rates after total hip arthroplasty, but will lead to earlier and better resumption of activities and higher patient satisfaction. These results appear to hold up for various surgical approaches.

No difference between intra-articular injection of hyaluronic acid and placebo for mild to moderate knee osteoarthritis: a randomized, controlled, double-blind trial.

The main goal of our study was to examine the effectiveness and safety of Fermathron plus, a specific brand of hyaluronic acid (HA), in patients with mild to moderate knee osteoarthritis. In a randomized, controlled, double-blind trial, 196 patients with symptomatic knee osteoarthritis (mean age ± SD, 59.4 ± 9.9 years, Kellgren-Lawrence grade 1-3) were given either 3 weekly intra-articular injections of HA or saline (placebo). Although pain and functional scores (WOMAC scale) improved significantly from baseline up to 6 months, HA was not superior to placebo at any follow-up (VAS pain 50 m walking from 56.4 to 38.1, P < .001, and 58.2 to 39.6, P < .001, respectively). No subgroup analysis resulted in superior outcomes. No serious adverse events were noticed.

Treatment of pseudotumors after metal-on-metal hip resurfacing based on magnetic resonance imaging, metal ion levels and symptoms.

Peri-prosthetic pseudotumor formation can be a severe complication following Metal-on-Metal hip resurfacing arthroplasty (MoMHRA), with limited data on the optimal management of this complication. The aims of this study were (1) to evaluate the prevalence and severity of pseudotumors in a consecutive cohort of 248 MoMHRA (214 patients, mean follow-up 4.6 years, range: 1 - 8.2), and (2) to present a clinical guideline for their treatment based on severity grading with Metal Artefact Reduction Sequence Magnetic Resonance Imaging, metal ion levels and symptoms. Pseudotumor prevalence was 36.3%: 61 mild, 25 moderate and four were graded severe. Five revisions followed, all in symptomatic patients with elevated metal ion levels. Pseudotumor severity grading allowed us to be conservative with revision surgery for mild and moderate MoM disease.

Current evidence of percutaneous nucleoplasty for the cervical herniated disk: a systematic review.

BACKGROUND: Although percutaneous cervical nucleoplasty (PCN) has been shown to be both safe and effective, its application is still debated. PCN applied in disk herniation has not been systematically reviewed before, resulting in a limited insight into its effectiveness and safety, and the quality of available evidence. Therefore, we systematically reviewed the evidence on the efficacy and safety of PCN in patients with a (contained) herniated disk. METHODS: MEDLINE, EMBASE, and the Cochrane Library (Central Register of Controlled Trials) were searched for randomized controlled trials (RCTs) and nonrandomized studies using the following keywords: "Nucleoplasty," "Cervical," "Hernia," "Herniation," "Prolapse," "Protrusion," "Intervertebral disk," and "Percutaneous disk decompression." First, all articles were appraised for methodological quality, and then, RCTs were graded for the level of evidence according a best-evidence synthesis, because a meta-analysis was not possible. Finally, the RCTs' applicability and clinical relevance also was assessed. RESULTS: Of 75 identified abstracts, 10 full-text articles were included (3 RCTs and 7 nonrandomized studies). These studies represented a total of 1021 patients: 823 patients (≥ 892 disks) were treated by PCN. All studies showed low methodological quality, except for two. The level of evidence of the RCTs was graded as moderate, with low to moderate applicability and clinical relevance. CONCLUSION: All included studies showed PCN to be an effective and safe procedure in the treatment of (contained) herniated disks at short-, mid-, and long-term follow-up. However, the level of evidence is moderate and shows only low to moderate applicability and clinical relevance.

Satisfactory adherence to the Dutch physical therapy guideline for patients with a total knee arthroplasty. A survey study involving 103 specialised physical therapists.

