What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

Validation of a Patient Questionnaire Assessing Patient Satisfaction With Orthopedic Outpatient Clinic Consultation

Previous qualitative research has identified a number of factors which influence patient satisfaction with orthopedic outpatient clinic visits. To further evaluate these factors, the authors initially generated a number of items or statements representing these factors. This cohort of items was then subjected to analysis by an expert group to assess which 3 items best represented each factor. These items formed the basis of a draft survey which was then administered to 323 orthopedic outpatients to assess these factors as characteristics of patient satisfaction. Items and factors were also assessed against 2 global measures of patient satisfaction. One hundred and one survey responses were returned and subjected to factorial analysis. Results indicated that factors of trust, empathy, and relatedness were not distinguishable and subsequently combined to represent a single factor, the therapeutic relationship. A final 5-factor model is proposed incorporating 3 interpersonal factors (communication, expectation, therapeutic relationship) and 2 environmental factors (clinic wait time, clinical contact time). The factors identified by this study should be considered in surveys evaluating patient satisfaction with orthopedic outpatient services.

The influence of expectation modification in knee arthroplasty on satisfaction of patients: a randomized controlled trial

AIMS

Meeting preoperative expectations is known to be of major influence on postoperative satisfaction after total knee arthroplasty (TKA). Improved management of expectation, resulting in more realistic expectations can potentially lead to higher postoperative satisfaction. The objective of this study was to assess the effect of an additional preoperative education module, addressing realistic expectations for long-term functional recovery, on postoperative satisfaction and expectation fulfilment.

METHODS

In total, 204 primary TKA patients with osteoarthritis were enrolled in this randomized controlled trial (RCT). Patients were allocated to either usual preoperative education (control group) or usual education plus an additional module on realistic expectations (intervention group). Primary outcome was being very satisfied (numerical rating scale for satisfaction ≥ 8) with the treatment result at 12 months' follow-up. Other outcomes were change in preoperative expectations and postoperative expectation fulfilment.

RESULTS

A total of 187 patients (91.7%) were available for analysis at follow-up. In the intention-to-treat analysis, 58.5% (55/94) of patients were very satisfied with the treatment result in the control group, and 69.9% (65/93) of patients in the intervention group (adjusted odds ratio (AOR) 1.72, 95% confidence interval (CI) 0.90 to 3.29). A per-protocol analysis for patients who attended the education session (92.0%, n = 172) showed that 56.9% (49/86) of patients were very satisfied in the control group and 74.4% (61/86) in the intervention group (AOR 2.44, 95% CI 1.21 to 4.91). After preoperative education, the expectation scores in the intervention group were significantly lower (mean difference -6.9 (95% CI -10.2 to -3.6)) and did not alter in the control group (mean difference 0.5 (95% CI -2.9 to 3.9)). Overall, fulfilment of expectations at 12 months was significantly higher in the intervention group (mean difference 11.4% (95% CI 2.3 to 20.5)).

CONCLUSION

Improved preoperative patient education can modify patient expectations, resulting in higher postoperative fulfilment of expectation and higher satisfaction in the group that attended the preoperative education. This is the first RCT to confirm the potential of improved expectation management on satisfaction after TKA. Cite this article: Bone Joint J 2021;103-B(4):619-626.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire

INTRODUCTION

The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture.

METHODS

This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes.

RESULTS

Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores.

CONCLUSION

Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Computationally Efficient Optimization Method to Quantify the Required Surgical Accuracy for a Ligament Balanced TKA

OBJECTIVE

This study proposes a computationally efficient method to quantify the effect of surgical inaccuracies on ligament strain in total knee arthroplasty (TKA). More specifically, this study describes a framework to determine the implant position and required surgical accuracy that results in a ligament balanced post-operative outcome with a probability of 90%.

METHODS

The response surface method is used to translate uncertainty in the implant position parameters to uncertainty in the ligament strain. The designed uncertainty quantification technique allows for an optimization with feasible computational cost towards the planned implant position and the tolerated surgical error for each of the twelve degrees of freedom of the implant position.

RESULTS

It is shown that the error does not allow for a ligament balanced TKA with a probability of 90% using preoperative planning. Six critical implant position parameters can be identified, namely AP translation, PD translation, VV rotation, IE rotation for the femoral component and PD translation, VV rotation for the tibial component.

CONCLUSION

We introduced an optimization process that allows for the computation of the required surgical accuracy for a ligament balanced postoperative outcome using preoperative planning with feasible computational cost.

SIGNIFICANCE

Towards the research society, the proposed method allows for a computationally efficient uncertainty quantification on a complex model. Towards surgical technique developers, six critical implant position parameters were identified, which should be the focus when refining surgical accuracy of TKA, leveraging better patient satisfaction.

The dynamics of satisfaction in surgical and non-surgical adult spinal deformity patients

PURPOSE

For adult spinal deformity (ASD) patients receiving operative (op) and non-operative (non-op) treatment, the relationship between HRQoL measures, complications and self-reported satisfaction remains unclear. The objective of this analysis is to study nonlinear association dynamics between ASD patient satisfaction, HRQoL, and complications over a two-year follow-up period.

METHODS

From a prospective multicenter international adult spinal deformity database, all patients with 2-year follow-up data on satisfaction (21st question of SRS-22r) were identified and included. A total of 12 LOESS (local polynomial fit) regressions were performed between patient satisfaction (SRS22 item 21) and HRQoL measures (ODI, SF36PCS and SRS22 subtotal) interacting with surgery at baseline, 6 months and 1 and 2 years of follow-up.

RESULTS

A total of 856 patients (527 op and 329 non-op) were included. At baseline, satisfaction was lower for patients scheduled for surgery even when HRQL was similar to those elected for conservative treatment. The nonlinear correlations showed that for similar PROMs, op patients reached higher satisfaction levels during follow-up, especially at six months. In fact, at six months operated patients with a deterioration of their initial PROMs had some improvement in their satisfaction, which could not be further observed at the end of follow-up.

CONCLUSIONS

Satisfaction does not correlate well with other PROMs, and it might be subject to other external factors not directly related to treatment. Even if patient satisfaction is important in evaluating well-being and patient's experience with medical care, it should not be considered as an isolated proxy to measure quality of treatment.

Improvements in sexual function following arthroscopic rotator cuff repair

BACKGROUND

Three-fourths of Americans are sexually active, and studies show a correlation between sexual activity and good health. Rotator cuff tears and subsequent repairs can cause significant disruption in daily living including sexual activity. Orthopedic surgeons rarely discuss sexual activity with patients. Therefore, patients have little information about expectations, restrictions, and return to sexual activity. The primary goal of this study was to evaluate patient improvement in sexual activity following arthroscopic rotator cuff repair and evaluate factors that affect sexual activity.

METHODS

An anonymous 20-item multiple-choice survey was sent to patients > 6 months after arthroscopic rotator cuff repair performed by 7 fellowship-trained orthopedic shoulder and elbow surgeons between March 2018 and May 2019. The survey assessed preoperative and postoperative sexual activity and included questions regarding frequency, pain, positioning, and postoperative injury.

RESULTS

A total of 88 patients met the inclusion criteria and completed the survey. Preoperatively, 65% of patients admitted that their shoulder interfered with the quality and/or frequency of their sexual activity, most commonly secondary to an inability to bear weight on the affected arm (31%). Postoperatively, the majority of patients (79%) found it easier to engage in sexual activity, with 35% of patients attributing this to less pain. At 6 weeks postoperatively, 72% of patients returned to sexual activity. The overall trend demonstrated a statistically significant (P < .001) increase in sexual activity frequency as one progressed from his or her operative date. It is interesting to note that 31% of patients removed their sling to engage in sexual activity after surgery, with 7% admitting to aggravating their shoulder or causing significant pain.

