Paul Hoogervorst

Translation and validation of the German version of the foot and ankle outcome score

PurposeOutcome assessment is critical in evaluating the efficacy of orthopaedic procedures. The Foot and Ankle Outcome Score (FAOS) is a 42-item questionnaire divided into five subscales, which has been validated in several languages. Germany has no validated outcome score for general foot and ankle pathology. The aim of this study was to develop a German version of the FAOS and to investigate its psychometric properties.Materials and methodsForward and backward translation was executed according to official guidelines. The final version of the FAOS was investigated in 150 patients with various foot and ankle disorders. All patients completed the FAOS, Short Form-36, numeric rating scales for pain and disability, and the Hannover questionnaire. The FAOS was re-administered after 1 week. Test–retest reliability, internal consistency, minimal detectable change, construct validity, and floor and ceiling effects were analyzed.ResultsTest–retest reliability and internal consistency of each subscale were excellent (intraclass correlation coefficient, 0.88–0.95; Cronbach’s α, 0.94–0.98). The minimal detectable changes of each subscale were 17.1–20.8 at the individual level and 2.0–2.4 at group level. There were moderate to strong correlations between FAOS subscales and physical outcomes and low to moderate correlations between FAOS subscales and mental outcomes. Floor and ceiling effects were not present.ConclusionThe German version of the FAOS is a reliable and valid instrument for use in foot and ankle patients.

Is etoricoxib effective in preventing heterotopic ossification after primary total hip arthroplasty

PurposeHeterotopic ossification is a common complication after total hip arthroplasty. Non-steroidal anti-inflammatory drugs (NSAIDs) are known to prevent heterotopic ossifications effectively, however gastrointestinal complaints are reported frequently. In this study, we investigated whether etoricoxib, a selective cyclo-oxygenase-2 (COX-2) inhibitor that produces fewer gastrointestinal side effects, is an effective alternative for the prevention of heterotopic ossification.MethodsWe investigated the effectiveness of oral etoricoxib 90xa0mg for sevenxa0days in a prospective two-stage study design for phase-2 clinical trials in a small sample of patients (nu2009=u200942). A cemented primary total hip arthroplasty was implanted for osteoarthritis. Six months after surgery, heterotopic ossification was determined on anteroposterior pelvic radiographs using the Brooker classification.ResultsNo heterotopic ossification was found in 62xa0% of the patients that took etoricoxib; 31xa0% of the patients had Brooker grade 1 and 7xa0% Brooker grade 2 ossification.ConclusionsEtoricoxib seems effective in preventing heterotopic ossification after total hip arthroplasty. This finding further supports the use of COX-2 inhibitors for the prevention of heterotopic ossification following total hip arthroplasty.

A 21 % conversion rate to total knee arthroplasty of a first-generation patellofemoral prosthesis at a mean follow-up of 9.7 years

PurposeTo evaluate the mid- to long-term results of the Richards’ type II patellofemoral arthroplasty (PFA) in terms of functional scores, number and type of complications, patient satisfaction and survival.MethodsWe retrospectively studied patients that received a Richards’ type II PFA at our institution between 1998 and 2007. Patients with a functioning PFA at the time of this study were evaluated. Outcomes included survival rates with endpoint loss of prosthesis, number and type of complications, Knee Society Scores (KSS) and Visual Analogue Scale (VAS) for pain. In addition, patients were asked how surgery influenced their original symptoms.ResultsTwenty-four patients (33 prostheses) were included. Follow-up ranged from 2.2 to 18.8xa0years with a mean of 9.7xa0years. Survival at 10xa0years was 73xa0% (95xa0% CI, 57–93xa0%). Median KSS score was 163 (range, 110–200). Median VAS Pain was 30 (range, 0–80) and VAS Satisfaction median was 90 (range, 50–100). Thirteen (62xa0%) PFAs were rated excellent, six (28xa0%) as good and two (10xa0%) as fair. Twelve (36xa0%) of the cases required further surgery within 4xa0years after implantation. Seven of these (21xa0%) were converted to TKA after a mean time of 5.5xa0years, five out of seven were converted because of ongoing tibiofemoral osteoarthritis (TFOA).ConclusionsWe found a rate of 21xa0% (7/33) conversion of the Richards’ II PFA to TKA after a mean of 5.5xa0years; 71xa0% (5/7) of cases were because of TFOA. We strongly advise not to use PFA if there is any sign of joint disease in other compartments than patellofemoral.

Pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture.

A pseudo-arthrosis repair of a 4-year-old bony avulsion fracture of the PCL using a minimally invasive technique, screw fixation, and bone grafting is reported. The case presented seems to be rather unique due to the fragment size and the approach for pseudo-arthrosis repair. There was a good functional result following minimally invasive pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture. There are no previous reports of similar pseudo-arthrosis repairs, and other authors report good results of delayed refixation of PCL avulsion fractures. Therefore, refixation and pseudo-arthrosis repair should be considered as a viable treatment.

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly.

Purpose of ReviewTreatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.Recent FindingsTreatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.SummaryAn optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.

