Independent and sensitive gait parameters for objective evaluation in knee and hip osteoarthritis using wearable sensors.

BACKGROUND: Although it is well-established that osteoarthritis (OA) impairs daily-life gait, objective gait assessments are not part of routine clinical evaluation. Wearable inertial sensors provide an easily accessible and fast way to routinely evaluate gait quality in clinical settings. However, during these assessments, more complex and meaningful aspects of daily-life gait, including turning, dual-task performance, and upper body motion, are often overlooked. The aim of this study was therefore to investigate turning, dual-task performance, and upper body motion in individuals with knee or hip OA in addition to more commonly assessed spatiotemporal gait parameters using wearable sensors. METHODS: Gait was compared between individuals with unilateral knee (n = 25) or hip OA (n = 26) scheduled for joint replacement, and healthy controls (n = 27). For 2 min, participants walked back and forth along a 6-m trajectory making 180° turns, with and without a secondary cognitive task. Gait parameters were collected using 4 inertial measurement units on the feet and trunk. To test if dual-task gait, turning, and upper body motion had added value above spatiotemporal parameters, a factor analysis was conducted. Effect sizes were computed as standardized mean difference between OA groups and healthy controls to identify parameters from these gait domains that were sensitive to knee or hip OA. RESULTS: Four independent domains of gait were obtained: speed-spatial, speed-temporal, dual-task cost, and upper body motion. Turning parameters constituted a gait domain together with cadence. From the domains that were obtained, stride length (speed-spatial) and cadence (speed-temporal) had the strongest effect sizes for both knee and hip OA. Upper body motion (lumbar sagittal range of motion), showed a strong effect size when comparing hip OA with healthy controls. Parameters reflecting dual-task cost were not sensitive to knee or hip OA. CONCLUSIONS: Besides more commonly reported spatiotemporal parameters, only upper body motion provided non-redundant and sensitive parameters representing gait adaptations in individuals with hip OA. Turning parameters were sensitive to knee and hip OA, but were not independent from speed-related gait parameters. Dual-task parameters had limited additional value for evaluating gait in knee and hip OA, although dual-task cost constituted a separate gait domain. Future steps should include testing responsiveness of these gait domains to interventions aiming to improve mobility.

Preparing for an orthopedic consultation using an eHealth tool: a randomized controlled trial in patients with hip and knee osteoarthritis.

BACKGROUND: To evaluate the effect of a stand-alone mobile and web-based educational intervention (eHealth tool) compared to usual preparation of a first orthopedic consultation of patients with hip or knee osteoarthritis (OA) on patients' satisfaction. METHODS: A two-armed randomized controlled trial involving 286 patients with (suspicion of) hip or knee OA, randomly allocated to either receiving an educational eHealth tool to prepare their upcoming consultation (n = 144) or usual care (n = 142). Satisfaction with the consultation on three subscales (range 1-4) of the Consumer Quality Index (CQI - primary outcome) and knowledge (assessed using 22 statements on OA, range 0-22), treatment beliefs (assessed by the Treatment beliefs in OsteoArthritis questionnaire, range 1-5), assessment of patient's involvement in consultation by the surgeon (assessed on a 5-point Likert scale) and patient satisfaction with the outcome of the consultation (numeric rating scale), were assessed. RESULTS: No differences between groups were observed on the 3 subscales of the CQI (group difference (95% CI): communication 0.009 (- 0.10, 0.12), conduct - 0.02 (- 0.12, 0.07) and information provision 0.02 (- 0.18, 0.21)). Between group differences (95% CI) were in favor of the intervention group for knowledge (1.4 (0.6, 2.2)), negative beliefs regarding physical activities (- 0.19 (- 0.37, - 0.002) and pain medication (- 0.30 (- 0.49, - 0.01)). We found no differences on other secondary outcomes. CONCLUSIONS: An educational eHealth tool to prepare a first orthopedic consultation for hip or knee OA does not result in higher patient satisfaction with the consultation, but it does influence cognitions about osteoarthritis. TRIAL REGISTRATION: Dutch Trial Register (trial number NTR6262). Registered 30 January 2017.

