Max Reijman

The Dutch version of the knee injury and osteoarthritis outcome score: A validation study

BackgroundThe Knee Injury and Osteoarthritis Outcome Score (KOOS) was constructed in Sweden. This questionnaire has proved to be valid for several orthopedic interventions of the knee. It has been formally translated and validated in several languages, but not yet in Dutch. The purpose of the present study was to evaluate the clinimetric properties of the Dutch version of the KOOS questionnaire in knee patients with various stages of osteoarthritis (OA).MethodsThe Swedish version of the KOOS questionnaire was first translated into Dutch according to a standardized procedure and second tested for clinimetric quality. The study population consisted of patients with different stages of OA (mild, moderate and severe) and of patients after primary TKA, and after a revision of the TKA. All patients filled in the Dutch KOOS questionnaire, as well as the SF-36 and a Visual Analogue Scale for pain. The following analyses were performed to evaluate the clinimetric quality of the KOOS: Cronbachs alpha (internal consistency), principal component analyses (factor analysis), intraclass correlation coefficients (reliability), spearmans correlation coefficient (construct validity), and floor and ceiling effects.ResultsFor all patients groups Cronbachs alpha was for all subscales above 0.70. The ICCs, assessed for the patient groups with mild and moderate OA and after revision of the TKA patients, were above 0.70 for all subscales. Of the predefined hypotheses 60% or more could be confirmed for the patients with mild and moderate OA and for the TKA patients. For the other patient groups less than 45% could be confirmed. Ceiling effects were present in the mild OA group for the subscales Pain, Symptoms and ADL and for the subscale Sport/Recreation in the severe OA group. Floor effects were found for the subscales Sport/Recreation and Qol in the severe OA and revision TKA groups.ConclusionBased on these different clinimetric properties within the present study we conclude that the KOOS questionnaire seems to be suitable for patients with mild and moderate OA and for patients with a primary TKA. The Dutch version of the KOOS had a lower construct validity for patients with severe OA on a waiting list for TKA and patients after revision of a TKA. Further validation studies on the Dutch version of the KOOS should also include a knee specific questionnaire for assessing the construct validity.

Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review.

OBJECTIVESnRecently, numerous studies have reported that psychological factors can influence the outcome of total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, a systematic overview is missing. The objective of this study was to examine which psychological factors influence the outcome of TKA and THA and to what extent.nnnMETHODSnData were obtained from the MEDLINE and EMBASE databases from inception to January 2011. Search terms included TKA and THA, outcome measures, and psychological aspects. Two reviewers independently selected the studies. Studies with a prospective before-after design with a minimum follow-up time of 6 weeks were included. One reviewer extracted the results and 2 reviewers independently conducted quality assessment. We distinguished between follow-up shorter and equal or longer than 1 year.nnnRESULTSnThirty-five of 1837 studies met the inclusion criteria and were included in this systematic review. In follow-ups shorter than 1 year, and for knee patients only, strong evidence was found that patients with pain catastrophizing reported more pain postoperatively. Furthermore, strong evidence was found that preoperative depression had no influence on postoperative functioning. In long-term follow-up, 1 year after TKA, strong evidence was found that lower preoperative mental health (measures with the SF-12 or SF-36) was associated with lower scores on function and pain. For THA, only limited, conflicting, or no evidence was found.nnnCONCLUSIONSnLow preoperative mental health and pain catastrophizing have an influence on outcome after TKA. With regard to the influence of other psychological factors and for hip patients, only limited, conflicting, or no evidence was found.

Recovery of Physical Functioning After Total Hip Arthroplasty: Systematic Review and Meta-Analysis of the Literature

