No difference in joint awareness after mobile- and fixed-bearing total knee arthroplasty: 3-year follow-up of a randomized controlled trial.

PURPOSE: To compare the patients ability to forget the artificial knee joint in everyday life who were randomized to be operated for mobile- or fixed-bearing total knee arthroplasty (TKA). METHODS: This single-center randomized controlled trial evaluated the 3-year follow-up of the cemented mobile- and fixed-bearing TKA from the same brand in a series of 41 patients. Clinical examination was during the pre-, 6-week, 6-month, 1-, 2- and 3-year follow-up containing multiple patient-reported outcome measures (PROMs) including the 12-item Forgotten Joint Score (FJS-12) at 3 years. Effect size was calculated for each PROM at 3-year follow-up to quantify the size of the difference between both bearings. RESULTS: At 3-year follow-up, general linear mixed model analysis showed that there were no significant or clinically relevant differences between the two groups for all outcome measures. Calculated effect sizes were small (<0.3) for all the PROMs except for the FJS-12; these were moderate (0.5). CONCLUSION: The results of this study demonstrate that joint awareness was slightly lower in patients operated with the MB TKA with comparable improved clinical outcome and PROMs at 3-year follow-up. Measuring joint awareness with the FJS-12 is useful and provides more stringent information at 3-year follow-up compared to other PROMs and should be the PROM of choice at each follow-up after TKA. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

No difference in terms of radiostereometric analysis between fixed- and mobile-bearing total knee arthroplasty: a randomized, single-blind, controlled trial.

PURPOSE: A concern that arises with any new prosthesis is whether it will achieve satisfactory long-term implant stability. The gold standard of assessing the quality of fixation in a new or relatively new implant is to undertake a randomized controlled trial using radiostereometric analysis. It was hypothesized that both mobile-bearing total knee arthroplasty and fixed-bearing total knee arthroplasty have comparable migration patterns at 2-year follow-up. This study investigated two types of cemented total knee arthroplasty, the mobile- or fixed-bearing variant from the same family with use of radiostereometric analysis. METHODS: This prospective, patient-blinded, randomized, controlled trial was designed to investigate early migration of the tibia component after two years of follow-up with use of radiostereometric analysis. A total of 50 patients were randomized to receive a mobile- or fixed-bearing TKA from the same family. Patients were evaluated during 2-year follow-up, including radiostereometric analysis, physical and clinical examination and patient reported outcome measures (PROMs). RESULTS: At two-year follow-up, the mean (±SD) maximum total point motion (MTPM) in the fixed-bearing group was 0.82 (±1.16) versus 0.92 mm (±0.64) in the mobile-bearing group (p = n.s) with the largest migration seen during the first 6 weeks (0.45 ± 0.32 vs. 0.54 ± 0.30). The clinical outcome and PROMs significantly improved within each group, not between both groups. CONCLUSIONS: Measuring early micromotion is useful for predicting clinical loosening that can lead to revision. The results of this study demonstrate that early migration of the mobile-bearing is similar to that of the fixed-bearing component at two years and was mainly seen in the first weeks after implantation. LEVEL OF EVIDENCE: Randomized, single-blind, controlled trial, Level I.

Ten- to 15-year results of the Oxford Phase III mobile unicompartmental knee arthroplasty: a prospective study from a non-designer group.

