No difference in the use of revision components and rerevision rate in conversion to total knee replacement following Oxford Partial Knee Microplasty Instrumentation: a registry study of 529 conversions.

BACKGROUND AND PURPOSE: Microplasty Instrumentation was introduced to improve Oxford Mobile Partial Knee placement and preserve tibial bone in partial knee replacement (PKR). This might therefore reduce revision complexity. We aimed to assess the difference in use of revision total knee replacement (TKR) tibial components in failed Microplasty versus non-Microplasty instrumented PKRs. PATIENTS AND METHODS: Data on 529 conversions to TKR (156 Microplasty instrumented and 373 non-Microplasty instrumented PKRs) from the Dutch Arthroplasty Register (LROI) between 2007 and 2019 was used. The primary outcome was the difference in use of revision TKR tibial components during conversion to TKR, which was calculated with a univariable logistic regression analysis. The secondary outcomes were the 3-year re-revision rate and hazard ratios calculated with Kaplan-Meier and Cox regression analyses. RESULTS: Revision TKR tibial components were used in 29% of the conversions to TKR after failed Microplasty instrumented PKRs and in 24% after failed non-Microplasty instrumented PKRs with an odds ratio of 1.3 (CI 0.86-2.0). The 3-year re-revision rates were 8.4% (CI 4.1-17) after conversion to TKR for failed Microplasty and 11% (CI 7.8-15) for failed non-Microplasty instrumented PKRs with a hazard ratio of 0.77 (CI 0.36-1.7). CONCLUSION: There was no difference in use of revision tibial components for conversion to TKR or in re-revision rate after failed Microplasty versus non-Microplasty instrumented PKRs nor in the 3-year revision rate.

Patient-specific instruments do not show advantage over conventional instruments in unicompartmental knee arthroplasty at 2 year follow-up: a prospective, two-centre, randomised, double-blind, controlled trial.

PURPOSE: The aim of this two-centre RCT was to compare pre- and post-operative radiological, clinical and functional outcomes between patient-specific instrumentation (PSI) and conventional instrumented (CI) unicompartmental knee arthroplasty (UKA). It was hypothesised that both alignment methods would have comparable post-operative radiological, clinical and functional outcomes. METHODS: One hundred and twenty patients were included, and randomly allocated to the PSI or the CI group. Outcome measures were peri-operative outcomes (operation time, length of hospital stay and intra-operative changes of implant size) and post-operative radiological outcomes including the alignment of the tibial and femoral component in the sagittal and frontal plane and the hip-knee-ankle-axis (HKA-axis), rate of adverse events (AEs) and patient-reported outcome measures (PROMs) pre-operatively and at 3, 12 and 24 months post-operatively. RESULTS: There was a statistically significant difference (p < 0.05) in alignment of the femoral component in the frontal plane in favour of the CI method. No statistically significant differences were found for the peri-operative data or in the functional outcome at 2-year follow-up. In the PSI group, the approved implant size of the femoral component was correct in 98.2% of the cases and the tibial component was correct in 60.7% of the cases. There was a comparable rate of AEs: 5.1% in the CI and 5.4% in the PSI group. CONCLUSION: The PSI method did not show an advantage over CI in regard of positioning of the components, nor did it show an improvement in clinical or functional outcome. We conclude that the possible advantages of PSI do not outweigh the costs of the MRI scan and the manufacturing of the PSI. LEVEL OF EVIDENCE: Randomised controlled trial, level I.

Acute femoral fracture does not compromise the outcome of total hip arthroplasty : 5 year results from a single center cohort study in 2,782 patients.

