September 2014, Vol. 21, Nummer 3. Nederlands Tijdschrift rthopaedie. voor. Officieel orgaan van de Nederlandse Orthopaedische Vereniging

September 2014, Vol. 21, Nummer 3

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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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September 2014, Vol. 21, Nummer 3

oorwoord In augustus 2014 werden zowel in het Medisch Contact als in de Bone and Joint Journal artikelen gepubliceerd die zich bezig hielden met burn out, werkdruk en kwaliteit van leven van de a(n)ios in ons land. Het laatste artikel is overigens vanuit de Zwolse onderzoeksschool die hiermee een nieuwe onderzoekslijn lijkt te hebben aangeboord. Door de titel “hoge werkdruk a(n)ios vooral door weinig grip” en de conclusie dat er “een significant deel van de huidige aios orthopedie tekenen vertoont van burn out en verminderde kwaliteit van leven” werd ik aan het denken gezet. Ik vroeg mij af of dit verschijnsel nieuw was en kenmerkend voor de huidige generatie of dat de 100-urige werkweek van vroeger (aldus mijn opleiders) ook leidde tot burn out, maar dat dat toen als normaal werd gezien. In het artikel uit het Medisch Contact werd het gebrek aan grip en invloed op de dagelijkse bezigheden als reden opgegeven. Vele klusjes die kunnen wachten maar toch als spoed gekenmerkt worden of die ook door anderen zouden kunnen worden opgeknapt, zouden hiervoor de oorzaak zijn. Dit claimende gedrag en de bijbehorende administratiedruk zijn in de medische wereld reeds iedereen bekend. Veel taken worden weer aan de arts toebedeeld, terwijl deze voorheen door de verpleegkundige prima werden geregeld. Daarmee vroeg ik me ook af of dit specifiek was voor het medische bedrijf of dat het een “sign of the times” was. In de bedrijfswereld is dit ook een issue maar wordt deze activiteit doorberekend aan de klant, iets wat in de medische wereld niet is geaccepteerd. In onze tak van sport wordt de verhoging van de kwaliteit van de zorg gezien als een nieuw onderdeel, maar wel voor dezelfde prijs en liefst met minder personeel. Het verantwoordelijk zijn voor, maar geen grip hebben op, zaken is het perfecte uitgangspunt voor een “high demand, low control” situatie, waarmee elke nieuwe regel wordt ervaren als een extra tralie van de kooi waarin men zit. Omdat aan de “high demand” kant van deze vergelijking de huidige maatschappij geen concessies zal willen doen, zal de oplossing dus moeten zitten in het terug krijgen van invloed op de wijze waarop het werk wordt uitgeoefend: “low control” wordt dan weer “in control”. De vraag is natuurlijk hoe deze situatie weer veranderd moet worden. In een verandercyclus zijn er visie, vaardigheden, middelen, prikkels en een plan van aanpak nodig. Ontbreken van een van deze ingredienten leidt dan op zijn beurt respectievelijk tot verwarring, weerstand, chaos, frustratie en angst. Pas bij aanwezigheid van alle ingredienten ontstaat verandering. Persoonlijk zie ik in deze verandercyclus een belangrijke rol voor de ziekenhuisorganisaties en de verzekeraars. Samen met hen moet worden gewerkt aan het zichtbaar maken van de kwaliteit van de zorgactiviteiten en het leveren van middelen en prikkels die het plan van aanpak mogelijk maken. We zouden hierbij kunnen denken aan verbetering van “processen in onze zorg”, maar ook discussie voeren over de werkelijke evidence van een behandeling en taakontlasting AIOS door verbetering ICT en protocollair werken. Dr. Taco Gosens, hoofdredacteur

Inhoud Voorwoord Taco Gosens

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Fractures of the proximal fifth metatarsal - how to differentiate and select the best treatment option Eelco Bronsema, Martijn te Stroet and Job van Susante

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Hemiarthroplasty or total hip arthroplasty for displaced femoral neck fractures in the fit elderly? Paul Burgers, Michel van den Bekerom, Elsa Hilverdink, Esther van Lieshout, Rudolf Poolman and Ernst Raaymakers

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Burns after arthroscopic shoulder surgery Maarten Koenis, Christiaan Rompen, Roy Hoogeslag, Kees Verheyen and Rianne Huis in ’t Veld

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Case report - “Orthopaedic” dysphagia Remco Dinjens, Pieter Monteban, Henk van Santbrink and Wouter van Hemert

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Fast-track total knee arthroplasty in a patient with Parkinson’s disease Martijn Schotanus, Bas van Dun and Nanne Kort

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Proefschriftbespreking Kees Verheyen

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Van de Vereniging

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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 Quick Response (QR) codes worden gebruikt voor een directe link naar het proefschrift. Hiervoor heeft u een smartphone en een QR code reader app nodig.

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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 Paul de Baat Dr. Frank W.M. Faber Arnoud R. van Geene Bas L.E.F. ten Have Rien M.P. Heiboer Max A. Hoelen Dr. Hans Peter W. van Jonbergen Dr. Job L.C. van Susante Dr. Cornelis P.J. Visser Dr. Rutger G. Zuurmond

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 1.550 exemplaren, verschijnt elk kwartaal ABONNEMENTEN Het Nederlands Tijdschrift voor Orthopaedie wordt gratis toegezonden aan alle leden van de Nederlandse Orthopaedische Vereniging. Abonnementen Beneluxlanden F 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.

Fractures of the proximal fifth metatarsal - how to differentiate and select the best treatment option Eelco Bronsema, Martijn te Stroet and Job van Susante Fractures of the proximal fifth metatarsal are often seen on the emergency ward and represent a number of subtypes of fractures. To choose the right treatment is crucial for this injury because it is known for its poor healing tendency. Recognition of the various subtypes of fractures is therefore critical to apply the appropriate treatment. Non-displaced avulsion fractures should be treated conservatively with an elastic wrapping and weight baring as tolerated. However for non-displaced fractures of the fifth metatarsal that involve ≥30% of the metatarsal-cuboid joint surface then operative treatment should be considered. For avulsion fractures with displacement (>2mm) or angulation (>10°), operative treatment with K-wiring or a small fragment screw is recommended. The Jones fracture, a transverse fracture at the junction of the diaphysis and the metaphysis without extension and distal to the fourth-fifth intermetatarsal articulation, can be treated conservatively with a non-weight bearing short leg cast for a period of 6-8 weeks, when the X-ray shows a Torg type 1. Type 2 fractures should be treated with intramedullary screw fixation especially in high demanding patients, but can be treated conservatively if the patient does not prefer an operation and is aware of the risk of developing a non-union. The Jones fracture Torg type 3 is a surgical indication and fixation should be combined with reaming of the medullary canal. Literature suggest applying bone graft as an option to stimulate union of the bone. The treatment of the diaphyseal stress fracture is also based upon the Torg classification and is similar to the treatment of a Jones fracture.

Introduction Fractures of the metatarsal bones are often seen when a trauma of the foot has occurred.1-3 Approximately 70% of these fractures involve the fifth metatarsal.3-5 The incidence of this fracture has been recorded to be 1.8 per 1000 person years5,6 and can occur at any age. However a peak incidence is seen between the ages of 10 and 29 years.7 Several groups are prone to develop a fracture. These are, for instance, soccer players and dancers, but also elderly women, probably due to osteoporosis.8-10 There are a few ways to classify fractures of the fifth metatarsal. Classifications can be based upon anatomical region, radiographic findings or trauma mechanism.8,11-18 There are three types of fractures that can occur at the base of the fifth metatarsal: the avulsion fracture (A), the proximal diaphyseal fracture (B) also known as the Jones fracture, and the stress fracture (C) (Figure 1).15,19-21 Most fractures have a good healing tendency and are best treated conservatively.22 However the diaphyseal fracture also known as the ‘Jones’ fracture is notorious for its poor healing capacity.23-27 There are several treatment options, these can be divided into conservative and operative treatment. Within these categories there are several techniques available. Conservative methE. Bronsema, M.A.J. te Stroet, Dr. J.L.C. van Susante, Rijnstate Ziekenhuis, Arnhem, The Netherlands Corresponding author: E. Bronsema Email: [email protected]

Figure 1. Illustration of the three different types of fractures of the proximal fifth metatarsal as described by Lawrence SJ, Botte MJ. A, Tuberosity avulsion; B, Metaphyseal-diaphyseal junction (Jones); C, diaphyseal stress. (Figure modified from Den Hartog, 2009).40

ods are casts, orthoses, compression dressings or hard soled shoes. All these methods provide support, maintain the anatomical position and attempt to prevent fracture displacement. Operative treatment offers a few options: intramedullary screw fixation, tension band wiring, Kirschnerwires, metal plates and external fixation. All these methods should prevent movement of the different fragments and support decent bone healing. The purpose of this review is to evaluate the current evidence of treatment of fractures of the proximal fifth metatarsal and to assess the clinical and radiological outcome of interventions, while treating different types of proximal fifth metatarsal fractures. With this review we provide a comprehensive overview of the various subtypes of proximal fractures of the fifth metatarsal bone and their most appropriate treatment. Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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The authors performed a search within the Embase, Cochrane, and Medline libraries. The reference list of each article found was scanned for relevant publications. Search terms: fifth metatarsal fracture, Jones fracture, non-operative treatment, and operative treatment. Limits: systematic review and English. The obtained references were used to write a review on current classifications and subsequent treatment recommendations. Results Epidemiology The prevalence of metatarsal fractures varies between 3.2% and 6.8% of all fractures, the incidence is reported to be 75.4 new patients per 10.000 persons per year. Metatarsal fractures represent about 33-88.5% of all fractures within the foot.3 The incidence of fractures of the fifth metatarsal differs between age groups. The incidence of fractures of the fifth metatarsal among children is approximately 28% of all metatarsal fractures.28 However during the second till fifth decade the numbers shift and increase to 68% of all metatarsal fractures.29 Most of these are the result of a supination trauma (48%)3 inflicted while participating a team sport. Another group at risk are the white Caucasian females probably due to osteoporosis.5 Trauma mechanism and anatomy The trauma mechanism differs between the different fractures. The avulsion fracture usually occurs after inversion trauma with a fixed forefoot. Studies on cadavers showed that the lateral band of the plantar aponeurosis causes the initial fracture, while the peroneus brevis tendon causes dislocation of the fracture (Figure 2).30

Figure 2. Ligaments and tendons involved in causing displacement of fractures of the proximal fifth metatarsal. (Figure modified from Richli and Rosenthal, 1984).30

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The Jones fracture was first described by sir Robert Jones in 1902 after judging his own X-rays.23 The initial description of the Jones fracture was a fracture of the proximal ¾ of the shaft distal to the styloid caused by indirect violence. Due to abusive use of the term Jones fracture many authors attempted to clarify this by developing their own definition. The most commonly accepted definition of a true Jones fracture is a transverse fracture at the junction of the diaphysis and the metaphysis without extension distal to the fourth-fifth intermetatarsal articulation.31 The fracture is usually localized between the insertions of the peroneus brevis and the peroneus tertius and is caused by a force on the base of the metatarsal in a vertical or mediolateral direction while the foot is plantarflexed and the weight of the patient is lateral of the foot.23,24 The blood supply of the fifth metatarsal is quite delicate. The occurrence of a fracture can disrupt the blood supply from the distal side of the fracture. This creates an avascular zone also called a watershed area (Figure 3), due to presence of the waterhed area the fracture is poorly vascularised and it has a very poor healing tendency.32-34

Figure 3. Illustration of the vascularisation of the proximal part of the fifth metatarsal which demonstrates the occurrence of a watershed after the fracture already has occurred. (Figure modified from Den Hartog, 2009).40

The stress fracture of the fifth metatarsal has a different pathology, Delee et al.21 defined it as a spontaneous fracture in normal bone as a result of accumulation of forces that would be harmless on their own. This fracture is foremost seen in young athletes or young military recruits. The fracture develops distally to the metatarsal-cuboid joint.11,22 During the prodromal phase the patient will experience pain while exercising. After 2-6 weeks a stress reaction may be visible on the radiographs, which is best described as linear lucencies or a fluffy periosteal reaction.4 When the patient does not cease activity the periosteal reaction can progress and a fracture line might appear which is hard to distinguish from an acute fracture on a radiograph. Therefore the stress fracture is best

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Fractures of the proximal fifth metatarsal - how to differentiate and select the best treatment option

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diagnosed based upon patient history and physical assessment in combination with radiographs, however a stress fracture cannot be diagnosed solely based on radiographic images.4,18

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Radiologic assessment The classification of fractures of the fifth metatarsal has been a point of discussion, especially the differentiation between the typical Jones fracture and the diaphyseal stress fracture. Therefore several classification systems were developed by several study groups. For instance, the AO-group developed an anatomic classification that differentiates between extra- (type A), intra-articular (type B) and dislocated fractures (type C and D) which subsequently are divided in several sub-groups. In turn, Dameron, Lawrence, and Quill11,13 also developed an anatomic classification based on three anatomical regions: zone 1 consists of avulsion fractures, zone 2 are fractures at the meta-/diaphyseal junction and zone 3 contains the diaphyseal stress fractures (Figure 1). Finally, Torg et al.15 developed a different classification based upon the healing tendency of a fracture. Torg described three different types of fractures. Type 1: a narrow fracture line without any signs of intramedullary sclerosis, Type 2: slight widening of the fracture line with evidence of intramedullary sclerosis and Type 3: a completely obliterated and sclerotic intramedullary canal (Figure 4). The latter classification has been used to determine the proper therapy. Treatment Avulsion fracture The avulsion fracture can be divided into two categories: non-displaced and displaced. The non-displaced fracture is often treated with a short leg weight-bearing cast or an elastic bandage. These two treatments were compared by several authors and finally these results were analysed in a meta-analysis by Smith et al.35 Although there was no statistical difference between the two treatments, in respect to the incidence of non-unions or re-fractures, Zenios et al.31 did report statistically significant (p>0.05) better AOFAS scores for patients treated with an elasticated tubular bandage (Tubigrip, SSL International Plc, Oldham, UK). Another advantage was the earlier return to preinjury level. According to Wiener et al.36 patients were back at a normal level after 33 days while using a bandage and 46 days after being treated with a short leg weight-bearing cast. In conclusion, a bandage seems to be the treatment of choice for non-displaced avulsion fractures. Displaced fractures (10° angulation or >2 mm displacement) and non-displaced fractures which