CONCLUSION

Prior to arthroscopic rotator cuff repair, most patients experience limitations in the quality and/or frequency of their sexual activity secondary to their shoulder. Following surgery, the majority of patients will more easily engage in sexual activity by 6 weeks, with increasing frequency as time progresses from surgery. Many patients are noncompliant with sling wear during sexual activity, and 7% will aggravate their shoulder.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial

BACKGROUND

Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher.

MATERIALS AND METHODS

A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals.

RESULTS

No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management.

CONCLUSION

When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Effect of BMI on the clinical outcome following microsurgical decompression in over-the-top technique: bi-centric study with an analysis of 744 patients

PURPOSE

Decompression is one of the most common interventions in spinal surgery. Obesity has become an increasing issue in surgical patients. Therefore, the aim of this study was to analyze the clinical outcome following lumbar microsurgical decompression in correlation with the patient's body mass index (BMI).

MATERIALS AND METHODS

A toal of 744 patients with spinal claudication that were seen at two specialized spine centers were included in this study. All patients underwent a bilateral microsurgical decompression in over-the-top technique. Patients were allocated in 4 groups based in their BMI category: 18.5-24.9 (n = 204), 25.0-29.9 (n = 318), 30.0-34.9 (n = 164) and ≥ 35 (n = 58). Clinical outcome data were recorded at baseline as well as 3, 12 and 24 months thereafter within a prospective study framework. The minimum follow-up was 12 months. For statistical analysis, data were adjusted for age, length of surgery and ASA and were analyzed by generalized linear gamma-based models.

RESULTS

Postoperative changes in all outcome parameters were clearly dependent on BMI. Patients with higher BMI were characterized by inferior baseline values for VAS Back (p < 0.05). Over the follow-up period, the groups with BMI 30-34.9 and BMI ≥ 35 benefitted significantly less from the surgery than the two slimmer groups (p < 0.05).

CONCLUSION

The data obtained from this large, homogenous cohort demonstrate that the quality of life improved substantially in all patients that were treated microsurgically for spinal stenosis. However, a BMI ≥ 30 may be considered as a negative predictor for a significantly inferior clinical outcome.

A prospective longitudinal study investigating outcomes including patient-reported outcome measures after surgery for metastatic bone disease

Aims

Surgery is often indicated in patients with metastatic bone disease (MBD) to improve pain and maximize function. Few studies are available which report on clinically meaningful outcomes such as quality of life, function, and pain relief after surgery for MBD. This is the published protocol for the Bone Metastasis Audit — Patient Reported Outcomes (BoMA-PRO) multicentre MBD study. The primary objective is to ascertain patient-reported quality of life at three to 24 months post-surgery for MBD.

Methods

This will be a prospective, longitudinal study across six UK orthopaedic centres powered to identify the influence of ten patient variables on quality of life at three months after surgery for MBD. Adult patients managed for bone metastases will be screened by their treating consultant and posted out participant materials. If they opt in to participate, they will receive questionnaire packs at regular intervals from three to 24 months post-surgery and their electronic records will be screened until death or five years from recruitment. The primary outcome is quality of life as measured by the European Organisation for Research and the Treatment of Cancer Quality of Life questionnaire (EORTC-QLQ) C30 questionnaire. The protocol has been approved by the Newcastle & North Tyneside 2 Research Ethics Committee (REC ref 19/NE/0303) and the study is funded by the Royal College of Physicians and Surgeons of Glasgow (RCPSG) and the Association for Cancer Surgery (BASO-ACS).

Discussion

This will be the first powered study internationally to investigate patient-reported outcomes after orthopaedic treatment for bone metastases. We will assess quality of life, function, and pain relief at three to 24 months post-surgery and identify which patient variables are significantly associated with a good outcome after MBD treatment.

Cite this article: Bone Jt Open 2021;2(2):79–85.

The Relationship between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One Year

OBJECTIVE

To determine the relationship between patients' pre-operative readiness for total knee arthroplasty (TKA) and surgical outcome at one-year.

METHODS

This prospective cohort study recruited knee osteoarthritis (OA) patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess WOMAC-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, General Self-Efficacy, PHQ-8, BMI, comorbidities and TKA readiness (Patient Acceptable Symptom State; willingness to undergo TKA), and one-year post-TKA to assess outcomes. A good TKA outcome was defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with results. Poisson regression with robust error estimation was used to estimate relative risk of a good outcome for exposures, before and after controlling for covariates.

RESULTS

Of 1,272 TKA recipients assessed at one year, 1,053 with data for our outcome were included (mean age 66.9 years (SD 8.8); 58.6% female). Most (87.8%) were definitely willing to undergo TKA and had 'unacceptable' knee symptoms (79.7%). 78.1% achieved a good TKA outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with greater likelihood of a good TKA outcome (adjusted RRs 1.18, 95% CI 1.04-1.35, and 1.14, 95% CI 1.02-1.27, respectively).

CONCLUSION

Among TKA recipients for knee OA, patients' psychological readiness and willingness for TKA were associated greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate use of TKA.

Periarticular analgesic injection containing a corticosteroid after total hip arthroplasty may prevent deep venous thrombosis: a retrospective comparative cohort study

BACKGROUND

Of late, periarticular analgesic injection (PAI) has become a common alternative treatment for pain following total hip arthroplasty (THA). However, the systemic effects of PAI containing corticosteroids in patients subjected to THA have not been investigated. This study evaluated the analgesic efficacy and systemic effects of PAI containing a corticosteroid in patients subjected to THA.

METHODS

This single-center, retrospective cohort study enrolled patients undergoing unilateral, primary THA. A total of 197 patients (200 hips) were included in the final analyses, with 87 hips in the PAI group and 113 hips in the control group. Numeric Rating Scale (NRS) and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7. Pearson's correlation coefficients were obtained to assess the correlations between the D-dimer level on POD 7 and each outcome measure on POD 1.

RESULTS

The postoperative white blood cell count (WBC) was significantly higher in the PAI group than in the control group. Postoperative NRS, creatine phosphokinase (CK), and C-reactive protein (CRP) levels were significantly lower in the PAI group. D-dimer levels were significantly lower in the PAI group on POD 7. Postoperative aspartate transaminase (AST), alanine aminotransferase, blood urea nitrogen, and creatinine levels were within reference ranges. D-dimer levels on POD 7 showed a significant negative correlation with WBC on POD 1 (r=-0.4652) and a significant positive correlation with the NRS score and AST, CK, CRP, and D-dimer levels on POD 1 (r = 0.1558, 0.2353, 0.2718, 0.3545, and 0.3359, respectively).

CONCLUSIONS

PAI containing a corticosteroid may be an effective treatment for pain and inflammation after THA, and it does not seem to cause drug-induced liver or kidney injury. Moreover, corticosteroid PAI can may accelerate early ambulation, which prevents the elevation of postoperative D-dimer levels, and may reduce the risk of deep venous thrombosis.

Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference?

OBJECTIVE

To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision.

METHODS

This postoperative survey assessed the parental assessment of pain control in 199 patients, ages<18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen.

RESULTS

Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively.

CONCLUSION

The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population

BACKGROUND

Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects.

METHODS

At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test.

RESULTS

A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males.

DISCUSSION AND/OR CONCLUSION

The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

Use of patient-reported outcome measures (PROMs) by orthopedic surgeons in Saudi Arabia

BACKGROUND

There is increasing literature on the usefulness of patient-reported outcome measures (PROMs), but far fewer studies to determine their use by orthopedic surgeons and the barriers they face in applying PROMs in their daily clinical activity.

METHODS

Cross-sectional study using a questionnaire that was distributed in both soft and hard copy formats to a sample of 262 orthopedic surgeons. Participants included orthopedic surgeons who are employed by the Ministry of Health (MOH) in Riyadh and the Eastern Province, Saudi Arabia. The questionnaire was distributed through on-site visitations to orthopedic departments in MOH hospitals as well as through online correspondence by email, WhatsApp, and social media.

