Maart 2014, Vol. 21, Nummer 1. Nederlands Tijdschrift voor. rthopaedie. Officieel orgaan van de Nederlandse Orthopaedische Vereniging

Maart 2014, Vol. 21, Nummer 1

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NederlandsTijdschrift voor

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Officieel orgaan van de

Nederlandse Orthopaedische Vereniging

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England and Wales: The 21,170 Triathlon knees reported in the 2012 NJR have the lowest revision rate of the top 5 brands (1.65% at 5 years)1. Sweden: The 2,951 Triathlon knees reported in the Swedish Knee Arthroplasty Register have the lowest relative risk of revision at 0.49% of all brands2. New Zealand: The 1,616 Triathlon knees reported in the 2011 registry have the joint lowest revision rate of the top 5 brands3.

1/ England and Wales National Joint Registry 2012. 2/ Swedish Knee Arthroplasty Register Annual Report 2012. 3/ The New Zealand Joint Registry Report 2011.

This communication is strictly intended for healthcare practitioners and should not be distributed to patients. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. The products depicted are CE marked according to the Medical Device Directive 93/42/EEC. Products may not be available in all markets because product availability is subject to the regulatory and/ or medical practices in individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate afﬁliated entities own, use or have applied for the following trademarks or service marks: Stryker, Triathlon. All other trademarks are trademarks of their respective owners or holders. The products listed above are CE marked according to European Medical Device Directive. This material is not intended for distribution outside the EU and EFTA. TRIATH-POS-13

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oorwoord Soms zijn dingen niet zo als ze lijken. Soms zitten er haken en ogen aan ogenschijnlijk duidelijke gebeurtenissen. Soms hebben voordelen ook nadelen. De bergen goud die in Sochi werden gewonnen hebben wellicht een groot nadeel: de lange afstanden van het langebaan schaatsen zullen van het programma verdwijnen als we de internationale schaatsbobo (overigens afkomstig uit het kunstrijden) mogen geloven. Nederland wordt de te kloppen partij, aldus de chef de mission van deze gouden lichting. In de bespreking van het proefschrift van Jose Smolders over de hip resurfacing worden de gouden bergen en de gouden standaard van elkaar onderscheiden. Zaken die aanvankelijk prachtig leken, laten nu al enkele jaren de keerzijde van die medaille zien. In de opleiding tot orthopedisch chirurg was de toekomst ook geschreven met gouden letters: de bevolking vergrijst, kwaliteit van leven in het ouder worden is een groot goed en wie is nu eigenlijk de aangewezen medisch specialist om ook de ouder wordende mens in beweging te houden? Maar met de crisis vervaagden deze feiten en zijn de gouden bergen die deze gezondheidszorg kost gesmolten en is er een overschot aan jonge klaren. In 2014 moeten er bergen maatregelen genomen worden om het tot voorheen vanzelfsprekende ondernemerschap in de zorg veilig te stellen. Creatief als wij Nederlanders zijn, gaan wij deze uitdagingen te lijf: we gaan ons specialiseren in de massastart bij de langere afstanden en volgen de ploegentactiek die bij het marathonschaatsen al zo gewoon is, we kondigden als eersten in de wereld een pas op de plaats af bij het resurfacen van de heup, de Taskforce Jonge Klaren beraamde een actieplan en de nieuwe voorzitter Koot wil graag aan tafel met de bankiers en Bos. We laten met de LROI-Rapportage 2012 zien hoe de dingen zijn en niet hoe ze lijken, dat haken en ogen ook een houvast kunnen betekenen en dat sommige nadelen ook voordelen hebben. Zo zijn de voor(oor)delen dat een inzending aan het NTVO een geheide publicatie betekent ondertussen ten nadele voor de inzendende auteurs aan het veranderen. De redactieraad is blij te kunnen melden dat er tegenwoordig steeds kritischer gekeken kan worden naar de manuscripten. Deze tegenstrijdige bewering is een uiting van een verhoging van de kwantiteit van de inzendingen en komt de kwaliteit van ons tijdschrift ten goede. Uiteraard ga ik u geen gouden bergen beloven over een eventuele indexering, want kwaliteit gaat aan medailles vooraf, maar is er geen garantie voor.

Maart 2014, Vol. 21, Nummer 1

Inhoud Voorwoord Taco Gosens

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Good results of a thoracic doublehook claw construct in 40 consecutive adolescent idiopathic scoliosis patients Paul de Baat and Luuk W.L. de Klerk

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Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen

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Total Elbow Arthroplasty after Trauma - case report and review of the literature Dirk E. Schrander, Wouter Gronheid and Aart D. Verburg

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Intramuscular hemangioma of the extremities - a case report and review of the literature Stijn E.W. Geraets, Anneke A.M. van der Wurff and Taco Gosens

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Proefschriftbespreking Koen Bos

28

Van de Vereniging

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Dr. Taco Gosens, hoofdredacteur i Voor sommige artikelen is additioneel materiaal beschikbaar op de website www.ntv-orthopaedie.nl, waaronder kleurenfoto’s en/of videobeelden. Deze artikelen zijn herkenbaar aan de volgende pictogrammen: Kleurenfoto's Videobeelden

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REDACTIE Dr. Taco Gosens, hoofdredacteur Dr. Harmen B. Ettema Dr. Wouter L.W. van Hemert Dr. Hans (J).G.E. Hendriks Dr. Loes Janssen Dr. Job L.C. van Susante CORRECTOREN Mw. Sue Morrenhof-Atkinson Dr. Ernst L.F.B. Raaymakers REVIEWERS Bas Bosmans Alex W.F.M. Fiévez Dr. Taco Gosens Prof. dr. Marinus de Kleuver Dr. Rudolf W. Poolman Dr. Jan Roorda Prof. dr. Barend J. van Royen Dr. Michiel A.J. van de Sande

UITGEVER & REDACTIESECRETARIAAT Serendipity Publishing Dorpsweg 81 1676 GE Twisk Telefoon: 0651-174410 E-mail: [email protected] Richtlijnen voor Auteurs www.ntv-orthopaedie.nl OPLAGE & FREQUENTIE 1.350 exemplaren, verschijnt elk kwartaal ABONNEMENTEN Het Nederlands Tijdschrift voor Orthopaedie wordt gratis toegezonden aan alle leden van de Nederlandse Orthopaedische Vereniging. Abonnementen Beneluxlanden  61,82 per jaar (excl. 6 % BTW). COPYRIGHT © 2014 NOV & Serendipity Publishing ISSN 1 380-653X

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De Nederlandse Orthopaedische Vereniging werd op 1 mei 1898 in Amsterdam opgericht. De Vereniging heeft als doel: - Het bevorderen van studie en het verbreiden van kennis van de conservatieve en operatieve orthopedie onder artsen. - Het behartigen van de sociale belangen van de artsen die de orthopedie uitoefenen, zowel binnen de vereniging als daar buiten. Het Nederlands Tijdschrift voor Orthopaedie is het officiële orgaan van de Nederlandse Orthopaedische Vereniging. Het heeft ten doel de leden van de Vereniging en andere geïnteresseerden te informeren over ontwikkelingen op orthopedisch gebied, waarbij zowel klinische als fundamentele aspecten worden belicht. Deze doelstelling wordt verwezenlijkt in de vorm van oorspronkelijke artikelen, editorials en verslagen van wetenschappelijke vergaderingen, met name die van de NOV. Naast verenigingsnieuws wordt ook aandacht besteed aan recent verschenen literatuur en proefschriften. Voorts worden congressen, symposia en workshops op het gebied van de orthopedie aangekondigd. Beweringen en meningen, geuit in de artikelen en mededelingen in deze publikatie, zijn die van de auteur(s) en niet (noodzakelijkerwijs) die van de redactie. Grote zorgvuldigheid wordt betracht bij de samenstelling van de artikelen. Fouten (in de gegevensverwerking) kunnen echter niet altijd voorkomen worden. Met het oog hierop en omdat de ontwikkelingen in de medische wetenschap snel voortschrijden, wordt de lezer aangeraden onafhankelijk inlichtingen in te winnen en/of onderzoek te verrichten wat betreft de vermelde diagnostische methoden, doseringen van medicijnen, enz. De redactie wijst elke verantwoordelijkheid of aansprakelijkheid voor (de juistheid van) dergelijke gegevens van de hand en garandeert noch ondersteunt enig produkt of enige dienst, geadverteerd in deze publikatie, noch staat de redactie garant voor enige door de vervaardiger van dergelijke produkten gedane bewering. Conform de richtlijnen van de Inspectie voor de Gezondheidszorg (sectie reclametoezicht) zijn reclame-uitingen voor en productinformatie van receptgeneesmiddelen door farmaceutische bedrijven in het Nederlands Tijdschrift voor Orthopaedie alleen gericht op personen die bevoegd zijn om de betreffende geneesmiddelen voor te schrijven.

Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients Paul de Baat and Luuk W.L. de Klerk Background Context: Adolescent idiopathic scoliosis (AIS) surgery often consists of posterior spinal fusion. All-pedicle screw instrumentation has become very popular and seems to be the gold standard nowadays. In the past decennium, a double-hook claw construction had been used in our centre for several years as a standard for thoracic fixation of the posterior instrumentation in AIS surgery. Purpose: To evaluate the results of this hybrid construction retrospectively with special interest in curve correction, maintenance of correction over time, failures of instrumentation, and occurrence of junctional kyphosis. Study Design: Retrospective cohort study. Patient Sample: Forty consecutive AIS patients who underwent posterior spinal fusion in our centre using this technique between August 2003 and December 2007. Methods: Patients were followed in the outpatient clinic for at least two years postoperatively. Clinical results were noted and spinal X-rays were taken at every visit. At the two-yearly follow-up, all patients were requested to complete a validated Dutch version of the SRS-22 questionnaire. Results: The mean follow-up period was 44 months ± 15 . Mean age at surgery was 15.1 years ± 1.8 . The mean coronal Cobb angle of the main curve improved from 65.7° ± 9.9 preoperatively to 21.4° ± 9.1° immediately postoperatively, indicating a correction of 68.2% ± 10.3. At the two-yearly follow-up, the mean coronal Cobb angle of the main curve was 25.0° ± 8.6, indicating a relapse of 5.7% ± 8.5. At the two-yearly follow-up, the mean overall SRS-22 score was 90.8 ± 10.7 points. During follow-up, one patient underwent surgical removal of the proximal part of the construction because of local pain. No long-term neurological complications were recorded. Conclusions: Within the limitations of this study, in our cohort of 40 AIS patients, posterior fusion with a hybrid construction including a proximal double-hook claw seems to be an effective and safe treatment for AIS. When comparing these results with the literature, they seem comparable, or at least not inferior, to all-pedicle screw constructs and possibly better than hook or other hybrid constructs. A possible explanation is the claw configuration of the hook construction.

Introduction Surgical treatment of progressive or severe adolescent idiopathic scoliosis (AIS) often consists of posterior spinal fusion. Through the years, different instrumentation techniques have been used. There are constructions with rods, hooks, wires, screws and combinations thereof. In 1995, Suk et al. introduced the concept of using all-pedicle screw instrumentation in AIS.1 This method has become very popular since then, supported by several retrospective in vitro and in vivo studies. When compared to hook or hybrid constructions, the current opinion is that thoracic pedicle screws have a higher pull-out strength2-7 and give an improved coronal Cobb angle correction and an improved maintenance of correction over time.8-15 Maybe of even more importance, it seems that with pedicle screws better correction of rotational deformities can be P. de Baat, orthopedic resident and Dr. L.W.L. de Klerk, orthopedic surgeon, Erasmus MC, location Sophia, Rotterdam, The Netherlands Corresponding author: P. de Baat Email: [email protected]

achieved.14 Nowadays, thoracic pedicle screws seem to be the gold standard and there seems to be little place for thoracic hook constructions. However, in the past decennium, a double-hook claw construction had been used in our centre for several years as a standard for thoracic fixation of the posterior instrumentation in AIS surgery. This construction consisted of a bilateral combination of two transverse process hooks proximally and two laminar hooks distally. The purpose of this study is to evaluate the results of this hybrid construction retrospectively with special interest in curve correction, maintenance of correction over time, failures of instrumentation, and occurrence of junctional kyphosis. Our hypothesis is that a hybrid construction with a proximal double-hook claw construct is capable of giving good clinical and radiological results in AIS surgery. In this study, we present the short term results of this proximal double-hook claw construction in 40 consecutive AIS patients, regarding the coronal Cobb angle correction, the relapse of correction after at least 2 years, sagittal balance, compliNederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients

cation and revision rates, and patient satisfaction, assessed using the SRS-22 questionnaire.

A

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Materials and methods

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Between August 2003 and December 2007, 40 consecutive patients with AIS underwent surgery in our centre by a single spinal surgeon. This cohort was evaluated retrospectively at intermittent times, first in 2005. Indications for surgery were severe scoliosis with a coronal Cobb angle of the main curve ≥45° or progressive scoliosis despite bracing. Scoliosis was defined as progressive when the coronal Cobb angle had increased by 5° or more during 1 year. Preoperative clinical data Preoperative work-up consisted of magnetic resonance imaging (MRI) to verify any intraspinal pathology, standard laboratory tests (hemoglobin, hematocrit, blood type and antibody screening), standing X-rays of the entire spine (anteroposterior, lateral bending, and lateral), and assessment of somatosensory evoked potentials (SSEP). The spinal X-rays were analyzed using the classification systems according to Lenke16 and Risser17, and coronal Cobb angles were measured.18 With regard to the postoperative lateral X-rays, we did not measure Cobb angles but only determined the sagittal profile according to Lenke’s classification (normal, hyper-, or hypokyphosis).16 Operative procedure All patients were operated under general anaesthesia whilst lying in a prone position andapproached posteriorly. In all patients, SSEP signals were recorded during surgery. After dissection of the spine with thorough decortications of the posterior laminas, all patients underwent posterior instrumentation with a combination of pedicle screws in the lower thoracic and lumbar spine, and a hook claw construction in the upper thoracic spine (Monarch® 5.50 or 6.35 Ti Spine System, DePuy). Pedicle screws were inserted bilaterally with a free-hand technique at all preoperatively decided levels with the help of an image intensifier. The hook claw construction consisted of two proximal transverse process hooks and two distal laminar hooks at each side (Figure 1). The laminar hooks were applied at the level of the facet joints, without facetectomy. A double rod system was applied, and curve correction was carried out under spinal cord monitoring by SSEPs. First, the rod at the convex side of the curve was applied and proximally fixated. Then the rod was translated towards the screws, followed by subtle segmental distraction or compression.

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Figure 1. Posteroanterior (1a) and lateral (1b) image of a proximal double-hook claw consisting of a bilateral combination of two transverse process hooks proximally and two laminar hooks distally.