National arthroplasty registries reveal a higher risk of revision for periprosthetic fracture and dislocation after total hip arthroplasty (THA) in patients with a femoral neck fracture compared to those with osteoarthritis (OA). Since these registries may con- tain confounding factors, we conducted a single center cohort study comparing survival and reason for failure between THA for an acute femoral neck fracture and OA using the same hip prosthesis after a minimum follow-up of 2 years. We retrospectively analyzed 2782 patients who had undergone THA with an Accolade TMZF stem and a Trident cup between March 2009 and September 2014. Primary diagnosis before THA was osteoarthritis (OA group : n=2610) or acute femoral fracture (Fracture group : n=172). Patients in both groups were operated on by the same hip surgeons. Effect of diagnosis on THA survival was analyzed using Cox-regression analysis. Chi-square tests were used to illustrate the different reasons for revision between the groups. Mean follow-up was 4.6 years (2-7.6). A total of 100 revisions were performed. The revision risk was comparable between the OA and Fracture group (HR=1.04, 95% CI :0.46-2.39). No differences were found between the OA and Fracture group with respect to the occurrence of periprosthetic fractures (0.8% vs. 0.6%, p=0.71) and revisions for dislocation (0.6% vs. 1.2%, p=0.38). We found no difference in outcome or reason for revision between THA for OA or femoral neck frac- ture. Using an implant with a proven ODEP rating and having experienced hip surgeons carry out the procedures may be more important than the primary diagnosis.

Patients return to work sooner after unicompartmental knee arthroplasty than after total knee arthroplasty.

PURPOSE: It is not yet known if unicompartmental knee arthroplasty (UKA) patients are more likely to return to work sooner or have improved ability to work (i.e., workability) than total knee arthroplasty (TKA) patients. The following questions were addressed: patients were assessed to determine: (1) whether they returned to work sooner following UKA compared to TKA; (2) whether UKA patients had better WORQ function scores compared to TKA patients; and (3) if UKA patients have higher workability scores and greater satisfaction regarding workability than TKA patients. METHODS: A multicenter retrospective cohort study was performed that included patients at least 2 years after having undergone either UKA or TKA surgery and on the condition that patients had been in work in the 2 years prior to surgery. Time period between stopping work and returning to work was assessed; the WORQ scores (0 = worst-100 = best) and the Work Ability Index (WAI = 0-10) and reported satisfaction with work ability. RESULTS: UKA patients (n = 157, median 60 years, 51% male) were compared to TKA patients (n = 167, median 60 years, 49% male) (n.s.). Of the 157 UKA patients, 115 (73%) returned to work within 2 years compared to 121 (72%) of TKA patients (n.s.). More UKA patients return to work within 3 months (73% versus 48%) (p < 0.01). WORQ scores improved similarly in both groups. The WAI was also comparable between the groups. Dissatisfaction with workability was comparable (UKA 15% versus TKA 18% (n.s.). CONCLUSION: TKA and UKA patients have similar WORQ, WAI, and satisfaction scores. However, in this study population, UKA patients to return to work after surgery significantly sooner than TKA patients, which improves their quality of life and allows them to participate actively in society. This information can help health care providers and patients weigh-up the pros and cons and choose the best treatment and timing for patients in the working population. LEVEL OF EVIDENCE: III.

Does Activity-Based Rehabilitation With Goal Attainment Scaling Increase Physical Activity Among Younger Knee Arthroplasty Patients? Results From the Randomized Controlled ACTION Trial.

BACKGROUND: Especially in younger knee osteoarthritis patients, the ability to perform physical activity (PA) after knee arthroplasty (KA) is of paramount importance, given many patients' wish to return to work and perform demanding leisure time activities. Goal Attainment Scaling (GAS) rehabilitation after KA may improve PA because it uses individualized activity goals. Therefore, our aim was to objectively quantify PA changes after KA and to compare GAS-based rehabilitation to standard rehabilitation. METHODS: Data were obtained from the randomized controlled ACTION trial, which compares standard rehabilitation with GAS-based rehabilitation after total and unicompartmental KA in patients <65 years of age. At 2 time points, preoperatively and 6 months postoperatively, 120 KA patients wore a validated 3-dimensional accelerometer for 1 consecutive week. Data were classified as sedentary (lying, sitting), standing, and active (walking, cycling, running). Repeated measures analysis of variance was used to compare PA changes over time. RESULTS: Complete data were obtained for 97 patients (58% female), with a mean age of 58 years (±4.8). For the total group, we observed a significant increase in PA of 9 minutes (±37) per day (P = .01) and significant decrease in sedentary time of 20 minutes (±79) per day (P = .02). There was no difference in standing time (P = .11). There was no difference between the control group and the intervention group regarding changes in PA, nor between the total KA group and the unicompartmental KA group. CONCLUSION: We found a small but significant increase in overall PA after KA, but no difference between GAS-based rehabilitation and standard rehabilitation. Likely, enhanced multidisciplinary perioperative strategies are needed to further improve PA after KA.

