Ten-Year Survival Rate of 82% in 262 Cases of Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

BACKGROUND: The long-term sustainability of arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT) remains a matter of debate. The primary aim of the present study was to assess the 10-year survival free from revision in ankles that had undergone arthroscopic BMS for an OLT. The secondary aim was to evaluate the influence of baseline patient and lesion characteristics on survival. METHODS: Patients who underwent arthroscopic BMS for a symptomatic OLT and had a minimum follow-up of 10 years were included to assess procedure survival. The primary outcome, the 10-year cumulative survival rate, was analyzed by the Kaplan-Meier survival method. Secondary outcomes were the median time to revision and the effects of baseline factors (lesion size, primary or non-primary lesion type, preoperative cysts, and obesity as defined by a body mass index [BMI] of ≥30 kg/m2) on survival, analyzed with a Cox regression model and reported using hazard ratios (HRs). RESULTS: The 262 included patients had a mean follow-up of 15.3 ± 4.8 years. The 10-year cumulative survival rate of the arthroscopic BMS procedures was 82% (95% confidence interval [CI]: 77% to 87%). At 15 years of follow-up, the cumulative survival rate was 82% (95% CI: 76% to 86%). The median time to revision was 2.4 years (interquartile range: 1.3 to 5.1 years). Of the baseline factors, obesity (HR: 3.0 [95% CI: 1.44 to 6.43], p < 0.01) was associated with decreased survival. Lesion size (HR: 0.9 [95% CI: 0.5 to 1.8], p = 0.8), non-primary lesion type (HR: 1.8 [95% CI: 0.9 to 3.4], p = 0.1), and the presence of preoperative cysts (HR: 1.0 [95% CI: 0.6 to 1.9], p = 0.9) were not significantly associated with survival. CONCLUSIONS: At a minimum follow-up of 10 years, the survival rate of arthroscopic BMS for OLT was 82%. At 15 and 20 years of follow-up, survival appeared to remain stable. Obesity (BMI ≥ 30 kg/m2) was associated with a higher likelihood of revision surgery. This risk factor should be incorporated into the treatment algorithm for OLT when counseling patients regarding surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the early postoperative outcomes of cementless and cemented medial unicompartmental knee arthroplasty.

Aims: The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques. Methods: We analyzed 10,862 cementless and 7,917 cemented UKA cases enrolled in the Dutch Arthroplasty Registry, operated between 2017 and 2021. Pre- to postoperative change in outcomes at six and 12 months' follow-up were compared using mixed model analyses. Kaplan-Meier and Cox regression models were applied to quantify differences in implant survival. Adjustments were made for patient-specific variables and annual hospital volume. Results: Change from baseline in the Oxford Knee Score (OKS) and activity-related pain was comparable between groups. Adjustment for covariates demonstrated a minimally greater decrease in rest-related pain in the cemented group (ß = -0.09 (95% confidence interval (CI) -0.16 to -0.01)). Cementless fixation was associated with a higher probability of achieving an excellent OKS outcome (> 41 points) (adjusted odds ratio 1.2 (95% CI 1.1 to 1.3)). The likelihood of one-year implant survival was greater for cemented implants (adjusted hazard ratio (HR) 1.35 (95% CI 1.01 to 1.71)), with higher revision rates for periprosthetic fractures of cementless implants. During two to three years' follow-up, the likelihood of implant survival was non-significantly greater for cementless UKA (adjusted HR 0.64 (95% CI 0.40 to 1.04)), primarily due to increased revision rates for tibial loosening of cemented implants. Conclusion: Cementless and cemented medial UKA led to comparable improvement in physical function and pain reduction during the initial postoperative year, albeit with a greater likelihood of achieving excellent OKS outcomes after cementless UKA. Anticipated differences in early physical function and pain should not be a decisive factor in the choice of fixation technique. However, surgeons should consider the differences in short- and long-term implant survival when deciding which implant to use.

Mid-term survival of the Optimys short stem: A prospective case series of 500 patients.