RESULTS

The study sample included 262 orthopedic surgeons (13.7% females and 86.3% males). Surgeons aged < 34, 35-44, and 45-54 years old represented 28.66%, 38.9%, and 20.2% of the study sample, respectively. The majority of the included surgeons did not use PROMs (69.1%), and some (17.2%) used it for research purposes. Only 5% used it regularly in daily clinical work.

CONCLUSION

The clinical use of PROMs among orthopedic surgeons was negligible, even though an overwhelming majority were interested in using PROMs. The reasons provided included a lack of knowledge on how to use PROMs and the perception that it is too time-consuming to add to regular clinical routine. There should be more efforts towards training surgeons on how to use PROMs, whereas increasing compatibility with existing software tools used by MOH hospitals may help offset time-related reservations.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies

Background

Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care.

Methods

A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality.

Results

The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates.

Conclusions

Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes.

Trial registration

PROSPERO registration number: CRD42020145151.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07683-7.

A randomized controlled trial comparing the efficacies of ketorolac and parecoxib for early pain management after total knee arthroplasty

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to reduce pain after orthopedic surgery. Currently, selective COX-2 inhibitors can provide effective pain reduction with less platelet inhibition compared with conventional NSAIDs. We aimed to compare the analgesic effect and perioperative blood loss (PBL) after total knee arthroplasty (TKA) between ketorolac and parecoxib administration.

METHODS

We conducted a prospective randomized controlled study of 100 unilateral TKAs. The ketorolac group of 50 patients received an intraoperative periarticular injection (PAI) with 100 mg of bupivacaine and 30 mg of ketorolac. Afterwards, 30 mg of ketorolac was intravenously injected every 12 h until 48 h. In the parecoxib group of 50 patients, 20 mg of parecoxib was added to PAI, and the first intravenous dose was 20 mg followed by 40 mg every 12 h. The primary outcomes were visual analog scales (VASs) of postoperative pain, amount of morphine consumption, PBL, and blood transfusion rate.

RESULTS

The ketorolac group had a significantly lower VAS pain score than the parecoxib group at 6 h after TKA (2.38 ± 2.52 vs. 4.12 ± 2.86, P < 0.01). Thereafter, the VAS of both groups and total morphine consumption at 24 and 48 h were comparable. The PBLs of the ketorolac and parecoxib groups were 529.72 ± 263.02 and 402.40 ± 191.47 ml, respectively (P = 0.01). However, the blood transfusion rates between groups were not different.

CONCLUSION

Parecoxib provides comparable analgesic effects to ketorolac. Additionally, perioperative use of parecoxib is safe and is associated with significantly less blood loss after TKA.

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Systematic Review of the Surgical Outcomes of Elbow Plicae

Background:

Surgical resection is usually required for symptomatic elbow plicae that have failed nonoperative therapy. However, evidence of surgical outcomes has not been presented.

Purpose:

To review the surgical outcomes for the treatment of synovial plicae in the radiocapitellar joint.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, and Embase databases using keywords as well as Medical Subject Headings terms and Emtree ([(elbow OR humeroradial joint OR radiohumeral joint) AND (meniscus OR plica)] OR snapping elbow OR snapping triceps OR synovial fold syndrome OR synovial fringe) for English-language studies. We conducted a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results:

A total of 14 articles comprising four level 5 and ten level 4 studies were identified, including 279 patients (284 elbows). The triggering factors reported for 58 patients were heavy labor (29 patients; 50.0%), sporting activities (17 patients; 29.3%), and nonspecific trauma (12 patients; 20.7%). Overall, 92 patients (33.0%) were administered a steroid injection before surgery. Arthroscopic plica resection was performed in 266 patients (95.3%). Intraoperatively, plicae were mostly found in the posterior (44.0%) and posterolateral (28.6%) sites, and chondromalacia of the radial head was observed in 25 patients (9.2%). Of the reported surgical outcomes, 67.7% showed a resolution of symptoms. However, 9.3% of patients had residual symptoms, which were likely associated with pre-existing radial head chondromalacia. The complication rate was reported as 1.8%.

Conclusion:

Symptomatic elbow plicae were mostly treated arthroscopically, with most of the results being favorable. Pre-existing chondromalacia and the underestimation of concomitant intra-articular abnormalities may yield an inferior outcome.

A patient satisfaction survey investigating pre- and post-operative information provision in lower limb surgery

Background

Planned lower limb surgery is common, with over 90,000 hip replacements, 95,000 knee replacements and 15,000 anterior cruciate ligament reconstructions performed in the UK each year. These procedures are primarily indicated to treat osteoarthritis, sporting injuries and trauma. Patient satisfaction is an important element of healthcare provision, which is usually measured by functional outcomes but influenced by other factors. Few studies have assessed patients’ views on the information given to them pertaining surgery and patients are infrequently consulted when designing leaflets and information packs, which can lead to confusion during the recovery period and poor long-term outcomes. Furthermore, previous studies have not directly asked patients what resources they would prefer, or which format would suit them best. This project aimed to assess if patients were satisfied with the information they received around their operations and to identify potential improvements.

Methods

Set in a National Health Service (NHS) run major trauma centre in the West Midlands, a multiple choice and free-text answer survey was administered to patients who used the orthopaedic service over the course of 1 month. Surveys were designed in Qualtrics and administered face-to-face on paper. Thematic content analysis was performed on the results.

Results

Eighty patients completed the survey, of which 88.8% of patients were satisfied with the information they received. Discussions with surgeons were the most useful resource and 53% of patients requested more internet resources. Post-operative patients were statistically more likely to be dissatisfied with information provision than pre-operative patients. Over 20% of the study population requested more information on post-operative pain and recovery timelines.

Conclusions

Although patients were satisfied in general, areas for change were identified. Suggested resources took the form of webpages and mobile platforms. These resources could contain educational videos, patient experience blogs or interactive recovery timelines, to be of benefit to patients. These suggestions may enable NHS Trusts to “get into the digital age”, however, more research on patient satisfaction around information provision and the impact it has on recovery and decision making is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03761-w.

Is there an optimal age for total knee arthroplasty?: A systematic review

PURPOSE

The purpose of this systematic review was to elucidate the optimal age for patients undergoing total knee arthroplasty (TKA), to optimize the balance between the benefits and risks by analyzing patient-reported outcome measurements (PROM), revision rate, and mortality according to age.

MATERIALS AND METHODS

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data were extracted according to the following: study design, patients enrolled, patient age at the time of surgery, follow-up period, PROM, revision rate, and mortality.

RESULTS

Thirty-nine articles were included in the final analysis. The results were inconsistent in the PROM analysis, but there was consensus that PROM were good in patients in their 70s . In the revision rate analysis, there was consensus that the revision rate tends to increase in TKA in younger patients, but no significant difference was observed in patients > 70 years of age. In the mortality analysis, there was consensus that the mortality was not significantly different in patients < 80 years of age, but tended to increase with age.

CONCLUSION

This systematic review shows that the PROM were good when TKA was performed in patients between 70 and 80 years of age; the best PROM could be achieved around 70 years of age, and no significant difference in the revision or mortality rates was observed between 70 and 80 years of age; however, mortality tended to increase with age. Therefore, the early 70s could be recommended as an optimal age to undergo TKA.

Assessment of Patient's Satisfaction and Associated Factors regarding Postoperative Pain Management at the University of Gondar Compressive Specialized Hospital, Northwest Ethiopia

Objective

We aimed to assess the level of patient's satisfaction and associated factors regarding postoperative pain management.

Methods

An institution-based cross-sectional study was conducted from April to May 2018 at the University of Gondar, and comprehensive specialized hospital data were collected through semistructured questionnaire and chart review. Level of satisfaction was measured using five-point Likert scale. Statistical analysis was done using SPSS software version 23. Both bivariable and multivariable logistic regression analyses were done. Variables of P value ≤0.2 in the bivariable analysis were a candidate for multivariable logistic regression. A P value ≤0.05 was considered as significantly associated with patient's level of satisfaction at 95% CI.

