Daniel Haverkamp

Obesity in total hip arthroplasty—does it really matter?: A meta-analysis

Background and purpose Discussion persists as to whether obesity negatively influences the outcome of hip arthroplasty. We performed a meta-analysis with the primary research question of whether obesity has a negative effect on short- and long-term outcome of total hip arthroplasty. Methods We searched the literature and included studies comparing the outcome of hip arthroplasty in different weight groups. The methodology of the studies included was scored according to the Cochrane guidelines. We extracted and pooled the data. For continuous data, we calculated a weighted mean difference and for dichotomous variables we calculated a weighted odds ratio (OR). Heterogeneity was calculated using I2 statistics. Results 15 studies were eligible for data extraction. In obese patients, dislocation of the hip (OR = 0.54, 95% CI: 0.38–0.75) (10 studies, n = 8,634), aseptic loosening (OR = 0.64, CI: 0.43–0.96) (6 studies, n = 5,137), infection (OR = 0.3, CI: 0.19–0.49) (10 studies, n = 7,500), and venous thromboembolism (OR = 0.56, CI: 0.32–0.98) (7 studies, n = 3,716) occurred more often. Concerning septic loosening and intraoperative fractures, no statistically significant differences were found, possibly due to low power. Subjective outcome measurements did not allow pooling because of high heterogeneity (I2 = 68%). Interpretation Obesity appears to have a negative influence on the outcome of total hip replacement.

The Harris hip score: Do ceiling effects limit its usefulness in orthopedics?

Background and purpose The Harris hip score (HHS), a disease-specific health status scale that is frequently used to measure the outcome of total hip arthroplasty, has never been validated properly. A questionnaire is suitable only when all 5 psychometric properties are of sufficient quality. We questioned the usefulness of the HHS by investigating its content validity. Methods We performed a systematic review based on a literature search in PubMed, Embase, and the Cochrane Library for descriptive studies published in 2007. 54 studies (59 patient groups) met our criteria and were included in the data analysis. To determine the content validity, we calculated the ceiling effect (percentage) for each separate study and we pooled data to measure the weighted mean. A subanalysis of indications for THA was performed to differentiate the populations for which the HHS would be suitable and for which it would not. A ceiling effect of 15% or less was considered to be acceptable. Results Over half the studies (31/59) revealed unacceptable ceiling effects. Pooled data across the studies included (n = 6,667 patients) suggested ceiling effects of 20% (95%CI: 18–22). Ceiling effects were greater (32%, 95%CI:12–52) in those patients undergoing hip resurfacing arthroplasty. Interpretation Although the Harris hip score is widely used in arthroplasty research on outcomes, ceiling effects are common and these severely limit its validity in this field of research.

Translation and validation of the Dutch version of the Oxford 12-item knee questionnaire for knee arthroplasty.

Background In 1998, the Oxford 12-item knee questionnaire was developed by Dawson et al. as a self-administered disease- and site-specific questionnaire, specifically developed for knee arthroplasty patients. Since then, it has proven to be an effective outcome questionnaire, and is widely used. Despite the positive psychometric properties for the Total Knee Arthroplasty (TKA) population, the 12-item knee questionnaire has only been translated into a few languages. We thus translated and validated the Oxford 12-item knee questionnaire for the Dutch population. Methods and results After translation according to a forward/backward protocol, 174 knee arthroplasty patients were asked to answer the questionnaire together with an SF-36, an AKSS and a VAS. The reliability, validity, content validity and the sensitivity to change were all tested. Our Dutch version of the Oxford 12-item knee questionnaire achieved excellent scores in all of these properties. Interpretation The Dutch Oxford 12-item knee questionnaire proved to be an excellent evaluation instrument for the Dutch orthopedic surgeon and can be used for all total knee arthroplasty patients.

Biomechanical and Clinical Evaluation of Posterior Malleolar Fractures. A Systematic Review of the Literature

INTRODUCTION Ankle fractures often have involvement of the posterior malleolus. Treatment guidelines exist based on limited biomechanical evidence and still is considered controversial. The objective of this article is to review the biomechanical literature concerning changes in tibiotalar contract area, changes in contact pressures, changes in ankle stability and incongruency of the joint after a posterior malleolar ankle fracture, and to review the clinical literature concerning the outcome of operative and nonoperative treatment of these fractures. Ultimately, the goal is to try to formulate helpful recommendations for clinical practice. MATERIAL The databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and Embase were searched from 1988 to November 2007 to identify studies relating to changes in tibiotalar contact area, contact pressures, ankle stability, clinical outcome, and radiographic osteoarthritis after a posterior malleolar fracture. The search was restricted to articles written in the English, German, and Dutch language. RESULTS Eight biomechanical studies, involving 96 cadaveric ankles were included and 10 clinical studies, involving 447 fractured ankles, were included. DISCUSSION No consensus in the literature was found as to which fragment size of the posterior malleolus (=posterior tibial margin) should be internally fixed. This is partially because of the lack of standardization in examining functional outcomes, making it difficult to compare results. It is not the peak pressure or changes in tibiotalar contact area, but rather the changes in peak pressure distribution that play a large role in posttraumatic arthritis development. It seems important to restore the medial and lateral constraints of the ankle because these, rather than the articular surfaces, provide the majority of ankle stability after an ankle fracture involving the posterior malleolar ankle fracture.

