Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips.

INTRODUCTION: The incidence and natural course of pseudotumors in metal-on-metal total hip arthroplasties is largely unknown. The objective of this study was to identify the true incidence and risk factors of pseudotumor formation in large head metal-on-metal total hip arthroplasties. MATERIALS AND METHODS: Incidence, time course and risk factors for pseudotumor formation were analysed after large femoral head MoM-THA. We defined a pseudotumor as a (semi-)solid or cystic peri-prosthetic soft-tissue mass with a diameter ≥2 cm that could not be attributed to infection, malignancy, bursa or scar tissue. All patients treated in our clinic with MoM-THA's were contacted. CT scan, metal ions and X-rays were obtained. Symptoms were recorded. RESULTS: After median follow-up of 3 years, 706 hips were screened in 626 patients. There were 228 pseudotumors (32.3 %) in 219 patients (35.0 %). Pseudotumor formation significantly increased after prolonged follow-up. Seventy-six hips (10.8 %) were revised in 73 patients (11.7 %), independent risk factors were identified. Best cutoff point for cobalt and chromium was 4 µg/l (68 and 77 nmol/l). CONCLUSIONS: This study confirms a high incidence of pseudotumors, dramatically increasing after prolonged follow-up. Risk factors for pseudotumors are of limited importance. Pain was the strongest predictor for pseudotumor presence; cobalt chromium and swelling were considered poor predictors. Cross-sectional imaging is the main screening tool during follow-up.

Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey).

INTRODUCTION: Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results. MATERIALS AND METHODS: All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier. RESULTS: The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%). CONCLUSIONS: Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.

Acetabular augmentation ring for recurrent dislocation of total hip arthroplasty: 60% stability rate after an average follow-up of 74 months.

Between 1988 and 2002, 47 patients (50 hips) were treated with acetabular shell augmentation arthroplasty for recurrent idiopathic dislocation of their total hip arthroplasty. Apparent causes for dislocation such as deep infection, component malposition, or polyethylene wear were excluded. Follow-up averaged 74 months (range, 12-178 months), and clinically, 30 hips (60%) did not present a subsequent dislocation at most recent follow-up. In five hips (10%), deep infection after the augmentation procedure necessitated removal of the entire prosthesis. In our opinion, this technique cannot be recommended as it has an unacceptable failure and high infection rate.

In vivo wear reduction of argon compared to air sterilized UHMW-polyethylene liners.

INTRODUCTION: To date, no studies have been published that report on the in vivo advantages of sterilisation in argon (ARGON) versus air (AIR) of UHMWPE liners with respect to wear extend and pattern in uncemented total hip arthroplasty. METHOD: Femoral penetration rates were measured in 93 AIR and 79 ARGON liners, during a mean follow-up of 8 (3-12) years. RESULTS: During the first 3 years after implantation, both groups showed no differences in mean wear rate (P = 0.13). Thereafter, the ARGON liner demonstrated a decrease in wear rate of 0.04 mm/year from 4 to 6 years (P = 0.006), 0.14 mm/year from 7 to 9 years (P < 0.001), and 0.33 mm/year beyond 9 years follow-up (P = 0.015) compared to the AIR liner. One AIR acetabular component required revision.

Porous-coated femoral components with or without hydroxyapatite in primary uncemented total hip arthroplasty: a systematic review of randomized controlled trials.

The purpose of this systematic review was to determine the clinical and radiologic benefit of hydroxyapatite coating in uncemented primary total hip arthroplasty. A database of Medline articles published up to September 2007 was compiled and screened. Eight studies involving 857 patients were included in the review. Pooled analysis for Harris hip score as a clinical outcome measure demonstrated no advantage of the hydroxyapatite coating (WMD: 1.49, P = 0.44). Radiologically, both groups showed equal presence of endosteal bone ingrowth (RR: 1.04, P = 0.66) and radioactive lines (RR: 1.02, P = 0.74) in the surface area of the prosthesis. This meta-analysis demonstrates neither clinical nor radiologic benefits on the application of a hydroxyapatite coating on a femoral component in uncemented primary total hip arthroplasty.

[Gouty arthritis in a total knee prosthesis]. / Jichtartritis van een totale knieprothese.

