Gino M. M. J. Kerkhoffs

The Influence of Obesity on the Complication Rate and Outcome of Total Knee Arthroplasty: A Meta-Analysis and Systematic Literature Review

BACKGROUND The increase in the number of individuals with an unhealthy high body weight is particularly relevant in the United States. Obesity (body mass index ≥ 30 kg/m2) is a well-documented risk factor for the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty. METHODS A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I2 statistic. RESULTS After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval [CI], 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67). CONCLUSIONS Obesity had a negative influence on outcome after total knee arthroplasty.

Terminology and classification of muscle injuries in sport: The Munich consensus statement

Objective To provide a clear terminology and classification of muscle injuries in order to facilitate effective communication among medical practitioners and development of systematic treatment strategies. Methods Thirty native English-speaking scientists and team doctors of national and first division professional sports teams were asked to complete a questionnaire on muscle injuries to evaluate the currently used terminology of athletic muscle injury. In addition, a consensus meeting of international sports medicine experts was established to develop practical and scientific definitions of muscle injuries as well as a new and comprehensive classification system. Results The response rate of the survey was 63%. The responses confirmed the marked variability in the use of the terminology relating to muscle injury, with the most obvious inconsistencies for the term strain. In the consensus meeting, practical and systematic terms were defined and established. In addition, a new comprehensive classification system was developed, which differentiates between four types: functional muscle disorders (type 1: overexertion-related and type 2: neuromuscular muscle disorders) describing disorders without macroscopic evidence of fibre tear and structural muscle injuries (type 3: partial tears and type 4: (sub)total tears/tendinous avulsions) with macroscopic evidence of fibre tear, that is, structural damage. Subclassifications are presented for each type. Conclusions A consistent English terminology as well as a comprehensive classification system for athletic muscle injuries which is proven in the daily practice are presented. This will help to improve clarity of communication for diagnostic and therapeutic purposes and can serve as the basis for future comparative studies to address the continued lack of systematic information on muscle injuries in the literature. What are the new things Consensus definitions of the terminology which is used in the field of muscle injuries as well as a new comprehensive classification system which clearly defines types of athletic muscle injuries. Level of evidence Expert opinion, Level V.

Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results

Objective: To analyze the long-term (5-27 years) functional and radiologic results of surgically treated fractures of the tibial plateau. Design: Retrospective study. Setting: University hospital. Patients and Methods: Two hundred two consecutive tibial plateau fractures were included in this study. All fractures were classified according to both the AO and the Schatzker classification. There were 112 men and 90 women. The mean age at injury was 46 years (16 to 88). One hundred sixty-three patients had isolated fractures and 39 had multiple fractures. A 1 year follow-up was done in all 202 patients. One hundred nine of these patients also had an additional long-term follow-up visit. Functional results of these 109 patients were graded with the Neer- and HSS-knee scores. Radiologic results were graded with the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. Results: An uneventful union was present at the 1 year follow-up in 95% of the patients, along with a mean knee ROM of 130 degrees (range, 10-145 degrees). One hundred nine patients had a long-term follow-up visit after a mean period of 14 years (range, 5-27 years). The mean ROM at this time was 135 degrees (range, 0-145 degrees). Functional results showed a mean Neer score of 88.6 points (range, 56-100 points) and a mean HSS score of 84.8 points (range, 19-100 points). Monocondylar fractures showed statistically significant better functional results compared to bicondylar fractures. In 31% of the patients, secondary osteoarthritis had developed but was well tolerated in most (64% of the patients). Patients with a malalignment of more then 5 degrees developed a moderate to severe grade of osteoarthritis statistically significant more often (27% of the patients) compared to patients with an anatomic knee axis (9.2%; MWU, P = 0.02). Age did not appear to have any influence on the results. Conclusion: Long-term results after open reduction and internal fixation for tibial plateau fractures are excellent, independent of the patients age.

Proximal tibial varus osteotomy : Indications, technique, and five to twenty-one-year results