Results

A total of 418 patients were included in this study with a response rate of 98.58%. The overall proportion of patients who were satisfied with pain management services was 72.2% (95% CI: 67.7-76.6). ASA1 (AOR = 3.55: 95% CI = 1.20-10.55) and ASA2 patients (AOR = 3.72: 95% CI = 1.04-13.28), absence of postoperative pain (AOR = 1.86: 95% CI = 1.02-3.39), peripheral nerve block done (AOR = 9.14: 95% CI = 3.93 20.86), received analgesic before request (AOR = 6.90: 95% CI = 3.72-12.83), and received systemic analgesics (AOR = 6.10: 95% CI = 1.17-33.91) were significantly associated with the level of satisfaction.

Conclusion

The level of patient satisfaction with postoperative pain management was considerably low. Hence, it is vital to implement time-interval pain assessment method during the first 24 hours of postoperative period and treat accordingly based on the WHO pain ladder. Moreover, we suggested that all patients who underwent major surgery should receive peripheral nerve block as part of multimodal analgesia to decrease the incidence and severity of post op pain.

Quality of life, chronic pain, insomnia, and jaw malfunction in patients after alloplastic temporomandibular joint replacement: a questionnaire-based pilot study

Studies of patients undergoing alloplastic total temporomandibular joint replacement seldom report on quality of life (QoL) and sleep. The aim of this pilot study was to assess these factors in such a patient cohort using validated psychometric questionnaires. Data were collected via online surveys comprising the following six questionnaires: Short Form-12 Health Survey (SF-12), Patient Health Questionnaire-15, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, Insomnia Severity Index, Graded Chronic Pain Scale, and Jaw Disability List. Pain intensity, limitation in nutrition, and treatment satisfaction were assessed using numerical rating scales. Mouth opening was measured at follow-up. The SF-12 Physical Composite Score was markedly lower than that of the age-matched general population, whereas the Mental Composite Score did not differ significantly. Participants indicated a low somatization level and low level of disability due to pain, but reduced QoL. Clinically relevant insomnia was reported by 36% of participants. In conclusion, the results of this pilot study indicate that QoL and sleep in patients with a total temporomandibular joint replacement differ from those in the general population, indicating the need for a comprehensive outcome assessment utilizing validated psychometric tools in accordance with the current biopsychosocial model of chronic disorders.

Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial

OBJECTIVE

To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty.

DESIGN

Parallel group randomised controlled trial.

SETTING

13 secondary and tertiary care centres in the UK providing postoperative physiotherapy.

PARTICIPANTS

334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol.

INTERVENTIONS

All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist).

MAIN OUTCOME MEASURES

Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery.

RESULTS

334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval -0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, -0.78 to 0.28, P=0.36) or worst pain (0.22 points, -0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval -14.25 to 4.96, P=0.34).

CONCLUSIONS

Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures.

TRIALS REGISTRATION

Current Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445.

Satisfaction Rates Are Low following Revision Total Knee Arthroplasty in Asians Despite Improvements in Patient-Reported Outcome Measures

With the aging population in Asia and increase in total knee arthroplasty (TKA) utilization rates, the number of patients requiring revision TKA (rTKA) are expected to increase as well. The purpose of this study was to evaluate outcomes and satisfaction rates following rTKA in an Asian population that has unique cultural demands. Registry data of patients who underwent rTKA from 2006 to 2010 and had completed 5 years of follow-up were analyzed. Flexion range, Oxford Knee score (OKS), Knee Society score (KSS), the Short-Form 36 (SF-36), and satisfaction rates were assessed for improvement from preoperative values, as well as by the minimum clinically important difference (MCID) criterion. rTKA was performed in 163 patients. There were significant improvements seen at 2 years postoperatively and these were sustained up to 5 years. The minimal clinically important difference (MCID) criterion for KSS, OKS, and SF-36 physical component score (PCS) was met at 2 and 5 years postoperatively. The overall complication rate was 3.7% at a mean follow-up of 8.4 years. A total of 121 patients (74.2%) were satisfied at 5 years postoperatively. Within our cohort, rTKA results in significantly improved patient-reported outcome measures with a low complication rate of 3.7% at a minimum of 5-year follow-up. Despite these encouraging results, satisfaction rates remain low.

Outcome of carpal tunnel decompression with pre-surgical diagnosis determined on general practitioner assessment and nerve conduction study

BACKGROUND

Accurate diagnosis of carpal tunnel syndrome is key to successful treatment. At our center a treatment pathway was recently established for patients with carpal tunnel syndrome. Within this pathway patients are assessed by their community practitioner. Patients who fail to improve with conservative treatment and have a positive nerve conduction study are put forward for surgery without a specialist assessment. Recent literature has shown nerve conduction study may produce a high rate of false-positive results when used to diagnose carpal tunnel syndrome. The aim of this study was to retrospectively review outcomes of carpal tunnel decompression surgery in patients whose diagnoses was based on a community practitioner assessment and positive nerve conduction study.

METHODS

All patients who had carpal tunnel release surgery between August 1, 2017 and August 31, 2018 at our center were screened for eligibility. Data from hospital records and a standardized telephone questionnaire was used to assess surgical outcome.

RESULTS

The final study population included 128 operated hands. The mean follow up time after surgery was 9.6 months. We found 79% of patients reported significant improvement of their symptoms following carpal tunnel release. The overall complication rate was 2.3%.

CONCLUSION

This study has demonstrated good outcomes from carpal tunnel decompressive surgery are possible in a cohort of patients whose diagnosis was made on the basis of a positive nerve conduction study and community practitioner assessment.

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BACKGROUND

Up to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.

METHODS

Prospectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.

RESULTS

The calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.

CONCLUSION

OHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.

Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT

BACKGROUND

Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a technique similar to TURP. The small amount of existing literature suggests that there may be potential advantages of ThuVARP over TURP.

OBJECTIVE

To determine whether or not the outcomes from ThuVARP are equivalent to the outcomes from TURP in men with BPO treated in the NHS.

DESIGN

A multicentre, pragmatic, randomised controlled parallel-group trial, with an embedded qualitative study and economic evaluation.

SETTING

Seven UK centres - four university teaching hospitals and three district general hospitals.

PARTICIPANTS

Men aged ≥ 18 years who were suitable to undergo TURP, presenting with bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO.

INTERVENTIONS

Patients were randomised 1 : 1 to receive TURP or ThuVARP and remained blinded.

MAIN OUTCOME MEASURES

Two co-primary outcomes - patient-reported International Prostate Symptom Score (IPSS) and clinical measure of maximum urine flow rate (Qmax) at 12 months post surgery.

RESULTS

In total, 410 men were randomised, 205 to each arm. The two procedures were equivalent in terms of IPSS [adjusted mean difference 0.28 points higher for ThuVARP (favouring TURP), 95% confidence interval (CI) -0.92 to 1.49 points]. The two procedures were not equivalent in terms of Qmax (adjusted mean difference 3.12 ml/second in favour of TURP, 95% CI 0.45 to 5.79 ml/second), with TURP deemed superior. Surgical outcomes, such as complications and blood transfusion rates, and hospital stay were similar for both procedures. Patient-reported urinary and sexual symptoms were also similar between the arms. Qualitative interviews indicated similar patient experiences with both procedures. However, 25% of participants in the ThuVARP arm did not undergo their randomised allocation, compared with 2% of participants in the TURP arm. Prostate cancer was also detected less frequently from routine histology after ThuVARP (65% lower odds of detection) in an exploratory analysis. The adjusted mean differences between the arms were similar for secondary care NHS costs (£9 higher for ThuVARP, 95% CI -£359 to £376) and quality-adjusted life-years (0.01 favouring TURP, 95% CI -0.04 to 0.01).