OBJECTIVE: To explore and gain more insight into the usual preoperative and postoperative physical therapy (PT) treatment of patients with a total knee arthroplasty (TKA) among Dutch physical therapists experienced with TKA rehabilitation. Secondly, to evaluate physical therapists' adherence to guideline recommendations for postoperative rehabilitation. METHODS: In this cross-sectional study, physical therapists working in primary care within a designated Dutch hospital's catchment area were surveyed online. The survey queried PT treatment approaches before surgery, during hospitalisation, and after surgery. All data were analysed descriptively. When both education and all recommended exercise modalities were used postoperatively, therapists were considered fully adherent with the Dutch clinical practice guideline. RESULTS: One hundred and three therapists participated, representing a response rate of 58%. Postoperative PT treatment was applied by all therapists, of which 65 (63.1%) were fully adherent to the guideline. Partial adherence was mainly due to not using the aerobic exercise modality. Furthermore, beyond the modalities recommended in the guideline, a range of PT interventions were used. Preoperative treatment was applied by 73 therapists (70.9%). These 73 indicated that only a median of 20% (IQR 10%-40%) of their patients received preoperative PT. CONCLUSIONS: This study revealed satisfactory adherence to guideline recommendations on postoperative management of patients with a TKA among experienced physical therapists. Aerobic exercises were utilised less often or with inappropriate intensity. Correct adherence to guideline recommendations on aerobic exercise training can result in more physically active individuals and important general health benefits.

Double-Leg and Single-Leg Jump Test Reference Values for Athletes With and Without Anterior Cruciate Ligament Reconstruction Who Play Popular Pivoting Sports, Including Soccer and Basketball: A Scoping Review.

OBJECTIVE: To synthesize and present reference values for double-leg and single-leg jump tests in healthy athletes who play pivoting sports, and athletes with anterior cruciate ligament reconstruction (ACLR) who play pivoting sports. DESIGN: Scoping review. LITERATURE SEARCH: We searched PubMed, the Cochrane Library, MEDLINE, Embase, and Web of Science until April 7, 2023. STUDY SELECTION CRITERIA: We included reference values in 2 different categories: (1) double-leg and/or single-leg jump test outcomes in pivoting-sport athletes with ACLR at a specific time point during rehabilitation, and (2) double-leg and/or single-leg jump test outcomes in healthy pivoting-sport athletes. DATA SYNTHESIS: We performed data synthesis for reference values from double-leg jump tests (squat jump and countermovement jump) and single-leg jump tests (vertical hop, single hop for distance, triple hop for distance, crossover hop for distance, medial triple hop for distance, lateral triple hop for distance, 6-m timed hop, side hop, drop jump, and 10-second repeated hop) that were performed according to a standardized test description. We summarized the data for type of sport, sex, sport participation level, and age group. RESULTS: Of the 27 included studies, nine reported reference values from healthy soccer players, six from healthy basketball players, and eleven from other healthy pivoting-sport athletes. LSI dominant/nondominant (LSI-D/ND) ranged between 97% and 106% for healthy soccer players, and between 99% and 120% for healthy basketball players. Four studies reported reference values from pivoting-sport athletes with ACLR from 7 to 10 months postsurgery. CONCLUSION: This scoping review summarizes double-leg and single-leg jump test reference values for athletes who play common pivoting sports, including soccer and basketball. J Orthop Sports Phys Ther 2024;54(6):1-14. Epub 20 March 2024. doi:10.2519/jospt.2024.12374.

Coccidioidomycosis infection of a total knee arthroplasty in a nonendemic region.

Fungal prosthetic joint infections are rare and difficult to treat. There is an ongoing discussion about the type and duration of antifungal treatment and the necessity of prosthesis removal. We report the first European case of an infected total knee arthroplasty with Coccidioides immitis. Treatment consisted of lifelong treatment with oral fluconazole at a dose of 400 mg/d, without total knee arthroplasty removal. After 6 months, the initial complaints of pain and swelling were completely resolved. This case report clearly states that a travel history and culturing for fungi are helpful in patients with persisting complaints after joint arthroplasty.

The long-term efficacy and safety of percutaneous cervical nucleoplasty in patients with a contained herniated disk.