BACKGROUND: In recent years, there has been an increase in the number of total hip arthroplasty procedures in the younger patient population. This active group has higher expectations of their prosthesis in comparison to the older population, and there is a greater physical demand for the prosthesis. Short femoral stems were introduced to retain proximal bone stock and joint biomechanics and became more common to implant in this specific population. Currently, the long-term survival and functional outcomes of various short stems are still being investigated in different clinics. AIM: To determine the 5-year survival of the Optimys hip stem. METHODS: This was a prospective multicenter cohort study of 500 patients conducted in two hospitals in the Netherlands. All patients received the Optimys short stem (Mathys Ltd, Bettlach, Switzerland). The primary outcome measure was survival of the hip stem, with revision as the endpoint. The secondary outcome measurements included patient-reported outcome measures (PROMs). Kaplan-Meier analysis was used to calculate the 5-year survival rate. Log-minus-log transformation was performed to calculate the 95% confidence interval (95%CI). Mixed model analyses were performed to assess the course of the PROMs during the 1st 2 years after surgery. Analyses were modeled separately for the 1st and 2nd years to calculate the yearly change in PROMs during both follow-up periods with accompanying 95%CIs. RESULTS: The mean age of the total 500 patients was 62.3 years (standard deviation: 10.6) and 202 were male (40%). At a median follow-up of 5.5 years (interquartile range: 4.5-6.7), 7 patients were deceased and 6 revisions were registered, for infection (n = 3), subsidence (n = 2) and malposition (n = 1). This resulted in an overall 5-year survival of 98.8% (95%CI: 97.3-99.5). If infection was left out as reason for revision, a stem survival of 99.4% (95%CI: 98.1-99.8) was seen. Baseline questionnaires were completed by 471 patients (94%), 317 patients (63%) completed the 1-year follow-up questionnaires and 233 patients (47%) completed the 2-year follow-up. Both outcome measures significantly improved across all domains in the 1st year after the operation (P < 0.03 for all domains). In the 2nd year after surgery, no significant changes were observed in any domain in comparison to the 1-year follow-up. CONCLUSION: The Optimys stem has a 5-year survival of 98.8%. Patient-reported outcome measures increased significantly in the 1st postoperative year with stabilization at the 2-year follow-up.

Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

OBJECTIVES: Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. DESIGN: Retrospective study. SETTING: Single level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. OUTCOME MEASURES AND COMPARISONS: Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. RESULTS: In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. CONCLUSIONS: This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of patient- and proxy-reported outcomes for children with impairment of the lower extremity: A systematic review using the COnsensus-based Standards for selection of health Measurement INstruments methodology.

Background: Patient-reported outcome measures have become crucial in the clinical evaluation of patients. Appropriate selection, in a young population, of the instrument is vital to providing evidence-based patient-centered healthcare. This systematic review applies the COnsensus-based Standards for selection of health Measurement INstruments methodology to provide a critically appraised overview of patient-reported outcome measures targeted at pediatric orthopedic patients with lower limb impairment. Method: A systematic search of electronic databases was performed to identify original studies reporting the development and/or validation of patient-reported outcome measures evaluating children with impairment of the lower extremity. Data extraction, quality assessment, and risk of bias evaluation were performed following the COnsensus-based Standards for selection of health Measurement INstruments guidelines and Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Results: A total of 6919 articles were screened. Thirty-three studies were included, reporting evidence on the measurement properties of 13 different patient-reported outcome measures and 20 translations. Four studies reported on content validity and patient-reported outcome measure development. The methodological quality of studies on structural validity, content validity, or patient-reported outcome measure development was mostly rated as "doubtful" or "very good." The quality of evidence on measurement properties varied noticeably, with most studies needing to perform improve their methodological quality to justify their results. Conclusion: This review provides an extensive overview of all available patient-reported outcome measures for patients with lower extremity impairment within pediatric orthopedics. We cautiously advise the use of four patient-reported outcome measures. However, the scarce availability of research on content validity and patient-reported outcome measure development highlights an area for future research endeavors to improve our knowledge on the currently available patient-reported outcome measures. Level of evidence: Diagnostic level 1.

