Socioeconomic inequalities in patient-reported outcome measures of Dutch primary hip and knee arthroplasty patients for osteoarthritis.

OBJECTIVE: To study socio-economic inequalities in patient-reported outcomes in primary hip and knee arthroplasty (THA/TKA) patients for osteoarthritis, using two analytical techniques. METHODS: We obtained data from 44,732 THA and 30,756 TKA patients with preoperative and 12-month follow-up PROMs between 2014 and 2020 from the Dutch Arthroplasty Registry. A deprivation indicator based on neighborhood income, unemployment rate, and education level was linked and categorized into quintiles. The primary outcome measures were the EQ-5D-3L index and Oxford Hip/Knee Score (OHS/OKS) preoperative, at 12-month follow-up, and the calculated change score between these measurements. We contrasted the most and least deprived quintiles using multivariable linear regression, adjusting for patient characteristics. Concurrently, we calculated concentration indices as a non-arbitrary tool to quantify inequalities. RESULTS: Compared to the least deprived, the most deprived THA patients had poorer preoperative (EQ-5D -0.03 (95%CI -0.02, -0.04), OHS -1.26 (-0.99, -1.52)) and 12-month follow-up health (EQ-5D -0.02 (-0.01, -0.02), OHS -0.42 (-0.19, -0.65)), yet higher mean change (EQ-5D 0.02 (0.01, 0.03), OHS 0.84 (0.52, 1.16)). The most deprived TKA patients had similar results. The higher mean change among the deprived resulted from lower preoperative health in this group (confounding). After accounting for this, the most deprived patients had a lower mean change. The concentration indices showed similar inequality effects and provided information on the magnitude of inequalities over the entire socio-economic range. CONCLUSION: The most deprived THA and TKA patients have worse preoperative health, which persisted after surgery. The concentration indices allow comparison of inequalities across different outcomes (e.g., revision risk).

Are serum cobalt and chromium levels predictors for patient-reported outcome measures in the ASR hip resurfacing arthroplasty?

Aims: The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate. Methods: A total of 62 patients with an ASR-HRA were included and monitored yearly postoperatively. At follow-up, serum Co and Cr levels were measured and the HHS and the HOOS were scored. In addition, preoperative patient and implant variables and the need for revision surgery were recorded. We used a linear mixed model to relate the serum Co and Cr levels to different patient-reported outcome measures (PROMs). For the survival analyses we used the Kaplan-Meier and Cox regression model. Results: We found that an increase of one part per billion (ppb) in serum Co and Cr levels correlated significantly with worsening of the HHS in the following year. This significant correlation was also true for the HOOS-Pain and HOOS-quality of life sub scores. The overall ten-year survival rate in our cohort was 65% (95% confidence interval (CI) 52.5 to 77.6). Cox regression analysis showed a significant hazard ratio (HR) of 1.08 (95% CI 1.01 to 1.15; p = 0.028) for serum Co level. No significance was found with sex or inclination angle. Conclusion: This study shows that increasing serum Co and Cr levels measured in patients with an ASR-HRA are predictive for deterioration in HHS and HOOS subscales in the following year. Increasing serum Co and Cr should forewarn both surgeon and patient that there is a heightened risk of failure. Continued and regular review of patients with an ASR-HRA implant by measurement of serum Co/Cr levels and PROMs remains essential.

Do physical tests have a prognostic value in chronic midportion Achilles tendinopathy?

