The effect of pregabalin and s-ketamine in total knee arthroplasty patients: A randomized trial.

BACKGROUND AND AIMS: Pain reduction is important for rehabilitation after total knee arthroplasty. Intra- and peri-articular infiltration with local anesthetics may be an alternative to commonly used locoregional techniques. Adding pregabalin orally and s-ketamine intravenously may further reduce postoperative pain. MATERIAL AND METHODS: This prospective, randomized, double-blind, placebo-controlled study compared two methods of perioperative analgesia. Control patients received a standardized multimodal postoperative analgesic regime of paracetamol, diclofenac, and piritramide-patient-controlled analgesia, including ropivacaine knee infiltration during surgery. The study group received pregabalin orally and s-ketamine intravenously as an additional medication to the standard multimodal regimen. The control group received placebo. RESULTS: The study group showed lower piritramide consumption during the first 24 h (P: 0.043), but with more side effects such as diplopia and dizziness. CONCLUSION: Addition of pregabalin and s-ketamine resulted in lower piritramide consumption during the first 24 h postoperatively. However, more investigation on benefits versus side effects of this medication is required.

Treatment changes and improved outcomes in RA: an overview of a large inception cohort from 1989 to 2009.

OBJECTIVE: The introduction of effective treatment strategies in the past two decades has changed the management of RA dramatically. The objective was to analyse the changes in disease activity, function, joint damage and incidence of orthopaedic surgery over a period of 20 years (1989-2009) for patients with RA. METHODS: Data acquired from 1989 to 2008 inclusive from the Nijmegen RA inception cohort were studied. By repeated measures analysis the course of the population mean disease activity score (DAS28) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) corrected for age, gender, RF and disease duration was determined. Orthopaedic interventions were analysed as incidence rates with a Poisson distribution. We calculated the prevalence of the various therapies that patients were receiving. RESULTS: By 2009, 992 patients with RA had been included and 273 had been excluded. From 1989 onwards, the proportion of patients using MTX increased from 5% (8 of 164) to 62% (486 of 780), and biologic response modifiers from 0% to 22% (168 of 780) in 2008. The average MTX dosage increased to 16.1 ± 5.5 mg/week in 2008. The mean DAS28 (3.1) and HAQ-DI (0.47) were least (P < 0.008) in 2008 compared with previous years. There was a significant trend towards lower incidence rates of orthopaedic intervention in the period 2006-2008 than in almost all previous years. CONCLUSION: Treatment strategy changed in a large inception cohort of patients with RA which coincided with decreased disease activity, increased functional ability and fewer orthopaedic interventions since the early 1990s.

Loosely-guided, self-directed learning versus strictly-guided, station-based learning in gross anatomy laboratory sessions.

Anatomy students studying dissected anatomical specimens were subjected to either a loosely-guided, self-directed learning environment or a strictly-guided, preformatted gross anatomy laboratory session. The current study's guiding questions were: (1) do strictly-guided gross anatomy laboratory sessions lead to higher learning gains than loosely-guided experiences? and (2) are there differences in the recall of anatomical knowledge between students who undergo the two types of laboratory sessions after weeks and months? The design was a randomized controlled trial. The participants were 360 second-year medical students attending a gross anatomy laboratory course on the anatomy of the hand. Half of the students, the experimental group, were subjected without prior warning to station-based laboratory sessions; the other half, the control group, to loosely-guided laboratory sessions, which was the course's prevailing educational method at the time. The recall of anatomical knowledge was measured by written reproduction of 12 anatomical names at four points in time: immediately after the laboratory experience, then one week, five weeks, and eight months later. The strictly-guided group scored higher than the loosely-guided group at all time-points. Repeated ANOVA showed no interaction between the results of the two types of laboratory sessions (P = 0.121) and a significant between-subject effect (P ≤ 0.001). Therefore, levels of anatomical knowledge retrieved were significantly higher for the strictly-guided group than for the loosely-guided group at all times. It was concluded that gross anatomy laboratory sessions with strict instructions resulted in the recall of a larger amount of anatomical knowledge, even after eight months.