Mortality and revision rate of cemented and uncemented hemiarthroplasty after hip fracture: an analysis of the Dutch Arthroplasty Register (LROI).

Background and purpose - Femoral neck fractures are commonly treated with cemented or uncemented hemiarthroplasties (HA). We evaluated differences in mortality and revision rates in this fragile patient group.Patients and methods - From January 1, 2007 until December 31, 2016, 22,356 HA procedures from the Dutch Arthroplasty Register (LROI) were included. For each HA, follow-up until death, revision, or end of follow-up (December 31, 2016) was determined. The crude revision rate was determined by competing risk analysis. Multivariable Cox regression analyses were performed to evaluate the effect of fixation method (cemented vs. uncemented) on death or revision. Age, sex, BMI, Orthopaedic Data Evaluation Panel (ODEP) rating, ASA grade, surgical approach, and previous surgery were included as potential confounders.Results - 1-year mortality rates did not differ between cemented and uncemented HA. 9-year mortality rates were 53% (95% CI 52-54) in cemented HA compared to 56% (CI 54-58) in uncemented HA. Multivariable Cox regression analysis showed similar mortality between cemented and uncemented HA (HR 1.0, CI 0.96-1.1). A statistically significantly lower 9-year revision rate of 3.1% (CI 2.7-3.6) in cemented HA compared with 5.1% (CI 4.2-6.2) in the uncemented HA was found with a lower hazard ratio for revision in cemented compared with uncemented HA (HR 0.56, CI 0.47-0.67).Interpretation - Long-term mortality rates did not differ between patients with a cemented or uncemented HA after an acute femoral neck fracture. Revision rates were lower in cemented compared with uncemented HA.

Higher risk of revision for partial knee replacements in low absolute volume hospitals: data from 18,134 partial knee replacements in the Dutch Arthroplasty Register.

Background and purpose - Partial knee replacement (PKR) survival rates vary a great deal among registries and cohort studies. These discrepancies can largely be attributed to inappropriate indications of the PKR and low thresholds for revision, but also to the PKR volume. This study used Dutch Arthroplasty Register data to analyze whether absolute PKR or proportional PKR hospital volume is associated with the risk of revision.Patients and methods - 18,134 PKRs were identified in the Dutch Arthroplasty Register from 2007 to 2016. For each year, hospitals were divided into 4 groups based on the quartiles for the absolute volume (< 22, 22-36, 36-58 and > 58 PKRs per year) and the proportional volume (< 8.5, 8.6-14.2, 14.3-25.8 and > 25.8% PKRs). Kaplan-Meier survival analysis was performed to determine survival rates. A multivariable Cox regression adjusted for age category, sex, ASA score, year of surgery, diagnosis, unicondylar side, and type of hospital was used to estimate hazard ratios (HR) for revision.Results and interpretation - Proportional PKR volume did not, but absolute PKR volume did influence the risk of revision. The adjusted HR for hospitals with an absolute volume of 22-36 PKRs per year was 1.04 (95% CI 0.91-1.20), 0.96 (CI 0.83-1.10) for the hospitals with 36-58 PKRs, and 0.74 (CI 0.62-0.89) for hospitals with more than 58 PKRs compared with hospitals that had fewer than 22 PKRs per year. So, patients treated with a PKR in a high absolute volume hospital have a lower risk of revision compared with those treated in a low absolute volume hospital.

Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work, sports, and leisure activities.

Background and purpose - Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. Patients and methods - A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned. Results - The questionnaire was completed by 175 patients, age 66 years (range 38-84), 57% female, BMI 29 (IQR 25-33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3-intra-articular injection-was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best. Interpretation - Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up.

BACKGROUND: In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved. METHODS/DESIGN: A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in 'Visual Analogue Scale'). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment. DISCUSSION: When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy. TRIAL REGISTRATION: This study is registered in the Trial Register ( www.trialregister.nl ) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569.

Eight respectively nine out of ten patients return to sport and work after distal femoral osteotomy.