This article describes a 69-year-old man with a bilateral total knee prosthesis in whom both knees were swollen and painful. Fever was present and the levels of inflammation markers were markedly elevated. Gout was diagnosed in the right knee and haemarthros during calcium carbasalate use in the left knee. Gout in a knee with a total knee prosthesis is rare and can mimic septic arthritis. Early diagnosis is of particular importance as the therapy of the two conditions differs considerably. Gout is treated with medication while surgical treatment is necessary in a case of septic arthritis, which may even involve removal of the prosthesis.

[Indications for antibiotic prophylaxis in patients with a prosthetic joint]. / Indicaties voor antibiotische profylaxe bij patiënten met een gewrichtsprothese.

Under certain circumstances, patients with a prosthetic joint and a focal infection elsewhere in the body may be at risk of developing bacterial infection of the prosthesis. Patients and physicians should actively prevent infections that can spread systemically. Routine antibiotic prophylaxis is not recommended for all patients with a prosthetic joint and suspected bacteraemia. Antibiotic prophylaxis is warranted in three groups of patients with a prosthetic joint who must undergo an invasive procedure that could cause bacteraemia: patients with a predisposing immunocompromising systemic condition or those receiving immunosuppressive therapy, patients with a dermatological infection, and patients with an obvious focal infection, e.g., urosepsis. If the patient is already receiving antibiotics for the infection, additional prophylaxis is usually unnecessary. For patients undergoing dental procedures who require antibiotic prophylaxis, amoxicillin-clavulanic acid or clindamycin are preferred.

[How many steps does a doctor take in the hospital? No difference between internists and general surgeons, but a relationship with age and BMI]. / Hoeveel stappen zet een dokter in het ziekenhuis? Geen verschil tussen internisten en algemeen chirurgen, maar wel samenhang met leeftijd en BMI.

OBJECTIVE: To determine the number of steps taken during working days in the hospital by both internists and general surgeons and whether there is a difference between housemen, registrars and members of the staff. DESIGN: Comparative analysis. METHOD: A validated pedometer was used to count the number of steps taken by housemen, registrars and staff members in the departments of internal medicine and general surgery. The 2 groups of doctors comprised 131 subjects from 13 training hospitals. Possible factors likely to affect the number of steps, such as age, sex, weight and height, were recorded. RESULTS: The average number of steps taken per day was 5325 (range: 1105-10,250) and the average number per hour was 548 (range: 143-1105), with an average working day of 9.8 hours and 8.4 measured days. When corrected for age, sex and hierarchic status, no significant difference was observed between surgeons and internists (p = 0.097). There were also no differences within the hierarchic structure after correction (p = 0.936). Age and BMI seemed to be the most important factors predicting the number of steps in this population. Each additional year of age corresponded with an average decrease of 5 steps per hour on the job (p = 0.001), while each point rise in BMI (+1 kg/m) coincided with an average decrease of 20 steps per hour (p = 0.001). CONCLUSION: After correcting for confounding factors, no differences were observed in the number of steps taken in the hospital by general surgeons and internists. There was also no difference between hierarchic levels. Age and BMI were the most important variables that predicted the number of steps taken per hour in this research population.

[Thromboprophylaxis is not indicated for knee arthroscopy and cast immobilisation]. / Tromboseprofylaxe niet geïndiceerd bij artroscopie van de knie en gipsimmobilisatie.

The incidence ofvenous thromboembolism following knee arthroscopy and plaster-cast immobilisation of the lower extremity is considerable (10-20%). The available data are insufficient to demonstrate that pharmacological thromboprophylaxis reduces the incidence of venous thromboembolism significantly. Withholding patients thromboprophylaxis in these situations is therefore a reasonable approach.

[Registration of assessments in orthopaedic residents' portfolios is falling short]. / Praktijktoetsen van aiossen onvoldoende geregistreerd.