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Figure 4. A-C. The stadia of the classification described by Torg et al. from left to right. A, Torg type 1, B, Torg type 2, and C, Torg type 3. (Figure modified from Zwitser and Breederveld, 2010).4

contain ≥30% of the metatarsal-cuboid joint surface, however demand a different approach.37,38 Literature suggests reduction and internal fixation for these fractures using either K-wiring or screw fixation.4,18 The fracture should be supported by casting, only allowing partial weight-bearing, and will heal in approximately 8 weeks.18 Internal fixation is also recommended in case of a non-union.18 Jones fracture Jones fractures are notorious for its prolonged healing and the tendency to become a non-union. Crucial to this characteristic is the watershed area that often occurs shortly after the trauma. Another problem occurs in fracture stability, the fifth metatarsal has the largest range of motion of all the metatarsals and has little support from the cuboid bone.12,33,34 The combination of the watershed with little fracture stability makes the Jones fracture hard to treat. Torg et al. was the first to recognise this and described a treatment which has become the golden standard.15 Whether or not to treat the Jones fracture surgically has been a point of discussion for many years. Recently a meta-analysis by Smith et al.35 showed no significant difference in delayed union and re-fracturing, between the surgical en non-surgical group, (p>0.05), after pooling the data from Josefsson et al. and Mologne et al.26,39 This analysis contained 103 patients and a review of separate results indicate there is a trend towards surgical treatment, although the authors were not able to prove a significant difference. Josefsson et al. reported that 10 out of 44 patients, treated nonsurgically with an elastic bandage or plaster cast, required surgical

Eelco Bronsema, Martijn A.J. te Stroet and Job L.C. van Susante

treatment due to refracture (n=2) and delayed union (n=8). In the group that was treated surgically, refracture occurred in three patients out of 22. Mologne et al. also reported 5 non-unions, 1 delayed union, and 2 refractures out of 18 patients treated non-surgically. Within the surgical group there was one treatment failure out of 19. Comparing these two groups 44% of the nonsurgical group failed while only 5% of the surgical group failed. Mologne et al. also compared the time to return to sporting which showed a statistical significant (p>0.01) difference between the two groups. The surgical group showed a mean time to union and return to sporting activities of respectively 7.5 and 8 weeks, while the nonsurgical groups showed mean times of 14.5 and 15 weeks. Treatment of a non-displaced Jones fracture can be realised nonsurgically by applying non-weightbearing ambulation in a short leg cast for a period of 6-8 weeks.18 However when a fracture shows signs of non-union (Torg type 2 or 3) after 8 weeks, one might reconsider a surgical intervention. The period of sick leave becomes very long when a patient develops a non-union. Therefore the recommendation made by Mologne et al. to not only treat athletes with screw fixation, but high demanding patients in general should be taken into account when deciding the proper treatment. When a patient is treated with intramedullary screw fixation, the screw should be 40-55 mm long and between 4.5 and 6.5 mm wide. If a longer screw is used a fracture might occur when putting a straight screw into a slightly curved bone. The intra-medullary canal should be reamed when the X-rays shows signs of sclerosis.40 In conclusion, a low threshold for the use of intramedullary screw fixation should be considered. Patients have to be aware of the risk of non-union, whenever conservative treatment is chosen, and high demanding patients should be aware of the significantly shorter time to return to sporting activities. Whenever patient and clinician agree to treat the fracture conservatively a strict follow-up scheme should be followed to prevent the development of a non-union and adjustments in treatment can be realised in time. Stress fracture Stress fractures are seen foremost in the athletic population. Literature on this subject suggests useing the Torg classification to determine the treatment for this fracture. Torg type 1 should be treated with a non-weight-bearing short leg cast for 6 to 8 weeks. However treatment of a Torg type 2 or 3 was described by Quill13 and Den Hartog40. The golden standard is intramedullary screw fixation as

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described above. Because the fracture might exist for a length of time the use of a bone graft inlay after reaming of the sclerotic canal was promoted by Torg et al.15 Because the treatment is exactly the same Polzer et al.1 even suggested dividing the metatarsal fractures into two functional zones. Conclusion Fractures of the proximal fifth metatarsal are challenging injuries to manage because the pathology differs between the three different subtypes of fractures. The non-displaced avulsion fracture should be treated conservatively. Whenever there is displacement of the fracture of more than two millimetres, or angulation of more than 10°, operative treatment should be considered. For treatment of the Jones fracture the Torg classification can be followed. Torg type 1 can be treated conservatively. Whenever a Torg type 2, a high demanding patient, or a displaced Jones fracture is encountered, treatment with intramedullary screw fixation should be considered. Patients with a Jones fracture Torg type 3 should always receive intramedullary screw fixation in combination with reaming of the sclerotic canal. The treatment of stress fractures is comparable to the treatment of Jones fractures. Conflict of interest statement The authors declare that there is no conflict of interest.

References 1. Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012;43(10):1626-32. 2. Spector FC, Karlin JM, Scurran BL, Silvani SL. Lesser metatarsal fractures. Incidence, management, and review. JAMA. 1984;74(6):259-64. 3. Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg. 2011;131(2):241-5. 4. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010;41(6):555-62. 5. Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF. Foot and ankle fractures in elderly white women. Incidence and risk factors. J Bone and Joint Surg. 2003;85-A(5):820-4. 6. Harmath C, Demos TC, Lomasney L, Pinzur M. Stress fracture of the fifth metatarsal. Orthopedics. 2001;24(2):204-8. 7. Nielsen TR, Lindblad BE, Faun P. Long-term results after fracture of the fifth metatarsal. Foot and Ankle Surg. 1998;4(4):227-32. 8. Fetzer GB, Wright RW. Metatarsal shaft fractures and


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fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25(1):139-5 9. Goulart M, O’Malley MJ, Hodgkins CW, Charlton TP. Foot and ankle fractures in dancers. Clin Sports Med. 2008;27(2):295-304. 10. Popovic N, Jalali A, Georis P, Gillet P. Proximal fifth metatarsal diaphyseal stress fracture in football players. Foot and Ankle Surg. 2005;11(3):135-41. 11. Dameron TB, Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone and Joint Surg. 1975;57(6):788-92. 12. Lehman RC, Torg JS, Pavlov H, DeLee JC. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot & ankle. 1987;7(4):245-52. 13. Quill GE, Jr. Fractures of the proximal fifth metatarsal. Orthop clin North Am. 1995;26(2):353-61. 14. Torg JS. Fractures of the base of the fifth metatarsal distal to the tuberosity. Orthopedics. 1990;13(7):731-7. 15. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone and Joint Surg. 1984;66(2):209-14. 16. Dameron TB, Jr. Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option. J Am Acad Orthop Surg. 1995;3(2):110-4. 17. Gray AC, Rooney BP, Ingram R. A prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. Foot (Edinb). 2008;18(3):156-8. 18. Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2000;8(5):332-8. 19. Metcalfe SA. Non-united fifth metatarsal metaphyseal fractures. The Foot. 2001;11(2):99-102. 20. Landorf KB. Fifth metatarsal fractures are not all the same: proximal diaphyseal fractures are prone to delayed healing. The Foot. 1998;8(1):38-45. 21. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-53. 22. Anderson LD. Injuries of the forefoot. Clin Orthop Relat Res. 1977(122):18-27. 23. Jones R. I. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Ann Surg. 1902;35(6):697-700 24. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone and Joint Surg. 1978;60(6):776-82. 25. Lui TH. Endoscopic bone grafting for management of nonunion of the tuberosity avulsion fracture of

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the fifth metatarsal. Arch Orthop Trauma Surg. 2008;128(11):1305-7. 26. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970-5. 27. Sarimo J, Rantanen J, Orava S, Alanen J. Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis. Am J Sports Med. 2006;34(3):476-80. 28. Singer G, Cichocki M, Schalamon J, Eberl R, Hollwarth ME. A study of metatarsal fractures in children. J Bone and Joint Surg. 2008;90(4):772-6. 29. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27(3):172-4. 30. Richli WR, Rosenthal DI. Avulsion fracture of the fifth metatarsal: experimental study of pathomechanics. AJR Am J Roentgenol. 1984;143(4):889-91. 31. Zenios M, Kim WY, Sampath J, Muddu BN. Functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. 2005;36(7):832-5. 32. Carp L. Fracture of the fifth metatarsal bone: with special reference to delayed union. Ann Surg. 1927;86(2):308-20. 33. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle. 1992;13(3):143-52. 34. Shereff MJ, Yang QM, Kummer FJ, Frey CC, Greenidge N. Vascular anatomy of the fifth metatarsal. Foot & ankle. 1991;11(6):350-3. 35. Smith TO, Clark A, Hing CB. Interventions for treating proximal fifth metatarsal fractures in adults: a metaanalysis of the current evidence-base. Foot Ankle Surg. 2011;17(4):300-7. 36. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int. 1997;18(5):267-9. 37. Rettig AC, Shelbourne KD, Wilckens J. The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes. Am J Sports Med. 1992;20(1):50-4. 38. Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77-86. 39. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Jones fracture. Surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1994(299):252-5. 40. Den Hartog BD. Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2009;17(7):458-64.


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Hemiarthroplasty or total hip arthroplasty for displaced femoral neck fractures in the fit elderly? Paul Burgers, Michel van den Bekerom, Elsa Hilverdink, Esther van Lieshout, Rudolf Poolman and Ernst Raaymakers

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The worldwide incidence of femoral neck fractures is expected to increase enormously with aging of populations globally and increasing industrialization and urbanization. The scientific debate and discussions during morning reports which type of arthroplasty to use for femoral neck fractures in the fit elderly, reflect the ongoing controversies of this topic. The following relevant outcome parameters in decision making between the 2 types of arthroplasties will be discussed: functional outcomes, rates of complications, acetabular erosion, dislocations, revisions, surgical volume, and (in) direct costs as these are relevant in deciding between total hip arthroplasty and hemiarthroplasty.

Introduction About half of the fractures of the proximal femur are located in the femoral neck. The incidence of femoral neck fractures will increase enormously due to aging of populations globally and increasing industrialization and urbanization.10 The aim of hip fracture management should be the return of the patient in optimal condition to their pre-fracture functional status as quickly as possible. Challenges in the treatment of patients with a fragility fracture of the femoral neck include medical co morbidities, frailty of the elderly patient, osteoporosis, and rehabilitation issues. The optimal surgical treatment of mobile, independent, mentally fit patients who have sustained a displaced intracapsular femoral neck fracture remains controversial. Already in 1958, the Committee on Fractures and Traumatic Surgery of the American Academy of Orthopedic Surgeons issued a report discussing the role of prosthetic replacement, including a discussion of the merits of different prostheses, operative techniques, and postoperative management.11 P.T.P.W. Burgers1,2, MD, M.P.J. van den Bekerom3, MD, E.F. Hilverdink4, MD, E.M.M. van Lieshout2, PhD, R.W. Poolman3, MD PhD, E.L.F.B. Raaymakers4, MD PhD 1 IJsselland Ziekenhuis, Department of Surgery, Capelle aan den IJssel, The Netherlands 2 Erasmus MC, University Medical Center Rotterdam, Trauma Research Unit Department of Surgery, Rotterdam, The Netherlands 3 Joint Research, Onze Lieve Vrouwe Gasthuis, Department of Orthopaedic Surgery, Amsterdam, The Netherlands 4 Academic Medical Centre, Department of Orthopaedic Surgery, Amsterdam, The Netherlands Corresponding author: P.T.P.W. Burgers Email: [email protected]

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Compared with internal fixation, arthroplasty has a lower risk of revision surgery caused by nonunion, malunion, and osteonecrosis, at the cost of greater blood loss and operative time.12 Also, arthroplasty is associated with an increased infection rate, dislocation, femoral stem loosening, and onset of buttock or groin pain caused by either acetabular protrusion or acetabular cartilage erosion.13,14 Unipolar hemiarthroplasty (HA) has been used for managing femoral neck fractures for more than 50 years. Bipolar prostheses, consisting of a prosthesis-acetabular articulation and a femoral head– polyethylene articulation, were introduced in the 1970s in an effort to avoid wear of the acetabulum. The prosthesis-prosthesis articulation theoretically decreases acetabular wear by shifting some hip movement away from the acetabulum to the internal prosthesis prosthesis articulation. Based on the literature, there is no consensus either supporting or rejecting the use of bipolar rather than unipolar HA.15 In this Cochrane search, no advantages, or disadvantages were found of the bipolar prosthesis compared to the unipolar prosthesis. Today there is consensus that patients with a displaced femoral neck fracture with concurrent acetabular disease (osteoarthritis, rheumatoid arthritis, or Paget’s disease) require a total hip arthroplasty (THA).13,14 Surgeons have been considering the role of THA as primary management of displaced femoral neck fractures since the 1970s. Already in 1980 authors reported on 112 patients treated with a THA for their femoral neck fracture.16 THA is currently an accepted treatment for the elderly, cognitive fit patient with a displaced femoral neck fracture but the question is whether or not the patients without acetabular disease will also benefit from a THA. Surgeons who preferred arthroplasty for displaced femoral neck fractures in sixty to eighty-year-old

