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

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

Comparison of early migration patterns between a ceramic and polyethylene liner in uncemented Trabecular Titanium cups: a 2-year randomized controlled trial of 52 hips using radiostereometric analysis.

BACKGROUND AND PURPOSE: Ceramic liners may reduce early stability of uncemented acetabular components due to higher stiffness. However, the bone ingrowth capacities of porous trabecular titanium might compensate for this effect. This prospective randomized trial quantifies migration patterns of the Delta-TT cup, and compares polyethylene and ceramic liners. PATIENTS AND METHODS: Patients undergoing primary uncemented total hip arthroplasty with the Delta-TT cup and femoral stem with ceramic head were randomized to a polyethylene (n = 25) or ceramic (n = 28) liner. Radiostereometric analysis (RSA) radiographs, patient-reported hip function (HOOS-PS, OHS), and quality of life (EQ5D) were collected at baseline and 1.5, 3, 6, 12, and 24 months postoperatively. Model-based RSA was used to calculate 3D cup translation and rotation, and mixed models were used to compare effects over time between groups. RESULTS: At 2 years follow-up, Delta-TT cups showed similar mean proximal translation of 0.56 mm (95% CI 0.38-0.75) in the ceramic (CE) group and 0.54 mm (0.30-0.77) in the polyethylene (PE) group, with a between group effect of 0.02 mm (-0.20-0.23). Most cup migration occurred in the first 1.5 to 3 months, stabilizing within 6 months. Any between-group effects were ≤ 0.30 mm for translation and ≤ 0.45° for rotation. Improvements in patient-reported hip function and quality of life were similar in both groups. INTERPRETATION: Regardless of liner type, Delta-TT cups showed some initial migration and stabilized within 6 months, which seems promising for long-term fixation in both cup-liner constructs.

Digital medical history implementation to triage orthopaedic patients during COVID-19: Findings from a rapid cycle, semi-randomised A/B testing quality improvement project.

INTRODUCTION: The COVID-19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised. METHODS: We analysed 640 patients using a rapid cycle, semi-randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion. ETHICAL APPROVAL: N/A (Quality Improvement Project) RESULTS: Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients [63 out of 81 patients]). Across all patients, increasing age (odds ratio [OR]: 0.985 (95% CI: 0.976-0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234-0.666), p = 0.001), and patients with non-specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176-0.623), p = 0.001) were associated with decreased odds of DMH completion. DISCUSSION AND CONCLUSION: DMHs can be valuable in helping triage orthopaedic patients in resource-strapped settings, times of crisis, or as we transition towards value-based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.

Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial.

BACKGROUND: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. PURPOSE: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. RESULTS: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. CONCLUSION: Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. REGISTRATION: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Responsiveness and interpretability of the Animated Activity Questionnaire for assessing activity limitations of patients with hip or knee osteoarthritis.

PURPOSE: The aim of the study was to determine the responsiveness and interpretability of the Animated Activity Questionnaire (AAQ), an online questionnaire in which osteoarthritis patients select animations that best match their performance of daily activities. METHODS: A longitudinal study was carried out, in which 94 patients with hip or knee osteoarthritis were assessed at baseline, and 3 and 6 months after treatment (conservative and surgical). Responsiveness was assessed by means of testing hypotheses about expected correlations between change in AAQ, a Global Rating Scale of change (GRS) and change in the Activities of Daily Living subscale of the Hip disability or Knee injury and Osteoarthritis Outcome Score (H/KOOS), and a combination of performance-based tests (the 30 s chair-stand test, the timed up-and-go test and the nine-step stair climbing test). The minimal important change (MIC) was estimated by means of the receiving operating characteristics (ROC) method. RESULTS: The correlations of the AAQ with the H/KOOS were as expected, but other correlations were lower than anticipated. The area under the ROC curve was 0.74 at 6 months. At 3 months' follow-up, the correlations were too low to calculate a MIC. A total of 20% of the results at 3 months and 80% of the results at 6 months were in accordance with the hypotheses. The MIC was 9 points at 6 months. CONCLUSIONS: The AAQ was sufficiently responsive at the six-months follow-up, but not at the three-month follow-up. The MIC at the 6-month follow-up (9 points) was slightly lower than the smallest detectable change of 14 points found in a previous study.