Finally, the second rod was applied and fixated. Autologous bone grafts from the iliac crest were used for fusion, and two subfascial drains were left in situ. Intravenous antibiotic prophylaxis was administered in all patients preoperatively and maintained postoperatively for 3 days. Postoperative recovery, assessments and follow-up No postoperative cast or brace was used. During the first few days post surgery, lying anteroposterior and lateral X-rays of the entire spine were taken. Patients were discharged from the hospital after mobilisation and without wound healing problems. Patients were followed routinely in the outpatient clinic after 6 weeks, 3 months, 6 months, 1 year, and 2 years post surgery. Standing anteroposterior and lateral X-rays of the entire spine were repeatedly taken until at least 2 years post surgery. After at least 2 years of follow-up, all patients were requested to complete a validated Dutch version of the SRS-22 questionnaire. This questionnaire has five domains: pain, self-image, function/activity, mental health and satisfaction with the management. The maximum score is 110 points. Results The 40 patients had a mean follow-up period of 44 months ± 15 (range, 14-77 months). Except for one patient, all patients had a minimum follow-up

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period of 2 years. There were 36 female and 4 male patients . Mean age at surgery was 15.1 years ± 1.8 (range, 11.4 years - 20.9 ).

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Preoperative clinical data The majority of patients had thoracic structural curves, according to Lenke’s classification.16 The group consisted of 1 type 1A, 10 types 1B, 7 types 1C, 1 type 2A, 4 types 2B, 2 types 2C, 1 type 3A, 1 type 3B, 10 types 3C, 2 types 5C, and 1 type 6C Lenke curves. With regard to skeletal maturity, there were 3 Risser grade 3, 6 grade 2, 16 grade 3, 11 grade 4, and 4 grade 5 iliac apophyses. The mean coronal Cobb angle of the main curve was 65.7° ± 9.9. In two patients preoperative lateral X-rays were not available. In 29 patients there was a normal thoracic sagittal profile, in 2 patients there was a hyperkyphosis, and in 7 patients there was a hypokyphosis. Preoperative MRI showed a syrinx at Th12 in one patient and an upper thoracic diastematomyelia with a small syrinx in another patient. These findings were no contraindication for surgery. Operative procedure Table 1 presents the operative details of the cohort. In all 40 patients, a posterior spinal fusion was performed. No abnormalities during perioperative SSEP monitoring were found. No intraoperative complications occurred. Postoperative recovery, evaluation and follow-up Table 2 presents postoperative curve data of the cohort. The mean immediate postoperative coronal Cobb angle of the main curve was 21.4° ± 9.1, indicating an immediate postoperative correction of 68.2% ± 10.3. At 2-year follow-up, the mean coronal Cobb angle of the main curve was 25.0° ± 8.6, indicating a correction of 62.5 ± 10.2%. The relapse of correction at the 2-yearly follow-up was 5.7% ± 8.5. With regard to the sagittal profile, both hyperkyphotic curves and one hypokyphotic curve were corrected to normal. Six hypokyphotic curves remained hypokyphotic postoperatively. We did not observe any proximal or distal junctional kyphosis. Unfortunately six complications occurred in 40 patients (15.0%) . Two complications occurred immediately postoperatively and four complications after discharge from the hospital (Table 3). Immediately postoperatively, one sensory leg impairment occurred, probably because of pressure on the peroneal and lateral femoral cutaneous nerve while lying on the operating table. This resolved without any intervention. One patient needed additional surgery during follow-up. This patient suffered pain caused by the instrumentation materi-

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als. Radiographically, no failure of the construction itself could be determined. Three years postoperatively, she showed improvement after surgical removal of the proximal part of the rod and two transverse process hooks. All other complications were successfully treated conservatively. Table 4 presents the results of the SRS-22 questionnaire. The mean score per question (range, 1-5 points) is shown for each single domain of the questionnaire as well as for all domains together. In the subgroup satisfaction with the management, the mean score was 8.8 out of 10 possible points. In this subgroup, one patient scored 3 points for satisfaction and the remaining patients scored 7 points or more. The mean overall score of the questionnaire was 90.8 points ± 10.7 , out of a maximum of 110 points. Discussion Posterior spinal fusion is a common surgical treatment option for progressive or severe AIS. We presented our results in 40 consecutive AIS patients treated with posterior spinal instrumentation using a hybrid construction with a thoracic double-hook claw. This type of instrumentation was introduced in our centre in 2002 and uniformly applied in AIS patients since 2003. The rationale for this policy was the lower risk of pedicle breach and neurological injury at thoracic levels. Firstly, we discuss radiological correction of the curve. Many AIS studies have compared the results of coronal Cobb angle correction of screw constructions with hook/hybrid constructions. Most studies showed significantly better correction results in screw construction groups immediately postoperatively1,8-15,19 whereas others reported no significant differences.20-22 Immediate postoperative correction with all-screw constructions and with hook/hybrid constructions was 56-76%and 4563%, respectively.1,8,9,11,12,19,22 At the 2-yearly follow-up, correction with all-screw constructions and with hook/hybrid constructions was 50-72% and 3461%, respectively.1,8,9,11,12,14,15,19 Comparison of these studies with the result of the present study, shows our construction to be successful. In our study using the proximal double-hook claw construction, the mean immediate postoperative coronal Cobb angle correction was 68.2% ± 10.3 (Table 2). At the 2-yearly follow-up, the mean correction was 62.5% ± 10.2. The results of our construction with a proximal double-hook claw seem similar to results of all-pedicle screw constructions and better than results of hook/hybrid constructions.1,8,9,11, 12,14,15,19,22 Only recently, a systematic review was

Paul de Baat and Luuk W.L. de Klerk

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Table 1. Operative details of the adolescent idiopathic scoliosis cohort (n=40) Type of surgery

Posterior spinal fusion (n=40)

Extent of fusion

T2 (n=16), T3 (n=17), T4 (n=7) T12 (n=1), L1 (n=7), L2 (n=9), L3 (n=12), L4 (n=5), L5 (n=6)

proximally distally

Cross connector

Single one (n=34), double (n=6)

SSEP monitoring

Normal (n=40)

Mean blood loss intraoperatively postoperatively

1275cc ± 789 650cc ± 466

Mean duration of surgery

319mins ± 37

Intraoperative complications

None

Mean days of hospitalization

10.0 days ± 1.9

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Table 2. Mean postoperative curve details of the adolescent idiopathic scoliosis cohort (n=40) Main curve Cobb angle preoperatively Cobb angle immediately postoperatively Cobb angle at 2-year follow-up Cobb angle correction immediately postoperatively Cobb angle correction at 2-year follow-up Cobb angle relapse of correction at 2-year follow-up Secondary curve Cobb angle preoperatively Cobb angle immediately postoperatively Cobb angle at 2-year follow-up Cobb angle correction immediately postoperatively Cobb angle correction at 2-year follow-up

published to the effectiveness of pediatric pedicle screws versus hook and hybrid constructions.13 This review included 13.536 screws and showed a mean Cobb angle correction of all-pedicle screw, allhook and hybrid constructs of 61±11%, 46±14%, and 56±10%, respectively. These results were in favour of all-pedicle screw constructs. However, the Cohen’s effect size correlation coefficient for screws was only small to medium in comparison with hybrid constructions (r=0.24).13 The clinical relevance of this difference is not known. Furthermore, one

65.7° ± 9.9 21.4° ± 9.1 25.0° ± 8.6 68.2% ± 10.3 62.5% ± 10.2 5.7%± 8.5

43.3°± 13.1 15.3° ± 10.2 16.8° ± 12.0 67.0% ± 18.6 64.3% ± 21.8

should evaluate the costs of pedicle screws versus hook/hybrid constructions. A recent study showed that pedicle screws are more expensive overall, per fused level, and per degree of correction.23 With regard to relapse of the correction at the 2-yearly follow-up, many studies showed less relapse of the correction in screw construction groups compared to hook/hybrid construction groups; however, the difference was not significant in all studies.1,8,9,11,12,15,19 In the literature, the reported absolute relapse of Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Table 3. Complications during follow-up of the adolescent idiopathic scoliosis cohort (n=40) Immediately postoperatively (n=2)

sensory impairment nervus peroneus and nervus cutaneus femoris lateralis (n=1) - gradual spontaneous recovery, resolved after 6 months

paralytic ileus (n=1) - treated with a stomach tube and diet limitations, resolved within a few days Vol 21

During follow-up (n=4) superficial wound infection (n=1) - 2 weeks postoperatively, treated by washing twice a day, healed within a few weeks

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urinary tract infection (n=1) - 2 weeks postoperatively, E. coli in urine culture, intravenous antibiotics for 4 days, healed without complications

decompensation of the lumbar secondary curve (n=1) - 18 months postoperatively, no surgical intervention necessary

pain caused by instrumentation materials (n=1) - 3 years postoperatively, improved by surgical removal of the proximal part of the rod and two transverse process hooks

Table 4. SRS-22 questionnaire* results after the two-year follow-up of the adolescent idiopathic scoliosis cohort (n=40), and comparison with results in the literature Domain

Score cohort (rate of maximum possible, mean)

Score cohort (points Literature9,36,39 (points per question, mean)* per question, mean)*

Total

82.6%

4.1 ± 0.5

Pain

86.6%

4.3 ± 0.7

4.1 to 4.6 points

Self Image

79.5%

4.0 ± 0.5

3.5 to 4.5 points

Function/Activity

82.4%

4.1 ± 0.6

3.3 to 4.3 points

Mental Health

79.7%

4.0 ± 0.7

3.6 to 4.6 points

Satisfaction

87.5%

4.4 ± 0.7

4.1 to 4.7 points

* Score range per question 1-5 points

coronal Cobb angle correction was 1-9% and 6-14% for the all-screw and the hook/hybrid constructs, respectively.1,8,9,11,12,19 The relapse of correction in our study was 5.7% ± 8.5. When comparing the relapse of correction in our cohort with those of reported screw and hook/hybrid constructs, our construct again appears to be as successful.

Secondly, most cadaveric studies show that the pull-out strength of an all-pedicle screw construction is higher when compared to that of a hook or hybrid construction.2-5,7,24 However, some comment is required. First, the majority of pull-out assessments were performed in cadavers of elderly people, thus perhaps precluding extrapolation of the results from adolescent scoliotic spines. SecNederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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ond, the pull-out strength of pedicle screws depends on their anchoring in the pedicle.8 Screws violating the medial or lateral pedicle wall have less pull-out strength, and the same applies to small-diameter screws due to insufficient fixation in strong cortical bone. Third, the study of Cordista et al. reported a higher pull-out strength of hooks in a claw construction (pedicle hook inferior and laminar hook superior) when compared to a pedicle screw construct in cadaveric thoracic spines.25 In conclusion, similar to corrective forces, thoracic pedicle screws are generally believed to be superior to hooks with regard to pull-out strength. However, hooks placed in a claw-like formation seem to be capable of withstanding higher pull-out forces than single hooks. Therefore a hook-claw seems to compete better with screws than single hooks. With regard to pull-out strength, in the present study, no serious complications occurred that were potentially related to the presumed low strength of the proximal double-hook construct . However, one patient needed reoperation because of pain due to instrumentation materials 3 years postoperatively. Radiographically, no failure of the construction itself could be determined. Pain relief was achieved after removal of the proximal part of the rod and two transverse process hooks (Table 3). Junctional kyphosis did not occur in the present study. Of interest is a recent study of Helgeson et al. in which all-screw constructions resulted in a significant increase in proximal junctional kyphosis when compared to hybrid constructs.26 They suggested placing hooks on top of an all-pedicle screw construct in order to create a transition zone which might decrease the risk of proximal junctional kyphosis. We recognize our construction in this suggestion, but we have to admit there is no evidence yet for this hypothesis and further investigation is required. Thirdly, thoracic pedicle screws carry a theoretically higher risk of neurological injury compared to thoracic hook constructs. Correct placement of thoracic pedicle screws can be technically demanding and, due to the small size of thoracic pedicles, breach of cortex is fairly common. A breach event may result in reduced pull-out strength, dural tears or neurological problems because of possible violation of the spinal canal (medial wall violation), and vascular injury because of the proximity of the aorta (lateral wall violation).27-31 In the literature, the incidence of thoracic pedicle screw misplacement in AIS patients is 3.7-20.0%, with an incidence of medial wall violations of 1.4-10.8%.32-35 Fortunately, the majority of these cases occurred without neurological complications. The incidence of

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screw-related neurological complications in spinal surgery is reported to be low (0.0-2.3%).32-38 Recently, a systematic review of paediatric pedicle screws showed an accuracy of screw placement of 94,9%.13 However, one should keep in mind that most case series published represent the experience of highly specialized spine surgeons employed in high-volume medical centres. It is reported that surgeons’ experience was negatively associated with the rate of medial wall perforations.33,35 Using a thoracic double-hook claw construction largely avoids these specific risks. In our cohort, no longterm neurological complications were recorded. However, patient numbers were low. Finally, we discuss patient satisfaction. For this study we used the Scoliosis Research Society (SRS)-22 questionnaire, which is a modification of the SRS-24 questionnaire. Over the years, different versions of the SRS questionnaire have been developed and validated. In order to roughly compare our results with the different SRS questionnaire versions in the literature, we present each score as a rate of the maximum possible score (Table 4). Few studies have retrospectively compared the SRS questionnaire results between an all-pedicle screw construction and a hook/hybrid construction.8,10,14,15,39 None of the studies found significant differences in either the total score or in any domain. We observed a mean postoperative total SRS score of 82.6%, which seems similar to the reported scores for all-screw constructions (78.389,1%)8,11,15,40, and hook/hybrid constructions (80.8-85.5%).8,11,15,41 The various domain scores of the SRS questionnaire were also similar to those reported in the literature (Table 4).10,39,42 Since this follow-up study was retrospective, we do not have preoperative questionnaire results. In conclusion, there is no observed difference in patient satisfaction between the present study and all-screw or hook/hybrid constructions in the literature. However, the present study has limitations. First, the study did not have a prospective design and there was no control group. For comparison, we used reports from the literature. Second, a 2-yearly follow-up is relatively short. However, in most other studies, authors have used the same followup period. Third, the main outcome parameter was the coronal Cobb angle, which shows intra- and interobserver variability; however, in the literature this is a commonly used outcome parameter. Fourth, scoliosis is a three-dimensional deformity, and we were not able to measure exact sagittal Cobb angles in all patients. However, no sagittal imbalance or junctional kyphosis occurred. Finally,


the second outcome parameter were the subjective results measured by the SRS-22 questionnaire. Unfortunately, because no preoperative baseline measurements were available, we were unable to measure alterations over time. In conclusion, within the limitations of this study, in our cohort of 40 AIS patients, posterior fusion with a hybrid construction including a proximal double-hook claw seems to be a very effective and safe treatment for AIS. When comparing these results with the literature, they seem comparable to all-pedicle screw constructions and possibly better than hook or other hybrid constructs. A possible explanation is the claw configuration of the hook construct. This type of construct lacks the neurological and vascular risks of thoracic pedicle screws. Nowadays, we vary between thoracic pedicle screws and the hook claw construct. In idiopathic scoliosis with large rotational deformities, we tend to use thoracic pedicle screws because of better opportunities for rotation correction. In other curves with mainly coronal plane deformities, especially in younger children, we believe that the hook claw construct can be safely applied, with not more than only a few degrees less correction, but with less neurological and vascular risks and with similar functional outcome. Disclosure No conflict of interest.