AIMS: The interest in unicompartmental knee arthroplasty (UKA) for medial osteoarthritis has increased rapidly but the long-term follow-up of the Oxford UKAs has yet to be analysed in non-designer centres. We have examined our ten- to 15-year clinical and radiological follow-up data for the Oxford Phase III UKAs. PATIENTS AND METHODS: Between January 1999 and January 2005 a total of 138 consecutive Oxford Phase III arthroplasties were performed by a single surgeon in 129 patients for medial compartment osteoarthritis (71 right and 67 left knees, mean age 72.0 years (47 to 91), mean body mass index 28.2 (20.7 to 52.2)). Both clinical data and radiographs were prospectively recorded and obtained at intervals. Of the 129 patients, 32 patients (32 knees) died, ten patients (12 knees) were not able to take part in the final clinical and radiological assessment due to physical and mental conditions, but via telephone interview it was confirmed that none of these ten patients (12 knees) had a revision of the knee arthroplasty. One patient (two knees) was lost to follow-up. RESULTS: The mean follow-up was 11.7 years (10 to 15). A total of 11 knees (8%) were revised. The survival at 15 years with revision for any reason as the endpoint was 90.6% (95% confidence interval (CI) 85.2 to 96.0) and revision related to the prosthesis was 99.3% (95% CI 97.9 to 100). The mean total Knee Society Score was 47 (0 to 80) pre-operatively and 81 (30 to 100) at latest follow-up. The mean Oxford Knee Score was 19 (12 to 40) pre-operatively and 42 (28 to 55) at final follow-up. Radiolucency beneath the tibial component occurred in 22 of 81 prostheses (27.2%) without evidence of loosening. CONCLUSION: This study supports the use of UKA in medial compartment osteoarthritis with excellent long-term functional and radiological outcomes with an excellent 15-year survival rate. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):41-7.

Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals.

INTRODUCTION: The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: "acute primary shoulder dislocation, diagnostics and treatment" in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD. MATERIALS AND METHODS: An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals. RESULTS: The overall response rate was 60%. Of the respondents, 75% had a local protocol for managing AFASD, of which 28% had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36% of the surgeons perform only arthroscopic procedures, 7% only open and 57% perform both open and arthroscopic procedures. CONCLUSIONS: Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.

Autologous wound drains have no effect on allogeneic blood transfusions in primary total hip and knee replacement: a three-arm randomised trial.

We hypothesised there was no clinical value in using an autologous blood transfusion (ABT) drain in either primary total hip (THR) or total knee replacement (TKR) in terms of limiting allogeneic blood transfusions when a modern restrictive blood management regime was followed. A total of 575 patients (65.2% men), with a mean age of 68.9 years (36 to 94) were randomised in this three-arm study to no drainage (group A), or to wound drainage with an ABT drain for either six hours (group B) or 24 hours (group C). The primary outcome was the number of patients receiving allogeneic blood transfusion. Secondary outcomes were post-operative haemoglobin (Hb) levels, length of hospital stay and adverse events. This study identified only 41 transfused patients, with no significant difference in distribution between the three groups (p = 0.857). The mean pre-operative haemoglobin (Hb) value in the transfused group was 12.8 g/dL (9.8 to 15.5) versus 14.3 g/dL (10.6 to 18.0) in the non-transfused group (p < 0.001, 95% confidence interval: 1.08 to 1.86). Post-operatively, the median of re-transfused shed blood in patients with a THR was 280 mL (Interquartile range (IQR) 150 to 400) and in TKR patients 500 mL (IQR 350 to 650) (p < 0.001). ABT drains had no effect on the proportion of transfused patients in primary THR and TKR. The secondary outcomes were also comparable between groups.

Comparison of different pseudotumor grading systems in a single cohort of metal-on-metal hip arthroplasty patients.

OBJECTIVE: Follow-up of pseudotumors observed with metal-artefact reducing sequence (MARS)-magnetic resonance imaging (MRI) following metal-on-metal total hip arthroplasty (MoMTHA) depends on how severe these pseudotumors are graded. Several pseudotumor grading systems for MARS-MRI have emerged but little is known of their validity. We studied the intra- and interobserver reliability of three different pseudotumor grading systems in a single cohort of MoMTHA. PATIENTS AND METHODS: Two experienced musculoskeletal radiologists independently used three different pseudotumor grading systems for classifying MARS-MRI results of the same cohort of 42 MoMTHA patients (49 hips, mean follow-up 5.2 years). Intraobserver and interobserver reliability for each grading system was measured using Cohen's kappa (κ). Variance in pseudotumor severity grading between systems was analyzed. RESULTS: Intraobserver reliability on grading pseudotumor severity with the Anderson, Matthies, and Hauptfleisch grading system scored 0.47, 0.10, and 0.35 (observer 1), and 0.75, 0.38, and 0.42 (observer 2), respectively. Interobserver reliability scores for pseudotumor severity were 0.58, 0.23, and 0.34, respectively. CONCLUSIONS: Intraobserver reliability for grading pseudotumor severity on MARS-MRI ranged from poor to good, dependent on observer and grading system used. Interobserver reliability scored best with the Anderson system. A more succinct pseudotumor severity grading system is needed for clinical use.