Higher Age is Associated with Lower Likelihood of Conversion to Surgery after Primary Nonoperative Treatment for Osteochondral Lesions of the Talus.

INTRODUCTION: The first line of treatment for osteochondral lesions of the talus (OLT) is nonoperative. To date, there is limited evidence on risk factors that may influence conversion to surgery after primary nonoperative treatment for symptomatic OLTs. The aim of this study was therefore to identify risk factors for conversion to surgery after initial nonoperative treatment of OLTs. METHODS: For this cohort study, patients with a primary OLT who were nonoperatively treated for at least 6 months between 1990 and 2020 were included. Univariable Cox regression analysis, resulting in hazard ratios (HRs), on the primary outcome (i.e. conversion to surgery after initial nonoperative treatment) was performed for potential risk factors. The following risk factors were analyzed: gender, age, body mass index (BMI), numeric rating scale (NRS), lesion size (depth, sagittal length, coronal length, volume, surface), lesion morphology (presence of fragments and presence of cysts), lesion location (medial/central/lateral), congruency of the ankle joint and trauma in history. Data imputation was conducted according to the multiple data principle with pooling. RESULTS: Forty-two patients with primary OLTs were included in this study: 23 (55%) males and 19 (45%) females with a mean age of 39.1 (SD: 14.2). The median overall follow-up time was 66 months (range: 7-188). Around 23% of the patients had a conversion to surgery at the median observation time. The Kaplan-Meier analysis revealed a survival rate of 93% (95% confidence interval [CI]:84-100), 90% (95% CI: 81-99), and 77% (95% CI: 63-91) at 1, 2, and 5 years after the initiation of treatment, respectively. After performing the COX regression analysis, age was the sole risk factor significantly associated with conversion to surgery with an HR of 0.93 (95% CI: 0.87-0.99). The different HRs for all other risk factors were as follows: gender: 0.33 (95% CI: 0.08-1.34), BMI: 0.87 (95% CI 0.76-1.01), depth: 0.97 (95% CI: 0.79-1.18), coronal length: 1.19 (95% CI: 0.97-1.44), sagittal length: 0.98 (95% CI: 0.87-1.12), surface area: 1.17 (95% CI: 0.41-3.31), volume: 0.96 (95% CI: 0.24-3.91), presence of fragments: 4.17 (95% CI: 0.84-20.61). CONCLUSION: For primary OLTs, 77% of the patients were successfully treated nonoperatively at a median follow-up of 66 months without the need for a surgical intervention. Survival rates of 93%, 90%, and 77% were found at 1, 2, and 5 years after the initiation of treatment, respectively. We found that a higher age at the moment of diagnosis was significantly associated with a lower likelihood of conversion to surgery with a 7% decrease of likelihood each year the patient is older at the moment of diagnosis. The findings of this study are clinically relevant as it ameliorates the quality of the shared decision-making process between the patient and the treating team as we can advise OLT patients at a higher age with tolerable symptomatology that there is a relatively lower risk of conversion to surgery.

The Rise of the Direct Anterior Approach: Trends, Learning Curves, and Patient Characteristics of 63,182 Primary Total Hip Arthroplasties in the Dutch Arthroplasty Register (LROI).

BACKGROUND: The use of the direct anterior approach (DAA) in total hip arthroplasty (THA) has steadily increased in the Netherlands since 2007. The aim of this study was to outline how the DAA has been implemented in the Netherlands. Moreover, we investigated the learning curve of the DAA at a hospital level, and explored patient characteristics of the DAA compared with other approaches and during the learning phase after implementing the DAA. METHODS: In this population-based cohort study, we included all primary THAs between 2007 and 2020 (n = 342,473) from the Dutch Arthroplasty Register. For hospitals implementing the DAA (n > 20), patients were categorized in 4 experience groups using the date of surgery: 1 to 50, 51 to 100, 101 to 150, or > 150. Subsequently, data from different hospitals were pooled and survival rates were calculated using Kaplan-Meier survival analyses. Adjusted revision rates were calculated using mixed Cox proportional hazard models (frailty). RESULTS: The use of the DAA gradually rose from 0.2% in 2007 to 41% of all primary THAs in 2020. A total of 64 (56%) hospitals implemented the DAA. However, not all hospitals continued using this approach. After implementation, the 5-year survival rate for the first 50 procedures was significantly lower (96% confidence interval [CI] 95.8 to 97.2) compared to >150 procedures (98% CI 97.7 to 98.1). Multivariable Cox hazard analyses demonstrated a higher risk of revision during the first 50 procedures compared with >150 procedures (hazard ratio 1.6, CI 1.3 to 2.0). CONCLUSIONS: The use of DAA for primary THA significantly increased. For hospitals implementing DAA, a considerable learning curve with increased revision risk was seen.

