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Blount's disease or bowed leg deformity, is a unilateral or bilateral growth deformity of the medial proximal tibia that leads to a tibial varus deformity. A distinction can be made in an early and late onset type. The disease seems to have a predisposition for certain descends. Since the first publication of Blount's disease, different hypotheses on the aetiology are proposed but no consensus exists. The objective of this study is to provide an overview of the available hypotheses on the aetiology of Blount's disease since its first description and assessment of the available level of evidence, the quality of evidence and the occurrence of bias supporting these individual hypotheses. A systematic search according to the PRISMA statement was conducted using PubMed, MEDLINE, EMBASE and the Cochrane Library using a broad combination of terminology to ascertain a complete selection. Proper MESH search criteria were formulated and the bibliographic search was limited to English and Dutch language articles. Articles with no mention of aetiology or a disease related to Blount's were excluded. Level of evidence and types of bias were assessed. Thirty-two articles that discuss the aetiology of Blount's disease were selected. A variety of hypotheses was postulated in these articles with most research in the field of increased mechanical pressure (obesity, early walking age) and race (descend). Blount's disease most likely has a multifactorial origin with influence of genetic and racial predisposition, increased mechanical pressure on the growth plate as a consequence of obesity or early walking age and possibly also nutrition. However, the exact aetiology remains unclear, the probable explanation is that multifactorial factors are all contributing to the development of Blount's disease. Histological research has shown that a disorganization of bone and cartilage structures on the medial side of the proximal tibial physis is present in patients with Blount's disease. Based on the available evidence on the aetiology of Blount's disease, we conclude that it is multifactorial. Most papers focus only on one hypotheses of Blount's disease occurrence and all are characterized as low level of evidence. There seems to be a preference for certain descends. Further research on especially genetic predisposition is needed to provide more insight in this factor of Blount's disease.

Purpose: To assess the interchangeability of various existing answering scales within the subjective part of the Constant-Murley Score (CMS) and to determine the effect of the different answering scales on the inter- and intraobserver reliability.Methods: In this prospective, single-center, cross-sectional trial, patients with shoulder problems were included from June to September 2018. Subjects recruited were 18 years or older, presented various shoulder complaints, e.g., diagnosis of osteoarthritis, subacromial pain syndrome, rotator cuff or biceps tendon problems, or frozen shoulder. An extended version of the CMS was prepared including the same questions multiple times but with varying answer scales. Six versions were made with random order of the questions. The answering scales were a verbal and paper based visual analog scale (VAS), smiley face scale, Numeric Rating Scale (NRS), and categories. Internal consistency of the various CMS, Spearman correlation coefficients, intraobserver, and interobserver agreement was assessed (ICC).Results: In total, 93 patients were included. The total CMS using the paper-based VAS, smiley face score, and NRS were 46.9 ± 19.4, 45.2 ± 18.5, and 45.0 ± 18.7. Correlations of the total scores of the different versions varied from 0.98 to 0.99. CMS-category versus CMS-smiley face score and CMS-category versus CMS-NRS pain were significantly different (P = .02 and P = .01). Good internal consistency (0.76-0.79) and acceptable inter- and intraobserver reliability were found (ICC: 0.89-0.97, 0.98-0.99; P < .001).Conclusions: The different answering scales for the subjective subscales within the CMS for pain, work, and recreational activity were not interchangeable on item level and significantly influenced the total CMS score. Differences were below the smallest detectable change and interpreted as not clinically relevant. Particularly on item level, data from different studies cannot be pooled and compared when different answering scales are being used. The inter- and intraobserver reliability were excellent.Level of Evidence: Level I, prospective cross-sectional study.

ObjectiveThe objective of this study is to study familial inheritance for Blount disease to create better understanding of the aetiology of Blount disease.MethodsAfter reviewing patient files and conventional roentgenologic imaging, 139 patients with Blount disease were included in this cross-sectional study, of which 102 patients were interviewed. During the interviews, patient characteristics and family history were collected. Blood samples were taken from five patients and three families and a whole exome sequencing was performed.ResultsAlthough patients came from all over the country, 90% of the patients belonged to the Akan tribe. A positive family history was found in 63 families (62%), of which, almost two-third had a positive family history in a first-degree family member. In most of the cases (64%), the varus legs resolved over time. In 9%, severe bowing remained ‘just like the patient’. The results of the whole exome sequencing did not show a genetic predisposition.ConclusionThis study describes a large group of Blount patients. Because of the high numbers of positive family history and the centralisation of patients in the Akan region, a familial predisposition is suggested. Further genetic research is essential for better understanding of the possible multifactorial aetiology in Blount disease.

This dissertation was conducted to optimise the care of rotator cuff pathology and to offer some tools for the daily orthopaedic practice. Suggestions are made for optimising the treatment of degenerative rotator cuff tears, visualising shoulder pathology and accurately analysing results with the appropriate measuring instruments. The importance of identifying the source of pain in degenerative rotator cuff tears and the scientific evidence that justifies certain treatment options are emphasised. Rotator cuff tears, particularly in their degenerative form, are common in our population and understanding all aspects associated with these tears is of great importance in optimising shoulder function and keeping people physically active. This dissertation provides insight into the optimisation of diagnostics, treatment, aftercare and shoulder-specific patient outcome measures with regard to rotator cuff pathology.