[Open lateral clavicle resection in acromioclavicular osteoarthritis: favourable results after 1 year]. / Open laterale clavicularesectie bij acromioclaviculaire artrose: gunstige resultaten na 1 jaar.

OBJECTIVE: To determine the follow-up outcomes of open lateral clavicle resection 1 year postoperatively in patients with acromioclavicular osteoarthritis. The operation involves resection of a small part of the lateral clavicle. DESIGN: Prospective descriptive. METHOD: Data were collected from all patients who had undergone an open lateral clavicle resection in the period July 1999 to June 2008 and who were examined preoperatively and 1 year postoperatively. This concerned 23 operations in 22 patients. The Constant score for the functionality of the shoulder was determined and visual analogue scales (VAS) were used to determine the pain and satisfaction concerning the operated shoulder. The results were evaluated with the paired t-test and the non-parametric Wilcoxon test. RESULTS: The mean length of the lateral clavicle resection was 7.8 mm. Preoperatively the mean Constant score was 64 (SD: 14) and 1 year after the operation 86 (SD: 14; p < 0.001). Ninety-one percent had an increase in the postoperative Constant score compared with the preoperative score. The median VAS score for pain decreased from 70 (95% CI: 60-77) preoperatively to 25 (0-48) 1 year postoperatively (p < 0.001). The median VAS score for satisfaction increased from 40 (40-50) preoperatively to 85 (68-100) (p < 0.001). CONCLUSION: The open lateral clavicle resection was a treatment option to reduce the symptoms in patients with acromioclavicular osteoarthritis in whom conservative treatment and medication proved to be insufficient.

Unsuspected sonographic findings in patients with posttraumatic shoulder complaints.

PURPOSE: To prospectively assess the frequency of abnormal sonographic findings in patients with posttraumatic shoulder pain and/or disability in whom ultrasound (US) was not considered and to assess the effect of sonographic findings on working diagnosis and therapeutic strategy, to analyze the possible role of US in the diagnostic workup of these patients. METHODS: A survey was performed under general practitioners and orthopedic surgeons. They were requested to refer patients with persistent posttraumatic complaints for an US examination of the shoulder and to fill out a questionnaire concerning working diagnosis and therapy. In 50 patients examinations were performed separately by two radiologists. Findings were confirmed with additional radiographs and/or MRI and/or surgery. Four weeks after the US examination, the survey was repeated to inquire about changes in diagnosis and/or treatment that resulted from US. RESULTS: US showed relevant pathology in 45 (90%) of 50 patients, a proximal humerus fracture in 25 (50%) patients, and a rotator cuff tear in 43 (86%) patients. Twenty-three (92%) fractures were accompanied by a rotator cuff tear, and 23 (54%) rotator cuff tears were accompanied by a fracture. Ten fractures were initially missed radiographically. US findings changed the working diagnosis and therapeutic strategy in 37 (74%) and 26 (52%) patients, respectively. CONCLUSION: In patients with posttraumatic shoulder complaints, US showed a high rate (90%) of relevant pathology. This changed the initial working diagnosis in 74% of the patients and the therapeutic strategy in more than half of the patients. Active referral for US examination may identify these abnormalities in an earlier phase and improve clinical outcome.

A sliding stem in revision total knee arthroplasty provides stability and reduces stress shielding.

BACKGROUND AND PURPOSE: In the reconstruction of unicondylar femoral bone defects with morselized bone grafts in revision total knee arthroplasty, a stem extension appears to be critical to obtain adequate mechanical stability. Whether stability is still assured by this reconstruction technique in bicondylar defects has not been assessed. The disadvantage of relatively stiff stem extensions is that bone resorption is promoted due to stress shielding. We therefore designed a stem that would permit axial sliding movements of the articulating part relative to the intramedullary stem. METHODS: This stem was used in the reconstruction with impaction bone grafting (IBG) of 5 synthetic distal femora with a bicondylar defect. A cyclically axial load was applied to the prosthetic condyles to assess the stability of the reconstruction. Radiostereometry was used to determine the migrations of the femoral component with a rigidly connected stem, a sliding stem, and no stem extension. RESULTS: We found a stable reconstruction of the bicondylar femoral defects with IBG in the case of a rigidly connected stem. After disconnecting the stem, the femoral component showed substantially more migrations. With a sliding stem, rotational migrations were similar to those of a rigidly connected stem. However, the sliding stem allowed proximal migration of the condylar component, thereby compressing the IBG. INTERPRETATION: The presence of a functional stem extension is important for the stability of a bicondylar reconstruction. A sliding stem provides adequate stability, while stress shielding is reduced because compressive contact forces are still transmitted to the distal femoral bone.

