The shoulder prosthesis is increasingly used as a solution for various shoulder problems. On the ... more The shoulder prosthesis is increasingly used as a solution for various shoulder problems. On the basis of a few cases, an overview is given of the various situations in which a shoulder prosthesis can be used, with a small risk of complications, a high risk of pain reduction and a long survival. In addition, a shoulder prosthesis improves the quality of life and is cost-effective. It is important, however, to set the correct indication with an eye for various psychosocial factors. The individual end result depends on patient-related factors such as pathology, general condition, activity and expectations. But the type of prosthesis and surgical expertise and experience also play a role.
Whereas osteoarthritis used to be thought of as only wear and tear of a joint, it is now regarded... more Whereas osteoarthritis used to be thought of as only wear and tear of a joint, it is now regarded as an extremely complex, multifactorial, degenerative disease. Due to an ageing population and the increasing BMI of the average Dutch person, the prevalence of osteoarthritis and the associated costs of care are rising. In this teaching article, we provide practical information about the condition, methods of diagnosis and treatment. This is done by means of 10 questions relevant to general practitioners, specialists in internal medicine and surgeons.
A 77-year-old male who had had an olecranon fracture 15 years ago presented himself with mild pai... more A 77-year-old male who had had an olecranon fracture 15 years ago presented himself with mild pain of the right elbow. Physical examination revealed painless hardening of the finger and wrist flexors in an area of 10 cm from the origin. Conventional radiographs showed a mature myositis ossificans.
- Intra-articular injections have been in use for over 60 years. However, there is increasing awa... more - Intra-articular injections have been in use for over 60 years. However, there is increasing awareness of potential side effects associated with the intra- and peri-articular use of both glucocorticoids and topical analgesics.- In this review we will discuss the effects and side effects of intra-articular glucocorticoid injections in the context of non-rheumatic knee and shoulder conditions. Other commonly used indications for glucocorticoid use are also described.- For almost all indications, intra-articular glucocorticoid injections provide a small and short-term pain-suppressing effect. Long-term therapeutic effects do not exist.- Side effects range from local skin problems to adrenocortical suppression which can persist for weeks.- Glucocorticoid injections may be indicated in daily practice but have no long-term effect. In view of the potential (harmful) side effects, it is advisable to use the lowest possible effective dose.
The current treatment for patients with end-stage generalised osteoarthritis of the knee is total... more The current treatment for patients with end-stage generalised osteoarthritis of the knee is total knee replacement. In a recent paper in Plos One the authors examined an alternative approach, namely knee joint distraction. On the basis of a model, they claim that this treatment can postpone total knee replacement for about 20 years. This would reduce the costs for the healthcare services and improve quality of life for these patients. Although these claims seem promising, the model is only based on extrapolations of short-term results of small cohort studies. Furthermore, concerns about potential complications, e.g. osteomyelitis following pin-tract infections, are not mentioned. Further high quality studies in knee joint distraction are needed to prove its long-term efficacy and safety before this procedure can be implemented in standard clinical care.
In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, sh... more In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, shared decision-making is explicitly mentioned as a prerequisite during doctor-patient encounters. This entails explicit exploration of the patient's wishes, views and preferences and their integration in medical decision-making. There is growing interest in shared decision-making from patient advocacy and professional societies, the government, and healthcare insurers. However, both care professionals and patients are not yet used to applying this in their encounters. Creating awareness, training and organisational changes are essential aspects to foster shared decision-making. Various (umbrella) organisations in healthcare have developed (digital) tools for both care professionals and patients to support shared decision-making. This article addresses these tools to nudge all stakeholders towards shared decision-making.
Today more and more papers are published about the operative treatment of femoral fractures in ch... more Today more and more papers are published about the operative treatment of femoral fractures in children and even uncomplicated and isolated fractures are treated by using elastic nails, plates or an external fixator. Advantages are said to be a shorter stay in the hospital, easier handling by parents and nurses, less costs and better control of rotational disorders, and without complications from anaesthesia or an operation. We summarised our results in treating conservatively 50 femoral fractures in 49 children treated between 1992 and 1997. The mean age was 6.2 years; male/female ratio was 30/19. We included five children with minor polytraumatisation (including one girl with a bilateral femoral fracture) and two children with complicated fractures (grade I). Children younger than three years of age were treated by Bryant-traction (18), and children older than three years were treated by Weber-traction (23). In both groups the callus was palpable after 2 to 3 weeks and a “one-legged” hipspica-plaster-cast was applied. Full weight bearing was permitted. Children needing surgery (major polytraumas, brain damage, etc.) were excluded. Seven cases had a fracture without dislocation and were treated by early casting. One boy was treated by Russell-traction. An unacceptable dislocation of the fracture still existed in two cases after one week with Weber-traction. Peroperatively, interposition of the soft tissues appeared to be the reason. There were no problems of alignment and rotation, but differences in leg length or problems in consolidation were seen in the group treated with Bryant- traction. In the Weber-traction group, the girl with the bilateral femoral fracture developed a mild endorotation in the left leg, but we saw no further complications. We think that these results in treating femoral fractures conservatively are satisfying and there is still a place for conservative treatment of femoral fractures in children. In our hospital we try to advance this type of conservative treatment by selecting cases that are appropriate for home traction, which is better for children and their parents and also less expensive for the Health Care System.