Background: Although high tibial osteotomy has been proved effective for the treatment of painful osteoarthritis of the medial compartment of the knee, the role of proximal tibial varus osteotomy for the treatment of painful osteoarthritis of the lateral compartment still remains controversial. Methods: From 1974 to 1993, we performed proximal tibial varus osteotomy for the treatment of osteoarthritis of the lateral compartment of the knee in thirty-six consecutive patients. The procedure consisted of a proximal lateral opening-wedge varus osteotomy of the tibia with use of corticocancellous bone grafts from the iliac crest. The valgus deformity was posttraumatic in twenty-three patients, followed a lateral meniscectomy in five, was due to overcorrection of a varus deformity in four, and was idiopathic in four. The preoperative valgus deformity averaged 11.6° (range, 4° to 22°). Results: At a mean of eleven years (range, five to twenty-one years) after the operation, the clinical results for thirty-four of the thirty-six patients were analyzed. None of the patients had severe progression of the osteoarthritis after the osteotomy, and none had a meaningful loss in the range of motion of the knee joint. A superficial wound infection developed in one patient, and another patient had thrombophlebitis. Three patients (9%) had a transient palsy of the peroneal nerve. According to the system of Insall et al., the mean knee score was 84 points (range, 54 to 99 points). According to the knee score described by Lysholm and Gillquist, the subjective result was excellent in nine patients (26%), good in twenty-one (62%), fair in three (9%), and poor in one (3%). Conclusions: We concluded that when the indications outlined in this study are followed and our opening-wedge technique is used, a proximal lateral opening-wedge varus osteotomy of the tibia is a good alternative for the treatment of isolated osteoarthritis of the lateral compartment of the knee. High accuracy in preoperative planning, based on a slight overcorrection, is important to prevent failure.

Conservative Treatment of Lateral Epicondylitis Brace Versus Physical Therapy or a Combination of Both—A Randomized Clinical Trial

Background The authors evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with tennis elbow. Methods Patients were randomized over 3 groups: brace-only treatment, physical therapy, and the combination of these. Main outcome measures were success rate, severity of complaints, pain, disability, and satisfaction. Data were analyzed using both intention-to-treat and per-protocol analyses. Follow-up was 1 year. Results A total of 180 patients were randomized. Physical therapy was superior to brace only at 6 weeks for pain, disability, and satisfaction. Contrarily, brace-only treatment was superior on ability of daily activities. Combination treatment was superior to brace on severity of complaints, disability, and satisfaction. At 26 weeks and 52 weeks, no significant differences were identified. Conclusion Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term.

Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline

Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.

Immobilisation for acute ankle sprain. A systematic review.

Abstract The variation of practice with respect to the treatment of the acutely sprained ankle suggests a lack of evidence-based management strategies for this problem. The objective of this review was to assess the effectiveness of the various methods of immobilisation for acute ankle sprain. An electronic database search was conducted using MEDLINE, EMBASE, BIOSIS, CINAHL, Cochrane Controlled Trial Register and Current Contents. Randomised and quasi-randomised clinical trials describing skeletally mature individuals with an acute ankle sprain and comparing immobilisation for the treatment of injuries to the lateral ligament complex of the ankle were evaluated for inclusion. Two reviewers independently assessed the validity of included trials and extracted relevant data on the treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcomes and weighted mean differences (WMD) for continuous outcome measures with 95% confidence intervals (95% CI). Heterogeneity between trials was tested using a standard chi-square test. A total of 22 studies met the inclusion criteria. Statistically significant differences were found for six outcome measures, all in favour of functional treatment compared with immobilisation: return to sports (RR: 1.85; 95% CI: 1.2 to 2.8), (WMD: 4.57 days; 95% CI: 1.5 to 7.6), return to work (WMD: 7.12 days; 95% CI: 5.6 to 8.7), persistent swelling (RR: 1.44; 95% CI: 1.1 to 2.0), objective instability by stress X-ray (WMD: 2.48; 95% CI: 1.3 to 3.6), range of motion (RR: 1.64; 95% CI: 1.1 to 2.6) and patient satisfaction (RR: 6.50; 95% CI: 1.8 to 24) . None of the other results were significantly in favour of immobilisation. Sensitivity analysis showed that a non-concealed treatment allocation did not influence the statistical significance of the overall results. Based on our results, functional treatment currently seems a more appropriate treatment and should be encouraged. Concerning effectiveness, immobilisation, if necessary, should be restricted to certain patients and for short time periods.

Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up.

