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

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

2 Proven Performance Orthopaedics England and Wales: The,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 brands 2. New Zealand: The 1,616 Triathlon knees reported in the 2011 registry have the joint lowest revision rate of the top 5 brands 3. 1/ England and Wales National Joint Registry / Swedish Knee Arthroplasty Register Annual Report / The New Zealand Joint Registry Report 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 For more information visit or contact our productmanager: or +31 (0)

3 oorwoord Maart 2014, Vol., Nummer 1 Soms zijn dingen niet zo als ze lijken. Soms zitten er haken en ogen aan ogenschijnlijk duidelijke gebeurtenissen. Soms hebben voordelen ook nadelen. De bergen goud die in Sochi werden gewonnen hebben wellicht een groot nadeel: de lange afstanden van het langebaan schaatsen zullen van het programma verdwijnen als we de internationale schaatsbobo (overigens afkomstig uit het kunstrijden) mogen geloven. Nederland wordt de te kloppen partij, aldus de chef de mission van deze gouden lichting. In de bespreking van het proefschrift van Jose Smolders over de hip resurfacing worden de gouden bergen en de gouden standaard van elkaar onderscheiden. Zaken die aanvankelijk prachtig leken, laten nu al enkele jaren de keerzijde van die medaille zien. In de opleiding tot orthopedisch chirurg was de toekomst ook geschreven met gouden letters: de bevolking vergrijst, kwaliteit van leven in het ouder worden is een groot goed en wie is nu eigenlijk de aangewezen medisch specialist om ook de ouder wordende mens in beweging te houden? Maar met de crisis vervaagden deze feiten en zijn de gouden bergen die deze gezondheidszorg kost gesmolten en is er een overschot aan jonge klaren. In 2014 moeten er bergen maatregelen genomen worden om het tot voorheen vanzelfsprekende ondernemerschap in de zorg veilig te stellen. Creatief als wij Nederlanders zijn, gaan wij deze uitdagingen te lijf: we gaan ons specialiseren in de massastart bij de langere afstanden en volgen de ploegentactiek die bij het marathonschaatsen al zo gewoon is, we kondigden als eersten in de wereld een pas op de plaats af bij het resurfacen van de heup, de Taskforce Jonge Klaren beraamde een actieplan en de nieuwe voorzitter Koot wil graag aan tafel met de bankiers en Bos. We laten met de LROI-Rapportage 2012 zien hoe de dingen zijn en niet hoe ze lijken, dat haken en ogen ook een houvast kunnen betekenen en dat sommige nadelen ook voordelen hebben. Zo zijn de voor(oor)delen dat een inzending aan het NTVO een geheide publicatie betekent ondertussen ten nadele voor de inzendende auteurs aan het veranderen. De redactieraad is blij te kunnen melden dat er tegenwoordig steeds kritischer gekeken kan worden naar de manuscripten. Deze tegenstrijdige bewering is een uiting van een verhoging van de kwantiteit van de inzendingen en komt de kwaliteit van ons tijdschrift ten goede. Uiteraard ga ik u geen gouden bergen beloven over een eventuele indexering, want kwaliteit gaat aan medailles vooraf, maar is er geen garantie voor. Inhoud Voorwoord Taco Gosens Good results of a thoracic doublehook claw construct in 40 consecutive adolescent idiopathic scoliosis patients Paul de Baat and Luuk W.L. de Klerk Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen Total Elbow Arthroplasty after Trauma - case report and review of the literature Dirk E. Schrander, Wouter Gronheid and Aart D. Verburg Intramuscular hemangioma of the extremities - a case report and review of the literature Stijn E.W. Geraets, Anneke A.M. van der Wurff and Taco Gosens Proefschriftbespreking Koen Bos Van de Vereniging Dr. Taco Gosens, hoofdredacteur i Voor sommige artikelen is additioneel materiaal beschikbaar op de website waaronder kleurenfoto s en/of videobeelden. Deze artikelen zijn herkenbaar aan de volgende pictogrammen: Kleurenfoto's Videobeelden

4 ONederlands Tijdschrift voor rthopaedie V o l REDACTIE Dr. Taco Gosens, hoofdredacteur Dr. Harmen B. Ettema Dr. Wouter L.W. van Hemert Dr. Hans (J).G.E. Hendriks Dr. Loes Janssen Dr. Job L.C. van Susante CORRECTOREN Mw. Sue Morrenhof-Atkinson Dr. Ernst L.F.B. Raaymakers REVIEWERS Bas Bosmans Alex W.F.M. Fiévez Dr. Taco Gosens Prof. dr. Marinus de Kleuver Dr. Rudolf W. Poolman Dr. Jan Roorda Prof. dr. Barend J. van Royen Dr. Michiel A.J. van de Sande UITGEVER & REDACTIESECRETARIAAT Serendipity Publishing Dorpsweg GE Twisk Telefoon: Richtlijnen voor Auteurs OPLAGE & FREQUENTIE exemplaren, verschijnt elk kwartaal ABONNEMENTEN Het Nederlands Tijdschrift voor Orthopaedie wordt gratis toegezonden aan alle leden van de Nederlandse Orthopaedische Vereniging. Abonnementen Beneluxlanden 61,82 per jaar (excl. 6 % BTW). COPYRIGHT 2014 NOV & Serendipity Publishing ISSN X 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 ortho pedie 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. 3 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