Posterolateral corner reconstruction in combined injuries of the knee: Improved stability with Larson's fibular sling reconstruction and comparison with LaPrade anatomical reconstruction.

BACKGROUND: The goal of this prospective cohort study was to present the clinical results of a two-year follow-up of a Larson's posterolateral corner reconstruction (fibular sling) in patients with symptomatic instability of the knee. These data were compared with data of an anatomical reconstruction of the posterolateral corner as described by LaPrade et al. (combined tibial tunnel and fibular sling) [1]. METHODS: Eleven patients underwent a Larson's posterolateral corner reconstruction. Cruciate ligament ruptures were reconstructed if present. Multiple subjective knee outcome scores (VAS satisfaction score, Tegner, Lysholm, Noyes score, and IKDC subjective knee score) were obtained pre-operatively and two years after surgery. Laxity of the joint was measured using bilateral varus stress radiographs. RESULTS: All patients had concomitant ACL or PCL surgery. VAS satisfaction, the Tegner, Noyes and the IKDC subjective knee score all improved significantly. Median varus laxity of the injured knee on varus stress radiographs improved significantly from 6.2° (3.1-10.1) to 3.9° (1.1-5.7), p = .0076. Post-operative varus laxity did not return to the level of the uninjured knee: 2.7° (1-5.7), p = .028. In comparison with our data on the reconstruction technique according to LaPrade, no statistically significant differences in clinical outcome were observed. CONCLUSION: Reconstruction of the posterolateral corner in combined injuries of the knee using a Larson fibular sling technique results in improved varus stability but not to the level of the uninjured knee. Functional knee scores improved significantly. We found no differences in functional and radiological outcome between the Larson's fibular sling reconstruction and LaPrade anatomical reconstruction. LEVEL OF EVIDENCE: IV.

An Electronic Health Tool to Prepare for the First Orthopedic Consultation: Use and Usability Study.

BACKGROUND: The use of electronic health (eHealth) technology to prepare patients with hip or knee osteoarthritis (OA) for their first orthopedic consultation seems promising. Exploration of the use and usability of an educational eHealth tool may highlight potential modifications that could increase patient engagement and effectiveness. OBJECTIVE: This study aimed to (1) identify the use and usability of a stand-alone educational eHealth tool for patients with suspected hip or knee OA, (2) explore whether the recorded questions in the eHealth tool were in line with an existing widely used question prompt list, and (3) investigate whether user characteristics are related to use and usability. METHODS: We used data from 144 participants in the intervention group of a randomized controlled trial, who were asked to use the educational eHealth tool to prepare for their upcoming first orthopedic consultation. We defined users and nonusers based on whether they had opened the tool at least once. Users were characterized as active or superficial depending on the extent of their use of the tool. The recorded questions for the consultation preparation were categorized into themes fitting 3 predefined questions or in a remaining category. Usability was measured using the System Usability Scale (SUS, 0-100). Data were collected including the patient demographic and clinical characteristics, knowledge of OA, and internet and smartphone usage in daily life. The characteristics associated with users and nonusers were analyzed using a multivariable logistic regression analysis. RESULTS: A total of 116/144 (80.6%) participants used the educational eHealth tool, of whom 87/116 (75.0%) were active users. Of the three components of the tool (information, my consultation, and medication), medication was the least used (34%). On the basis of recorded questions of the users, the fourth predefined question could be proposed. The mean (SD) SUS score was 64.8 (16.0). No difference was found between the SUS scores of superficial and active users (mean difference 0.04, 95% CI -7.69 to 7.77). Participants with a higher baseline knowledge of OA (odds ratio [OR] 1.2, 95% CI 1.0 to 1.4) and who used the internet less frequently in their daily life (OR 0.6, 95% CI 0.5 to 0.9) were more likely to use the educational eHealth tool. We found no differences between the demographics and clinical characteristics of the superficial and active users. CONCLUSIONS: Based on the results of this study, it can be concluded that the use of an educational eHealth tool to prepare patients with hip and knee OA for the first orthopedic consultation is feasible. Our results suggest some improvements that should be made to the content of the tool to improve its usability. No clear practical implications were found to support the implementation of the educational eHealth tool in specific subgroups. TRIAL REGISTRATION: Netherlands Trial Register NTR6262; https://www.trialregister.nl/trial/6262.