OBJECTIVE: To evaluate of the number of registered competency assessments in the portfolios of orthopaedic residents in the Netherlands, for whom a competency-based training programme is mandatory. DESIGN: National cohort study. METHOD: We collected data regarding the registered assessments of all orthopaedic residents who finished their training between 2012-2015. We determined the number of registered assessments of 'standard orthopaedic treatments' (evaluating residents' competency in 70 different orthopaedic treatments), objective structured clinical skills evaluations (OSCEs), critically appraised topics (CATs), and 360 degree feedback appraisals. We compared the number of registered assessments in the portfolios with the minimum requirements laid down by the training curriculum. RESULTS: A total of 196 residents finished their training between 2012 and 2015. These residents finished their training with a mean (i.e., percentage of minimally required number of assessments) of 17.0 (34%) 'standard orthopaedic treatments' (level 4 or 5), 13.6 (34%) OSCEs, 2.6 (33%) CATs and 0.2 (4%) 360 degree feedback. CONCLUSION: On average, only one-third of the minimally required number of assessments were registered in the portfolios of orthopaedic residents (OSCEs and standard orthopaedic treatments level 4 or 5). These revelations show that action is needed to improve the way in which the progress of residents is monitored. These findings are going to have an effect on the new curriculum which must be more practical and less complex. Additionally, external quality control will focus more on residents at the end of their training and on the training region involved. This information may serve as a framework for postgraduate training programmes in other scientific associations which also find themselves in the same process of modernisation.

[How representative is the healthcare assessment website Zorgkaart Nederland? The evaluation of medical specialists by patients in the Netherlands]. / Hoe representatief is Zorgkaart Nederland? De waardering van specialisten door patiënten in beeld gebracht.

OBJECTIVE: To describe the number of ratings and the corresponding scores given to medical specialists on the Dutch healthcare assessment website 'Zorgkaart Nederland.nl', and evaluation of this website as tool for evaluation of quality. DESIGN: Explorative descriptive study. METHOD: In July 2015, data were gathered from the public section of the healthcare assessment website 'ZorgkaartNederland.nl'. The number of specialists, the mean ratings per department (group mark), the number of evaluations, the number of medical specialists without a rating and the number of specialists with at least 9 ratings were registered per speciality, per hospital. Outcomes measures were the median number of ratings per speciality and the group score. Data were analysed using descriptive and non-parametric statistics. RESULTS: Each month, 763,000 unique visitors access ZorgkaartNederland.nl; on average, 0.08% of these registers a vote. There were 15,337 medical specialists, spread across 97 hospitals and 2,060 specialities on ZorgkaartNederland.nl, with a total of 45,548 evaluations. Of these, 6,682 (43.4%) specialists were not rated, and 1.165 (7.6%) had ≥ 9 ratings. Additionally, 327 (15.9%) departments were unrated. Surgical departments were evaluated more often, and their grades were significantly higher, than those of non-surgical departments. CONCLUSION: The website ZorgkaartNederland.nl shows ratings for 56.6% of all medical specialists. When the lower limit of at least 9 evaluations per specialist introduced by ZorgkaartNederland.nl was applied, only the grades for 7.6% of all specialists are valid. On average, 0.08% of unique visitors cast a vote. Surgical specialities have a higher number of evaluations and a higher score than non-surgical ones. ZorgkaartNederland.nl in its current form does not constitute a valid tool for evaluation of the quality of medical specialist care in the Netherlands. This article provides recommendations for improvement.

Mid-term wear characteristics of an uncemented acetabular component.

We investigated the rate of polyethylene wear of a cementless acetabular component at different periods of follow-up in order to test the hypothesis than an irrecoverable deformation process (creep) was followed by an initially low, but gradually increasing wear rate. We studied prospectively 93 uncemented total hip arthroplasties in 83 patients (mean age 50 years (22 to 63)) with a mean follow-up of 8.2 years (3 to 12). We measured the penetration of the femoral head from radiographs taken immediately after surgery at three, six and nine years, or at the latest follow-up. The median wear rate was 0.17 mm per year in the first three years, a finding which we considered to be caused by creep. Thereafter, the rate of wear declined to 0.07 mm per year (four- to six-year period) and then increased to 0.17 mm per year (seven to nine years) and 0.27 mm per year (more than nine years), which we considered to be a reflection of genuine polyethylene wear. After the nine-year follow-up the wear rates were higher in patients with marked osteolysis. We found no relationship between the inclination angle of the acetabular component or femoral head orientation and the rate of wear. No acetabular component required revision.

Adherence to a metal, polymer and composite by Staphylococcus aureus and Staphylococcus epidermidis.

Bacterial adherence on to several materials with a potential application in reconstructive surgery was studied. Polymer (poly(L-lactide)), composite (hydroxyapatite/poly(L-lactide)) and metal (316L stainless steel) were evaluated both as smooth and sandblasted specimens. All materials were incubated in phosphate-buffered saline, challenged with Staphylococcus aureus or S. epidermidis and evaluated for up to 24 h. S. aureus showed a preference for the metal and composite tested over the polymer used. For S. epidermidis no preference was found for one of the investigated materials. The influence of surface roughness on bacterial growth was demonstrated by increased colonization on the sandblasted specimens.