Diagnostic value of a preoperative acromioclavicular injection for symptomatic acromioclavicular osteoarthritis: a retrospective study of cross-sectional midterm outcomes.

BACKGROUND: It is essential to distinguish between symptomatic- and asymptomatic radiographic acromioclavicular (AC) osteoarthritis (OA) because AC-targeted physical examinations are dubious. This study aimed to determine the diagnostic value of a preoperative AC injection in discriminating between symptomatic- and asymptomatic radiographic AC OA based on patient arthroscopic distal clavicle resection (aDCR) outcomes. METHODS: Forty-eight patients who underwent aDCR for AC OA were included. Their satisfaction was objectified using a 5-point Likert scale and patient willingness to repeat the surgery. The Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), and the Numerical Rating Scale (NRS) were used to assess postoperative shoulder function and pain. Patients were subdivided into groups based on their good or minimal reaction to an AC injection (good reaction: ≥7 consecutive days of pain reduction, Minimal reaction: <7 consecutive days of pain reduction). RESULTS: Twenty-seven patients had a good reaction and 21 patients had a minimal reaction to the AC injection (median follow-up, 45.0 months; range, 31.0-52.8 months). No significant differences were found in level of satisfaction (P=0.234) or willingness to repeat the surgery (P=0.861). No significant differences were found in OSS (P=0.612), SSV (P=0.641), NRS at rest (P=0.684) or during activity (P=0.422). CONCLUSIONS: This study found no significant differences between patients with a good reaction or a minimal reaction to an AC injection after aDCR surgery. The outcomes of this study seem to suggest that a distinction between symptomatic and asymptomatic radiographic AC OA is unnecessary, as all patients were equally satisfied with the outcome. Level of evidence: IV.

The Diagnostic Characteristic and Reproducibility of Bone Scintigraphy Single-Photon Emission Computed Tomography/Computed Tomography for Diagnosing Aseptic Loosening of Uncemented Total Knee Arthroplasty.

BACKGROUND: The primary objective of this study was to investigate the diagnostic characteristics of bone scintigraphy single-photon emission computed tomography/computed tomography (BS-SPECT/CT) for diagnosing aseptic loosening after uncemented total knee arthroplasty (TKA), and to evaluate the following aspects: how to manage inconclusive results, the interobserver reliability, and the location of tracer uptake between symptomatic cases with and without aseptic loosening. METHODS: In this study, 180 patients who had uncemented TKA and persistent knee pain suspected of aseptic loosening were included. As part of routine medical care, BS-SPECT/CT was used, and its results were compared with the reference standard, which involved revision surgery for aseptic loosening or a 12-month follow-up without revision or imaging. Inconclusive BS-SPECT/CT results were considered either negative (best-case scenario) or positive (worst-case scenario). Sensitivity, specificity, positive/negative likelihood ratios (LRs), and positive/negative predictive values (PPV and NPV) were calculated. Sensitivity analyses were conducted by comparing the diagnostic characteristics between cases with a follow-up of less and more than 2 years of follow-up. The anatomical distribution of tracer uptake and interobserver reliability were also evaluated. RESULTS: Of the 180 BS-SPECT/CT scans conducted, 22 were determined positive, 113 negative, and 45 inconclusive. The best-case scenario showed a sensitivity of 66.7%, specificity of 93.8%, +LR 10.8, -LR 0.4, PPV 54.6%, and NPV 96.2%. In contrast, the worst-case scenario had a sensitivity of 94.4%, specificity of 69.1%, +LR 3.1, -LR 0.1, PPV 25.4%, and NPV 99.1%. Sensitivity analyses revealed no relevant differences in characteristics between the 2 TKA-interval groups. The interobserver reliability was fair-to-moderate (κ = 0.39; 95% confidence interval 0.18 to 0.60), with an estimated agreement of 79% (95% confidence interval 70 to 87). Four prosthetic zones had a notably higher proportion of cases with tracer uptake in those with aseptic loosening compared to those without. CONCLUSIONS: The test characteristics of BS-SPECT/CT were deemed appropriate in patients who have complaints of uncemented TKA suspected of aseptic loosening. Inconclusive cases were best categorized as negative, especially in patients who have a short interval between TKA and the first BS-SPECT/CT. Increased tracer uptake in 4 prosthetic zones was observed in cases of aseptic loosening, although interobserver reliability was fair to moderate. LEVEL OF EVIDENCE: Level III, Diagnostic Retrospective Cohort Study.