Asymptomatic pseudotumours after metal-on-metal hip resurfacing show little change within one year.

The aim of this study was to establish the natural course of unrevised asymptomatic pseudotumours after metal-on-metal (MoM) hip resurfacing during a six- to 12-month follow-up period. We used repeated metal artefact reduction sequence (MARS)-magnetic resonance imaging (MRI), serum metal ion analysis and clinical examination to study 14 unrevised hips (mean patient age 52.7 years, 46 to 68, 5 female, 7 male) with a pseudotumour and 23 hips (mean patient age 52.8 years, 38 to 69, 7 female, 16 male) without a pseudotumour. The mean post-operative time to the first MARS-MRI scan was 4.3 years (2.2 to 8.3), and mean time between the first and second MARS-MRI scan was eight months (6 to 12). At the second MRI scan, the grade of severity of the pseudotumour had not changed in 35 hips. One new pseudotumour (Anderson C2 score, moderate) was observed, and one pseudotumour was downgraded from C2 (moderate) to C1 (mild). In general, the characteristics of the pseudotumours hardly changed. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation. In 23 patients without pseudotumour, one new asymptomatic pseudotumour was detected. This is the first longitudinal study on the natural history of pseudotumours using MARS-MRI scans in hip resurfacing, and mirrors recent results for 28 mm diameter MoM total hip replacement.

Comparison of contamination of femoral heads and pre-processed bone chips during hip revision arthroplasty.

With bone impaction grafting, cancellous bone chips made from allograft femoral heads are impacted in a bone defect, which introduces an additional source of infection. The potential benefit of the use of pre-processed bone chips was investigated by comparing the bacterial contamination of bone chips prepared intraoperatively with the bacterial contamination of pre-processed bone chips at different stages in the surgical procedure. To investigate baseline contamination of the bone grafts, specimens were collected during 88 procedures before actual use or preparation of the bone chips: in 44 procedures intraoperatively prepared chips were used (Group A) and in the other 44 procedures pre-processed bone chips were used (Group B). In 64 of these procedures (32 using locally prepared bone chips and 32 using pre-processed bone chips) specimens were also collected later in the procedure to investigate contamination after use and preparation of the bone chips. In total, 8 procedures had one or more positive specimen(s) (12.5 %). Contamination rates were not significantly different between bone chips prepared at the operating theatre and pre-processed bone chips. In conclusion, there was no difference in bacterial contamination between bone chips prepared from whole femoral heads in the operating room and pre-processed bone chips, and therefore, both types of bone allografts are comparable with respect to risk of infection.

Retrograde bridging nail in periprosthetic femoral fracture treatment which allows direct weight bearing.

The bridging nail is a retrograde intramedullary femoral nail designed to stabilize periprosthetic femoral fractures. It offers a minimal invasive surgical approach in combination with early mobilization. The goal of this study was to evaluate the osteosynthesis under full weight-bearing conditions. Three groups of five composite fibreglass femora were prepared with a cemented hip stem. Group 1 underwent cyclic axial loading with 1500 N during 150 000 cycles. After completion, linear loading to failure was conducted. Groups 2 and 3 were submitted to linear increased torsional loading with and without an axial load respectively. Failure was defined as rotational movement of the connection (slippage). In the axial cyclic loading configuration, one specimen failed after 122 000 cycles. Four specimens passed 150 000 cycles and failed after linearly increasing the axial loading of 1940-2600 N (mean, 2408 N +/- 313 standard deviation (SD)). Slippage was first detected at a torque varying between 2.5 and 8.2 Nm (mean, 5.1 Nm +/- 2.1 SD) in group 2 and between 10.0 and 15.4 Nm (mean, 13.0 N m +/- 2.3 SD) in group 3. In conclusion the bridging nail offers a stable connection with the stem of a hip arthroplasty which can resist high repetitive loads, representative of direct full axial weight bearing. The biomechanical results support the clinical experience of a stable osteosynthesis enabling early post-operative mobilization.

Pre-operative injections of epoetin-alpha versus post-operative retransfusion of autologous shed blood in total hip and knee replacement: a prospective randomised clinical trial.