5 Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients Paul de Baat and Luuk W.L. de Klerk Background Context: Adolescent idiopathic scoliosis (AIS) surgery often consists of posterior spinal fusion. All-pedicle screw instrumentation has become very popular and seems to be the gold standard nowadays. In the past decennium, a double-hook claw construction had been used in our centre for several years as a standard for thoracic fixation of the posterior instrumentation in AIS surgery. Purpose: To evaluate the results of this hybrid construction retrospectively with special interest in curve correction, maintenance of correction over time, failures of instrumentation, and occurrence of junctional kyphosis. Study Design: Retrospective cohort study. Patient Sample: Forty consecutive AIS patients who underwent posterior spinal fusion in our centre using this technique between August 2003 and December Methods: Patients were followed in the outpatient clinic for at least two years postoperatively. Clinical results were noted and spinal X-rays were taken at every visit. At the two-yearly follow-up, all patients were requested to complete a validated Dutch version of the SRS-22 questionnaire. Results: The mean follow-up period was 44 months ± 15. Mean age at surgery was 15.1 years ± 1.8. The mean coronal Cobb angle of the main curve improved from 65.7 ± 9.9 preoperatively to.4 ± 9.1 immediately postoperatively, indicating a correction of 68.2% ± At the two-yearly follow-up, the mean coronal Cobb angle of the main curve was 25.0 ± 8.6, indicating a relapse of 5.7% ± 8.5. At the two-yearly follow-up, the mean overall SRS-22 score was 90.8 ± 10.7 points. During follow-up, one patient underwent surgical removal of the proximal part of the construction because of local pain. No long-term neurological complications were recorded. Conclusions: Within the limitations of this study, in our cohort of 40 AIS patients, posterior fusion with a hybrid construction including a proximal double-hook claw seems to be an effective and safe treatment for AIS. When comparing these results with the literature, they seem comparable, or at least not inferior, to all-pedicle screw constructs and possibly better than hook or other hybrid constructs. A possible explanation is the claw configuration of the hook construction. Vol Introduction Surgical treatment of progressive or severe adolescent idiopathic scoliosis (AIS) often consists of posterior spinal fusion. Through the years, different instrumentation techniques have been used. There are constructions with rods, hooks, wires, screws and combinations thereof. In 1995, Suk et al. introduced the concept of using all-pedicle screw instrumentation in AIS. 1 This method has become very popular since then, supported by several retrospective in vitro and in vivo studies. When compared to hook or hybrid constructions, the current opinion is that thoracic pedicle screws have a higher pull-out strength 2-7 and give an improved coronal Cobb angle correction and an improved maintenance of correction over time Maybe of even more importance, it seems that with pedicle screws better correction of rotational deformities can be P. de Baat, orthopedic resident and Dr. L.W.L. de Klerk, orthopedic surgeon, Erasmus MC, location Sophia, Rotterdam, The Netherlands Corresponding author: P. de Baat achieved. 14 Nowadays, thoracic pedicle screws seem to be the gold standard and there seems to be little place for thoracic hook constructions. However, in the past decennium, a double-hook claw construction had been used in our centre for several years as a standard for thoracic fixation of the posterior instrumentation in AIS surgery. This construction consisted of a bilateral combination of two transverse process hooks proximally and two laminar hooks distally. The purpose of this study is to evaluate the results of this hybrid construction retrospectively with special interest in curve correction, maintenance of correction over time, failures of instrumentation, and occurrence of junctional kyphosis. Our hypothesis is that a hybrid construction with a proximal double-hook claw construct is capable of giving good clinical and radiological results in AIS surgery. In this study, we present the short term results of this proximal double-hook claw construction in 40 consecutive AIS patients, regarding the coronal Cobb angle correction, the relapse of correction after at least 2 years, sagittal balance, compli- Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

6 Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients cation and revision rates, and patient satisfaction, assessed using the SRS-22 questionnaire. A B Materials and methods V o l Between August 2003 and December 2007, 40 consecutive patients with AIS underwent surgery in our centre by a single spinal surgeon. This cohort was evaluated retrospectively at intermittent times, first in Indications for surgery were severe scoliosis with a coronal Cobb angle of the main curve 45 or progressive scoliosis despite bracing. Scoliosis was defined as progressive when the coronal Cobb angle had increased by 5 or more during 1 year. Preoperative clinical data Preoperative work-up consisted of magnetic resonance imaging (MRI) to verify any intraspinal pathology, standard laboratory tests (hemoglobin, hematocrit, blood type and antibody screening), standing X-rays of the entire spine (anteroposterior, lateral bending, and lateral), and assessment of somatosensory evoked potentials (SSEP). The spinal X-rays were analyzed using the classification systems according to Lenke 16 and Risser 17, and coronal Cobb angles were measured. 18 With regard to the postoperative lateral X-rays, we did not measure Cobb angles but only determined the sagittal profile according to Lenke s classification (normal, hyper-, or hypokyphosis). 16 Operative procedure All patients were operated under general anaesthesia whilst lying in a prone position andapproached posteriorly. In all patients, SSEP signals were recorded during surgery. After dissection of the spine with thorough decortications of the posterior laminas, all patients underwent posterior instrumentation with a combination of pedicle screws in the lower thoracic and lumbar spine, and a hook claw construction in the upper thoracic spine (Monarch 5.50 or 6.35 Ti Spine System, DePuy). Pedicle screws were inserted bilaterally with a free-hand technique at all preoperatively decided levels with the help of an image intensifier. The hook claw construction consisted of two proximal transverse process hooks and two distal laminar hooks at each side (Figure 1). The laminar hooks were applied at the level of the facet joints, without facetectomy. A double rod system was applied, and curve correction was carried out under spinal cord monitoring by SSEPs. First, the rod at the convex side of the curve was applied and proximally fixated. Then the rod was translated towards the screws, followed by subtle segmental distraction or compression. Figure 1. Posteroanterior (1a) and lateral (1b) image of a proximal double-hook claw consisting of a bilateral combination of two transverse process hooks proximally and two laminar hooks distally. Finally, the second rod was applied and fixated. Autologous bone grafts from the iliac crest were used for fusion, and two subfascial drains were left in situ. Intravenous antibiotic prophylaxis was administered in all patients preoperatively and maintained postoperatively for 3 days. Postoperative recovery, assessments and follow-up No postoperative cast or brace was used. During the first few days post surgery, lying anteroposterior and lateral X-rays of the entire spine were taken. Patients were discharged from the hospital after mobilisation and without wound healing problems. Patients were followed routinely in the outpatient clinic after 6 weeks, 3 months, 6 months, 1 year, and 2 years post surgery. Standing anteroposterior and lateral X-rays of the entire spine were repeatedly taken until at least 2 years post surgery. After at least 2 years of follow-up, all patients were requested to complete a validated Dutch version of the SRS-22 questionnaire. This questionnaire has five domains: pain, self-image, function/activity, mental health and satisfaction with the management. The maximum score is 110 points. Results The 40 patients had a mean follow-up period of 44 months ± 15 (range, months). Except for one patient, all patients had a minimum follow-up 5 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