A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement.

Sixty-two consecutive patients with painful limited dorsiflexion of the ankle not responding to nonoperative treatment participated in a prospective study. All 42 men and 20 women (average age, 31 years) underwent arthroscopic surgery. Preoperative radiographs were graded according to an osteoarthritic and an impingement classification. Standardized followup took place at 4 months and 1 and 2 years after surgery. Results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs. The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally.

Humeral shaft nonunion: evaluation of uniform surgical repair in fifty-one patients.

OBJECTIVE: To determine whether a standardized treatment of aseptic humeral shaft nonunions results in union after one operation without substantial complications. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: Between 1975 and 1998, fifty-eight patients sustained a humeral shaft fracture that resulted in an aseptic nonunion. Fifty-one patients between the ages of twenty-three and eighty-six years (mean 50.8 years) were included and evaluated. INTERVENTION: Surgical treatment consisted of an anterolateral approach with radial nerve identification and subsequent neurolysis, decortication, compression plating, and frequent application of autogenous bone grafts. No immobilization with brace or cast after treatment was functional. MAIN OUTCOME MEASURES: Success rate of nonunion repair, reinterventions, complications, range of motion, patient satisfaction. RESULTS: After one year, consolidation was apparent in all cases. All but two patients had an essentially normal range of motion of the shoulder and elbow, and 96 percent rated their result as excellent or good. After nonunion repair, two patients had a transient sensory neuropathy of the radial nerve. In one patient, a second intervention was needed after a fall from bed one week after the index operation. CONCLUSIONS: The results of this study indicate that our standard surgical procedure for treatment of nonunion of the humeral shaft is reliable and achieves consolidation in one procedure without significant complications.

[Thrombosis prophylaxis in orthopaedic surgery: considerations and uncertainties]. / Tromboseprofylaxe in de orthopedische chirurgie: inzichten en onzekerheden.

As it is not always possible to identify patients at extra risk of deep-venous thrombosis after major orthopaedic surgery, it is considered advisable to prescribe prophylactic treatment. Prophylaxis with a low dose of unfractionated heparin is more effective than no prophylaxis at all but less effective than low molecular-weight heparin or cumarine derivatives. Acetylsalicylic acid does not appear to have a place in the prevention of venous thromboemboli in elective total-hip and total-knee surgery. Its usefulness in the operative treatment of hip fractures has not been established. Starting prophylaxis postoperatively has not been shown to be less safe or effective than starting it preoperatively. The incidence of thrombosis is lower if the course of prophylactic treatment is lengthened to 4-6 weeks following arthroplasty of the hip or knee. The optimal period of medicinal prophylaxis has yet to be ascertained. Intermittent pneumatic compression appears to be effective after total-knee arthroplasty but in practice is difficult to deliver. Support stockings, a foot pump and rapid mobilization have little effect on the incidence of proximal deep-venous thrombosis. There are insufficient data regarding the use of thrombosis prophylaxis in day surgery.

Burnout and quality of life among orthopaedic trainees in a modern educational programme: importance of the learning climate.

We aimed to determine quality of life and burnout among Dutch orthopaedic trainees following a modern orthopaedic curriculum, with strict compliance to a 48-hour working week. We also evaluated the effect of the clinical climate of learning on their emotional well-being. We assessed burnout, quality of life and the clinical climate of learning in 105 orthopaedic trainees using the Maslach Burnout Inventory, linear analogue scale self-assessments, and Dutch Residency Educational Climate Test (D-RECT), respectively. A total of 19 trainees (18%) had poor quality of life and 49 (47%) were dissatisfied with the balance between their personal and professional life. Some symptoms of burnout were found in 29 trainees (28%). Higher D-RECT scores (indicating a better climate of learning) were associated with a better quality of life (r = 0.31, p = 0.001), more work-life balance satisfaction (r = 0.31, p = 0.002), fewer symptoms of emotional exhaustion (r = -0.21, p = 0.028) and depersonalisation (r = -0,28, p = 0.04). A reduced quality of life with evidence of burnout were still seen in a significant proportion of orthopaedic trainees despite following a modern curriculum with strict compliance to a 48-hour working week. It is vital that further work is undertaken to improve the quality of life and reduce burnout in this cohort.