Normative values and affecting factors for the elbow range of motion.

INTRODUCTION: Abnormalities in the elbow range of motion (ROM) can be subtle; therefore, it is important that the examiner can compare findings with reliable reference values, matching the patients' characteristics. Primarily, we aimed to provide normative values for the elbow ROM in subpopulations based on age, sex, dominance and body mass index (BMI). The secondary objective was to determine intra- and inter-rater reliability. METHODS: aROM (active range of motion) and pROM (passive range of motion) were measured bilaterally in healthy adults using a universal goniometer. The influence of factors affecting the ROM was calculated using Pearson's correlation coefficient. In two samples of subjects, intra-rater and inter-rater reliability were determined. RESULTS: The study population (n = 352) consisted of 47.2% male and 52.8% female subjects. For aROM (dominant hand), mean flexion was 146°, extension -2°, pronation 80° and supination 87°. Male subjects had smaller ROM compared to females (p < 0.001). Differences between dominant and nondominant hand were less than one degree. pROMs were 3° to 5° larger than aROMs (p < 0.001). Intra- and inter-rater reliability was good. CONCLUSIONS: Elbow ROM is influenced by age, sex and BMI. In the general population, the ROM of the uninjured side can serve as a reference in case of an injured elbow.

Increased Persistent Mid-Thigh Pain After Short-Stem Compared With Wedge-Shaped Straight-Stem Uncemented Total Hip Arthroplasty at Medium-Term Follow-Up: A Randomized Double-Blinded Cross-Sectional Study.

BACKGROUND: Femoral prosthesis design may impact the frequency of mid-thigh pain. We compared current, incidental, and persistent mid-thigh pain between the short-stem, Collum Femoris femur prosthesis, and the wedge shaped straight-stem, Zweymüller femur prosthesis and studied the associations between demographics, radiographic measurements, and mid-thigh pain. METHODS: We contacted patients from a randomized controlled trial who underwent uncemented total hip arthroplasty (THA) for hip osteoarthritis at a mean follow-up of 44 months (range 24-64 months). Patients were specifically assessed for current (during assessment), incidental (any time postoperatively for >1 week) mid-thigh pain, and persistent (any time postoperatively for >2 years) mid-thigh pain. Furthermore, we used regression analysis to study associations between demographics, radiographic measurements, and mid-thigh pain. RESULTS: One hundred forty of 150 patients (93%) responded to our assessment. Mean age at the time of operation was 62 years (±7.0). Current mid-thigh pain occurred in 16 patients (23%) in the Collum Femoris Preserving (CFP) group compared with 10 patients (14%) in the Zweymüller group (P = .192). Incidental mid-thigh pain occurred in 24 patients (34%) in the CFP group compared with 15 patients (21%) in the Zweymüller group (P = .090). Persistent mid-thigh pain was found in 13 patients (19%) in the CFP group compared with five patients (7%) in the Zweymüller group (P = .043). Varus malalignment (odds ratio 1.819 [95% confidence interval 1.034-3.200]) and leg lengthening (odds ratio 1.107 per cm lengthening [95% confidence interval 1.026-1.195]) showed significant associations with mid-thigh pain. CONCLUSIONS: We found more persistent mid-thigh pain after short-stem uncemented THA compared to wedge-shaped straight-stem uncemented THA during medium-term follow-up. Varus malalignment and leg lengthening were associated with mid-thigh pain.

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.

Feedback to Patients About Patient-reported Outcomes Does Not Improve Empowerment or Satisfaction.