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis.

PURPOSE: Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes. METHODS: A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications. RESULTS: The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections. CONCLUSION: Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications). LEVEL OF EVIDENCE: Level IV, Systematic Review and Meta-Analysis.

Total Knee Arthroplasty in the Post-Traumatic Knee: Revision Risks and Functional Outcomes Compared to Osteoarthritic Knees. A Report of Primary Procedures From the Dutch Arthroplasty Register.

BACKGROUND: Total knee arthroplasty (TKA) for post-traumatic arthritis (PTA) poses higher challenges and increased risks of complications compared to TKA for osteoarthritis (OA). This study aimed to compare implant survivorships, reasons for revision, and patient-reported outcome measures between OA and PTA as indications for TKA. METHODS: We selected all primary TKAs for PTA or OA between 2007 and 2020 from the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies). The study included 3,897 TKA procedures for PTA (median follow-up 4.6 years; interquartile range: 2.2, 7.3) and 255,259 procedures for OA (median follow-up 4.7 years; interquartile range 2.2, 7.6). A total of 10,480 revision procedures were performed across both groups (238 in PTA knees; 10,242 in OA knees). We analyzed the prevalence of preoperative comorbidities and postoperative complications, as well as the reasons for revision, and calculated the implant survival rates. RESULTS: The survival revision rate in the OA group was significantly lower at both follow-up moments (5- and 10- years). The likelihood for revision was increased in TKA for PTA compared to TKA for OA (hazards ratio: 1.16 [95% confidence interval 1.02 to 1.33], P = .03). The most common reason for a revision was instability and arthrofibrosis in the PTA group compared to patellar pain for the OA group. CONCLUSION: This study demonstrated an increased risk for revision for any reason in TKA for PTA compared to OA. Revision for instability and arthrofibrosis were more prevalent in the PTA group, while revision for patellar pain was less prevalent compared to TKA for OA.

Increased risk of aseptic loosening for posterior stabilized compared with posterior cruciate-retaining uncemented total knee replacements: a cohort study of 13,667 knees from the Dutch Arthroplasty Registry.

BACKGROUND AND PURPOSE: While registry studies have suggested a higher risk of revision for posterior-stabilized (PS) compared with posterior cruciate-retaining (CR) total knee replacements (TKR) using cement, it is unknown whether this is also the case for uncemented TKR. We aimed to compare the revision rates of PS and CR designs in patients receiving primary uncemented TKR. PATIENTS AND METHODS: Data from the Dutch arthroplasty register (LROI) was analyzed, comprising 12,226 uncemented primary CR TKRs and 750 uncemented PS TKRs registered between 2007 and 2022. Competing risk and multivariable Cox regression analyses were used to compare revision rates, risks of revision, and reasons for revision between groups. Sensitivity analyses were performed to analyze the risk, concerning the 5 most commonly used implants and performing hospitals for each group. RESULTS: Uncemented PS TKRs had higher 10-year revision rates for any reason and aseptic loosening (6.5%, 95% confidence interval [CI] 4.6-9.2 and 3.9%, CI 2.6-6.7) compared with uncemented CR TKRs (4.2%, CI 3.8-4.7 and 1.4%, CI 1.2-1.7). PS TKRs were 1.4 and 2.5 times more likely to be revised for any reason and aseptic loosening, respectively. These results remained consistent after adjustment for age, sex, BMI, previous surgeries, bearing mobility, and surface modification, with sensitivity analyses. CONCLUSION: We found that uncemented PS implants have a higher rate of revision than uncemented CR implants, mainly due to a higher risk of aseptic loosening.