PURPOSE: Distal femoral osteotomy (DFO) is a well-accepted procedure for the treatment of femoral deformities and associated symptoms including osteoarthritis, especially in younger and physically active patients in whom knee arthroplasty is undesirable. Still, there is an apparent need for evidence on relevant patient outcomes, including return to sport (RTS) and work (RTW), to further justify the use of knee osteotomy instead of surgical alternatives. Therefore, the purpose of the present study was to investigate the extent and timing of patients' RTS and RTW after DFO. METHODS: This monocentre, retrospective cohort study included consecutive DFO patients, operated between 2012 and 2015. Out of 126 eligible patients (18-70 years, 63% female), all patients responded, and 100 patients completed the questionnaire. Median follow-up was 3.4 years (range 1.5-5.2). The predominant indication for surgery was symptomatic unicompartmental osteoarthritis and valgus or varus leg alignment caused by a femoral deformity. The primary outcome measure was the percentage of RTS and RTW. Secondary outcome measures included time to RTS/RTW, sports level and frequency, the median pre-symptomatic and postoperative Tegner activity score (1-10, higher is more active) and the postoperative Lysholm score (0-100, higher is better). RESULTS: Out of 84 patients participating in sports preoperatively, 65 patients (77%) returned to sport postoperatively. Forty-six patients (71%) returned to sports within 6 months. Postoperative participation in high-impact sports was possible though less frequent compared to preoperative participation. Out of 80 patients working preoperatively, 73 (91%) returned to work postoperatively, of whom 59 patients (77%) returned within 6 months. The median pre-symptomatic Tegner activity score [4.0 (range 0-10)] was significantly higher (p < 0.01) than the reported Tegner score at follow-up [3.0 (range 0-10)]. The mean Lysholm score at follow-up was 68 (± 22). No significant differences were found between the osteoarthritis- and non-osteoarthritis group. CONCLUSION: Eight out of ten patients return to sport and nine out of ten patients return to work after DFO. These are clinically relevant findings, because they further justify DFO as a surgical alternative to KA in young, active knee OA patients who wish to return to high activity levels. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

The negative effect of joint line elevation after total knee arthroplasty on outcome.

PURPOSE: Total knee arthroplasty (TKA) is widely used as a treatment for knee osteoarthritis. However, still up to 20% of the patients are dissatisfied. Joint line elevation after TKA might be a contributing factor as it alters knee kinematics. The aim of this study was to investigate the effect of joint line elevation on outcome. METHODS: A systematic review of the literature was performed to select studies that reported on joint line alterations after primary or revision TKA and outcome. Studies with comparable outcome parameters were included in a correlation analysis. RESULTS: In total, 396 studies were identified, of which 27 met the inclusion criteria. 8 studies could be included in the correlation analysis. Mean joint line elevation after primary TKA was 3.0 mm and after revision TKA this was 3.6 mm. A statistically significant negative correlation was found between joint line elevation and the postoperative Knee Society Score (KSS) function score (ρ = - 0.496, p < 0.001). In a pooled analysis, the maintained joint line revision TKA group had statistically significant better postoperative KSS total scores compared to an elevated joint line group (p < 0.001). CONCLUSION: In this systematic review, a negative correlation between joint line elevation and outcome was found. Furthermore, revision TKAs with a maintained joint line have statistically significant better postoperative KSS scores compared to an elevated joint line group. To achieve optimal outcome after TKA, restoration of the joint line is one of the parameters that should be pursued and introduced elevation should not exceed 4 mm. LEVEL OF EVIDENCE: IV.

Surgical approaches for total elbow arthroplasties using data from the Dutch Arthroplasty Register.