References 1. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine 1995; 20: 1399–1405. 2. Gayet LE, Pries P, Hamcha H, Clarac JP, Texereau J. Biomechanical study and digital modeling of traction resistance in posterior thoracic implants. Spine 2002; 27: 707-14. 3. Hitchon PW, Brenton MD, Black AG, et al. In vitro biomechanical comparison of pedicle screws, sublaminar hooks, and sublaminar cables. J Neurosurg 2003; 99 (1 Suppl): 104-9. 4. Jones GA, Kayanja M, Milks R, Lieberman I. Biomechanical characteristics of hybrid hook-screw constructs in shortsegment thoracic fixation. Spine 2008; 33: 173-7. 5. Liljenqvist U, Hackenberg L, Linke T, Halm H. Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg 2001; 67: 157-63. 6. Lenke LG. Debate: Resolved, a 55 degrees right thoracic adolescent idiopathic scoliotic curve should be treated by posterior spinal fusion and segmental instrumentation using thoracic pedicle screws: Pro: Thoracic pedicle screws should be used to treat a 55 degrees right thoracic

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adolescent idiopathic scoliosis. J Pediatr Orthop 2004; 24: 329-34. 7. Laar van W, Meester RJ, Smit TH, Royen van BJ. A biomechanical analysis of the self-retaining pedicle hook device in posterior spinal fixation. Eur Spine J 2007; 16: 1209-14. 8. Kim YJ, Lenke LG, Cho SK, Bridwell KH, Sides B, Blanke K. Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 2004; 15: 2040-8. 9. Dobbs MB, Lenke LG, Kim YJ, Kamath G, Peelle MW, Bridwell KH. Selective posterior thoracic fusions for adolescent idiopathic scoliosis: comparison of hooks versus pedicle screws. Spine 2006; 31: 2400-4. 10. Di Silvestre M, Bakaloudis G, Lolli F, Vommaro F, Martikos K, Parisini P. Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80 degrees: pedicle screws versus hybrid instrumentation. Eur Spine J 2008; 17: 1336-49. 11. Kim YJ, Lenke LG, Kim J, et al. Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 2006; 31: 291-8. 12. Wu X, Yang S, Xu W, et al. Comparative Intermediate and Long-term Results of Pedicle Screw and Hook Instrumentation in Posterior Correction and Fusion of Idiopathic Thoracic Scoliosis. J Spinal Disord Tech 2010; 23: 467-73. 13. Ledonio CG, Polly DW Jr, Vitale MG, Wang Q, Richards BS. Pediatric pedicle screws: comparative effectiveness and safety: a systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force. J Bone Joint Surg Am 2011; 93: 1227-34. 14. Luhmann SJ, Lenke LG, Erickson M, Bridwell KH, Richards BS. Correction of moderate (<70 degrees) Lenke 1A and 2A curve patterns: comparison of hybrid and all-pedicle screw systems at 2-year follow-up. J Pediatr Orthop 2012; 32: 253-8. 15. Yilmaz G, Borkhuu B, Dhawale AA, et al. Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis. J Pediatr Orthop 2012; 32: 490-9. 16. Lenke LG, Betz RR, Clements D, et al. Curve prevalence of a new classification of operative adolescent idiopathic scoliosis. Spine 2002; 27: 604-11. 17. Risser J. The Iliac apophysis: an invaluable sign in the management of scoliosis. Clin Orthop Relat Res 1958; 11: 111–9. 18. Cobb JR. Outline for the study of scoliosis. In: American Academy of Orthopaedic Surgeons, instructional course lectures. St Louis, CV Mosby; 1948: 261-75. 19. Liljenqvist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H. Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J 2002; 11: 336-43. 20. Vora V, Crawford A, Babekhir N, et al. A pedicle screw construct gives an enhanced posterior correction of adolescent idiopathic scoliosis when compared with other constructs. Myth or reality. Spine 2007; 32: 1869-74. 21. Karatoprak O, Unay K, Tezer M, Ozturk C, Aydogan M, Mirzanli C. Comparative analysis of pedicle screw versus


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hybrid instrumentation in adolescent idiopathic scoliosis surgery. Int Orthop 2008; 32: 523-8. 22. Lowenstein JE, Matsumoto H, Vitale MG, et al. Coronal and sagittal plane correction in adolescent idiopathic scoliosis: a comparison between all pedicle screw versus hybrid thoracic hook lumbar screw constructs. Spine 2007; 32: 448-52. 23. Jaquith BP, Chase A, Flinn P, et al. Screws versus hooks: implant cost and deformity correction in adolescent idiopathic scoliosis. J Child Orthop 2012; 6: 137-43. 24. Hackenberg L, Link T, Liljenqvist U. Axial and tangential fixation strength of pedicle screws versus hooks in the thoracic spine in relation to bone mineral density. Spine 2002; 27: 937-42. 25. Cordista A, Conrad B, Horodyski M, Walters S, Rechtine G. Biomechanical evaluation of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Spine J 2006; 6: 444-9. 26. Helgeson MD, Shah SA, Newton PO, et al. Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation. Spine 2010; 35: 177-81. 27. Kasten MD. Proximal thoracic pedicle screw complications: fractures with spinal cord injury. Presented at Scoliosis Research Society Annual Meeting, Buenos Aires, Argentina, Sept. 2004. 28. Richards S. Debate: Resolved, a 55 degrees right thoracic adolescent idiopathic scoliotic curve should be treated by posterior spinal fusion and segmental instrumentation using thoracic pedicle screws: Con: Thoracic pedicle screws are not needed to treat a 55 degrees right thoracic adolescent idiopathic scoliosis. J Pediatr Orthop 2004; 24: 334-7. 29. Rinella A. Thoracic pedicle expansion after pedicle screw placement in a pediatric cadaveric spine: a biomechanical analysis. Presented at Scoliosis Research Society Annual Meeting, Buenos Aires, Argentina, Sept. 2004. 30. Boos N, Webb JK. Pedicle screw fixation in spinal fixation in spinal disorders: a European view. Eur Spine J 1997; 6: 2-18. 31. Brown CA, Eismont FJ. Complications in spinal fusion. Orthop Clin North Am 1998; 29: 679-99. 32. Kuklo TR, Lenke LG, O’Brien MF, Lehman RA Jr, Polly

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DW Jr, Schroeder TM. Accuracy and efficacy of thoracic pedicle screws in curves more than 90 degrees. Spine 2005; 30: 222-6. 33. Samdani AF, Ranade A, Sciubba DM, et al. Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make? Eur Spine J 2010; 19: 91-5. 34. Sarlak AY, Tosun B, Atmaca H, Sarisoy HT, Buluç L. Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis. Eur Spine J 2009; 18:1892-7. 35. Abul-Kasim K, Ohlin A. The rate of screw misplacement in segmental pedicle screw fixation in adolescent idiopathic scoliosis: the effect of learning and cumulative experience. Acta Orthop 2011; 82: 50-5. 36. Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine 2004; 29: 333-42. 37. Verma R, Krishan S, Haendlmayer K, Mohsen A. Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws. Eur Spine J 2010; 19: 370-5. 38. Cuartas E, Rasouli A, O’Brien M, Shufflebarger HL. Use of all-pedicle-screw constructs in the treatment of adolescent idiopathic scoliosis. J Am Acad Orthop Surg 2009; 17: 550-61. 39. Arlet V, Ouellet JA, Shilt J, et al. Subjective evaluation of treatment outcomes of instrumentation with pedicle screws or hybrid constructs in Lenke Type 1 and 2 adolescent idiopathic scoliosis: what happens when judges are blinded to the instrumentation? Eur Spine J 2009; 18: 1927-35. 40. Lehman RA Jr, Lenke LG, Keeler KA, et al. Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases. Spine 2008; 33: 1598-604. 41. Bridwell KH, Hanson DS, Rhee JM, Lenke LG, Baldus C, Blanke K. Correction of thoracic idiopathic scoliosis with segmental hooks, rods, and Wisconsin wires posteriorly: it’s bad and obsolete, correct? Spine 2002; 27: 2059-66. 42. Merola AA, Haher TR, Brkaric M, et al. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine 2002; 27: 2046-51.

Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen Introduction: The incidence of negative arthroscopies of the knee varies from 4% to 25%. Up to this date, no tests are available that identify individuals who are likely to experience a negative arthroscopy. Materials and methodology: We investigated potential factors that predict a negative arthroscopy of the knee. A retrospective cohort study was conducted. Two groups were evaluated, i.e. a group subjected to an arthroscopy with intervention (n=288) and a group without intervention (n=322). Demographic data, diagnosis, history, physical examination and imaging were recorded. Results: The proportion of negative arthroscopies without intervention was 9.1%. The proportion of negative arthroscopies without abnormalities was 3.7%. Predictors for a negative arthroscopy (without intervention) were gender, age and knee effusion (p<0.01). Patients without intervention during arthroscopy had more normal MRIs than patients subjected to arthroscopies with intervention. ACL-ruptures (p=0.01) and radiological osteoarthritis (p=0.00) in pre-operative diagnosis were less common in arthroscopies without intervention. Conclusion: The most important factors to predict a negative arthroscopy in our population were age, gender and knee effusion. Younger women without a knee effusion were more likely to experience a negative arthroscopy. In order to diagnose a meniscal lesion, one should not just rely on a positive McMurray’s test. These factors should be taken into consideration before performing an arthroscopy of the knee.

Introduction Worldwide about 4 million arthroscopies of the knee are performed annually, including more than 60,000 in the Netherlands.1,2 Literature reports conflicting results on whether patient history, physical examination or imaging (MRI) has the highest sensitivity and specificity for diagnosing a lesion of ligaments or menisci.3,4,5 The incidence of a negative arthroscopy of the knee following preoperatively diagnosed meniscal or ligament injuries varies from 4% and 10% to over 25%.5,6,7 A negative arthroscopy of the knee can be defined as either an arthroscopic procedure resulting in no intervention (e.g. meniscectomy) or one that does not lead to an observation of abnormality. In this study, we adhered to the former interpretation of no concomitant intervention. Because of the important role of MRI as a diagnostic tool, there is basically no need for an invasive procedure, such as a diagnostic arthroscopy of the knee, with the exception of arthroscopic assisted synovial or osseous biopsies.8 There is controversy J.C. Rekveldt1, MPA, B.J. Kollen2, PhD, C. van Egmond1, MD and C.C.P.M. Verheyen1, MD PhD 1 Department of orthopaedic surgery and traumatology, Isala klinieken Zwolle, The Netherlands 2 Department of General Practice, University of Groningen, University Medical Centre Groningen, The Netherlands Corresponding author: Dr. C.C.P.M. Verheyen Email: [email protected]

about whether to subject a patient to an arthroscopy prior to a possible osteotomy or knee prosthesis.8 In this study, our goal was to identify factors derived from demographic data, history, physical examination, imaging and diagnosis that may explain and predict a negative arthroscopy of the knee in our population. Identification of these predictors could help to lower the incidence of negative arthroscopies of the knee. Materials and Methodology A retrospective cohort study was performed in a group of patients who underwent an arthroscopy of the knee over a period of three years in the Isala clinics in Zwolle, The Netherlands. In this orthopaedic department about 1300 arthroscopies of the knee are performed annually. Between January 1st, 2006 and December 31st, 2008, all surgeries were recorded. From all patients with records coded as arthroscopy of the knee without intervention, the operative reports were checked, to confirm no intervention was carried out. From the database, a SPSS generated random sample of all patients with a recorded additional intervention (e.g. meniscectomy), i.e. arthroscopy with intervention, was taken to serve as a control group. In this group, arthroscopies without intervention or with ACLreconstruction were excluded. Information about demographic data, history, physical examination, imaging and diagnosis was Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients

Figure 1. Flow diagram of the selection procedure. Study population is based on samples in grey shaded areas.

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retrieved from outpatient charts and preoperative records of consultations from anesthesiologists. Statistical methods Descriptive statistics were used to compare groups on gender, age, BMI, preoperative diagnosis, previous knee surgery, trauma, locking, joint effusion and positive McMurray test. Categorical data were tested using cross-tabulation (Chi-square test).9 In order to determine which factors predicted a negative arthroscopy, a multivariate logistic regression model was developed based on a best subset stepwise forward selection procedure. This procedure involved including stepwise (one by one) relevant factors to the regression model, i.e. gender, age, BMI, preoperative diagnosis, earlier knee surgery, trauma, locking, knee effusion and McMurray’s test. Each time the model was fitted with an extra factor, variables that were not significant in the model were removed (P in: p≤0.05; P out p>0.05). Ultimately, the final model contained only factors with a p-value smaller than or equal to 0.05. As these significant factors best explained the outcome in our population they were considered predictors for a negative arthroscopy. All statistical calculations were performed in SPSS. Results During 2006, 2007 and 2008, in total 3530 knee arthroscopies were performed in the orthopaedic

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department of the Isala klinieken (ACL-reconstructions excluded). In 322 arthroscopies, no intervention had taken place. In 131 of these 322 arthroscopies, no intra-articular abnormalities were observed (“normal knees”). A random sample of 322 patients was taken from the population of patients with arthroscopies with intervention (n=3208, Figure 1). After exclusion of incorrect coded surgeries, 288 patients remained. The proportion of negative arthroscopies (without intervention) was 9.1% (322 of 3530), 7.0% in males versus 12.7% in females (p=0.00). The proportion of the negative arthroscopies in knees without any observed abnormalities (normal knees) was 3.7% (131 of 3530), 2.6% in males versus 5.4% in females (p =0.01). The mean age of patients with normal knees subjected to arthroscopies was lower than the mean age of those with arthroscopies with intervention (27.8 versus 43.9 years of age, p=0.00). The final logistic regression model generated 3 predictors for a negative arthroscopy without intervention (Table 2). A negative arthroscopy without intervention is more likely to occur in females than in males (OR = 2.12, CI: 1.43-3.14), and less likely with each added year of age of the patient (OR = 0.96, CI: 0.95-0.97) and in the presence of joint effusion (hydrops or haemarthros) (OR: 0.48, CI: 0.33-0.72). Compared to the control group (arthroscopies with intervention), patients with normal knees during arthroscopy had more normal MRIs (p=0.01) and were diagnosed pre-operatively with less

Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen

Table 1. Results

Arthroscopy without intervention

All Normal knees n= 322 n=131 Demographic data male 47.8% 45.4% female 52.2% 54.6% age (average) 34.4 (10-74) 27.8 (10-52) BMI (average) 25.6 (16-43) 24.0 (16-39)

Arthroscopy with intervention

n=288

63.9% 36.1% 43.9 (13-77) 26.8 (19-48)

Pre-operative diagnosis Medial meniscus lesion 59.1% 70.0% Lateral meniscus lesion 17.7% 16.2% ACL-rupture 16.7% 6.9% Chondropathy 11.3% 1.5% Loose body 3.5% 1.6%

65.6% 19.4% 13.2% 9.7% 3.1%

Intra-operative diagnosis Medial meniscus lesion 0.6% 0.0% Lateral meniscus lesion 0.0% 0.0% ACL-rupture 19.9% 0.0% Chondropathy 37.9% 0.0% Loose body 0.0% 0.0%

63.8% 19.2% 20.6% 46.0% 4.5%

History Earlier knee surgery 39.0% 32.7% Physical therapy 85.5% 87.8% Trauma 58.3% 64.9% Swelling 65.9% 57.3% Locking 56.7% 68.1%