OBJECTIVES: To determine whether baseline physical tests have a prognostic value on patient-reported outcomes in Achilles tendinopathy. DESIGN: Prospective cohort study, secondary analysis of data from a randomized trial. METHODS: Patients with chronic midportion Achilles tendinopathy performed a progressive calf muscle exercise program. At baseline and after 2, 6, 12 and 24 weeks, patients completed the Victorian Institute of Sports Assessment-Achilles questionnaire and performed the following physical tests: ankle dorsiflexion range of motion with a bent knee or an extended knee, calf muscle strength, jumping height and pain on palpation (Visual Analogue Scale; 0-100) and after 10 hops (Visual Analogue Scale-10-hops). Associations between baseline test results and improvement (Victorian Institute of Sports Assessment-Achilles scores) were determined using a Mixed Linear Model. RESULTS: 80 patients were included. The mean Victorian Institute of Sports Assessment-Achilles score improved 20 points (95 % confidence interval, 16-25, P < .001) after 24 weeks. There were significant associations between the baseline ankle dorsiflexion range of motion with a bent knee (ß 0.2, 95 % confidence interval 0.001 to 0.3, P = .049), the baseline pain provocation tests (Visual Analogue Scale palpation: ß -0.2; 95 % confidence interval: -0.4 to -0.1; P < .001, Visual Analogue Scale-10-hops: ß -0.3; 95 % confidence interval: -0.4 to -0.2; P < .001) and the change in the Victorian Institute of Sports Assessment-Achilles score. CONCLUSIONS: In patients with chronic midportion Achilles tendinopathy, easy-to-perform pain provocation tests have a clinically relevant prognostic value on patient-reported improvement. Patients with less pain during pain provocation tests at baseline have a better improvement in pain, function and activities after 24 weeks than patients with high baseline pain scores.

Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial.

OBJECTIVE: To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up. METHODS: We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon. RESULTS: At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period. CONCLUSION: Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period. TRIAL REGISTRATION NUMBER: NL 2618.

Validation of the Activ8 Activity Monitor for Monitoring Postures, Motions, Transfers, and Steps of Hospitalized Patients.

Sedentary behaviors and low physical activity among hospitalized patients have detrimental effects on health and recovery. Wearable activity monitors are a promising tool to promote mobilization and physical activity. However, existing devices have limitations in terms of their outcomes and validity. The Activ8 device was optimized for the hospital setting. This study assessed the concurrent validity of the modified Activ8. Hospital patients performed an activity protocol that included basic (e.g., walking) and functional activities (e.g., room activities), with video recordings serving as the criterion method. The assessed outcomes were time spent walking, standing, upright, sedentary, and newly added elements of steps and transfers. Absolute and relative time differences were calculated, and Wilcoxon and Bland-Altman analyses were conducted. Overall, the observed relative time differences were lower than 2.9% for the basic protocol and 9.6% for the functional protocol. Statistically significant differences were detected in specific categories, including basic standing (p < 0.05), upright time (p < 0.01), and sedentary time (p < 0.01), but they did not exceed the predetermined 10% acceptable threshold. The modified Activ8 device is a valid tool for assessing body postures, motions, steps, and transfer counts in hospitalized patients. This study highlights the potential of wearable activity monitors to accurately monitor and promote PA among hospital patients.

Impact of the COVID-19 lockdown on patient-reported outcome measures in Dutch hip and knee arthroplasty patients.

BACKGROUND AND PURPOSE: During the first COVID-19 lockdown elective surgery was greatly reduced. Prioritization of patients with greater need and expected benefit in terms of quality of life was advised. The lockdown also potentially affected follow-up outcomes. Therefore, our study compared patient-reported outcome measures (PROMs) retrieved during the lockdown of Dutch primary total hip and knee arthroplasty (THA, TKA) patients with previous years. PATIENTS AND METHODS: We performed cross-sectional analyses using national data from the Dutch Orthopaedic Registry (LROI). All primary elective THA and TKA patients with preoperative or postoperative PROMs (EQ-5D-3L index, OHS/OKS) during the first COVID-19 lockdown between March and July 15, 2020 were included. Patients with PROMs during the same months in 2018 plus 2019 were used as control. Finally, 33,453 THA and 27,335 TKA patients were included. Patient characteristics were compared during versus before the lockdown. Subsequently, the lockdown effect on PROMs scores was analyzed with multivariable linear regression. RESULTS: During the COVID-19 lockdown, THA and TKA patients had a lower age and BMI preoperatively, and more often had surgery in private clinics. Both preoperative PROMs in THA patients, but not in TKA patients, were worse (EQ-5D: Adjusted mean difference (AMD) -0.021, p < 0.001) during the lockdown compared with prior years. Both postoperative PROMs in THA and TKA patients were better during the lockdown (12-month EQ-5D in THA: AMD 0.010, p = 0.003; and in TKA: AMD 0.013, p < 0.001). INTERPRETATION: During the COVID-19 lockdown, THA patients had slightly worse preoperative PROMs, suggesting selection of patients with greater urgency. Postoperative PROMs in both THA and TKA patients differed minimally. Overall, the observed differences were likely not clinically relevant.