Detection of rotator cuff tears: the value of MRI following ultrasound.

OBJECTIVE: To evaluate the need for additional magnetic resonance imaging (MRI) following ultrasound (US) in patients with shoulder pain and/or disability and to compare the accuracy of both techniques for the detection of partial-thickness and full-thickness rotator cuff tears (RCT). METHODS: In 4 years, 5,216 patients underwent US by experienced musculoskeletal radiologists. Retrospectively, patient records were evaluated if MRI and surgery were performed within 5 months of US. US and MRI findings were classified into intact cuff, partial-thickness and full-thickness RCT, and were correlated with surgical findings. RESULTS: Additional MR imaging was performed in 275 (5.2%) patients. Sixty-eight patients underwent surgery within 5 months. US and MRI correctly depicted 21 (95%) and 22 (100%) of the 22 full-thickness tears, and 8 (89%) and 6 (67%) of the 9 partial-thickness tears, respectively. The differences in performance of US and MRI were not statistically significant (p = 0.15). CONCLUSIONS: MRI following routine shoulder US was requested in only 5.2% of the patients. The additional value of MRI was in detecting intra-articular lesions. In patients who underwent surgery, US and MRI yielded comparably high sensitivity for detecting full-thickness RCT. US performed better in detecting partial-thickness tears, although the difference was not significant.

The presence of periosteum is essential for the healing of large diaphyseal segmental bone defects reconstructed with trabecular metal: a study in the femur of goats.

Large segmental diaphyseal bone defects can be reconstructed with massive structural allografts, but this technique is associated with high complication rates. Tantalum tabecular metal implants have been successfully used to restore bone defects associated with revision total knee or hip arthroplasties. The aim of this study was to investigate if tantalum cylinders could be used to reconstruct large load bearing segmental diaphyseal bone defects in the presence or absence of a periosteum coverage. Segmental bone defects were reconstructed with tantalum cylinders with or without preservation of the periosteum and stabilized by an intramedullary nail. Radiological analysis was performed postop and at 26 weeks follow-up. New bone was labeled with fluorochromes at 13 and 26 weeks follow-up. Reconstructions were tested mechanically and subsequently investigated histologically. Contra-lateral femurs were used as controls. Clinically all goats returned to normal functional loading after 2 weeks allowing unlimited weight bearing. Radiologically, all tantalum cylinders with periosteum coverage united with the host bone. Reconstructions with cylinders without periosteum coverage lead to radiological nonunion in five out of six cases. The strengths of the reconstruction with and without periosteum preservation were respectively 102.1% and 24.5% compared to controls. In the periosteum covered implants, bone contact was found at all levels of the tantalum cylinder and more and deeper bone ingrowth was found in this group. Tantalum cylinders seem a safe and reliable alternative for a massive cortical graft to reconstruct large diaphyseal bone defects in a goat model if healthy periosteum is present.

Sit-to-stand movement as a performance-based measure for patients with total knee arthroplasty.