It has recently been suggested that patients with metal-on-metal (MOM) hip implants have an incre... more It has recently been suggested that patients with metal-on-metal (MOM) hip implants have an increased chance of mortality. These observations come from a meta-analysis including many small randomised controlled trials (RCTs) and cohort studies. Because of the high risk of bias there is no reason for great concern. In the Netherlands, the Dutch Orthopaedic Association (NOV) advised against the use of MOM implants in 2012, and that all patients with MOM implants should be followed up every year. There are good arguments to continue this policy because of the high risk of revision associated with MOM implants and the potential toxic effects of metal ions. There are also good reasons to follow up patients after a total hip procedure in which a large metal head (> 36 mm) has been used, because they also have increased metal ion release. The tragic story of MOM hip implants stresses that a minimum of 10 years of good clinical data should be required before widespread use of new hip implants is implemented.
Introduction Periprosthetic bone loss is a major cause of concern in patients undergoing total hi... more Introduction Periprosthetic bone loss is a major cause of concern in patients undergoing total hip arthroplasty (THA). In this study we monitored the periprosthetic bone loss around two different types of femoral implant to evaluate their design and investigate the relationship with the preoperative bone mineral density (BMD). Materials and Methods Sixty patients (35 female, 25 male, mean age 63 (range, 46–75) years) undergoing THA were randomised to either the ABG or Mallory Head femoral stem. Preoperative DEXA scans were acquired of the posteroanterior (PA) and lateral lumbar spine, the contra-lateral hip and the non-dominant forearm. Postoperative DEXA scans were performed at 10 days (treated as baseline), six weeks, and 3, 6, 12, 24 and 36 months after THA. Results A total of 50 patients (24 ABG, 26 MH) completed the study. Three months after THA there was a statistically significant BMD decrease in every Gruen zone that varied between 5.6% and 13.8% for the ABG pros-thesis and between 3.8% and 8.7% for the MH prosthesis. Subsequently, in most zones BMD reached a plateau or showed a small recovery. However, BMD continued to fall in Gruen zones 1 and 7 in ABG patients and Gruen zone 1 in MH patients. Bone loss was less in every Gruen zone in MH patients compared with ABG with the largest difference (10%, P = 0.018) in Gruen zone 7. After adjustment for multiple comparisons the relationship between peri-prosthetic bone loss and preoperative BMD was highly statistically significant for spine, hip and radius BMD. Discussion The present study showed that statistically significant bone loss occurred with both stems during the first three months following implantation, and confirmed that prosthesis design influences peri-prosthetic bone loss. Although the greater bone loss in patients with lower spine, hip or forearm BMD may not adversely affect the outcome for patients in the short and mid-term, preservation of femoral bone stock may be important in the longer term because a low femoral BMD can adversely affect the results of a subsequent revision. Greater femoral bone stock may be particularly advantageous in younger patients in whom a future revision is more likely.
American Journal of Hospice and Palliative Medicine®
Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, l... more Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25...
Background: Body fractures of the scapula are generally treated nonoperatively, and few functiona... more Background: Body fractures of the scapula are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaires and objective range of motion and muscle-strength testing to evaluate a series of patients who had received nonoperative care for a fracture of the body of the scapula. Methods: We identified twenty-three patients (seventeen men and four women with a mean age of forty-four yours) who had sustained an isolated fracture of the body of the scapula. All patients were treated non-operatively. At a mean of sixty months, and a minimum of thirty months, outcomes were measured with the Constant shoulder score, the DASH (Disabilities of the Arm, Shoulder and Hand) and the RAND 36 (Rand 36 item Health Survey) patient questionnaires. Additionally we … Results: On all scores a good to excellent result was obtained in those patients with an i...