A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set.

Background: The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research. Methods: Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher. Results: In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%). Conclusion: Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

The Modified Tampa-Scale of Kinesiophobia for Anterior Shoulder Instability.

Purpose: To assess content validity and to modify the Tampa Scale of Kinesiophobia (TSK) to make it suitable for application in patients with anterior shoulder instability. Methods: A four-round Delphi method was performed to establish expert consensus on developing the Tampa Scale of Kinesiophobia for patients with anterior shoulder instability (TSK-SI) using an expert group of Dutch shoulder-specialized orthopedic surgeons and physiotherapists. During round 1, experts were asked to score the 17 items of the original TSK on relevance and construction using the COSMIN guidelines. With this feedback, questions were reviewed and modified. During round 2, experts were asked to score the modified items. This process was repeated until consensus was established. Then, patients were asked to participate in a moderator-guided, three-step-test interview using a Web-based platform to assess the modified scale. Sessions were recorded and evaluated by the working group. The modified scale was finally adjusted on the basis of the input of these patients. Results: Thirty Dutch shoulder experts were included, of which 25 completed all 4 rounds, after which consensus was established. One question was added to the modified scale based on feedback in round 1, establishing the 18-item TSK-SI. Sixteen patients with shoulder instability were included, which all completed the three-step test interview. Following this, question 4 (changed to present tense) and question 7 (hypothetical component added) were adjusted, resulting in the final TSK-SI. Conclusions: This consensus modification of the TSK to TSK-SI can support the content validity of the instrument to assess kinesiophobia in patients with anterior shoulder instability. These modifications may improve the responsiveness and validity of the TSK-SI, as it does not match all the items of the original TSK. Level of evidence: Level V, consensus statement.

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration.

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

The Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale has good to excellent construct validity, internal consistency, and test-retest reliability when assessing athletes undergoing rehabilitation after ACL injury or ACL reconstruction.

OBJECTIVES: To examine the validity and reliability of the Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale (short ACL-RSI-NL) in recreational athletes undergoing rehabilitation after ACL injury or ACL reconstruction (ACLR). METHODS: The original 12-item version of the ACL-RSI had been translated into Dutch. Short ACL-RSI-NL items were derived from this 12-item Dutch version. Content validity was evaluated by a team consisting of eight ACL experts and eight athletes. A cohort of 115 athletes with ACL injury or after ACLR completed the short ACL-RSI-NL and related questionnaires at various time points during their rehabilitation. Construct validity (hypothesis testing using Spearman correlations), internal consistency (Cronbach's alpha), floor and ceiling effects (percentage of athletes having the lowest or highest score possible), and structural validity (exploratory factor analysis) were evaluated in the entire ACL athlete group. Test-retest reliability (using intra-class correlation, ICC; standard error of measurement, SEM; smallest detectable change, SDC, at both group and individual levels) was investigated in a subgroup of athletes with a stable outcome on psychological readiness within a two-week interval (n â€‹= â€‹27). RESULTS: The short ACL-RSI-NL demonstrated good construct validity (83% of hypotheses confirmed). Internal consistency was excellent (Cronbach's alpha 0.84), and there were no floor and ceiling effects (≤13.9% lowest or highest score). Test-retest reliability was good (ICC 0.89 with 95% CI 0.77-0.95, SEM 6.93, SDC individual level 19.2, SDC group level 3.7). Exploratory factor analysis confirmed the presence of a single underlying factor (accounting for 56.4% of the total variance of the score). CONCLUSION: The short ACL-RSI-NL exhibited good to excellent construct validity, internal consistency, and test-retest reliability. An averaged score ranging from 0 to 100 can be used to measure psychological readiness to return to sport. The short ACL-RSI-NL has potential for use in day-to-day practice to assess the psychological readiness of recreational athletes to return to sport after ACL injury or ACLR during their rehabilitation process. LEVEL OF EVIDENCE: Level II.