BACKGROUND: Although patient-reported outcome measures (PROMs) are helpful to define whether an intervention has improved a patient's status in ways the patient feels are important, they may also serve an empowering educational role; specifically, sharing a patient's scores might help the patient understand his or her progress during treatment. However, whether sharing PROM scores in this way improves the sense of empowerment or satisfaction with the process of care has not been well explored. Also, less is known whether specific demographic factors or coping strategies are associated with empowerment. QUESTIONS/PURPOSES: We asked the following: (1) Does giving patients feedback on their PROM scores improve a patient's sense of empowerment or satisfaction? (2) Do demographic factors, duration of disability, or self-efficacy correlate with patient empowerment? METHODS: In this prospective cohort study, we assigned patients with osteoarthritis of the knee or hip sequentially such that the first 70 patients did not receive the intervention and the next 72 did. Patients enrolled in the control cohort were managed according to standard care, whereas patients enrolled in the intervention cohort completed web-based questionnaires measuring their physical function and pain. After filling out the questionnaires, a printout with the scores was given to the patients providing feedback about their physical function and pain. The primary outcome measure was patient empowerment, as measured by the Patient Activation Measure. Secondary outcomes were patient satisfaction, as measured by an 11-point Likert scale and Patient Doctor Relation Questionnaire. Independent variables were demographic factors and coping, measured by the Pain Self-efficacy Questionnaire. Bivariate and multivariable analyses were performed to determine the influence of the feedback. Although no minimum clinically important differences have been defined for the patient empowerment or satisfaction scales, we believe that differences smaller than 10% are unlikely to be clinically important, even if they are statistically significant. RESULTS: Although the group that received PROM feedback had higher scores for empowerment than the group that did not, the effect size was small and likely not to have been clinically important (2.8 ± 0.85 versus 3.1 ± 0.811; mean difference -0.31; 95% confidence interval, 2.8-3.1; p = 0.037). With the numbers available, there were no differences between the group given PROM feedback and the group that did not receive such feedback in terms of satisfaction scores (8.6 ± 1.4 versus 8.8 ± 1.2; mean difference -0.19; p = 0.39). After controlling for demographic factors such as level of education and duration of complaint, we found that the group that received PROM feedback and who had a higher level of self-efficacy had higher scores for empowerment than the group that did not, although the effect size was small. CONCLUSIONS: PROM feedback did not have a clinically important impact on empowerment or satisfaction. This might indicate that counseling based on PROMs during a single visit may be ineffective. The most important positive finding is that more effective coping strategies are associated with greater patient empowerment. LEVEL OF EVIDENCE: Level II, therapeutic study.

Better early functional outcome after short stem total hip arthroplasty? A prospective blinded randomised controlled multicentre trial comparing the Collum Femoris Preserving stem with a Zweymuller straight cementless stem total hip replacement for the treatment of primary osteoarthritis of the hip.

OBJECTIVES: Primary aim was to compare the functional results at 3 months and 2 years between short and conventional cementless stem total hip arthroplasty (THA). Secondary aim was to determine the feasibility of a double-blind implant-related trial. DESIGN: A prospective blinded randomised controlled multicentre trial in patients with osteoarthritis of the hip. All patients, research assistants, clinical assessors, investigators and data analysts were blinded to the type of prosthesis. POPULATION: 150 patients between 18 and 70 years with osteoarthritis of the hip, 75 in the short stem and 75 in the conventional stem group. Mean age: 60 years (SD 7). INTERVENTIONS: the Collum Femoris Preserving short stem versus the Zweymuller Alloclassic conventional stem. MAIN OUTCOME MEASURES: The Dutch version of the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes measures: Harris Hip Score, the Physical Component Scale of the SF12, the Timed Up and Go test, Pain and the EQ-5D. Feasibility outcomes: continued blinding, protocol adherence and follow-up success rate. RESULTS: No significant difference between the two groups. Mean HOOS total score in the short stem group increased 32.7 points from 36.6 (95% CI 32.9 to 40.2) preoperatively to 69.3 (95% CI 66.4 to 72.1) at 3 months follow-up. Mean HOOS total score in the conventional straight stem group increased 36.3 points from 37.1 (95% CI 33.9 to 40.3) preoperatively to 73.4 (95% CI 70.3 to 76.4) at 3 months follow-up. 91.2% of patients remained blinded at 2 years follow-up. Both protocol adherence and follow-up success rate were 98%. CONCLUSIONS: Functional result at 3 months and 2 years after short stem THA is not superior to conventional cementless THA. There were more perioperative and postoperative complications in the short stem group. Direct comparison of two hip implants in a double-blinded randomised controlled trial is feasible. TRIAL REGISTRATION NUMBER: NTR1560.