BACKGROUND: Percutaneous cervical nucleoplasty (PCN) is a safe and effective treatment in symptomatic patients with contained cervical herniated disks. It provides simple and efficient disk decompression, using a controlled and highly localized ablation, but evidence regarding long-term efficacy is limited. We conducted a retrospective study to investigate the long-term efficacy and safety of PCN, and the influence of ideal selection settings. METHODS: A total of 27 patients treated with PCN fulfilling ideal selection criteria (Group A) were studied and compared to 42 patients not meeting these criteria (Group B). Outcomes were assessed using the Visual Analogue Scale (VAS) and a four-level Likert item for perceived pain and satisfaction, the Neck Disability Index (NDI), and the Short Form 36 (SF-36). Additional relevant outcomes were retrieved from medical records. RESULTS: The postoperative mean VAS pain for Group A was 29.9 (SD ± 32.6) at a mean follow-up of 24 months (range: 2-45). Only 10% of these patients reported mild transient adverse events. There was a trend, but no difference between both groups in pain scores; however, treatment satisfaction was higher for Group A (74.1 ± 27.2-55.5 ± 31.4, P = 0.02). Group A also reported better physical functioning based on the Physical Component Summary (43.6 ± 10.6-37.3 ± 12.0, P = 0.03) and showed a larger proportion of patients no longer using any medication postoperatively (63-26%, P = 0.01). CONCLUSION: These results show long-term effectiveness and safety of PCN in patients with a one-level contained cervical herniated disk, and the reliance of selecting patients meeting ideal criteria for successful PCN.

A 20 mg dose of dexamethasone does not reduce the proportion of joint replacement patients needing rescue analgesia: a matched cohort study.

Background: Consistent pain control after total joint replacement (TJR) has not yet been reached in all patients managed with a multimodal analgesia regime. Questions remain on dosage and timing of analgesics. Glucocorticoids such as dexamethasone are considered most powerful in reducing the surgery-induced inflammatory response with most pain studies using a 6-12 mg dose. Reviews agree that additional glucocorticoids may provide more analgesia, but a dose-finding analysis is limited. The primary aim of this study was to determine if a high, single preoperative dose of dexamethasone resulted in a reduced need for rescue analgesics during the first 24 hours after TJR when compared to a standard 8 mg dose of dexamethasone. Methods: A cohort study in which 59 patients who received 20 mg dexamethasone intravenously just prior to incision were matched 1:1 to patients who received a standard 8 mg dose. Consecutive elective hip and knee replacement patients managed by one anaesthesiologist were included in the high dose group between June 2019 and March 2020. Patients were matched for arthroplasty type, gender, age, anaesthesia type and pre-operative pain. Patients with opioid use before surgery or with diabetes mellitus were excluded. Oxynorm rescues analgesics (number of times given and dosage) usage during hospitalization was retrieved from the electronic nursing files. Results: There were no significant differences between groups in gender distribution, mean age and body mass index (BMI), in American Society of Anesthesiologists (ASA), type of arthroplasty, anaesthesia type and pre-operative pain score. In the 20 mg group 54 patients (91.5%) needed oxynorm during hospitalization versus 58 (98.3%) in the 8 mg group (P=0.09). High dose group patients received a median of 5 mg [interquartile range (IQR): 0] oxynorm versus 5 mg (IQR: 0) in the standard dose group (P=0.70). Conclusions: In this matched cohort study there was no difference in the proportion of patients needing rescue analgesics during hospitalization between the group of patients who preoperatively received 20 mg dexamethasone and the group of patients who received 8 mg. Future blinded randomized controlled trials are needed to further investigate the effect of different glucocorticoids dosages on pain after joint replacement surgery.

Direct active rehabilitation after reverse total shoulder arthroplasty: an international multicentre prospective cohort safety study with 1-year follow up.

OBJECTIVES: To gain insight in the safety of direct active rehabilitation without immobilisation in patients undergoing reverse total shoulder arthroplasty without subscapularis reattachment, measured by the occurrence of complications until 1-year follow up. Next, to explore improvement in shoulder function and in patient-reported outcome measures. DESIGN: An international multicentre prospective cohort safety study. SETTING: Patients indicated for reverse total shoulder arthroplasty, visiting the orthopaedics outpatient clinic at two hospitals in the Netherlands and one hospital in Curaçao between January 2019 and July 2021, were selected. PARTICIPANTS: 100 patients (68% female, mean age 74±7.0 years) undergoing unilateral primary shoulder replacement were included if: ≥50 years, diagnosed with shoulder osteoarthritis, rotator cuff arthropathy or avascular necrosis, and selected for reverse total shoulder arthroplasty. A sling was used for only 1 day, followed by a progressive active rehabilitation for ≥12 weeks with no precautions. MAIN OUTCOME MEASURES: Complications, range of motion and patient-reported outcome measures (Oxford Shoulder Score, Pain Numeric Rating Scale and EuroQol-5D for quality of life). Patients were evaluated preoperatively and 6 weeks, 3 months and 1 year postoperatively. RESULTS: In total, 17 complications were registered (17.0%) including five (5.0%) categorised as potentially related to the rehabilitation strategy: one dislocation, one acromion fracture and three cases with persistent pain. Anteflexion, abduction and external rotation, pain scores and the Oxford Shoulder Score all improved significantly (p<0.05) at all time points compared with preoperative. Quality of life improved significantly from 3 months onwards. These secondary outcomes improved further until 1 year postoperatively. CONCLUSION: Direct active rehabilitation after reverse total shoulder arthroplasty seems to be safe and effective. Potentially, this approach will lead to less dependent patients and faster recovery. Larger studies, preferably including a control group, should corroborate our results. TRIAL REGISTRATION NUMBER: NL7656.