BACKGROUND The primary aim of this study was to assess the long-term clinical and radiographic outcomes of arthroscopic debridement and bone marrow stimulation for talar osteochondral defects. The secondary aim was to identify prognostic factors that affect the long-term results. METHODS Fifty (88%) of fifty-seven eligible patients with a primary osteochondral defect treated with arthroscopic debridement and bone marrow stimulation were evaluated after a mean follow-up of twelve years (range, eight to twenty years). Clinical assessment included the Ogilvie-Harris score, Berndt and Harty outcome question, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Short Form-36 (SF-36) as well as resumption of work and sports. Weight-bearing radiographs were compared with preoperative radiographs with use of an ankle osteoarthritis classification system. The size, location, and classification of the defect, patient age and body mass index, traumatic etiology, and duration of symptoms were recorded and analyzed with use of univariate logistic regression. RESULTS The Ogilvie-Harris score was excellent in 20% of patients, good in 58%, fair in 22%, and poor in 0%. According to the Berndt and Harty outcome question, 74% of patients rated the ankle as good, 20% as fair, and 6% as poor. The median AOFAS score was 88 (range, 64 to 100). Of the eight subscales of the SF-36, six were comparable with population norms and two were superior in the study group. Ninety-four percent of patients had resumed work and 88% had resumed sports. The radiographs indicated an osteoarthritis grade of 0 in 33% of the patients, I in 63%, II in 4%, and III in 0%. Compared with the preoperative osteoarthritis classification, 67% of radiographs showed no progression and 33% showed progression by one grade. None of the prognostic factors was significantly associated with the Ogilvie-Harris score or progression of osteoarthritis. CONCLUSIONS This study suggests that initial success of arthroscopic debridement and bone marrow stimulation for osteochondral defects of the talus are maintained over time. No factors that were predictive of the outcome could be identified.

Functional treatments for acute ruptures of the lateral ankle ligament: a systematic review.

Our aim with this systematic review was to assess the effectiveness of various functional treatments for acute ruptures of the lateral ankle ligament in adults. We performed an electronic database search using MEDLINE, EMBASE, COCHRANE CONTROLLED TRIAL REGISTER and CURRENT CONTENTS. We evaluated randomized clinical trials describing skeletally mature subjects with an acute rupture of the lateral ankle ligament and compared functional treatments for inclusion in this study. 9 trials met our inclusion criteria. Two reviewers independently assessed the quality of these trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences ((W)MD) for continuous outcome measures with 95% confidence intervals (95% CI). Heterogeneity between the trials was tested using a standard chi-square test. Persistent swelling at short-term follow-up was less with lace-up ankle support than with semi-rigid ankle support (RR 4.2 95% CI 1.3-14), an elastic bandage (RR 5.5; 95% CI 1.7-18) and tape (RR 4.1; 95% CI 1.2-14). A semi-rigid ankle support required a shorter period for return to work than an elastic bandage (WMD 4.2; 95% CI 2.4-6.1) (p = 0.7). One trial reported better results for subjective instability using the semi-rigid ankle support than the elastic bandage (RR 8.0; 95% CI 1.0-62). Treatment with tape resulted in more complications, mostly skin problems, than that with an elastic bandage (RR 0.1; 95% CI 0.0-0.8). We found no other statistically significant differences. We conclude that an elastic bandage is a less effective functional treatment. Lace-up supports seem better, but the data are insufficient as a basis for definite conclusions.

Medium- to Long-Term Outcome of Ankle Arthrodesis

Background: Despite improvement in outcome after ankle arthroplasty, fusion of the ankle joint is still considered the gold standard. A matter of concern is deterioration of clinical outcome as a result of loss of motion and advancing degeneration of adjacent joints. We performed a long-term study to address these topics. Methods: Between 1990 and 2005 a total of 121 ankle arthrodeses were performed at our institute. Thirty-five cases were excluded because of simultaneous subtalar arthrodesis. Ten had died and ten were lost to followup. Six had a bilateral ankle arthrodeses, leaving 60 patients (66 ankles) eligible for followup. There were 40 males and 26 females with a mean age at surgery of 47 years. In 60 ankles, fusion was obtained using a two-incision, three-screw technique. All patients were assessed using validated questionnaires and clinical rating systems: Short Form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Foot and Ankle Ability Measure (FAAM) and a subjective satisfaction rating. Radiological progression of osteoarthritis of the adjacent joints was assessed. Results: Fusion was achieved in 91% after primary surgery. In six patients rearthrodesis was needed to obtain fusion. The mean SF-36 score was 63 (SD, 22) for the physical component scale and 81 (SD, 15) for the mental component scale. The mean FAAM score was 69 (SD, 17) and the mean AOFAS Ankle Hindfoot score was 67 (SD, 12). Ninety-one percent were satisfied with their clinical result. Infection occurred once. No other serious adverse events were encountered. In all contiguous joints significant progression of arthritis was appreciated. Conclusion: Ankle arthrodesis using a two-incision, three-screw technique was a reliable and safe technique for the treatment of end-stage osteoarthritis of the ankle. It resulted in a good functional outcome at a mean followup of 9 years. Progressive osteoarthritis of the contiguous joints was clearly appreciated but the functional and clinical importance of these findings remains unclear. Level of Evidence