Hypothesis This study determined the response shift in patients undergoing rotator cuff repair using the Western Ontario Rotator Cuff index (WORC), a disease-specific quality of life questionnaire. We hypothesized there would be a response shift with a positive recalibration (overestimated their preoperative disability) on the WORC and increases over time. Methods The study prospectively included 36 patients undergoing arthroscopic rotator cuff repair. At baseline, 3 months (T1), and 1 year (T2) after surgery the WORC, EuroQol (EQ)-5D-3L, and the patient's level of satisfaction after surgery were scored. To evaluate the response shift, patients also completed the WORC at 3 months (Pre-T1) and 1 year (Pre-T2) as how they perceived themselves to have been before surgery. Results The result on Pre-T1 and Pre-T2 results revealed that patients retrospectively rated their overall WORC score comparable with the baseline WORC score (Pre-T0; T0 = 40.5 ± 18.4, Pre-T1 = 45.0 ± 22.7, Pre-T2 = 34.3 ± 21.3). No response shift was observed on all domains except a negative recalibrated response shift for emotional disability on T1 ( P = .04). Conclusions No significant group-level response shift was observed using the WORC, except for the subdomain emotional disability at 3 months after arthroscopic rotator cuff repair. With the absence of any shift in patient's perception on the self-administered quality of life–related WORC questionnaire, this study suggests one could retrospectively reliably conduct group-level preoperative baseline information on quality of life up to 1 year after surgery.

Optimization of the management of rotator cuff tears is still needed. Preoperative patient selection, perioperative surgical techniques, and postoperative care are all important topics that are studied extensively. This commentary will examine the current situation and important fields of interest for future research. Postoperative pain management is scrutinized in relation to the level of abduction using an abduction brace.

Purpose: The W/M serrated high tibial osteotomy is a not frequently described surgical technique for simultaneously correcting the varus and torsional deformity in patients with Blount’s disease. Without the need for internal fixation, this surgical treatment is well suited for developing countries. This study describes the short‑term results of the bilateral and unilateral W/M serrated osteotomy in patients with infantile Blount’s disease. Methods: Between May 2008 and January 2013, 52 patients were treated with uni‑ ( n = 22) or bi‑lateral ( n = 30) W/M serrated osteotomy of the proximal tibia due to a tibial varus deformity in two district hospitals in Ghana. Other causes than infantile Blount’s disease were excluded from the analysis. Pre‑ and post‑operative clinical and radiological measurements were done, and complications were monitored up to 12 weeks after surgery. Results: Seventeen patients (five males, 12 females; mean age 4.9 [standard deviation: 2.10]) were included, which underwent a total of 25 W/M serrated osteotomies. The femorotibial angle was corrected from 34.1° ([mean] range: 6 68°) to − 7.1° ([mean] range: −28–5°). Only one patient had developed a wound infection, and all reached full consolidation. Conclusions: The W/M serrated osteotomy seems a profitable alternative technique for treating the varus and torsional deformity in patients with Blount’s disease in the circumstances of developing countries. The short‑term outcomes are good and promising with a low complication rate and good consolidation. Long‑term follow‑up results of these patients are needed to observe possible complications. Level of Evidence: IV, therapeutic case series. Keywords: Blount’s disease, complications, infantile, osteotomy, tibia vara

Fatty infiltration is an important prognostic factor for cuff healing after rotator cuff repair. Treatment options for stage 2–3 Goutallier rotator cuff tears vary widely and there is lack of decent comparative studies. Purposes The objective of this study was 1) to give an overview of the treatment options of stage 2–3 Goutallier rotator cuff tears and their clinical outcome and 2) to give a recommendation of the optimal treatment within this specific subgroup. Methods We searched the databases of Medline, Embase, Cochrane library, NHS Centre for Reviews and Dissemination, PEDro from inception to December 12th, 2016. Two authors, F.H. and N.W., selected the studies after consensus. Data was extracted by one author (F.H.) and checked for completeness by a second author (N.W.). Our primary outcome was physical function, measured by shoulder-specific patient reported outcomes. Secondary outcomes were cuff integrity after rotator cuff repair, shoulder pain, general health, quality of life, activity level and adverse events. Results For the first research question 28 prospective as well as retrospective studies were included. For the clinical outcome of these treatments three randomized controlled trials were included. Conclusions Despite the high reported retear rate, rotator cuff repair has comparable results (clinical improvement) as partial repair and isolated bicepstenotomy or tenodesis. These findings suggest that the additional effect of rotator cuff repair compared to the less extensive treatment options like isolated bicepstenotomy or tenodesis should be studied, as these might form a good alternative treatment based on this systematic review. Level of evidence Level IV; systematic review.