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial.

OBJECTIVE: High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT. DESIGN: A double-blind, randomized, placebo-controlled clinical trial. SETTING: Sports medicine department at a district general hospital. PATIENTS: Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32). INTERVENTION: A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine. MAIN OUTCOME MEASURES: Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up. RESULTS: There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93). CONCLUSION: A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI. TRIAL REGISTRATION: NCT02996409.

Adding false-profile radiographs improves detection of developmental dysplasia of the hip, data from the CHECK cohort.

The aim of this study was to determine the additional value of the false-profile (FP) view radiograph in the diagnosis of developmental dysplasia of the hip (DDH), as compared with an anteroposterior (AP) pelvic radiograph only, and evaluate the correlation between the Wiberg-lateral center edge angle (W-LCEA) and Wiberg-anterior center edge angle (W-ACEA). We used baseline data from a nationwide prospective cohort study (Cohort Hip and Cohort Knee). DDH was quantified on AP pelvic and FP hip radiographs using semi-automatic measurements of the W-LCEA and W-ACEA. A threshold of <20° was used to determine DDH for both the W-LCEA and the W-ACEA. The proportion of DDH only present on the FP view determined the FP view additional value. The correlation between the W-LCEA and W-ACEA was determined. In total 720 participants (1391 hips) were included. DDH was present in 74 hips (5.3%), of which 32 were only present on the FP view radiograph (43.2%). The Pearson correlation coefficient between W-LCEA and W-ACEA of all included hips was 0.547 (95% confidence interval: 0.503-0.591) and 0.441 (95% confidence interval: 0.231-0.652) in hips with DDH. A mean difference of 9.4° (SD 8.09) was present between the W-LCEA and the W-ACEA in the hips with DDH. There is a strong additional value of the FP radiograph in the diagnosis of DDH. Over 4 out of 10 (43.2%) individuals' DDH will be missed when only using the AP radiograph. In hips with DDH a moderate correlation between W-LCEA and W-ACEA was calculated indicating that joints with normal acetabular coverage on the AP view can still be undercovered on the FP view.

Arthroscopic partial meniscectomy versus physical therapy for traumatic meniscal tears in a young study population: a randomised controlled trial.

OBJECTIVE: To compare outcomes from arthroscopic partial meniscectomy versus physical therapy in young patients with traumatic meniscal tears. METHODS: We conducted a multicentre, open-labelled, randomised controlled trial in patients aged 18-45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomised to arthroscopic partial meniscectomy or standardised physical therapy with an optional delayed arthroscopic partial meniscectomy after 3-month follow-up. The primary outcome was the International Knee Documentation Committee (IKDC) score (best 100, worst 0) at 24 months, which measures patients' perception of symptoms, knee function and ability to participate in sports activities. RESULTS: Between 2014 and 2018, 100 patients were included (mean age 35.1 (SD 8.1), 76% male, 34 competitive or elite athletes). Forty-nine were randomised to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during the follow-up period. In both groups, improvement in IKDC scores was clinically relevant during follow-up compared with baseline scores. At 24 months mean (95% CI) IKDC scores were 78 (71 to 84) out of 100 points in the arthroscopic partial meniscectomy group and 78 (71 to 84) in the physical therapy group with a between group difference of 0.1 (95% CI -7.6 to 7.7) points out of 100. CONCLUSIONS: In this trial involving young patients with isolated traumatic meniscal tears, early arthroscopic partial meniscectomy was not superior to a strategy of physical therapy with optional delayed arthroscopic partial meniscectomy at 24-month follow-up. TRIAL REGISTRATION: https://www.trialregister.nl/trials.

