Geert H I M Walenkamp

Lateral extensor release for tennis elbow. A prospective long-term follow-up study.

A prospective study was done of the results of lateral release of the common extensor origin in sixty-three patients who had a tennis elbow. Fifty-seven of these patients were followed for a mean of fifty-nine months (range, fifty to sixty-five months). At the time of the operation, the extensor origin was macroscopically normal in all but six patients. Forty-seven (76 per cent) of the sixty-two patients who were evaluated at one year had no pain or only slight pain, whereas before the operation three patients (5 per cent) had had slight pain and sixty (95 per cent), severe pain. Of the fifty-seven patients who were re-examined after five years, fifty-two (91 per cent) had no pain or only slight pain. At one year, twenty patients (32 per cent) had an excellent over-all result; twenty-three (37 per cent), a good result; twelve (19 per cent), a fair result; and seven (11 per cent), a poor result. At five years, there were thirty-two excellent results (56 per cent), nineteen good results (33 per cent), four fair results (7 per cent), and two poor results (4 per cent). No association between the preoperative findings and the results of the operation was found. It was concluded that lateral extensor release, a relatively simple operation that can be performed in an outpatient setting, may be regarded at this time as the operative procedure with which other operations for tennis elbow should be compared.

LOCAL CORTICOSTEROID INJECTION VERSUS CYRIAX-TYPE PHYSIOTHERAPY FOR TENNIS ELBOW

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects.

Osteomyelitis treated with gentamicin-PMMA beads : 100 patients followed for 1-12 years

We treated 100 patients having osteomyelitis with debridement and gentamicin-PMMA beads and followed them for 5 (1–12) years. 66 of the infections were chronic, in 18 cases combined with arthritis and in 3 cases with pseudarthrosis. They underwent 117 “treatment periods”, consisting of one or more operations (total 152), in most cases with an interval of 2 weeks. No systemic antibiotics were necessary besides the local antibiotic treatment in 52 of the treatment periods. Healing was achieved in 92 patients, in 78 after a single treatment period which included 1–5 operations, in 14 after two or three treatment periods. Healing was more difficult to achieve when the infection was chronic, especially with a duration of more than 6 years or when caused by elective surgery. Local antibiotic treatment with gentamicin PMMA beads has the advantage that the wound can be closed primarily and that a higher local antibiotic concentration in the tissues can be achieved, often making systemic antibiotic treatment unnec...

Incidence of low-grade infection in aseptic loosening of total hip arthroplasty

Purpose We investigated the hypothesis that many total hip arthroplasty revisions that are classified as aseptic are in fact low-grade infections missed with routine diagnostics. Methods In 7 Dutch hospitals, 176 consecutive patients with the preoperative diagnosis of aseptic loosening of their total hip arthroplasty were enrolled. During surgery, between 14 and 20 tissue samples were obtained for culture, pathology, and broad-range 16S rRNA PCR with reverse line blot hybridization. Patients were classified as either not being infected, suspected of having infection, or infected according to strict, predefined criteria. Each patient had a follow-up visit after 1 year. Results 7 patients were classified as infected, 4 of whom were not identified by routine culture. 15 additional patients were suspected of having infection. 20 of these 22 patients received a cemented prosthesis, fixated with antibiotic-loaded bone cement. All 22 patients received prophylactic systemic antibiotics. 7 of them reported complaints one year after surgery, but only one showed signs of early loosening. However, additional surgery was not performed in any of the patients. Interpretation Although the proportions were not as high as previously reported in the literature, between 4% and 13% of patients with the preoperative diagnosis of aseptic loosening were infected. However, as thorough debridement was performed during surgery and prophylactic antibiotics were used, the diagnosis of infection did not have any obvious clinical consequences, as most patients performed well at the 1-year follow-up. Whether this observation has implications for long-term implant survival remains to be seen.

Small PMMA beads improve gentamicin release

The in vivo release of gentamicin base from conventional polymethyl methacrylate 7-mm beads was compared with that from the recently introduced 3 x 5-mm minibeads. The release in 14 days from minibeads was 93 percent of their gentamicin content, while the large beads released an average of 24 percent. The volume of the minibeads is one fifth of that of the large beads. Owing to the improved release combined with the smaller size, total release from minibeads in a cavity may be some seven times that from large beads. When in smaller cavities a strong bactericidal effect is desired, minibeads are to be preferred to large beads.

Silicone arthroplasty for hallux rigidus Implant wear and osteolysis

Between 1980 and 1985, silicone hemiprostheses were implanted because of hallux rigidus in 58 feet of 43 patients who were followed up after an average of 5 years. The majority were satisfied and had good function without pain. However, the toes had shortened because of implant wear, and there was considerable associated osteolysis.