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8 Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients V o l period of 2 years. There were 36 female and 4 male patients. Mean age at surgery was 15.1 years ± 1.8 (range, 11.4 years ). Preoperative clinical data The majority of patients had thoracic structural curves, according to Lenke s classification. 16 The group consisted of 1 type 1A, 10 types 1B, 7 types 1C, 1 type 2A, 4 types 2B, 2 types 2C, 1 type 3A, 1 type 3B, 10 types 3C, 2 types 5C, and 1 type 6C Lenke curves. With regard to skeletal maturity, there were 3 Risser grade 3, 6 grade 2, 16 grade 3, 11 grade 4, and 4 grade 5 iliac apophyses. The mean coronal Cobb angle of the main curve was 65.7 ± 9.9. In two patients preoperative lateral X-rays were not available. In 29 patients there was a normal thoracic sagittal profile, in 2 patients there was a hyperkyphosis, and in 7 patients there was a hypokyphosis. Preoperative MRI showed a syrinx at Th12 in one patient and an upper thoracic diastematomyelia with a small syrinx in another patient. These findings were no contraindication for surgery. Operative procedure Table 1 presents the operative details of the cohort. In all 40 patients, a posterior spinal fusion was performed. No abnormalities during perioperative SSEP monitoring were found. No intraoperative complications occurred. Postoperative recovery, evaluation and follow-up Table 2 presents postoperative curve data of the cohort. The mean immediate postoperative coronal Cobb angle of the main curve was.4 ± 9.1, indicating an immediate postoperative correction of 68.2% ± At 2-year follow-up, the mean coronal Cobb angle of the main curve was 25.0 ± 8.6, indicating a correction of 62.5 ± 10.2%. The relapse of correction at the 2-yearly follow-up was 5.7% ± 8.5. With regard to the sagittal profile, both hyperkyphotic curves and one hypokyphotic curve were corrected to normal. Six hypokyphotic curves remained hypokyphotic postoperatively. We did not observe any proximal or distal junctional kyphosis. Unfortunately six complications occurred in 40 patients (15.0%). Two complications occurred immediately postoperatively and four complications after discharge from the hospital (Table 3). Immediately postoperatively, one sensory leg impairment occurred, probably because of pressure on the peroneal and lateral femoral cutaneous nerve while lying on the operating table. This resolved without any intervention. One patient needed additional surgery during follow-up. This patient suffered pain caused by the instrumentation materials. Radiographically, no failure of the construction itself could be determined. Three years postoperatively, she showed improvement after surgical removal of the proximal part of the rod and two transverse process hooks. All other complications were successfully treated conservatively. Table 4 presents the results of the SRS-22 questionnaire. The mean score per question (range, 1-5 points) is shown for each single domain of the questionnaire as well as for all domains together. In the subgroup satisfaction with the management, the mean score was 8.8 out of 10 possible points. In this subgroup, one patient scored 3 points for satisfaction and the remaining patients scored 7 points or more. The mean overall score of the questionnaire was 90.8 points ± 10.7, out of a maximum of 110 points. Discussion Posterior spinal fusion is a common surgical treatment option for progressive or severe AIS. We presented our results in 40 consecutive AIS patients treated with posterior spinal instrumentation using a hybrid construction with a thoracic double-hook claw. This type of instrumentation was introduced in our centre in 2002 and uniformly applied in AIS patients since The rationale for this policy was the lower risk of pedicle breach and neurological injury at thoracic levels. Firstly, we discuss radiological correction of the curve. Many AIS studies have compared the results of coronal Cobb angle correction of screw constructions with hook/hybrid constructions. Most studies showed significantly better correction results in screw construction groups immediately postoperatively 1,8-15,19 whereas others reported no significant differences Immediate postoperative correction with all-screw constructions and with hook/hybrid constructions was 56-76%and 45-63%, respectively. 1,8,9,11,12,19,22 At the 2-yearly follow-up, correction with all-screw constructions and with hook/hybrid constructions was 50-72% and 34-61%, respectively. 1,8,9,11,12,14,15,19 Comparison of these studies with the result of the present study, shows our construction to be successful. In our study using the proximal double-hook claw construction, the mean immediate postoperative coronal Cobb angle correction was 68.2% ± 10.3 (Table 2). At the 2-yearly follow-up, the mean correction was 62.5% ± The results of our construction with a proximal double-hook claw seem similar to results of all-pedicle screw constructions and better than results of hook/hybrid constructions. 1,8,9,11, 12,14,15,19,22 Only recently, a systematic review was 6 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

9 Paul de Baat and Luuk W.L. de Klerk Table 1. Operative details of the adolescent idiopathic scoliosis cohort (n=40) Type of surgery Extent of fusion proximally distally Posterior spinal fusion (n=40) T2 (n=16), T3 (n=17), T4 (n=7) T12 (n=1), L1 (n=7), L2 (n=9), L3 (n=12), L4 (n=5), L5 (n=6) Cross connector SSEP monitoring Single one (n=34), double (n=6) Normal (n=40) Vol Mean blood loss intraoperatively 1275cc ± 789 postoperatively 650cc ± 466 Mean duration of surgery 319mins ± 37 Intraoperative complications None Mean days of hospitalization 10.0 days ± 1.9 Table 2. Mean postoperative curve details of the adolescent idiopathic scoliosis cohort (n=40) Main curve Cobb angle preoperatively 65.7 ± 9.9 Cobb angle immediately postoperatively.4 ± 9.1 Cobb angle at 2-year follow-up 25.0 ± 8.6 Cobb angle correction immediately postoperatively 68.2% ± 10.3 Cobb angle correction at 2-year follow-up 62.5% ± 10.2 Cobb angle relapse of correction at 2-year follow-up 5.7%± 8.5 Secondary curve Cobb angle preoperatively 43.3 ± 13.1 Cobb angle immediately postoperatively 15.3 ± 10.2 Cobb angle at 2-year follow-up 16.8 ± 12.0 Cobb angle correction immediately postoperatively 67.0% ± 18.6 Cobb angle correction at 2-year follow-up 64.3% ±.8 published to the effectiveness of pediatric pedicle screws versus hook and hybrid constructions. 13 This review included screws and showed a mean Cobb angle correction of all-pedicle screw, allhook and hybrid constructs of 61±11%, 46±14%, and 56±10%, respectively. These results were in favour of all-pedicle screw constructs. However, the Cohen s effect size correlation coefficient for screws was only small to medium in comparison with hybrid constructions (r=0.24). 13 The clinical relevance of this difference is not known. Furthermore, one should evaluate the costs of pedicle screws versus hook/hybrid constructions. A recent study showed that pedicle screws are more expensive overall, per fused level, and per degree of correction. 23 With regard to relapse of the correction at the 2-yearly follow-up, many studies showed less relapse of the correction in screw construction groups compared to hook/hybrid construction groups; however, the difference was not significant in all studies. 1,8,9,11,12,15,19 In the literature, the reported absolute relapse of Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

