Excellent survival of two anatomically adapted hydroxyapatite coated cementless Total Hip Arthroplasties. A mean follow-up of 11.3 years.

There are many different types of cementless anatomically adapted Total Hip Arthroplasties (THAs) on the market, the Anatomic Benoist Gerard (ABG) I and II are such types of cementless THAs. In this retrospective single-centre study we evaluated the overall survival with revision for any reason and aseptic loosening as endpoint at more than 11 years follow-up. Between 2000 and 2004, 244 cementless THAs were performed in 230 patients in a primary care hospital. At a mean of 11.3 years follow-up (range 9.8 - 12.8 years) clinical examination, plain radiography and Patient Reported Outcome Measures (PROMs) were obtained and analysed. The PROMs consisted of the Oxford Hip Score (OHS) and the Western Ontario and McMaster University Index (WOMAC). At a mean of 11.3 years follow-up 32 patients (13.1%) had died of unrelated causes. Of the remaining cohort all 198 patients (212 THAs) have been reached for evaluation. There were no patients considered as lost to follow-up. At a mean of 11.3 years 11 patients (11 THAs) have had a revision of either the femoral implant or acetabular component resulting in an overall survival of 95.5%. There was no statistically significant difference (p=0.564) in survival between the ABG I and II THAs. Radiographic there were no changes between the ABG I and II last follow up. The ABG II performed statistically significant better in PROMs. We concluded that both anatomically adapted hydroxyapatite coated cementless THAs show excellent survival at more than 11 years follow-up.

Less wear in deep-dished mobile compared to fixed bearing total knee arthroplasty of the same design at 5-year follow-up: a randomised controlled model-based Roentgen stereophotogrammetric analysis trial.

PURPOSE: The aim of this prospective randomised controlled study was to compare wear characteristics and functional outcome between deep-dished mobile bearing (MB) and fixed bearing (FB) cemented total knee arthroplasty (TKA). We hypothesised that deep-dished MB reduces polyethylene wear and improves patient-reported outcome measures. METHODS: A total of 50 patients were randomised to receive a MB or FB tibia component of the same cemented TKA design. Patients were evaluated over a 5-year follow-up period. Medial and lateral wear were assessed using model-based Roentgen Stereophotogrammetric Analysis (RSA) and compared with the direct postoperative minimal joint space measurement. Functional outcome was assessed by the clinician-derived KSS and OKS, WOMAC, LEAS, and FJS-12. All data were derived using a general linear mixed model. RESULTS: At 5-year follow-up, decreased wear in the MB compared to the FB group was observed on the lateral side (0.07 ± 0.17 mm, p = 0.026), but not on the medial side (0.31 ± 0.055 mm, p = 0.665). Functional outcomes improved with a statistical significant effect over time, with no significant differences between groups (all p > 0.17). CONCLUSION: This model-based RSA study with 5-year follow-up showed that cemented deep-dished MB reduced lateral polyethylene wear as compared to FB in a single TKA system, whilst clinical outcomes were comparable. Longer follow-up is needed to establish clinical implications of these altered wear patterns and determine type of wear. LEVEL OF EVIDENCE: Level 1 randomised controlled trial.

No differences in mid-term survival and clinical outcome between CT- and MRI-based patient-specific instrumentation for total knee arthroplasty, a randomized controlled trial.

PURPOSE: The purpose of this prospective randomized controlled trial was to compare the clinical outcome and the survival rate of total knee arthroplasty between CT- and MRI-based patient-specific instrumentation 5 years after initial surgery. METHODS: At a mean follow-up of 5.8 years (SD 0.3), 98 patients (64% women, loss to follow-up 28%) were included in this analysis. To assess the differences in clinical outcome, patients fulfilled PROMs preoperatively and at each follow-up moment. At final follow-up, the Forgotten Joint Score was adjusted. RESULTS: At final follow-up, no new patients underwent revision surgery in both groups. Regarding the clinical outcome, no statistically significant difference between the groups was found. The Forgotten Joint Score was only performed at final follow-up and showed no significant difference between both groups. CONCLUSION: At mid-term follow-up, survival rates between CT- and MRI-based patient-specific instrumentation did not show a significant difference. Regarding clinical outcome, only the EQ-5D-VAS (p < 0.040) showed a statistically significant difference over time, in favor of the MRI-group. LEVEL OF EVIDENCE: Level I.

