Parental experiences of children with developmental dysplasia of the hip: a qualitative study.

OBJECTIVE: The aim of this qualitative study was to explore the experiences of Dutch parents of children with developmental dysplasia of the hip (DDH), treated with a Pavlik harness, during the diagnostic and treatment process in the first year of life. DESIGN: A qualitative study by means of semistructured interviews was conducted between September and December 2020. Qualitative content analysis was applied to code, categorise and thematise data. SETTING: A large, tertiary referral centre for paediatric orthopaedics in the Netherlands. PARTICIPANTS: A purposive sample of parents of children aged younger than 1 year, who were treated for DDH with a Pavlik harness, were interviewed until data saturation was achieved. A total of 20 interviews with 22 parents were conducted. RESULTS: Five main themes emerged: (1) positive experiences with professionals and peers, (2) insufficient information, (3) treatment concerns, (4) difficulties parenting and (5) emotional burden. Most prominent features that resonated across the interviews which led to insecurity by parents were: insufficient pre-hospital information, unfiltered online information and the lack of overview of the patient journey. CONCLUSION: This study offers novel insights into parental experiences in DDH care. Parents were generally satisfied with DDH care provided by the hospital. The biggest challenges were to cope with (1) insufficient and unfiltered information, (2) the lack of patient journey overview and (3) practical problems and emotional doubts, which led to concerns during treatment. Future research and interventions should focus on optimising information provision and guidance with practical and emotional support for parents of children with DDH.

Recovery patterns in patients undergoing revision surgery of the primary knee prosthesis.

PURPOSE: Despite good survival rates of revised knee prostheses, little is known about recovery trajectories within the first 12 months after surgery. This retrospective observational study explored recovery trajectories in terms of pain, function and quality of life in patients after revision knee arthroplasty over 12 months. METHODS: Eighty-eight revision knee arthroplasty patients rated changes in daily physical functioning using the anchor question (0: very much worsened; 7: very much improved). Patient reported outcome measures (PROMs) of pain (range 0-10), function (Oxford Knee Score) and quality of life (EQ-5D-3L) were assessed preoperatively, at 3 and 12 months postoperatively. Four recovery trajectories were identified using the anchor question at 3 and 12 months postoperatively: no improvement, late improvement, early improvement, and prolonged improvement. Repeated measures ANOVA was conducted with recovery trajectories as dependent variable and PROM assessments as independent variables. RESULTS: Sixty percent reported improvement in daily physical functioning at 12 months postoperatively. Age and reason for revision differed between groups. Pain, function and EQ-5D-3L differed between groups over time. Late and prolonged improvement groups improved on all PROMs at 12 months. The early improvement group did not report improvement in daily physical functioning at 12 months, while improvements in function and pain during activity were observed. CONCLUSIONS: Different recovery trajectories seem to exist and mostly match PROMs scores over time. Not all patients may experience beneficial outcome of revision knee arthroplasty. These findings are of importance to provide appropriate information on possible recovery trajectories after revision knee arthroplasty to patients. LEVEL OF EVIDENCE: III.

Translation and transcultural validation of the Dutch hospital for special surgery paediatric functional activity brief scale (HSS Pedi-FABS).

BACKGROUND: There is a need for a validated simple Dutch paediatric activity scale. The purpose was to translate and transculturally validate the Dutch Hospital for Special Surgery Paediatric Functional Activity Brief Scale (HSS Pedi-FABS) questionnaire in healthy children and adolescents. METHODS: The original HSS Pedi-FABS was translated forward and backward and was transculturally adapted after performing a pilot study among children and professionals. The final version of the Dutch HSS Pedi-FABS was validated in healthy children and adolescents aged 10 to 18 years old. Children who had any condition or injury limiting their normal physical activity were excluded. The interval between the first questionnaire T0 (HSS Pedi-FABS, Physical Activity Questionnaire for children or adolescents (PAQ-C/A) and Tegner activity scale) and the second questionnaire T1 (HSS Pedi-FABS) was 2 weeks. Construct validity, interpretability and reliability were evaluated. Content validity was evaluated through cognitive interviews among a smaller group of children and through a questionnaire among professionals. RESULTS: To evaluate content validity, 9 children and adolescents were interviewed, and 30 professionals were consulted. Content validity among professionals showed a relevance of less than 85% for most items on construct. However, content validity among children was good with a 92% score for item relevance. Readability was scored at a reading level of 11- to 12-year-olds. The validation group consisted of 110 healthy children and adolescents (mean age of 13.9 years ±2.6). Construct validity was considered good as 8 out of 10 hypotheses were confirmed. The Dutch HSS Pedi-FABS showed no floor or ceiling effect. Analysis of the internal consistency in the validation group resulted in a Cronbach's alpha of 0.82. Test-retest reliability was evaluated among 69 children and adolescents and revealed an Intraclass Correlation Coefficient (ICC) of 0.76. CONCLUSION: The Dutch HSS Pedi-FABS showed good psychometric properties in a healthy Dutch paediatric and adolescent population. Limitations of the current Dutch HSS Pedi-FABS are content validity on construct of items reported by professionals.