Paul T.P.W. Burgers, Michel P.J. van den Bekerom, Elsa F. Hilverdink, Esther M.M. van Lieshout, Rudolf W. Poolman and Ernst L.F.B. Raaymakers

patients remained discordant in their choice between HA and THA. An international survey suggested that over 90% of the respondents believed that HA (either a unipolar or bipolar prosthesis) is the treatment of choice in elderly patients who sustained a displaced fracture of the femoral neck.17 The infrequent use of THA for this patient group may be related to surgeon experience, patient health status, or geographic variation.17 The objective of this study was to review the current literature on this topic. The most relevant outcome measures which will be important for the surgeon and patient in deciding between HA or THA are: functional outcome, complication rate, rate of acetabular erosion after HA, dislocation rate, revision rate, surgical volume, and the (in)direct health care costs. Available evidence In a previous systematic review with meta-analysis we analyzed the results of eight randomized clinical trials,1-8 summing up to a total of 986 patients.9 Three were single center trials and five were multicenter trials. One trial used uncemented THAs and the other used cemented THAs. Several types of HAs were used with regard to the use of cement and the use of bipolar or unipolar HA. In the same period two other systematic reviews were published on the same trials.18,19 Before the data of the largest trial were available, Hopley et al. also included studies with a lower level of evidence.20 In 2010 Parker et al. updated their Cochrane database.15 Functional Outcome Bhandari et al. reported that many orthopedic surgeons felt that the short-term outcome following a bipolar HA was comparable with that after a THA.17 Four trials reported on the Harris Hip Score. This score ranges from 0 to 100 points and includes function, pain, deformity and range of motion. Two of the three latest meta-analyses showed better Harris Hip Scores in patients with a THA compared to the patients with a HA.9,19 Sensitivity analysis by sequential omission of individual studies showed no change in significance.19 Complications Authors of the four reviews published in 2012 found no significant difference in general complications and infection rates.9,18,19,21 Also, Hopley et al. did not find a significant difference in general complication rates after either form of arthroplasty.20 Deep infections occurred in 33 of 1602 patients en-

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rolled in 11 studies. No significant difference in the pooled relative risks of infection was found when comparing HA with THA.20 Dislocation Dislocation is the major concern after primary total hip arthroplasty for the treatment of intracapsular femoral neck fractures. It is obvious that appropriate restoration of neck length and offset are essential in prevention of dislocations. Berry et al. demonstrated a 1.8-fold increased hazard estimate of dislocation risk when the preoperative diagnosis of hip fracture was compared with osteoarthritis.22 When patients with a single, early (within four months after surgery) hip dislocation were excluded from dislocation statistics, HA and THA had similar long-term dislocation rates.23 A recurrent dislocation of the hip arthroplasty in the treatment of patients with femoral neck fractures seems to result in a persisting deterioration in the quality of life, while patients with a single dislocation seem to experience only a temporary deterioration.24 Burgers et al. included in their meta-analysis seven trials which provided data on dislocation. The overall dislocation rate was 3% in HA patients versus 8% in the THA patients, which was a significant difference.9 The reported dislocation rates after HA ranged from 0% to 11% and after THA from 0% to 18%. The pooled analysis of Hopley et al. showed no significant difference concerning the risk for dislocation between HA and THA. A tendency was, however, noted towards a higher risk for dislocation after THA.20 There are two important risk factors for the dislocation rate of THA in patients with femoral neck fractures. The first risk factor is the surgical approach; the posterolateral approach is associated with higher dislocation rates,1,24,25 while other (antero/anterolateral) surgical approaches have been recommended for patients who are prone to dislocation. With the Hardinge (direct lateral) approach there is a risk of injury to the superior gluteal nerve and it also requires taking down the anterior third of the gluteus medius tendon from the greater trochanter.26 This detaching of the muscle can cause abductor weakness.1 A second risk factor for dislocation is the head size. Larger heads achieve greater stability and result in a better function by the increased impingement free range of motion. A 32 mm head provides a lower dislocation rate than 28mm or 22 mm heads. New options with thin, highly cross-linked polyethylene allow for large heads (≥32 mm) to be used with smaller acetabular cup diameters, enhancing the ability for stable reconstruction in this patient popNederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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Hemiarthroplasty or total hip arthroplasty for displaced femoral neck fractures in the fit elderly?

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ulation.22 A dual-mobility acetabular component, as developed and described by Gilles Bousquet, was developed in order to reduce the incidence of dislocation in patients at risk of instability.27 It consists of a large, fixed, porous-coated acetabular component and a bipolar femoral component. Although the long-term durability of these implants is not known, this is expected not to be a problem in the patients with a femoral neck who have a higher mortality and morbidity with lower implant demand than in patients with osteoarthritis.28

Costs

Patients treated with a hemiarthroplasty have the potential risk for deteriorating of hip function, especially in the highly active patients and in those with a long life expectancy. This is attributed to the articulation of a large metal head on articular cartilage, which is associated with acetabular erosion and groin pain. However, 2 out of 5 available meta-analyses showed no significant difference concerning this topic. This theory is in contrast with clinical practice because when meta-analyzing all currently available RCTs on this topic no significant difference was observed in two of the five metaanalyses.9,18 An overall revision rate of 5% of all arthroplasties is found. When comparing patients below and above the age of 75 years, the hazard ratio was 3.6 (confidence interval: 1.6- 8.2) for patients less than 75 of age.29 This implicates that younger patients with a better functional status may require an internal fixation or a more durable arthroplasty like a THA.

An important aspect of the treatment of hip fractures in the elderly is the cost of care. Slover et al. performed a cost-effectiveness study based on a theoretical cohort of patients aged 70 years old, who sustained a displaced femoral neck fracture.35 They used cost data from 2003 and concluded that available data supported the use of total hip arthroplasty as the more cost-effective treatment strategy in active otherwise healthy population. This resulted in an incremental cost-effectiveness ratio of $1,960 for the THA treatment strategy, which was well below the $50,000 threshold used for determining the cost-effectiveness of treatment interventions.35 Keating et al. performed a cost analysis alongside their randomized trial and suggested that the costs of total hip replacement are lower, but the confidence intervals do not rule out the possibility that it may be more expensive.36 A systematic review and cost-effectiveness analysis of hospital treatment for the initial and subsequent admissions concluded that THA appears to be more cost-effective than HA, remarking that the follow up was only a 2-year period.37 Rogmark et al. showed that the costs of the material of a THA (US$ 1,274) were US$ 550 higher than for HA (US$ 725).38 Iorio et al. performed a cost-effectiveness analysis during a 2-year postoperative period. Taking into account the complication rates, mortality rates, revision rates, and function, they concluded that THA was more cost-effective than internal fixation, unipolar HA, and bipolar HA.39

Acetabular erosion

Surgeon and hospital volume

The main disadvantage of HA is the potential for wear of acetabular articular cartilage and groin pain related to the metallic femoral head against the host acetabulum. This can result in a second operation for placement of an acetabular cup and conversion to THA. Young age and high activity level are generally accepted as the most important factors related to acetabular erosion.30,31 The reported rates of acetabular erosion have ranged from 0% to 26% for bipolar designs and from 2.2% to 36% for unipolar designs.32-34 In elderly patients this wear does not lead to a difference in overall revision rate as already discussed. Undersizing of the HA head is associated with increased acetabular erosion and pain. Oversized heads are associated with decreased motion and pain of the hip. Active elderly patients with high demand requirements are not completely satisfied with these suboptimal outcomes.

The association between greater surgeon and hospital procedure volumes and improved patient outcomes has been well established with respect to a variety of procedures and treatments.40 Surgeon volume had a greater effect on patients than hospital volume for primary and revision joint arthroplasties.40 Also in the treatment of hip fractures with an arthroplasty surgeon volume and hospital volume seem to be independent factors for patient outcomes.41-45 The mechanism through which surgeon volume impacts patient outcomes remains unclear. Some surgeons have better outcomes than others and there can be variations in outcomes between these care providers. Variation in performance is clearly linked to experience, although it is unclear why exactly this experience influences outcomes. Patient selection would seem to be less of a factor in nonelective surgery such as hip fracture fixation.42 The surgeon-volume relationship is just

Revision

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one of many variables that determine overall quality of care, and many other factors may outweigh any outcome data in determining the appropriate care for the individual patient. There is no consensus on the importance of several variables such as anesthesia staff, nursing staff, hospital protocols, standardized care pathways, and ancillary services like physical therapy.45 The association between volume and decreased length of stay and in-hospital cost has been demonstrated in a variety of elective arthroplasty procedures as well as with arthroplasty for hip fracture.41-45 Length of stay and patient charges are becoming increasingly important and relevant in the current health care environment and could be expected to be a significant area of focus for future research and policy.42 Additional studies are required to investigate the effects of limiting performance of orthopedic procedures to high-volume providers and identify practical strategies for providing patients and physicians with better information with which to make referral decisions. These studies are needed before any changes can be made in health care policy and resource utilization. Discussion and Conclusion Historically, randomized controlled trials have been scarce in orthopedic literature but should play a major role in determining best practices for fracture care.46 However, all systematic reviews/ meta-analyses, have similar conclusions and state that heterogeneity across the available trials and distinct subgroup effects preclude definitive statements and require further research in this field.9,15,18-21,47,48 Given the large sample size the HEALTH trial (Hip Fracture Evaluation with ALternatives of Total Hip Arthroplasty versus HemiArthroplasty) will have a significant impact on the question which type of arthroplasty is the best solution to treat patients with displaced femoral neck fractures. This is a multi-center randomized trial comparing total hip arthroplasty and hemiarthroplasty on revision surgery and quality of life in patients with displaced femoral neck fractures (registered trial number: NCT00556842). Based upon the evidence available to date, THA is the preferred treatment for mentally fit patients with a displaced femoral neck fracture below the age of 75 years, patients with a pathological fracture, and patients with diseases of the hip joint like rheumatoid arthritis, osteoarthritis, or Paget’s disease. Patients older than 75 years who have a long life expectancy may benefit from a THA because of the better functional outcome at the cost

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of a higher dislocation rate. Simon et al. advised to perform a THA in patients with a life expectancy of 10 years or longer.49 It is important to recognize there are deficiencies in the literature that limit our present ability to draw strong conclusions concerning the relative merits of modern THA compared with modern HA. Some papers that compared HA with THA, describe the results of an uncemented Austin-Moore implant. We now know that these arthroplasties have inferior results concerning the functional and pain outcomes.50,51 The comparison between studies using HAs and THAs can only be relevant when cemented stem designs are compared with new generation of uncemented stem designs. Most trials are performed with mentally competent (i.e., able to sign informed consent), independent, and active patients. This probably means that patients included in the trials are “better” patients with less comorbidity than the general patients who suffer from a displaced femoral neck fracture. Maybe the better functional results of patients with a THA could be explained by the fact that patients who are less mobile and have less functional demands are not included in the trials. This was indeed the fact in the Arthro trial.1 Also it is known that the use of the Harris Hip Score as functional outcome has its limits.52 It can be concluded that, based on the current literature, HA is the preferable treatment in patients who are “biologically” older than 75 years, because of the lower dislocation rate, shorter operation time and less perioperative blood loss.1 THA can be considered for active and mentally fit patients below the age of 75 years with a displaced femoral neck fracture. Future research should focus on indentifying predictors for patients who will benefit from a THA for a femoral neck fracture. Disclosure statement A modified version of this article will be published in the French journal Maîtrise Orthopédique. The editor gave permission for the current publication. Acknowledgements Neither the authors nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Paul T.P.W. Burgers, Michel P.J. van den Bekerom, Elsa F. Hilverdink, Esther M.M. van Lieshout, Rudolf W. Poolman and Ernst L.F.B. Raaymakers

References 1. van den Bekerom MP, Hilverdink EF, Sierevelt IN, Reuling EM, Schnater JM, Bonke H, et al. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. J Bone Joint Surg Br 2010;92:1422-8. 2. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am 2006;88:2583-89. 3. Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br 2007;89:160-65. 4. Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty 1986;1:21-28. 5. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am 2006;88:249-60. 6. Macaulay W, Nellans KW, Iorio R, Garvin KL, Healy WL, Rosenwasser MP. Total hip arthroplasty is less painful at 12 months compared with hemiarthroplasty in treatment of displaced femoral neck fracture. HSS J 2008;4:48-54. 7. Mouzopoulos G, Stamatakos M, Arabatzi H, Vasiliadis G, Batanis G, Tsembeli A, et al. The four-year functional result after a displaced subcapital hip fracture treated with three different surgical options. Int Orthop 2008;32:367-73. 8. Skinner P, Riley D, Ellery J, Beaumont A, Coumine R, Shafighian B. Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Injury 1989;20:291-93. 9. Burgers PT, Van Geene AR, Van den Bekerom MP, Van Lieshout EM, Blom B, Aleem IS, et al. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop 2012;36:1549-60. 10. Cheng SY, Levy AR, Lefaivre KA, Guy P, Kuramoto L, Sobolev B. Geographic trends in incidence of hip fractures: a comprehensive literature review. Osteoporos Int 2011;22:2575-86. 11. Reynolds FC. Preliminary report of the Committee on Fractures and Traumatic Surgery on the use of a prosthesis in the treatment of fresh fractures of the neck of the femur. J Bone Joint Surg Am 1958;40-A:877-85; discussion 85-6 passim. 12. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, 3rd, Obremskey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am

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2003;85-A:1673-81. 13. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg 2006;14:287-93. 14. Masson M, Parker MJ, Fleischer S. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2003. 15. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010:CD001706. 16. Sim FH, Stauffer RN. Management of hip fractures by total hip arthroplasty. Clin Orthop Relat Res 1980:191-97. 17. Bhandari M, Devereaux PJ, Tornetta P, Swiontkowski MF, Berry DJ, Haidukewych G, et al. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am 2005;87:2122-30. 18. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplasty 2012;27:583-90. 19. Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res 2012;470:2235-43. 20. Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ 2010;340:c2332. 21. Liao L, Zhao J, Su W, Ding X, Chen L, Luo S. A metaanalysis of total hip arthroplasty and hemiarthroplasty outcomes for displaced femoral neck fractures. Arch Orthop Trauma Surg 2012;132:1021-9. 22. Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2456-63. 23. Papandrea RF, Froimson MI. Total hip arthroplasty after acute displaced femoral neck fractures. Am J Orthop (Belle Mead NJ) 1996;25:85-88. 24. Enocson A, Hedbeck C-J, Tidermark J, Pettersson H, Ponzer S, Lapidus LJ. Dislocation of total hip replacement in patients with fractures of the femoral neck. Acta Orthop 2009;80:184-89. 25. Enocson A, Tidermark J, Tornkvist H, Lapidus LJ. Dislocation of hemiarthroplasty after femoral neck fracture: better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips. Acta Orthop 2008;79:211-17. 26. Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br 1982;64:17-9. 27. Philippot R, Adam P, Farizon F, Fessy MH, Bousquet G. [Survival of cementless dual mobility sockets: ten-year follow-up]. Rev Chir Orthop Reparatrice Appar Mot 2006;92:326-31. 28. Guyen O, Pibarot V, Vaz G, Chevillotte C, Carret J-P, Bejui-Hugues J. Unconstrained tripolar implants for primary total hip arthroplasty in patients at risk for dislocation. J Arthroplasty 2007;22:849-58. 29. van den Bekerom MP, Sierevelt IN, Bonke H, Raaymakers