Prosthetic hip-associated cobalt toxicity: a systematic review of case series and case reports.

Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty. The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms. A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients. The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases). Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system. The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings. We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing. Level of Evidence: Level V, systematic review.

Safety and efficacy of outpatient hip and knee arthroplasty: a systematic review with meta-analysis.

INTRODUCTION: This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways. MATERIALS AND METHODS: An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways-following hip and/or (partial) knee arthroplasty-were included. Included studies were assigned-based on OJA definition-to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate. RESULTS: A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41-0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02. CONCLUSION: OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.

Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study.

BACKGROUND: Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties. METHODS: Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties. RESULTS: A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision. CONCLUSION: Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

A short-term radiological and clinical comparison between the bi-cruciate and cruciate retaining total knee arthroplasty A retrospective case controlled study.

PURPOSE: The aim of this study was to provide a short term comparison in radiological and clinical outcome between Bi-Cruciate Retaining (BCR)- and Cruciate Retaining (CR) Total Knee Arthroplasty (TKA). METHODS: The cohort consists of 122 patients undergoing a TKA with PSI, equally distributed over the BCR- and CR-TKA group. Perioperative conditions were observed and radiological images were analysed pre-, 6-weeks, and 1-year postoperative to quantify alignment differences between BCR- and CR-TKA. Preoperatively predicted templates were compared with the implanted size to determine predictive value. In addition mean range of motion and revision rates were determined in both groups. RESULTS: No significant difference was observed in amount of outliers in component alignment between BCR- and CR-TKA. Outliers of the Hip-Knee-Ankle-Axis (HKA-axis) occurred significantly more frequent (P = 0.009) in the BCR-group (37.7%) compared to CR-TKA (18.0%). No clinically relevant differences regarding the predictive sizing of implant components was obtained. No significant differences were observed in revision rates (P = 1.000) and ROM (p = 0.425) between the BCR-groep and CR-group at 2-years FU. CONCLUSION: This study illustrates that although the HKA-axis was not fully restored, bi-cruciate retaining surgical technique for BCR-TKA is safe and effective with comparable radiological and clinical outcome as CR TKA. Randomized controlled trials with longer follow up on the HKA-axis alignment and clinical parameters are needed to confirm the presented results and should focus on possible cut off values concerning leg axis in order to define in what patients a BCR-TKA can safely be used. LEVEL OF EVIDENCE IV: Retrospective Case Controlled Study.

CR-lipped bearing is an adequate functional solution to patients with perioperative excessive laxity in cruciate retaining total knee arthroplasty.

BACKGROUND: The cruciate retaining lipped (CR-lipped) bearing is designed to provide more anterior-posterior (AP) stability and could be employed to resolve excessive intraoperative laxity during the cruciate retaining TKA (CR-TKA). The aim of the study was to determine whether the CR-lipped bearing in CR-TKAs with a perioperative excessive laxity allows equivalent functional results as compared to the standard CR articulation. METHODS: A cohort of 111 TKAs with CR-lipped bearings was matched to a cohort of conventional CR bearings regarding age and sex. The CR-lipped bearing was used in patients with excessive knee AP laxity and the regular CR bearing was used in patients without excessive AP laxity during TKA. Various PROMs (WOMAC, KSS, SF-36) were assessed preoperatively and at 5-years postoperative in combination with revision rate and Range of Motion (ROM). RESULTS: PROMs did not differ significantly between both groups 5-years postoperatively. Mean ROM (flexion) 5-years postoperatively was not significantly different. The implant survivorship was 100% for both cohorts with revision for any reason as end point. CONCLUSION: Based on these results, the CR-lipped bearing is a safe and effective solution for mild interoperatively assessed PCL laxity during CR-TKA without loss of function or decreased survivorship at 5 years. Peroperative conversion to a PS-TKA in order to obtain satisfactory functional scores might therefore not be necessary when mild PCL laxity is observed during surgery. Further research should focus on verifying this approach and longer follow-up is needed to generate data on long term survivorship. LEVEL OF EVIDENCE: Level IV therapeutic, retrospective, cohort study.

Subsidence after total lumbar disc replacement is predictable and related to clinical outcome.