BACKGROUND: Functional recovery of patients after a total knee arthroplasty (TKA) usually is measured with questionnaires. However, these self-report measures assess the patient's perspective on his or her ability to perform a task. Performance-based tests are needed to assess the patient's actual ability to perform a task. OBJECTIVE: The main purpose of this study was to quantify improvement in performance of the sit-to-stand movement of patients with a TKA. DESIGN AND METHODS: In this prospective study of 16 patients with end-stage knee osteoarthritis followed by a TKA, the maximal knee angular extension velocity and amount of unloading (shifting weight) of the affected leg during the sit-to-stand movement and the visual analog scale score for pain were assessed preoperatively and 6 months and 1 year postoperatively. These data were compared with data for a control group of individuals who were healthy (n=27). RESULTS: Before surgery, the participants in the TKA group unloaded their affected leg, but within 6 months after implantation, the affected leg was almost fully loaded again and comparable to the loading symmetry ratio of the control group. Furthermore, knee extension velocity also had increased, but remained lower than that of the control group. The changes in knee extension velocity took place during the first 6 months, after which a plateau was visible. Limitations A potential limitation of the study design was that the patients were not perfectly matched with the control subjects. CONCLUSIONS: Implantation of a total knee prosthesis partly improved performance of the sit-to-stand movement. Participants in the TKA group could fully load their operated leg, but they could not generate enough knee angular velocity during rising compared with the control group.

Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis. A concise follow-up, at eight to nineteen years, of a previous report.

We previously reported our results at a minimum of three years after thirty-five revisions of total hip arthroplasty acetabular components in twenty-eight patients with rheumatoid arthritis. The revisions were performed with use of impacted morselized bone graft and a cemented cup. This update report presents the results at eight to nineteen years after the surgery, which, to our knowledge, is the longest follow-up available in the literature. No patient was lost to follow-up. Since our previous report, there were two additional cup failures due to aseptic loosening, at ten and sixteen years postoperatively. Kaplan-Meier analysis showed the probability of survival of the acetabular component at twelve years to be 80% (95% confidence interval, 65% to 95%) with removal of the cup for any reason as the end point and 85% (95% confidence interval, 71% to 99%) with aseptic loosening as the end point. Cup revisions performed with cement and use of impaction bone-grafting in patients with rheumatoid arthritis led to acceptable long-term prosthetic survival rates. This technique is attractive from a biological standpoint because of the possibility of maintaining acetabular bone stock.

The stability of impacted morsellized bone grafts in a metal cage under dynamic loaded conditions: an in vitro reconstruction of a segmental diaphyseal bone defect.

INTRODUCTION: Reconstructions of segmental diaphyseal bone defects with massive allografts are related to complications like nonunion and fractures. A reconstruction of these defects with a cage filled with an impacted morsellized bone graft could be an alternative. The bone graft in these cages should ideally be loaded to prevent resorption. Loading of morsellized bone grafts however can cause instability. The goal of this study was to assess the stability of an impacted morsellized bone graft in a cage under dynamic loaded conditions in an in vitro reconstruction of a segmental diaphyseal bone defect. The second goal was to assess the influence of cage type, washing of the graft and bone-cage fit. MATERIALS AND METHODS: Two different cage types were filled with impacted morsellized bone graft. The grafts were used washed and unwashed and in variable bone-cage fit conditions. We recorded the bone graft deformation in the cage under dynamic loaded conditions. RESULTS: Stability appeared to be not very sensitive to the cage type and whether the bone chips were washed or not. However, quality of the fit of the cage with the bone segment was an important parameter and should be optimized during surgery. CONCLUSIONS: Morsellized impacted bone graft in a cage is stable in dynamic loaded conditions in an in vitro reconstruction of a segmental diaphyseal bone defect. We believe that this method of reconstruction is a promising alternative for the reconstruction of large diaphyseal bone defects and should be tested relative to its biological merits in animal experiments.

Is an impacted morselized graft in a cage an alternative for reconstructing segmental diaphyseal defects?

