No decline in high patient satisfaction after total hip arthroplasty at long-term follow-up.

INTRODUCTION: Patient satisfaction is gaining popularity as an important outcome parameter in today's healthcare system and in particular in evaluating the outcome of joint arthroplasty. Total hip arthroplasty (THA) is a very successful procedure with reports on high patient satisfaction at short-term follow-up. Commonly used clinical outcome parameters remain good at long-term follow-up; however, whether this also accounts for patient satisfaction remains unclear. This study presents a prospective follow-up of patient satisfaction after THA, and a possible correlation with common outcome parameters was established. METHODS: This study entails a concise follow-up of an earlier study on patient satisfaction 2.5 years after THA. Patient satisfaction was repeatedly measured with a visual analogue scale (VAS) after a mean follow-up of 13.5 (12.6-14.2) years in a prospective cohort of 147 patients (153 THAs). In addition, VAS pain and common clinical outcome parameters (WOMAC, OHS and SF-36) were also reassessed and were compared with short-term results after a mean follow-up of 2.5 (1.3-3.0) years. RESULTS: At a follow-up of 13.5 (12.6-14.2) years, the median VAS for satisfaction was 95 (26-100) compared to a median VAS satisfaction of 98 (0-100) at earlier follow-up (p = 0.781). Overall, the clinical outcome parameters also remained good at long-term follow-up without significant changes. However, a rather low correlation with VAS satisfaction was encountered. Pain during activity showed the highest correlation (- 0.686) with VAS satisfaction. CONCLUSION: Patient satisfaction after THA remains high after prolonged follow-up. Apparently patients do not get used to the successful results of their THA. A rather low correlation with common clinical outcome parameters suggests that patient satisfaction is a separate entity. Since patient satisfaction correlated best with pain during activity, this is probably the most important aspect in patient satisfaction. Measurement of patient satisfaction has additional value and may even replace some of the more commonly used questionnaires.

Better clinical results after closed- compared to open-wedge high tibial osteotomy in patients with medial knee osteoarthritis and varus leg alignment.

PURPOSE: Studies comparing mid- or long-term outcomes of open- and closed-wedge high tibial osteotomy are limited. Here, the midterm survival rate and clinical and radiographic outcomes were compared for these two techniques. The study hypothesis, based on short-term follow-up, was that after midterm follow-up, the two techniques would not differ. METHODS: A prospective follow-up study was conducted for a previously reported randomized controlled trial of an original 50 patients (25 open-wedge osteotomy and 25 closed-wedge osteotomy) with medial knee osteoarthritis and a varus leg alignment. We analyzed patients without knee arthroplasty (mean age 48.7 years, SD 8.0) for clinical and radiographic follow-up. RESULTS: Five patients in each group had undergone conversion to a total knee arthroplasty or unicompartmental knee arthroplasty, leaving 19 patients for analysis in each group. At 7.9 years of follow-up (range 7-9 years), survival did not differ significantly between groups (open-wedge group 81.3% [95% confidence interval (CI) 75.2-100], closed-wedge group 82.0% [95% CI 66.7-100]). At final follow-up, total Dutch Western Ontario and McMaster Universities Arthritis (WOMAC), Knee Society Score, and visual analog scale (VAS) pain did not differ between groups. However, the results were significantly better in the closed-wedge group for VAS satisfaction and WOMAC pain and stiffness compared to the open-wedge group. Radiographic evaluation did not differ between groups for any outcome at final follow-up. CONCLUSION: After a mean follow-up of 7.9 years, patients undergoing a closed-wedge osteotomy had favorable clinical results compared to those who underwent an open-wedge osteotomy. LEVEL OF EVIDENCE: II.

Does the experience level of the radiologist, assessment in consensus, or the addition of the abduction and external rotation view improve the diagnostic reproducibility and accuracy of MRA of the shoulder?