Most Important Frequently Asked Questions From Patients With Hip or Knee Osteoarthritis: A Best-Worst Scaling Exercise.

OBJECTIVE: To collect and prioritize the frequently asked questions (FAQs) that patients with hip or knee osteoarthritis (OA) and health care professionals consider to be the most important; to identify informational needs that go beyond guideline recommendations. METHODS: FAQs were collected among health care professionals and from the arthritis helpline of the Dutch Arthritis Foundation. After deleting overlapping FAQs, the remaining FAQs were prioritized by patients and health care professionals using a maximum difference scaling method. A hierarchical Bayesian method was used to calculate relative importance scores. Differences between health care professionals and patients were analyzed using independent t-tests. RESULTS: A total of 28 health care professionals and the arthritis helpline provided 192 FAQs. After deleting overlapping FAQs, 60 FAQs were prioritized by 94 patients (57 [60.6%] women, mean age 67.3 years) and 122 health care professionals (67 [54.9%] women, mean age 45.7 years). The FAQ "What can I do myself to decrease symptoms and to prevent the OA from getting worse?" was prioritized as the most important by both patients and professionals. FAQs that were highly prioritized by patients but significantly different from professionals were more directed toward treatment options offered by health care professionals, whereas highly prioritized FAQs of professionals were more often focused on treatment options involving self-management. CONCLUSION: The health care professionals' perspective on informational needs differs from that of OA patients. These differences are important to address in order to achieve more active involvement of patients in their own treatment process.

Preliminary effects of a regional approached multidisciplinary educational program on healthcare utilization in patients with hip or knee osteoarthritis: an observational study.

BACKGROUND: Providing relevant information on disease and self-management helps patients to seek timely contact with care providers and become actively involved in their own care process. Therefore, health professionals from primary care, multiple hospitals and health organisations jointly decided to develop an educational program on osteoarthritis (OA). The objective of the present study was to determine preliminary effects of this OA educational program on healthcare utilization and clinical outcomes. METHODS: We developed an educational group-based program consisting of 2 meetings of 1.5 h, provided by a physiotherapist, a general practitioner (GP) and orthopaedic surgeon or specialized nurse. The program included education on OA, (expectations regarding) treatment options and self-management. Patients were recruited through searching the GPs' electronic patients records and advertisements in local newspapers. At baseline and at 3 months follow-up participating OA patients completed questionnaires. Paired-sample t-tests, McNemar's test and Wilcoxon Signed-Rank test were used to estimate the preliminary effects of the program. RESULTS: A total of 146 participants in 3 districts attended the sessions, of whom 143 agreed to participate in this study; mean age 69.1 years (SD10.2).107 (75%) participants completed both baseline and follow up assessments. The proportion of participants who had visited their GP in the 3 months after the program was lower than 3 months previous to the program (40% versus 25%, p-value 0.01). Also, we observed a decrease in proportion of patients who visited the physio- and exercise therapist, (36.1% versus 25.0%, p-value 0.02). Both illness perceptions and knowledge on OA and treatment options changed positively (Δ-1.8, 95%CI:0.4-3.4, and Δ2.4, 95%CI:-3.0 - -1.6 respectively). No changes in BMI, pain, functioning and self-efficacy were found. However, a trend towards an increase in physical activity was observed. CONCLUSIONS: Our results show that a multidisciplinary educational program may result in a decrease in healthcare utilization and has a positive effect on illness perceptions and knowledge on OA due to clear and consistent information on OA and it treatment options. TRIAL REGISTRATION: Netherlands Trial Register ( NTR5472 ). Registered 22 September 2015.

A cemented cup with acetabular impaction bone grafting is more cost-effective than an uncemented cup in patients under 50 years.