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11 Paul de Baat and Luuk W.L. de Klerk Table 3. Complications during follow-up of the adolescent idiopathic scoliosis cohort (n=40) Immediately postoperatively (n=2) sensory impairment nervus peroneus and nervus cutaneus femoris lateralis (n=1) - gradual spontaneous recovery, resolved after 6 months During follow-up (n=4) paralytic ileus (n=1) - treated with a stomach tube and diet limitations, resolved within a few days superficial wound infection (n=1) - 2 weeks postoperatively, treated by washing twice a day, healed within a few weeks urinary tract infection (n=1) - 2 weeks postoperatively, E. coli in urine culture, intravenous antibiotics for 4 days, healed without complications Vol decompensation of the lumbar secondary curve (n=1) - 18 months postoperatively, no surgical intervention necessary pain caused by instrumentation materials (n=1) - 3 years postoperatively, improved by surgical removal of the proximal part of the rod and two transverse process hooks Table 4. SRS-22 questionnaire* results after the two-year follow-up of the adolescent idiopathic scoliosis cohort (n=40), and comparison with results in the literature Domain Score cohort (rate of Score cohort (points Literature 9,36,39 (points maximum possible, mean) per question, mean)* per question, mean)* Total 82.6% 4.1 ± 0.5 Pain 86.6% 4.3 ± to 4.6 points Self Image 79.5% 4.0 ± to 4.5 points Function/Activity 82.4% 4.1 ± to 4.3 points Mental Health 79.7% 4.0 ± to 4.6 points Satisfaction 87.5% 4.4 ± to 4.7 points * Score range per question 1-5 points coronal Cobb angle correction was 1-9% and 6-14% for the all-screw and the hook/hybrid constructs, respectively. 1,8,9,11,12,19 The relapse of correction in our study was 5.7% ± 8.5. When comparing the relapse of correction in our cohort with those of reported screw and hook/hybrid constructs, our construct again appears to be as successful. Secondly, most cadaveric studies show that the pull-out strength of an all-pedicle screw construction is higher when compared to that of a hook or hybrid construction. 2-5,7,24 However, some comment is required. First, the majority of pull-out assessments were performed in cadavers of elderly people, thus perhaps precluding extrapolation of the results from adolescent scoliotic spines. Sec- Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

12 Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients V o l ond, the pull-out strength of pedicle screws depends on their anchoring in the pedicle. 8 Screws violating the medial or lateral pedicle wall have less pull-out strength, and the same applies to small-diameter screws due to insufficient fixation in strong cortical bone. Third, the study of Cordista et al. reported a higher pull-out strength of hooks in a claw construction (pedicle hook inferior and laminar hook superior) when compared to a pedicle screw construct in cadaveric thoracic spines. 25 In conclusion, similar to corrective forces, thoracic pedicle screws are generally believed to be superior to hooks with regard to pull-out strength. However, hooks placed in a claw-like formation seem to be capable of withstanding higher pull-out forces than single hooks. Therefore a hook-claw seems to compete better with screws than single hooks. With regard to pull-out strength, in the present study, no serious complications occurred that were potentially related to the presumed low strength of the proximal double-hook construct. However, one patient needed reoperation because of pain due to instrumentation materials 3 years postoperatively. Radiographically, no failure of the construction itself could be determined. Pain relief was achieved after removal of the proximal part of the rod and two transverse process hooks (Table 3). Junctional kyphosis did not occur in the present study. Of interest is a recent study of Helgeson et al. in which all-screw constructions resulted in a significant increase in proximal junctional kyphosis when compared to hybrid constructs. 26 They suggested placing hooks on top of an all-pedicle screw construct in order to create a transition zone which might decrease the risk of proximal junctional kyphosis. We recognize our construction in this suggestion, but we have to admit there is no evidence yet for this hypothesis and further investigation is required. Thirdly, thoracic pedicle screws carry a theoretically higher risk of neurological injury compared to thoracic hook constructs. Correct placement of thoracic pedicle screws can be technically demanding and, due to the small size of thoracic pedicles, breach of cortex is fairly common. A breach event may result in reduced pull-out strength, dural tears or neurological problems because of possible violation of the spinal canal (medial wall violation), and vascular injury because of the proximity of the aorta (lateral wall violation) In the literature, the incidence of thoracic pedicle screw misplacement in AIS patients is %, with an incidence of medial wall violations of % Fortunately, the majority of these cases occurred without neurological complications. The incidence of screw-related neurological complications in spinal surgery is reported to be low ( %) Recently, a systematic review of paediatric pedicle screws showed an accuracy of screw placement of 94,9%. 13 However, one should keep in mind that most case series published represent the experience of highly specialized spine surgeons employed in high-volume medical centres. It is reported that surgeons experience was negatively associated with the rate of medial wall perforations. 33,35 Using a thoracic double-hook claw construction largely avoids these specific risks. In our cohort, no longterm neurological complications were recorded. However, patient numbers were low. Finally, we discuss patient satisfaction. For this study we used the Scoliosis Research Society (SRS)-22 questionnaire, which is a modification of the SRS-24 questionnaire. Over the years, different versions of the SRS questionnaire have been developed and validated. In order to roughly compare our results with the different SRS questionnaire versions in the literature, we present each score as a rate of the maximum possible score (Table 4). Few studies have retrospectively compared the SRS questionnaire results between an all-pedicle screw construction and a hook/hybrid construction. 8,10,14,15,39 None of the studies found significant differences in either the total score or in any domain. We observed a mean postoperative total SRS score of 82.6%, which seems similar to the reported scores for all-screw constructions ( ,1%) 8,11,15,40, and hook/hybrid constructions ( %). 8,11,15,41 The various domain scores of the SRS questionnaire were also similar to those reported in the literature (Table 4). 10,39,42 Since this follow-up study was retrospective, we do not have preoperative questionnaire results. In conclusion, there is no observed difference in patient satisfaction between the present study and all-screw or hook/hybrid constructions in the literature. However, the present study has limitations. First, the study did not have a prospective design and there was no control group. For comparison, we used reports from the literature. Second, a 2-yearly follow-up is relatively short. However, in most other studies, authors have used the same followup period. Third, the main outcome parameter was the coronal Cobb angle, which shows intra- and interobserver variability; however, in the literature this is a commonly used outcome parameter. Fourth, scoliosis is a three-dimensional deformity, and we were not able to measure exact sagittal Cobb angles in all patients. However, no sagittal imbalance or junctional kyphosis occurred. Finally, 9 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