Intra-articular Administration of Triamcinolone Acetonide in a Murine Cartilage Defect Model Reduces Inflammation but Inhibits Endogenous Cartilage Repair.

BACKGROUND: Cartilage defects result in joint inflammation. The presence of proinflammatory factors has been described to negatively affect cartilage formation. PURPOSE: To evaluate the effect and timing of administration of triamcinolone acetonide (TAA), an anti-inflammatory drug, on cartilage repair using a mouse model. STUDY DESIGN: Controlled laboratory study. METHODS: A full-thickness cartilage defect was created in the trochlear groove of 10-week-old male DBA/1 mice (N = 80). Mice received an intra-articular injection of TAA or saline on day 1 or 7 after induction of the defect. Mice were euthanized on days 10 and 28 for histological evaluation of cartilage defect repair, synovial inflammation, and synovial membrane thickness. RESULTS: Mice injected with TAA had significantly less synovial inflammation at day 10 than saline-injected mice independent of the time of administration. At day 28, the levels of synovitis dropped toward healthy levels; nevertheless, the synovial membrane was thinner in TAA- than in saline-injected mice, reaching statistical significance in animals injected on day 1 (70.1 ± 31.9 µm vs 111.9 ± 30.9 µm, respectively; P = .01) but not in animals injected on day 7 (68.2 ± 21.86 µm vs 90.2 ± 21.29 µm, respectively; P = .26). A thinner synovial membrane was moderately associated with less filling of the defect after 10 and 28 days (r = 0.42, P = .02; r = 0.47, P = .01, respectively). Whereas 10 days after surgery there was no difference in the area of the defect filled and the cell density in the defect area between saline- and TAA-injected knees, filling of the defect at day 28 was lower in TAA- than in saline-injected knees for both injection time points (day 1 injection, P = .04; day 7 injection, P = .01). Moreover, there was less collagen type 2 staining in the filled defect area in TAA- than in saline-injected knees after 28 days, reaching statistical significance in day 1-injected knees (2.6% vs 18.5%, respectively; P = .01) but not in day 7-injected knees (7.4% vs 15.8%, respectively; P = .27). CONCLUSION: Intra-articular injection of TAA reduced synovial inflammation but negatively affected cartilage repair. This implies that inhibition of inflammation may inhibit cartilage repair or that TAA has a direct negative effect on cartilage formation. CLINICAL RELEVANCE: Our findings show that TAA can inhibit cartilage defect repair. Therefore, we suggest not using TAA to reduce inflammation in a cartilage repair setting.

Modulation of Inflamed Synovium Improves Migration of Mesenchymal Stromal Cells in Vitro Through Anti-Inflammatory Macrophages.

OBJECTIVE: Inflammation is known to negatively affect cartilage repair. However, it is unclear how inflammation influences the migration of mesenchymal stromal cells (MSCs) from the underlying bone marrow into the defect. We therefore aimed to investigate how synovial inflammation influences MSC migration, and whether modulation of inflammation with triamcinolone acetonide (TAA) may influence migration. DESIGN: Inflamed human osteoarthritic synovium, M(IFNγ+TNFα) pro-inflammatory macrophages, M(IL4) repair macrophages, M(IL10) anti-inflammatory macrophages, or synovial fibroblasts were cultured with/without TAA. Conditioned medium (CM) was harvested after 24 hours, and the effect on MSC migration was studied using a Boyden chamber assay. Inflammation was evaluated with gene expression and flow cytometry analysis. RESULTS: Synovium CM increased MSC migration. Modulation of synovial inflammation with TAA further increased migration 1.5-fold (P < 0.01). TAA significantly decreased TNFA, IL1B, and IL6 gene expression in synovium explants and increased CD163, a gene associated with anti-inflammatory macrophages. TAA treatment decreased the percentage of CD14+/CD80+ and CD14+/CD86+ pro-inflammatory macrophages and increased the percentage of CD14+/CD163+ anti-inflammatory macrophages in synovium explants. Interestingly, MSC migration was specifically enhanced by medium conditioned by M(IL4) macrophages and by M(IL10) macrophages treated with TAA, and unaffected by CM from M(IFNγ+TNFα) macrophages and synovial fibroblasts. CONCLUSION: Macrophages secrete factors that stimulate the migration of MSCs. Modulation with TAA increased specifically the ability of anti-inflammatory macrophages to stimulate migration, indicating that they play an important role in secreting factors to attract MSCs. Modulating inflammation and thereby improving migration could be used in approaches based on endogenous repair of full-thickness cartilage defects.