This prospective randomised clinical trial evaluated the effect of alternatives for allogeneic blood transfusions after total hip replacement and total knee replacement in patients with pre-operative haemoglobin levels between 10.0 g/dl and 13.0 g/dl. A total of 100 patients were randomly allocated to the Eprex (pre-operative injections of epoetin) or Bellovac groups (post-operative retransfusion of shed blood). Allogeneic blood transfusions were administered according to hospital policy. In the Eprex group, 4% of the patients (two patients) received at least one allogeneic blood transfusion. In the Bellovac group, where a mean 216 ml (0 to 700) shed blood was retransfused, 28% (14 patients) required the allogeneic transfusion (p = 0.002). When comparing Eprex with Bellovac in total hip replacement, the percentages were 7% (two of 30 patients) and 30% (nine of 30 patients) (p = 0.047) respectively, whereas in total knee replacement, the percentages were 0% (0 of 20 patients) and 25% (five of 20 patients) respectively (p = 0.042). Pre-operative epoetin injections are more effective but more costly in reducing the need for allogeneic blood transfusions in mildly anaemic patients than post-operative retransfusion of autologous blood.

Retransfusion of filtered shed blood in everyday orthopaedic practice.

The efficiency of post-operative cell saving after major joint arthroplasty has been demonstrated in prospective studies focusing on blood management. In everyday practice, however, it is likely that transfusion policy is followed less rigorously because of a slackening in attention to blood management, with a reduced efficiency of post-operative cell saving. The primary research question of this retrospective study was whether the number of allogeneic blood transfusions administered to patients treated with a retransfusion system was similar to the results found in a preceding prospective study. A total of 438 patients treated with the Bellovac ABT retransfusion system were analysed in which the majority was operated on a total hip arthroplasty (THA) and total knee arthroplasty (TKA). The amount of retransfused shed blood, the perioperative haemoglobin levels and the number of allogeneic blood transfusions were registered. The average amount of retransfusion was 152 mL in THA and 410 mL in TKA, whereas the allogeneic blood transfusion rate was 8.4 and 5.1% in both groups, respectively. The average percentage of allogeneic blood transfusions administered in this study (i.e. 7%) proved to be marginally higher than the percentage found in a preceding prospective study (i.e. 6%) because of slackening of attention for transfusion policy in everyday practice. Limited bone resection procedures such as resurfacing THA or unicompartmental knee arthroplasty were associated with very limited shed blood and low risk of allogeneic blood transfusion, indicating the doubtful cost efficiency of using a retransfusion system in these patients. It can be concluded that the efficiency of the retransfusion system in everyday practice was similar to the efficiency shown in a preceding prospective study focusing on blood management. However, continual training of the clinical team is crucial.

The open modified Bankart procedure: outcome at follow-up of 10 to 15 years.

We report the outcome of a modified Bankart procedure using suture anchors in 31 patients (31 shoulders) with a mean follow-up of 11 years (10 to 15). The mean age of the patients was 28 years (16 to 39). At follow-up, the mean Rowe score was 90 points (66 to 98) and the Constant score was 96 points (85 to 100). A total of 26 shoulders (84%) had a good or excellent result. The rate of recurrence varied between 6.7% and 9.7% and depended on how recurrence was defined. Two patients had a significant new injury at one and nine years, respectively after operation. The overall rate of instability (including subluxations) varied between 12.9% and 22.6%. All patients returned to work, with 29 (94%) resuming their pre-operative occupation and level of activity. Mild radiological osteoarthritis was seen in nine shoulders (29%) and severe osteoarthritis in one. We conclude that the open modified Bankart procedure is a reliable surgical technique with good long-term results.

Scarf versus chevron osteotomy in hallux valgus: a randomized controlled trial in 96 patients.