Hyaluronic Acid in the Treatment of Knee Osteoarthritis

AbstractBackground: Although accepted as a conservative treatment option for knee osteoarthritis, the debate about the effectiveness of intra-articular treatment with hyaluronic acid (HA) is still ongoing because of contrasting outcomes in different clinical studies. Several well designed clinical studies showed a significant improvement in pain at follow-up compared with baseline but no significant improvement comparing the efficacy of HA with placebo (saline) or with other conservative treatment options. Notwithstanding the effectiveness of different types of intra-articular HA products, the question of whether one HA product is better than another is still unanswered. In this systematic review we compare the effects of intra-articularly administered HA with intra-articularly administered placebo in general and, more specifically, the effects of individual HA products with placebo. We also compare the efficacy of different HA products. Methods: A systematic review of randomized controlled trials (RCTs) was conducted using databases including MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register and EMBASE. Results: Seventy-four RCTs were included in this systematic review. HA improves pain by approximately 40–50% compared with baseline levels. However, when compared with saline the difference in efficacy is not that large. Due to a large ‘placebo effect’ of saline (approximately 30% pain reduction, persisting for at least 3 months) we determined a weighted mean difference between the efficacy of HA and saline of just 10.20 using the visual analog scale for pain. It is debatable whether this difference reaches the minimum clinically important difference. Comparing the different HA products, which vary in the molecular weight, concentration, and volume of HA, we were not able to conclude that one brand has a better efficacy than another due to the heterogeneity of the studies and outcomes. Discussion: In the future it will be important to determine the exact mechanism of action of placebo as this may give us an idea of how to treat osteoarthritis more efficiently. Due to the limitations of this review (follow-up of just 3 months and large heterogeneity of the included studies), it is also important to compare the different HA products to determine which product(s), or which molecular weight range, concentration, or volume of HA is the best option to treat osteoarthritis. Our recommendation is to start large (multicenter) RCTs to give us more evidence about the efficacy of the different HA products.

Translation and Validation of the Dutch Version of the International Knee Documentation Committee Subjective Knee Form

Background For knee-related surgery, there is a great demand for internationally useable subjective scoring systems. Before such measurements can be used, they should be translated and validated for the population they are used on. For the Dutch population, only the Western Ontario and McMaster Universities Osteoarthritis Index and Oxford 12 Questionnaire have been validated. However, these scores can only be used regarding osteoarthritis of the knee. In 2001, the International Knee Documentation Committee presented the Subjective Knee Form, which is a knee-specific rather than a disease-specific questionnaire. Study Design Cohort study (diagnosis/symptom prevalence); Level of evidence, 2. Methods The authors describe the translation procedure and validation of the Dutch Subjective Knee Form. After a forward backward translation protocol, the reliability, validity, and content validity were tested. The responses of 145 consecutive knee patients on 2 questionnaires containing the Short Form–36, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford 12 Questionnaire score, a visual analog scale, and the Dutch International Knee Documentation Committee Subjective Knee Form were used. Reliability was tested by measuring the test-retest reliability and internal consistency. Validity was tested by correlating the questionnaire to the other outcome measurements, and content validity was tested by measuring the floor and ceiling effects. Results The reliability proved excellent with an intraclass coefficient of 0.96 for test-retest. Internal consistency was strong (Cronbach [.alpha],. 92). The construct, convergent, and divergent validities were good. The content validity was good; no floor or ceiling effect occurred. Conclusion The validation procedure shows that the Dutch International Knee Documentation Committee Subjective Knee Form is an excellent evaluation instrument for Dutch patients with knee-related injuries.

Construct validity and reliability of the disability of arm, shoulder and hand questionnaire for upper extremity complaints in rheumatoid arthritis

Objective The Disability of Arm, Shoulder and Hand (DASH) questionnaire is a tool for measuring physical function and symptoms of the upper extremity. Although widely used, it is not validated for rheumatoid arthritis (RA). In this study the DASH was validated for this patient group. Methods In total, 102 patients participated in this study. For the validation, the questionnaires of the DASH, the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study Short Form-36 (SF-36), and the Arthritis Impact Measurement Scale (AIMS2) were used. Patients were examined clinically before completing the questionnaires. Pain was scored by each patient using a visual analog scale (VAS). The DiseaseActivity Score (DAS28) was obtained and grip strength was measured. Reliability was tested by a second DASH questionnaire after 2 days. Validity was tested using a Pearson correlation analysis for the relevant domains of the questionnaires and for the clinical aspects. Results The reliability of the DASH was excellent (intraclass correlation coefficient 0.97). Internal consistency was strong (Cronbach’s alpha 0.97). Validity was proven with excellent results for Pearson correlation with the relevant domains of the questionnaires: HAQ, r = 0.88; SF-36, r = 0.70; and AIMS2, r = 0.85. The clinical scores had a relatively low correlation with the DASH (DAS28, r = 0.42; and grip strength, r = 0.41–0.48), except for the VAS (r = 0.60–0.65). Conclusion The DASH is a reliable and valid questionnaire in patients with RA. It can be used as a measurement tool of physical disability of the upper extremity.

Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: what is the current evidence?

BackgroundThe use of intra-articular hyaluronic acid (HA) is a well known treatment in patients with knee osteoarthritis (OA). In other joints, less evidence is available about the efficacy of treatment with intra-articular HA. HA is also used intra-articularly in the metatarsophalangeal-1 joint, the ankle, the hip, the sacroiliac joint, the facet joints, the carpometacarpal-1 joint, the shoulder and the temporo-mandibular joint. In this systematic review we include all prospective studies about the effects of intra-articular HA in the above-mentioned joints. Its use in the knee joint, however, will be discussed in a separate article in this journal.MethodsA systematic review was conducted using databases including MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and EMBASE.ResultsAfter performing a solid systematic review using a rigid methodology and trying to pool the outcomes of different studies, we noticed that, compared with baseline, there is statistical evidence for a positive effect of intra-articular HA. However, there is limited evidence HA is superior to placebo and no evidence that intra-articular HA is better than corticosteroids or other conservative therapies.ConclusionOur recommendation for future research is that one should focus on adequately powered randomized trials comparing HA treatment with other types of intra-articular or conservative treatment. We think it is useless to further perform and publish (large) non-comparative prospective studies about the use of HA in the treatment of problems caused by OA. It is well perceived that HA exerts positive effects in the treatment of OA, but up to now there is no (strong) evidence available that HA is superior to other treatments of OA such as corticosteroids, physiotherapy or other conservative measures.

Outcome of Kienböck's disease 22 years after distal radius shortening osteotomy.

Loading of the lunate in patients with Kienböck‘s disease and a negative ulnar variance provide the rationale for a radial shortening osteotomy. This osteotomy decreases forces transmitted from the radius to the lunate. We retrospectively reviewed 12 patients with Kienböcks disease who had 13 radial shortening osteotomies to ascertain whether the reported short- and medium-term results endured in the long term. We evaluated nine osteotomies in nine of the 12 patients with a minimum of 16 years followup (average, 22 years; range, 16-31 years). Three patients died and one was lost to followup. For the nine patients, the range of motion was impaired compared with the normal side. Grip strength was on average 90% of the unaffected side. The average visual analog scale score for pain was 2.4 and the average Disabilities of the Arm, Shoulder, and Hand score was 14 at latest followup. In eight patients, the Lichtman classification of Kienböcks disease did not change at followup, but in three patients there was radiographic progression of the disease, which occurred during the first 10 years postoperatively. The medium- and long-term results therefore were comparable. We recommend radial shortening in stable wrists (Stage 3A or less) with a negative ulnar variance. The radius should be shortened to the level of the ulna, normally 4 to 6 mm, after which stable (plate) fixation should be performed under compression.Level of Evidence: Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Intra-articular infiltration therapy for patients with glenohumeral osteoarthritis: A systematic review of the literature

Background: Conservative treatments are especially in patients with glenohumeral osteoarthritis (GH-OA) important, since shoulder arthroplasty has its limitations. In this systematic review, we will evaluate the current evidence regarding the efficacy of intra-articular (IA) infiltration treatment options in patients with GH-OA. Materials and Methods: The following databases are searched: Pubmed/Medline, Cochrane Clinical Trial Register, Embase and the WHO clinical trial register. All IA injection products used for the treatment of shoulder OA in humans are included. Results: A total of 8 studies could be included in this review. Hyaluronic acid (HA) showed effect sizes of 2.07, 2.02 and 2.11 at 6, 12 and 26 weeks follow-up, respectively. Placebo (1.60, 1.82 and 1.68) also showed stable effect sizes at the same time points. The efficacy of corticosteroids (CS) decreased rapidly at follow-up (1.08, 0.43 and 0.19). Although statistical significant, the maximum difference in effect sizes between HA and placebo was only 0.43 with absolute values between 2.0 and 6.4 on a 100-point visual analogue score for pain. Conclusion: IA treatment with HA has a good efficacy at follow-up compared to baseline. However, the difference in efficacy between HA and placebo never reaches the minimal clinically important difference at any of the follow-up points. We are not able to give clear recommendations for the use of IA CS injections in patients with GH-OA. In future research, we recommend focusing on sufficiently powered randomized trials to compare the efficacies of HA, CS, placebo and other IA treatment options in patients with GH-OA.