Educational online prevention programme (the SPRINT study) has no effect on the number of running-related injuries in recreational runners: a randomised-controlled trial.

OBJECTIVES: The aim of this study was to examine the effectiveness of an enhanced online injury prevention programme on the number of running-related injuries (RRIs) in recreational runners. METHODS: We conducted a randomised-controlled trial in runners who registered for running events (distances: 10-42.195 km) in the Netherlands. Adult runners who provided informed consent were randomised into the intervention or control group. Participants in the intervention group received access to the online prevention programme, which included items to prevent RRIs. Participants in the control group followed their regular preparation for the running event. The primary outcome measure was the number of new RRIs from baseline to 1 month after the running event. To determine differences between injury proportions, univariate and multivariate logistic regression analyses were performed. RESULTS: This study included 4050 recreational runners (63.5% males; mean (SD) age: 42.3 (12.1) years) for analyses. During follow-up, 35.5% (95% CI: 33.5 to 37.6) of the participants in the intervention group sustained a new RRI compared with 35.4% (95% CI: 33.3 to 37.5) of the participants in the control group, with no between-group difference (OR: 1.03; 95% CI: 0.90 to 1.17). There was a positive association between the number of items followed in the injury prevention programme and the number of RRIs (OR: 1.05; 95% CI: 1.00 to 1.11). CONCLUSION: The enhanced online injury prevention programme had no effect on the number of RRIs in recreational runners, and being compliant with the programme paradoxically was associated with a slightly higher injury rate. Future studies should focus on individual targeted prevention with emphasis on the timing and application of preventive measures. TRIAL REGISTRATION NUMBER: NL7694.

Why, When, and in Which Patients Nonoperative Treatment of Anterior Cruciate Ligament Injury Fails: An Exploratory Analysis of the COMPARE Trial.

BACKGROUND: The optimal treatment strategy for patients with an anterior cruciate ligament (ACL) rupture is still under debate. Different determinants of the need for a reconstruction have not been thoroughly investigated before. PURPOSE: To investigate why, when, and which patients with an ACL rupture who initially started with rehabilitation therapy required reconstructive surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: In the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation (COMPARE) trial, 167 patients with an ACL rupture were randomized to early ACL reconstruction or rehabilitation therapy plus optional delayed ACL reconstruction. We conducted an exploratory analysis of a subgroup of 82 patients from this trial who were randomized to rehabilitation therapy plus optional delayed ACL reconstruction. The reasons for surgery were registered for the patients who underwent a delayed ACL reconstruction. For these patients, we used the International Knee Documentation Committee (IKDC) subjective knee form, Numeric Rating Scale for pain, and instability question from the Lysholm questionnaire before surgery. To determine between-group differences between the nonoperative treatment and delayed ACL reconstruction group, IKDC and pain scores during follow-up were determined using mixed models and adjusted for sex, age, and body mass index. RESULTS: During the 2-year follow-up of the trial, 41 of the 82 patients received a delayed ACL reconstruction after a median time of 6.4 months after inclusion (interquartile range, 3.9-10.3 months). Most reconstructions occurred between 3 and 6 months after inclusion (n = 17; 41.5%). Ninety percent of the patients (n = 37) reported knee instability concerns as a reason for surgery at the moment of planning surgery. Of these patients, 18 had an IKDC score ≤60, 29 had a pain score of ≥3, and 33 patients had knee instability concerns according to the Lysholm questionnaire before surgery. During follow-up, IKDC scores were lower and pain scores were higher in the delayed reconstruction group compared with the nonoperative treatment group. Patients in the delayed reconstruction group had a significantly younger age (27.4 vs 35.3 years; P = .001) and higher preinjury activity level compared with patients in the nonoperative treatment group. CONCLUSION: Patients who experienced instability concerns, had pain during activity, and had a low perception of their knee function had unsuccessful nonoperative treatment. Most patients received a delayed ACL reconstruction after 3 to 6 months of rehabilitation therapy. At baseline, patients who required reconstructive surgery had a younger age and higher preinjury activity level compared with patients who did not undergo reconstruction.