36.3% 73.0% 53.1% 73.4% 56.1%

Physical exam Knee effusion 52.3% 40.4% Flexion<120° 19.3% 10.9% Extension<0° 21.1% 17.9% McMurray positive 41.2% 45.5% Lachman positive 26.9% 15.8%

70.9% 14.1% 31.4% 50.5% 23.1%

Imaging X-ray degeneration 14.6% 4.0% MRI abnormalities 79.2% 76.1%

30.9% 97.4%

ACL-ruptures (p=0.01) and degeneration (p=0.00). No difference was found between the pre-operative diagnoses medial (p=0.14) and lateral meniscal lesions (p=0.40) (table 1). In the group with normal knees there was also less swelling, joint effusion and positive Lachman tests. However, it was remarkable that in normal knees, locking was more frequently reported (p=0.01). Likewise,

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compared to the control group patients with normal knees showed no differences in positive McMurray tests (p=0.57). Compared to arthroscopies with intervention, arthroscopies without intervention showed less medial meniscal lesions in the pre-operative diagnosis (p=0.05). This group (without intervention) showed more preoperative diagnosed ACL-ruptures Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Table 2. Predictors for negative arthroscopy without intervention Predictive factor OR

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95% CI

p

Gender (1=male, 2=female)

2.12

1.43-3.14

<0.01

Age

0.96

0.95-0.97

<0.01

Knee effusion

0.48

0.33-0.72

<0.01

(p=0.01) and radiological osteoarthritis (p=0.00). There was no difference in the proportion of individuals diagnosed with a lateral meniscus lesion (p=0.71). Discussion This study showed that the preoperative factors such as age, joint effusion, and gender are predictive of a negative arthroscopy of the knee, i.e. younger women without knee effusion are less likely to require an intervention. One is more likely to find discrete degenerative meniscal lesions with increasing age. When such a lesion is found, generally a debridement will follow and the patient is subjected to an intervention with questionable result.10 In the group of patients with negative arthroscopies, over 20% had a normal MRI (Table I). This raises the question as to why an MRI scan was made. If the symptoms and clinical findings gave reason to believe an arthroscopy is warranted, then the outcome of an MRI scan was not likely to confirm the tentative diagnosis. When in doubt about the accuracy of the diagnosis, and the MRI is negative, the logical consequence would be that no arthroscopy is performed. As the diagnostic accuracy of an MRI is not perfect, it is conceivable to perform an arthroscopy following a negative MRI when clinical symptoms are indicative of intra-articular pathology. On the other hand, when an MRI is warranted but turns out to be negative the obvious choice would be not to operate. Arthroscopies without intervention occurred more often in patients with diagnosed ACL-rupture and chondropathy. Both conditions do not constitute primary indications for an arthroscopic procedure.8 Most arthroscopies had a preoperative diagnosis of medial meniscal lesion. This diagnosis will often be based on a positive McMurray’s test. However, this test is not always conducted and reported according to generally accepted standards, and has a low sensitivity and specificity.4,11 As a consequence, conclusions based on this test alone are not reliable. Considering multiple meniscal tests

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outcomes may improve the reliability of physical examination.11 The frequently reported locking in arthroscopically normal knees can possibly be explained by the fact that mechanical symptoms justify an arthroscopy and consequently discrete (pseudo)locking is reported as a locked knee. The medial meniscal lesions observed in the group with no intervention (0.6%) were mostly interpreted as irrelevant discrete lesions and not trimmed. In the group with negative arthroscopies in normal knees, no pathology was found in 32.7% of the cases despite prior surgery. However, it is conceivable that signs of prior surgery were observed, but not reported as pathology. The proportion of negative arthroscopies in this study was close to the lowest reported in the literature. The percentage MRI scans (28.2%) and the preoperative diagnoses of negative arthroscopies were similar to that reported in the literature.6,5 Given the favourable patient satisfaction rates after a negative arthroscopy (64% feels better afterwards, 2% worse), and the very low risk of sustaining complications after such procedure, it can be surmised that a negative arthroscopy may not represent a major problem.7,12 We strongly oppose to this conclusion because a negative arthroscopy of the knee should always be avoided as every surgical procedure has its risks and complications. Additionally, the 9.1% of negative arthroscopies observed in this study signifies over 5000 unnecessary and partly avoidable surgical procedures each year in the Netherlands and potentially over 400.000 worldwide.1 This represents a substantial healthcare and economic problem. Given the retrospective nature of the data collection in this study, no firm conclusions can be drawn. It is recommended to carry out a prospective study. Conclusion The most important factors to predict a negative arthroscopy in our population were age, gender and knee effusion. Younger women without a knee effusion were more likely to experience a negative

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arthroscopy. In order to diagnose a meniscal lesion, one should not just rely on a positive McMurray’s test. These factors should be taken into consideration before performing an arthroscopy of the knee. The study is carried out in the department of orthopaedic surgery and traumatology, Isala klinieken Zwolle, The Netherlands. Vol 21 mrt ’14

Disclosure statement No competing interests declared.

References 1. AOSSM, American Orthopaedic Society for Sports Medicine, 2008. www.sportsmed.org/secure/reveal/ admin/uploads/documents/ST%20Arthroscopy%2008.pdf 2. CBO, Dutch Institute for Health Care Improvement. Consensus Arthroscopy 1998. www.orthopeden.org/ uploads/450/1171/nov04ak.pdf 3. Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2004 ; 20-7 : 696-700 4. Konan S, Rayan F, Haddad FS. Do physical diagnostic

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tests accurately detect meniscal tears? Knee Surgery Sports Traumatology Arthroscopy 2009 ; 17-7 : 806-11 5. Nickinson R, Darrah C, Donell S. Accuracy of clinical diagnosis in patients undergoing knee arthroscopy. International Orthopedics 2009 ; 34-1 : 39-44 6. Brooks S, Morgan M. Accuracy of clinical diagnosis in knee arthroscopy. Ann R Coll Surg Engl. 2002 ; 84-4 : 265-268 7. Hossain S, Manthravadi S. Negative Knee Arthroscopy: Is It Really Negative? Arthroscopy: The Journal of Arthroscopic and Related Surgery 2001 ; 17-6 : 620-3 8. NOV, Dutch Orthopaedic Society, Guideline arthroscopy of the knee, indication and treatment, 2010. http://www.kwaliteitskoepel.nl/kwaliteitsbibliotheek/ richtlijnen/artroscopie_van_de_knie_indicatie_en_behandeling.html?search=artroscopie&periode[van]=0&p eriode[tot]=0&_type=Richtlijnen&specialisme=47 9. Katz MH. Multivariate analysis. A practical guide for clinicians. Cambridge University Press. 1999 pp.192 10. Crevoisier, X., Munzinger, U., Drobny, T. Arthroscopic partial meniscectomy in patients over 70 years of age. Arthroscopy 2001 : 17 : 732-736 11. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assesing a torn meniscus in the knee: a systematic review with a meta-analysis. J Orthop Sports Phys Ther 2007 ; 37-9 : 541-550 12. Cardosa M, Rudkin GE, Osbourne GA.. Outcome from daycare knee arthroscopy in a major teaching hospital. Arthroscopy 1994 ; 10-6 : 624-629

Total Elbow Arthroplasty after Trauma – case report and review of the literature i www.ntv-orthopaedie.nl/schrander2101/

Dirk E. Schrander, Wouter Gronheid and Aart D. Verburg Complex fractures of the distal humerus in the elderly remain a management challenge. The increase in elderly women with potentially osteoporotic bone means that fixation techniques or joint replacement techniques will play important roles in the future management of these injuries, in our aging society. Open reduction and internal fixation is less predictable in older patients owing to failure of fixation related to osteoporosis. Total elbow arthroplasty (TEA) can be a suitable treatment option when encountering a highly comminuted distal humerus fracture in the elderly patient. This indication for placement of TEA is only used sporadically in the Netherlands. We describe a case of an eighty-one year-old female patient with a grade I open comminuted distal humerus fracture of the dominant arm. TEA is performed eight days after initial trauma, with excellent results at the one year follow-up. TEA can be an alternative form of treatment for severely comminuted fractures of the distal aspect of the humerus in older patients, even in open fractures. This procedure is not an alternative to osteosynthesis in younger patients.

Introduction Complex fractures of the distal humerus in the elderly remain a management challenge.1,2,3 Open reduction and internal fixation is less predictable in older patients owing to failure of fixation related to osteoporosis.4 TEA as primary management is increasingly popular in older patients with comminuted fractures of the distal humerus and poor bone quality.3,5,6 This indication for placement of TEA is only used sporadically in the Netherlands.

of comminution made open reduction and internal fixation (ORIF) an unattractive option.

Patient In October 2011, an eighty-one year-old female patient was admitted after a low-energetic fall on the pavement. She presented with pain, swelling, ulnaropathy and deformation of the right elbow. There was a grade I open fracture with laceration over the olecranon. The patient was still active in daily life. Acenocoumarol was used for a history of cardiac events. Anteroposterior and lateral X-rays of the distal part of the right humerus showed an AO type C3 distal humerus fracture. A computed tomography (CT) scan with three-dimensional reconstruction was performed for further fracture assessment, revealing a comminuted fracture with multiple fractures lines through the humeral capitulum (Figure 1). The type of fracture and level

D.E. Schrander, MD, W. Gronheid and A.D. Verburg, MD, PhD, Department of Orthopaedics, Orbis Medisch Centrum, Sittard-Geleen, The Netherlands Corresponding author: D.E. Schrander, MD Email: [email protected]

Figure 1. I,II: Lateral and anterior-posterior X-rays of the AO type C3 fracture of the right distal humerus. III, IV: CT-scan with three-dimensional reconstruction. V, VI: Linked total elbow prosthesis. Wiring used to fix the large medial condyl fragment. Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Total Elbow Arthroplasty after Trauma – case report and review of the literature

Intervention

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Eight days after the primary injury, after sufficient wound healing was observed, a linked total elbow arthroplasty (TEA) was placed (Discovery®; Biomet Inc., Warsaw, IN). With the patient in supine position, a triceps reflecting approach to the elbow was used as described by van Gorder. The n. ulnaris was identified and inspected in detail, revealing no defects. The medial condylar fragment was fixed with tension band wiring. During the first six weeks, elbow flexion was restricted to 50 degrees to protect the triceps tendon. After 6 weeks the patient was pain-free, with an elbow flexion of 90 degrees and a full extension. Radiographic evaluation showed a satisfactory prosthetic placement (Figure 1). Comparison Currently, ORIF is considered the best treatment strategy in distal humerus fractures requiring operative intervention. The least satisfactory results

have been found when treating AO C3 distal humerus fractures with ORIF.7 Achieving stable internal fixation of these fractures is difficult because of multiple fracture planes, metaphyseal comminution, small fragment size, and complex fragmentation of the articular surface.2,3 There are reports of good results after ORIF of type C fractures in the elderly, and if the surgeon feels that the fracture is suitable for stable fixation and early movement, it is an adequate treatment modality.3,7.8 For infirm, inactive, noncompliant, older patients nonoperative treatment (the so-called “bag of bones” treatment) is advised. For more active patients, both TEA and ORIF are an option.5 When poor bone quality prohibits functional after- treatment, TEA can be considered.5 The implants used for TEA can be divided into 3 types: constrained, semi-constrained, and unconstrained. They can also be divided into linked and unlinked prosthesis.9 Several studies suggested primary linked TEA is a reliable treatment for severe intra-articular distal humerus fractures in the elderly.8,10-12 When considering to proceed with elbow replacement, consideration

Table 1. Published results of TEA in distal humerus fractures. FU: follow-up, MEPS: Mayo Elbow Performance Score. Study

Patients/ Elbows

Examined Sex Prosthesis patients/elbows

Ducrot et al. 20/20 20/20 18F-2M (2013)

Coonrad-Morrey (semiconstrained)

80

Antuna et al. 16/16 16/16 15F-1M (2012)


76

Chalidis et al. 11/11 11/11 9F-2M (2009)

Discovery elbow system (semiconstrained)

80

McKee et al. 25/25 20/20 19F-1M (2009)


78

Prasad et al. 32/32 32/32 25F-7M (2008)


78

Lee et al. 7/7 7/7 5F-2M (2006)


73

Kamineni et al. 48/49 43/43 31F-12M (2004)


69

Frankle et al. 12/12 12/12 12F (2003)


72

Gambirasio et al. 10/10 10/10 10F (2002)


85

Garcia et al. 19/19 16/16 12F-4M (2002)


73

Ray et al. 7/7 7/7 7F (2000)


82

Coonrad-Morrey

72

Cobb and Morrey

20/21

20/21

15F-5M

(1997)

18

Mean age (years)

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(semiconstrained)

Dirk E. Schrander, Wouter Gronheid and Aart D. Verburg

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should be made with regard to both age and activity level. The expertise and familiarization of the surgeon is another determining factor in the choice between ORIF and TEA, since the placement of elbow prostheses remains low volume procedure.

visable that the patient must understand the limitations of a TEA, such as limited lifting of weight and no active push-up, to minimize this complication.6

There are risks and complications with either treatment approach. ORIF carries the risk for non-union, loss of fixation, infection, and stiffness. In TEA, the overall complication rate has been reported between 20% and 70%.10,13 Complications related to the implant include component fracture or uncoupling, periprosthetic fractures, bushing wear and aseptic or septic loosening. Specific complications related to TEA include triceps insufficiency, reflex sympathetic dystrophy, heterotopic ossification and ulnar nerve symptoms.10,11,13-15 Postoperatively there is a 10% rate of permanent ulnar nerve dysfunction following TEA after trauma.16 There is a theoretic concern that trauma patients have a greater functional demand compared to patients with inflammatory arthritis and therefore are at higher risk for early failure of the implant. It is ad-

After one year, the patient continued to be pain free. Range of motion had improved to 155 degrees of flexion and 5 degrees of hyperextension. Proand supination were 85 and 80 degrees, respectively. The patient-reported mayo elbow performance score (MEPS) was 89, indicating a good to excellent result at the one yearly follow-up. Although the sensory function of the n. ulnaris was not restored fully, there were no limitations in daily life.

Mean Infection MEPS

Outcome

Literature Our search in the English and International literature revealed 12 other clinical studies describing the results of TEA in 214 patients with 215 distal humeral fractures (Table 1).1,8,10-14,17-21 There were 178 females (83.2%) and 36 males (16.8%).