LIMITATIONS

Complications were recorded in prespecified categories; those not prespecified were excluded owing to variable reporting. Preoperative Qmax and IPSS data could not be collected for participants with indwelling catheters, making adjustment for baseline status difficult.

CONCLUSIONS

TURP was superior to ThuVARP in terms of Qmax, although both operations resulted in a Qmax considered clinically successful. ThuVARP also potentially resulted in lower detection rates of prostate cancer as a result of the smaller volume of tissue available for histology. Length of hospital stay after ThuVARP, anticipated to be a key benefit, was equal to that after TURP in this trial. Overall, both ThuVARP and TURP were effective procedures for BPO, with minor benefits in favour of TURP. Therefore, the results suggest that it may be appropriate that new treatment alternatives continue to be compared with TURP.

FUTURE WORK

Longer-term follow-up to assess reoperation rates over time, and research into the comparative effectiveness of ThuVARP and TURP in large prostates.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00788389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 41. See the NIHR Journals Library website for further project information.

Anal Sphincter Injury Associated with Vaginal Twin Delivery

OBJECTIVE

Obstetric anal sphincter injury remains the most common cause of fecal incontinence in women, and research in twin pregnancies is sparse. This study aimed to examine risk factors for sphincter injury in twin deliveries over a 10-year period.

STUDY DESIGN

This was a retrospective study of twin vaginal deliveries in a tertiary-level hospital over 10 years. We examined the demographics of women who had a vaginal delivery of at least one twin. Logistic regression analysis was used to examine risk factors.

RESULTS

There were 1,783 (2.1%) twin pregnancies, of which 556 (31%) had a vaginal delivery of at least one twin. Sphincter injury occurred in 1.1% (6/556) women with twins compared with 2.9% (1720/59,944) singleton vaginal deliveries. Women with sphincter injury had more instrumental deliveries (83.3 vs. 27.6%; p = 0.008). On univariate analysis, only instrumental delivery was a significant risk factor (odds ratio: 2.93; p = 0.019).

CONCLUSION

Sphincter injury occurs at a lower rate in vaginal twin pregnancies than in singletons. No twin-specific risk factors were identified. Discussion of the risk of sphincter injury should form part of patient counseling with regard to the mode of delivery.

Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial

Objectives

To assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up.

Design

Multicentre, randomised, participant- and outcome assessor-blinded, placebo-surgery controlled trial.

Setting

Orthopaedic departments in five public hospitals in Finland.

Participants

146 adults, mean age 52 years (range 35–65 years), with knee symptoms consistent with degenerative medial meniscus tear verified by MRI scan and arthroscopically, and no clinical signs of knee osteoarthritis were randomised.

Interventions

APM or placebo surgery (diagnostic knee arthroscopy).

Main outcome measures

We used two indices of radiographic knee osteoarthritis (increase in Kellgren and Lawrence grade ≥1, and increase in Osteoarthritis Research Society International (OARSI) atlas radiographic joint space narrowing and osteophyte sum score, respectively), and three validated patient-relevant measures of knee symptoms and function (Western Ontario Meniscal Evaluation Tool (WOMET), Lysholm, and knee pain after exercise using a numerical rating scale).

Results

There was a consistent, slightly greater risk for progression of radiographic knee osteoarthritis in the APM group as compared with the placebo surgery group (adjusted absolute risk difference in increase in Kellgren-Lawrence grade ≥1 of 13%, 95% CI −2% to 28%; adjusted absolute mean difference in OARSI sum score 0.7, 95% CI 0.1 to 1.3). There were no relevant between-group differences in the three patient-reported outcomes: adjusted absolute mean differences (APM vs placebo surgery), −1.7 (95% CI −7.7 to 4.3) in WOMET, −2.1 (95% CI −6.8 to 2.6) in Lysholm knee score, and −0.04 (95% CI −0.81 to 0.72) in knee pain after exercise, respectively. The corresponding adjusted absolute risk difference in the presence of mechanical symptoms was 18% (95% CI 5% to 31%); there were more symptoms reported in the APM group. All other secondary outcomes comparisons were similar.

Conclusions

APM was associated with a slightly increased risk of developing radiographic knee osteoarthritis and no concomitant benefit in patient-relevant outcomes, at 5 years after surgery.

Trial registration

ClinicalTrials.gov (NCT01052233 and NCT00549172).

The Natural Evolution of Facial Surgical Scars: A Retrospective Study of Physician-Assessed Scars Using the Patient and Observer Scar Assessment Scale Over Two Time Points

Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.

Translation and Validation of Forgotten Joint Score for Total Hip Arthroplasty for Indian Population

BACKGROUND

The ultimate success of a total hip replacement lies in patients forgetting about their artificial joints during routine activities. "Forgotten Joint Score (FJS)" is emerging as an important tool in assessing outcomes of total hip arthroplasty. There has been no version of this score available in commonly spoken vernaculars in India. This study aims to formulate and validate the Hindi version of FJS in Indian population.

METHODS

A total of 136 patients with a minimum follow-up of 6 months and a maximum follow-up of 18 months after total hip arthroplasty were asked to fill the translated and adapted version of FJS questionnaire, at two points of time 2 weeks apart. The Hindi version of FJS (I-FJS) was tested for reliability and responsiveness, floor and ceiling effect and validity against modified Harris Hip Score (mHHS). Construct validity was expressed as the Pearson correlation coefficient. Internal consistency was expressed as Cronbach's alpha and test-retest reliability as the intra-class correlation coefficient (ICC).

RESULTS

I-FJS showed excellent internal consistency with Cronbach's alpha of 0.88. Intra-class correlation coefficient (ICC) was 0.94. I-FJS showed good correlation with m-HHS (r = 0.8, p = 0.001). The standard error of measurement was 3.6 and the smallest detectable change was 9.97. There was no floor or ceiling effect observed with I-FJS. Data from this study were insufficient to establish adequate responsiveness of I-FJS.

CONCLUSION

I-FJS is a valid, reliable and reproducible score for hip function in post-THA patients. It is devoid of any floor or ceiling effect. Hindi version of FJS could be an effective tool for studying hip function in the Indian population.

Kinematic alignment in total knee arthroplasty

Kinematic alignment (KA) is an alternative philosophy for aligning a total knee replacement (TKR) which aims to restore all three kinematic axes of the native knee.

Many of the studies on KA have actually described non-KA techniques, which has led to much confusion about what actually fits the definition of KA.

Alignment should only be measured using three-dimensional cross-sectional imaging. Many of the studies looking at the influence of implants/limb alignment on total knee arthroplasty outcomes are of limited value because of the use of two-dimensional imaging to measure alignment, potentially leading to inaccuracy.

No studies have shown KA to be associated with higher complication rates or with worse implant survival; and the clinical outcomes following KA tend to be at least as good as mechanical alignment.

Further high-quality multi-centre randomized controlled trials are needed to establish whether KA provides better function and without adversely impacting implant survival.

Cite this article: EFORT Open Rev 2020;5:380-390. DOI: 10.1302/2058-5241.5.200010

Alterations of kinematics in knees after single versus multiple radius femoral prostheses total knee arthroplasty: a retrospective study

BACKGROUND

Design modifications in prostheses may cause alterations in gait kinematics, thus influencing functional restoration of knees after total knee arthroplasty (TKA). The aim of the study was to investigate the differences in gait kinematics and clinical outcomes after single radius (SR) versus multiple radius (MR) TKA.

METHOD

The present retrospective study included 38 unilateral TKA involving 20 knees using MR design implant and 18 knees using SR design implant. Thirty-six healthy volunteers were also recruited. The mean follow-up time was 16 ± 3 months. At the end of follow-up, the 6 degrees of freedom (DOF) kinematics of knees and range of motion (ROM) were measured with a portable optical tracking system. Knee society score (KSS) and knee injury, and osteoarthritis outcome score (KOOS) were also collected.