Outcomes of 3-D corrective osteotomies for paediatric malunited both-bone forearm fractures.

Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III.

Standardized pain mapping for diagnosing Achilles tendinopathy.

OBJECTIVES: To assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy. DESIGN: Cross-sectional study. METHODS: Eligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy. RESULTS: 110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78-0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54-0.79). CONCLUSIONS: There is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.

One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study.

Patients with midportion Achilles tendinopathy (AT) are thought to experience a gradual symptomatic improvement over time. The aim of this study was to prospectively investigate if patients with midportion AT have symptoms at 10-year follow-up. Patients withmidportion AT were invited to complete an online questionnaire 10 years after inclusion in an intervention trial. The primary outcomewas the presence of AT symptoms. Secondary outcomes were: the Victorian Institute of Sports Assessment-Achilles tendinopathy (VISA-A, 0-100) score and sports activity level. Of the 54 patientsincluded, 43 (80%) completed the questionnaire at an average follow-up of 10.4 years. Persisting symptoms were reported by 19%. The mean (standard deviation-SD) VISA-A score improved from 52 (17) at baseline to 79 (21) at 10-years follow-up with a mean change of 27 points (95% confidence interval: 21; 35, p < 0.001). Of the 38 active patients, 16 (42%) returned to their pre-injury level sports,of whom 14 (37%) performed them pain free. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10years. One-third of patients were able to perform sports pain-free atpre-injury level. Patients should be adequately counselled to giverealistic expectations. Trial registration number: clinicaltrials.gov (identifier: NCT00761423).

Victorian Institute of Sport Assessment-Achilles (VISA-A) Questionnaire-Minimal Clinically Important Difference for Active People With Midportion Achilles Tendinopathy: A Prospective Cohort Study.

OBJECTIVE: To determine the minimal clinically important difference (MCID) for the Victorian Institute of Sport Assessment-Achilles (VISA-A) score in patients with midportion Achilles tendinopathy (AT). DESIGN: Prospective cohort study. METHODS: We included physically active patients with midportion AT who received exercises and an injection. We measured the VISA-A score (ranging from 0 to 100 points, where 100 points represents a healthy tendon) at baseline and at 12 weeks and 24 weeks after treatment, and the 7-point Global Assessment Scale (ranging from "worse than ever" to "completely recovered") at 12 weeks and 24 weeks after treatment. We dichotomized the Global Assessment Scale to not improved ("worse than ever" to "unchanged") or improved ("moderately improved" to "completely recovered"). The area under the curve and the Youden's index value closest to 1 were determined for both MCIDs (12 and 24 weeks), with corresponding sensitivity and specificity. RESULTS: Sixty-four patients were included, and 61 patients (95%) completed the 24-week follow-up. The MCID was 14 points (95% confidence interval [CI]: 3, 19) over a 12-week period, corresponding to 57% sensitivity and 88% specificity. The MCID was 7 points (95% CI: -10, 28) over a 24-week period, with 85% sensitivity and 62% specificity. CONCLUSION: A change in VISA-A score of at least 14 points after 12 weeks or at least 7 points after 24 weeks of exercise therapy and an injection reflects a meaningful change for physically active patients with midportion AT. J Orthop Sports Phys Ther 2021;51(10):510-516. doi:10.2519/jospt.2021.10040.