Classification systems for distal radius fractures.

Background and purpose - The reliability of conventional radiography when classifying distal radius fractures (DRF) is fair to moderate. We investigated whether reliability increases when additional computed tomography scans (CT) are used. Patients and methods - In this prospective study, we performed pre- and postreduction posterior-anterior and lateral radiographs of 51 patients presenting with a displaced DRF. The case was included when there was a (questionable) indication for surgical treatment and an additional CT was conducted within 5 days. 4 observers assessed the cases using the Frykman, Fernández, Universal, and AO classification systems. The first 2 assessments were performed using conventional radiography alone; the following 2 assessments were performed with an additional CT. We used the intraclass correlation coefficient (ICC) to evaluate reliability. The CT was used as a reference standard to determine the accuracy. Results - The intraobserver ICC for conventional radiography alone versus radiography and an additional CT was: Frykman 0.57 vs. 0.51; Fernández 0.53 vs. 0.66; Universal 0.57 vs. 0.64; AO 0.59 vs. 0.71. The interobserver ICC was: Frykman: 0.45 vs. 0.28; Fernández: 0.38 vs. 0.44; Universal: 0.32 vs. 0.43; AO: 0.46 vs. 0.40. Interpretation - The intraobserver reliability of the classification systems was fair but improved when an additional CT was used, except for the Frykman classification. The interobserver reliability ranged from poor to fair and did not improve when using an additional CT. Additional CT scanning has implications for the accuracy of scoring the fracture types, especially for simple fracture types.

Cross-Cultural and Construct Validity of the Animated Activity Questionnaire.

OBJECTIVE: The Animated Activity Questionnaire (AAQ) assesses activity limitations in patients with hip/knee osteoarthritis and consists of video animations; the patients choose the animation that best matches their own performance. The AAQ has shown good validity and reliability. This study aims to evaluate cross-cultural and construct validity of the AAQ. METHODS: Cross-cultural validity was assessed using ordinal logistic regression analysis to evaluate differential item functioning (DIF) across 7 languages. Construct validity was assessed by testing correlations between the AAQ and a patient-reported outcome measure (PROM) and performance-based tests. RESULTS: Data from 1,239 patients were available. Compared to the Dutch language (n = 279), none of the 17 items showed DIF in English (n = 202) or French (n = 193), 1 item showed uniform DIF in Spanish (n = 99) and Norwegian (n = 62), and 2 items showed uniform DIF in Danish (n = 201). In all these languages, the occurrence of DIF did not influence the total score, which remained comparable with the original Dutch version. For Italian (n = 203) versus Dutch, however, 6 items showed uniform DIF, and 1 item showed nonuniform DIF, indicating some problems with the cross-cultural validity between these countries. With regard to construct validity, the correlations with PROM (0.74) and performance-based tests (0.36-0.68) were partly as expected (>0.60). CONCLUSION: The AAQ, an innovative tool to measure activity limitations that can be placed on the continuum between PROMs and performance-based tests, showed a good overall cross-cultural validity, and seems to have great potential for international use in research and daily clinical practice in many European countries.