PURPOSE: As yet, there are no studies describing a relationship between radiographic subsidence after lumbar total disc replacement (TDR) and patient symptoms. To investigate if subsidence, in terms of penetrated bone volume or angular rotation over time (ΔPBV and ΔAR), is related to clinical outcome. To assess if subsidence can be predicted by position implant asymmetry (IA) or relative size of the TDR, areal undersizing index (AUI) on direct post-operative radiographs. METHODS: Retrospective cohort study consists of 209 consecutive patients with lumbar TDR for degenerative disc disease. A three-dimensional graphical representation of the implant in relation to the bony endplates was created on conventional radiographs. Consequently, the PBV, AR, IA and AUI were calculated, direct post-operative (DPO) and at last follow-up (LFU). For clinical evaluation, patients with substantial pain (VAS ≥ 50) and malfunction (ODI ≥ 40) were considered failures. RESULTS: At a mean follow-up of 16.7 years, 152 patients (73%) were available for analysis. In 32 patients, revision by spinal fusion had been performed. Both ΔAR (4.33° vs. 1.83°, p = 0.019) and ΔPBV (1448.4 mm3 vs. 747.3 mm3, p = 0.003) were significantly higher in the failure-compared to the success-group. Using ROC curves, thresholds for symptomatic subsidence were defined as ΔPBV ≥ 829 mm3 or PBV-LFU ≥ 1223 mm3 [area under the curve (AUC) 0.723, p = 0.003 and 0.724, p = 0.005, respectively]. Associations between symptomatic subsidence and AUI-DPO ≥ 0.50 (AUC 0.750, p = 0.002) and AR-DPO ≥ 3.95° (AUC 0.690, p = 0.022) were found. CONCLUSION: Subsidence of a TDR is associated with a worse clinical outcome. The occurrence of subsidence is higher in case of incorrect placement or shape mismatch.

Preliminary experience with an image-free handheld robot for total knee arthroplasty: 77 cases compared with a matched control group.

BACKGROUND: Achieving an optimal limb alignment is an important factor affecting the long-term survival of total knee arthroplasty (TKA). This is the first study to look at the limb alignment and orientation of components in TKA using a novel image-free handheld robotic sculpting system. METHODS: This case-controlled study retrospectively compared limb and component alignment of 77 TKAs performed with a robot (Robot-group) with a matched control group of patients who received conventional alignment with intramedular rods (Control group). Alignment and component positioning was measured on full-leg weight-bearing and standard lateral X-rays by two independent observers. The image-free handheld robotic sculpting system calculated the planned and achieved mechanical axis (MA). Outliers were defined as > 3° deviation from planned alignment. RESULTS: Mean MA was 180.1° (SD = 1.9) in the Robot-group, compared to the Control group with a mean MA of 179.1° (SD = 3.1, p = 0.028). We observed 5 outliers (6%) in the Robot-group and 14 outliers (18%, p = 0.051) in the Control group. Fraction of outliers of the frontal tibial component was 0% in the Robot-group versus 8% in the Control group (p = 0.038). There were no other statistical differences regarding the implant positioning between both groups. CONCLUSION: The Robot-group showed significantly less outliers compared to the conventional technique. Whether these differences are clinically relevant is questionable and should be investigated on the long term. Randomized controlled trials with larger patient series will be needed in the future to confirm our preliminary results.

Long-term clinical outcome of the Charité III total lumbar disc replacement.

PURPOSE: To compare the long-term clinical results and complications of two revision strategies for patients with failed total disc replacements (TDRs). METHODS: In 19 patients, the TDR was removed and the intervertebral defect was filled with a femoral head bone strut graft. In addition, instrumented posterolateral fusion was performed (removal group). In 36 patients, only a posterolateral instrumented fusion was performed (fusion group). Visual analogue scale (VAS) for pain and Oswestry Disability Index (ODI) were completed pre- and post-revision surgery. Intra- and post-operative complications of both revision strategies were assessed. RESULTS: The median follow-up was 12.3 years (range 5.3-24.3). In both the removal and fusion group, a similar (p = 0.515 and p = 0419, respectively) but significant decrease in VAS- (p = 0.001 and p = 0.001, respectively) and ODI-score (p = 0.033 and p = 0.013, respectively) at post-revision surgery compared to pre-revision surgery was seen. A clinically relevant improvement in VAS- and ODI-score was found in 62.5% and 43.8% in the removal group and in 43.5% and 39.1% in the fusion group (p = 0.242 and p = 0.773, respectively). Removal of the TDR was associated with substantial intra-operative complications such as major vessel bleeding and ureter lesion. The percentage of late reoperations for complications such as pseudarthrosis was comparable for both revision strategies. CONCLUSIONS: Revision of a failed TDR is clinically beneficial in about half of the patients. No clear benefits for additional TDR removal as compared to posterolateral instrumented fusion alone could be identified. Particularly, when considering the substantial risks and complications, great caution is warranted with removal of the TDR. These slides can be retrieved under Electronic Supplementary Material.

