Inge H. F. Reininga

Minimally invasive and computer-navigated total hip arthroplasty: a qualitative and systematic review of the literature

BackgroundBoth minimally invasive surgery (MIS) and computer-assisted surgery (CAS) for total hip arthroplasty (THA) have gained popularity in recent years. We conducted a qualitative and systematic review to assess the effectiveness of MIS, CAS and computer-assisted MIS for THA.MethodsAn extensive computerised literature search of PubMed, Medline, Embase and OVIDSP was conducted. Both randomised clinical trials and controlled clinical trials on the effectiveness of MIS, CAS and computer-assisted MIS for THA were included. Methodological quality was independently assessed by two reviewers. Effect estimates were calculated and a best-evidence synthesis was performed.ResultsFour high-quality and 14 medium-quality studies with MIS THA as study contrast, and three high-quality and four medium-quality studies with CAS THA as study contrast were included. No studies with computer-assisted MIS for THA as study contrast were identified. Strong evidence was found for a decrease in operative time and intraoperative blood loss for MIS THA, with no difference in complication rates and risk for acetabular outliers. Strong evidence exists that there is no difference in physical functioning, measured either by questionnaires or by gait analysis. Moderate evidence was found for a shorter length of hospital stay after MIS THA. Conflicting evidence was found for a positive effect of MIS THA on pain in the early postoperative period, but that effect diminished after three months postoperatively. Strong evidence was found for an increase in operative time for CAS THA, and limited evidence was found for a decrease in intraoperative blood loss. Furthermore, strong evidence was found for no difference in complication rates, as well as for a significantly lower risk for acetabular outliers.ConclusionsThe results indicate that MIS THA is a safe surgical procedure, without increases in operative time, blood loss, operative complication rates and component malposition rates. However, the beneficial effect of MIS THA on functional recovery has to be proven. The results also indicate that CAS THA, though resulting in an increase in operative time, may have a positive effect on operative blood loss and operative complication rates. More importantly, the use of CAS results in better positioning of acetabular component of the prosthesis.

Subjects with hip osteoarthritis show distinctive patterns of trunk movements during gait-a body-fixed-sensor based analysis

BackgroundCompensatory trunk movements during gait, such as a Duchenne limp, are observed frequently in subjects with osteoarthritis of the hip, yet angular trunk movements are seldom included in clinical gait assessments. Hence, the objective of this study was to quantify compensatory trunk movements during gait in subjects with hip osteoarthritis, outside a gait laboratory, using a body-fixed-sensor based gait analysis. Frontal plane angular movements of the pelvis and thorax and spatiotemporal parameters of persons who showed a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp.MethodsA Body-fixed-sensor based gait analysis approach was used. Two body-fixed sensors were positioned at the dorsal side of the pelvis and on the upper thorax. Peak-to-peak frontal plane range of motion (ROM) and spatiotemporal parameters (walking speed, step length and cadence) of persons with a Duchenne limp during gait were compared to healthy subjects and persons without a Duchenne limp. Participants were instructed to walk at a self-selected low, preferred and high speed along a hospital corridor. Generalized estimating equations (GEE) analyses were used to assess group differences between persons with a Duchenne limp, without a Duchenne limp and healthy subjects.ResultsPersons with a Duchenne limp showed a significantly larger thoracic ROM during walking compared to healthy subjects and to persons without a Duchenne limp. In both groups of persons with hip osteoarthritis, pelvic ROM was lower than in healthy subjects. This difference however only reached significance in persons without a Duchenne limp. The ratio of thoracic ROM relative to pelvic ROM revealed distinct differences in trunk movement patterns. Persons with hip osteoarthritis walked at a significantly lower speed compared to healthy subjects. No differences in step length and cadence were found between patients and healthy subjects, after correction for differences in walking speed.ConclusionsDistinctive patterns of frontal plane angular trunk movements during gait could be objectively quantified in healthy subjects and in persons with hip osteoarthritis using a body-fixed-sensor based gait analysis approach. Therefore, frontal plane angular trunk movements should be included in clinical gait assessments of persons with hip osteoarthritis.

Elbow-specific clinical rating systems: extent of established validity, reliability, and responsiveness.

BACKGROUND The modern standard of evaluating treatment results includes the use of rating systems. Elbow-specific rating systems are frequently used in studies aiming at elbow-specific pathology. However, proper validation studies seem to be relatively sparse. In addition, these scoring systems might not always be used for appropriate populations of interest. Both of these issues might give rise to invalid conclusions being reported in the literature. Our aim was to investigate the extent to which the available elbow-specific outcome measurement tools have been validated and the quality of the validation itself. We also aimed to provide characteristics of the populations used for validation of these scales to enable clinicians to use them appropriately. METHODS A literature search identified 17 studies of 12 different elbow-specific scoring systems. These were assessed for validity, reliability, and responsiveness characteristics. The quality of these assessments was rated according to the Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist criteria, a standardized and validated tool developed specifically for this purpose. RESULTS Currently, the only elbow-specific rating system that is validated using high-quality methodology is the Oxford Elbow Score, a patient-administered outcome measure tool that has been validated on heterogeneous study populations. CONCLUSION Other rating systems still have to be proven in the future to be as good as the Oxford Elbow Score for clinical or research purposes. Additional validation studies are needed.