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EL. The natural history of the hemiarthroplasty for displaced intracapsular femoral neck fractures. Acta Orthop 2013;84:555-60. 30. Phillips TW. Thompson hemiarthroplasty and acetabular erosion. J Bone Joint Surg Am 1989;71:913-17. 31. Warwick D, Hubble M, Sarris I, Strange J. Revision of failed hemiarthroplasty for fractures at the hip. Int Orthop 1998;22:165-68. 32. Calder SJ, Anderson GH, Jagger C, Harper WM, Gregg PJ. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians: a randomised prospective study. J Bone Joint Surg Br 1996;78:391-94. 33. Soreide O, Skjaerven R, Alho A. The risk of acetabular protrusion following prosthetic replacement of the femoral head. Acta Orthop Scand 1982;53:791-94. 34. Squires B, Bannister G. Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty? Injury 1999;30:345-48. 35. Slover J, Hoffman MV, Malchau H, Tosteson ANA, Koval KJ. A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in the active, healthy, elderly population. J Arthroplasty 2009;24:854-60. 36. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technol Assess 2005;9:iii-iv, ix-x, 1-65. 37. Carroll C, Stevenson M, Scope A, Evans P, Buckley S. Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis. Health Technol Assess 2011;15:1-74. 38. Rogmark C, Carlsson A, Johnell O, Sembo I. Costs of internal fixation and arthroplasty for displaced femoral neck fractures: a randomized study of 68 patients. Acta Orthop Scand 2003;74:293-98. 39. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ. Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop Relat Res 2001:229-42. 40. Shervin N, Rubash HE, Katz JN. Orthopaedic procedure volume and patient outcomes: a systematic literature review. Clin Orthop Relat Res 2007;457:35-41.

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41. Ames JB, Lurie JD, Tomek IM, Zhou W, Koval KJ. Does surgeon volume for total hip arthroplasty affect outcomes after hemiarthroplasty for femoral neck fracture? Am J Orthop (Belle Mead NJ) 2010;39:84-89. 42. Browne JA, Pietrobon R, Olson SA. Hip fracture outcomes: does surgeon or hospital volume really matter? J Trauma 2009;66:809-14. 43. Hughes RG, Garnick DW, Luft HS, McPhee SJ, Hunt SS. Hospital volume and patient outcomes. The case of hip fracture patients. Med Care 1988;26:1057-67. 44. Lavernia CJ. Hemiarthroplasty in hip fracture care: effects of surgical volume on short-term outcome. J Arthroplasty 1998;13:774-78. 45. Shah SN, Wainess RM, Karunakar MA. Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. J Arthroplasty 2005;20:503-08. 46. Poolman RW, Struijs PAA, Krips R, Sierevelt IN, Lutz KH, Bhandari M. Does a “Level I Evidence” rating imply high quality of reporting in orthopaedic randomised controlled trials? BMC Med Res Methodol 2006;6:44-44. 47. He JH, Zhou CP, Zhou ZK, Shen B, Yang J, Kang PD, et al. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced femoral neck fractures in patients over 70 years old. Chin J Traumatol 2012;15:195-200. 48. Goh SK, Samuel M, Su DH, Chan ES, Yeo SJ. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture. J Arthroplasty 2009;24:400-6. 49. Simon P, Gouin F, Veillard D, Laffargue P, Ehlinger M, Bel JC, et al. [Femoral neck fractures in patients over 50 years old]. Rev Chir Orthop Reparatrice Appar Mot 2008;94 Suppl:108-32. 50. Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: A randomised controlled trial in 400 patients. J Bone Joint Surg Br 2010;92:116-22. 51. Schmidt AH, Leighton R, Parvizi J, Sems A, Berry DJ. Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer? J Orthop Trauma 2009;23:428-33. 52. Wamper KE, Sierevelt IN, Poolman RW, Bhandari M, Haverkamp D. The Harris hip score: Do ceiling effects limit its usefulness in orthopedics? Acta Orthop 2010;81:703-7.

Burns after arthroscopic shoulder surgery i www.ntv-orthopaedie.nl/rompen2103/

Maarten Koenis, Christiaan Rompen, Roy Hoogeslag, Kees Verheyen and Rianne Huis in ’t Veld

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Introduction

Patients

Arthroscopic shoulder surgery is a common elective orthopaedic procedure. Reported complication rates in shoulder arthroscopy vary greatly between less than 1% and up to 10%, depending on the type of co-interventions (e.g. subacromial decompression, cuff repair) and definition of the complication.1,2 In this case-report we describe a rare complication in two patients; the development of cutaneous burns of the shoulder area after arthroscopic subacromial decompression and bursectomy for shoulder impingement syndrome. This could be due to leaking of hot irrigation fluid or a reaction to chlorohexidine. Complications associated with the use of radiofrequency (RF) coblation devices to cut tissue and coagulate bleeding vessels in orthopedic surgery have been reported.2 After reviewing the literature, eight patients have been described in three case-reports to have burns caused by hot irrigation fluid, after the use of RF during shoulder arthroscopy.3,4,5,6 Complications associated with the use of chlorohexidine include the development of chemical burns. Only one case report describes two patients with burns due to chlorohexidine.7 Despite the fact that burns after arthroscopic shoulder surgery are extremely uncommon, the proper management of the irrigation fluid flow rate across the operating field, in order to avoid thermal injuries, is hardly emphasized in the literature.1,2

Two healthy males (45 and 46 year old) presented with persistent subacromial impingement syndrome and a suspected rotator cuff rupture, also not responding to physiotherapy or subacromial injections of steroids and bupivacaine. No allergies were reported.

M.J.J. Koenis, MD, resident orthopaedic surgery1, J.C. Rompen, MD, Orthopeadic Surgeon1, R.A.G. Hoogeslag, MD, Orthopaedic Surgeon1, C.C.P.M. Verheyen, MD, PhD, Orthopaedic Surgeon2, M.H.A. Huis in ‘t Veld, PhD, Research Coordinator / Human Movement Scientist1 1 Department of Orthopaedic Surgery and Traumatology, Orthopaedic Center East Netherlands, Hengelo, The Netherlands. 2 Department of Orthopaedic Surgery and Traumatology, Isala Clinics, Zwolle, The Netherlands. Corresponding author: J.C. Rompen, MD Email: [email protected]

Intervention Both patients underwent left shoulder arthroscopy with subacromial decompression, following the same protocol, by two different surgeons (JCR and RAH). The patient was placed in a lateral decubitus position, supported by a full-length moldable beanbag with suction activation and with his left arm in traction for the desired position of abduction and flexion of the arm. The dry skin was disinfected with 0.5% chlorohexidine digluconate and 70% alcohol, no evident pooling of chlorohexidine was noted. The arthroscope was introduced through a posterior portal. First, the glenohumeral joint was inspected. The rotator cuff, labrum and biceps tendon anchor appeared to be intact and no chondropathy of the glenoid or humeral head was observed. Subsequently, an outflow cannula was inserted laterally into the subacromial space and the arthroscope was positioned. The decompression was performed using an acromionizer and a coblation device (ArthroCare Corporation, Austin, TX, U.S.A.) The portals were then sutured. During the procedure, no complications were noted. The patient was discharged with the advice to start mobilization of the shoulder with a physical therapist. Comparison That same evening, the first patient visited our emergency department because he had noticed two sharply defined erythematous bullous skin lesions, located on his anterior shoulder region. One was located at the ventral side of his upper arm and the other just caudally of the coracoid process. At that point, it was thought to be a dermolysis, resulting from an allergic reaction to the adhesive draping Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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Figure 1A. Skin burns two weeks after surgery.

Figure 1B. Scarring and keloid formation in the same patient, eight months after surgery.

material, and the patient was discharged with analgesics. During a checkup visit to the outpatient clinic 5 days later, a dermatologist was consulted because the skin lesions persisted. The dermatologist diagnosed burns and prescribed Flammazine. The lesions healed within two weeks (Figure 1A). Eighteen days postoperatively the second patient reported having had a sharply defined bullous lesion at the anterior aspect of his shoulder, leaving a scar that was diagnosed by the orthopedic surgeon as a possible consequence of a skin burn. This diagnosis was confirmed at a later stage by a plastic surgeon.

moval of the target tissue with minimal damage to surrounding tissue. Cell viability decreases above 45°C.10 During the coblation procedure, intraarticular fluid temperature can be maintained below 45°C by continuous irrigation of fluid through the joint via inflow and outflow cannulas.11 Several variables, such as obstruction of outflow, continuous and prolonged activation of the radiofrequency probe and minor joint volume, can cause an increase in intra-articular temperature.12,13,14 In vivo and cadaveric studies reported that joint fluid temperatures over 45°C were observed at some point during every trial, regardless of the flow rate or heat setting used.12,13 Furthermore, it has been established that when the dissipated heat cannot adequately be discharged, temperature can even rise above 60°C. This can result in intra-articular complications that include tendon rupture, chondrolysis and nerve damage.12,13,14 The deleterious effects of high intra-articular temperature have been previously described. In shoulder arthroscopy we are aware of eight cases of skin burns adjacent to the portals.3,4,5,6 These were attributed to leaking of hot irrigation fluid from the portals, due to an improper placed outflow cannula or dripping directly from the hot device wand. In our cases the lesions were located at the attachment sites of the sterile drapes, this could suggest that the burns were a result of leakage of hot irrigation fluid pooling in the folds where the drapes attach to the patient’s body, causing burns. The pattern of the burns follows gravity in the lateral decubitus position. In this case it is not completely understood why no skin burns were seen in the area of the portals. We suggest that the outflow cannula was improperly attached to the drain hose temporarily, and hot irrigation fluid could leak directly on the patient’s skin, as demonstrated by Troxell et al.5 Notably, just like us,Troxell, Kouk and Gomez

Outcome In both patients pain and erythema reduced within one week but scars were still evident eight months after surgery (Figure 1B), further rehabilitation of the shoulder was uneventful. In the second patient similar scars remained, rehabilitation was complicated by a frozen shoulder. Relevant literature Thermal damage to the skin from hot irrigation fluid and chemical damage from chlorohexidine have both been described in recent literature to be the cause of burns after shoulder arthroscopy.3,4,5,6,7,8 The use of radiofrequency coblation in orthopaedic arthroscopic surgery has gained popularity in recent years as a tool for resection, ablation and coagulation.9,10 In coblation technology, electrolytes in a conductive medium, such as a saline solution, are locally excited by radiofrequency energy produced by the probe. In this way, the probe generates a highly focused plasma field containing sufficient energy to break molecular bonds within soft tissue. It is claimed that this occurs at relatively low temperatures (typically 40°C to 70°C), enabling re-


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all used a coblation devise from ArthroCare. A second potential cause of burns associated with shoulder arthroscopy are topical agents used for disinfection of the skin. Chlorohexidine has a bactericidal effect and is widely used as an antiseptic to prep the skin pre-operatively. Allergy, hypersensitivity, anaphylaxis and chemical injuries have been described with the use of chlorohexidine. Mostly, newborns showed chemical burn wounds due to the immature skin, recently, one case-report described burns in adults after shoulder arthroscopy.7 It is suggested that a combination of fluid pooling and traction, on the skin, can lead to chemical burns. This could explain the development of burns in our cases, although no evident pooling of chlorohexidine was noted in our patients. Because of unawareness of the occurrence of skin burns in orthopaedic shoulder arthroscopy, the lesions were initially diagnosed as allergic skin reactions to the adhesive material of the sterile drapes.15 This caused a doctor’s delay in adequate treatment. In both cases, early recognition of these lesions as skin burns would have made swift adequate treatment possible, and may have prevented excessive scarring. Recommendations Concluding, it is unsure what exactly caused burns in the two cases we presented. To avoid a thermal burn in shoulder arthroscopy, we suggest using radiofrequency probes only intermittently and establishing adequate continuous flow of fluid throughout the operation. It is also essential to maintain unobstructed continuous outflow with a well-positioned outflow cannula. The elongation of the outflow cannula with an aspiration tube, as described by Gomez et al., is an easy and inexpensive way to direct potentially hot irrigation fluid away from the skin.6 To avoid chemical burns we suggest checking for, and rinsing of, pooled chlohexidine. Finally, awareness of the possibility of the origination of skin burns, as a result of orthopaedic arthroscopic surgery, can result in early recognition and treatment, and prevent treatment delay. Abstract Cutaneous burns after shoulder arthroscopy are rare. This could be due to leaking of hot irrigation fluid or a reaction to chlorohexidine. Two cases are described in which patients report cutaneous burns after shoulder arthroscopy. Careful management of the flow of irrigation fluid when using thermal

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devices and checking for pooled chlorohexidine can prevent these complications. Awareness of the possibility of burns can benefit from early recognition and treatment. Disclosure statement No disclosure.