Long-term clinical outcome of two revision strategies for failed total disc replacements.

PURPOSE: To compare the long-term clinical results and complications of two revision strategies for patients with failed total disc replacements (TDRs). METHODS: In 19 patients, the TDR was removed and the intervertebral defect was filled with a femoral head bone strut graft. In addition, instrumented posterolateral fusion was performed (removal group). In 36 patients, only a posterolateral instrumented fusion was performed (fusion group). Visual Analogue Scale (VAS) for pain and Oswestry Disability Index (ODI) were completed pre- and post-revision surgery. Intra- and post-operative complications of both revision strategies were assessed. RESULTS: The median follow-up was 12.3 years (range 5.3-24.3). In both the removal and fusion groups, a similar (p = 0.515 and p = 0419, respectively) but significant decrease in VAS (p = 0.001 and p = 0.001, respectively) and ODI score (p = 0.033 and p = 0.013, respectively) at post-revision surgery compared to pre-revision surgery was seen. A clinically relevant improvement in VAS and ODI score was found in 62.5% and 43.8% in the removal group and in 43.5% and 39.1% in the fusion group (p = 0.242 and p = 0.773, respectively). Removal of the TDR was associated with substantial intra-operative complications such as major vessel bleeding and ureter lesion. The percentage of late re-operations for complications such as pseudarthrosis were comparable for both revision strategies. CONCLUSIONS: Revision of a failed TDR is clinically beneficial in about half of the patients. No clear benefits for additional TDR removal as compared to posterolateral instrumented fusion alone could be identified. In particular, when considering the substantial risks and complications, great caution is warranted with removal of the TDR. These slides can be retrieved under Electronic Supplementary Material.

Short-term pain reduction after low-dose radiotherapy in patients with severe osteoarthritis of the hip or knee joint: a cohort study and literature review.

BACKGROUND: Low-dose radiotherapy (LDRT) for pain reduction in osteoarthritis (OA) is a frequently used treatment in Germany and Eastern European countries. The evidence on the effects of LDRT on pain in patients with OA remains unclear. This study evaluated the effect of LDRT on pain in patients with severe OA of the hip or knee joint. METHODS: This prospective study included a total of 16 joints in 12 patients (4 hips and 12 knees). The inclusion criteria were: patients older than 50 years, severe OA (Kellgren-Lawrence grade III-IV) of the hip or knee joint, patients not responding to conservative treatment and patients who are inoperable or not willing to undergo surgery. The joint was irradiated with a total dose of 6.0 Gray. The Numeric Rating Scale for pain (NRS-pain) and patient-reported outcome measures were obtained at pre-, 6, 13, 26, 39 and 52 weeks post-radiation. A decrease of two points on the NRS-pain was defined as clinical relevant. RESULTS: The median age of the included patients was 74 years (range 58-89). In 50% of the joints (n = 8, 3 hip and 5 knee joints), a clinical relevant difference in pain at 6 weeks post-radiation was observed. This clinical relevant difference decreased to 25% at 52 weeks post-radiation. CONCLUSION: LDRT showed a clinical relevant pain relief at 6 weeks after radiotherapy. The long-term effect of LDRT, however, was limited. A randomized placebo-controlled trial is necessary to assess the effect of LDRT on pain in patients with OA of the hip or knee joint.

No difference in mid-term survival and clinical outcome between patient-specific and conventional instrumented total knee arthroplasty: a randomized controlled trial.