Assessment of Graft Maturity After Anterior Cruciate Ligament Reconstruction Using Autografts: A Systematic Review of Biopsy and Magnetic Resonance Imaging studies.

PURPOSE: The purpose of this investigation was to evaluate systematically the literature concerning biopsy, MRI signal to noise quotient (SNQ) and clinical outcomes in graft-maturity assessment after autograft anterior cruciate ligament reconstruction (ACLR) and their possible relationships. METHODS: The systematic review was reported and conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies through May 2019 evaluating methods of intra-articular ACL autograft maturity assessment were considered for inclusion. Eligible methods were histologic studies of biopsy specimens and conventional MRI studies reporting serial SNQ and/or correlation with clinical parameters. RESULTS: Ten biopsy studies and 13 imaging studies, with a total of 706 patients, met the inclusion criteria. Biopsy studies show that graft remodeling undergoes an early healing phase, a phase of remodeling or proliferation and a ligamentization phase as an ongoing process even 1 year after surgery. Imaging studies showed an initial increase in SNQ, peaking at approximately 6 months, followed by a gradual decrease over time. There is no evident correlation between graft SNQ and knee stability outcome scores at the short- and long-term follow-up after ACLR. CONCLUSIONS: The remodeling of the graft is an ongoing process even 1 year after ACLR, based on human biopsy studies. MRI SNQ peaked at approximately 6 months, followed by a gradual decrease over time. Heterogeneity of the MRI methods and technical restrictions used in the current literature limit prediction of graft maturity and clinical and functional outcome measures by means of MRI graft SNQ after ACLR. LEVEL OF EVIDENCE: Level IV, systematic review, including level III and IV studies.

Timing of anterior cruciate ligament reconstruction and preoperative pain are important predictors for postoperative kinesiophobia.

PURPOSE: Fear of movement (kinesiophobia) is a major limiting factor in the return to pre-injury sport level after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to gain insight into the prevalence of kinesiophobia pre-ACLR, 3 months post-ACLR and 12 months post-ACLR. Furthermore, the preoperative predictability of kinesiophobia at 3 months post-ACLR was addressed. METHODS: A retrospective study with data, which were prospectively collected as part of standard care, was conducted to evaluate patients who underwent ACLR between January 2017 and December 2018 in an orthopaedic outpatient clinic. Patient characteristics (age, sex, body mass index), injury-to-surgery time, preoperative pain level (KOOS pain subscale) and preoperative knee function (IKDC-2000) were used as potential predictor variables for kinesiophobia (TSK-17) at 3 months post-ACLR in linear regression analysis. RESULTS: The number of patients with a high level of kinesiophobia (TSK > 37) reduced from 92 patients (69.2%) preoperatively to 44 patients (43.1%) 3 months postoperatively and 36 patients (30.8%) 12 months postoperatively. The prediction model, based on a multivariable regression analysis, showed a positive correlation between four predictor variables (prolonged injury-to-surgery time, high preoperative pain level, male sex and low body mass index) and a high level of kinesiophobia at 3 months postoperatively (R2 = 0.384, p = 0.02). CONCLUSION: The prevalence of kinesiophobia decreases during postoperative rehabilitation, but high kinesiophobia is still present in a large portion of the patients after ACLR. Timing of reconstruction seems to be the strongest predictor for high kinesiophobia 3 months post-ACLR. This study is the first step in the development of a screening tool to detect patients with kinesiophobia after ACLR. Identifying patients preoperatively opens the possibility to treat patients and thereby potentially increase the return to pre-injury sport level rate after ACLR. LEVEL OF EVIDENCE: III.

First results of a uniform regional treatment protocol and registration for acute prosthetic join infection in the South-East of the Netherlands.