13 Paul de Baat and Luuk W.L. de Klerk the second outcome parameter were the subjective results measured by the SRS-22 questionnaire. Unfortunately, because no preoperative baseline measurements were available, we were unable to measure alterations over time. In conclusion, within the limitations of this study, in our cohort of 40 AIS patients, posterior fusion with a hybrid construction including a proximal double-hook claw seems to be a very effective and safe treatment for AIS. When comparing these results with the literature, they seem comparable to all-pedicle screw constructions and possibly better than hook or other hybrid constructs. A possible explanation is the claw configuration of the hook construct. This type of construct lacks the neurological and vascular risks of thoracic pedicle screws. Nowadays, we vary between thoracic pedicle screws and the hook claw construct. In idiopathic scoliosis with large rotational deformities, we tend to use thoracic pedicle screws because of better opportunities for rotation correction. In other curves with mainly coronal plane deformities, especially in younger children, we believe that the hook claw construct can be safely applied, with not more than only a few degrees less correction, but with less neurological and vascular risks and with similar functional outcome. Disclosure No conflict of interest. References 1. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine 1995; 20: Gayet LE, Pries P, Hamcha H, Clarac JP, Texereau J. Biomechanical study and digital modeling of traction resistance in posterior thoracic implants. Spine 2002; 27: Hitchon PW, Brenton MD, Black AG, et al. In vitro biomechanical comparison of pedicle screws, sublaminar hooks, and sublaminar cables. J Neurosurg 2003; 99 (1 Suppl): Jones GA, Kayanja M, Milks R, Lieberman I. Biomechanical characteristics of hybrid hook-screw constructs in shortsegment thoracic fixation. Spine 2008; 33: Liljenqvist U, Hackenberg L, Linke T, Halm H. Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg 2001; 67: Lenke LG. Debate: Resolved, a 55 degrees right thoracic adolescent idiopathic scoliotic curve should be treated by posterior spinal fusion and segmental instrumentation using thoracic pedicle screws: Pro: Thoracic pedicle screws should be used to treat a 55 degrees right thoracic adolescent idiopathic scoliosis. J Pediatr Orthop 2004; 24: Laar van W, Meester RJ, Smit TH, Royen van BJ. A biomechanical analysis of the self-retaining pedicle hook device in posterior spinal fixation. Eur Spine J 2007; 16: Kim YJ, Lenke LG, Cho SK, Bridwell KH, Sides B, Blanke K. Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 2004; 15: Dobbs MB, Lenke LG, Kim YJ, Kamath G, Peelle MW, Bridwell KH. Selective posterior thoracic fusions for adolescent idiopathic scoliosis: comparison of hooks versus pedicle screws. Spine 2006; 31: Di Silvestre M, Bakaloudis G, Lolli F, Vommaro F, Martikos K, Parisini P. Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80 degrees: pedicle screws versus hybrid instrumentation. Eur Spine J 2008; 17: Kim YJ, Lenke LG, Kim J, et al. Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine 2006; 31: Wu X, Yang S, Xu W, et al. Comparative Intermediate and Long-term Results of Pedicle Screw and Hook Instrumentation in Posterior Correction and Fusion of Idiopathic Thoracic Scoliosis. J Spinal Disord Tech 2010; 23: Ledonio CG, Polly DW Jr, Vitale MG, Wang Q, Richards BS. Pediatric pedicle screws: comparative effectiveness and safety: a systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force. J Bone Joint Surg Am 2011; 93: Luhmann SJ, Lenke LG, Erickson M, Bridwell KH, Richards BS. Correction of moderate (<70 degrees) Lenke 1A and 2A curve patterns: comparison of hybrid and all-pedicle screw systems at 2-year follow-up. J Pediatr Orthop 2012; 32: Yilmaz G, Borkhuu B, Dhawale AA, et al. Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis. J Pediatr Orthop 2012; 32: Lenke LG, Betz RR, Clements D, et al. Curve prevalence of a new classification of operative adolescent idiopathic scoliosis. Spine 2002; 27: Risser J. The Iliac apophysis: an invaluable sign in the management of scoliosis. Clin Orthop Relat Res 1958; 11: Cobb JR. Outline for the study of scoliosis. In: American Academy of Orthopaedic Surgeons, instructional course lectures. St Louis, CV Mosby; 1948: Liljenqvist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H. Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J 2002; 11: Vora V, Crawford A, Babekhir N, et al. A pedicle screw construct gives an enhanced posterior correction of adolescent idiopathic scoliosis when compared with other constructs. Myth or reality. Spine 2007; 32: Karatoprak O, Unay K, Tezer M, Ozturk C, Aydogan M, Mirzanli C. Comparative analysis of pedicle screw versus Vol Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