References 1. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy. 2002;18(2 Suppl 1):88-95 2. Noud PH, Esch J. Complications of Arthroscopic Shoulder Surgery. Sports Med Arthrosc Rev 2013;21;89-96. 3. Mohammed KD, Hayes MG, Saies AD. Unusual complications of shoulder arthroscopy. J Shoulder Elbow Surg 2009;9:350-3. 4. Kouk SN, Zoric B, Stetson WB. Complication of the Use of a Radiofrequency Device in Arthroscopic Shoulder Surgery: Second-Degree Burn of the Shoulder Girdle. Arthroscopy. 2011;27(1);136-141. 5. Troxell CR, Morgan CD, Rajan S, Leitman EH, Bartolozzi AR. Dermal Burns Associated With Bipolar Radiofrequency Ablation in the Subacromial Space. Arthroscopy. 2011;27(1);142-144. 6. Gomez-Rice A, García-Germán D, Villarrubia E, Viloria F, Canillas F. Dermal burns associated with shoulder arthroscopy. Arthroscopy. 2011 Aug;27(8):1027-8; author reply 1028 7. Sanders TH, Hawken SM. Chlorhexidine burns after shoulder arthroscopy. Am J Orthop. 2012;41(4): 172-174 8. Sivathasan N, Ramamurthy NK, Pabla RS. Chemical burns associated with chlorhexidine-alcohol solution: an avoidable complication? J Burn Care Res. 2010;31(5): 833 9. Fanton GS. Arthroscopic electrotermal surgery of the shoulder. Oper Tech Sports Med. 1998;6;139-146. 10. Voss JR, Lu Y, Edwards RB, Bogdanske JJ, Markel MD. Effects of thermal energy on chondrocyte viability. Am. J. Vet. Res. 2006;67:1708-12 11. McKeon B, Baltz MS, Curtis A, Scheller A. Fluid temperatures during radiofrequency use in shoulder arthroscopy: a cadaveric study. J Shoulder Elbow Surg. 2007;16:107-11. 12. Barker SL, Johnstone AJ, Kumar K. In vivo temperature measurement in the subacromial bursa during arthroscopic subacromial decompression. J Shoulder Elbow Surg 2012;21;804-807. 13. Good CR, Shindle MK, Griffith MH, Wanich T, Warren RF. Effect of radiofrequency energy on glenohumeral fluid temperature during shoulder arthroscopy. J Bone Joint Surg Am. 2009;91(2):429-34. 14. Zoric BB, Horn N, Braun S, Millett PJ. Factors influencing intra-articular fluid temperature profiles with radiofrequency ablation. J Bone Joint Surg Am. 2009;91(10):2448-54. 15. Carol E. Cheng, MD a, Daniela Kroshinsky. Iatrogenic skin injury in hospitalized patients. Clin Dermatol. 2011;29,622–632.

Case report - “Orthopaedic” dysphagia Remco Dinjens, Pieter Monteban, Henk van Santbrink and Wouter van Hemert

20-30%, but remain asymptomatic in most cases.1 When large enough, osteophytes can compress surrounding structures. The above named diseases need to be considered in the differential diagnosis in patients presenting with dysphagia. We present two cases of “orthopaedic” dysphagia, and discuss the clinical work-up and possible treatments. We will mainly focus on DISH. Patients

Figure 1. AP and lateral x-rays of patient A of the cervical spine showing extensive osteophyte formation at the ventral side of the cervical spine.

Introduction Dysphagia is a common complaint, but infrequently seen in orthopaedics. Orthopaedic causes for dysphagia are senile degenerative skeletal disease, diffuse idiopathic skeletal hyperostosis (DISH), ankylosing spondylitis and spondylosis deformans. Considerable morbidity is seen in the geriatric population. In 75% of people aged ≥65 years, cervical vertebral changes are seen on x-rays.1 In the general population, osteophytes are present in R. Dinjens1, orthopedic resident, P. Monteban1, orthopedic resident, Dr. H. van Santbrink2, neurosurgeon, Dr. W.L.W. van Hemert1, orthopedic surgeon Atrium Medical Centre, Spine Unit, department of Orthopaedics and Traumatology1, department of Neurosurgery2, Heerlen and Maastricht University Medical Centre

Patient A, a 75-year old man, known with Parkinson’s disease (PD) since 1997, was referred to the department of internal medicine because of weight loss and progressive dysphagia. The dysphagia started three years before and progressed in line with his PD. He only complained about a stiff and painful neck. There were no gastrointestinal or neurologic symptoms. His appetite was good, but solid foods caused swallowing complaints (e.g. globus sensation). Current medication included stalevo, pramipexol, levodopa-carbidopa, amitriptyline, pantoprazol and macrogol. He had no intoxications and showed no allergies. Physical examination revealed a painful and limited range of motion of the neck. Neurological investigation revealed no abnormalities, besides PD symptoms. An x-ray of the cervical spine displayed extensive osteophyte formation at the ventral side of all cervical vertebrae (Figure 1). Analysis by means of barium swallow x-rays revealed a narrow aspect of the origo of the esophagus caused by impression from the anterior border of the cervical spine ( Figure 2). The patient was referred to the department of orthopaedics. An additional CT-scan displayed osteophyte formation of approximately 1,5 centimetres in ventral direction at multiple levels between C2-Th2, with severe impression of the dorsal wall of the oroand hypopharynx ( Figure 3). Patient B, a 45-year old man, known with M. Bechterew, experienced progressive dysphagia with a globus sensation and incidental dyspnoea during physical exercise. Symptoms could be influenced by turning his head rightward. Prior nasal endoscoNederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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Figure 2. Barium swallow x-ray of patient A showing a narrow origo of the oesophagus.

py revealed mechanical obstruction, confirmed by a barium swallow study. The patient was a smoker and consumed 1-2 alcoholic beverages daily. He used no medication Physical examination revealed a non-painful limited range of motion of the cervical spine when facing leftward (30 degrees) in comparison to the right (45 degrees). Further neurological examination revealed no abnormalities. X-ray examination of the cervical spine showed an ankylosing aspect of all facet joints and the anterior longitudinal ligament typical for M. Bechterew. Severe ventral osteophyt formation was seen at C2-C3 that was also confirmed on CT.

for determining the best possible treatment, no additional x-rays of the sacroiliac joint were performed on patient A. The definitive diagnosis could therefore not be made.

Investigation of dysphagia in general may include plain lateral x-rays, barium swallow studies, nasal endoscopy, CT and/or MRI of the head and neck.1,2,3 Laboratory tests give no additional information.2 In patient A, differentiation between DISH and senile degenerative skeletal disease could have been made by additional x-rays of the sacroiliac joint. Radiological findings of DISH can be a coincidence and therefore, radiographic criteria to diagnose DISH were proposed by Resnick.4,5 The Resnick radiographic criteria involve the presence of flowing ossification and calcification along the anterolateral aspect of ≥4 contiguous vertebral bodies, normal intervertebral disc heights in the involved vertebrae, and absence of apophyseal joint bony ankylosis and sacroiliac joint erosion.4,5 Because further differentiation between senile degenerative skeletal disease and DISH had no implication

Comparison

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Figure 3. CT investigations revealing osteophyte formation in ventral direction at multiple levels between C2-Th2 (patient A).

Intervention Patient A refused operative treatment because his current situation was satisfactory. Speech and swallow training and dietary measures were advised. Patient B was operated on as symptoms were considered unacceptable. Resection of the C2-3 osteophytes was performed via the laterocervical approach, followed by spinal fixation in order to reduce the occurrence of new osteophytes. The main reason for spinal fixation with respect to the patient’s young age was the surgeon’s preference.

Treatment depends on the severity of clinical symptoms and impact of these symptoms on the patient’s daily functioning. Asymptomatic patients only require monitoring. Conservative treatment, like physiotherapy, non-steroidal antiinflammatory drugs, speech and swallow training or dietary measures can relieve symptoms.1,2,3,6,7 In patients with major co-morbidities in whom

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surgical options should be avoided, the main concern is weight monitoring.2 Surgical intervention has to be considered in case of recurrent laryngeal nerve palsy, radiculopathy or myelopathy, whereas other causes of dysphagia (neoplastic, injury, diverticula, pharyngeal or esophageal stenoses) should be ruled out.2 Resection of osteophytes at the level of C3-4 or C4-5 is most commonly described.1,3,7,8 Discectomy or spinal fixation is not necessary, although some reports advise spinal fixation in patients <70 years of age in order to prevent osteophyte recurrence.1,4,6,8,9 The laterocervical approach, through the presternocleidomastoidal/retrolaryngeal approach with particular focus on the recurrent laryngeal nerve, is most commonly performed.1,3,7,8 Resection, limited to the protruding part of the osteophyte toward the pharynx is sufficient. An endo-oral approach is not recommended, as the mucosal wound has a higher risk of complications during the healing process compared to the external approach.1 Possible surgical complications include hematoma, salivary fistula, esophageal perforation and infection and resection or compression of the superior and/or inferior laryngeal nerves, the marginal mandibular branch of the facial nerve, the hypoglossal nerve or its descending branch, and the cervical sympathetic nerve causing hoarseness and/or dysphagia.1,7 Literature DISH with cervical involvement was first described in 1950 by Forestier and Rotes-Querol as an abnormal ossification along the anterior and lateral aspects of the vertebral column.1,6,10 Isolated or diffuse anterior cervical osteophytes can be seen, but are often idiopathic and part of a form called Forestier’s disease. DISH has a higher prevalence in men than in woman (ratio 2:1) and the incidence increases with age (around 60 years).6,11,12 In the Netherlands, a prevalence of 17% was found after examining 501 outpatient chest X-rays . However, this is likely to be under-reported because it is an uncommon entity in clinical practice.13 Senile degenerative skeletal disease, DISH, ankylosing spondylitis and spondylosis deformans should be included in the differential diagnosis. Ankylosing spondylitis involves the anterior longitudinal ligament and shows squaring of the vertebrae (“bamboo spine”) with involvement of the vertebral discs and sacroiliitis on radiological examination. In spondylosis deformans, involvement of the thoracic part of the anterior longitudinal ligament is not seen.2 Although the aetiology of DISH is still unknown, var-

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ious hypotheses involving mechanical factors, diet, metabolic conditions (hypertension, obesity, diabetes mellitus type 2) and environmental exposures are proposed.1,4,6,14 Traumatic events or iatrogenic forms (especially following spinal surgery) can also cause osteophytes.1 An increase in obesity and diabetes mellitus type 2 is seen worldwide, which can lead to an expected increase in the prevalence of DISH in the next decades.15 It is thought that a combination of all these factors play a role in causing the physical complaints. In PD, approximately 50-80% of the patients develop dysphagia.16 In most circumstances this is located at the oropharynx, but the anatomical or physiological factors causing the dysphagia remain unknown.16 Symptoms vary from pain and disability of the neck, thoracic and lumbar spine and/or extremities, and are dependant on the localisation and involvement of adjacent structures. Symptoms result mainly from changed skeletal biomechanics. Of all patients presenting dysphagia, 11% is caused by osteophytes.17 It is also reported as a cause of difficult intubation.17,18 Solid food is less tolerated than liquids, but no correlation has been found between the size of the osteophyte and symptoms.19 Dysphagia is mainly caused by osteophytes at the level of C5-6 and in a lesser extent at C4-5, presumably due to the heaviest weight load and movement span.1,3,7,9 Clinical examination can show a decreased range of motion of the spine. Anomalies during neurological examination can be found when posterior ligament calcifications compress the spinal cord. Surgical resection of the osteophytes is safe and gives satisfactory results.1,3,7,8,9 Significant improvement in all patients concerning their dysphagia within 3 months following surgery was reported by Carlson et al. One complication (e.g. cerebrovascular accident) was found in this study.3 Urrutia et al. reported complete disappearance of dysphagia between 5-20 days after surgery. A normal diet was tolerated and no complications were reported.20 Vodičar et al. found immediate postoperative improvement without complications and complete resolution of dysphagia in 5 out of 9 patients and in 2 cases within 3 weeks after surgery. The relief of symptoms after surgery is a result of elimination of mechanical obstruction. Slower disappearance of symptoms or persistent dysphagia could be the result of long-term periesophageal inflammation which can cause irreversible changes in tissue around the esophagus.16 Postoperatively, patients are allowed food the same evening.1 Longterm follow-up showed asymptomatic reoccurrence of osteophytes, regaining its preoperative size after 14-20 years.9,20

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Figure 4. Postoperative lateral and dens x-rays of patient B of the cervical spine showing spinal fixation.

Outcome

Abstract

A stable situation was seen in patient A after 3 months. Swallow training and postural head exercises could not improve symptoms. However switching to more liquid intake was satisfactory. In patient B, the postoperative course was complicated by progressive complaints of dysphagia and dyspnoea. Whilst mild swelling and erythema in the postcricoid region were found, MRI displayed no bleeding. The patient was treated with antibiotics and cortisones after which the symptoms subsided. An explanation for the complication was not found. Swallow training stimulated the patient in reducing his urge to turn his head to the right when swallowing. Six weeks postoperative, there were no complaints and x-rays showed a satisfactory spinal fixation (Figure 4).

“Orthopaedic” dysphagia. Patients can suffer from swallowing complaints due to an underlying orthopaedic cause like senile degenerative skeletal disease, diffuse idiopathic skeletal hyperostosis (DISH), ankylosing spondylitis and spondylosis deformans in which ventral osteophytes are formed along the (cervical) spine. These diseases remain under-diagnosed (systemic) conditions when examining swallowing complaints. We present two cases of “orthopaedic” dysphagia, and discuss the clinical work-up and possible treatments. We will mainly focus on diffuse idiopathic skeletal hyperostosis (DISH).

Conclusion Two patients sustained dysphagia by mechanical obstruction of the esophagus, caused by extensive anterior cervical osteophytes. Conservative treatment may give satisfactory relief of the swallowing complaints. Satisfactory short- and long-term results are also seen after surgical resection. The choice between conservative or surgical treatment depends on the disabilities experienced in daily life due to complaints, the patient’s choice and the surgeon’s preference. Surgical intervention is preferred in case of recurrent laryngeal nerve palsy, radiculopathy or myelopathy.

References 1. Lecerf P, Malard O. How to diagnose and treat symptomatic anterior cervical osteophytes? European Annals of Otorhinolaryngology, Head and Neck diseases. 2010;127:111-116. 2. Krishnarasa B, Vivekanandarajah A, Ripoll L, Chang E, Wetz R. Diffuse idiopathic skeletal hyperostosis (DISH) – A rare etiology of dysphagia. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2011;4:71-75. 3. Carlson M, Archibald D, Graner D, Kasperbauer J. Surgical management of dysphagia and airway obstruction in patients with prominent ventral cervical osteophytes. Dysphagia. 2011;26:34-40. 4. Baraliakos X, Listing J, Buschmann J, von der Recke A, Braun J. A comparison of new bone formation in patients with ankylosing spondylitis and patients with diffuse idiopathic skeletal hyperostosis. Arthritis & rheumatism. 2012;64: 4 1127-1133.