Introduction: Prosthetic joint infection (PJI) is a relatively uncommon (average incidence 0.5-2%) but devastating complication, with significant morbidity and leading to tremendously increased health care costs. In 2013, delegates from nine hospitals covering a large region in the South-East Netherlands composed one combined treatment protocol for acute PJI of total hip and knee arthroplasty (THA and TKA). This protocol was based on the definition of acute PJI according to Workgroup of the American Musculoskeletal Infection Society (MSIS) and the principles of debridement, antibiotics, irrigation and retention (DAIR). Methods: Patients with a THA or TKA treated with DAIR because of suspicion of PJI were selected from the online PJI database. PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected prosthetic joint. Acute PJIs, occurring within 90 days after primary implantation, between January 2014 and December 2016, were analyzed. We analyzed the PJI incidence rate, patient clinical and microbiological characteristics of PJI, outcome of the DAIR treatment and adherence to the regional protocol. Results: A total of 310 primary THA or TKA with a suspected PJI were registered in the regional PJI database, 236 met the definition of acute PJI, representing overall incidence of 1.12%. Following the regional treatment protocol replacement of exchangeable parts took place in 45% in 2014 to 70% in 2016. After 12 months follow-up, prosthesis retention was achieved in 87% and 3% of the patients died within one year after the primary surgery. Conclusion: Results of the regional cohort are in line with the available literature. Regional collaboration and regular feedback on registered data resulted in better adherence to the combined treatment protocol. Despite our attempts to improve PJI care, PJI remains a serious complication of THA and TKA with a significant mortality rate and burden for the patient.

Validation of Simendo Knee Arthroscopy Virtual Reality Simulator.

PURPOSE: To determine the face and construct validity as well as educational value and user-friendliness of the Simendo knee arthroscopy virtual reality simulator. METHODS: Sixty participants were recruited and equally divided into novices (0 arthroscopic procedures), intermediates (1-59 arthroscopic procedures), and experts (60 or more arthroscopic procedures). Participants were excluded if they had previously trained with the studied simulator. Construct validity, that is, the ability to discriminate between different levels of expertise, was examined by a navigation task. All participants were asked to perform 5 navigation trials within 10 minutes. Face validity, educational value, and user-friendliness were examined by questionnaires before and after the navigation trials. Face validity is the subjective impression of how closely the simulation replicates the real environment. RESULTS: The novices were significantly slower than the intermediates in the first (P < .001) and the third (P = .031) trial. The novices were significantly slower than the experts in all trials (P = .016), except for the fifth (P = .054). The experts were significantly faster than the intermediates in every trial except for the fourth (P = .069). Median task time for the fifth trial was 63 seconds (44-80 seconds) for novices, 58 seconds (46-80 seconds) for intermediates, and 41 seconds (33-55 seconds) for experts. Ninety-two percent of all participants agreed that the simulator can be used to train for surgical inspection, and 95% indicated sufficient user-friendliness. CONCLUSIONS: Based on the results, this knee simulator can be applied to train the basic arthroscopic hand-eye coordination skills at the start of resident education programs. Further testing is necessary to determine whether the skills are retained. CLINICAL RELEVANCE: The simulator is partly validated, which contributes to training of basic arthroscopic skills without compromising patient safety.

Optimization of the empirical antibiotic choice during the treatment of acute prosthetic joint infections: a retrospective analysis of 91 patients.

Background and purpose - The preferred treatment of an acute prosthetic joint infection (PJI) is debridement, antibiotics, irrigation and retention of the prosthesis (DAIR). The antibiotic treatment consists of an empirical and targeted phase. In the empirical phase, intravenous antibiotics are started after surgery before micro-organisms are determined in microbiological cultures. Which empirical antibiotic is used differs between hospitals, partly reflecting geographic differences in susceptibility spectrums. We investigated whether flucloxacillin should remain the antibiotic of choice in our hospital for empiric treatment of acute PJI with DAIR. Patients and methods - We retrospectively analyzed 91 patients treated for PJI with DAIR between 2012 and 2016. The susceptibility of micro-organisms was determined in multiple cultures of periprosthetic tissue and synovial fluid for 3 antibiotics: amoxicillin/clavulanic acid, cefazolin, and flucloxacillin. Results - Positive microbiological cultures from 68 patients were analyzed. Staphylococcus aureus was the predominant pathogen, cultured in half of the patients. In one-third of patients more than 1 micro-organism was found. On a patient level, the data showed that 65% were responsive to flucloxacillin, 76% to amoxicillin/clavulanic acid, and 79% to cefazolin. Interpretation - Flucloxacillin appeared to be a suboptimal choice in our patient population treated with DAIR. We therefore changed our practice to cefazolin as the preferred antibiotic in the empirical treatment of acute PJI with DAIR.

The OARSI core set of performance-based measures for knee osteoarthritis is reliable but not valid and responsive.