Mean FU (months)

Average extension /flexion (deg)

Radio- Fracture lucency

Ulnar nerve lesion

Revision

42.6

33-130

83

0

7

1

2

0

57

28-117

73

3

3

0

-

0

33.2

10-117

90

0

8

1

1

1

24

26-133

86

4

1

0

3

1

56.1

26-118

85

2

6

0

2

2

24.9

41.4-130

94.3

0

0

0

0

0

84

24-131

93

1

3

3

3

5

45

15-125

95

1

1

0

2

0

17.8

23.5-125.5

94

0

2

0

0

0

36

24-125

93

1

1

0

0

0

44.4

25-130

92

1

2

0

0

0

39.6

25-130

-

1

3

1

1

1


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The mean age of the patients varied from 69 to 84.9 years of age with an average follow up from 17.8 months to 84 months. The vast majority of elbow prostheses used in the reported trauma trials were linked semiconstrained elbow prostheses. The mean MEPS among the studies range between 73 and 95 points, representing a good to excellent result. Likewise,the flexion-extension arc indicated normal elbow movement, while significant limitations in elbow motion or function were not observed. There is only one multicentre prospective randomized controlled trial comparing ORIF versus TEA in elderly patients. McKee et al. concluded that primary semi-constrained TEA was superior to ORIF as measured by both surgeon-based (MEPS) and patient-based (disabilities of arm, shoulder & hand score) outcome scores, especially in the early postoperative period. Operative time was shorter by a mean of 32 minutes in the TEA group. There were trends toward a reduced reoperation rate and improved range of motion in the TEA group, which were not statistically significant. In addition, 25% of patients randomized to ORIF required intraoperative conversion to TEA, a consistent figure in multiple studies that could represent a subset of individuals with this fracture type who are not amenable to ORIF.13 Frankle et al. compared the results over ORIF and TEA in the treatment of AO type C distal humeral fractures in 24 women older than 65 years old. In the twelve patients with ORIF, only 2 out of 3 cases has good to excellent results, and ORIF failed completely in 1 of 4 cases.12 Egol et al. did not find a significant difference in functional outcome between ORIF and TEA in a group of 20 patients. However, four patients with TEA developed radiographic loosening after a mean follow-up of 15 months. One patient needed revision surgery. In the ORIF group one non-union occurred.3 New developments in ORIF material, such as low profile anatomic plates and locking compression plates have yet to be compared with the use of TEA in trauma. Prasad et al. was the first to describe long-term follow-up after early implantation of TEA after trauma, resulting in an acceptable 93% survival rate after 88 months in an early treatment group.1 Garcia et al. described good outcomes in a group of 16 patients treated with TEA after fractures of the distal humerus. At the three-yearly follow-up there was only one patient with radiological signs of loosening. Fifteen patients were satisfied with the outcome.10 Although our search described radiologic

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lucency in 37 out of 215 TEA after trauma (17.2%), the revision rate after an average follow-up of 49.2 months is significantly lower. There were 10 revision TEA and two resection arthroplasties described to our knowledge, resulting in a total survival at 4 years of 95,3%. The possibility to treat comminuted distal humerus fractures and their sequelae with distal humerus hemiarthroplasty (DHH) is less established.22 DHH eliminates the need for an ulnar component and placement of polyethylene, which in theory allows for a more durable treatment in the younger patient population. DHH may have certain advantages not achievable with TEA. All complications associated with polyethylene wear, debris and loosening of the ulnar-sided implant are avoided. The rigid physical restrictions for weight bearing that are mandatory after TEA, are less applicable in DHH. Furthermore, several implants can be converted to (un)constrained TEA if necessary.23 There is little literature regarding the use of DHH in distal humerus fractures. Initial results in functional and patient-reported outcome are promising, however the complication rate is considerable.22-25 Longterm results have yet to be described. The most commonly described complication is olecranon wear. Although Adolfson and Nestorson describe olecranon wear in 37.5% of patients (3/8) at the mean follow-up after four years, Hohman et al. describe this complication occurring in 100% of patients (7/7) at the mean follow-up after three years.24,25 As cartilage wear is likely to occur with time, especially in active patients, the current recommendation is to use DHH only for elderly and multimorbid low-demand patients.22 DHH for distal humerus fractures should be used with caution, pending the outcome of further information on larger cohorts followed up for longer periods.23-25 Recommendation Joint arthroplasty for displaced fractures of the neck of the femur and head of the humerus in the elderly is accepted practice and primary elbow replacement in similar circumstances could be considered. The expertise and familiarization of the surgeon is an important determining factor in the choice between ORIF and TEA in distal humerus fractures, since the placement of elbow prostheses remains a low volume procedure. TEA can be an alternative form of treatment for severely comminuted fracture of the distal aspect of the humerus in older patients, even in open fractures. This procedure is not an alternative to osteosynthesis in younger patients. Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Disclosure statement There was no external funding source for this study. None of the authors had a financial benefit.

References

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1. Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment. The Journal of bone and joint surgery. British volume. 2008;90(3):343-8. 2. Athwa GS, Goetz TJ, Pollock JW, Faber KJ. Prosthetic replacement for distal humerus fractures. The Orthopedic clinics of North America. 2008;39(2):201-12. 3. Egol KA, Tsai P, Vazques O, Tejwani NC. Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows. American journal of orthopedics. 2011;40(2):67-71. 4. Mehlhoff TL, Bennett JB. Distal humeral fractures: fixation versus arthroplasty. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons. 2011;20:97-106. 5. Patino, JM. Complex distal humerus fractures in elderly patients: open reduction and internal fixation versus arthroplasty. The Journal of hand surgery, 2012;37(8):1699-701. 6. Armstrong AD, Yamaguchi K. Total elbow anthroplasty and distal humerus elbow fractures. Hand clinics. 2004;20(4):475-83. 7. Letsch R, Schmit-Neuerburg KP, Stürmer KM, Walz M. Intraarticular fractures of the distal humerus. Surgical treatment and results. Clinical orthopaedics and related research. 1989;(241):238-44. 8. Gambirasio R, Riand N, Stern R, Hoffmeyer P. Total elbow replacement for complex fractures of the distal humerus. An option for the elderly patient. The Journal of bone and joint surgery. British volume. 2001;83(7):974-8. 9. Prasad N, Dent C. Outcome of total elbow replacement for rheumatoid arthritis: single surgeon’s series with Souter-Strathclyde and Coonrad-Morrey prosthesis. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons. 2010;19(3):376-83. 10. Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. The Journal of bone and joint surgery. British volume. 2002;84(6):812-6. 11. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. The Journal of bone and joint surgery. American volume. 1997;79(6):826-32. 12. Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. Journal of orthopaedic trauma. 2003;17(7):473-80.

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13. McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R et al. A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons. 2009;18(1):3-12. 14. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. The Journal of bone and joint surgery. American volume. 2004;86(5):940-7. 15. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons. 2011;20(1):158-68. 16. Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ. Functional outcome of semiconstrained total elbow arthroplasty. The Journal of bone and joint surgery. American volume. 2000;82-A(10):1379-86. 17. Ducrot G, Ehlinger M, Adam P, Di Marco A, Clavert P, Bonnomet F. Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases. OrthopTraumatolSurg Res. 2013;99(1):10-20. 18. Antuña SA, Laakso RB, Barrera JL, Espiga X, Ferreres A. Linked total elbow arthroplasty as treatment of distal humerus fractures.ActaOrthop Belg. 2012;78(4):465-72. 19. Chalidis B, Dimitriou C, Papadopoulos P, Petsatodis G, Giannoudis PV. Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature. Injury. 2009;40(6):582-90. 20. Lee KT, Lai CH, Singh S. Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients. J Trauma. 2006;61(4):889-92. 21. Ray PS, Kakarlapudi K, Rajsekhar C, Bhamra MS. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury. 2000;31(9):687-92. 22. Burkhart JK, Nijs S, Mattyasovszky SG, Wouters R, Gruszka D, Nowak TE, et al. Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient. J Trauma 2011;71:635-42. 23. Argintar E, Berry M, Narvy SJ, Kramer J, Omid R, Itamura JM. Hemiarthroplasty for the treatment of distal humerus fractures: Short term clinical results. The cutting edge 2012;35(12):1042-45. 24. Adolfsson L, Nestorson J. The Kudo humeral component as primary hemiarthroplasty in distal humeral fractures. J Shoulder Elbow Surg 2012;21:451-5. 25. Hohman DW, Nodzo SR, Qvick LM, Duquin TR, Paterson PP. Hemiarthroplasty of the distal humerus for acute and chronic complex intra-articular injuries. J Shoulder Elbow Surg 2013;18:1-8.

Intramuscular hemangioma of the extremities a case report and review of the literature Stijn E.W. Geraets, Anneke A.M. van der Wurff and Taco Gosens Introduction: Intramuscular hemangiomas are quite a rare entity and frequently misdiagnosed. Therefore we present this thorough review of the current literature of intramuscular hemangiomas of the extremities. Patient: 22 year old man with an intramuscular hemangioma in the deltoid muscle. Medical history revealed a palpable swelling which increased during exercise with progressive pain. A mass was palpable. Intervention: In accordance to MRI,surgical excision revealed an intramuscular hemangioma. Comparison: Literatures most important and most described features are presented in this review. Outcome: After a follow up of 1 year the patient did not have any recurrence of pain or a palpable mass and had completely resumed his sport activities. Recommendation: Best suitable diagnostic modalities are primarily ultrasound and secondarily MRI investigations. In experienced hand both diagnostics can be followed by biopsy. By far the most reported therapy is surgery which is indicated in a symptomatic intramuscular hemangioma.The best margin seemed to be a wide or marginal excision.

Introduction Intramuscular hemangiomas (IMH) are a quite rare entity and frequently misdiagnosed. Therefore we present this thorough review of the current literature of IMH of the extremities. Interpolation of data from the United States1 presents an annual incidence in The Netherlands of approximately 51.000 benign soft tissue tumors, compared with only 340 malignant soft tissue tumors. Hemangiomas are seen in 7% of all benign tumors.2 Intramuscular hemangiomas occur in 0.8% of all hemangiomas3-6 The extension “-oma” constrains a lesion arised by cellular proliferation and describes a benign neoplasma.7

any pathology. An MRI (Figures 1 and 2) revealed a hyperintens lesion on SPIR and T2 consisting of a lobulated structure. In T1 an isointens lesion was visible. The lesion was located intramuscular and no other shoulder muscle pathology was visible, in particular no previous suspected tendinitis.

Patient A 22 year old sportsman presented with pain localized in the upper arm. Medical history revealed a palpable swelling which increased during exercise with progressive pain. In the spinal part of the deltoid muscle, a mass of 8 cm distal to the acromion was palpable. During physical examination we could not provoke any pain and range of motion was not limited. Plain radiographs and ultrasound did not reveal S.E.W. Geraets1 MD, A.A.M. van der Wurff2 MD PhD and T. Gosens1 MD PhD 1 Department of Orthopaedic Surgery, St.Elisabeth Hospital, Tilburg, The Netherlands 2 Department of Pathology, St.Elisabeth Hospital, Tilburg, The Netherlands Corresponding author: S.E.W. Geraets Email: [email protected]

Figure 1. T2 MRI with the IMH located in the dorsal part of the deltoid.

Figure 2. T1 MRI. Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Intramuscular hemangioma of the extremities - a case report and review of the literature

Intervention Surgery followed with incision transverse in the direction of the deltoid muscle and a rich vascularized swelling was found. Margins of the lesion were hard to define and the lesion was resected intralesional. Pathologic examination revealed an arteriovenous hemangioma. Vol 21 mrt ’14

Comparison Presentation An IMH can occur in almost every muscle, very often head, neck and extremities are affected.7 Most IMH occur in the lower extremities,3,5,6,8 with the thigh being described as the most common single location.8 Current literature describes an IMH peak in adolescent woman and 80-90% of them are under the age of 30.5,6,9-11 The natural history is that the IMH remains relatively dormant until triggered by a trauma, a growth spurt or pregnancy.3,12,13 The deep intramuscular hemangiomas rarely show skin manifestations.1 A mass is nearly always present and was found in 98% of patients,3,6,13 and on palpation a hemangioma is compressible.1 Pain is an essential symptom occurring in 55-60% of the cases.3,6,13 The pain and/or swelling often worsen during excersize1,5 while rest could lessen or make the lesion disappear.1 Collected data from 45 patients in 37 case reports3,5,10,11,13-45 confirm those demographic facts: 64.4% of all patients are women and the average age is 21.4 (Range 0-70). The lower extremities were affected in 66.6%. However, the existence of pain and swelling differed in the case reports: 69% of the patients experienced pain and 64% noticed a swelling. The symptoms existed for an average time of 45.8 months (range 1 week -23 year) Hemangioma types are usually classified as small vessel (capillary type), large vessel (cavernous type) and the mixed type.2,8 The IMH have no tendency to metastasize,6,23 and malignant change is extremely rare. Review of the literature showed us only one new case of an angiosarcoma arising in a hemangioma.46 IMH are often misdiagnosed, seen the rarity of the lesions.9,11 Wild referred to 3 studies which proved misdiagnosis in 90% of all intramuscular hemangiomas.6 Differential diagnostic malignant tumors should be taken into consideration. However more aggressive vascular tumors such as the low grade malignant epithelioid hemangio-endothelioma and the intermediate grade angiosarcoma are rare in older children and young adults.7 Also difficult to

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differentiate from hemangiomas are angiolipomas, lymphangiomas.9 On the other hand an IMH can be considered as being a more common lesion, as in the case reports where the IMH was contiguous to the ulnar nerve11 and radial nerve branches24 and were mimicking neuromas. Nakamura described a rare case in which a IMH of the gastrocnemicus muscle caused a recurrent ankle equinus deformity. The patient had undergone four open tendoachilles lengthening procedures with the diagnosis idiopathic shortening of the tendoachilles before IMH was diagnosed.3 Furthermore, Sunil described a case with an IMH in the flexor digitorum superficialis presenting with a Volkmann’s contracture.25 Finally a characteristic orthopedic complaint, the snapping hip, was due to a IMH in the case report by Lin.30 Diagnostics Lesions arising in a muscle may create significant diagnostic uncertainty. However, IMH can be diagnosed with some confidence.1 Literatures most important and most described features are given in Table 1. The advice of Griffin is to perform ultrasound as an excellent tool helping to make the diagnosis, although MRI is preferred for surgical planning. When uncertainty exists, a clinical or image-guided biopsy may be performed safely.48 Therefore both the surgeon as well as the pathologist should have experience in dealing with all preoperative differential diagnoses.1 Performing ultrasound in diagnosing IMH of the extremities is confirmed by Kang Bin who found the ultrasound diagnostics of perfect accuracy with 100% diagnostic accuracy.49 According to the study of Wu, the sensitivity of MRI using the presentation of a lobulated pattern in T2-weighted MR imaging to detect the cavernous type IMH, is 93.3% and the using of the serpiginous to the capillary type it is 55.6%. The specificity is 66.7% and 100%, respectively.50 Nuclear imaging is described by Verdú, where increased Thallium-201 uptake supported the possibility of malignancy, but increasing uptake with Tc-99m red blood cells suggested a hemangioma.51 Mandell supported this already in 1986 describing the extra-osseous uptake in the delayed fase of bone imaging.52 Two case reports described the rare phenomenon of ossifications in IMH.53,54 Periostal reaction has been described as a reaction in the bone adjacent to the IMH. X rays showed a hypertrophic periostal reaction with cortical thickening, bone hypertrophy and erosions.20,55,56 The periostal reaction mimics other periostal or paraosteal lesions such as osteosarcoma, chondrosarcoma, a ganglion and