Casting methods and plantar pressure: effects of custom-made foot orthoses on dynamic plantar pressure distribution.

Foot orthoses are widely used to treat various foot problems. A literature search revealed no publications on differences in plantar pressure distribution resulting from casting methods for foot orthoses. Four casting methods were used for construction of orthoses. Two foam box techniques were used: accommodative full weightbearing method (A) and functional semiweightbearing method (B). Also, two suspension plaster casting techniques were used: accommodative casting (C) and functional subtalar joint neutral position (Root) method (D). Their effects on contact area, plantar pressure, and walking convenience were evaluated. All orthoses increased the total contact area (mean, 17.4%) compared with shoes without orthoses. Differences in contact areas between orthoses for total plantar surface were statistically significant. Peak pressures for the total plantar surface were lower with orthoses than without orthoses (mean, 22.8%). Among orthoses, only the difference between orthoses A and B was statistically significant. Differences between orthoses for the forefoot were small and not statistically significant. The gait lines of the shoe without an insole and of the accommodative orthoses are more medially located than those of functional orthoses. Walking convenience in the shoe was better rated than that with orthoses. There were no differences in perception of walking convenience between orthoses A, B, and C. Orthosis D had the lowest convenience rating. The four casting methods resulted in differences between orthoses with respect to contact areas and walking convenience but only slight differences in peak pressures.

Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics

Background Deep postoperative and hematogenous prosthesis infections may be treated with retention of the prosthesis, if the prosthesis is stable. How long the infection may be present to preclude a good result is unclear. Patients and methods We retrospectively studied 89 deep-infected stable prostheses from 69 total hip replacements and 20 total knee replacements. There were 83 early or delayed postoperative infections and 6 hematogenous. In the postoperative infections, treatment had started 12 days to 2 years after implantation. In the hematogenous infections, symptoms had been present for 6 to 9 days. The patients had been treated with debridement, prosthesis retention, systemic antibiotics, and local antibiotics: gentamicin-PMMA beads or gentamicin collagen fleeces. The minimum follow-up time was 1.5 years. We investigated how the result of the treatment had been influenced by the length of the period the infection was present, and by other variables such as host characteristics, infection stage, and type of bacteria. Results In postoperative infections, the risk of failure increased with a longer postoperative interval: from 0.2 (95% CI: 0.1–0.3) if the treatment had started ≥ 4 weeks postoperatively to 0.5 (CI: 0.2–0.8) if it had started at ≥ 8 weeks. The relative risk for success was 0.6 (CI: 0.3–0.95) if the treatment had started ≥ 8 weeks. In the hematogenous group, 5 of 6 infections had been treated successfully. Interpretation A longer delay before the start of the treatment caused an increased failure rate, but this must be weighed against the advantage of keeping the prosthesis. We consider a failure rate of < 50% to be acceptable, and we therefore advocate keeping the prosthesis for up to 8 weeks postoperatively, and in hematogenous infections with a short duration of symptoms.

Bone graft substitutes in active or suspected infection. Contra-indicated or not?

Treatment of infection in clinical orthopaedic and trauma care is a time consuming and costly endeavour. More than once, it will lead to extraction of implant material and additional surgical interventions. Currently, debridement, implantation of PMMA beads impregnated with antibiotics most often with implant exchange are the gold standard for deep infection treatment. Recently bone graft substitute materials such as calcium phosphate, collagen fleeces and bioglasses have appeared for specific use in infection treatment. Although these materials show great potential, their supporting level of evidence is still limited. This review paper provides an overview of current understanding and therapies for infection treatment and provides concepts for the use of new developed biomaterials in infection treatment. Furthermore, the benefits and risks of using biomaterials in infection treatment are discussed and the level of evidence of a number of new materials is presented.

The relationship of the position of the metatarsal heads and peak plantar pressure

We test the premise that peak plantar pressure is located directly under the bony prominences in the forefoot region. The right foot of standing volunteers was examined in three different postures by a CT-scanner. The plantar pressure distribution was simultaneously recorded. The position of the metatarsal heads and the sesamoids could be related to the corresponding local peak plantar pressures. The metatarsal heads 1, 4, and 5 had a significantly different position than the local peak plantar pressures. The average difference in distance between the position of the metatarsal heads and the peak plantar pressure showed a significant correlation: on the medial side the head was located more distally to the local peak plantar pressure, on the lateral side more proximally. The findings suggest that normal plantar soft tissue is able to deflect a load. The observations might improve insight into the function of the normal forefoot and might direct further research on the pathological forefoot and on the design of footwear.