PURPOSE: Acetabular deficiencies in young patients can be restored in several ways during total hip arthroplasty. Currently, cementless cups are most frequently used. Impaction bone grafting of acetabular defects is a more biological approach, but is it cost-effective in young patients on the long term? METHODS: We designed a decision model for a cost-utility analysis of a cemented cup with acetabular impaction bone grafting versus an uncemented cup, in terms of cost per quality-adjusted life year (QALY) for the young adult with acetabular bone deficiency, in need for a primary total hip arthroplasty. Outcome probabilities and effectiveness were derived from the Radboud University Nijmegen Medical Centre and the Norwegian Hip Register. Multiple sensitivity analyses were used to assess the contribution of the included variables in the model's outcome. RESULTS: Cemented cups with impaction bone grafting were more cost-effective compared to the uncemented option in terms of costs per QALY. A scenario suggesting equal primary survival rates of both cemented and uncemented cups still showed an effect gain of the cemented cup with impaction bone grafting, but at higher costs. CONCLUSIONS: Based on this model, the first choice of treatment of the acetabular bone deficient osteoarthritic hip in a young patient is reconstruction with impaction bone grafting and a cemented cup.

Long-term results of cemented total hip arthroplasty in patients younger than 30 years and the outcome of subsequent revisions.

BACKGROUND: The number of total hip arthroplasties in patients under 30 years is increasing over the years. Almost all of them will face at least one or more future revisions in their life. Therefore, the implant used should have a high survival rate, and needs to be easily revisable resulting in a low re-revision rate. Several studies have evaluated the outcome of total hip arthroplasties in patients under 30 years. However, only a few reported on the follow-up outcome of 10 years or more. In addition, none of these reports published data of the subsequent revisions of these implants within their original report. METHODS: We studied historically prospective collected data of 48 consecutive patients (69 hips) younger than 30 years, treated with a cemented primary total hip prosthesis between 1988 and 2004. Since the last evaluation of this cohort, two patients were lost to follow-up. For all hip revisions in this cohort, again cemented implants were used, mostly in combination with bone impaction grafting. Kaplan-Meier survival curves at 10- and 15 years for the primary total hip arthroplasties and revisions were determined. RESULTS: The mean age at time of primary surgery was 25 years (range, 16 to 29 years). Mean follow-up of the primary hips was 11.5 years (range, 7 to 23 years). During follow-up 13 revisions were performed; in 3 cases a two-stage total revision was performed for septic loosening and 9 cups were revised for aseptic loosening. There were no aseptic stem revisions. The 10 and 15-year survival rates with endpoint revision for aseptic loosening of the primary total hip were 90% (95% CI: 79 to 96) and 82% (95% CI: 65 to 92) respectively. None of our 13 subsequent revisions needed a re-revision within 10 years after re-implantation. CONCLUSIONS: Cemented total hip implants in patients under 30 years have an encouraging outcome at 10 and 15 years after surgery in these young patients. The 13 revised hips, treated with bone grafting and the third generation cement technique, were performing well with no re-revisions within ten years after surgery.

Non-Hodgkin's lymphoma of the synovium discovered in total knee arthroplasty: a case report.

BACKGROUND: Musculoskeletal involvement occurs in 25% of patients with non-Hodgkin's lymphoma (NHL). Primary lymphoma in the joint is rare. It can present as a bone lesion or as atypical soft tissue proliferation. NHL has an increased incidence in patients with autoimmune rheumatic diseases. CASE PRESENTATION: We present a case in which non-Hodgkin's lymphoma was found coincidentally in the synovium during knee joint replacement surgery in a 69-year old woman with rheumatoid arthritis. Pigmented, vitreous tissue was resected, which turned out to be a diffuse large B-cell lymphoma after histological examination. The coincidental intraoperative finding of intra-articular non-Hodgkin's lymphoma was reported twice before, presenting as synovial proliferation in elbow and shoulder surgery. In a few other cases non-Hodgkin's lymphoma presented most often in the knee, as a bone lesion or, when soft tissue was involved, as arthritis. CONCLUSION: Non-Hodgkin's lymphoma should be considered in patients with autoimmune rheumatic diseases. In case of persistent arthritis, non-respondent to anti-inflammatory drugs, a biopsy might be warranted. Moreover, when arthroscopy or arthrotomy is planned, any atypical tissue should be sent for histological analysis. Early diagnosis of NHL can contribute to improved outcome of its rapidly developing treatment options.

High survivorship of cemented sockets with roof graft for severe acetabular dysplasia.