Stijn E.W. Geraets, Anneke A.M. van der Wurff and Taco Gosens

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Table 1. Clinical summary Clinical features Long clinical history.48,58 Most IMH occur in the lower extremities.3,5,6,8 The thigh is the most common single location.8 Peak in adolescent woman, 80-90% before the age of 30.5,6,9-11 A mass is nearly always present (98%).3,6,13 Pain is an essential symptom (55-60%).3,6,13 Pain and/or swelling often worsen during excersize.1,5

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Diagnostic modalities Perform ultrasound as an excellent tool helping to make the diagnosis.48,49 MRI is preferred for surgical planning.48 Clinical or image-guided biopsy in case of existing uncertainty.48 Diagnostic Radiologic features Sonography: higher suspicion when encountered a hyperechogenic structure.59 MRI T1: IMH is typically poorly marginated and isointense to skeletal muscle. Intralesional regions, lace like to thick bands, of increased signal approximating that of subcutaneous fat.55,60 MRI T2: IMH is typically well marginated, hyperintense compared to subcutaneous fat. Segments and septations are isointense to fat and\or muscle.55,60-62 Presence of fat (most of which contained in the margins of the lesion), calcification and large internal vessels should alert to the diagnosis of benign IMH48,58, especially the characteristic vascular fibrofatty structure.61-63 The presence of phleboliths and calcium deposits may be helpful in diagnosing an IMH but does not appear to be a constant feature.10,11,19,20,22,25,64,65 Treatment Minor discomfort: supervised neglect.20,23 Surgical treatment in symptomatic IMH: Wide or marginal excision.3,6,8,57

periostitis.10,18,20 In a retrospective study of 115 histologically proven deep soft tissue hemangiomas 20% demonstrated phleboliths and 21% reactive bone changes.56 MRI performed in the same study demonstrated absence of bone changes in 39 of 55 patients56 and subsequent also normal radiographs do occur.5 Treatment Hemangiomata with minor local discomfort or asymptomatic IMH merely require supervised neglect.20,23 Surgical therapy is indicated in symptomatic IMH2,with acceleration of tumor growth,functional impairment, risk of local skin necrosis, thrombocytopenia, cosmetic deformity and suspicion of malignancy.8 It is described as the only treatment that can rule out malignancy of the entire tumor.6 The surgical margin is the major determinant for

local recurrence free survivorship while tumor size has lesser influence as a risk factor.8 17-20% recurrence rate is thought to be related with inadequate primary surgical excision.5,9 Some authors do state that intralesional or marginal excision is the recommended surgical treatment, seen as an hemangioma is considered being a benign lesion.2 However, most studies, of some with larger patients population, recommend to strive to achieve en bloc,3 wide or marginal excision.6,8,57 This resulted in 92% recurrence- free survival after 5 years in contrast to 65% recurrence- free survival after 5 years when only intralesional excision was obtained.8 Bella states that the best treatment for IMH is unclear, in part, because of a variable outcome with recurrence rates ranging from 18% to 61%. The given variance is due to deficiencies in previous reports as lack of a detailed demographic description.8 Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Other treatment modalities, which are obviously less frequent described, are suture ligation of all feeding and draining veins17 and YAG laser therapy. The laser therapy used to treat an IMH of the soleus muscle resulted after a follow up of 6 months in a 75-80% reduction in lesion size on MRI with relief of symptoms.27 Three patients in case reports treated with sclerotherapy did not have complete remission of their initial complaints.5,14,26 Embolisation, cryotherapy or combined modalities are described, however those did not appeared in the present search. Outcome After a follow up of 1 year the patient did not have any recurrence of pain or a palpable mass and had completely resumed his sport activities. Relevant literature We conducted a thorough systematic search since a systematic review does not exist. Therefore we conducted a MEDLINE (1966 to January 2013), EMBASE (1989 to January 2013), and Google Scholar search to retrieve all literature concerning intramuscular hemangiomas of the extremities. Recommendation Previous authors all agree IMH are often difficult to diagnose and are susceptible for diagnostic delay. The patient is typically an adolescent woman under the age of 30. With a deeply located mass which is often painful. Best suitable diagnostic modalities are primarily ultrasound and secondarily MRI investigation. In experienced hands both diagnostics can be followed by biopsy. By far the most reported therapy is surgery which is indicated in a symptomatic IMH. The best margin seemed to be a wide or marginal excision. It is of great importance to keep in mind this review, it presents an overview of the existing literature consisting solely of case reports and descriptive studies. Such rare pathology therefore belong to specialized multidisciplinary teams. Conflict of Interest Statement No conflicts of interest reported.

References 1. Damron TA, Beauchamp CP, Rougraff BT, Ward WG, Sr. Soft-tissue lumps and bumps. Instr Course Lect 2004;53:625-37. 2. Tang P, Hornicek FJ, Gebhardt MC, Cates J, Mankin HJ.

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Surgical treatment of hemangiomas of soft tissue. Clin Orthop Relat Res 2002(399):205-10. 3. Nakamura T, Matsumine A, Nishiyama M, Uchida A, Sudo A. Recurrent ankle equinus deformity due to intramuscular hemangioma of the gastrocnemius: case report. Foot Ankle Int 2010;32(9):905-7. 4. Fern SE, Coggins CA, Massey HD, Foster WC. Intramuscular angiomatous tumors associated with periosteal changes and pain. J Surg Orthop Adv 2005;14(1):37-41. 5. Wisniewski SJ, Newcomer K, Stanson AW. Intramuscular hemangioma of the foot: a diagnostic dilemma. Med Sci Sports Exerc 2005;37(10):1655-7. 6. Wild AT, Raab P, Krauspe R. Hemangioma of skeletal muscle. Arch Orthop Trauma Surg 2000;120(3-4):139-43. 7. Hein KD, Mulliken JB, Kozakewich HP, Upton J, Burrows PE. Venous malformations of skeletal muscle. Plast Reconstr Surg 2002;110(7):1625-35. 8. Bella GP, Manivel JC, Thompson RC, Jr., Clohisy DR, Cheng EY. Intramuscular hemangioma: recurrence risk related to surgical margins. Clin Orthop Relat Res 2007;459:186-91. 9. Quinn PS, Sieunarine K, Lawrence-Brown M, Tan P. Intramuscular haemangiomas: hookwire localization prior to surgical excision: report of four cases. ANZ J Surg 2001;71(1):62-6. 10. Farrokh D. Intramuscular hemangioma mimicking a bone tumor on plain film. JBR-BTR 2000;83(3):105-7. 11. Pulidori M, Capuano C, Mouchaty H, Cioffi F, Di Lorenzo N. Intramuscular thrombosed arteriovenous hemangioma of the upper right arm mimicking a neuroma of the ulnar nerve: case report. Neurosurgery 2004;54(3):770-1; discusion 771-2. 12. Cho MW, Johnston S, Neitzschman HR. Radiology case of the month: 11-year-old girl with intramuscular hemangioma. Intramuscular hemangioma within the right soleus muscle. J La State Med Soc 2011;163(4):234, 236. 13. Chang JJ, Lui TH. Intramuscular haemangioma of flexor digitorum brevis. Foot Ankle Surg 2010;16(2):e8-11. 14. Brown RA, Crichton K, Malouf GM. Intramuscular haemangioma of the thigh in a basketball player. Br J Sports Med 2004;38(3):346-8. 15. Chadha M, Singh AP. Unusual knee swelling: a diagnostic dilemma. Arch Orthop Trauma Surg 2007;127(7):593-6. 16. Constantinou M, Vicenzino B. Differential diagnosis of a soft tissue mass in the calf. J Orthop Sports Phys Ther 2005;35(2):88-94. 17. Hristov N, Atanasov Z, Zafirovski G, Mitrev Z. Intramuscular cavernous hemangioma in the left soleus muscle: successful surgical treatment. Interact Cardiovasc Thorac Surg 2011;13(5):521-2. 18. Kayias EH, Drosos GI, Kazakos KI, Iatrou C, Blatsoukas KS, Verettas DA. Intramuscular haemangioma of the extensor pollicis brevis muscle with periosteal reaction of the radius: a case report and review of the literature. J Int Med Res 2007;35(5):724-30. 19. Kim DH, Hwang M, Kang YK, Kim IJ, Park YK. Intramuscular hemangioma mimicking myofascial pain syndrome: a case report. J Korean Med Sci 2007;22(3):580-2. 20. Kudawara I, Yoshikawa H, Araki N, Ueda T. Intramuscular haemangioma adjacent to the bone surface with periosteal reaction. Report of three cases and review of the

Stijn E.W. Geraets, Anneke A.M. van der Wurff and Taco Gosens

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lower extremity. GaziMedJ 2006;17(2):114-115. 41. Bouwen A, Vanderstraeten G, Mastelinck C. [Cavernous hemangioma in the right long flexor muscle of the toe. A case report]. Acta Belg Med Phys 1990;13(1):27-8. 42. Nack J, Gustafson L. Intramuscular hemangioma. Case report and literature review. J Am Podiatr Med Assoc 1990;80(8):441-3. 43. Picci P, Sudanese A, Greggi T, Baldini N. Intramuscular hemangioma in infancy: diagnostic and therapeutic considerations. J Pediatr Orthop 1989;9(1):72-5. 44. Shajrawi I, Dreyfuss UY, Stahl S, Boss JH. Intramuscular haemangioma of the forearm. J Hand Surg Br 1990;15(3):362-5. 45. Kryzak TJ, Jr., DeGroot H, 3rd. Adult onset flatfoot associated with an intramuscular hemangioma of the posterior tibialis muscle. Orthopedics 2008;31(3):280. 46. Rossi S, Fletcher CD. Angiosarcoma arising in hemangioma/vascular malformation: report of four cases and review of the literature. Am J Surg Pathol 2002;26(10):1319-29. 47. Russell S, Watts RG, Royal SA, Barnhart DC. Group A streptococcal infection of an intramuscular venous malformation: a case report and review of the literature. Pediatr Emerg Care 2008;24(12):839-41. 48. Griffin N, Khan N, Thomas JM, Fisher C, Moskovic EC. The radiological manifestations of intramuscular haemangiomas in adults: magnetic resonance imaging, computed tomography and ultrasound appearances. Skeletal Radiol 2007;36(11):1051-9. 49. Kang B, Du J, Huang J. Ultrasonographic diagnosis of hemangiomas of soft tissue. J Tongji Med Univ 1997;17(3):168-71. 50. Wu JL, Wu CC, Wang SJ, Chen YJ, Huang GS, Wu SS. Imaging strategies in intramuscular haemangiomas: an analysis of 20 cases. Int Orthop 2007;31(4):569-75. 51. Verdu J, Martinez A, Anton MA, Munoz JM, Riera M, Jover R, et al. Increased thallium-201 uptake and Tc-99m red blood cell accumulation in hemangioma. Clin Nucl Med 2005;30(1):25-6. 52. Mandell GA, Harcke HT, Davis N. Accumulation of technetium-99m MDP in an intramuscular hemangioma. Clin Nucl Med 1986;11(7):487-90. 53. Nagira K, Yamamoto T, Marui T, Akisue T, Yoshiya S, Kurosaka M. Ossified intramuscular hemangioma: multimodality imaging findings. Clin Imaging 2001;25(5):368-72. 54. Jin W, Kim GY, Lee JH, Yang DM, Kim HC, Park JS, et al. Intramuscular hemangioma with ossification: emphasis on sonographic findings. J Ultrasound Med 2008;27(2):281-5. 55. Yuh WT, Kathol MH, Sein MA, Ehara S, Chiu L. Hemangiomas of skeletal muscle: MR findings in five patients. AJR Am J Roentgenol 1987;149(4):765-8. 56. Sung MS, Kang HS, Lee HG. Regional bone changes in deep soft tissue hemangiomas: radiographic and MR features. Skeletal Radiol 1998;27(4):205-10. 57. Muramatsu K, Ihara K, Tani Y, Chagawa K, Taguchi T. Intramuscular hemangioma of the upper extremity in infants and children. J Pediatr Orthop 2008;28(3):387-90. 58. Papp DF, Khanna AJ, McCarthy EF, Carrino JA, Farber AJ, Frassica FJ. Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions. J Bone


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Joint Surg Am 2007;89 Suppl 3:103-15. 59. Derchi LE, Balconi G, De Flaviis L, Oliva A, Rosso F. Sonographic appearances of hemangiomas of skeletal muscle. J Ultrasound Med 1989;8(5):263-7. 60. Kransdorf MJ. Magnetic resonance imaging of musculoskeletal tumors. Orthopedics 1994;17(11):1003-16. 61. Buetow PC, Kransdorf MJ, Moser RP, Jr., Jelinek JS, Berrey BH. Radiologic appearance of intramuscular hemangioma with emphasis on MR imaging. AJR Am J Roentgenol 1990;154(3):563-7. 62. Cohen EK, Kressel HY, Perosio T, Burk DL, Jr., Dalinka MK, Kanal E, et al. MR imaging of soft-tissue hemangiomas: correlation with pathologic findings. AJR Am J Roentgenol 1988;150(5):1079-81.

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63. Jenner G, Soderlund V, Bauer HF, Brosijo O. MR imaging of skeletal muscle hemangiomas. A report of 16 cases. Acta Radiol 1996;37(2):140-4. 64. Greenspan A, McGahan JP, Vogelsang P, Szabo RM. Imaging strategies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI, and ultrasonography in 12 histologically proven cases. Skeletal Radiol 1992;21(1):11-8. 65. Yamamoto H, Schafer H, Sakae T, Mishima H. Phlebolithiasis associated with intramuscular hemangioma. X-ray diffractometric, X-ray microanalytical and scanning electron microscopic investigations. Pathol Res Pract 1986;181(1):55-9.