AIM: To prospectively evaluate the influence of observer experience, consensus assessment, and abduction and external rotation (ABER) view on the diagnostic performance of magnetic resonance arthrography (MRA) in patients with traumatic anterior-shoulder instability (TASI). MATERIALS AND METHODS: Fifty-eight MRA examinations (of which 51 had additional ABER views) were assessed by six radiologists (R1-R6) and three teams (T1-T3) with different experience levels, using a seven-lesion standardized scoring form. Forty-five out of 58 MRA examination findings were surgically confirmed. Kappa coefficients, sensitivity, specificity, and differences in percent agreement or correct diagnosis (p-value, McNemar's test) were calculated per lesion and overall per seven lesion types to assess diagnostic reproducibility and accuracy. RESULTS: Overall kappa ranged from poor (k = 0.17) to moderate (k = 0.53), sensitivity from 30.6-63.5%, and specificity from 73.6-89.9%. Overall, the most experienced radiologists (R1-R2) and teams (T2-T3) agreed significantly more than the lesser experienced radiologists (R3-R4: p = 0.014, R5-R6; p = 0.018) and teams (T2-T3: p = 0.007). The most experienced radiologist (R1, R2, R3) and teams (T1, T2) were also consistently more accurate than the lesser experienced radiologists (R4, R5, R6) and team (T3). Significant differences were found between R1-R4 (p = 0.012), R3-R4 (p = 0.03), and T2-T3 (p = 0.014). The overall performance of consensus assessment was systematically higher than individual assessment. Significant differences were established between T1-T2 and radiologists R3-R4 (p<0.001, p = 0.001) and between T2 and R3 (p<0.001/p = 0.001) or R4 (p = 0.050). No overall significant differences were found between the radiologists' assessments with and without ABER. CONCLUSION: The addition of ABER does not significantly improve overall diagnostic performance. The radiologist's experience level and consensus assessment do contribute to higher reproducibility and accuracy.

Evidence-based rehabilitation following anterior cruciate ligament reconstruction.

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT's) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.

Partial versus unrestricted weight bearing after an uncemented femoral stem in total hip arthroplasty: recommendation of a concise rehabilitation protocol from a systematic review of the literature.

The aim of this systematic review was to find evidence-based support in the literature to allow immediate unrestricted weight bearing after primary uncemented total hip arthroplasty (THA). Accelerated rehabilitation programs for THA are becoming increasingly popular to shorten hospital stay and to facilitate rapid restoration of function. The goals of these rehabilitation programs could be more easily achieved if immediate unrestricted weight bearing (UWB) could be allowed after a THA. So far, however, immediate weight bearing is frequently contraindicated in widely accepted protocols for uncemented THA due to fear for subsidence and absence of osseous integration of the femoral stem. Thus, frequently protected weight bearing and restricted activities are still advocated for at least 6 weeks after surgery. In addition, we analyzed the literature to come to a recommendation on gait pattern and walking aid. From a systematic search in several electronic databases 13 studies met the inclusion criteria. These studies were reviewed according to the Cochrane methodology. We found moderate to strong evidence that no adverse effects on subsidence and osseous integration of the femoral stem after uncemented THA occur after immediate UWB. Based on this literature review, we recommend early rehabilitation after uncemented THA with a reciprocally gait pattern using crutches, one cane for independency in ADL in case patients walk limp-free and walking without crutches as soon as possible. During the first weeks after surgery only stair climbing should be performed with protected weight bearing because of high torsion loads on the hip.

Surgeon satisfaction agreement after total knee arthroplasty using a visual analogue scale: a single surgeon series.

INTRODUCTION: The outcome of total knee arthroplasty (TKA) is traditionally rated by objective criteria such as the knee society clinical rating system (KSCRS). Subjective criteria, such as satisfaction, will be of more importance, because health-care is shifting towards a market model. The aim of this study was to investigate the agreement on satisfaction after TKA between two orthopaedics surgeons, when one of the surgeons reviews his own results. PATIENTS AND METHODS: We investigated a group of 57 patients (63 TKAs) using a visual analogue scale (VAS) for satisfaction. There were 53 TKAs available and were separately seen by the two orthopaedic surgeons for clinical follow-up. RESULTS: After we split the satisfaction rate as excellent-good and fair-poor (VAS smaller or equal to 20 was excellent-good), we found a substantial agreement (kappa = 0.77) between the orthopaedic surgeons. However, we found that the surgeon who viewed his own results (B) scored a significantly lower satisfaction than surgeon A when analysing the complete group. CONCLUSIONS: The interobserver agreement of satisfaction, using a VAS, was high between the two orthopaedic surgeons. The satisfaction VAS is a simple tool to quantify satisfaction of surgeons and patients after TKA and could be used to evaluate quality. Comparison between studies could be more efficient and reliable using the satisfaction VAS method.