The shoulder prosthesis is increasingly used as a solution for various shoulder problems. On the ... more The shoulder prosthesis is increasingly used as a solution for various shoulder problems. On the basis of a few cases, an overview is given of the various situations in which a shoulder prosthesis can be used, with a small risk of complications, a high risk of pain reduction and a long survival. In addition, a shoulder prosthesis improves the quality of life and is cost-effective. It is important, however, to set the correct indication with an eye for various psychosocial factors. The individual end result depends on patient-related factors such as pathology, general condition, activity and expectations. But the type of prosthesis and surgical expertise and experience also play a role.
Whereas osteoarthritis used to be thought of as only wear and tear of a joint, it is now regarded... more Whereas osteoarthritis used to be thought of as only wear and tear of a joint, it is now regarded as an extremely complex, multifactorial, degenerative disease. Due to an ageing population and the increasing BMI of the average Dutch person, the prevalence of osteoarthritis and the associated costs of care are rising. In this teaching article, we provide practical information about the condition, methods of diagnosis and treatment. This is done by means of 10 questions relevant to general practitioners, specialists in internal medicine and surgeons.
A 77-year-old male who had had an olecranon fracture 15 years ago presented himself with mild pai... more A 77-year-old male who had had an olecranon fracture 15 years ago presented himself with mild pain of the right elbow. Physical examination revealed painless hardening of the finger and wrist flexors in an area of 10 cm from the origin. Conventional radiographs showed a mature myositis ossificans.
- Intra-articular injections have been in use for over 60 years. However, there is increasing awa... more - Intra-articular injections have been in use for over 60 years. However, there is increasing awareness of potential side effects associated with the intra- and peri-articular use of both glucocorticoids and topical analgesics.- In this review we will discuss the effects and side effects of intra-articular glucocorticoid injections in the context of non-rheumatic knee and shoulder conditions. Other commonly used indications for glucocorticoid use are also described.- For almost all indications, intra-articular glucocorticoid injections provide a small and short-term pain-suppressing effect. Long-term therapeutic effects do not exist.- Side effects range from local skin problems to adrenocortical suppression which can persist for weeks.- Glucocorticoid injections may be indicated in daily practice but have no long-term effect. In view of the potential (harmful) side effects, it is advisable to use the lowest possible effective dose.
The current treatment for patients with end-stage generalised osteoarthritis of the knee is total... more The current treatment for patients with end-stage generalised osteoarthritis of the knee is total knee replacement. In a recent paper in Plos One the authors examined an alternative approach, namely knee joint distraction. On the basis of a model, they claim that this treatment can postpone total knee replacement for about 20 years. This would reduce the costs for the healthcare services and improve quality of life for these patients. Although these claims seem promising, the model is only based on extrapolations of short-term results of small cohort studies. Furthermore, concerns about potential complications, e.g. osteomyelitis following pin-tract infections, are not mentioned. Further high quality studies in knee joint distraction are needed to prove its long-term efficacy and safety before this procedure can be implemented in standard clinical care.
In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, sh... more In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, shared decision-making is explicitly mentioned as a prerequisite during doctor-patient encounters. This entails explicit exploration of the patient's wishes, views and preferences and their integration in medical decision-making. There is growing interest in shared decision-making from patient advocacy and professional societies, the government, and healthcare insurers. However, both care professionals and patients are not yet used to applying this in their encounters. Creating awareness, training and organisational changes are essential aspects to foster shared decision-making. Various (umbrella) organisations in healthcare have developed (digital) tools for both care professionals and patients to support shared decision-making. This article addresses these tools to nudge all stakeholders towards shared decision-making.
Today more and more papers are published about the operative treatment of femoral fractures in ch... more Today more and more papers are published about the operative treatment of femoral fractures in children and even uncomplicated and isolated fractures are treated by using elastic nails, plates or an external fixator. Advantages are said to be a shorter stay in the hospital, easier handling by parents and nurses, less costs and better control of rotational disorders, and without complications from anaesthesia or an operation. We summarised our results in treating conservatively 50 femoral fractures in 49 children treated between 1992 and 1997. The mean age was 6.2 years; male/female ratio was 30/19. We included five children with minor polytraumatisation (including one girl with a bilateral femoral fracture) and two children with complicated fractures (grade I). Children younger than three years of age were treated by Bryant-traction (18), and children older than three years were treated by Weber-traction (23). In both groups the callus was palpable after 2 to 3 weeks and a “one-legged” hipspica-plaster-cast was applied. Full weight bearing was permitted. Children needing surgery (major polytraumas, brain damage, etc.) were excluded. Seven cases had a fracture without dislocation and were treated by early casting. One boy was treated by Russell-traction. An unacceptable dislocation of the fracture still existed in two cases after one week with Weber-traction. Peroperatively, interposition of the soft tissues appeared to be the reason. There were no problems of alignment and rotation, but differences in leg length or problems in consolidation were seen in the group treated with Bryant- traction. In the Weber-traction group, the girl with the bilateral femoral fracture developed a mild endorotation in the left leg, but we saw no further complications. We think that these results in treating femoral fractures conservatively are satisfying and there is still a place for conservative treatment of femoral fractures in children. In our hospital we try to advance this type of conservative treatment by selecting cases that are appropriate for home traction, which is better for children and their parents and also less expensive for the Health Care System.