BACKGROUND: The degree of correction of hallux valgus deformity using a distal chevron osteotomy is reported as limited. The scarf osteotomy is reported to correct large intermetatarsal angles (IMA). The purpose of this study was to evaluate if one technique gave greater correction of the IMA and hallux valgus angle (HVA) than the other. METHODS: After informed consent, 96 feet in 83 patients were randomized into two treatment groups (49 scarf and 47 chevron osteotomies). The results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Valgus Scale and radiographic HVA and IMA measurements. RESULTS: At 27 (range 23-31) months followup both groups improved. The AOFAS score in the chevron group improved from 48 to 89 points and in the scarf group from 47 to 91 points. In the chevron group the HVA corrected from 30 to 17 degrees, and in the scarf group the HVA corrected from 29 to 18 degrees. In both groups, the IMA was corrected from 13 to 10 degrees. The differences were not statistically significant. Three patients in the chevron group developed a partial metatarsal head necrosis. In the scarf group, four patients developed grade 1 complex regional pain syndrome compared to one patient in the chevron group. CONCLUSIONS: No differences of statistical significance could be measured between the two groups with respect to the AOFAS score, HVA, and IMA. Although both groups showed good to excellent results, we favor the chevron osteotomy because the procedure is technically less demanding.

Retrograde bridging nailing of periprosthetic femoral fractures.

A retrograde femoral nail was designed to slide over the tip of the femoral stem. Eighteen patients (4 male symbol, 14 female symbol) were treated with this retrograde nail between 1995 and 2003. The mean age was 81.4 years (range 61-96) with a mean follow-up of 21 months (range 4-61 months). Eight patients suffered from severe comorbidity. Mean surgical time was 91 min. Fourteen patients regained their preoperative functional level. Six patients died within the first post-operative year of natural causes. Their knee- and hip-function were reasonable considering the age group and co-morbidity. One revision was required and one patient had a protruding nail. In all patients radiological union of the fracture was seen between 4 and 12 months after surgery. Retrograde bridging nailing of the periprosthetic fractured femur is a therapeutic option in geriatric or impaired patients and can serve as a definitive implant.

[Atypical tuberculous osteomyelitis of the humeral shaft caused by Mycobacterium avium]. / Atypische tuberculeuze osteomyelitis van de humerusschacht door Mycobacterium avium.

A 41-year-old man underwent skeletal scintigraphy due to chronic pain in the left foot and polyarthralgia. He was taking medication for gout and had previously had sarcoidosis, for which he had received corticosteroids and other therapy that was discontinued 4 years ago. Scintigraphy revealed a mass in the shaft of the left humerus that, according to biopsy, was an asymptomatic osteomyelitis caused by Mycobacterium avium. The shaft of the left humerus is an uncommon site for tuberculous osteomyelitis. A viable fistula remained after the biopsy that persisted despite pharmacologic treatment with ethambutol, rifabutin and clarithromycin. Four months later, sequestrectomy was performed with insertion of gentamicin-impregnated beads, which resulted in rapid resolution. The foot pain resolved spontaneously. The incidence of bone tuberculosis has increased over the last 2 decades. The most commonly affected sites are the spine and large joints. Infection with M. avium is sometimes involved. Because of the increasing incidence it is important to include mycobacterial infections in the differential diagnosis of focal bone lesions, especially when standard cultures are initially negative.

Peri-operative blood management in elective orthopaedic surgery. A critical review of the literature.

Blood loss during orthopaedic procedures can be extensive and the need for allogeneic blood is a common requirement. However, blood transfusion conceals a number of well-recognised risks and complications and blood products have become more expensive because of their specific preparation procedure. Surgical technique, awareness of the problem and restriction of transfusion triggers are important factors affecting the management of blood loss. Several studies have additionally shown the efficacy of epoetin injections in increasing the pre-operative haemoglobin level. On the other hand, the true benefit of pre-operative autologous donation, acute normovolemic haemodilution and COX-2 selective NSAIDs remains under dispute. Regarding the role of platelet rich plasmapheresis, fibrin sealing and anti-fibinolytic drugs more data are needed. Hypotensive epidural anaesthesia seems to be an advantageous method in minimising peri-operative blood loss. However, this is not a widely performed technique in orthopaedic surgery. In addition, post-operative blood cell saving systems after total knee or hip arthroplasty have been reported to significantly minimise allogeneic blood transfusions when compared to control groups. It can be concluded that many interventions diminish more or less allogeneic blood transfusion in elective orthopaedic surgery. Nevertheless more prospective studies are needed and appropriate algorithms should be applied in peri-operative blood loss management. This review presents an overview of the available interventions which aim to diminish the use of allogeneic blood in elective orthopaedic surgery.