MR arthrography of traumatic anterior shoulder lesions showed modest reproducibility and accuracy when evaluated under clinical circumstances.

INTRODUCTION: We examined the reproducibility and accuracy of high-field MRA in traumatic anterior shoulder instability under conditions resembling clinical practice and assessed the influence of observer experience. MATERIALS AND METHODS: Two radiologists with different experience levels evaluated 61 MRAs. Assessment was independent, blinded and non-sequential. For 40 MRAs, surgical reports were available to assess diagnosis accuracy and influence of observer experience. The assessed lesions were cuff lesions, Hill-Sachs lesions, bony and classic Bankart lesions, greater humeral tuberosity fractures, SLAP lesions and joint capsule lesions. Reproducibility was quantified using kappa coefficients. Accuracy was evaluated with sensitivity and specificity rates, positive and negative predictive values. Differences in the percentage of correctly diagnosed MRAs between the radiologists were tested using McNemar's test for paired proportions. RESULTS: Inter-observer k-values ranged from 0.03 for joint capsule lesions to 0.45 for humeral head lesions. The overall kappa was 0.21 (95% CI; 0.12-0.30). We also observed markedly lower sensitivity and specificity rates than those reported in the literature for most lesions. The more experienced radiologist correctly diagnosed 78.9% of all lesions compared to 65.4% for the less experienced radiologist (P < 0.001; McNemar's test). CONCLUSION: MRA-interpretations of traumatic anterior shoulder instability should be regarded with caution in clinical practice. The experience level of radiologists can affect reproducibility and accuracy.

No local recurrence of enchondroma after curettage and plaster filling.

INTRODUCTION: The most common treatment of enchondromas is curettage (with or without adjuvant therapy) followed by cancellous bone grafting. To avoid donor-site morbidity of the iliac crest, we applied plaster of Paris as a bone defect filler after curettage of enchondromas. MATERIALS AND METHODS: We treated 19 enchondromas of the hand and foot in 19 patients (mean age 40 years, range 21-79 years) with curettage and filling of the cavity with sterile plaster of Paris (calcium sulphate/phosphate) tablets. RESULTS: The diagnosis was histologically confirmed in all cases. After a mean follow-up of 53 months (range 15-139 months), the mean functional Muskuloskeletal Tumor Society Score was 29.1 points (97%; range 28-30). There were no local recurrences although adjuvant therapy was not utilized. CONCLUSION: Plaster of Paris appears safe and effective as a bone-filling substance after curettage of enchondroma.

Biaxial total wrist arthroplasty in rheumatoid arthritis. Satisfactory functional results.

We reviewed 16 uncemented biaxial total wrist arthroplasties (TWA) in 14 patients with rheumatoid or juvenile arthritis. The mean follow-up was 25 months (range 5-60). According to the Hospital for Special Surgery scoring system (HSS), good-to-excellent results were accomplished in 69%, moderate in 19%, and poor in 12%. The mean pain score was 0.4 on a visual analog scale from 0-10 (0=no pain). The Wrightington activities of daily life assessment chart showed a 63% improvement, and we found a threefold increase in range of motion at follow-up. Four TWAs showed early dislocation, one of which was revised. Biaxial TWA yields good short-term results in rheumatoid patients, although instability is a frequent complication.

Are surgeons equally satisfied after total knee arthroplasty?

INTRODUCTION: We performed a clinical follow-up study to investigate whether three orthopaedic surgeons were equally satisfied after total knee arthroplasty (TKA). PATIENTS AND METHODS: Thirty-six patients (39 TKAs, mean follow-up 12 months) were reviewed, using the Knee Society Clinical Rating System (KSCRS). For the assessment of satisfaction a visual analogue scale (VAS) was used. RESULTS: We did not find a significant difference in satisfaction between the surgeons. However, there was a significant difference in the knee score and function score of the KSCRS as evaluated by the orthopaedic surgeons (p=0.006 and p=0.04, respectively). The correlation between the knee score and the surgeons' satisfaction was high, which indicates that pain, range of motion and deformity are important success criteria for surgeons. CONCLUSIONS: In this study, surgeons scored differently in the KSCRS but were equally satisfied after TKA.