Proefschriftbespreking Hip resurfacing, does it meet the expecations? - Heup resurfacing, gouden bergen of gouden standaard? José Smolders, Radboud Universiteit Nijmegen, 18 september 2013 De succesvolle behandeling van coxartrose met heupprothesen heeft in de loop van jaren geleid tot een uitbreiding van het indicatiegebied. Ten einde ook bij jongere patiënten goede lange termijnresultaten te bereiken na het plaatsen van een toale heupprothese, worden hogere eisen gesteld aan implantaten en materiaaleigenschappen. Aseptische loslating op basis van polyethyleenslijtage heeft geleid tot een zoektocht naar nieuwe, slijtvastere materialen, waardoor ook andere eigenschappen van de implantaten, zoals de grootte van de heupkop, konden worden geoptimaliseerd. De korte termijnresultaten van de Birmingham heup resurfacing prothese hebben eind jaren 90 geleid tot een grootschalige introductie van metaal-opmetaal (MoM) resurfacing heupprotheses op de markt. Het van de markt halen van een van deze prothesen in 2010 heeft uiteindelijk mede geleid

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tot een advies in 2012 van onze vereniging om geen MoM-heupprothesen met grote koppen (≥36 mm) te plaatsen totdat lange termijnresultaten de werkzaamheid en veiligheid aantonen. Internationaal werden andere maatregelen genomen en adviezen geformuleerd. Dat bleek onder andere tijdens de laatste bijeenkomst van de European Hip Society 2012, waar naast kritische voordrachten ook nieuwe series met enthousiasme werden gepresenteerd. Het blijft daarom belangrijk om de ervaringen en resultaten van uitgevoerd en nog lopend onderzoek te volgen. Op 18 september 2013 promoveerde José Smolders op een proefschrift waarin zij de verschillende resultaten van een RCT presenteert, waarbij een resurfacing heup arthroplastiek (RHA) werd vergeleken een ongecementeerde heupprothese, ook met MoM articulatie. Het samenvattende doel van dit

Post-operatieve infectie? tŽŶĚ͕Ͳ ĞŶ /ŵƉůĂŶƚĂĂƚ ŝŶĨĞĐƟĞƐ ǁŽƌĚĞŶ ƐƚĞĞĚƐ ǀĂŬĞƌ ǀĞƌŽŽƌǌĂĂŬƚĚŽŽƌƌĞƐŝƐƚĞŶƚĞďĂĐƚĞƌŝģŶ͘ ŽǀĞŶĚŝĞŶ ǌŝũŶ ďŝũ ƐŽŵŵŝŐĞ ŽƌƚŚŽƉĞĚŝƐĐŚĞ ŝŶĨĞĐƟĞƐ ŵŝĐƌŽͲ ŽƌŐĂŶŝƐŵĞŶŵŽĞŝůŝũŬƚĞŬǁĞŬĞŶ͘ Ğ hŶǇǀĞƌŽ ϯ ŵŽůĞĐƵůĂŝƌĞ ŝŶĨĞĐƟĞ ĚŝĂŐŶŽƐƟĞŬ ŵĂĂŬƚ ŚĞƚ ǀƌŽĞŐƟũĚŝŐ ŽƉƐƉŽƌĞŶ ǀĂŶ ǌŝĞŬƚĞǀĞƌǁĞŬŬĞƌƐ ĞŶ ĂŶƟďŝŽƟĐĂ ƌĞƐŝƐƚĞŶƟĞƐ ŵŽŐĞůŝũŬ met één ďĞƉĂůŝŶŐ͘ ,ĞƚƌĞƐƵůƚĂĂƚŝƐŝŶĐĂ͘ϰͲϱƵƵƌďĞƐĐŚŝŬďĂĂƌ͘ĂĂƌŵĞĞŝƐĞĞŶƐŶĞůůĞ ĞŶŐĞƌŝĐŚƚĞƐƚĂƌƚǀĂŶĚĞƚŚĞƌĂƉŝĞ ŵŽŐĞůŝũŬ͘

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proefschrift is de evaluatie van klinische resultaten, dynamiek van metaalionconentraties en veranderingen in botdichtheid van een RHA en deze te vergelijken met een conventionele prothese.

Vol 21 mrt ’14

In hoofdstuk 1 wordt een algemene introductie gegeven over heupartrose en de behandeling daarvan. De geschiedenis van de heupprothese en met name de MoM prothesen wordt gevolgd door de beschrijving van de potentiële voordelen van de RHA. In hoofdstuk 2 wordt een analyse beschreven van de eerste serie van 40 RHA patiënten, in 4 cohorten van 10, waarmee de leercurve van één chirurg werd bestudeerd. De preoperatief geplande, ideale positie van de componenten, gebaseerd op onderzoek van Beaule uit 2004, werd vergeleken met de - radiologisch vastgestelde - bereikte positie. Additioneel werd nog de positie van het steeltje van de femurcomponent geëvalueerd door het collum in 3 gelijke derden te verdelen op de AP en axiale opname. In het laatste cohort was gemiddeld 10 minuten minder operatietijd nodig en de optimale positie werd in het verloop van de 4 cohorten steeds beter bereikt. De boodschap van deze studie was dat de optimale protheseoriëntatie met grote reproduceerbaarheid door een ervaren heupchirurg binnen 40 patiënten bereikt werd.

In hoofdstuk 3 wordt voor het eerst de randomised controlled trial (RCT) beschreven die de basis vormt voor dit proefschrift. In dit hoofdstuk wordt de functionele uitkomst op korte termijn beschreven en wordt een analyse verricht van de metaalionconcentraties van de RCT waarin de Conserve Plus resurfacing heupprothese werd vergeleken met de Zweymuller Classic Metasul prothese met 28mm MoM articulatie. Achtendertig patiënten werden gerandomiseerd voor een RHA en 33 voor een THP. De auteurs presenteren, i.v.m. de toenemende wetenschappelijke zorg over de RHA en potentieel negatieve effecten van metaalionen, de tussentijdse resultaten van de eerste 40 patiënten met de gebruikelijke minimale 2 jaar en van 70 patienten met 1 jaar follow up. Er waren geen verschillen in baseline gegevens, de groepen waren vergelijkbaar. De RHA operaties duurden langer, het bloedverlies was niet verschillend. Er was een duidelijke functionele verbetering in beide groepen en hoewel de Harris Hip Score gelijk was na 24 maanden, was er een functioneel voordeel voor de RHA patiënten met betrekking tot de UCLA-activiteitenscore, de Oxford Hip score en VAS tevredenheid. De volbloedconcentraties na 24 maanden voor Chroom en Kobalt waren in de RHA groep hoger dan in de THP groep, maar bleven wel onder de afwijkende waarden. De baseline concentraties lagen onder de normaalwaarde van 0,1μg/L. Complicaties bestonden uit 3 recidiverende luxaties in de THP groep, waarvan 2 patienten een vroege revisie ondergingen en 1 vroege loslating op basis van avasculaire necrose in de RHA groep. In hoofdstuk 4 wordt onderzocht wat de invloed is van voorkeur van patiënten voor een van de ingrepen op de klinische uitkomst en tevredenheid. Hiervoor werden 28 opeenvolgende patiënten (28 heupen) uit de RCT die een RHA kregen vergeleken met 22 patiënten (24 heupen) die niet aan de studie wilden meedoen omdat zij een voorkeur hadden voor de RHA. Er werd geen verschil gevonden in klinische uitkomstmaten na 12 maanden; wel scoorde de voorkeurgroep preoperatief lager op de SF-12 score maar dit verdween na 12 maanden. De invloed van voorkeur op patiënttevredenheid en vroege klinische uitkomsten na RHA kon niet worden vastgesteld. De onderzoekers stellen dat de evaluatie van metaalionconcentraties bij MoM heupprothesen steeds meer gebruikt wordt als indicator van het functioneren van de prothese en bij het bepalen van de veiligheid. In hoofdstuk 5 wordt bestudeerd of de metaalionconcentraties in serum en volbloed vergelijkbaar zijn en of het mogelijk is deze waarden naar elkaar toe om te rekenen. Dit wordt gedaan door van de patiënten uit de RCT en een RHA co-

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hort (60 RHA, 32 MoM-THP) 343 samples volbloed en serum te vergelijken. Complexe statistische methoden werden gebruikt om de data te analyseren. Kobalt serumwaarden waren iets lager dan volbloedconcentraties (gemiddelde verschil +0,13μg/L). Chroom serumwaarden waren hoger dan volbloedwaarden (gemiddelde verschil -0,91μg/L). Deze verschillen zijn in overeenstemming met data uit een eerdere studie. Er wordt een formule gegeven waarmee de concentraties kunnen worden omgerekend. Hierbij moet men onder andere rekening houden met een acceptabele foutmarge van 1,0 μg/L. De auteurs konden op basis van dit onderzoek geen aanbeveling doen of serum dan wel volbloed verkozen dient te worden voor de evaluatie van de gemeten metaalionconcentraties. In hoofdstuk 6 wordt bij de 48 patiënten met een unilaterale RHA onderzocht of er een verschillende trend bestaat van metaalionconcentraties tussen patiënten met een goed en slecht functionerende RHA. De concentraties werden gemeten op baseline, na 3, 6, 12, 24 en 36 maanden. Suboptimaal functionerende MoM-prothesen (6 patiënten) hadden een andere trend van metaalionconcentraties dan de goed functionerende prothesen (42 patiënten), een hoger percentage stijgers en een grotere absolute toename per tijdsinterval. Het advies was om laagdrempelig concentraties metaalionen te herhalen, met name van kobalt. Systemische klachten, een steile cupplaatsing en te hoge of stijgende metaalionconcentraties kunnen indicatief zijn voor een zogenaamde ‘adverse reaction metal debris’ (ARMD). Zorgvuldige klinische controle van deze patiënten met aanvullend beelvormend en bloedonderzoek wordt geadviseerd. Omdat de waarde van metal artifact reduction sequence-MRI (MARS-MRI) nog niet vast staat werd, vooruitlopend op mogelijk toekomstige screening, het screeningsprotocol van 298 RHA’s geïntensiveerd. De MRI’s van deze RHA’s, zonder klinische verdenking op pseudotumorvorming, werden gebruikt. Op basis van geslacht, cupinclinatie >45° en prothesediameter >50 mm. en symptomen werden drie risicogroepen voor ARMD gedefinieerd. Laagrisico (n=11 12 heupen), hoogrisico (n=10, 10 heupen), routine groep opeenvolgende patiënten. Het risico op pseudotumorvorming volgens de Anderson classificatie in de laagrisicogroep 0,33, in de hoogrisicogroep 0,45 en in de routinegroep 0,30. Er werden 15 pseudotumoren gevonden; volgens Anderson waren 6 geclassificeerd als lichte vorm van MoM-ziekte, 8 matig en 1 ernstig. Twaalf patiënten hadden geen symptomen, en werden beschouwd als stille pseudotumoren. Bij 80% van de patiënten was de metaalionconcentratie normaal. Geconcludeerd kon worden dat zonder cross-

sectionele beeldvorming er minder pseudotumoren gevonden worden. Er is echter geen consensus over de klinische relevantie en de consequentie van het vaststellen van pseudotumorvorming. In hoofdstuk 8 wordt de verandering van de periacetabulaire botmineraaldichtheid (BMD) na HRA vergeleken met die na THP plaatsing. In contrast met de opgestelde hypothese werd gevonden dat de periacetabulaire BMD beter behouden blijft na RHA dan na een conventionele THP. Lange termijnstudies zullen moeten aantonen of dit gevonden verschil ook op lange termijn blijft bestaan en of dit een klinisch voordeel oplevert. In de discussie wordt de indicatie voor HRA besproken. Gebaseerd op de huidige literatuur en de gegevens uit de implantaatregisters zijn hiervoor criteria op te stellen: mannelijk geslacht, jonger dan 55 jaar, femorale diameter groter dan 50 mm., BMI <35 kg/ m2 en primaire heupartrose. Het revisiepercentage na 10 jaar van RHA is bij mannen, met een femorale diameter >50 mm. ongeacht de leeftijd, 5,1%. Het revisiepercentage bij mannen, jonger dan 55 jaar, met primaire heupartrose is na 10 jaar 6,1% voor HRA en voor de ‘gouden standaard’ metaal-op-polyethyleen THP 9,3%. De resultaten variëren tussen de HRA van verschillende fabrikanten. Er bestaan verschillen in productie en productkenmerken, verschillen in preklinisch en klinisch vooronderzoek, introductie op de markt en training van chirurgen. In de discussie wordt verder ingegaan op de toenemende bezorgdheid over MoM prothesen en wordt de time-out wat betreft MoM prothesen bediscussieerd. De resultaten van dit proefschrift zijn gebaseerd op een specifiek RHA-merk en alle patiënten werden geopereerd door een beperkt aantal ervaren heupchirurgen. Bovendien betreft het onderzoek met een relatief korte follow-up (maximaal 3 jaar). Dit cohort RHA patiënten en de patiënten uit de RCT zullen in langere termijn follow-up leerzame gegevens opleveren die mede bepalen in welke mate er plaats is voor RHA en kleine diameter MoM-THP. José Smolders (en haar begeleiders) leveren met dit proefschrift een goede bijdrage aan de groeiende kennis over de MoM heupprothesen. De introductie van nieuwe implantaten in de praktijk dient zorgvuldig te gebeuren. Uiteindelijk zullen goed uitgevoerd onderzoek en duidelijk gepresenteerde onderzoeksresultaten met interpretatie daarvan ons leren welke nieuwe implantaten daadwerkelijk een verbetering vormen voor de, al succesvolle, behandeling van heupartrose. Bovenstaand proefschrift vormt daar een mooi voorbeeld van. Koen Bos Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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Van de Vereniging

Task Force Jonge Klaren Actieplan 2014 In 2013 is de Task Force Jonge Klaren in het leven geroepen. Taak: initiatieven ontplooien die zoveel mogelijk Jonge Klaren aan het werk helpen.

Uit de VOCA-cijfers (tabel 1) blijkt dat medio dit jaar bijna honderd orthopedisch chirurgen geen vaste aanstelling hebben. Deze situatie bestaat al even en was voor het NOV-bestuur in 2013 aanleiding om de Task Force Jonge Klaren te installeren. Doel: de situatie analyseren en zo snel mogelijk zo veel mogelijk Jonge Klaren aan het werk helpen. Tabel 1: Aantal orthopedisch chirugen zonder of met een tijdelijk dienstverband (bron: VOCA). Orthopedisch chirurgen: Begin 2014 Medio 2014 - zonder baan 14 24 - met tijdelijk dienstverband 64 71 Verwachtte uitstroom: 40

NOV Fellowship Orthopedie Specifiek voor 2014 laat Task Force-voorzitter Sjoerd Bulstra weten dat tijdens de afgelopen ALV het reglement NOV Fellowship Orthopedie is vastgesteld. Bulstra heeft de NOV Werkgroepen verzocht een fellowship inhoudelijk te beoordelen. Het Concilium is belast met de coördinatie van de adviezen die werkgroepen geven, met de nalevingscontrole en met de accreditatie. Bultstra voegt toe: “Deze officiële fellowstatus zorgt ook voor enthousiasme bij de industrie. Ik ben positief gestemd dat dit tot resultaat gaat leiden.” Buitenland bemiddeling De blik gaat ook naar het buitenland. Bulstra: “Op de site staat al een link naar een Duits bureau dat bemiddelt in aanstellingen in Duitsland. We streven ernaar een dergelijk aanbod ook te doen voor Noorwegen en Zweden.” NOV Beroepsoriëntatiedag Het plan is om in het najaar een NOV Beroepsoriën-

tatiedag te organiseren. “Doel is ons aller blik te verruimen: waar is orthopedische kennis nog meer waardevol inzetbaar en hoe kun je je nog verder en breder ontwikkelen”, aldus Bulstra. “Wellicht zijn er mooie alternatieve carrièrekansen; niet alleen voor Jonge Klaren, maar ook voor collega’s die geheel of deels een andere carrière nastreven.” Ook op dit vlak zijn positieve gesprekken met de industrie gaande, evenals met ziekenhuisorganisaties, organisaties van bedrijfsartsen en verzekeringsartsen en met het bedrijfsleven. “Medische kennis is breed inzetbaar en bijvoorbeeld waardevol voor bedrijven die zich richten op bio engineering, eHealth, instrumentinnovatie of medisch juridische aspecten.” Gabriëlle Kuijer, communicatieadviseur NOV, [email protected] Deze situatie ís op te lossen De tijden van een baanzekerheid na je opleiding orthopedie zijn even voorbij. Gesprekken onder collega jonge klaren maken dit pijnlijk duidelijk. Een fellow in het buitenland, parttime betaald werk, werk buiten de orthopedie, een promotieplek of zelfs een onbetaalde ervaringsplek … zo ziet de markt eruit voor degenen die net orthopedisch chirurg geworden zijn. Zelf gebruik ik mijn tijd om te promoveren en heb ik een functie als waarnemend orthopedisch chirurg. Maar de onzekerheid over de toekomst is bij alle jonge orthopeden sterk voelbaar. Er zijn wat meer tijdelijke plekken gekomen nu het aanbod jonge orthopeden zo gegroeid is. Maar dat betekent nog steeds dat je binnen een half jaar tot een jaar weer op straat staat, samen met de 80 andere jonge klaren zonder vaste plek. De meesten van ons zien de toekomst toch rooskleurig. De vraag naar orthopedische expertise zal door de huidige vitale oudere generatie blijven toenemen. Maar hoe lang kunnen we daar nog op wachten. Mijn overtuiging is dat het tijdelijke overschot aan orthopeden kan worden opgelost als de gehele orthopedische beroepsgroep zich sterk maakt om jonge klaren aan het werk te helpen. Wieneke Metsaars, orthopedisch chirurg, lid van de Task Force Jonge Klaren.