The completely patient-reported version of the American Orthopaedic Foot and Ankle Society (AOFAS) score: A valid and reliable measurement for ankle osteoarthritis.

BACKGROUND: The American Orthopaedic Foot and Ankle score (AOFAS) is an outcome measure for ankle and hindfoot conditions, which requires scoring from both the patients and the physician. A completely patient-reported version has been developed and used before, but its measurements properties are unknown. Our goal was to determine the measurement properties and the minimally important change (MIC) of a completely patient-reported AOFAS (PR-AOFAS) in patients with ankle osteoarthritis. Additionally, the MIC of both the PR-AOFAS and the AOFAS was estimated, which had not previously been done. MATERIALS AND METHODS: The PR-AOFAS of 112 patients was evaluated for reliability, construct validity (using the AOFAS, Foot and Ankle Outcome Score, Ankle Osteoarthritis Score, Visual Analogue Scale, and Short Form-36), and responsiveness. The MIC was estimated using the optimal cut-off point of the receiver operating characteristic curve. This was a substudy of a randomized clinical trial on the efficacy of platelet-rich plasma injections for ankle osteoarthritis (OA). RESULTS: The PR-AOFAS had sufficient construct validity, internal consistency, test-retest reliability, and responsiveness. The smallest detectable change at group level was 2.34. The MIC was 6.5 points (95% confidence interval: 0.6-14.4). CONCLUSIONS: The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. The minimally important change of the PR-AOFAS is smaller than its smallest detectable change, making it more suitable for use in groups of patients, such as a research setting. LEVEL OF CLINICAL EVIDENCE: 1.

Mid- to long-term success rate and functional outcomes of acromioclavicular injections in patients with acromioclavicular osteoarthritis.

BACKGROUND: Acromioclavicular (AC) osteoarthritis (OA) is a frequent pathology of the shoulder in elderly patients. Drug injection plays an important role in treatment of AC OA. Literature has demonstrated excellent short-term results regarding shoulder function and pain. However, mid- to long-term results are lacking. The aim of this study was to assess the efficacy of a single intra-articular AC injection in patients with AC OA and to identify predictive factors for success. METHODS: A retrospective study was performed to analyze success rate, shoulder function, and pain perception after a single intra-articular injection in patients with AC OA. Success was defined as the absence of reinterventions such as additional injection or surgery. Outcome measures were 1-year success rate and clinical outcome scores of Numeric Rating Scale (NRS) for pain, Oxford Shoulder Score, and Subjective Shoulder Value. RESULTS: Ninety-eight patients participated in this study. At a median final follow-up of 0.8 years (interquartile range, 0-6), 57 of these patients (58%) had undergone a reintervention. The 1-year success rate was 47% (95% confidence interval, 37%-57%), with NRS at rest as the sole factor significantly associated with success. Thirty patients not requiring reintervention reported significant improvement from baseline for all reported outcome measures at final follow-up. CONCLUSIONS: AC injections offer a 1-year success rate of 47%. The AC injection produces good mid- to long-term clinical outcomes regarding shoulder function, quality of life, and pain perception in one-third of patients. Further research is essential to analyze mid- to longterm outcomes of AC injections. Level of evidence: Level IV.

Association Between Surface Modifications for Biologic Fixation and Aseptic Loosening of Uncemented Total Knee Arthroplasties.