It has recently been suggested that patients with metal-on-metal (MOM) hip implants have an incre... more It has recently been suggested that patients with metal-on-metal (MOM) hip implants have an increased chance of mortality. These observations come from a meta-analysis including many small randomised controlled trials (RCTs) and cohort studies. Because of the high risk of bias there is no reason for great concern. In the Netherlands, the Dutch Orthopaedic Association (NOV) advised against the use of MOM implants in 2012, and that all patients with MOM implants should be followed up every year. There are good arguments to continue this policy because of the high risk of revision associated with MOM implants and the potential toxic effects of metal ions. There are also good reasons to follow up patients after a total hip procedure in which a large metal head (> 36 mm) has been used, because they also have increased metal ion release. The tragic story of MOM hip implants stresses that a minimum of 10 years of good clinical data should be required before widespread use of new hip implants is implemented.
Introduction Periprosthetic bone loss is a major cause of concern in patients undergoing total hi... more Introduction Periprosthetic bone loss is a major cause of concern in patients undergoing total hip arthroplasty (THA). In this study we monitored the periprosthetic bone loss around two different types of femoral implant to evaluate their design and investigate the relationship with the preoperative bone mineral density (BMD). Materials and Methods Sixty patients (35 female, 25 male, mean age 63 (range, 46–75) years) undergoing THA were randomised to either the ABG or Mallory Head femoral stem. Preoperative DEXA scans were acquired of the posteroanterior (PA) and lateral lumbar spine, the contra-lateral hip and the non-dominant forearm. Postoperative DEXA scans were performed at 10 days (treated as baseline), six weeks, and 3, 6, 12, 24 and 36 months after THA. Results A total of 50 patients (24 ABG, 26 MH) completed the study. Three months after THA there was a statistically significant BMD decrease in every Gruen zone that varied between 5.6% and 13.8% for the ABG pros-thesis and between 3.8% and 8.7% for the MH prosthesis. Subsequently, in most zones BMD reached a plateau or showed a small recovery. However, BMD continued to fall in Gruen zones 1 and 7 in ABG patients and Gruen zone 1 in MH patients. Bone loss was less in every Gruen zone in MH patients compared with ABG with the largest difference (10%, P = 0.018) in Gruen zone 7. After adjustment for multiple comparisons the relationship between peri-prosthetic bone loss and preoperative BMD was highly statistically significant for spine, hip and radius BMD. Discussion The present study showed that statistically significant bone loss occurred with both stems during the first three months following implantation, and confirmed that prosthesis design influences peri-prosthetic bone loss. Although the greater bone loss in patients with lower spine, hip or forearm BMD may not adversely affect the outcome for patients in the short and mid-term, preservation of femoral bone stock may be important in the longer term because a low femoral BMD can adversely affect the results of a subsequent revision. Greater femoral bone stock may be particularly advantageous in younger patients in whom a future revision is more likely.
American Journal of Hospice and Palliative Medicine®
Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, l... more Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25...
Background: Body fractures of the scapula are generally treated nonoperatively, and few functiona... more Background: Body fractures of the scapula are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaires and objective range of motion and muscle-strength testing to evaluate a series of patients who had received nonoperative care for a fracture of the body of the scapula. Methods: We identified twenty-three patients (seventeen men and four women with a mean age of forty-four yours) who had sustained an isolated fracture of the body of the scapula. All patients were treated non-operatively. At a mean of sixty months, and a minimum of thirty months, outcomes were measured with the Constant shoulder score, the DASH (Disabilities of the Arm, Shoulder and Hand) and the RAND 36 (Rand 36 item Health Survey) patient questionnaires. Additionally we … Results: On all scores a good to excellent result was obtained in those patients with an i...
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