Effectiveness of computer-navigated minimally invasive total hip surgery compared to conventional total hip arthroplasty: design of a randomized controlled trial

BackgroundModerate to severe osteoarthrosis is the most common indication for Total Hip Arthroplasty (THA). Minimally Invasive Total Hip Surgery (MIS) and computer-navigated surgery were introduced several years ago. However, the literature lacks well-designed studies that provide evidence of superiority of computer-navigated MIS over a conventional THA technique. Hence, the purpose of this study is to compare (cost)effectiveness of computer-navigated MIS with a conventional technique for THA. It is our hypothesis that computer-navigated MIS will lead to a quicker recovery during the early postoperative period (3 months), and to an outcome at least as good 6 months postoperatively. We also hypothesize that computer-navigated MIS leads to fewer perioperative complications and better prosthesis positioning. Furthermore, cost advantages of computer-navigated MIS over conventional THA technique are expected.Methods/designA cluster randomized controlled trial will be executed. Patients between the ages of 18 and 75 admitted for primary cementless unilateral THA will be included. Patients will be stratified using the Charnley classification. They will be randomly allocated to have computer-navigated MIS or conventional THA technique. Measurements take place preoperatively, perioperatively, and 6 weeks and 3 and 6 months postoperatively. Degree of limping (gait analysis), self-reported functional status and health-related quality of life (questionnaires) will be assessed preoperatively as well as postoperatively. Perioperative complications will be registered. Radiographic evaluation of prosthesis positioning will take place 6 weeks postoperatively. An evaluation of costs within and outside the healthcare sector will focus on differences in costs between computer-navigated MIS and conventional THA technique.DiscussionBased on studies performed so far, few objective data quantifying the risks and benefits of computer-navigated MIS are available. Therefore, this study has been designed to compare (cost) effectiveness of computer-navigated MIS with a conventional technique for THA. The results of this trial will be presented as soon as they become available.

Cross-cultural adaptation of the Dutch Short Musculoskeletal Function Assessment questionnaire (SMFA-NL) : Internal consistency, validity, repeatability and responsiveness

The purpose of this study was to translate and culturally adapt the Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SMFA-NL) and to investigate the internal consistency, validity, repeatability and responsiveness of the translated version. The original SMFA was first translated and culturally adapted from English into Dutch according to a standardised procedure and subsequently tested for clinimetric quality. The study population consisted of 162 patients treated for various musculoskeletal injuries or disorders at the departments of Orthopedics and Traumatology. All respondents filled in the SMFA-NL and the SF-36 and a region-specific questionnaire. To determine repeatability, 87 respondents filled in the SMFA-NL for a second time after a time interval of three to four weeks. To determine responsiveness, 29 respondents who were treated for their injury within three months before the first assessment filled in the SMFA-NL for a second time after two to three months. The following analyses were performed to evaluate clinimetric quality of the SMFA-NL: factor analysis and Cronbachs alpha (internal consistency), floor and ceiling effects, Spearmans Rho (construct validity), intraclass correlation coefficients and the Bland & Altman method (repeatability), and standardised response means (SRM) (responsiveness). Factor analysis demonstrated four subscales of the SMFA-NL. Both the newly identified subscales of the SMFA-NL and the conventional subscales of the SMFA showed good internal consistency. No floor and some ceiling effects were found. Construct validity was good, as high correlations were found between the subscales of the SMFA-NL and the respective subscales of the SF-36 and the region-specific questionnaires. Repeatability of the SMFA-NL subscales was high, with no systematic bias between first and second assessment. Responsiveness of the SMFA-NL was moderate, as small to moderate SRMs were found. We successfully translated and culturally adapted a Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SFMA-NL). This study shows that the SMFA-NL is a valid, reliable and moderately responsive method for the assessment of functional status of patients who have a broad range of musculoskeletal disorders. Furthermore, it will allow for comparison between different patient groups as well as for cross-cultural comparisons.

Reliability and validity of the Dutch version of the foot and ankle outcome score (FAOS)

BackgroundThe Foot and Ankle Outcome Score (FAOS) is a patient-reported questionnaire measuring symptoms and functional limitations of the foot and ankle. Aim is to translate and culturally adapt the Dutch version of the FAOS and to investigate internal consistency, validity, repeatability and responsiveness.MethodsAccording to the Cross Cultural Adaptation of Self-Report Measures guideline, the FAOS was translated into Dutch. Eighty-nine patients who had undergone an ankle arthroscopy, ankle arthrodesis, ankle ligament reconstruction or hallux valgus correction completed the FAOS, FFI, WOMAC and SF-36 questionnaires and were included in the validity study. Sixty-five of them completed the FAOS a second time to determine repeatability. Responsiveness was analysed in an additional 15 patients who were being treated for foot or ankle problems.ResultsInternal consistency of the FAOS is high (Cronbach’s alphas varying between 0.90 and 0.96). Repeatability can be considered good, with ICC’s ranging from 0.90 to 0.96. Construct validity can be classified as good with moderate-to-high correlations between the FAOS subscales and subscales of the FFI (0.55 to 0.90), WOMAC (0.57 to 0.92) and SF-36 subscales physical functioning, pain, social functioning and role-physical (0.33 to 0.81). Low standard response means were found for responsiveness (0.0 to 0.4).ConclusionsThe results of this study show that the Dutch version of the FAOS is a reliable and valid questionnaire to assess symptoms and functional limitations of the foot and ankle.