Is minimally invasive surgery less invasive in total hip replacement? A pilot study.

It has been suggested that minimally invasive surgery (MIS) in total hip replacement (THR) is less traumatic than standard techniques. This study was designed to address the question of whether an anterior MIS approach generates less inflammation and muscle damage than the standard posterolateral (PL) approach. Inflammation parameters such as interleukin-6 (IL-6), muscle damage parameters like heart type fatty acid binding protein (H-FABP), and haemoglobin (Hb) levels were determined pre-operatively and at five consecutive points post-operatively in 10 patients operated through a MIS anterior approach and in 10 patients operated through a PL approach. The mean IL-6 concentration increased from 3 pg/ml in both groups pre-operatively to 78.5 pg/ml (PL group) vs 74.8 pg/ml (MIS group) at 6 hours post-operatively and reached a maximum of 100 pg/ml (PL group) vs 90.5 pg/ml pg/ml (MIS group) after 24 hours. Up to this time point, there was a decrease in both groups. The post-operative mean H-FABP concentration increased to 10.7 microg/l in the PL group vs 15.8 microg/l in the MIS group. It formed a plateau and decreased after 24 hours post-operatively. The Hb levels were 14.5 g/dl before surgery and decreased to 10.7 g/dl (PL group) and 10.0 g/dl (MIS group) at 72 hours post-operatively. No significant differences were found between the two approaches either in inflammation and muscle damage or blood loss. Although the absence of a learning curve may explain the lack of a difference between both techniques, we speculate that the term MIS is at least doubtful in terms of being less traumatic.

Experience in the first four years of rapid recovery; is it safe?

The average length of hospital stay after Total Hip Replacement (THR) has been decreasing over time. Recently, many hospitals have commenced rapid recovery programs such as Joint Care. In Joint Care the patients are usually discharged on the fifth post-operative day with relatively fresh surgical wounds. The aim of this study is to evaluate the Joint Care program after THR. Between February 2000 and February 2004, the Joint Care program was used in 611 patients after THR. The average age of the patients was 66.3 yrs (SD 9.3; range 24-86 yrs) and 68% (n= 415) of them were female. All clinical and outpatient charts as well as nursery records were evaluated. The follow up was from 6 months to 4 years (average: 2.5 years). At the planned fifth post-operative day, 92% (n = 562) of patients were discharged from hospital (SD 1.7 days; range 6-25 days). 3.8% (n= 23) of the remaining cases faced wound problems--prolonged wound drainage in 2.3% (n = 14) and potential superficial infection in 1.5% (n = 9) - causing a delay in their discharge. The readmission rate was 6.4% (n = 39) due to hip dislocation (3.4%; n = 21), re-evaluation of wound (1.5%; n= 9), deep infection (1.2%; n = 7)) and cardiac events (0.3%; n = 2). All the infection cases were treated effectively with debridement and antibiotics and no revision for any reason was reported. The Joint Care program seems to be effective after THR. Post-operative hip dislocation was the main reason for post-operative readmission. However, no clear signs that the intensive rehabilitation program caused more complications compared to previous regimens were evident. The above results encourage the application of rapid recovery programs in Orthopaedic surgery and joint replacement.

Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study.

Surgical treatment is considered the last option for chronic tennis elbow. The purpose of this pilot study was to compare treatment with botulinum toxin infiltration of the wrist extensor, a less invasive method, with a surgical wrist extensor release (Hohmann operation). Forty patients were included in the prospective randomized study; one group of patients had surgery (n = 20), the other group of patients was treated with botulinum toxin (n = 20). The results of evaluations after 3, 6, 12, and 24 months are presented. One year after treatment 13 (65%) patients in the botulinum toxin group and 15 (75%) patients in the operative group had good to excellent results. Two years after treatment 15 patients in the botulinum toxin group (75%) had good to excellent results; four patients had been operated on after initial treatment with botulinum toxin Type A. Seventeen patients in the operative group scored good to excellent (85%) at 2 years. When analyzed with an overall scoring system, no differences were found between the two forms of treatment. Botulinum toxin infiltration, a less invasive technique, may be an alternative for surgical treatment of tennis elbow.