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Remco Dinjens, Pieter Monteban, Henk van Santbrink and Wouter van Hemert

5. Verlaan J, Boswijk P, de Ru J, Dhert W, Cumhur Oner F. Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction. The Spine Journal. 2011;11:1058-1067. 6. Resnick D, Niwayama G. Radiographic and pathological features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology. 1976;119:559-68. 7. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis. 1950;9:321−30. 8. Miyamoto K, Sugiyama S, Hosoe H, Iinuma N, Suzuki Y, Shimizu K. Postsurgical recurrence of osteophytes causing dysphagia in patients with diffuse idiopathic skeletal hyperostosis. Eur Spine J. 2009;18:1652-1658. 9. Vodičar M, Košak R, Vengust R. Long Term Results of Surgical Treatment for Symptomatic Anterior Cervical Osteophytes: A Case Series With Review of The Literature. J Spinal Disord Tech. 2013 Apr 3. [Epub ahead of print]. 10. Mader R. Diffuse idiopathic skeletal hyperostosis: a distinct clinical entity. Isr. Med Assoc J. 2003;5:506-8. 11. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis. 1950;9:321-30. 12. Westerveld LA, van Ufford HM, Verlaan JJ, Oner FC. The prevalence of diffuse idiopathic skeletal hyperostosis in an outpatient population in The Netherlands. J Rheumatol. 2008;35:1635-8.

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13. Sarzi-Puttini P, Atzeni F. New developments in our understanding of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin Rheumatol. 2004;16:287-92. 14. Mader R, Lavi I. Diabetes mellitus and hypertension as risk factors for early diffuse idiopathic skeletal hyperostosis (DISH). Osteoarthritis Cartilage 2009;17:825-8. 15. Grandville LJ, Musson N, Altman R, Silverman M. Anterior cervical osteophytes as a cause of pharyngeal stage dysphagia. J Am Geriatr Soc. 1998;46:1003-7. 16. Mu L, Sobotka S, Chen J, Su H, Sanders I, Adler CH et al. Altered pharyngeal muscles in Parkinson disease. J Neuropathol Exp Neurol. 2012 Jun; 71(6):520-30. 17. Broadway JVV. Forestier’s disease (ankylosing hyperostosis): a cause for difficult intubation. Anesthesia. 1994;49:919-20. 18. Palmer JH, Ball DR. Awake tracheal intubation with the intubating laryngeal mask in a patient with diffuse idiopathic skeletal hyperostosis. Anesthesia. 2000;55:70-4. 19. Seidler TO, Perez Alvarez JC, Wonneberger K, Hacki T. Dysphagia caused by ventral osteophytes of the cervical spine: clinical and radiographic findings. Eur Arch Otorhinolaryngol. 2009;266:285-91. 20. Urrutia J, Bono C. Long-term results of surgical treatment of dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis. The Spine Journal 9 (2009);e13-e17.


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Fast-track total knee arthroplasty in a patient with Parkinson’s disease Martijn Schotanus, Bas van Dun and Nanne Kort

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Parkinson’s patients have to cope with surgical stress to avoid complications and further deterioration of their functional activity after surgery. Early aggressive rehabilitation can be successful in patients with Parkinson’s disease after TKA. Incidence of knee arthritis and arthroplasty are unknown in this population. We describe the case of a 62-year old male patient with Parkinson’s disease indicated for Fast-track TKA. Within 6 hours after surgery he was able to transfer from bed to a chair and walk more than 20 meters without significant pain. This was made possible due to local infiltration of analgesia. The patient was discharged on day four, mobilizing in a safe manner. To our knowledge, this is the first report that describes Fast-track TKA in a patient with Parkinson’s disease. With the use of LIA it is possible to provide effective analgesia to reduce the compounded surgical stress experienced by patient’s with neurological deficits such as Parkinson’s disease. Appropriate early, aggressive rehabilitation is vital to reduce post-surgical complications. Fast-track TKA in Parkinson’s diseased patients ensures early mobilisation and discharge from the hospital in a responsible manner.

Introduction Parkinson’s disease (PD) is a progressive neurological disorder that affects 1-2% of the population.1 Most patients are over 65 years of age.2,3 Exact numbers are unknown, but due to the aging population this figure is expected to increase over the years causing significant stress on the hospital system and carers. Parkinson’s patients typically have several comorbidities including degenerative knee joints.4 This affects mobility and activities in daily function.5 Thus these patients generally become candidates for total knee arthroplasty (TKA).6-13 They have to cope with surgical stress to avoid complications after surgery and further decline of their functional activity.14 Incidence of knee arthritis and arthroplasty are unknown in this population. Early and aggressive postoperative rehabilitation can be successful in recovery of patients with PD after TKA.8,15 Previously published literature described a positive response in parameters such as pain, direct postoperative neurological and clinical outcomes after TKA in patients with PD.6,8-10,16 Fasttrack TKA can have favourable effects in patients with PD, including reduction of surgical stress, postoperative pain, nausea and vomiting.17-21 Furthermore Fast-track simplifies pain management and ensures early mobilisation and discharge M.G.M. Schotanus, researcher, B. van Dun, MD, orthopedic resident and N.P. Kort, MD, PhD, orthopedic surgeon, Department of Orthopedic Surgery, Orbis Medisch Centrum, Sittard-Geleen, The Netherlands Corresponding author: M.G.M. Schotanus Email: [email protected]

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from hospital with increased patient satisfaction.20 However available published studies on Fast-track TKA have been applied to “healthy” populations. To our knowledge, there is no published case that focuses on the effect of Fast-track TKA in patients with neurological deficits such as PD. Patient This case is of a sixty-two year-old non obese male with PD quantified with bilateral involvement without impairment of balance (Hoehn and Yahr score, Stage II)22, indicated with osteoarthritis of the right knee with valgus alignment and impaired function during everyday activities (Table 1) without other comorbidities. Medical history revealed operations of the medial and lateral meniscus in the early seventies. The patient uses a stack of medication for side effects of PD: Sinemet (Levodopa, 125 mg; 4 times daily (TD)), Sifrol (Pramipexol, 0.5mg; 3TD) and Seresta Forte (Oxazepam, 50mg; 1TD). The patient was initiated for Fast-track TKA. Intervention Slowly but surely, more and more orthopedic surgeons are convinced of revolutionary changes on evidence-based interventions within the elective knee arthroplasty. Modification of a selected number of scientifically supported procedures used together, can be implemented in a care pathway. Such optimisation is also known as Fast-track, a multimodal clinical pathway.23-26 As part of the Fast-track pathway, 6 weeks before surgery patients visit the “Joint

Martijn G.M. Schotanus, Bas van Dun and Nanne P. Kort

school” to get familiar with the postoperative exercises, the training program and walking (stairs) with crutches under the supervision of a physiotherapist. Intra-operatively local infiltration analgesia (LIA) will be injected by the orthopedic surgeon as described by the protocol of Kehlet and Andersen for early postoperative pain relief.20 Intra-articulair infiltration (150 ml ropivacaine (2mg/ml) with 1,5 ml adrenaline (1mg/ml) of all tissue is performed intra operatively before insertion of the prosthesis. First posterior (50ml) and anterior (50ml) joint capsule is injected. After inflation of the tourniquet, the prosthesis is cemented and the subcutis is infiltrated (50ml). Fast-track does not include the use of drains and catheters. Urine retention is tested with the use of a bladder scan. Within 6 hours of infusion of spinal anesthesia the patient starts to mobilize under the supervision of a physiotherapist. Daily exercises are executed in a group as well as individually, as each patient has a patient specific program. Patients will be discharged if following criteria is met: knee flexion of >70°, safe mobilisation, transfers and able to walk stairs with crutches if necessary. Comparison Fast-track incorporates pre-, peri- and post -operative management in patients undergoing elective surgery with the focus on preoperative education and training of patients, pre- and post -operative multimodal pain protocol, nausea prevention and early mobilization.26,27 This pathway has favourable effects on medical outcome, recovery time, length of hospital stay, improved patient satisfac-

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tion and cost effectiveness compared to conventional pathways.18,24,28,29 Length of Hospital stay in Western European countries varies between discharge on the day of operation and almost 8 days postoperative.30 Decreased mobility is a common symptom in people with osteoarthritis. Attention should be addressed to patients with osteoarthritis requiring TKA complicated by co-morbidities. Patients with neurological deficits such as PD can have significant muscle rigidity, poor coordination associated with their condition and increased surgical stress. Clearly these factors influence the rehabilitation plan. Outcome Preoperative, the neurologist was consulted because of PD and recommended to continue with his PD medication during surgery and use intra operative spinal anesthesia with sedation. Surgery was performed according to the medial patellar approach with use of patient specific instruments for femur and tibia (Signature™, Biomet, Warsaw IN). Within 6 hours after TKA surgery the patient was able to transfer from bed to a chair and walked with crutches (>20 meters) Pain scores (VAS) before (BFM) and after (AFM) first mobilisation show that he could walk without significant pain. (Table 2) The patient was motivated through ‘coaching’ by a family member. Under the supervision of a physiotherapist, the patient was able to flex his knee 80 degrees and walk stairs with crutches post-operative on day two. A knee flexion of 90 degrees with complete extension was obtained on day 3. The patient mobilized in a responsible manner with crutches and was able to walk stairs on day 4, and he was discharged to his home environment in a stable condition.

Table 1. Pre and post-operative (PO) patient reported outcome for Oxford Knee Score (OKS; 12= good function and 48= worst function during everyday activities) and Western Ontario McMaster Osteo-Arthritis Index (WOMAC; 100= best function and 0= worst function during everyday activities).

OKS WOMAC

Pre- operative

3 Months PO

1 Year PO

25 57,6

16 95

14 97

Table 2. Pre and post-operative (PO) VAS pain scores measured on 100mm lickerd scale (0= painless and 100= worse pain imaginable). Before (BFM) and after (AFM) the first mobilization.

VAS

Pre- operative

Direct PO

BFM

AFM

3 Months PO

1 Year PO

70

15

21

22

20

0


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Three months after discharge the patient was able to mobilise without crutches and could flex his knee up to 110° without extension deficit with improved function during everyday activities (Table 1). One year after surgery function (flexion 120°) and patient reported outcome measures still improved (Table 1). Literature Vol 21 sept ’14

Our search (Embase and Medline) in the International literature revealed 6 other clinical studies describing the results of TKA in 89 patients with PD (Table 3).8-13 Literature indicates the favorable effects of early and aggressive rehabilitation after total knee replacement surgery. These are beneficial for patients with neurological deficits. Early exercise in PD patients consist the use of continuous passive motion machines (CPM), starting on the recovery room. First mobilization started the day after surgery under supervision of a physiotherapist.8,13 Patients without neurological deficits can mobilise within 6 hours post operatively with less pain, nausea, vomiting and with short hospital stays.19,20 Positive effects on TKA in PD patients are described in published case series, but these results do not consist the prospect of early mobilisation (Table 3).9,11,12 Fast-track TKA has never been described before in this population. Immobilizing PD patients does not have beneficial results14 and rehabilitation in PD patients is not impossible in contrast with some literature.11 PD patients treated with immobilisation for 3 weeks with plaster cylinders after TKA have to cope with hamstring rigidity and fixed-flexion deformities.11 Immobilising the knee for two days and start walking with crutches or a walker on day 4 post-operatively can delay and impair knee flexion (Table 3).9,10

Mobilising patients immediately posoperatively with CPM in bed and with exercise training <24 hours postoperatively is possible (Table 3).8,13 Summarized, early aggressive mobilisation and rehabilitation is important.9,13,17,31 In PD patients it is vital to remain or increase muscle strength and prevent falling32-37 Early discharge in PD patients is in conflict with other literature that describes an extended postoperative rehabilitation period (Table 3).9,10 Our patient participated in the preoperative “Joint School”; he was able to walk <6 hours post -operatively without significant pain. He was discharged to home at day 4 post-operatively as described by the protocol of Kehlet and Andersen.18 Patients who had consultation by a neurologist immediately after TKA had comparable results. These patients were discharged to a rehabilitation center with a mean of 3.5 days compared to patients who had delayed consultation after surgery by a neurologist. They were discharged with a mean of 6 days (Table 3).8 If PD patients are able to follow prehabilitation, participate in the pre-operative “Joint School”, understand and cope with new information and are able to follow instructions for pre and post-operative exercises with the physiotherapist, the probability of a safe and successful rehabilitation will increase.8,9,13,31 Recommendation In the past, total knee arthroplasty was believed to be a contraindication in PD patients but now is favourable due to its reduction of peri- and postoperative mortality and morbidity.11,13 Fast-track surgery allows to perform TKA in patients with severe neurological diseases such as PD and expect good outcomes.14 With the use of LIA it is possible

Table 3. Published literature on TKA in PD patients. Study

N=

First Mobilization PO (hours)

Exercise

Hospitalization (days)

Mehta S. et al.8 Fast A. et al.9 Vince K.G. et al.10 Oni, O. O. A et al.11 Shah, S. N. et al.12 Duffy G.P. et al.13 Current case

39 1 12 3 1 33 1

DPO, >24 >48 >48, >96 NA DPO, >24 <6

CPM, PHY CPM walking CPM, PHY transfer, walk >20

3.5, 6 44 5 4

N= amount of operated total knees described in study; PO= post -operative; DPO= immediately PO; NA= not able; CPM= continuous passive motion machine; PHY=physiotherapy

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to provide effective analgesia to reduce the compounded surgical stress experienced by patients with PD.13,16,23 From our experience we suggest that patients with PD who are initiated for TKA must be provided with post-operative LIA to optimize post-operative pain, resulting in reduced surgical stress and early mobilization. We emphasize that Parkinson’s disease is not a contraindication for Fast-track total knee arthroplasty. Disclosures Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