Pulsed Radiofrequency 2 Hz Preserves the Dorsal Root Ganglion Neuron Physiological Ca2+ Influx, Cytosolic ATP Level, Δψm, and pERK Compared to 4 Hz: An Insight on the Safety of Pulsed Radiofrequency in Pain Management.

Background: Pulsed radiofrequency (PRF) is beneficial for radicular pain and is commonly administered at pulse frequencies of 2 or 4 Hz. However, its effects on healthy neurons have not yet been widely studied. This study aims to determine the effect of PRF at 2 Hz and 4 Hz on the physiology of healthy dorsal root ganglion (DRG) neurons. Methods: An in vitro experimental study was conducted using DRG neuron cultures divided into three groups. Control cells received no treatment, one cell group received 20 ms 2 Hz PRF for 360 s, and one cell group received a 4 Hz PRF 10 ms pulse for 360 s with similar energy. Ca2+ influx, mitochondrial membrane potential (Δψm), cytosolic Adenosine triphosphate (ATP), and phosphorylated extracellular signal-regulated kinase (pERK) levels were measured. The data were analyzed using the One-Way ANOVA variance with α=5%. Results: DRG neurons exposed to PRF 2 Hz did not experience a significant change in Ca2+ influx, whereas PRF 4 Hz caused a significant decrease in Ca2+ influx compared to the basal level. PRF at 2 Hz did not cause a change in Δψm, whereas PRF at 4 Hz caused a significant decrease in Δψm (p<0.05). Both 2 and 4 Hz PRF resulted in a significant elevation in cytosolic ATP concentration, but the 2 Hz PRF had a higher cytosolic ATP than the 4 Hz group (p<0.05). Both 2 and 4 Hz did not show a significant difference in pERK intensity with respect to the control (p>0.05), indicating that there was no significant neuron activation. Conclusion: Both frequencies did not significantly activate DRG neurons, but with similar energy delivery, PRF 2 Hz preserved the physiological properties of healthy neurons better than PRF 4 Hz did. A 2 Hz PRF is the preferred frequency in clinical applications for neuron-targeted therapy.

Hip resurfacing in a district general hospital: 6-year clinical results using the ReCap hip resurfacing system.

BACKGROUND: The purpose of our study was to prospectively report the clinical results of 280 consecutive hips (240 patients) who received a ReCap Hip Resurfacing System implant (Biomet Inc., Warsaw, USA) in a single district general hospital. Literature reports a large variation in clinical results between different resurfacing designs and published results using this particular design are scarce. METHODS: Mean follow up was 3.3 years (1.0 to 6.3) and four patients were lost to follow-up. All patients were diagnosed with end-stage hip osteoarthritis, their mean age was 54 years and 76.4% of all patients were male. RESULTS: There were 16 revisions and four patients reported a Harris Hip Score <70 points at their latest follow up. There were no pending revisions. Kaplan-Meier implant survival probability, with revision for any reason as endpoint, was 93.5% at six years follow-up (95%-CI: 88.8-95.3). There were no revisions for Adverse Reactions to Metal Debris (ARMD) and no indications of ARMD in symptomatic non-revised patients, although diagnostics were limited to ultrasound scans. CONCLUSIONS: This independent series confirms that hip resurfacing is a demanding procedure, and that implant survival of the ReCap hip resurfacing system is on a critical level in our series. In non-revised patients, reported outcomes are generally excellent. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00603395.