14 Good results of a thoracic double-hook claw construct in 40 consecutive adolescent idiopathic scoliosis patients V o l hybrid instrumentation in adolescent idiopathic scoliosis surgery. Int Orthop 2008; 32: Lowenstein JE, Matsumoto H, Vitale MG, et al. Coronal and sagittal plane correction in adolescent idiopathic scoliosis: a comparison between all pedicle screw versus hybrid thoracic hook lumbar screw constructs. Spine 2007; 32: Jaquith BP, Chase A, Flinn P, et al. Screws versus hooks: implant cost and deformity correction in adolescent idiopathic scoliosis. J Child Orthop 2012; 6: Hackenberg L, Link T, Liljenqvist U. Axial and tangential fixation strength of pedicle screws versus hooks in the thoracic spine in relation to bone mineral density. Spine 2002; 27: Cordista A, Conrad B, Horodyski M, Walters S, Rechtine G. Biomechanical evaluation of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Spine J 2006; 6: Helgeson MD, Shah SA, Newton PO, et al. Evaluation of proximal junctional kyphosis in adolescent idiopathic scoliosis following pedicle screw, hook, or hybrid instrumentation. Spine 2010; 35: Kasten MD. Proximal thoracic pedicle screw complications: fractures with spinal cord injury. Presented at Scoliosis Research Society Annual Meeting, Buenos Aires, Argentina, Sept Richards S. Debate: Resolved, a 55 degrees right thoracic adolescent idiopathic scoliotic curve should be treated by posterior spinal fusion and segmental instrumentation using thoracic pedicle screws: Con: Thoracic pedicle screws are not needed to treat a 55 degrees right thoracic adolescent idiopathic scoliosis. J Pediatr Orthop 2004; 24: Rinella A. Thoracic pedicle expansion after pedicle screw placement in a pediatric cadaveric spine: a biomechanical analysis. Presented at Scoliosis Research Society Annual Meeting, Buenos Aires, Argentina, Sept Boos N, Webb JK. Pedicle screw fixation in spinal fixation in spinal disorders: a European view. Eur Spine J 1997; 6: Brown CA, Eismont FJ. Complications in spinal fusion. Orthop Clin North Am 1998; 29: Kuklo TR, Lenke LG, O Brien MF, Lehman RA Jr, Polly DW Jr, Schroeder TM. Accuracy and efficacy of thoracic pedicle screws in curves more than 90 degrees. Spine 2005; 30: Samdani AF, Ranade A, Sciubba DM, et al. Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make? Eur Spine J 2010; 19: Sarlak AY, Tosun B, Atmaca H, Sarisoy HT, Buluç L. Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis. Eur Spine J 2009; 18: Abul-Kasim K, Ohlin A. The rate of screw misplacement in segmental pedicle screw fixation in adolescent idiopathic scoliosis: the effect of learning and cumulative experience. Acta Orthop 2011; 82: Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine 2004; 29: Verma R, Krishan S, Haendlmayer K, Mohsen A. Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws. Eur Spine J 2010; 19: Cuartas E, Rasouli A, O Brien M, Shufflebarger HL. Use of all-pedicle-screw constructs in the treatment of adolescent idiopathic scoliosis. J Am Acad Orthop Surg 2009; 17: Arlet V, Ouellet JA, Shilt J, et al. Subjective evaluation of treatment outcomes of instrumentation with pedicle screws or hybrid constructs in Lenke Type 1 and 2 adolescent idiopathic scoliosis: what happens when judges are blinded to the instrumentation? Eur Spine J 2009; 18: Lehman RA Jr, Lenke LG, Keeler KA, et al. Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases. Spine 2008; 33: Bridwell KH, Hanson DS, Rhee JM, Lenke LG, Baldus C, Blanke K. Correction of thoracic idiopathic scoliosis with segmental hooks, rods, and Wisconsin wires posteriorly: it s bad and obsolete, correct? Spine 2002; 27: Merola AA, Haher TR, Brkaric M, et al. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine 2002; 27: Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

15 Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen Introduction: The incidence of negative arthroscopies of the knee varies from 4% to 25%. Up to this date, no tests are available that identify individuals who are likely to experience a negative arthroscopy. Materials and methodology: We investigated potential factors that predict a negative arthroscopy of the knee. A retrospective cohort study was conducted. Two groups were evaluated, i.e. a group subjected to an arthroscopy with intervention (n=288) and a group without intervention (n=322). Demographic data, diagnosis, history, physical examination and imaging were recorded. Results: The proportion of negative arthroscopies without intervention was 9.1%. The proportion of negative arthroscopies without abnormalities was 3.7%. Predictors for a negative arthroscopy (without intervention) were gender, age and knee effusion (p<0.01). Patients without intervention during arthroscopy had more normal MRIs than patients subjected to arthroscopies with intervention. ACL-ruptures (p=0.01) and radiological osteoarthritis (p=0.00) in pre-operative diagnosis were less common in arthroscopies without intervention. Conclusion: The most important factors to predict a negative arthroscopy in our population were age, gender and knee effusion. Younger women without a knee effusion were more likely to experience a negative arthroscopy. In order to diagnose a meniscal lesion, one should not just rely on a positive McMurray s test. These factors should be taken into consideration before performing an arthroscopy of the knee. Vol Introduction Worldwide about 4 million arthroscopies of the knee are performed annually, including more than 60,000 in the Netherlands. 1,2 Literature reports conflicting results on whether patient history, physical examination or imaging (MRI) has the highest sensitivity and specificity for diagnosing a lesion of ligaments or menisci. 3,4,5 The incidence of a negative arthroscopy of the knee following preoperatively diagnosed meniscal or ligament injuries varies from 4% and 10% to over 25%. 5,6,7 A negative arthroscopy of the knee can be defined as either an arthroscopic procedure resulting in no intervention (e.g. meniscectomy) or one that does not lead to an observation of abnormality. In this study, we adhered to the former interpretation of no concomitant intervention. Because of the important role of MRI as a diagnostic tool, there is basically no need for an invasive procedure, such as a diagnostic arthroscopy of the knee, with the exception of arthroscopic assisted synovial or osseous biopsies. 8 There is controversy J.C. Rekveldt 1, MPA, B.J. Kollen 2, PhD, C. van Egmond 1, MD and C.C.P.M. Verheyen 1, MD PhD 1 Department of orthopaedic surgery and traumatology, Isala klinieken Zwolle, The Netherlands 2 Department of General Practice, University of Groningen, University Medical Centre Groningen, The Netherlands Corresponding author: Dr. C.C.P.M. Verheyen about whether to subject a patient to an arthroscopy prior to a possible osteotomy or knee prosthesis. 8 In this study, our goal was to identify factors derived from demographic data, history, physical examination, imaging and diagnosis that may explain and predict a negative arthroscopy of the knee in our population. Identification of these predictors could help to lower the incidence of negative arthroscopies of the knee. Materials and Methodology A retrospective cohort study was performed in a group of patients who underwent an arthroscopy of the knee over a period of three years in the Isala clinics in Zwolle, The Netherlands. In this orthopaedic department about 1300 arthroscopies of the knee are performed annually. Between January 1 st, 2006 and December 31 st, 2008, all surgeries were recorded. From all patients with records coded as arthroscopy of the knee without intervention, the operative reports were checked, to confirm no intervention was carried out. From the database, a SPSS generated random sample of all patients with a recorded additional intervention (e.g. meniscectomy), i.e. arthroscopy with intervention, was taken to serve as a control group. In this group, arthroscopies without intervention or with ACLreconstruction were excluded. Information about demographic data, history, physical examination, imaging and diagnosis was Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