Timing of debridement, antibiotics, and implant retention (DAIR) for early post-surgical hip and knee prosthetic joint infection (PJI) does not affect 1-year re-revision rates: data from the Dutch Arthroplasty Register.

Debridement, antibiotics, and implant retention (DAIR) is a procedure to treat a periprosthetic joint infection (PJI) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). The timing between the primary procedure and the DAIR is likely a determinant for its successful outcome. However, the optimal timing of a DAIR and the chance of success still remain unclear. We aimed to assess the risk of re-revision within 1 year after a DAIR procedure and to evaluate the timing of the DAIR in primary THA and TKA. We used data from the Dutch Arthroplasty Register (LROI) and selected all primary THA and TKA in the period 2007-2016 which underwent a DAIR within 12 weeks after primary procedure. A DAIR was defined as a revision for infection in which only modular parts were exchanged. A DAIR was defined as successful if not followed by a re-revision within 1 year after DAIR; 207 DAIRs were performed < 4  weeks after THA, of which 16 (8 %) received a complete revision within 1 year. DAIR procedures performed between 4 and 12 weeks ( n = 98 ) had a failure rate of 9 % ( n = 9 ). After TKA 126 DAIRs were performed in less than 4  weeks, of which 11 (9 %) received a complete revision within 1 year; 83 DAIRs were performed between 4 and 12 weeks, of which 14 (17 %) were revised. There was no significant difference in 1-year re-revision rate after a DAIR procedure by timing of the DAIR procedure for total hip and knee arthroplasty based on Dutch registry data.

Effects of eccentric exercises on improving ankle dorsiflexion in soccer players.

PURPOSE: The purpose of this study was to determine the effect of targeted eccentric calf muscle exercises compared to regular training on ankle dorsiflexion in healthy adolescent soccer players with a decreased ankle dorsiflexion. METHODS: Male adolescent players (aged 14-21 years) from two professional soccer clubs were evaluated with the Weight Bearing Dorsiflexion Lunge Test (WBDLT) at baseline and after 12 weeks of this prospective controlled study. One club served as the control group and the other as the intervention group. Players with decreased ankle dorsiflexion (WBDLT) ≤ 10 cm) performed stretching and eccentric calf muscle exercises three times per week next to regular training in the intervention group, and performed only regular training in the control group. Primary outcome was the between-group difference in change in WBDLT between baseline and 12 weeks. RESULTS: Of 107 eligible players, 47(44 %) had a decreased ankle dorsiflexion. The WBDLT (± standard deviation) increased in the intervention group from 7.1 (± 1.8) to 7.4 (± 2.4) cm (95 % Confidence Interval (CI)[-0.493 to 1.108], p = 0.381) and in the control group from 6.1 (± 2.4) to 8.2 (± 2.9) cm (95 % CI [1.313 to 2.659], p < 0.001). The difference in change of WBDLT between both groups was statistically significant (95 % CI [-2.742 to -0.510], p = 0.005). CONCLUSIONS: Targeted eccentric calf muscle exercises do not increase ankle dorsiflexion in healthy adolescent soccer players. Compared to regular training, eccentric exercises even resulted in a decreased calf muscle flexibility. TRIAL REGISTRATION: This trial was registered retrospectively on the 7th of September 2016 in The Netherlands Trial Register (ID number: 6044).

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study.

OBJECTIVES: To analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients. DESIGN: Prospective cohort study. METHODS: Patients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, -1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13-18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0-100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model. RESULTS: Of 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p=0.459, p=0.478 and p=0.420, respectively). CONCLUSIONS: Contrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.