IntroductionFor patients who are diagnosed with lesions of the rotator cuff that present advanced levels of fatty degeneration, arthroscopic repair of the rotator cuff remains controversial. This controversy can be attributed to the frequently reported high failure rate of the tendon fixation and the fact that it remains unclear why repair for these tears results in significant clinical improvement independent of the occurrence of such a re-tear. Recent publications have reported comparable clinical improvements when merely a tenotomy of the long head of the biceps tendon was performed and the rotator cuff tear was left untreated. These observations raise questions on the value of performing the more extensive cuff repairs in degenerative cuff tears. Even more, rehabilitation after an isolated tenotomy is much less cumbersome as compared with rehabilitation after rotator cuff repair and, therefore, might result in improved patient satisfaction. The goal of this trial is to study function and quality-of-life of patients undergoing arthroscopic biceps tenotomy with or without an additional cuff repair and to include an economic evaluation.Methods and analysisThis multicentre randomised controlled non-inferiority trial, including an economic evaluation, is designed to compare the short-term and long-term outcome of patients who underwent an arthroscopic tenotomy of the long head of the biceps tendon with or without a cuff repair. We will include 172 patients with stage 2–3 Goutallier fatty infiltration cuff tears and with clinical symptoms of biceps pathology. Primary outcome is the rotator cuff specific quality-of-life (Western Ontario Rotator Cuff index) on the short term (6 months postoperatively). Secondary outcomes are quality-of-life 1, 2 and 5 year postoperatively and function (Constant-Murley score, glenohumeral range of motion), recovery status, pain (visual analogue scale), economic evaluation, satisfaction of treatment on the short-term and long-term and re-tear rate at 6 months determined with an ultrasound.Ethics and disseminationThis trial has been approved by the Medical Research Ethics Committees United (MEC-U), Nieuwegein, the Netherlands (NL54313.100.15) and will be performed in accordance with the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results of this study will be reported in peer-reviewed journals and at (inter)national conferences. Furthermore, we will share our findings with the appropriate guideline committees.Trial registration numberThe Dutch Trial Registry (NL4010).

Purpose To study the effects on pain as the main outcome parameter and on function and cuff integrity as the secondary outcome parameters after arthroscopic rotator cuff repair in the short term comparing the abduction brace with an antirotation sling for postoperative shoulder immobilization. Methods Eligible patients were between the ages of 18 and 75 years who were diagnosed with a traumatic or degenerative tear of the supraspinatus and/or infraspinatus tendon, confirmed by magnetic resonance imaging, for which an arthroscopic footprint repair was indicated and performed. Patients were randomly allocated to the antirotation sling or abduction brace group. Postoperative pain and use of analgesics were accurately registered up to 3 months after surgery using a patient diary. Follow-up examinations including the Constant-Murley score, Western Ontario Rotator Cuff index, and glenohumeral range of motion were scheduled 6 weeks, 3 and 6 months, and 1 year after surgery. Results The average level of pain measured directly postoperation up to 1 year after surgery was not significant different between groups. Postoperatively, function scores and glenohumeral range of motion improved significantly for both groups; however, no differences were observed between groups. No retears were observed on ultrasonograph 3 months after surgery. Conclusions In the short term, the level of pain, function, and quality of life were not significantly different between the use of an abduction brace and that of an antirotation sling after arthroscopic rotator cuff repair. Based on these findings, the abduction brace used in this study does not seem to be the solution for decreasing the pain experienced in the first postoperative weeks after arthroscopic rotator cuff repair, and both are recommendable. Level of Evidence Level I, randomized controlled trial.

Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb. In total hip arthroplasty and total knee arthroplasty, the incidence ranges from 7% to 84%. In this study, the incidence and risk factors for postoperative urinary retention were described in a cohort of 376 men undergoing total hip arthroplasty. Postoperative urinary retention was defined as the inability to void after surgery for which single or indwelling catheterization was performed. Risk factors were identified using multivariate regression analysis. Following total hip arthroplasty, 150 (39.9%) of the 376 men developed urinary retention. Patient-controlled analgesia (odds ratio, 4.10; 95% confidence interval, 1.79–9.40), use of spinal anesthesia (odds ratio, 1.79; 95% confidence interval, 1.07–2.99), and age 70 years or older (odds ratio, 1.77; 95% confidence interval, 1.06–2.95) were independent risk factors for urinary retention. Potential risk factors that were not confirmed included body mass index, American Society of Anesthesiologists physical status (Class I–III), hypertension, diabetes mellitus, prostate pathology, smoking, average pain during the first 24 hours after surgery, and length of surgery. Two of the 150 patients with urinary retention (1.3%) for which a catheter has been inserted developed a urinary tract infection vs none of the patients without urinary retention. The risk of urinary retention after total hip arthroplasty is increased in men older than 70 years, those receiving spinal anesthesia, and those with patient-controlled analgesia postoperatively. [ Orthopedics. 2015; 38(6):e507–e511.]