PURPOSE: The purpose of this multicentre prospective randomized controlled trial was to compare the survival rate and clinical outcome in total knee arthroplasty (TKA) after MRI-based patient-specific instruments (PSI) and conventional instruments 5 years after initial surgery. METHODS: At a mean follow-up of 5.1 years (0.4), 163 patients (90.6%) with a mean age of 71.8 years (8.7) were analysed. A survival analysis with revision of the TKA as endpoint was performed. The Knee Society Score (KSS), evaluations on plain radiographs and patient-reported outcome measures (PROMs) were obtained preoperatively and at each FU. RESULTS: At final follow-up, one TKA in the PSI- (1.2%) and 3 TKAs in the conventional group (3.8%) had undergone revision surgery (n.s.). No radiological abnormalities were noted at any time point. Postoperatively, the KSS and PROMs significantly improved within each group compared with the preoperative values. There were no clinically relevant differences for the KSS [PSI: 77.4, 9.8 (95% CI 75.0-79.7) vs. conventional: 77.3 10.5 (95% CI 74.9-79.8)] and the PROMs between both groups (n.s.) at 5 years follow-up. CONCLUSION: There is still a lack of reliable data on the survival of TKA and clinical evidence, when using PSI for TKA. Longer follow-up studies are, therefore, needed. LEVEL OF EVIDENCE: I.

Correction to: No difference in mid-term survival and clinical outcome between patient-specific and conventional instrumented total knee arthroplasty: a randomized controlled trial.

In the original article, one of the co-author's (W. van der Weegen) middle name has been missed in the publication of the article. The correct complete name should be W. van der Weegen.

A high rate of tibial plateau fractures after early experience with patient-specific instrumentation for unicompartmental knee arthroplasties.

PURPOSE: Patient-specific instrumentation (PSI) for unicompartmental knee arthroplasty (UKA) has been available for a few years. However, limited literature is available on this subject. Hence, the aim of this cohort study is to evaluate the 2 years' results of our first experiences with the use of PSI in UKA. It is hypothesised that there is no advantage in rate of adverse events and in radiological and functional outcomes in comparison to literature on the conventional method. METHODS: This cohort included 129 knees of 122 patients, operated by one surgeon. Outcome measures were the rate of adverse events (AEs); implant position as determined on radiographs; the accuracy of the default and approved planning of the implant sizes and the patient-reported outcome measures (PROMs) preoperatively, and at 3, 12 and 24 months, postoperatively. RESULTS: A total of 6 (4.9%) AEs were observed in this study, with 4 (3.3%) tibial fractures being the main complication. The mean postoperative biomechanical axis was 176.4° and in the majority of cases, the radiographic criteria, as determined by the manufacturer, were met. The tibial component showed 20 (16.4%) outliers in the sagittal and 3 (2.5%) outliers in the frontal plane. There were no outliers of the femoral component. For the femoral and tibial components, respectively, in 125 (96.9%) and 79 (61.7%) cases, there was an agreement between approved planning and implanted component size. All PROMs improved significantly after surgery. CONCLUSION: Tibial fracture was the most common AE, probably related to the transition from cemented to uncemented UKA. Perioperative modifications to the surgical technique were made in order to prevent this AE. Improvements should be made to the operation technique of the uncemented tibial plateau to obtain an adequate placement and at the same time reduce the risk for tibial fracture. The PSI technique was a reliable tool for the placement of the femoral component. Functional outcome was in line with literature on the conventional method. It is strongly recommended that the surgeon approves every preoperative plan, in order to optimise the accuracy during the PSI surgery. LEVEL OF EVIDENCE: III.

Cemented versus uncemented hemiarthroplasty of the hip in patients with a femoral neck fracture: a comparison of two modern stem design implants.

PURPOSE: We wished to compare the outcome of two types of cemented and uncemented modern stem design implants after hemiarthroplasty, with both an Orthopaedic Data Evaluation Panel rating of 10A. METHODS: This retrospective study compares data obtained from two centres, with a total study population of 655 (n = 393 cemented, n = 262 uncemented). Patients were matched at baseline for gender, age, surgery side, American Society of Anesthesiologists score, body mass index and pre-operative haemoglobin level. Outcome measurements were prosthesis-related complications, pre- and post-operative, with reoperation rate and mortality and other complications after 1 year, surgery time, blood loss and immobility at discharge. RESULTS: There were no significant differences in mortality after 1 year, total other complications, immobility at the time of discharge and total prosthesis-related complications between both groups. Significantly more periprosthetic fractures and post-operative infections were seen in the uncemented group with significantly more reoperations compared to the cemented group. Significant differences were seen in cardiovascular complications, blood loss and surgery time in favour of the uncemented group. CONCLUSIONS: In consequence of the significant higher prosthesis-related complications (e.g. infections, periprosthetic fractures and reoperations) in the uncemented group in this study, we recommend cemented hemiarthroplasty in patients with a femoral neck fracture. LEVEL OF EVIDENCE: Level III, Case Controlled Study.