Large diaphyseal bone defects often are reconstructed with large structural allografts but these are prone to major complications. We therefore asked whether impacted morselized bone graft could be an alternative for a massive structural graft in reconstructing large diaphyseal bone defects. Defects in the femora of goats were reconstructed using a cage filled with firmly impacted morselized allograft or with a structural cortical autograft (n = 6 in both groups). All reconstructions were stabilized with an intramedullary nail. The goats were allowed full weightbearing. In all reconstructions, the grafts united radiographically. Mechanical torsion strength of the femur with the cage and structural cortical graft reconstructions were 66.6% and 60.3%, respectively, as compared with the contralateral femurs after 6 months. Histologically, the impacted morselized graft was replaced completely by new viable bone. In the structural graft group, a mixture of new and necrotic bone was present. Incorporation of the impacted graft into new viable bone suggests this type of reconstruction may be safer than reconstruction with a structural graft in which creeping substitution results in a mixture of viable and necrotic bone that can fracture. The data suggest that a cage filled with a loaded morselized graft could be an alternative for the massive cortical graft in reconstruction of large diaphyseal defects in an animal model.

Surgeon's expectations do not predict the outcome of a total knee arthroplasty.

INTRODUCTION: It is fascinating for both the patient and the surgeon to predict the outcome of a TKA at an early stage. Satisfaction after TKA is primarily determined by the preoperative expectations of the patient. The purpose of this study was to investigate if the peri-operative expectations of the surgeon predicted the outcome of a TKA. PATIENTS AND METHODS: A prospective study of 53 primary TKAs was performed. Preoperatively, the surgeon described the assessment of the difficulty of the TKA on a VAS. Immediately postoperative, the surgeon gave his satisfaction VAS about the procedure. After 1 year the surgeon's satisfaction VAS, the patient's satisfaction VAS and the KSCRS were determined. RESULTS: The Spearman's correlation coefficients between the preoperative difficulty assessment, the immediate postoperative satisfaction and the outcome measurements after 1 year were all very poor (-0.01 to 0.23). CONCLUSIONS: The outcome of a TKA depends on multiple factors. Both the surgeon's preoperative assessment of the difficulty and the surgeon's immediate postoperative satisfaction do not independently predict the outcome of a TKA.

Treatment of knee prosthesis infections: evaluation of 15 patients over a 5-year period.

Our objective was to evaluate different treatment alternatives for total knee arthroplasty (TKA) infection and to compare outcomes depending on adherence to a current treatment algorithm. All patients treated for a first episode of TKA infection between January 2000 and July 2005 were included. Patient records were reviewed and data were extracted retrospectively. Fifteen patients were followed up for a median of 25 months. The cure rate in patients with two-stage exchange of knee prosthesis was higher than in patients who had débridement without implant removal (100 vs 37%, p = 0.03). Cure rates were not different between these two surgical approaches in ten patients who were treated according to a current treatment algorithm. Success rates for treatment of TKA infections varied considerably with the treatment strategy chosen. Our results support the use of existing algorithms to select patients who are eligible for débridement with retention of the prosthesis or need two-stage exchange of knee implants.

The trochlea is medialized by total knee arthroplasty: an intraoperative assessment in 61 patients.

BACKGROUND: A medialization of the femoral component in a total knee arthroplasty (TKA) causes abnormal patellar tracking, which could result in patellar instability, pain, wear, and failure. Previous reports defined medialization in relation to the neutral position of the femoral component, but omitted to compare it to the anatomical position of the trochlea. We assessed intraoperatively whether there is a systematic error of the position of the prosthetic groove relative to the anatomical trochlea. MATERIAL AND METHODS: A special instrument was developed to measure consecutively the mediolateral position of the anatomical trochlea and the mediolateral position of the prosthetic groove. 3 experienced knee surgeons determined the mediolateral error of the prosthetic groove in primary TKAs in 61 patients. RESULTS: There was a significant medial error of the prosthetic groove relative to the preoperative position of the trochlea, with a mean medial error of 2.5 mm (SD 3.3) INTERPRETATION: Our findings indicate that the trochlea is medialized by TKA. Because a conscious medialization of the femoral component in a TKA produces abnormal patellar tracking patterns, further investigations will be needed to analyze the clinical consequences of this medialization of the trochlea.

Injection of the subacromial-subdeltoid bursa: blind or ultrasound-guided?