Background After total hip arthroplasty (THA), patients today (who tend to be younger and more active than those who previously underwent this surgical procedure) have high expectations regarding functional outcome. Therefore, patients need to be well informed about recovery of physical functioning after THA. Purpose The purpose of this study was to review publications on recovery of physical functioning after THA and examine the degree of recovery with regard to 3 aspects of functioning (ie, perceived physical functioning, functional capacity to perform activities, and actual daily activity in the home situation). Data Sources Data were obtained from the MEDLINE and EMBASE databases from inception to July 2009, and references in identified articles were tracked. Study Selection Prospective studies with a before-after design were included. Patients included in the analysis had to have primary THA for osteoarthritis. Data Extraction and Synthesis Two reviewers independently checked the inclusion criteria, conducted the risk of bias assessment, and extracted the results. Data were pooled in a meta-analysis using a random-effects model. Results A total of 31 studies were included. For perceived physical functioning, patients recovered from less than 50% preoperatively to about 80% of that of controls (individuals who were healthy) 6 to 8 months postsurgery. On functional capacity, patients recovered from 70% preoperatively to about 80% of that of controls 6 to 8 months postsurgery. For actual daily activity, patients recovered from 80% preoperatively to 84% of that of controls at 6 months postsurgery. Limitations Only a few studies were retrieved that investigated the recovery of physical functioning longer than 8 months after surgery. Conclusions Compared with the preoperative situation, the 3 aspects of physical functioning showed varying degrees of recovery after surgery. At 6 to 8 months postoperatively, physical functioning had generally recovered to about 80% of that of controls.

Medial Knee Osteoarthritis Treated by Insoles or Braces: A Randomized Trial

Background There is controversial evidence regarding whether foot orthoses or knee braces improve pain and function or correct malalignment in selected patients with osteoarthritis (OA) of the medial knee compartment. However, insoles are safe and less costly than knee bracing if they relieve pain or improve function.Questions/purposesWe therefore asked whether laterally wedged insoles or valgus braces would reduce pain, enhance functional scores, and correct varus malalignment comparable to knee braces.Patients and MethodsWe prospectively enrolled 91 patients with symptomatic medial compartmental knee OA and randomized to treatment with either a 10-mm laterally wedged insole (index group, nxa0=xa045) or a valgus brace (control group, nxa0=xa046). All patients were assessed at 6xa0months. The primary outcome measure was pain severity as measured on a visual analog scale. Secondary outcome measures were knee function score using WOMAC and correction of varus alignment on AP whole-leg radiographs taken with the patient in the standing position. Additionally, we compared the percentage of responders according to the OMERACT-OARSI criteria for both groups.ResultsWe observed no differences in pain or WOMAC scores between the two groups. Neither device achieved correction of knee varus malalignment in the frontal plane. According to the OMERACT-OARSI criteria, 17% of our patients responded to the allocated intervention. Patients in the insole group complied better with their intervention. Although subgroup analysis results should be translated into practice cautiously, we observed a slightly higher percentage of responders for the insole compared with bracing for patients with mild medial OA.ConclusionsOur data suggest a laterally wedged insole may be an alternative to valgus bracing for noninvasively treating symptoms of medial knee OA.Level of Evidence Level I, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

Opposite cortical fracture in high tibial osteotomy: lateral closing compared to the medial opening-wedge technique

Background and purposeu2003The aim with high tibial valgus osteotomy (HTO) is to correct the mechanical axis in medial compartmental osteoarthritis of the knee. Loss of operative correction may threaten the long‐term outcome. In both a lateral closing‐wedge procedure and a medial opening‐wedge procedure, the opposite cortex of the tibia is usually not osteotomized, leaving 1 cm of bone intact as fulcrum. A fracture of this cortex may, however, lead to loss of correction; this was examined in the present study. Patients and methodsu2003We used a prospective cohort of 92 consecutive patients previously reported by Brouwer et al. (). The goal in that randomized controlled trial, was to achieve a correction of 4 degrees in excess of physiological valgus. In retrospect, we evaluated the 1‐year radiographic effect of opposite cortical fracture. Opposite cortical fracture was identified on the postero‐anterior radiographs in supine position on the first day after surgery. Resultsu200344 patients with a closing‐wedge HTO (staples and cast fixation) and 43 patients with an opening‐wedge HTO (non‐angular‐stable plate fixation) were used for analysis. 36 patients (four‐fifths) in the closing‐wedge group and 15 patients (one‐third) in the opening‐wedge group had an opposite cortical fracture (p < 0.001). At 1 year, the closing‐wedge group with opposite cortical fracture had a valgus position with a mean HKA angle of 3.2 (SD 3.5) degrees of valgus. However, the opening‐wedge group with disruption of the opposite cortex achieved varus malalignment with a mean HKA angle of 0.9 (SD 6.6) degrees of varus. Interpretationu2003Fracture of the opposite cortex is more common for the lateral closing wedge technique. Medial cortex disruption has no major consequences, however, and does not generally lead to malalignment. Lateral cortex fracture in the medial opening‐wedge technique, with the use of a non‐angular stable plate, leads more often to varus malalignment.

Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: a randomized controlled trial with a six-year follow-up.

BACKGROUNDnVarus deformity increases the risk of progression of medial compartment knee osteoarthritis. The aim of this study was to investigate the clinical and radiographic mid-term results of closing-wedge and opening-wedge high tibial osteotomy when used to treat this condition.nnnMETHODSnFrom January 2001 to April 2004, ninety-two patients were randomized to receive either a closing-wedge or an opening-wedge high tibial osteotomy. The clinical outcome and radiographic results were examined preoperatively; at one year; and, for the present study, at six years postoperatively. The outcomes that we reviewed included maintenance of the achieved correction, progression of osteoarthritis (based on the Kellgren and Lawrence classification), severity of pain (as assessed on a visual analog scale [VAS]), knee function (as measured with the Hospital for Special Surgery [HSS] score and Knee injury and Osteoarthritis Outcome Score [KOOS]), walking distance, complications, and survival with conversion to a total knee arthroplasty as the end point. The results were analyzed on the basis of the intention-to-treat principle.nnnRESULTSnSix years postoperatively, the mean hip-knee-ankle (HKA) angle (and standard deviation) was 3.2° ± 4.1° of valgus after a closing-wedge high tibial osteotomy and 1.3° ± 5.0° of valgus after an opening-wedge high tibial osteotomy (p = 0.343). In both groups, the six-year postoperative HKA angles did not differ from the respective one-year postoperative angles. No difference in the severity of pain or in knee function was found between the two groups. Four complications (9%) occurred in the closing-wedge group and seventeen (38%), in the opening-wedge group. Ten (22%) of the patients in the closing-wedge group and three (8%) in the opening-wedge group needed conversion to a total knee arthroplasty within the six-year period (p = 0.05). The difference in the percentage of cases with conversion to total knee arthroplasty was 14% (95% confidence interval [CI] = 21.7 to 0.2).nnnCONCLUSIONSnIn the group of patients without conversion to a total knee arthroplasty, there was no difference between the high tibial closing-wedge and opening-wedge osteotomies in terms of clinical outcomes or radiographic alignment at six years postoperatively. Opening-wedge osteotomy was associated with more complications, but closing-wedge osteotomy was associated with more early conversions to total knee arthroplasty.nnnLEVEL OF EVIDENCEnTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: Reliability of standard radiographs, CT scans, and 3D virtual reality images

Background and purpose Non-anatomic bone tunnel placement is the most common cause of a failed ACL reconstruction. Accurate and reproducible methods to visualize and document bone tunnel placement are therefore important. We evaluated the reliability of standard radiographs, CT scans, and a 3-dimensional (3D) virtual reality (VR) approach in visualizing and measuring ACL reconstruction bone tunnel placement. Methods 50 consecutive patients who underwent single-bundle ACL reconstructions were evaluated postoperatively by standard radiographs, CT scans, and 3D VR images. Tibial and femoral tunnel positions were measured by 2 observers using the traditional methods of Amis, Aglietti, Hoser, Stäubli, and the method of Benereau for the VR approach. Results The tunnel was visualized in 50–82% of the standard radiographs and in 100% of the CT scans and 3D VR images. Using the intraclass correlation coefficient (ICC), the inter- and intraobserver agreement was between 0.39 and 0.83 for the standard femoral and tibial radiographs. CT scans showed an ICC range of 0.49–0.76 for the inter- and intraobserver agreement. The agreement in 3D VR was almost perfect, with an ICC of 0.83 for the femur and 0.95 for the tibia. Interpretation CT scans and 3D VR images are more reliable in assessing postoperative bone tunnel placement following ACL reconstruction than standard radiographs.