Comparison of Gait in Patients Following a Computer-Navigated Minimally Invasive Anterior Approach and a Conventional Posterolateral Approach for Total Hip Arthroplasty : A Randomized Controlled Trial

Minimally invasive total hip arthroplasty (MIS THA) aims at minimizing damage to muscles and tendons to accelerate postoperative recovery. Computer navigation allows a precise prosthesis alignment without complete visualization of the bony landmarks during MIS THA. A randomized controlled trial (RCT) was conducted to determine the effectiveness of a computer‐navigated MIS anterior approach for THA compared to a conventional posterolateral THA technique on the restoration of physical functioning during recovery following surgery. Thirty‐five patients underwent computer‐navigated MIS THA via the anterior approach, and 40 patients underwent conventional THA using the conventional posterolateral approach. Gait analysis was performed preoperatively, 6 weeks, and 3 and 6 months postoperatively using a body‐fixed‐sensor based gait analysis system. Walking speed, step length, cadence, and frontal plane angular movements of the pelvis and thorax were assessed. The same data were obtained from 30 healthy subjects. No differences were found in the recovery of spatiotemporal parameters or in angular movements of the pelvis and thorax following the computer‐navigated MIS anterior approach or the conventional posterolateral approach. Although gait improved after surgery, small differences in several spatiotemporal parameters and angular movements of the trunk remained at 6 months postoperatively between both patient groups and healthy subjects.

After total knee arthroplasty, many people are not active enough to maintain their health and fitness: an observational study

QUESTIONS What proportion of people after total knee arthroplasty adheres to the physical activity regimen recommended for maintenance of health (moderate intensity physical activity for at least 30min on 5 days/week)? What proportion adheres to the activity regimen recommended to improve fitness (vigorous intensity physical activity for at least 20min on 3 days/week)? What factors are associated with adherence to these recommendations? DESIGN An observational study. PARTICIPANTS 830 adults who underwent a total knee arthroplasty between 2002 and 2006 at University Medical Center Gronigen or Martini Hospital Gronigen, the Netherlands. OUTCOME MEASURES The Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) was used to measure the physical activity behaviour of the participants. These data were analysed as adherence to each recommendation. RESULTS The health recommendation was adhered to by 51% of the participants. The fitness recommendation was adhered to by 53% of participants. Almost half (46%) of the participants fulfilled both recommendations, and 42% did not fulfil either recommendation. Males and more educated participants had higher odds of meeting the health, fitness, and both recommendations. Respondents living with family had higher odds of meeting the fitness recommendation. CONCLUSION After total knee arthroplasty, 42% of people are not active enough to maintain their health and fitness. Physiotherapists should encourage people with a total knee arthroplasty to undertake the recommended exercise regimens to maintain health and fitness, with particular attention to those people with characteristics known to be associated with poor adherence to the recommendations.

Assessment of Prosthesis Alignment after Revision Total Knee Arthroplasty Using EOS 2D and 3D Imaging: A Reliability Study

Introduction A new low-dose X-ray device, called EOS, has been introduced for determining lower-limb alignment in 2D and 3D. Reliability has not yet been assessed when using EOS on lower limbs containing a knee prosthesis. Therefore purpose of this study was to determine intraobserver and interobserver reliability of EOS 2D and 3D knee prosthesis alignment measurements after revision total knee arthroplasty (rTKA). Methods Forty anteroposterior and lateral images of 37 rTKA patients were included. Two observers independently performed measurements on these images twice. Varus/valgus angles were measured in 2D (VV2D) and 3D (VV3D). Intraclass correlation coefficients and the Bland and Altman method were used to determine reliability. T-tests were used to test potential differences. Results Intraobserver and interobserver reliability were excellent for VV2D and VV3D. No significant difference or bias between the first and second measurements or the two observers was found. A significant mean and absolute difference of respectively 1.00° and 1.61° existed between 2D and 3D measurements. Conclusions EOS provides reliable varus/valgus measurements in 2D and 3D for the alignment of the knee joint with a knee prosthesis. However, significant differences exist between varus/valgus measurements in 2D and 3D.

Physical Activity Participation Among Patients After Total Hip and Knee Arthroplasty

Total hip (THA) and knee arthroplasty (TKA) are successful operative interventions, yet little is known about the physical activity behavior of patients after THA/TKA. For older adults, there are beneficial effects of regular physical activity after THA/TKA. The objective of this paper is to review the benefits of physical activity after THA/TKA, the potential negative consequences of physical activity on hip or knee prosthesis, the measurement of physical activity, physical activity behavior, and the current opinion of health care professionals regarding types of physical activities recommended for patients after THA/TKA.