BACKGROUND: Socket fixation in patients with acetabular dysplasia can be technically demanding but the use of structural grafts can help to reconstruct the original center of hip rotation. Because reported survival rates differ, construct survival seems to depend on the technique of graft preparation and fixation. QUESTIONS/PURPOSES: What is the survivorship of cemented sockets with acetabular roof graft in patients with severe acetabular dysplasia? Do clinical scores equal those of patients without acetabular grafting? METHODS: We retrospectively reviewed 62 patients (74 hips) who had undergone cemented THA with acetabular roof graft. Mean age at surgery was 45 years (range, 19-71 years). Revisions and radiographic failures were determined and clinical scores (Oxford, SF-12) were obtained and matched to a control group. Kaplan-Meier analysis was used to determine survivorship at a minimum followup of 5 years (mean, 10.4 years; range, 5-16 years). RESULTS: Survivorship for all-cause revision was 98% (95% CI, 92.5%-100.0%) at 10 years followup. Two hips were revised for aseptic acetabular loosening and one hip for polyethylene wear. All grafts incorporated and no additional radiographic loosenings were seen. Patients with grafting had higher Oxford scores compared with the control group but other scores were equal. CONCLUSIONS: In contrast to reported series and the common use of cementless cups in patients with developmental dysplasia of the hip, we found high survivorship of cemented sockets with roof graft in severe acetabular dysplasia at a mean followup of more than 10 years. These patients showed higher Oxford scores than patients in a control group. This technique that restores bone stock is a reasonable solution for often young patients with dysplasia. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasties in young patients under 50 years: limited evidence for current trends. A descriptive literature review.

We examined all reported outcomes of uncemented and cemented total hip arthroplasty in patients younger than 50 years of age listed in Medline (1966- 1 January 2009) and PubMed, and scrutinised reference lists of relevant papers. In addition, we evaluated relevant data in the Swedish hip arthroplasty register. 109 relevant articles were identified, 37 of which had a mean follow-up longer than 10 years. Although uncemented implants are widely used in patients under 50 years of age, there are only 2 reports that fulfil the criteria published by the National Institute for Clinical Excellence (NICE) in the United Kingdom (follow-up of >10 yrs and survival of =90%). Current trends relating to implant selection remain unsupported by survival data, and additional information about the long-term results of newer implants is essential. As matters stand, the most reliable results relate to cemented implants.

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old: a concise follow-up, at twenty to twenty-eight years, of a previous report.

In a previous report, we presented our results of forty-two acetabular reconstructions, performed with use of impaction bone-grafting and a cemented polyethylene cup, in thirty-seven patients who were younger than fifty years and had a minimum of fifteen years of follow-up. The present update study shows the results after twenty to twenty-eight years. Eight additional cups had to be revised--four because of aseptic loosening, three because of wear, and one during a revision of the stem. Three additional cups were considered loose on radiographs. Survivorship of the acetabular reconstructions, with an end point of revision for any reason, was 73% after twenty years and 52% after twenty-five years. With revision for aseptic loosening as the end point, survival was 85% after twenty years and 77% after twenty-five years; for signs of loosening on radiographs, survival was 71% at twenty years and 62% at twenty-five years. In conclusion, our previous results have declined but the technique of using impacted morselized bone graft and a cemented cup is useful for the purpose of restoring bone stock in young patients whose acetabular defects require primary or revision total hip arthroplasty.

Osteoarticular infections in HIV-infected patients: 23 cases among 1,515 HIV-infected patients.

BACKGROUND: The reported incidence of osteoarticular infections in HIV-infected patients has varied in the literature. PATIENTS AND METHODS We determined the incidence and characteristics of osteoarticular infections reported in a database of 1,515 HIV-infected patients between 1983 and 2003. RESULTS: 23 HIV-infected patients were identified with an osteoarticular infection, 11 of whom had a spondylodiscitis. 16 were intravenous drug abusers; this was identified as a risk factor for developing an osteoarticular infection. The most common agent was Staphylococcus aureus. 6 patients required surgical intervention and in a worst-case scenario more than one-fifth had recurrence of their infection. CONCLUSION: Development of an osteoarticular infection is a rare complication in this group of HIV-infected patients, but a remarkably high number of infections of the spine were seen.

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old.

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.