RESULTS

Patients in the SR group had significantly higher scores in activities of daily living (84.7 ± 15.9) and sports and recreation (67.5 ± 25.2) KOOS sub-score than MR group (69.9 ± 17.6, P = 0.012; 50.0 ± 20.8, P = 0.027, respectively). Significant differences were detected between MR knees and SR knees (1.82° ± 3.11° vs 4.93° ± 3.58°, P = 0.009), and MR knees and healthy knees (1.82° ± 3.11° vs 3.62° ± 3.52°, P = 0.032) in adduction/abduction ROM. The proximal/distal translation was significantly smaller in MR knees (0.58 ± 0.54 cm) compared with SR knees (1.03 ± 0.53 cm, P = 0.003) or healthy knees (0.84 ± 0.45 cm, P = 0.039). SR knees (0.24 ± 0.40 cm) had smaller translation compared with the MR group (0.54 ± 0.33 cm, P = 0.017) and control group (0.67 ± 0.36 cm, P = 0.028). No significant difference was detected in the other DOFs during the gait cycle. Significant difference was detected in extension/flexion, internal/external rotation, adduction/abduction, proximal/distal and medial/lateral among MR, SR and healthy knees.

CONCLUSION

After TKA, patients have altered gait kinematics compared with the control group. MR and SR design showed varied characteristics in 6 DOF gait kinematics, which could be the cause of the difference in functional outcome.

High Pre-Operative Expectations Precede Both Unfulfilled Expectations and Clinical Improvement After Total Hip and Total Knee Replacement

BACKGROUND

This prospective study aimed to examine whether patients' and physicians' outcome expectations were related to subjective (ie, fulfillment of expectations) and objective outcomes (ie, change in pain and function) in hip and knee arthroplasty patients up to 6 months post-surgery.

METHODS

Patients' (N = 395) and physicians' outcome expectations were examined 1 week post-consultation. Patients' post-operative functional status and the extent of fulfillment of expectations were examined 5 weeks, 3 months, and 6 months post-surgery. Patients and physicians completed the Hospital for Special Surgery Hip/Knee Replacement (Fulfillment) Expectations Survey. Patients completed the Hip/Knee injury and Osteoarthritis Outcome Score. Linear regression analyses were performed to examine the relationship between physicians' expectations and patients' change in pain and function and extent of fulfillment of expectations, and a possible mediated effect of patients' pre-operative expectations.

RESULTS

Patients' high expectations were consistently associated with better objective outcomes (ie, change in pain and function). Yet, high expectations in patients were also negatively related to subjective outcomes (ie, the extent of fulfillment of expectations). Physicians' expectations were only positively associated with objective improvement in knee patients, and not in hip patients. Additionally, knee patients' expectations partly mediated the relationship between physicians' expectations and change in pain and function, 6 months post-surgery.

CONCLUSION

Although patients' high expectations were associated with better objective outcomes, improvement was still less than patients expected. Thus, patients often have too high expectations of outcomes of surgery. In addition, physicians were able to influence patients' expectations and to change experienced knee patients' outcomes.

Comparison of 5-Year Patient-Reported Outcomes (PROMs) of Total Ankle Replacement (TAR) to Total Knee Replacement (TKR) and Total Hip Replacement (THR)

BACKGROUND

Total ankle replacement (TAR) is becoming a more common alternative to ankle arthrodesis for the improvement of pain and function in end-stage arthritis of the ankle. The effects of end-stage arthritis of the ankle are similar to those of end-stage hip arthritis. There is a paucity of literature on patient-reported outcome measures (PROMs) following TARs in comparison with total hip replacement (THR) or total knee replacement (TKR). We aimed to study the 1-, 3-, and 5-year outcomes of TAR in comparison with TKR and THR.

METHODS

PROMs data from patients who underwent a primary THR, TKR, or TAR performed between March 2008 and 2013 over a 5-year period were collected from our hospital patient registry. They were divided into 3 groups based on the type of primary joint replacement. Patient demographics and patient-reported outcomes (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 36-item Short-Form (SF-36) scores, and patient satisfaction scores at follow-up) were compared preoperatively and at the 1-, 3-, and 5-year follow-ups.

RESULTS

There were data available on 2672 THR, 3520 TKR, and 193 TAR patients preoperatively. Preoperatively, TAR patients reported statistically significantly higher function scores when compared with THR and TKR patients (40 vs 33; P = .001 [P < .05] and 40 vs 36; P = .001 [P < .05]). For SF-36 scores, there was no statistically significant difference between groups for the general health and role emotional components (P = .171 and .064, respectively [P > .05]); TAR patients reported similar scores to TKR patients for physical domains at the 3- and 5-year follow-ups (P > .05), and TAR patients also reported similar scores to both THR and TKR patients for the mental domains (P > .05). At 5 years postoperatively, TAR patients reported lower scores than THR and TKR patients for function and stiffness. For SF-36 scores, TAR patients reported similar outcomes to THR and TKR patients for mental health components (P > .05), similar scores to TKR patients for 3 of 4 physical domains (P < .05), but lower satisfaction rates for activities of daily living (ADL) and recreation when compared with THR (P < .05).

CONCLUSION

TAR patients had similar outcomes to THR and TKR patients for disease-specific and mental health domains, and lower patient satisfaction rates in terms of pain relief, ADL, and recreation. Further research is warranted including clinical outcomes along with PROMs with a long-term follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Parental assessment of pain control following pediatric adenotonsillectomy: Do opioids make a difference?

INTRODUCTION

Postoperative prescribing of opioids following pediatric adenotonsillectomy can have negative consequences including unnecessary opioid exposure and potential for respiratory depression. While guidelines from The American Academy of Otolaryngology/Head & Neck Surgery recommend treatment of post adenotonsillectomy pain using acetaminophen and ibuprofen, many providers continue to prescribe opioids and may do so, in part with concern for parental dissatisfaction with post-operative analgesia. Our aim was to determine whether a post-operative prescription for opioids affects parental assessment of pain control following pediatric adenotonsillectomy.

METHODS

This post-operative survey assessed the parental assessment of pain control in 324 patients, ages 1-17 years undergoing adenotonsillectomy. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 1, 2018 through March 31, 2019. Post-operative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for post-operative analgesia based on the attending surgeons prescribing preferences. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric adenotonsillectomy as poor or inadequate based on the post-operative analgesic regimen including opioids.

RESULTS

Of the 798 surveys sent, the response rate was 42% (324/775) of those who received the survey email, and 69% (324/470) for those who opened the email. Between the opioid and non-opioid groups, there was no difference in gender (male; 48% vs. 51.3%; p = 0.58), race/ethnicity (white; 53% vs. 46%; p = 0.35) or insurance status (insured; 62% vs. 50.9%; p = 0.06). The proportion of parents who rated their child's pain as poor or inadequately controlled following adenotonsillectomy was relatively rare: 9% and 5% in the non-opioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following adenotonsillectomy were 58% and 50% in the non-opioids and opioid groups respectively.

CONCLUSION

The results of this study indicate that non-opioid analgesic regimens following pediatric adenotonsillectomy were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric adenotonsillectomy is feasible and does not result in worse parental satisfaction with the analgesic plan.

Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients

BACKGROUND

Intramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures.

METHODS

Trip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics.

RESULTS

Fifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively.

DISCUSSION & CONCLUSION

Patients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.

Statistical process control assessed implementation fidelity of patient-reported outcome measures (PROMs) in routine care

OBJECTIVES

Ensuring implementation fidelity of patient-reported outcome measures (PROMs) in the complex clinical setting remains exigent. We aimed to integrate the routine use of PROM reports in day-to-day patient care and assess the implementation outcomes using statistical process control (SPC) methods.