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Vol 21 mrt ’14

Interview Henk Koot, NOV-voorzitter “Zet mij maar met Bos en bankiers aan tafel”

Vol 21 mrt ’14

Tijdens het NOV Jaarcongres, de dag voordat de NOV-leden hem tot voorzitter kozen, hield Henk Koot zijn jaarrede. Zo’n rede zegt veel over degene die hem uitspreekt en verschillende aspecten geven aanleiding tot een nadere kennismaking met Henk Koot als voorzitter, maar vooral als persoon.

Uw jaarrede opent u met trots. Vindt u dat de orthopedisch chirurgen trots genoeg zijn op hun vak? “Mijn collega’s zijn zeker zeer trots op hun vak, en terecht. Maar ik denk wel dat we die trots met z’n allen wat meer mogen uitdragen. Voor onszelf is het heel gewoon wat we doen; we mogen er meer bewust bij stilstaan dat we een heel bijzonder vak hebben met voor onze patiënten een heel direct en vergaand resultaat.” De media lijken daar soms anders over te denken. Is er wel voldoende ruimte om trots te kúnnen zijn? “Over het algemeen richten de media zich op zaken die niet goed gaan. Als je alleen die berichten volgt en die negativiteit bij elkaar optelt, dan lijkt het misschien alsof elke trots misplaatst is. Zonder te willen stellen dat er geen verbeterpunten zijn, wil ik wel benadrukken dat we het heel goed doen. Nederland staat sinds 2005 steevast in de top drie van de European Health Consumer Index - de laatste vijf jaren staan we zelfs op de eerste plaats. Daarbij hebben we ons eigen kwaliteitsregister LROI en iedere orthopedisch chirurg werkt keihard, zodat de wachtlijsten nagenoeg verdwenen zijn. Die ruimte om onze trots te etaleren, moeten we ook zelf creëren; als NOV, maar ook elke maatschap en vakgroep in de eigen regio. Mijn maten en ik stoppen energie in een goede website, we twitteren, zoeken de regionale pers op, kozen voor een eigen achterzijde op Zorg voor beweging Jaarmagazine en we zorgen voor goede contacten met de zorgketen, vooral de huisartsen. Persoonlijk voel ik mij elke keer weer trots als de verwachtingen van een patiënt zijn waargemaakt, of overtroffen. Als iemand zijn werk weer kan oppakken, als iemand zijn of haar zelfstandigheid behoudt en niet naar een verzorgingshuis hoeft, als een (top) sporter weer kan presteren. Laatst ontving ik een brief van kinderen van een patiënte. Deze dame had heel veel pech en de afgelopen twintig jaar heb ik haar meerdere keren geopereerd. Ze was inmiddels in de tachtig en ongeneeslijk ziek. Haar kinderen schreven dat ze hen vertelde: ‘Alleen dokter Koot komt aan mijn poot’. Zo’n bericht stemt mij gelukkig.”

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Het NOV motto luidt: ‘Orthopedie houdt Nederland in beweging’ en sport & bewegen staan steeds hoger op de politieke agenda. Welke kansen liggen hier voor de orthopedie? “De relatie leefstijl-gezondheid krijgt inderdaad steeds meer belangstelling. Daarbij gaat het om de preventie van welvaartsziekten als diabetes en obesitas en om het psychisch welbevinden. Wij mogen vanuit de orthopedie sterker benadrukken dat ons vak een grote bijdrage levert aan die preventie en aan die kwaliteit van leven. Bovendien moet men bedenken dat orthopedie mensen actief in het arbeidsproces houdt.” Voor welke sport komt u in beweging? “Ik ben een voetballer en cricketer. De tijdplanning als orthopedisch chirurg in een teamsport is helaas moeilijk en dus ben ik gaan golfen. Die sport combineert actief buiten bezig zijn, plezier en sociale contacten. Daarbij presteert iedere golfer op zijn eigen niveau – het mijne is niet bijster hoog – en gaat dit toch goed samen in de baan; dat is ook waarom ik ieder jaar met veel plezier deelneem aan de Orthopeden Golfdag.” De zorg ligt in toenemende mate onder een vergrootglas. U zegt: kom maar op met die vergrootglazen. Waarom vindt u het belangrijk dat de orthopedie die vergrootglazen verwelkomt en welk nut hebben ze? “We registreren, we meten, we leiden op, we werken aan richtlijnen en aan kwaliteit … we toetsen onszelf en stellen ons toetsbaar op. Meten is weten en dat moeten we delen. Al onze richtlijnen staan in de Richtlijnendatabase en zijn openbaar. Daarmee stellen we ons ook kwetsbaar op, want hoewel zo’n richtlijn geen blauwdruk is, behoor je wel te kunnen motiveren waarom je er eventueel van afwijkt. En dat is in zichzelf juist weer een goede zaak. De LROI geeft informatie over kwaliteitsaspecten van de producten waarmee we werken en van ons handelen. De PROMs voegen daar een extra dimensie aan toe. Die dwingen ons om met de patiënt, de klant, samen te werken. De PROMs dwingen ons om te kijken naar de persoon achter bijvoorbeeld die artrotische knie. Waarom is het voor deze persoon zo belangrijk om een goed functionerende knie te hebben en wanneer vindt deze persoon dat de knieprothese inderdaad goed functioneert? Dit is voor ons belang-

rijke informatie: niet alleen als uitkomstmaat, maar ook als intake: kunnen wij de verwachtingen van de patiënt waarmaken? Of is het eventueel nodig al vooraf een verwachting te temperen. Oftewel: de PROMs als verwachtingsmanagement-instrument. Het nut van de vergrootglazen is verder dat ze ons dwingen op de toppen van ons kunnen te functioneren en ze manen ons om in beweging te blijven.”

Ik zal écht trots zijn als alle leden lid blijven en hun stem gehoord weten binnen de Federatie. Daarnaast wil ik een wezenlijke bijdrage leveren aan een optimale samenwerking met de algemene heelkunde binnen het deelgebied traumatologie. Ik richt me op de toekomst en op de synergie die we daar kunnen bewerkstelligen. Met uiteindelijk één doel: de patiënt moet er beter van worden.”

Waar zou u wel eens het vergrootglas ter hand willen nemen?

Gabriëlle Kuijer, communicatieadviseur NOV, [email protected]

“Toen Wouter Bos ons Jaarcongres opende, vergeleek hij ons met bankiers. In eerste instantie was ik hier niet zo blij mee. Ik denk ook nog steeds dat er meer verschillen dan overeenkomsten zijn, maar ik wil er met Bos en met een aantal bankiers op door gaan: waar zitten de verschillen en de overeenkomsten? Wat kunnen wij van de bankiers leren?”

Lees ook de volledige Jaarrede van Henk Koot: www.orthopeden.org.

Vol 21

Hoe heeft u de afgelopen tijd toegeleefd naar het moment van de Jaarrede en naar het moment dat u tijdens de ALV de voorzittersketting en -hamer kreeg overhandigd van uw voorganger Jan Verhaar?

Als u over een paar jaar terugkijkt op uw voorzitterschap, waarop zult u het meest trots zijn? “De huidige situatie vraagt erom dat we als medisch specialisten de handen ineenslaan. Het gebeurt nu al dat de politiek, de zorgverzekeraars en de patiëntenvertegenwoordigers ons tegen elkaar uitspelen. Het antwoord ligt in de Federatie Medisch Specialisten Nederland. Ik weet dat een aantal leden hier niet positief tegenover staat en ik zie het als mijn taak, mijn missie, om hen mee te krijgen op deze route.

Foto: Werry Crone

“De afgelopen periode was gevuld met trots maar ook met een gezonde spanning. Ik ervaar het als een grote eer dat ik voorzitter mag zijn van de NOV; de club van orthopedisch chirurgen waar ik zelf al zo lang met veel genoegen deel van uitmaak. Ik ben ook echt een NOV-man. Eerder was ik voorzitter van de BBC en secretaris van het Concillium. Ik wil me graag inzetten voor mijn collega’s en voor ons mooie vak. De gezonde spanning zit erin dat ik me meer dokter voel dan voorzitter. Maar dat is goed en ik heb die spanning ook nodig om te presteren. Als vicevoorzitter heb ik het afgelopen jaar nauw samengewerkt met Jan Verhaar. Hij was een fantastische voorzitter en het is niet makkelijk om hem op te volgen. Maar ik ga het doen en vertrouw daarbij op mijn kernwaarden: ik geloof in samenwerken en in verbinden, ik zet in op interpersoonlijk contact en zal mijn lach altijd bij me hebben.”

Henk Koot Gymnasium Emmauscollege Rotterdam (1977); biochemie Rijks Universiteit Leiden (1981); geneeskunde Rijks Universiteit Leiden (1987); vooropleiding chirugie bij dr. A. Brinkhorst, Ikazia Ziekenhuis Rotterdam (1989); vervolgopleiding orthopedie bij prof. Th. Slooff en prof. R. Veth, Radboud Ziekenhuis Nijmegen (1994); orthopedisch chirurg Diaconessenhuis Eindhoven, overgaand in Maxima Medisch Centrum Eindhoven-Veldhoven en sinds 2011 ook orthopedisch chirurg Catharina Ziekenhuis Eindhoven als lid van de maatschap Orthopedie Groot-Eindhoven. Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 1, maart 2014

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mrt ’14

LROI-Rapportage 2012 Meer inzicht in kwaliteit van orthopedische zorg

Vol 21 mrt ’14

De titel van de LROI-rapportage 2012 spreekt voor zich: ‘Meer inzicht in kwaliteit van orthopedische zorg’. Deze rapportage is eind 2013 verstuurd naar de NOV-leden, naar zorgverzekeraars, raden van bestuur van de ziekenhuizen en naar de industrie. De rapportage is als pdf beschikbaar op www.lroi.nl.

In de LROI-rapportage 2012 staat beschreven dat de compleetheid van de LROI inmiddels is opgelopen tot nagenoeg 100%. Hiervoor worden jaarlijks zo’n 23.500 primaire heupprothesen en 22.000 primaire knieprothesen geregistreerd. Om deze compleetheid te berekenen is het geregistreerde aantal knie- en heupimplantaten vergeleken met het aantal ingrepen volgens het ziekenhuisinformatiesysteem (ZIS) van elke instelling. Aan de orthopedisch chirurgen is gevraagd om deze gegevens op basis van de zogenaamde CTG-codes aan te leveren. Een uiteindelijke compleetheid van 94% voor zowel primaire totale heupprothesen als voor primaire knieprothesen over het registratiejaar 2012 is het resultaat. Hierin zien we een stijgende lijn sinds het begin van de registratie. In de eerste jaarrapportage is namelijk beschreven dat de compleetheid over 2010 90 procent is. De compleetheidgegevens zijn naar alle orthopedische vakgroepen en maatschappen teruggekoppeld. In 2014 is een validatiestudie van start gegaan om de compleetheid en validiteit van de registratie nog verder te verbeteren. De rapportage geeft dit jaar voor de eerste keer inzicht in de top tien van de meest gebruikte heupen knieprothesen in Nederland. Een vergelijking van de geregistreerde implantaten met de Scandinavische landen (Zweden, Noorwegen en Denemarken) laat een grote diversiteit zien in de gebruikte implantaten. Dit is een extra motivatie voor een Nederlands register om de kwaliteit van de implantaten in de Nederlandse patiëntenpopulatie te monitoren en om inzicht te krijgen in de implantaten die in Nederland worden gebruikt.

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Patiënteninformatie Informatie voor de patiënt is één van de speerpunten van de LROI. Daarom is naast de LROI-rapportage voor de professional dit jaar ook een start gemaakt met de terugkoppeling van belangrijke LROI-gegevens naar de patiënt. Hiertoe zijn twee infographics ontworpen; één voor de heupprothese en één voor de knieprothese. In een combinatie van tekst, beeld en grafische vormen geeft elke infographic een overzicht van hoeveel primaire heup- respectievelijk knieprothesen zijn geplaatst, van een aantal patiëntkenmerken, de wijze van fixatie (gecementeerd/ongecementeerd) en van de redenen waarom een prothese op termijn weer wordt verwijderd. De infographics vindt u op de LROI website, maar ook op de patiëntenwebsites van de NOV: www.zorgvoorbeweging.nl en www.mijnheupprothese.nl. Uiteraard kunt u op de website van uw vakgroep of maatschap ook een link plaatsen naar deze infographics. Geke Denissen, projectcoördinator LROI, [email protected].

De LROI breidt uit! Nu ook schouder-, elleboog- en enkelprothesen Op 1 januari 2014 is de registratie van schouder-, elleboog en enkelprothesen van start gegaan in de Landelijke Registratie Orthopedische Implantaten (LROI). Alle orthopedische vakgroepen en maatschappen dienen vanaf die datum de primaire en revisieoperaties van de geplaatste schouder-, elleboog- en enkelprothesen te registreren. De registratieformulieren zijn zorgvuldig samengesteld in overleg met de NOV-werkgroepen SchouderElleboog en Voet-Enkel, de Wetenschappelijke Adviesraad van de LROI en het LROI-bestuur. Inzicht in de resultaten van deze prothesen is waardevol om eventueel slechter presterende prothesen eerder te kunnen signaleren. Er is nog maar weinig bekend over de plaatsingsomvang van deze prothesen, de resultaten die hiermee gepaard gaan en welke prothesen gebruikt worden. Ook vanwege de traceerbaarheid van implantaten is de registratie van schouder-, elleboog- en enkelprothesen een belangrijke ontwikkeling. Zie ook www.lroi.nl.

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biomet.nl • +31.78.6292929 McLaughlin, J.R. and Lee, K.R. Survivorship at 22 to 26 Years. Reported with Uncemented Tapered Total Hip Stem. Orthopedics Today. 30(1): 1, 2010. ©2013 Biomet. All pictures, products, names and trademarks herein are the property of Biomet, Inc. or its subsidiaries. For full prescribing information visit biomet.com

Maart 2014, Vol. 21, Nummer 1. Nederlands Tijdschrift voor. rthopaedie. Officieel orgaan van de Nederlandse Orthopaedische Vereniging

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