PURPOSE: The Osteoarthritis Research Society International has identified a core set of performance-based tests of physical function for use in people with knee osteoarthritis (OA). The core set consists of the 30-second chair stand test (30-s CST), 4 × 10 m fast-paced walk test (40 m FPWT) and a stair climb test. The aim of this study was to evaluate the reliability, validity and responsiveness of these performance-based measures to assess the ability to measure physical function in knee OA patients. METHODS: A prospective cohort study of 85 knee OA patients indicated for total knee arthroplasty (TKA) was performed. Construct validity and responsiveness were assessed by testing of predefined hypotheses. A subgroup (n = 30) underwent test-retest measurements for reliability analysis. The Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form, pain during activity score and knee extensor strength were used as comparator instruments. Measurements were obtained at baseline and 12 months after TKA. RESULTS: Appropriate test-retest reliability was found for all three tests. Intraclass correlation coefficient (ICC) for the 30-s CST was 0.90 (95% CI 0.68; 0.96), 40 m FPWT 0.93 (0.85; 0.96) and for the 10-step stair climb test (10-step SCT) 0.94 (0.89; 0.97). Adequate construct validity could not be confirmed for the three tests. For the 30-s CST, 42% of the predefined hypotheses were confirmed; for the 40 m FPWT, 27% and for the 10-step SCT 36% were confirmed. The 40 m FPWT was found to be responsive with 75% of predefined hypothesis confirmed, whereas the responsiveness for the other tests could not be confirmed. For the 30 s CST and 10-step SCT, only 50% of hypotheses were confirmed. CONCLUSIONS: The three performance-based tests had good reliability, but poor construct validity and responsiveness in the assessment of function for the domains sit-to-stand movement, walking short distances and stair negotiation. The findings of the present study do not justify their use for clinical practice. LEVEL OF EVIDENCE: Level 1. Diagnostic study.

PROMs in paediatric knee ligament injury: use the Pedi-IKDC and avoid using adult PROMs.

PURPOSE: The aim of this systematic review was to present an evidence-based overview of psychometric properties of patient-reported outcome measures (PROMs) for children with knee ligament injury. METHODS: A systematic search of literature was performed in PubMed, EMBASE and Cochrane databases. The inclusion criteria were diagnostic studies evaluating psychometric properties (validity, reliability, responsiveness) and comprehensibility of PROMs as well as studies including children (age < 18 years) with knee ligament injury. The systematic review was performed following the PRISMA statement. RESULTS: Ten studies were included. Eight studies evaluated psychometric properties of PROMs, and two studies analysed comprehensibility of PROMs. The Pedi-IKDC has been evaluated in four studies and has acceptable psychometric properties. The KOOS-Child is evaluated in one study and has acceptable psychometric properties. The use of adult PROMs in children causes problems in comprehensibility. CONCLUSION: The Pedi-IKDC is an adequate PROM for children with knee ligament injuries. It is valid, reliable and responsive. The KOOS-Child might be an alternative PROM for the Pedi-IKDC, but has only been evaluated in one study. The clinical relevance of the present systematic review is that adult versions of PROMs are not recommended in children and adolescents. LEVEL OF EVIDENCE: III.

Gait kinetics in children with clubfeet treated surgically or with the Ponseti method: A meta-analysis.

BACKGROUND: Currently, the Ponseti method is the gold standard for treatment of clubfeet. For long-term functional evaluation of this method, gait analysis can be performed. Previous studies have assessed gait differences between Ponseti treated clubfeet and healthy controls. RESEARCH QUESTION/PURPOSE: The aims of this systematic review were to compare the gait kinetics of Ponseti treated clubfeet with healthy controls and to compare the gait kinetics between clubfoot patients treated with the Ponseti method or surgically. METHODS: A systematic search was performed in Embase, Medline Ovid, Web of Science, Scopus, Cochrane, Cinahl ebsco, and Google scholar, for studies reporting on gait kinetics in children with clubfeet treated with the Ponseti method. Studies were excluded if they only used EMG or pedobarography. Data were extracted and a risk of bias was assessed. Meta-analyses and qualitative analyses were performed. RESULTS: Nine studies were included, of which five were included in the meta-analyses. The meta-analyses showed that ankle plantarflexor moment (95% CI -0.25 to -0.19) and ankle power (95% CI -0.89 to -0.60, were significantly lower in the Ponseti treated clubfeet compared to the healthy controls. No significant difference was found in ankle dorsiflexor and plantarflexor moment, and ankle power between clubfeet treated with surgery compared to the Ponseti method. SIGNIFICANCE: Differences in gait kinetics are present when comparing Ponseti treated clubfeet with healthy controls. However, there is no significant difference between surgically and Ponseti treated clubfeet. These results give more insight in the possibilities of improving the gait pattern of patients treated for clubfeet.