BACKGROUND: Total elbow arthroplasty (TEA) is a relatively infrequently performed procedure. Therefore, nationwide databases help to provide more insight into factors that might influence implant survival, for example, the surgical approach used. Using data from the Dutch Arthroplasty Register, we aimed to reveal whether high-volume centers use different approaches than low-volume centers and whether the approach is implant specific. METHODS: Using data from 2014 to 2017, we compared the surgical approaches used for high- vs. low-volume centers, as well as for the 2 most frequently used types of TEA, by use of χ2 tests. RESULTS: We analyzed 276 procedures. In 2016 and 2017, when posterior approaches were further specified, the triceps-on approach was used most frequently in the high-volume center (27 of 42 procedures, 64%) and the triceps-flap approach was used most often in the low-volume centers (48 of 84 procedures, 57%) (P < .001). For the 2 most frequently used types of TEA, the Coonrad-Morrey and Latitude EV arthroplasties, the surgical approaches did not differ. When the high-volume center was compared with the low-volume centers, implant choice differed, with the Coonrad-Morrey arthroplasty being most often used in the high-volume center and the Latitude EV arthroplasty, in the low-volume centers. CONCLUSION: The posterior triceps-flap approach was the most frequently used surgical approach in primary TEA in the Netherlands, yet the triceps-on approach was used more often in the high-volume center. The surgical approaches did not differ between the 2 most frequently used types of TEA in the Netherlands.

Does surgeon volume influence the outcome after hip hemiarthroplasty for displaced femoral neck fractures; early outcome, complications, and survival of 752 cases.

INTRODUCTION: Surgeon volume of hip arthroplasties is of importance with regard to complication and revision rates in total hip arthroplasty. For hip hemiarthroplasty, the effect of surgeon volume on outcome is far less studied. We analyzed the outcome of hip hemiarthroplasties performed by orthopedic surgeons in a retrospective cohort in different volume categories, focusing on early survival of the prosthesis and complications. METHODS: Between March 2009 and January 2014, 752 hemiarthroplasties were performed for intracapsular femoral neck fracture by 27 orthopedic surgeons in a large Dutch teaching hospital. Surgeons were divided into four groups, a resident group and three groups based on the number of total hip arthroplasties and hemiarthroplasties performed per year: a low-volume (< 10 arthroplasties per year), moderate-volume (10-35 arthroplasties per year), and high-volume groups (> 35 arthroplasties per year). Outcome measures were stem survival using a competing risk analysis, complication rates, and mortality. Chi-square tests were used to compare complication rates and mortality between groups. RESULTS: Patients were followed for a minimum of 2 years or until revision or death. Overall 60% of the patients included had died at time of follow-up. We found comparable stem survival rates in the low-volume group (n = 48), moderate-volume group (n = 201), high-volume group (n = 446), and resident group (n = 57). There were no significant differences between the groups with regard to dislocation rate, incidence of periprosthetic fracture, infection, and mortality. CONCLUSION: Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. Hemiarthroplasty can safely be performed by both experienced hip surgeons and low-volume surgeons.

Use and outcome of 1,220 primary total elbow arthroplasties from the Australian Orthopaedic Association National Joint Arthroplasty Replacement Registry 2008-2018.

Background and purpose - The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate.Patients and methods - During 2008-2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan-Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates.Results - The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1-3.0) and RA (HR = 2.0, CI 1.3-3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%).Interpretation - The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.

Not Physical Activity, but Patient Beliefs and Expectations are Associated With Return to Work After Total Knee Arthroplasty.

BACKGROUND: After total knee arthroplasty (TKA), 17%-60% of the patients do not or only partially return to work (RTW). Reasons for no or partial RTW remain unclear, warranting further research. Physical activity (PA) has proven beneficial effects on work participation. Therefore, we hypothesized that preoperative PA is associated with RTW after TKA. METHODS: Working TKA patients participating in an ongoing prospective cohort study were included. Preoperatively and 1 year postoperatively, patients were asked to define their work status and PA level according to the Dutch Recommendation for Health-Enhancing PA and the Fitnorm. Multivariate logistic regression analysis was performed to assess the effect of PA on RTW, taking into account established prognostic factors for RTW among TKA patients. RESULTS: Of 283 eligible patients, 266 (93%) completed the questionnaires sufficiently. Preoperatively, 141 patients (54%) performed moderate PA for ≥5 d/wk and 42 (16%) performed intense PA for ≥3 d/wk. Concerning RTW, 178 patients (67%) reported full RTW, 59 patients (22%) partial RTW, and 29 patients (11%) no RTW. Preoperative PA was not associated with RTW. Patients who reported that their knee symptoms were not or only partially work-related had lower odds of no RTW (odds ratio 0.37, 95% confidence interval 0.17-0.81). Also, for each additional week patients expected to be absent from work, the likelihood of no RTW increased (odds ratio 1.11, 95% confidence interval 1.03-1.18). CONCLUSION: No association between preoperative PA and RTW after TKA was found. Patient beliefs and preoperative expectations did influence RTW and should be addressed to further improve RTW after TKA.