Helix wire osteosynthesis for proximal humeral fractures: unacceptable nonunion rate in two- and three-part fractures.

INTRODUCTION: Fractures of the proximal humerus are very common, but controversy still exists about the preferred type of operative treatment in displaced fractures. MATERIALS AND METHODS: We followed 15 patients (12 female and 3 male, average age 70 years) with 15 dislocated type II (9) and III (6) proximal humeral fractures after helix wire osteosynthesis. RESULTS: A nonunion developed in seven cases (47%). Three patients were reoperated (prosthesis: 2, repair: 1). Seven patients were available for follow-up (average: 14 months). Three patients had a Constant score of 80 or more and four patients had a score under 70 points. CONCLUSION: The results of the helix wire osteosynthesis for proximal humeral fractures are poor and we do not recommend its further use.

Limited posterior approach for internal fixation of a glenoid fracture.

We present the case of a patient who was treated by open reduction and internal fixation for a displaced glenoid fracture using a limited posterior approach.

Patient versus surgeon satisfaction after total hip arthroplasty.

We compared patient satisfaction with surgeon satisfaction after total hip arthroplasty (THA) in a group of 193 patients (200 THAs, mean follow-up six years) using a visual analogue scale (VAS), and two objective and two subjective scoring systems. We also determined the survival rate with different endpoints. For the 121 hips available for clinical follow-up, we did not find a significant difference in satisfaction between patient and surgeon. In a subgroup with low patient satisfaction, the surgeon was more satisfied than the patient (p = 0.04). The correlation between the patient satisfaction VAS and the different subjective and objective scoring systems suggests that pain during activity is the most important factor for the patient. The survivorship at six years decreased from 96.6% to 83.7% if dissatisfaction (VAS > 20) was added to revision as an endpoint in the survival analysis. The patient satisfaction VAS provides additional information to evaluate the outcome of THA. We recommend the use of both subjective and objective scoring systems to evaluate the outcome of THA.

The incidence of dislocation after primary total hip arthroplasty using posterior approach with posterior soft-tissue repair.

BACKGROUND: Dislocation after total hip arthroplasty (THA) is one of the most common major complications, and occurs more often through a posterior approach. We performed a retrospective study to determine the incidence of early dislocation and the relationship to the type of prosthesis and the surgeon's experience. METHODS: A group of 884 consecutive primary THAs (746 cemented and 138 cementless) approached through a posterior incision with repair of the posterior soft tissues was followed for a mean of 30 months. RESULTS: The overall dislocation rate was 1.36% (cemented: 1.1%; cementless: 2.9%). All dislocations were posterior and occurred within 6 months after surgery, 91% within 6 weeks. Dislocations were most common in rheumatoid patients (3.8%). Two revisions (0.23%) of the acetabular cup were performed for recurrent dislocations. The dislocation rate was not higher in the operations performed by less experienced surgeons. CONCLUSION: The early dislocation rate after primary THA through a posterior approach with repair of the posterior soft tissues was low, especially in cemented THA. Less experienced surgeons were not associated with a higher dislocation rate.

Open capsular shift for multi directional shoulder instability.

We evaluated the outcome of open antero-inferior capsular shift in 17 patients with multidirectional instability of the shoulder who failed to respond to conservative treatment. Six shoulders presented with secondary impingement syndrome and 11 with involuntary instability. The mean duration of follow-up was 39 months (range 7-89 months). Based on the Rowe and Constant scores and the 12-item questionnaire of Dawson, the results were rated excellent in 14 patients, fair in 2 and poor in 1. All but 2 patients were satisfied with the results, although 6 patients experienced some residual pain, and 4 suffered minor instability. There were no neurovascular complications, infections or symptomatic posterior instability. Open antero-inferior capsular shift yields promising short-term to medium-term results in multidirectional, involuntary instability of the shoulder.