STUDY DESIGN AND SETTING

This prospective pilot study used an implementation science framework to integrate PROMs. SPC analysis was applied to track patient completion rates and staff acknowledgment rates over time. Daily observational data across clinical areas were collected to assess potential variations.

RESULTS

Data were available from 324 patient encounters over 14 weeks. On average, 78% (52% to 100%) of eligible patients entering the clinic completed the PROMs; staff acknowledged 78% (50-100%) of these patient reports. Most patterns of fluctuation were inside the control frame. Dips in compliance relating to changes in clinic daily routine, including the introduction of the second randomized clinic, were quickly resolved with a structured response.

CONCLUSION

Implementation of PROMs was feasible with reasonable patient completion and staff acknowledgment rates. Fidelity was vulnerable to barriers impacting the daily routine or unusual events in the clinics, suggesting that greater standardization and integration into clinic processes may yet further improve compliance and consistency of reporting.

Assessment of the Quality of Nursing Care of Postoperative Pain in Patients Undergoing Vascular Procedures

PURPOSE

The purpose of this study was to evaluate the quality of nursing care of postoperative pain management in patients who underwent vascular procedures.

DESIGN

A survey using patient questionnaires.

METHODS

The sample was composed of 100 patients, aged 52 to 86 years, admitted to the Clinic of Cardiac and Vascular Surgery, University Clinical Centre, Gdansk, Poland. The study included the use of an interview questionnaire, that is,.e. a standardized research tool-the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale and a questionnaire designed to record sociodemographic characteristics.

FINDINGS

Analysis of the data indicated that the most numerous group of patients were men (80%). The total mean score obtained with the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale was 59.2 points (range, 14 to 70) meaning that the high quality of nursing care in each area was not provided. The results of this research revealed areas for improvement in postoperative pain management on the subscales: communication (12.9 points), action (15.3 points), and environment (12.5 points).

CONCLUSIONS

The overall level of quality of nursing care in terms of postoperative pain management as reported by patients after vascular procedures was not fully satisfying, and nursing care should improve. This indicates the need to educate nurses in postoperative pain management, its monitoring and prophylaxis, and communication techniques with patients. Our study indicates that gender, place of residence, education level, and satisfaction with pain management influence the assessment of the quality of care.

Wear Rates of XLPE Nearly 50% Lower Than Previously Thought After Adjusting for Initial Creep: An RCT Comparing 4 Bearing Combinations

Background

The ideal bearing combination for total hip arthroplasty (THA) remains debatable. Highly cross-linked polyethylene (XLPE) is widely used, but long-term wear rates are not fully known, nor is how much the initial "creep," if any, affects overall wear. Additionally, the use of oxidized zirconium (OxZir) is purported to lower polyethylene wear rates, but this has not been proven. We present the 10-year data of a cohort of patients who underwent THA. Patients were prospectively randomized to 1 of 4 bearing combinations: a conventional ultra-high molecular weight polyethylene (UHMWPE) or XLPE acetabular liner coupled with either a cobalt-chromium (CoCr) or OxZir femoral head. The aims of the study were to (1) assess the extent to which creep affected overall wear rates and (2) assess wear rates between OxZir and CoCr with polyethylene.

Methods

A total of 92 hips (92 patients) between the ages of 22 and 65 years (mean, 52.2 ± 9.3 years) were randomized to 4 groups. At 10 years, 70 (76%) of the hips were available for analysis; patients who had undergone revision, had died, or were lost to follow-up were excluded from final analysis. Radiographic analysis was performed using a validated digital assessment program to determine linear, volumetric, and directional wear of the polyethylene for all 4 bearing couples. Radiographic assessments were performed immediately postoperatively, at 6 and 12 weeks, and then annually for a minimum of 10 years.

Results

XLPE had significantly lower wear rates than UHMWPE. Once creep was eliminated, annual and overall wear rates were nearly 50% lower than have been previously reported. This was proportionally more important in the XLPE group than in the UHMWPE group. There was a nonsignificant trend toward a lower wear rate with OxZir heads.

Conclusions

Creep plays a notably more important role than first thought. Once creep was eliminated, the overall wear rate was even lower than previously assumed. This has important implications for the overall survivorship of hip arthroplasty implants.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Patient-reported outcomes following primary total hip arthroplasty in Crowe type III or IV developmental dysplasia are comparable to those in Crowe type I: a case-control study of 96 hips with intermediate-term follow-up

Background

A few previous studies have investigated patient satisfaction after total hip arthroplasty (THA) according to the degree of pelvic deformity. This study compared patient-reported outcomes after primary THA for Crowe types III, IV and I dysplasia.

Methods

This retrospective, single-center, single-surgeon case-control study included patients who underwent primary THA between 2008 and 2016. We sent postal questionnaires to 38 patients with Crowe type III and IV dysplasia. Among the questionnaire respondents, 23 patients, excluding those with a follow-up period of < 1 year, were enrolled as the H group. The control group included 46 patients with Crowe type I, matched for sex, age, body mass index and surgical approach. To investigate the influence of femoral shortening osteotomy, the H group was divided according to whether femoral shortening osteotomy was performed. Ten patients underwent THA with femoral shortening osteotomy (FO group), while 12 patients underwent THA without femoral shortening osteotomy (N-FO group). Patient demographics, mean follow-up period, surgical information, pre- and postoperative leg length discrepancy (LLD), and perioperative complications were investigated. Clinical evaluations were performed using the Japanese Orthopaedic Association (JOA) scores, 36-item short-form survey (SF-36), net promotor score (NPS), visual analogue scale (VAS), and questionnaires. The VAS and SF-36 scores were determined only at final follow-up.

Results

The H and control groups were not significantly different in the postoperative JOA scores and SF-36. In the H group, VAS at the final follow-up was significantly higher, and significantly more patients felt that postoperative rehabilitation was serious, expressing that they underwent THA for LLD correction. In addition, the VAS scores in the FO group was higher than those in the N-FO group. Postoperative LLD was significantly greater in the H group than in the control group. Each group had an NPS of > 50.

Conclusion

The postoperative VAS score was higher in Crowe type III and IV dysplasia than in Crowe type I dysplasia, but no significant differences were detected in the postoperative satisfaction, JOA score, and SF-36 score. These findings may help explain the effects of THA preoperatively to patients with Crowe type III and IV dysplasia.

Level of evidence

Therapeutic Level 3b.

Preparing for an orthopedic consultation using an eHealth tool: a randomized controlled trial in patients with hip and knee osteoarthritis

BACKGROUND

To evaluate the effect of a stand-alone mobile and web-based educational intervention (eHealth tool) compared to usual preparation of a first orthopedic consultation of patients with hip or knee osteoarthritis (OA) on patients' satisfaction.

METHODS

A two-armed randomized controlled trial involving 286 patients with (suspicion of) hip or knee OA, randomly allocated to either receiving an educational eHealth tool to prepare their upcoming consultation (n = 144) or usual care (n = 142). Satisfaction with the consultation on three subscales (range 1-4) of the Consumer Quality Index (CQI - primary outcome) and knowledge (assessed using 22 statements on OA, range 0-22), treatment beliefs (assessed by the Treatment beliefs in OsteoArthritis questionnaire, range 1-5), assessment of patient's involvement in consultation by the surgeon (assessed on a 5-point Likert scale) and patient satisfaction with the outcome of the consultation (numeric rating scale), were assessed.

RESULTS

No differences between groups were observed on the 3 subscales of the CQI (group difference (95% CI): communication 0.009 (- 0.10, 0.12), conduct - 0.02 (- 0.12, 0.07) and information provision 0.02 (- 0.18, 0.21)). Between group differences (95% CI) were in favor of the intervention group for knowledge (1.4 (0.6, 2.2)), negative beliefs regarding physical activities (- 0.19 (- 0.37, - 0.002) and pain medication (- 0.30 (- 0.49, - 0.01)). We found no differences on other secondary outcomes.