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.

Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial.

BACKGROUND: The elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program. METHODS/DESIGN: The SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb. DISCUSSION: A successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow. TRIAL REGISTRATION: The trial is registered at the Dutch Trial Register: NTR6067 , 31-8-2016.

Outpatient unicompartmental knee arthroplasty: who is afraid of outpatient surgery?

PURPOSE: In recent years, duration of hospitalisation after knee arthroplasty has decreased and fast track and outpatient surgery protocols have been developed. Studies have shown that outpatient surgery is feasible, safe, and cost effective. However, the psychological well-being of patients undergoing outpatient surgery has never been described before. The purpose of this study was to investigate how patients experience outpatient surgery for unicompartmental knee arthroplasty (UKA), examining levels of anxiety and depression, satisfaction, and pain. It was hypothesized that the same-day discharge following UKA would not result in higher levels of anxiety and depression, compared to the standard fast-track surgery. METHODS: This case-controlled study included 20 patients undergoing UKA in an outpatient surgery setting and 20 patients undergoing the standard fast-track procedure. The Hospital Anxiety and Depression Scale (HADS, 0-42, lower is better) and numeric rating scales (NRS, 0-10) for pain and satisfaction were collected preoperatively, on the day of surgery, on the first, second, and seventh postoperative days and after 6 and 12 weeks. The Oxford Knee Score (OKS), the KOOS, EuroQoL-5D, and Net Promoter Score (NPS) were collected preoperatively and 3 months postoperatively. RESULTS: 90% of patients in the outpatient surgery group were discharged on the day of surgery. At the first postoperative day, the median HADS score was significantly lower in the outpatient surgery group compared to the fast-track group (3 vs. 8, p = 0.02), the median NRS satisfaction score was significantly higher in the outpatient surgery group (8 vs. 5, p = 0.03), and no differences existed between both groups for the NRS pain scores. At 3 month follow-up, no significant differences in improvement scores existed between both groups for the HADS, the NRS scores, and for the OKS, KOOS, EuroQoL-5D, and NPS. CONCLUSION: The results of this study emphasize the feasibility of an outpatient surgery pathway in carefully selected UKA patients. The outpatient surgery pathway is safe, and clinical outcome, including levels of anxiety and depression, satisfaction, and pain, was similar in outpatient surgery patients compared to the standard fast-track patients. LEVEL OF EVIDENCE: Case-control study, Level III.

Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy.

PURPOSE: Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE. METHODS: Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported. RESULTS: Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular. CONCLUSION: Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.

Clinical and radiographic outcome of revision surgery of radial head prostheses: midterm results in 16 patients.

BACKGROUND: Little is known about revision surgery of radial head arthroplasty. The aim of this study was to report on the clinical and radiographic outcome of revision arthroplasty of the elbow with a bipolar metallic radial head prosthesis. METHODS: Between 2006 and 2013, we used either a press-fit or cemented RHS bipolar radial head prosthesis for revision surgery of radial head arthroplasty in 16 patients. Patients were prospectively enrolled in the study. Differences in outcome parameters before and after revision surgery were compared. RESULTS: At a mean follow-up of 75 months (range, 36-116 months), none of the revised radial head prostheses needed a second revision. None of the stems showed radiographic signs of loosening. In 1 patient the head was dissociated from the prosthesis. The average flexion-extension arc was 127° (range, 105°-140°), and the average pronation-supination arc was 138° (range, 90°-160°). Stability scores improved after revision surgery, resulting in 13 stable elbows (P = .01). In 8 patients the Oxford Elbow Score was between 37 and 48 points. The percentage of patients with either good or excellent results according to the Mayo Elbow Performance Score was 63%. The mean score on the EQ-5D (EuroQol Five Dimensions) was 80 (range, 63-100), and the visual analog scale scores both for pain at rest and for pain with activity improved to 3 (range, 0-9) and 4 (range, 0-9), respectively (P < .001). All but 1 patient was satisfied with the results of the revision procedure. CONCLUSION: The clinical and radiographic outcomes of revision surgery of a radial head prostheses are favorable.