BACKGROUND: Various surface modifications are used in uncemented total knee arthroplasties (TKAs) to enhance bony ingrowth and longevity of implants. This study aimed to identify which surface modifications are used, whether they are associated with different revision rates for aseptic loosening, and which are underperforming compared to cemented implants. METHODS: Data on all cemented and uncemented TKAs used between 2007 and 2021 were obtained from the Dutch Arthroplasty Register. Uncemented TKAs were divided into groups based on their surface modifications. Revision rates for aseptic loosening and major revisions were compared between groups. Kaplan-Meier, Competing-Risk, Log-rank tests, and Cox regression analyses were used. In total, 235,500 cemented and 10,749 uncemented primary TKAs were included. The different uncemented TKA groups included the following: 1,140 porous-hydroxyapatite (HA); 8,450 Porous-uncoated; 702 Grit-blasted-uncoated; and 172 Grit-blasted-Titanium-nitride (TiN) implants. RESULTS: The 10-year revision rates for aseptic loosening and major revision of the cemented TKAs were 1.3 and 3.1%, and for uncemented TKAs 0.2 and 2.3% (porous-HA), 1.3 and 2.9% (porous-uncoated), 2.8 and 4.0% (grit-blasted-uncoated), and 7.9% and 17.4% (grit-blasted-TiN), respectively. Both type of revision rates varied significantly between the uncemented groups (log-rank tests, P < .001, P < .001). All grit-blasted implants had a significantly higher risk of aseptic loosening (P < .01), and porous-uncoated implants had a significantly lower risk of aseptic loosening than cemented implants (P = .03) after 10 years. CONCLUSION: There were 4 main uncemented surface modifications identified, with different revision rates for aseptic loosening. Implants with porous-HA and porous-uncoated had the best revision rates, at least equal to cemented TKAs. Grit-blasted implants with and without TiN underperformed, possibly due to the interaction of other factors.

Graft failure and revision rate after ACL repair with dynamic intraligamentary stabilization. One-year results of a prospective case series of 155 patients.

PURPOSE: The aim of this study was to assess graft failure, revision rate, and functional outcomes after treatment of acute ACL rupture with dynamic intraligamentary stabilization (DIS) Ligamys device one year post surgery. Additionally, differences in functional outcome between patients with and without anteroposterior laxity were assessed. It was hypothesized that the failure rate of DIS was non-inferior to that of previously reported ACL reconstruction (10%). METHODS: In this prospectively designed multicenter study, including patients with an acute ACL rupture, DIS was performed within 21 days after rupture. Primary outcome was failure of the graft at 1 year post surgery, defined as 1) re-rupture of the graft, 2) revision of DIS, or 3) a > 3 mm side-to-side difference in anterior tibial translation compared to the non-operated knee (∆ATT), measured by the KT1000 device. Additional analysis was performed using a 5 mm threshold. The subjective International Knee Documentation Committee Score (IKDC) and Numerical Rating Scales (NRS) for pain and confidence were used to evaluate functional outcome. RESULTS: A total of 155 patients were included with a mean age at surgery of 27.8 years (SD 9.4). The mean interval from rupture to DIS was 16.4 days (SD 5.2). At a median follow-up of 13 months (IQR 12-18) the failure rate of the graft was 30.2% (95%CI:22.0-39.4); 11 patients (7%) required secondary reconstructive surgery and of the 105 patients who attended ATT measurement, 24 patients (23%) had an ∆ATT > 3 mm. Secondary analysis, based on a 5 mm threshold, revealed a failure rate of 22.4% (95%CI: 15.2; 31.1). A total of 39 patients (25%) reported at least one complication, comprising mainly arthrofibrosis, traumatic re-rupture and pain. In these patients, removal of the monoblock was performed in 21 cases (13.5%). At follow-up no significant differences in functional outcomes between patients with ∆ATT > 3 mm and stable ATT were observed. CONCLUSION: This prospective multicenter study found a high failure rate at one year follow-up of 30% (7% revision surgery and 23% > 3 mm side-to-side difference in anterior tibial translation) in patients treated by primary repair of the ACL with DIS, and did therefore not demonstrate non-inferiority to ACL reconstruction. For patients who did not require secondary reconstructive surgery, this study found good functional outcomes, also in case of persistent anteroposterior knee laxity (∆ATT > 3 mm). LEVEL OF EVIDENCE: Level IV.