Isometric muscle strength and mobility capacity in children with cerebral palsy.

PURPOSE: To determine the relationship between isometric leg muscle strength and mobility capacity in children with cerebral palsy (CP) compared to typically developing (TD) peers. METHOD: Participants were 62 children with CP (6-13 years), able to walk with (n = 10) or without (n = 52) walking aids, and 47 TD children. Isometric muscle strength of five muscle groups of the leg was measured using hand-held dynamometry. Mobility capacity was assessed with the 1-min walk, the 10-m walk, sit-to-stand, lateral-step-up and timed-stair tests. RESULTS: Isometric strength of children with CP was reduced to 36-82% of TD. When adjusted for age and height, the percentage of variance in mobility capacity that was explained by isometric strength of the leg muscles was 21-24% (walking speed), 25% (sit-to-stand), 28% (lateral-step-up) and 35% (timed-stair) in children with CP. Hip abductors and knee flexors had the largest contribution to the explained variance, while knee extensors showed the weakest correlation. Weak or no associations were found between strength and mobility capacity in TD children. CONCLUSION: Isometric strength, especially hip abductor and knee flexor strength, is moderately related to mobility capacity in children with CP, but not in TD children. To what extent training of these muscle groups will lead to better mobility capacity needs further study. Implications for Rehabilitation Strength training in children with cerebral palsy (CP) may be targeted more specifically at hip abductors and knee flexors. The moderate associations imply that large improvements in mobility capacity may not be expected when strength increases.

Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45†years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial.

INTRODUCTION: Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking. METHODS AND ANALYSIS: A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events. ETHICS AND DISSEMINATION: This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees. TRIAL REGISTRATION NUMBER: NCT01850719.

Does Computed Tomography Change our Observation and Management of Fracture Non-Unions?

BACKGROUND: The purpose of this study was to determine whether Multi-Detector Computed Tomography (MDCT) in addition to plain radiographs influences radiologists' and orthopedic surgeons' diagnosis and treatment plans for delayed unions and non-unions. METHODS: A retrospective database of 32 non-unions was reviewed by 20 observers. On a scale of 1 to 5, observers rated on X-Ray and a subsequent Multi Detector Helical Computer Tomography (MDCT) scan was performed to determine the following categories: "healed", "bridging callus present", "persistent fracture line" or "surgery advised". Interobserver reliability in each category was calculated using the Interclass Correlation Coefficient (ICC). The influence of the MDCT scan on the raters' observations was determined in each case by subtracting the two scores of both time points. RESULTS: All four categories show fair interobserver reliability when using plain radiographs. MDCT showed no improvement, the reliability was poor for the categories "bridging callus present" and "persistent fracture line", and fair for "healed" and "surgery advised". In none of the cases, MDCT led to a change of management from nonoperative to operative treatment or vice versa. For 18 out of 32 cases, the treatment plans did not alter. In seven cases MDCT led to operative treatment while on X-ray the treatment plan was undecided. CONCLUSION: In this study, the interobserver reliability of MDCT scan is not greater than conventional radiographs for determining non-union. However, a MDCT scan did lead to a more invasive approach in equivocal cases. Therefore a MDCT is only recommended for making treatment strategies in those cases.

Arthroscopic Partial Meniscectomy or Conservative Treatment for Nonobstructive Meniscal Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