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up.

PURPOSE: Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery. METHODS: We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27-61). At a mean of 19.8 years (15.4-30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0-100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0-100, 0 being the best score) for function. RESULTS: At latest follow-up, the median VAS pain score was 49 (0-96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8-46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12-70) abduction, 20° (10-50) forward flexion and 22° (- 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction. CONCLUSION: At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement. LEVEL OF EVIDENCE III: A retrospective cohort study.

Low incidence of postoperative urinary retention with the use of a nurse-led bladder scan protocol after hip and knee arthroplasty: a retrospective cohort study.

PURPOSE: Postoperative urinary retention (POUR), defined as the inability to empty the bladder voluntary after surgery, is a commonly reported complication. This study reports the incidence and possible risk factors for POUR after elective fast-track hip or knee arthroplasty when using a nurse-led bladder scan protocol. METHODS: This retrospective cohort study included data from 803 patients who underwent unilateral hip or knee arthroplasty. Patients' digital clinical records were reviewed for eligibility. Patients with incomplete data registration, preoperative bladder volume >250 ml, preexisting bladder catheterization, and/or patients following the outpatient pathway were excluded. Bladder volumes were assessed at different moments pre- and postoperatively. The outcome was the incidence of POUR, defined as the inability to void spontaneously with a bladder volume >600 ml, treated with indwelling catheterization. Further analysis between POUR and non-POUR patients was performed to detect possible risk factors for POUR. RESULTS: Six hundred and thirty-eight patients operated on primary unilateral hip or knee arthroplasty were analyzed. The incidence of POUR was 12.9% (n = 82, 95% CI 9.4-15.5). Gender, age, BMI, ASA classification, preoperative bladder volume, type of anesthesia, type of arthroplasty, and perioperative fluid administration were not significant different between POUR and non-POUR patients. Patients with a bladder volume of >200 ml at the recovery room were at higher risk (OR 5.049, 95% CI 2.815-9.054) for POUR. CONCLUSIONS: When using a nurse-led bladder scan protocol in fast-track hip and knee arthroplasty, the incidence of POUR was 12.9%, with a bladder volume of >200 ml at the recovery room as a risk factor for POUR. LEVEL OF EVIDENCE: A retrospective cohort study, Level III.

Clinical and radiological results 7 years after Copeland shoulder resurfacing arthroplasty in patients with primary glenohumeral osteoarthritis: an independent multicentre retrospective study.

PURPOSE: The aim of this multicentre cohort study was to evaluate the midterm outcomes and survival after cementless stemless resurfacing arthroplasty (CSRA) in a series of 33 shoulders in 27 patients with primary osteoarthritis. METHODS: Clinical outcome assessment included: Constant-Murley score (CMS); Simple Shoulder Test (SST); Disability of Arm, Shoulder, Hand (DASH); EuroQol-5D (EQ-5D) utility scores; Numerous Rating Scale (NRS) for pain. Radiographs were assessed by two independent observers for oversizing, radiolucency, glenohumeral subluxation, glenoid erosion and subsidence. Correlations between the clinical and radiological outcomes were calculated. Complications were registered, and revision and survival rates were calculated. RESULTS: Mean age at time of surgery and mean follow-up time were, respectively, 67.7 (range 50.2-85.1) and 7.2 years (range 5.7-9.3 years). Means (SD) for CMS, age- and gender-adjusted CMS, SST, DASH and EQ-5D utility scores were: 56.4 (20.2), 76.5 (25.0), 54.0 (29.8), 37.6 (23.3) and 0.8 (0.1), respectively. NRS for pain was 2.0 and 3.8, respectively, in rest and during activities. Radiographic assessment of the CSRAs showed oversizing in 54.5%; radiolucency in 18.2%; superior glenohumeral subluxation in 33.3%; glenoid erosion in 45.5%; and subsidence in 3.0%. Perioperative complications did not occur. Revision surgery was performed in one patient (3.0%). CONCLUSION: For primary osteoarthritis, the CSRA showed good clinical but poor radiological outcomes at midterm follow-up.