References 1. Riem D, Zuidema SU, Bor H, Poels PJE and Bloem BR. De ziekte van Parkinson, De prevalentie van de ziekte van Parkinson en parkinsonisme in Nederlandse verpleeghuizen Volume 34, Number 4 (2009), 127-131 2. Barbosa ER, Limongi JC, Cummings JL. Parkinson’s disease. Psychiatr Clin North Am.1997;20:769-790 3. McNaught KS, Olanow CW. Protein aggregation in the pathogenesis of familial and sporadic parkinson’s disease. Neurobiol Aging. 2006 Apr;27:530-45. 4. Mazzoni P, Shabbott B, Cortés JC. Motor control abnormalities in Parkinson’s disease. Cold Spring Harb Perspect Med. 2012 Jun;2:a009282 5. Ransmayr G. Physical occupational, speech and swallowing therapies and physical exercise in Parkinson’s disease. Journal of Neural Transmission 2011;118: 773-81 6. Leibson CL, Maraganore DM, Bower JH, Ransom JE, O’brien PC, Rocca WA. Comorbid conditions associated with Parkinson’s disease: a population-based study. Mov Disord. 2006 Apr;21:446-55 7. Sato Y, Kikuyama M, Oizumi K. High prevalence of vitamin D deficiency and reduced bone mass in Parkinson’s disease. Neurology. 1997;49:1273-1278 8. Mehta S, Van Kleunen JP, Booth RE, Lotke PA and Lonner JH. Total Knee Arthroplasty in Patients With Parkinson’s Disease: Impact of Early Postoperative Neurologic Intervention. Am J Orthop. 2008;37:513-516 9. Fast A, Mendelsohn E, Sosner J. Total knee arthroplasty in Parkinson’s disease. Arch Phys Med Rehabil. 1994;75:1269-1270 10. Vince KG, Insall JN, Bannerman CE. Total knee arthroplasty in the patient with Parkinson’s disease. J Bone Joint Surg Br. 1989;71:51-54 11. Oni OOA, and MacKenney RP. Total knee replacement in patients with Parkinson’s disease. J. Bone and Joint Surg., 1985 May 67-B: 424-425 12. Shah SN, Hornyak J and Urquhart AG. Flexion contracture after total knee arthroplasty in a patient with Parkinson’s disease: successful treatment with botulinum toxin type A. J Arthroplasty 2005 Dec; 20: 1078-1080

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13. Duffy GP, Trousdale RT. Total knee arthroplasty in patients with Parkinson’s disease. J Arthroplasty. 1996;11:899-904 14. Macaulay W, Geller JA, Brown AR, Cote LJ, Kiernan HA. Total knee arthroplasty and Parkinson disease: enhancing outcomes and avoiding complications. J Am Acad Orthop Surg. 2010 Nov;18:687-94 15. Soto-Hall R. Treatment of transcervical fractures complicated by certain common neurological conditions. Instr Course Lect 1960; 17:117-120. 151 16. Ranawat AS, Ranawat CS. Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty 2007, 22:12-15 17. Husted H, Lunn HT, Troelsen A, Gaarn-Larsen L, Kristensen BB and Kehlet HH. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthopaedica 2011; 82: 679–684 679 18. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362: 1921-8 19. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248: 189-98 20. Kehlet H, Andersen LØ. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand. 2011 Aug;55:778-84 21. Kerr DR and Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery. A case study of 325 patients Acta Orthopaedica 2008; 79: 174–183 22. Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. 1967. Neurology. 1998 Feb;50:318-334 23. Wilmore DW, Kehlet H. Management of patients in Fasttrack surgery. BMJ. 2001 Feb 24;322:473-6. 24. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002 Jun;183:630-41. 25. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248:189-98. 26. Husted H, Holm G. Injury. 2006 Fast-track in total hip and knee arthroplasty--experiences from Hvidovre University Hospital, Denmark. Dec;37 Suppl 5:S31-5. Erratum in: Injury. 2007 Oct;38:1224. 27. Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. 2011 Feb;7:9-15. 28. Reuben SS, Buvanendran A. Preventing the development of chronic pain after orthopaedic surgery with preventive multimodal analgesic techniques. J Bone Joint Surg Am. 2007 Jun;89:1343-58. 29. Savaridas T, Serrano-Pedraza I, Khan SK, Martin K, Malviya A, Reed MR. Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program. A study of 4,500 consecutive procedures. Acta Orthop. 2013 Feb;84:40-3. 30. Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM. The feasibility and perioperative complications of outpatient knee arthroplasty.Clin Orthop Relat Res. 2009 Jun;467(6):1443-9. 31. Londos E, Nilsson LT, Stromqvist B. Internal fixation of femoral neck fractures in Parkinson’s disease. 32


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patients followed for 2 years. Acta Orthop Scand. 1989;60:682-685 32. Allen NE, Canning CG, Sherrington C et all. The effects of an exercise program on fall risk factors in people with Parkinson’s disease: a randomized controlled trial. Mov Disord 2010 Jul 15 :25: 1217-1225 33. Earhart GM, Ellis T, Nieuwboer A, Dibble LE. Rehabilitation and Parkinson’s disease. Parkinsons Dis. 2012;2012:371406. 34. Ebersbach G, Ebersbach A, Edler D et all. Comparing exercise in Parkinson’s disease--the Berlin LSVT(R)BIG

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study. Mov Disord 2010 Sep 15:25: 1902-1908 35. Formisano R, Pratesi L, Modarelli FT, Bonifati V and Meco G (1992). Rehabilitation and Parkinson’s disease. Scand J Rehabil Med 1992 Sep;24:157-60.28 36. Jaggers JR, Simpson CD, Frost KL et all. Prehabilitation before knee arthroplasty increases postsurgical function: a case study. J Strength Cond Res 2007 May;21: 632-634 37. Swank AM, Kachelman JB, Bibeau W et all. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. J Strength Cond Res 2011 Feb 25: 318-325

Proefschriftbespreking Evidence based introduction of orthopaedic implants. RSA, implant quality and patient safety. Bart Pijls, LUMC, 16 januari 2014 The following statements in the introduction of the thesis grasp the essence of the subject of research: - Loosening of a joint replacement starts with submillimeter migration of the prosthesis components relative to the bone and gradually evolves into gross movements accompanied by clinical symptoms such as pain. It may take as long as 10 years before the final stages of gross loosening are visible on conventional X-rays. - Rontgen Stereophotogrammetric Analysis (RSA) is a highly accurate stereo X-ray technique for assessing three-dimensional movement between two rigid bodies i.e. migration of prosthesis relative to bone. - RSA encompasses a high precision which enables to predict long-term implant survival with a small sample of patients followed for a relatively short period of 2-3 years.

The aim of the thesis is to evaluate the clinical value of migration measured with RSA in totalknee and hip prostheses. First of all to establish an association of short term (2 yr) migrationand the likelihood for long term (10 yr) revision for aseptic loosening and secondly on the long term migration patterns of different types of fixation of different types of prosthesis as part of post market surveillance with RSA. Rephrasing the summary of the thesis and summarizing the different chapters is not what a book report is about as this information is open access available on several websites1. In this case it should rather target on testing the RSA philosophy by collecting proof through high quality studies and the phased evidence-based introduction of new joint prostheses. This thesis starts off with a bird’s-eye view on the role of RSA and registries in phased introduction of new implants. Then it reports on several quests establishing evidence for the predictive value of RSA for implant loosening. An exemplary study is presented in chapter 5 and published in the JBJS-B: a RSA-based RCT on the potential differences between mobile and fixed-bearing knee prostheses at 10-12 years follow-up. No significant differences could be demonstrated between groups in terms of fixation. Four other excellent other RSA-studies on knee and hip replacement are reported in this thesis. It is about hips and knees, HA-coatings or uncoated or cemented, mobile and fixed bearings, tibial and acetabular components. All these experiments serve one common goal: a safe, quick, transparent regimewith relative few patienys for the phased introduction of new joint implants in order to reduce the revision burden by as much as 35% with subsequent financial savings. The RSA-philosophy is perhaps best explained in chapter 7: two parallel systematic reviews and meta-analyses to determine the association between early migration of tibial components and late aseptic revision. In conclusion there was an 8% increase in revision rate for every mm increase in migration. A RSA-threshold was established for acceptable Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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migration after the first postoperative year (up to 0.5mm) to end below 5% revision after 10 years of implantation. The same trick was repeated in chapter 8 for acetabular hip components and recently de Vries et al. derived similar conclusions for femoral hip components2. Potentialissues and lack of uniformity can hamper the success of RSA: consensus on how RSA trials should be carried out and results reported, measurement error and precision, migration and migration direction data, how much micromotion is allowed for acceptable longterm results in general and specifically for each component design as patterns for implant loosening differ for different fixation techniques. Because of the relatively low numbers of patients the influence of outliers is significant. Finally RSA only evaluates aseptic loosening while other failure mechanisms as osteolysis or pseudotumours are not. The Leiden research group is to be complemented on their efforts to set the international standards on RSA as in uniformity in trial setup and reporting of results through their guidelines as well as long-term follow-up studies and reviews in order to detect inferior designs. This thesis is a significant step in the process of a leading role for RSA in the phased introduction of new implants. After preclinical testing RSA can select implants eligible for the larger multicentre clinical studies (Malchau flowchart). At this mo-

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ment it can limit the prostheses eligible for further clinical investigations but cannot substitute this step as RSA is currently a predictor for future results and not the “truth” especially not for the “at risk” category in the RSA results which is by far the largest category when compared to the “acceptable” and “unacceptable” category. Evidently more long-term follow-up studies of original RSA cohorts are needed to establish the predictive value of RSA. Without a doubt this thesis is a major contribution to this process with the ultimate goal to limit unsafe joint replacements reaching the market. Kees Verheyen 1. http://www.orthopeden.org/uploads/oI/es/ oIes2lIktyZNcCbNm0DWDw/Proefschrift-Pijls.pdf

2. de Vries LMA, van der Weegen W, Pilot P, Stolarczyk PA, Sijbesma T, Hoffman EL. The predictive value of radiostereomatic analysis for stem survical in Total hip arthroplasty. A systematic review. Hip Int 24: 215-222 (2014)

Van de Vereniging

Strategisch Plan LROI 2014-2016: Zicht op Kwaliteit & Veiligheid In augustus 2014 is het strategisch plan 2014-2016 van de Stichting LROI gepresenteerd, met als titel: ‘Zicht op Kwaliteit & Veiligheid’. Deze titel weerspiegelt de visie en de missie van de Stichting LROI om via een continu proces van meten, registreren en feedback direct bij te dragen aan de verbetering van de kwaliteit van zorg en aan het versterken van de patiëntveiligheid.

De LROI heeft als register de afgelopen jaren een sterke ontwikkeling doorgemaakt. De kwaliteit van de database is enorm gestegen en de compleetheidstudie toont aan dat inmiddels 95 procent van alle knie- en heupimplantaten staat geregistreerd. Uiteraard is het streven om dit percentage te verhogen en daarvoor heeft de Stichting LROI een junior onderzoeker aangetrokken; zie het interview met Anneke Spooren hieronder. Wat betreft de traceerbaarheid van de geregistreerde implantaten is de 100% al een feit. Mocht er sprake zijn van een calamiteit met een prothese,

dan is vanuit de LROI bekend welke ziekenhuizen deze prothese hebben geplaatst. Stichting LROI stelt hen direct op de hoogte en de ziekenhuizen kunnen vervolgens hun patiënten traceren. Een volgend kwaliteitsaspect betreft het LROI-dashboard: elke orthopedische vakgroep en maatschap kan via dit LROI-dashboard haar resultaten vergelijken met de landelijke cijfers. Zicht op deze getallen kan gebruikt worden om de kwaliteit binnen de vakgroep/ maatschap te optimaliseren. Een grote verandering in de LROI is de koppeling met de Patient Reported Outcome Measures (PROMs). Deze koppeling, waarover u in deze uitgave ook een separaat artikel aantreft, zorgt voor een verdere ontwikkeling in lijn met de gepresenteerde visie en missie: de LROI als kwaliteitsregistratie. De koppeling leidt immers tot een uniek inzicht in mogelijke relaties tussen operaties, implantaten, werkwijzen, patiëntpopulatiekenmerken en de resultaten van een ingreep. Middels het Strategisch Plan LROI zijn de doelen van de LROI voor de komende drie jaar uitgezet. De LROI ziet het als uitdaging om de kwaliteit en veiligheid nog verder te ontwikkelen. Geke Denissen, projectcoördinator LROI, [email protected].

Registratieoptimalisatie voor maximale kwaliteit LROI De LROI (Landelijke Registratie Orthopedische Implantaten) is een waardevol instrument om de kwaliteit van orthopedische zorg en de patiëntveiligheid te vergroten. Die waarde is onder andere afhankelijk van de compleetheid (registreren alle instellingen alle implantaten) en van de kwaliteit van de in de LROI geregistreerde data. Sinds begin 2014 biedt Stichting LROI instellingen op beide vlakken ondersteuning, op afstand en op locatie.