PURPOSE: To conduct a meta-analysis of randomized controlled trials comparing the outcome of arthroscopic partial meniscectomy (APM) with conservative treatment in adults with nonobstructive meniscal tears and to recommend a treatment of choice. METHODS: We systematically searched the databases of MEDLINE, Excerpta Medica Database, Cochrane, the National Health Service Centre for Reviews and Dissemination, and Physiotherapy Evidence Database from inception to May 2, 2016. Two authors independently searched the literature and selected eligible studies. The meta-analyses used a random-effects model. The primary outcome was physical function, measured by knee-specific patient-reported outcomes. Secondary outcomes included knee pain, activity level, the progression of osteoarthritis, adverse events, general health, and quality of life. RESULTS: We included 6 randomized controlled trials, with a total of 773 patients, of whom 378 were randomized to APM and 395 were randomized to the control treatment. After pooling the data of 5 studies, we found small significant differences in favor of the APM group for physical function at 2 to 3 months (mean difference [MD] = 3.31; 95% confidence interval [CI] = 0.69-5.93; P = .01; I(2) = 0% [Lysholm knee score]), and at 6 months (MD = 3.56; 95% CI = 0.24-6.88; P = .04; I(2) = 0% (Knee injury and Osteoarthritis Outcome Score [KOOS] and Western Ontario and McMaster Universities Osteoarthritis Index); standardized MD = 0.17; 95% CI = 0.01-0.32; P = .03; I(2) = 0% [Lysholm knee score, KOOS, and Western Ontario and McMaster Universities Osteoarthritis Index]). We also found small significant differences for pain at 6 months (MD = 3.56; 95% CI = 0.18-6.95; P = .04; I(2) = 0% [KOOS] and MD = 0.56; 95% CI = 0.28-0.83; P ≤ .0001; I(2) = 0% [visual analog scale and numeric rating scale]). We found no significant differences after 12 and 24 months. CONCLUSIONS: We found small, although statistically significant, favorable results of APM up to 6 months for physical function and pain. However, we found no differences at longer follow-up. LEVEL OF EVIDENCE: Level I, systematic review and meta-analysis of Level I studies.

Curved versus Straight Stem Uncemented Total Hip Arthroplasty Osteoarthritis Multicenter trial (CUSTOM): design of a prospective blinded randomised controlled multicentre trial.

INTRODUCTION: Answering the demands of an increasingly young and active patient population, recent developments in total hip arthroplasty (THA) have shifted towards minimising tissue damage. The Collum Femoris Preserving (CFP) stem was developed to preserve the trochanteric region of the femur, which potentially preserves the insertion of the gluteus musculature. This might accelerate early postoperative rehabilitation and improve functional outcome. Currently the functional results of the CFP stem have not been compared with conventional straight stems in a randomised controlled trial (RCT). The primary purpose of this trial is to compare the functional result of CFP stem THA with conventional uncemented straight stem THA, measured by the Dutch Hip disability and Osteoarthritis Outcome Score (HOOS) at 3-month follow-up. METHODS: A prospective blinded multicentre RCT will be performed. We aim to recruit 150 patients. The patients will be randomly allocated to a THA with a straight or a curved stem. All patients, research assistants, clinical assessors and investigators will be blinded for the type of prosthesis for 5 years. Clinical assessments and roentgenograms will be taken preoperative, at 6 weeks after surgery, at 1, 2, 3, 4 and 5 years after surgery. Patient reported outcome measures (PROMs) will be obtained at the same follow-up moments. In addition, the PROMs will also be sent to the patients at 3 and 6 months after surgery. The HOOS at 3-month follow-up will be our primary outcome. ETHICS AND DISSEMINATION: This trial will be performed in accordance with the Declaration of Helsinki. A local ethics committee has approved this trial. Written informed consent will be obtained from all participating patients. All serious adverse events will be reported to the ethics committee. RESULTS: Results will be submitted for publication to an orthopaedics related journal. TRIAL REGISTRATION NUMBER: NTR1560.

Can We Measure the Heel Bump? Radiographic Evaluation of Haglund's Deformity.