CONCLUSIONS

An educational eHealth tool to prepare a first orthopedic consultation for hip or knee OA does not result in higher patient satisfaction with the consultation, but it does influence cognitions about osteoarthritis.

TRIAL REGISTRATION

Dutch Trial Register (trial number NTR6262). Registered 30 January 2017.

Reduction in patient outcomes but implant-derived preservation of function following total knee arthroplasty: longitudinal follow-up of a randomized controlled trial

AIMS

There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes.

METHODS

A mid-term follow-up of the remaining 125 patients from a randomized cohort of total knee arthroplasty patients (initially comprising 212 recruited patients), comparing modern (Triathlon) and traditional (Kinemax) prostheses was undertaken. Functional outcomes were assessed with the Oxford Knee Score (OKS), knee range of movement, pain numerical rating scales, lower limb power output, timed functional assessment battery, and satisfaction survey. Data were linked to earlier assessment timepoints, and analyzed by repeated measures analysis of variance (ANOVA) mixed models, incorporating longitudinal change over all assessment timepoints.

RESULTS

The mean follow-up of the 125 patients was 8.12 years (7.3 to 9.4). There was a reduction in all assessment parameters relative to earlier assessments. Longitudinal models highlight changes over time in all parameters and demonstrate large effect sizes. Significant between-group differences were seen in measures of knee flexion (medium-effect size), lower limb power output (large-effect size), and report of worst daily pain experienced (large-effect size) favouring the Triathlon group. No longitudinal between-group differences were observed in mean OKS, average daily pain report, or timed performance test. Satisfaction with outcome in surviving patients at eight years was 90.5% (57/63) in the Triathlon group and 82.8% (48/58) in the Kinemax group, with no statistical difference between groups (p = 0.321).

CONCLUSION

At a mean 8.12 years, this mid-term follow-up of a randomized controlled trial cohort highlights a general reduction in measures of patient function with patient age and follow-up duration, and a comparative preservation of function based on implant received at time of surgery. Cite this article: Bone Joint J 2020;102-B(4):434-441.

Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients

End-stage osteoarthritis is commonly treated with joint replacement. Despite high clinical success rates, up to 28% of patients are dissatisfied with the outcome.

This best-evidence synthesis aimed to review studies with different forms of study design and methodology that examined the relationship between (fulfilment of) outcome expectations of hip and knee patients and satisfaction with outcome.

A literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane, and Google Scholar to identify studies conducted up to November 2017. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale.

In this best-evidence synthesis systematic review, the following main results could be seen. In only half of all studies were preoperative expectations associated with level of satisfaction, while in almost all studies (93%), fulfilment of expectations was related to satisfaction. The effect of met expectations did not differ between hip and knee patients or study design.

Fulfilment of expectations seems to be consistently associated with patient satisfaction with outcome. Emphasis in future research must be placed on the operationalization and measurement of expectations and satisfaction to determine the (strength of the) influence of these different forms of assessment on the (existence of the) relationship.

Cite this article: EFORT Open Rev 2020;5:226-240. DOI: 10.1302/2058-5241.5.190015

Streamlining the KOOS Activities of Daily Living Subscale Using Machine Learning

Background:

Functional outcome scores provide valuable data, yet they can be burdensome to patients and require significant resources to administer. The Knee injury and Osteoarthritis Outcome Score (KOOS) is a knee-specific patient-reported outcome measure (PROM) and is validated for anterior cruciate ligament (ACL) reconstruction outcomes. The KOOS requires 42 questions in 5 subscales. We utilized a machine learning (ML) algorithm to determine whether the number of questions and the resultant burden to complete the survey can be lowered in a subset (activities of daily living; ADL) of KOOS, yet still provide identical data.

Hypothesis:

Fewer questions than the 17 currently provided are actually needed to predict KOOS ADL subscale scores with high accuracy.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Pre- and postoperative patient-reported KOOS ADL scores were obtained from the Surgical Outcome System (SOS) data registry for patients who had ACL reconstruction. Categorical Boosting (CatBoost) ML models were built to analyze each question and its value in predicting the patient’s actual functional outcome (ie, KOOS ADL score). A streamlined set of minimal essential questions were then identified.

Results:

The SOS registry contained 6185 patients who underwent ACL reconstruction. A total of 2525 patients between the age of 16 and 50 years had completed KOOS ADL scores presurgically and 3 months postoperatively. The data set consisted of 51.84% male patients and 48.16% female patients, with a mean age of 29 years. The CatBoost model predicted KOOS ADL scores with high accuracy when only 6 questions were asked (R² = 0.95), similar to when all 17 questions of the subscale were asked (R² = 0.99).

Conclusion:

ML algorithms successfully identified the essential questions in the KOOS ADL questionnaire. Only 35% (6/17) of KOOS ADL questions (descending stairs, ascending stairs, standing, walking on flat surface, putting on socks/stockings, and getting on/off toilet) are needed to predict KOOS ADL scores with high accuracy after ACL reconstruction. ML can be utilized successfully to streamline the burden of patient data collection. This, in turn, can potentially lead to improved patient reporting, increased compliance, and increased utilization of PROMs while still providing quality data.

Are Patient and Surgeon Expectations after ACL Reconstruction Realistic?

BACKGROUND

Patient expectations may affect their satisfaction and functional outcomes after treatment of musculoskeletal injuries. Although there is evidence that patient expectations of ACL reconstruction (ACLR) are inflated, there is limited knowledge about the relationship between physician and patient expectations and patient outcomes after they completely recover from ACLR. Furthermore, it is unclear if specific patient factors influence these expectations.

QUESTIONS/PURPOSES

(1) Are patient and surgeon expectations of knee function 18 months after ACLR similar? (2) Are patients' and surgeons' expectations of outcomes similar to patients' actual 2-year outcomes? (3) Is there a relationship between preoperative or intraoperative parameters and expectations? (4) Is there a relationship between preoperative or intraoperative parameters and 2-year ACLR outcomes?

METHODS

One-hundred twenty-nine patients undergoing primary ACLR were prospectively enrolled in this study, with 98 (76%) completing 2-year follow-up. Patients completed the IKDC Subjective Knee Evaluation preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients also completed the same questionnaires preoperatively to evaluate expected knee function 18 months after surgery. Immediately postoperatively, surgeons completed the same questionnaires regarding the expected postoperative outcome at 18 months postoperative. Preoperative and intraoperative data were collected to determine an association between expectations and outcomes. Nonparametric analysis was performed using the Mann-Whitney U test, the paired Wilcoxon signed ranks tests and Spearman's correlations, as applicable.

RESULTS

There was no difference between patient and surgeon expectations (patient, 94.8 [range 47.4-100] versus surgeon, 94.3 [range 46-100]; p = 0.283), and there was no correlation between higher patient expectations and higher surgeon expectations (r = 0.168, p = 0.078). Patient and surgeon expectations were greater than the actual postoperative outcomes (2-year postoperative: 89.7 [range 32.2 to 100]; p < 0.0001); however, the differences are unlikely to be perceived. There was no correlation between higher 2-year postoperative outcomes and higher patient expectations (r = 0.14, p = 0.186) or higher surgeon expectations (r = 0.019, p = 0.86). Arthroscopic evidence of cartilage damage was independently associated with the worst patient and surgeon expectations. The surgeons themselves were also independently associated with surgeon expectation (p < 0.001). No parameters were associated with postoperative outcomes.

CONCLUSIONS

There are no clinically significant differences between surgeon expectations, patient expectations, and 2-year actual outcomes. However, there is also no correlation between the patient expectations, surgeon expectations, and actual outcomes. Although expectations are similar to actual outcomes for most patients, surgeons are unable to accurately predict outcomes for specific patients; thus, preventing adequate patient counseling. Surgeons should be cautious when evaluating and counseling patients preoperatively and avoid assuming high expectations.

LEVEL OF EVIDENCE

Level II, therapeutic study.