De LROI analyseert de geregistreerde data per kalenderjaar. Bovendien start één keer per jaar een validatietraject en elk jaar vindt een compleetheidsonderzoek plaats. Uit het compleetheidsonderzoek over het jaar 2012 bleek dat inmiddels alle instellingen die heup- en knieprothesen plaatsen, registreren in de LROI. Daarbij werden hoge percen-

Tabel 1: Compleetheid registratie heup- en knieprothesen in de LROI in 2012. Bron: LROI-Rapportage 2012. Heupprothesen Primaire totale heupprothesen 94% Revisie heupprothesen 83% Knieprothesen Primaire knieprothesen Revisie knieprothesen

94% 86%

tages compleetheid behaald, zoals tabel 1 laat zien. Naar 100% De LROI wint aan waarde als daadwerkelijk alle geplaatste prothesen in het register staan. Daarbij is de kwaliteit van de in de LROI geregistreerde Nederlands Tijdschrift voor Orthopaedie, Vol 21, Nr 3, september 2014

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Vol 21 sept ’14

Vol 21 sept ’14

data natuurlijk ook van belang. Daarom heeft de Stichting LROI in 2014 een nieuwe medewerker als junior onderzoeker aangetrokken, gezondheidswetenschapper Anneke Spooren. In een half jaar heeft zij 11 instellingen bezocht bij wie behoefte aan ondersteuning bestond. “Bij ieder van hen vergeleek ik één op één de volgens het ziekenhuisinformatiesysteem geplaatste prothesen met de registraties in de LROI. Zo werd exact duidelijk waar de gesignaleerde verschillen tussen het ziekenhuisinformatiesysteem en de LROI zich bevonden. In samenwerking met de instelling achterhaalden we vervolgens de eventuele oorzaken.” Correcte data Om te achterhalen of de in de LROI geregistreerde data correct zijn, bekeek Anneke of er tussen de geregistreerde data missende of onmogelijke waarden aanwezig waren. “Ook hier werkte ik samen Aandachtspunten voor een optimale registratiekwaliteit, gebaseerd op de praktijksituatie bij 11 instellingen in 2014: 1. Hanteer de juiste definities van categorieën prothesen: A. Primaire prothese: de eerste (primaire) plaatsing van een prothese ter vervanging van het oorspronkelijke gewricht. Bij de heup betreft het: totale of kophals heupprothesen. Bij de knie is mogelijk: totale, unicondylaire of patellofemorale knieprothese. B. Revisie prothese: elke verandering (plaatsing, vervanging en/of verwijdering) van één of meerdere componenten van de prothese. 2. Hanteer de juiste definitie van ‘indicatie’: de primaire reden voor protheseplaatsing. Dit betekent: maximaal één indicatie per ingreep. 3. Plak alleen stickers voor productnummers van de te registreren componenten. Voor de heup zijn dit: cement, acetabulum (cup), femur, inlay (insert) en femurkop (head). Voor de knie betreft het: cement, femur, tibia, inlay (insert) en patella. NB. Dit betekent dat de productnummers van onder andere de volgende componenten niet geregistreerd hoeven te worden: stem extentions, centralizers, hole eliminators, plugs, augmentations, sleeves, necks, cables, claws, screws, head adapters, wedges of spacers. 4. Voer altijd een antwoord in, ook als het antwoord ‘Nee’ of ‘Onbekend’ is. Dat schept duidelijkheid.

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met de instelling; met de invoerder of de orthopedisch chirurg bekeek ik alle inhoudelijke afwijkingen om de oorzaken te achterhalen. Daarnaast vergeleek ik tijdens mijn bezoek vijftig willekeurig geselecteerde LROI-formulieren met de digitale LROI-gegevens.” Uit beide analyses is gebleken dat een aantal zaken speciale aandacht verdienen, zie de kadertekst. “Deze aandachtspunten komen uit de praktijk; iedereen kan er direct zijn voordeel mee doen”, aldus Anneke. “Graag benadruk ik nogmaals dat de kwaliteit van de LROI al zeer groot is, maar het kan en moet nog beter voor een optimalisatie van de kwaliteit van de orthopedische zorgverlening en met name voor de traceerbaarheid van implantaten. Met de jaarrapportages en het dashboard profiteert bovendien elke instelling en elke orthopedisch chirurg van de complete en correcte LROI-data.” 5. Bij een gestructureerde registratie en invoer blijkt de registratielast beperkt te blijven. Tips vanuit de praktijk: A. Door consequent en regelmatig invoeren blijft de hoeveelheid in te voeren formulieren (relatief) klein. B. Een gestructureerde manier van verzamelen en opbergen van de LROI-formulieren draagt bij aan een completere en meer valide registratie; deze manier van werken zorgt voor overzicht en maakt het mogelijk eventuele onduidelijkheden na te kijken. C. Beperk het aantal mensen dat registreert; liefst tot één of twee personen. Dit brengt consequente fouten eerder aan het licht en maakt een snelle correctie mogelijk. D. Bouw controlemomenten in, bijvoorbeeld door het aantal prothesen per week of per maand op het OK-schema te tellen en na te gaan of dit overeenkomt met het aantal in de LROI geregistreerde prothesen (terug te vinden op het LROIdashboard). E. Besteed bij de overgang naar een nieuwe artsassistent aandacht aan (het belang van) de LROI registratie. In de praktijk blijkt dit een kwetsbaar moment te zijn, dat kan leiden tot grote gaten in de administratie en registratie. Heeft u vragen rondom het registreren in de LROI en/ of heeft u behoefte aan ondersteuning, neem dan contact op met het LROI-bureau, [email protected] of 073-700 34 10. Zie ook www.lroi.nl.

Koppeling PROMs – LROI: naar een landelijke benchmark

- De gevalideerde PROMs-vragenlijsten worden gebruikt.

Op het gebied van Patient Reported Outcome Measures (PROMs) loopt de orthopedie in Nederland sterk voorop. De PROMs beschrijven uitkomsten van zorg vanuit het perspectief van de patiënt. Deze uitkomsten geven op korte en lange termijn het ervaren effect weer van de interventie bij een bepaalde aandoening (zoals knie- en heupartrose) op de gezondheid en het dagelijks leven van de patiënt.

Als een softwareaanbieder aan deze vereiste voorwaarden voldoet, verloopt de PROMs-registratie in de LROI via een gestructureerde en uniforme manier. Een dergelijke eenheid van definities en aanleverprocessen is cruciaal voor de aggregatie en vergelijking van de resultaten op landelijk niveau en voor de uiteindelijke benchmark en spiegelinformatie die op deze gegevens gebaseerd zal worden.

Op 4 oktober 2012 heeft de Algemene Ledenvergadering van de NOV haar PROMs Advies vastgesteld. In dit plan staat vermeld welke PROMs-set voor de heup wordt geadviseerd. In 2013 is vervolgens het Implementatieplan PROMs-advies gepresenteerd. In dit Implementatieplan staat beschreven hoe de PROMs kunnen worden gemeten in de orthopedische praktijk. Ook wordt hierin beschreven dat een landelijke benchmark wenselijk is en dat het daarvoor mogelijk moet zijn om de PROMs-gegevens aan de implantaatgegevens in de LROI te koppelen. Vele orthopedische vakgroepen en maatschappen zijn met het PROMs Advies- en Implementatieplan aan de slag gegaan; zij meten inmiddels PROMs bij de patiënten. De manier van PROMs meten loopt uiteen. Er zijn immers meerdere manieren om PROMs af te nemen, namelijk via eigen software, via papieren vragenlijsten of via de digitale webforms van de LROI. LROI-certificaat Een groot deel van de vakgroepen en maatschappen verzamelt de PROMs-gegevens via een eigen softwaresysteem. Het meten van PROMs via eigen software geeft de mogelijkheid om vragen toe te voegen aan de lijsten, bijvoorbeeld voor wetenschappelijk onderzoek of voor extra informatie over de patiënt. Om de vakgroepen en maatschappen een handvat te geven, hebben de NOV en Stichting LROI enkele voorwaarden opgesteld. Hierin is onderscheid gemaakt tussen ‘vereiste’ en ‘zeer gewenste’ voorwaarden. Indien een softwareaanbieder aan de vereiste voorwaarden voldoet, komt deze in aanmerking voor een LROI-certificaat. De vereiste voorwaarden houden in: - De beveiliging van persoonsgegevens is geregeld via de geldende ISO- en/of NEN-normen. - De software maakt een upload van gegevens naar de LROI mogelijk.

LROI-webforms In augustus 2014 heeft de LROI haar vernieuwde webforms gepresenteerd; ze bieden meer functionaliteiten dan de oude versie. Nieuwe mogelijkheden zijn bijvoorbeeld: mogelijkheid om een logo toe te voegen; de patiënt kan de vragenlijst thuis invullen; er worden automatisch invul-herinneringen gestuurd op drie maanden en een jaar na de operatie. PROMs voor de knie De PROMs voor de knie zijn opgesteld door de NOV richtlijnwerkgroep Totale Knieprothese. Na aanname van de nieuwe richtlijn Totale Knieprothese in de ALV zullen de PROMs voor de knie ook worden geïmplementeerd in de LROI. De zorgverzekeraar meet ook PROMs Namens de zorgverzekeraars meet Miletus PROMs bij orthopedische patiënten met een heup- en/of knieprothese. Het kan dus voorkomen dat de patiënt door zowel de orthopedische vakgroep/maatschap als door Miletus een vragenlijst krijgt toegestuurd. Deze dubbele vragenlijst kan leiden tot verwarring bij de patiënt en kan een lager responspercentage tot gevolg hebben. Daarom zijn de NOV en Stichting LROI met Miletus in gesprek gegaan en dit heeft geleid tot een oplossing: als een instelling zijn verkregen PROMs-data met Miletus wil delen, dan meet Miletus geen PROMs meer bij de patiënten van die instelling. Het delen van deze gegevens kan via de LROI gerealiseerd worden, uiteraard zal dat pas geschieden na specifieke toestemming van de vakgroep/maatschap. Geke Denissen, projectcoördinator LROI, [email protected].


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Vol 21 sept ’14

De Murk Jansen lezing: twintig voordrachten sinds 1988

Vol 21 sept ’14

Om het jaar wordt tijdens de NOV Jaarvergadering de Murk Janzen-lezing uitgesproken. Het NOV-bestuur nodigt hiervoor een spreker uit; iemand die zich uitzonderlijk verdienstelijk heeft gemaakt voor de Vereniging, of voor de orthopedische chirurgie in het algemeen. De lezing eerder dit jaar, uitgesproken door prof. dr. R.G. Pöll, was de twintigste Murk Jansen-lezing. Dr. Murk Jansen was een van de grondleggers van de orthopedie in Nederland. Dit artikel geeft een zeer beknopte biografie van hem en een opsomming van degenen die zich met eenzelfde bezieling voor de orthopedie en orthopedische patiënten inzetten of zich hebben ingezet.

en assistent op de chirurgische afdeling. In 1904 verwerft Jansen de doctorstitel in Gent en twee maanden later begint hij als privaat-docent in de orthopaedie in Leiden. In datzelfde jaar opent in het Academisch Ziekenhuis Leiden een orthopedische kliniek; deze Rijkspolikliniek gaat in 1930 over naar de Anna Kliniek. De reden voor Murk Jansen’s belangstelling voor de orthopedie is niet precies bekend. Wel is duidelijk dat hij zich er met grote overgave op toelegt en veel contacten onderhoudt met het buitenland. Hij voelt de urgentie om de orthopedie in Nederland van de grond te krijgen. Mede daarom richt hij in 1919 met Anna Elisabeth Groll de ‘Vereeniging voor Misvoormden’ op en later de eerder genoemde Anna Kliniek, waarbij hij tijdens de opening wordt benoemd tot Ridder in de Orde van de Nederlandse Leeuw. Patiënten uit heel Nederland bezoeken de kliniek. Zijn internationale activiteiten bestaan onder andere uit het mede-oprichten van de Société Internationale de Chirurgie Orthopédique (S.I.C.O.T), in 1929 in Parijs. In 1932 wordt hij tijdens het tweede S.I.C.O.T.-congres in Londen tot voorzitter gekozen. In 1934 blijkt Murk Janssen ziek te zijn; op 1 maart 1935 overlijdt hij aan colon carcinoom. Bron: Biografie van de Nederlandse orthopaeden en enkele paramedici, Dr. L.F. Bakker, 1989. De twintig Murk Jansen-lezingen zijn uitgesproken door:

Dr. Murk Jansen Murk Jansen wordt op 23 september 1867 in Zaandam geboren. Zijn vader, Jacobus, is hoofdonderwijzer van een gemeenteschool; zijn moeder is Murkje Brandsma. Als vader Jansen begin 1879 hoofdonderwijzer wordt in Rotterdam, verhuist het gezin. Murk treedt in eerste instantie in de voetsporen van zijn vader. Liever wil hij dokter worden, maar het ontbreekt het gezin aan financiële middelen. In 1892 behaalt Murk zijn acte M.O. Engels. Hij gaat privélessen geven en legt het geld opzij. De financiën en de acte zelf verschaffen hem de basis om zich aan de universiteit in te schrijven. Dat doet hij in Leiden en in 1900 wordt hij daar tot arts bevorderd. Achtereenvolgens is hij prosector in de anatomie, assistent op de interne afdeling

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1988 W.Ph. van der List 1989 Dr. H.W. Wouters 1990 Dr. Th. Boesman 1991 Dr. H.S.M. Raat 1992 Dr. R. Spruit 1993 H. Herschel 1994 G.J. Onvlee 1995 Prof. dr. A.J. van der Linden 1996 Dr. B.E.E.M.J. Veraart 1997 Dr. G.P.H. Hermans 1999 A.M. van der Heyden 2000 Prof. dr. B. van Linge 2001 A.C.M. Koot 2002 Prof. dr. J.W. van der Eijken 2004 Dr. M.T.C. Speeckaert 2006 Prof. dr. R.K. Marti 2008 Prof. dr. J.R. van Horn 2010 Prof. dr. A.J. Verbout 2012 Prof. dr. G.H.I.M. Walenkamp 2014 Prof. dr. R.G. Pöll De Murk Jansen-lezing van prof. dr. R.G. Pöll vindt u op de NOV-website, onder [vereniging] [verenigingszaken]

Looks good? 96.4% Works even better! 96.4 % survival at seven years. [1, 2] The Affinis shoulder prosthesis has an excellent survival rate. The probability of having NO humeral component revision within the first seven years after surgery is 96.4 %. [1] Mid- to long-term survivorship of an anatomical shoulder prosthesis. Irlenbusch U, Berth A, Blatter G, Zenz P. White Paper, Mathys Ltd Bettlach, 2013. [2] Mid-term survival rates of an anatomical shoulder prosthesis. Zenz P, Berth A, Blatter G, Irlenbusch U. Data were presented at ÖGO Congress, 12–14 September 2013.

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©2013 Biomet. All pictures product names and trademarks herein are the property of Biomet, Inc. or its subsidiaries. References: 1. AOANJR (The Australian Orthopaedic Association National Joint Replacement Registry). Determined based on the comparison of cumulative survival rate at 10 years between PKA and TKA 2. Study by researchers at Washington University in St. Louis, Missouri, US. Portions of study funded by Biomet. Determined based on adjusted odds ratio calculation.

September 2014, Vol. 21, Nummer 3. Nederlands Tijdschrift rthopaedie. voor. Officieel orgaan van de Nederlandse Orthopaedische Vereniging

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