16 Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Figure 1. Flow diagram of the selection procedure. Study population is based on samples in grey shaded areas. V o l retrieved from outpatient charts and preoperative records of consultations from anesthesiologists. Statistical methods Descriptive statistics were used to compare groups on gender, age, BMI, preoperative diagnosis, previous knee surgery, trauma, locking, joint effusion and positive McMurray test. Categorical data were tested using cross-tabulation (Chi-square test). 9 In order to determine which factors predicted a negative arthroscopy, a multivariate logistic regression model was developed based on a best subset stepwise forward selection procedure. This procedure involved including stepwise (one by one) relevant factors to the regression model, i.e. gender, age, BMI, preoperative diagnosis, earlier knee surgery, trauma, locking, knee effusion and McMurray s test. Each time the model was fitted with an extra factor, variables that were not significant in the model were removed (P in: p 0.05; P out p>0.05). Ultimately, the final model contained only factors with a p-value smaller than or equal to As these significant factors best explained the outcome in our population they were considered predictors for a negative arthroscopy. All statistical calculations were performed in SPSS. Results During 2006, 2007 and 2008, in total 3530 knee arthroscopies were performed in the orthopaedic department of the Isala klinieken (ACL-reconstructions excluded). In 322 arthroscopies, no intervention had taken place. In 131 of these 322 arthroscopies, no intra-articular abnormalities were observed ( normal knees ). A random sample of 322 patients was taken from the population of patients with arthroscopies with intervention (n=3208, Figure 1). After exclusion of incorrect coded surgeries, 288 patients remained. The proportion of negative arthroscopies (without intervention) was 9.1% (322 of 3530), 7.0% in males versus 12.7% in females (p=0.00). The proportion of the negative arthroscopies in knees without any observed abnormalities (normal knees) was 3.7% (131 of 3530), 2.6% in males versus 5.4% in females (p =0.01). The mean age of patients with normal knees subjected to arthroscopies was lower than the mean age of those with arthroscopies with intervention (27.8 versus 43.9 years of age, p=0.00). The final logistic regression model generated 3 predictors for a negative arthroscopy without intervention (Table 2). A negative arthroscopy without intervention is more likely to occur in females than in males (OR = 2.12, CI: ), and less likely with each added year of age of the patient (OR = 0.96, CI: ) and in the presence of joint effusion (hydrops or haemarthros) (OR: 0.48, CI: ). Compared to the control group (arthroscopies with intervention), patients with normal knees during arthroscopy had more normal MRIs (p=0.01) and were diagnosed pre-operatively with less 13 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

17 Jeroen Rekveldt, Boudewijn Kollen, Cees van Egmond and Cees Verheyen Table 1. Results Arthroscopy without intervention Arthroscopy with intervention All normal knees n= 322 n=131 n=288 Demographic data male 47.8% 45.4% 63.9% female 52.2% 54.6% 36.1% age (average) 34.4 (10-74) 27.8 (10-52) 43.9 (13-77) BMI (average) 25.6 (16-43) 24.0 (16-39) 26.8 (19-48) Vol Pre-operative diagnosis Medial meniscus lesion 59.1% 70.0% 65.6% Lateral meniscus lesion 17.7% 16.2% 19.4% ACL-rupture 16.7% 6.9% 13.2% Chondropathy 11.3% 1.5% 9.7% Loose body 3.5% 1.6% 3.1% Intra-operative diagnosis Medial meniscus lesion 0.6% 0.0% 63.8% Lateral meniscus lesion 0.0% 0.0% 19.2% ACL-rupture 19.9% 0.0% 20.6% Chondropathy 37.9% 0.0% 46.0% Loose body 0.0% 0.0% 4.5% History Earlier knee surgery 39.0% 32.7% 36.3% Physical therapy 85.5% 87.8% 73.0% Trauma 58.3% 64.9% 53.1% Swelling 65.9% 57.3% 73.4% Locking 56.7% 68.1% 56.1% Physical exam Knee effusion 52.3% 40.4% 70.9% Flexion< % 10.9% 14.1% Extension<0.1% 17.9% 31.4% McMurray positive 41.2% 45.5% 50.5% Lachman positive 26.9% 15.8% 23.1% Imaging X-ray degeneration 14.6% 4.0% 30.9% MRI abnormalities 79.2% 76.1% 97.4% ACL-ruptures (p=0.01) and degeneration (p=0.00). No difference was found between the pre-operative diagnoses medial (p=0.14) and lateral meniscal lesions (p=0.40) (table 1). In the group with normal knees there was also less swelling, joint effusion and positive Lachman tests. However, it was remarkable that in normal knees, locking was more frequently reported (p=0.01). Likewise, compared to the control group patients with normal knees showed no differences in positive Mc- Murray tests (p=0.57). Compared to arthroscopies with intervention, arthroscopies without intervention showed less medial meniscal lesions in the pre-operative diagnosis (p=0.05). This group (without intervention) showed more preoperative diagnosed ACL-ruptures Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart

18 Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients Table 2. Predictors for negative arthroscopy without intervention Predictive factor or 95% CI p Gender (1=male, 2=female) <0.01 Age <0.01 V o l Knee effusion <0.01 (p=0.01) and radiological osteoarthritis (p=0.00). There was no difference in the proportion of individuals diagnosed with a lateral meniscus lesion (p=0.71). Discussion This study showed that the preoperative factors such as age, joint effusion, and gender are predictive of a negative arthroscopy of the knee, i.e. younger women without knee effusion are less likely to require an intervention. One is more likely to find discrete degenerative meniscal lesions with increasing age. When such a lesion is found, generally a debridement will follow and the patient is subjected to an intervention with questionable result. 10 In the group of patients with negative arthroscopies, over 20% had a normal MRI (Table I). This raises the question as to why an MRI scan was made. If the symptoms and clinical findings gave reason to believe an arthroscopy is warranted, then the outcome of an MRI scan was not likely to confirm the tentative diagnosis. When in doubt about the accuracy of the diagnosis, and the MRI is negative, the logical consequence would be that no arthroscopy is performed. As the diagnostic accuracy of an MRI is not perfect, it is conceivable to perform an arthroscopy following a negative MRI when clinical symptoms are indicative of intra-articular pathology. On the other hand, when an MRI is warranted but turns out to be negative the obvious choice would be not to operate. Arthroscopies without intervention occurred more often in patients with diagnosed ACL-rupture and chondropathy. Both conditions do not constitute primary indications for an arthroscopic procedure. 8 Most arthroscopies had a preoperative diagnosis of medial meniscal lesion. This diagnosis will often be based on a positive McMurray s test. However, this test is not always conducted and reported according to generally accepted standards, and has a low sensitivity and specificity. 4,11 As a consequence, conclusions based on this test alone are not reliable. Considering multiple meniscal tests outcomes may improve the reliability of physical examination. 11 The frequently reported locking in arthroscopically normal knees can possibly be explained by the fact that mechanical symptoms justify an arthroscopy and consequently discrete (pseudo)locking is reported as a locked knee. The medial meniscal lesions observed in the group with no intervention (0.6%) were mostly interpreted as irrelevant discrete lesions and not trimmed. In the group with negative arthroscopies in normal knees, no pathology was found in 32.7% of the cases despite prior surgery. However, it is conceivable that signs of prior surgery were observed, but not reported as pathology. The proportion of negative arthroscopies in this study was close to the lowest reported in the literature. The percentage MRI scans (28.2%) and the preoperative diagnoses of negative arthroscopies were similar to that reported in the literature. 6,5 Given the favourable patient satisfaction rates after a negative arthroscopy (64% feels better afterwards, 2% worse), and the very low risk of sustaining complications after such procedure, it can be surmised that a negative arthroscopy may not represent a major problem. 7,12 We strongly oppose to this conclusion because a negative arthroscopy of the knee should always be avoided as every surgical procedure has its risks and complications. Additionally, the 9.1% of negative arthroscopies observed in this study signifies over 5000 unnecessary and partly avoidable surgical procedures each year in the Netherlands and potentially over worldwide. 1 This represents a substantial healthcare and economic problem. Given the retrospective nature of the data collection in this study, no firm conclusions can be drawn. It is recommended to carry out a prospective study. Conclusion The most important factors to predict a negative arthroscopy in our population were age, gender and knee effusion. Younger women without a knee effusion were more likely to experience a negative 15 Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

19 Ondersteuning bij uw revisies Revisiecement met gentamicine en vancomycine COPAL G+V COPAL Copal de productlijn voor de revisieprothesiologie Alles uit één enkele bron: COPAL G+V speciaal cement met gentamicine en vancomycine voor gebruik bij septische revisies bijv. bij bewezen MRSA/MRSE infecties COPAL G+C dubbele bescherming en zekerheid bij 1 en 2 stage revisies COPAL spacem speciaal cement ter vervaardiging van spacers Telephone: Fax:

20 Predictive factors for a negative arthroscopy of the knee - a retrospective cohort study of 610 patients V o l arthroscopy. In order to diagnose a meniscal lesion, one should not just rely on a positive McMurray s test. These factors should be taken into consideration before performing an arthroscopy of the knee. The study is carried out in the department of orthopaedic surgery and traumatology, Isala klinieken Zwolle, The Netherlands. Disclosure statement No competing interests declared. References 1. AOSSM, American Orthopaedic Society for Sports Medicine, admin/uploads/documents/st%20arthroscopy%2008.pdf 2. CBO, Dutch Institute for Health Care Improvement. Consensus Arthroscopy uploads/450/1171/nov04ak.pdf 3. Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2004 ; 20-7 : Konan S, Rayan F, Haddad FS. Do physical diagnostic tests accurately detect meniscal tears? Knee Surgery Sports Traumatology Arthroscopy 2009 ; 17-7 : Nickinson R, Darrah C, Donell S. Accuracy of clinical diagnosis in patients undergoing knee arthroscopy. International Orthopedics 2009 ; 34-1 : Brooks S, Morgan M. Accuracy of clinical diagnosis in knee arthroscopy. Ann R Coll Surg Engl ; 84-4 : Hossain S, Manthravadi S. Negative Knee Arthroscopy: Is It Really Negative? Arthroscopy: The Journal of Arthroscopic and Related Surgery 2001 ; 17-6 : NOV, Dutch Orthopaedic Society, Guideline arthroscopy of the knee, indication and treatment, richtlijnen/artroscopie_van_de_knie_indicatie_en_behandeling.html?search=artroscopie&periode[van]=0&p eriode[tot]=0&_type=richtlijnen&specialisme=47 9. Katz MH. Multivariate analysis. A practical guide for clinicians. Cambridge University Press pp Crevoisier, X., Munzinger, U., Drobny, T. Arthroscopic partial meniscectomy in patients over 70 years of age. Arthroscopy 2001 : 17 : Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assesing a torn meniscus in the knee: a systematic review with a meta-analysis. J Orthop Sports Phys Ther 2007 ; 37-9 : Cardosa M, Rudkin GE, Osbourne GA.. Outcome from daycare knee arthroscopy in a major teaching hospital. Arthroscopy 1994 ; 10-6 : Nederlands Tijdschrift voor Orthopaedie, Vol, Nr 1, maart 2014

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