Influence of cast change interval in the Ponseti method: A systematic review.

BACKGROUND: Clubfeet are commonly treated using the Ponseti method. This method involves weekly manipulation and casting which gradually corrects the position of the foot. However, the reasons for following a weekly interval are not clear. QUESTION / PURPOSE: The aim is to investigate the influence of the cast change interval on treatment outcomes in the Ponseti method. METHODS: We performed a systematic review of comparative studies in which the cast change interval was varied. Scientific databases were searched for relevant publications, screened for eligibility and assessed for a risk of bias. A 'best evidence' synthesis tool was used to synthesize the results of the included studies and draw conclusions from relevant clinical outcomes. RESULTS: Nine papers matched the inclusion criteria, which provided data of 587 subjects who had a total of 870 clubfeet. There is strong evidence for a positive relation between cast change interval and treatment duration. However, there is no evidence for any relation between the cast change interval and the required number of casts, tenotomy rate, required surgery or failure rate. CONCLUSIONS: Accelerated versions are as effective and safe as the traditional Ponseti method. However, more research is needed to assess the long-term results and to identify an optimal cast change interval.

Identification and treatment of residual and relapsed idiopathic clubfoot in 88 children.

Background and purpose - The Ponseti treatment is successful in idiopathic clubfoot. However, approximately 11-48% of all clubfeet maintain residual deformities or relapse. Early treatment, which possibly reduces the necessity for additional surgery, requires early identification of these problematic clubfeet. We identify deformities of residual/relapsed clubfeet and the treatments applied to tackle these deformities in a large tertiary clubfoot treatment center. Patients and methods - Retrospective chart review of patients who visited our clinic between 2012 and 2015 focused on demographics, deformities of the residual/relapsed clubfoot, and applied treatment. Residual deformities were defined as deformities that were never fully corrected and needed additional treatment. We defined relapse as any deformity of the clubfoot reoccurring, after initial successful treatment, with necessity for additional treatment. Results - We identified 33 patients with residual and 55 patients with relapsed clubfeet. In both groups decreased dorsal flexion and adduction were the most often registered deformities. Furthermore, often equinus/decreased dorsiflexion, active supination, and varus occurred. In more than half, typical profiles of combined deformities were found. Relapses occurred at all stages of treatment and follow-up; half of the residual or relapsed clubfeet were identified before the end of the bracing period. In half of the patients, additional treatment consisted of the Ponseti treatment, one-quarter also required adaptation of the brace protocol, and one-quarter needed additional surgery. The Ponseti treatment was mainly reapplied if feet presented with relapses or residues until the age of 5. Interpretation - Practitioners should especially be aware of equinus/decreased dorsiflexion, adduction, and active supination as a sign of a residual or relapsed clubfoot. Due to the heterogeneous profiles of these clubfeet, treatment strategy should be based on a step-by step approach including recasting, bracing, and if necessary surgical intervention.

Outcomes in chevron osteotomy for Hallux Valgus in a large cohort.

Clinical and radiological related outcomes have been reported for Chevron osteotomy as correction for mild to moderate hallux valgus, but only for relatively small patient series. Moreover, evaluation of the patient's point of view has mostly been conducted by means of more physician-based outcome measures. The goal of this study was to evaluate the effect of the Chevron osteotomy for hallux valgus on patients' daily lives using the Foot and Ankle Outcome Score (FAOS) as a validated and a hallux valgus specific patient reported outcome measure (PROM). Secondary outcome measures were radiological correction, complication rate, and re-operations. All 438 Chevron procedures (336 patients), at two surgical hospital sites in the period between January 2010 and October 2014, were retrospectively evaluated with a follow-up of at least 6 months. Patients were invited to fill in a cross-sectional online FAOS. For the FAOS, a total response of 60% was achieved. The FAOS ranged between 71 and 88 with a follow-up of on average 36 months. Patients with an undercorrection of their hallux valgus (11.6% of the procedures) scored significantly lower on three subscales of the FAOS (range between 61 and 77 versus 72-84). Patients who had a reoperation (12.6% of the procedures) also scored significantly lower on four subscales: 58-100 versus 73-89. Postoperative radiological measurements improved significantly with a mean difference of 6.1 (5.9; 6.4) degrees for the intermetatarsal angle and 13.7 (13.0; 14.5) degrees for the hallux valgus angle. In this large study cohort, Chevron osteotomy for hallux valgus offers good PROM scores on FAOS. These scores were significantly lower in patients with radiological undercorrection or with a reoperation. Results of the FAOS appear to modulate with physician based outcomes and therapeutic incidents. Improvement of outcome may therefore well be possible by increased attention on these surgical details.