Patient satisfaction after total knee replacement—still a challenge

During a validation process of the Swedish Knee Arthroplasty Register (SKAR), living registered patients were sent a questionnaire to ask if they had been reoperated on. This gave an opportunity to pose a simple four-point question with respect to patient satisfaction which 95% of patients answered. We analyzed the answers of patients operated on between 1981 and 1995 and found that only 8% of the patients were dissatisfied regarding their knee arthroplasty 2–17 years postoperatively. The satisfaction rate was constant, regardless of when the operation had been performed during the 15-year period. The proportion of satisfied patients was affected by the preoperative diagnosis, patients operated on for a long-standing disease more often being satisfied than those with a short disease-duration. There was no difference in proportions of satisfied patients, whether they had primarily been operated on with a total knee arthroplasty (TKA) or a medial unicompartmental arthroplasty (UKA). For TKAs performed with primary patellar resurfacing, there was a higher ratio of satisfied patients than for TKAs not resurfaced, but this increased ratio diminished with time passed since the primary operation. Unrevised knees had a higher proportion of satisfied patients than knees that had been subject to revision, and among patients revised for medial UKA, the proportion of satisfied patients was higher than among patients revised for TKA. We conclude that satisfaction after knee arthroplasty is stable and long-lasting in unrevised cases and that even after revision most patients are satisfied

Heupfracturen zo snel mogelijk opereren

A recent retrospective study in the Netherlands found no significant association between delayed hip fracture surgery and the occurrence of complications. This argues against the use of the Dutch hospital quality indicator measuring the percentage of patients with hip fracture operated within 24 to 48 hours. However, much larger international prospective studies have shown that delaying surgery results in prolonged duration of pain and hospitalisation and increased rate of complications. There is no evidence that delaying surgery is beneficial for the patient. Therefore, the current Dutch hospital quality indicator for timely initiation of treatment for hip fractures should remain unchanged in the interest of this fragile patient group

Wat is er bekend over de werkzaamheid van 'Sonocur Plus'?

Letter by Dalhuisen with a response from Verhaa

Prognose van de totaleheupprothese

The prognosis of total hip arthroplasty is excellent and as many publications show, the survival of a good type of implant is well above 90 per cent at the 10-year follow-up. The results of the average orthopaedic surgeon may not match those obtained by the experts who have published these results. Therefore, in 1979 a prospective multicentre study was started in Sweden to evaluate the outcome of total hip arthroplasty. This National Hip Register has shown that the outcome is related to type of prosthesis, patient selection and operative technique. The results from one orthopaedic department to another differed considerably. The feedback from the Register resulted in improvements of the overall outcome and decrease of the differences between the orthopaedic departments in Sweden A Dutch National Implant Register is needed

Failure load of patellar tendon grafts at the femoral side: 10- versus 20-mm-bone blocks

The aim of the study was to investigate whether use of short bone blocks is safe in anterior cruciate ligament (ACL) reconstruction. Our hypothesis was that the smaller 10-mm-length bone blocks will fail at lower loads than 20-mm-bone blocks. Ten paired human cadaver knees were randomly assigned to the 10- or 20-mm group (group 1 and 2) and underwent bone-patellar tendon-bone femoral fixation with interference screw. Tensile tests were performed using a tensile testing machine (Instron). Stiffness, failure load and failure mode were recorded. Median stiffness was 72 N/mm (16-103) for 10-mm-bone blocks and 91 N/mm (40-130) for 20-mm-bone blocks. Median failure loads were 402 N (87-546) for 10-mm-long bone block and 456 N (163-636) for 20-mm-bone blocks. There was no statistically significant difference between groups (P = 0.35). All bone-patellar tendon-bone grafts were pulled out of the femoral tunnel with interference screw, due to slippage. We concluded that a 10-mm-long bone block was not significantly weaker than a 20-mm-long bone block. Failure loads of a 10-mm-bone block exceeded loading values at passive and active extension of the knee under normal conditions. Ten millimetre bone blocks offered sufficient fixation strength in ACL reconstruction

Total knee arthroplasty after high tibial osteotomy. A systematic review

Background: Previous 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. Methods: A 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. Results: Of 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. Conclusion: Our analysis suggests that osteotomy does not compromise subsequent knee replacement. However, the low quality of evidence precludes solid clinical conclusions

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