Haglund's deformity is a symptomatic posterosuperior deformity of the heel. The lateral radiograph of the ankle will show a prominent, large, posterosuperior part of the calcaneus, which can be measured using the Fowler and Philips angle (FPA, the angle between the posterior and plantar surface of the calcaneus) and the calcaneal pitch angle (CPA, the angle between the sole of the foot and the plantar part of the calcaneus). Although these angles are commonly used, these radiographic angle measurements have never shown a relationship with Haglund's deformity. In 78 patients (51% male) with symptomatic Haglund's deformity and a control group of 100 patients (41% male) with no heel complaints, we measured the FPA and CPA on weightbearing lateral radiographs of the foot. Using an unpaired t tests, no significant difference was found between the 2 groups in the FPA (p = .40). We measured a significant difference in the CPA between the Haglund group and the control group (p = .014). Subgroup analysis showed that this difference was mainly found in females (p < .00), with no significant difference seen in the males (p < .48). Females with Haglund's deformity will have a greater CPA than will females without Haglund's deformity. The CPA showed a difference between the Haglund and non-Haglund groups, although mainly in females. Although the evidence from our study is limited, it would be interesting to study the CPA further, because it implicates the verticalization of the calcaneus. This change in position results in extra traction on the Achilles tendon and can eventually cause tendinitis and bursitis. Radiographic measurement should be used as an auxiliary tool. If the calcaneus tends to change position, it would be interesting to understand this process, which could eventually lead to improvement in the treatment of Haglund's deformity.

The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear.

BACKGROUND: It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of rotator cuff tears. This study aimed to determine the diagnostic value of nine individual clinical tests for evaluating rotator cuff tear and to develop a prediction model for diagnosing rotator cuff tear. METHODS: This prospective cohort study included 169 patients with shoulder complaints. Patients who reported a previous shoulder dislocation were excluded from the analysis (N = 69). One experienced clinician conducted 25 clinical tests of which 9 are specifically designed to diagnose rotator cuff pathology (empty can, Neer, Hawkins-Kenney, drop arm, lift-off test, painful arc, external rotation lag sign, drop sign, infraspinatus muscle strength test). The final diagnosis, based on magnetic resonance arthrography (MRA), was determined by consensus between the clinician and a radiologist, who were blinded to patient information. A prediction model was developed by logistic regression analysis. RESULTS AND DISCUSSION: In this cohort, 38 patients were diagnosed with rotator cuff tears. The individual overall accuracy of the rotator cuff clinical tests was 61%-75%. After backward selection, the model determined that the most important predictors of rotator cuff tears were higher age and a positive Neer test. This internally validated prediction model had good discriminative ability (area under the receiver operating characteristic curve (AUC) = 0.73). CONCLUSION: Our results showed that individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. Our prediction model showed improved diagnostic value. However, the prediction value is still relatively low, supporting a low threshold for additional diagnostic tests for the diagnosis of rotator cuff tears. LEVEL OF EVIDENCE: Study of diagnostic test: level I.

Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection.

BACKGROUND: Treatment of an acute total hip arthroplasty (THA) infection aims at control of the infection with retention of the implant by surgical debridement and antibiotic treatment. There is no clear evidence whether a single surgical debridement is sufficient or whether multiple procedures are necessary for optimal treatment. METHODS: From a prospective database of patients with acute THA infection, we retrospectively reviewed 68 patients treated in 2 large teaching hospitals. Hospital S used a protocol in which each patient received a single surgical debridement and only additional surgery if infectious symptoms persisted (group S; n = 33). In hospital M, patients always received multiple surgical debridements (group M; n = 35). Both groups received systemic antibiotic treatment. Removal of the implant or persistent infection at follow-up was considered failure of treatment. Mean follow-up of the patients was 5 (2-11) years. RESULTS: Mean time between implantation and debridement was 19 days. 4 patients in group S were considered failure, as opposed to 10 patients in group M (p = 0.09). 9 patients in group S had additional surgery, which resulted in 3 of the 4 failures. At final follow-up, 30 patients in group S and 33 patients in group M had a good clinical result (p = 0.6). INTERPRETATION: In patients with acute THA infection, a single debridement with only additional surgery on indication appears to be at least as successful for retention of the primary implant and control of infection as a strategy with multiple surgical debridements.