BACKGROUND: Blind injection of the subacromial-sub-deltoid bursa (SSB) for diagnostic purposes (Neer test) or therapeutic purposes (corticosteroid therapy) is frequently used. Poor response to previous blind injection or side effects may be due to a misplaced injection. It is assumed that ultrasound (US)-guided injections are more accurate than blind injections. In a randomized study, we compared the accuracy of blind injection to that of US-guided injection into the SSB. PATIENTS AND METHODS: 20 consecutive patients with impingement syndrome of the shoulder were randomized for blind or US-guided injection in the SSB. Injection was performed either by an experienced orthopedic surgeon or by an experienced musculoskeletal radiologist. A mixture of 1 m'L methylprednisolone acetate, 4 mL prilocaine hydrochloride and 0.02 mL (0.01 mmol) Gadolinium DTPA was injected. Immediately after injection, a 3D-gradient T1-weighted magnetic resonance scan of the shoulder was performed. The location of the injected fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used. RESULTS: The accuracy of blind and US-guided injection was the same. The fluid was injected into the bursa in all cases. INTERPRETATION: Blind injection into the SSB is as reliable as US-guided injection and could therefore be used in daily routine. US-guided injections may offer a useful alternative in difficult cases, such as with changed anatomy postoperatively or when there is no effective clinical outcome.

Survivorship of the KUDO total elbow prosthesis--comparative study of cemented and uncemented ulnar components: 89 cases followed for an average of 6 years.

BACKGROUND: The Kudo total elbow prosthesis (TEP) is a well-established implant with good mid-term results. The ulnar component can be placed with or without cement, and the humeral component is normally placed without cement. METHODS: 89 Kudo type-5 total elbow prostheses were evaluated after a mean follow-up of 6 (1.7-11) years. The indication for joint replacement was rheumatoid arthritis in all cases. 49 prostheses were placed without cement. In 40 cases, the ulnar component was cemented and the humeral component was uncemented. RESULTS: In the uncemented group, 7 revisions had taken place. 3 of these ulnar components were shortstemmed and 4 were long-stemmed. No revisions had been performed in the hybrid group. In the uncemented group another 7 patients showed progressive radiolucencies, while 3 patients in the hybrid group showed progressive radiolucencies. INTERPRETATION: In this group of RA patients, the survivorship of the cemented ulnar component was better than that of the uncemented ulnar component.

Reviewer agreement in scoring 419 abstracts for scientific orthopedics meetings.

BACKGROUND: The selection of presentations at orthopedic meetings is an important process. If the peer reviewers do not consistently agree on the quality score, the review process is arbitrary and open to bias. The aim of this study was: (1) to describe the inter-reviewer agreement of a previously designed scoring scheme to rate abstracts submitted for presentation at meetings arranged by the Dutch Orthopedic Association; (2) to test whether the quality of reporting of submitted abstracts increased in the years after the introduction of the scoring scheme; and (3) to examine whether a review process with a larger workload had lower interrater agreement. METHODS: We calculated intraclass correlation coefficients (ICC) to measure the level of agreement among reviewers using the International Society of the Knee (ISK) quality-of-reporting system for abstracts. Acceptance rate and quality of the abstracts are described. RESULTS: Of 419 abstracts, 229 (55%) were accepted. Inter-reviewer agreement to rate abstracts was substantial (0.68; 95% CI: 0.47-0.83) to almost perfect (0.95; 95% CI: 0.92-0.97) and did not change over the eligible time period. A smaller proportion of abstracts were accepted after 2004. The mean ISK abstract score (with a maximum of 100 points) for accepted abstracts ranged from 60 (95% CI: 58-63) to 64 (95% CI: 62-66). The mean ISK abstract score for rejected abstracts varied from 46 (95% CI: 40-51) to 51 (95% CI: 47-55). Average scores for accepted and rejected abstracts did not change with time. The degree of workload of the reviewers did not influence their level of agreement. INTERPRETATION: The ISK abstract rating system has an excellent interobserver agreement. Other scientific orthopedic meetings should consider adopting this ISK rating system for further evaluation in a local or international setting.

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus.

The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the 'double line sign' (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.