Total knee arthroplasty after high tibial osteotomy. A systematic review

BackgroundPrevious osteotomy may compromise subsequent knee replacement, but no guidelines considering knee arthroplasty after prior osteotomy have been developed. We describe a systematic review of non-randomized studies to analyze the effect of high tibial osteotomy on total knee arthroplasty.MethodsA computerized search for relevant studies published up to September 2007 was performed in Medline and Embase using a search strategy that is highly sensitive to find nonrandomized studies. Included were observational studies in which patients had total knee arthroplasty performed after prior high tibial osteotomy. Studies that fulfilled these criteria, were assessed for methodologic quality by two independent reviewers using the critical appraisal of observational studies developed by Deeks and the MINORS instrument. The study characteristics and data on the intervention, follow-up, and outcome measures, were extracted using a pre-tested standardized form. Primary outcomes were: knee range of motion, knee clinical score, and revision surgery. The grade of evidence was determined using the guidelines of the GRADE working group.ResultsOf the 458 articles identified using our search strategy, 17 met the inclusion criteria. Fifteen studies were cohort study with a concurrent control group, one was a historical cohort study and one a case-control study. Nine studies scored 50% or more on both methodological quality assessments. Pooling of the results was not possible due to the heterogeneity of the studies, and our analysis could not raise the overall low quality of evidence. No significant differences between primary total knee arthroplasty and total knee arthroplasty after osteotomy were found for knee range of motion in four out of six studies, knee clinical scores in eight out of nine studies, and revision surgery in eight out of eight studies after a median follow-up of 5 years.ConclusionOur analysis suggests that osteotomy does not compromise subsequent knee replacement. However, the low quality of evidence precludes solid clinical conclusions.

Physical functioning four years after total hip and knee arthroplasty.

Our previous study showed that 6 months after total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients reported having less difficulty with daily activities, showed better functional capacity, and performed activities in their natural environment faster compared to preoperatively. However, their actual daily activity level was not significantly improved. Six months is a rather short follow-up period and the discrepancy in recovery among different aspects of functioning might be explained by this limited duration of follow-up. The objective of the present study was to examine the recovery of different aspects of physical functioning at a follow-up nearly 4 years after THA/TKA. Special attention was given to the actual daily activity level, and whether it had increased 4 years after THA/TKA compared to 6 months postoperatively. Seventy-seven (35 hip, 42 knee) patients who were measured preoperatively and postoperatively (6 months after surgery) in a previous study were invited to participate; 44 patients (23 hip, 21 knee) agreed to participate. The 4-year follow-up data were compared with the preoperative and 6-month postoperative data. The daily activity level after 4 years was found to be actually lower than at 6 months post-surgery (128 min vs. 138 min activity per 24h; p-value 0.48). However, the patients continued to improve in other aspects of physical functioning. In conclusion, 4-year post-surgery patients continued to improve on perceived physical functioning, capacity, and performance of activities in daily life. However, even in this relatively healthy study population, patients did not adopt a more active lifestyle 4 years after surgery.

Is T1ρ Mapping an Alternative to Delayed Gadolinium-enhanced MR Imaging of Cartilage in the Assessment of Sulphated Glycosaminoglycan Content in Human Osteoarthritic Knees? An in Vivo Validation Study

PURPOSEnTo determine if T1ρ mapping can be used as an alternative to delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) in the quantification of cartilage biochemical composition in vivo in human knees with osteoarthritis.nnnMATERIALS AND METHODSnThis study was approved by the institutional review board. Written informed consent was obtained from all participants. Twelve patients with knee osteoarthritis underwent dGEMRIC and T1ρ mapping at 3.0 T before undergoing total knee replacement. Outcomes of dGEMRIC and T1ρ mapping were calculated in six cartilage regions of interest. Femoral and tibial cartilages were harvested during total knee replacement. Cartilage sulphated glycosaminoglycan (sGAG) and collagen content were assessed with dimethylmethylene blue and hydroxyproline assays, respectively. A four-dimensional multivariate mixed-effects model was used to simultaneously assess the correlation between outcomes of dGEMRIC and T1ρ mapping and the sGAG and collagen content of the articular cartilage.nnnRESULTSnT1 relaxation times at dGEMRIC showed strong correlation with cartilage sGAG content (r = 0.73; 95% credibility interval [CI] = 0.60, 0.83) and weak correlation with cartilage collagen content (r = 0.40; 95% CI: 0.18, 0.58). T1ρ relaxation times did not correlate with cartilage sGAG content (r = 0.04; 95% CI: -0.21, 0.28) or collagen content (r = -0.05; 95% CI = -0.31, 0.20).nnnCONCLUSIONndGEMRIC can help accurately measure cartilage sGAG content in vivo in patients with knee osteoarthritis, whereas T1ρ mapping does not appear suitable for this purpose. Although the technique is not completely sGAG specific and requires a contrast agent, dGEMRIC is a validated and robust method for quantifying cartilage sGAG content in human osteoarthritis subjects in clinical research.