The Burden of High-Energy Musculoskeletal Trauma in High-Income Countries

Introduction to the problem Though declining in the recent decades, high-energy musculoskeletal trauma remains a major contributor to the burden of disease in high-income countries (HICs). However, due to limitations in the available body of the literature, evaluation of this burden is challenging. The purpose of this review is to assess: (1) the current epidemiologic data on the surgical burden of high-energy musculoskeletal trauma in HICs; (2) the current data on the economic impact of high-energy musculoskeletal trauma; and (3) potential strategies for addressing gaps in musculoskeletal trauma care for the future. Review of literature In 2016, mortality from road traffic injuries (RTIs) between the ages of 15–49 was reported to be 9.5% (9.0–9.9) in high-income countries, accounting for approximately 255xa0million DALYs. While RTIs do not fully capture the extent of high-energy musculoskeletal trauma, as the most common mechanism, they serve as a useful indicator of the impact on the surgical and economic burden. In 2009, the global losses related to RTIs were estimated to be 518 billion USD, costing governments between 1 and 3% of their gross domestic product (GDP). In the last decade, both the total direct per-person healthcare cost and the incremental direct per-person costs for those with a musculoskeletal injury in the USA rose 75 and 58%, respectively. Future directions: addressing the gaps While its impact is large, research on musculoskeletal conditions, including high-energy trauma, is underfunded compared to other fields of medicine. An increased awareness among policy makers and healthcare professionals of the importance of care for the high-energy musculoskeletal trauma patient is critical. Full implementation of trauma systems is imperative, and metrics such as the ICD–DALY have the potential to allow for real-time evaluation of prevention and treatment programs aimed to reduce injury-related morbidity and mortality. The dearth in knowledge in optimal and cost-effective post-acute care for high-energy musculoskeletal trauma is a reason for concern, especially since almost half of the costs are attributed to this phase of care. Multidisciplinary rehabilitation teams as part of a musculoskeletal trauma system may be of interest to decrease further the long-term negative effects and the economic burden of high-energy musculoskeletal trauma.

Does altering projection of the fractured clavicle change treatment strategy

BACKGROUNDnShortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy.nnnMETHODSnThirty-six AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment.nnnRESULTSnOn average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (Pu2009=u2009.01).nnnCONCLUSIONnThis study reveals the influence the projection of the midshaft clavicular fracture has on the surgeons decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.

Influence of x-ray direction on measuring shortening of the fractured clavicle

BACKGROUNDnMidshaft clavicle fractures are often associated with a certain degree of shortening. There is great variety in the imaging techniques and methods to quantify this shortening. This study aims to quantify the difference in measurements of shortening and length of fracture elements between 5 views of the fractured clavicle. Furthermore, the interobserver and intraobserver agreement between these views using a standardized method is evaluated.nnnMATERIALS AND METHODSnDigitally reconstructed radiographs were created for 40 computed tomography datasets in the anteroposterior (AP), 15° and 30° craniocaudal, and 15° and 30° caudocranial views. A standardized method for measuring the length of fracture elements and the amount of shortening was used. Interobserver and intraobserver agreement for each of the 5 views was calculated.nnnRESULTSnThe interobserver and intraobserver agreement was excellent for all 5 views, with all intraclass correlation coefficient values greater than 0.75. The measured differences in relative and absolute shortening between views were statistically significant between the 30° caudocranial view and all other views. The increase in median shortening measured between the commonly used 30° caudocranial view (2.7u2009mm) and the AP view (8.5u2009mm) was 5.8u2009mm (Pu2009<u2009.001). The relative median shortening between these views increased by 3.5% (Pu2009<u2009.001).nnnCONCLUSIONnThe length of fracture elements and the amount of shortening in the fractured clavicle can be reliably measured using a standardized method. The increase in absolute and relative shortening when comparing the caudocranial measurements with the AP and craniocaudal measurements may indicate that the AP and craniocaudal views provide a more accurate representation of the degree of shortening.

In Vivo CT Analysis of Physiological Fibular Motion at the Level of the Ankle Syndesmosis During Plantigrade Weightbearing

Background. It is clear that motion at the syndesmosis occurs due to ranging of the ankle joint, but the influence of weightbearing with the foot in the plantigrade position is unclear. In vivo computed tomographic (CT) evaluation of the syndesmosis has not been previously described. The purpose of this study is to quantify physiological fibular motion at the level of the ankle syndesmosis in both weightbearing and nonweightbearing conditions with the foot in the plantigrade position. Methods. CT images were obtained from 9 normal healthy subjects using a weightbearing CT imaging system. The subjects were positioned in a nonweightbearing and weightbearing state with their foot in the plantigrade position. Fibular translation and rotation were measured from the axial CT images using previously validated techniques. Results. Both the average lateral and anteroposterior translation of the fibula between weightbearing and nonweightbearing states was minimal (0.3 mm and 0.2 mm, respectively). The largest difference in translation observed in either direction was 0.9 mm. An average of 0.5° was found for rotational differences of the fibula between weightbearing and nonweightbearing. Neither of the translational and rotational parameters reached statistical significance. Conclusion. In vivo CT analysis of the distal tibiofibular joint with an intact syndesmosis did not reveal statistically significant physiological motion between weightbearing and nonweightbearing conditions with the foot in plantigrade position. Our findings suggest that weightbearing accounts for little motion at the syndesmosis and supports further investigation into the role of early protected weightbearing after syndesmosis fixation. Levels of Evidence: Level III: Case-control study

Midshaft clavicle fractures

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures. Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous. However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar. The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model. Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033