Outcomes measurement in orthopaedic trauma surgery

Development of a patient-reported outcome measure in limb reconstruction : a pilot study assessing face validity

Aims

Patients undergoing limb reconstruction surgery often face a challenging and lengthy process to complete their treatment journey. The majority of existing outcome measures do not adequately capture the patient-reported outcomes relevant to this patient group in a single measure. Following a previous systematic review, the Stanmore Limb Reconstruction Score (SLRS) was designed with the intent to address this need for an effective instrument to measure patient-reported outcomes in limb reconstruction patients. We aim to assess the face validity of this score in a pilot study.

Methods

The SLRS was designed following structured interviews with several groups including patients who have undergone limb reconstruction surgery, limb reconstruction surgeons, specialist nurses, and physiotherapists. This has subsequently undergone further adjustment for language and clarity. The score was then trialled on ten patients who had undergone limb reconstruction surgery, with subsequent structured questioning to understand the perceived suitability of the score.

Results

Ten patients completed the score and the subsequent structured interview. Considering the tool as a whole, 100% of respondents felt the score to be comprehensible, relevant, and comprehensive regarding the areas that were important to a patient undergoing limb reconstruction surgery. For individual questions, on a five-point Likert scale, importance/relevance was reported as a mean of 4.78 (4.3 to 5.0), with ability to understand rated as 4.92 (4.7 to 5.0) suggesting high levels of relevance and comprehension. Flesch-Kincaid reading grade level was calculated as 5.2 (10 to 11 years old).

Conclusion

The current SLRS has been shown to have acceptable scores from a patient sample regarding relevance, comprehensibility, and comprehensiveness. This suggests face validity, however further testing required and is ongoing in a larger cohort of patients to determine the reliability, responsiveness, precision, and criterion validity of the score in this patient group.

Cite this article: Bone Jt Open 2021;2(9):705–709.

Evaluation of health-related quality of life after total hip arthroplasty: a case-control study in the Iranian population

Background

As the total hip arthroplasty (THA) mainly aims to improve the quality of life of the patients, study of health-related quality of life (HRQoL) after THA has attracted much attention. Yet, the results considerably vary between studies. Here, we evaluate the HRQoL of the patient after THA, for the first time in the Iranian population.

Methods

In a case-control study, HRQoL was assessed in 217 patients after THA and compared with a matched reference population. The 36-item short-form health survey (SF-36) was used for the evaluation of HRQoL. A multiple linear regression model was used to investigate the influence of sociodemographic and clinical characteristics of the patients on the HRQOL.

Results

The mean follow-up of the patients was 27 ± 18 months. The mean total SF-36 score was 41.4 ± 22.2 in the case and 67.3 ± 26.6 in the control group (p = 0.001). The mean physical component score, but not the mental component score, was significantly lower in the patient group (p = 0.001). Except for the vitality and emotional role, all other SF-36 subscales were significantly lower in the case group. Male sex (B = 4.52, p = 0.023), number of comorbidities (B = − 4.82, p = 0.011), body mass index (B = − 1.18, p = 0.044), number of post-operative complications (B = − 6.57, p = 0.001), and adherence to physiotherapy protocol (B = 2.09, p = 0.014) were associated with HRQoL after THA.

Conclusion

Although THA is considered as one of the most successful orthopedic practices, it is associated with remarkable reduced HRQoL in Iranian population when compared with the reference population. A variety of patients-associated factors influence the HRQoL after THA.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2428-0) contains supplementary material, which is available to authorized users.

Patient-important outcome for the assessment of fracture repair

Current evidence indicates that fracture healing assessment is limited to the use of one or two domains (such as pain, range of motion or mobility) in any single study. Functional outcome measures, which include physician-rated or observer-based impairment ratings and patient self-reported or observer-based activity limitation measures, better position the effectiveness of a given intervention towards patient-important outcomes. Health status measures, for example, cover a wide-range of physical, emotional, and social health dimensions. In this paper, we will examine the utility of metrics to assess fracture healing that are important to both the patient and provider, with selected examples from the recent literature. We recommend outcome measures with established and verified reliability and validity. Policy-makers and other stakeholders need to have an accurate assessment of treatment outcome that includes changes in function over time-adequate measures, should be re-applied at periodic intervals.

Short- and long-term subjective medical treatment outcome of trauma surgery patients: the importance of physician empathy

PURPOSE

To investigate accident casualties' long-term subjective evaluation of treatment outcome 6 weeks and 12 months after discharge and its relation to the experienced surgeon's empathy during hospital treatment after trauma in consideration of patient-, injury-, and health-related factors. The long-term results are compared to the 6-week follow-up outcomes.

PATIENTS AND METHODS

Two hundred and seventeen surgery patients were surveyed at 6 weeks, and 206 patients at 12 months after discharge from the trauma surgical general ward. The subjective evaluation of medical treatment outcome was measured 6 weeks and 12 months after discharge with the respective scale from the Cologne Patient Questionnaire. Physician Empathy was assessed with the Consultation and Relational Empathy Measure. The correlation between physician empathy and control variables with the subjective evaluation of medical treatment outcome 12 months after discharge was identified by means of logistic regression analysis under control of sociodemographic and injury-related factors.

RESULTS

One hundred and thirty-six patients were included within the logistic regression analysis at the 12-month follow-up. Compared to the 6-week follow-up, the level of subjective evaluation of medical treatment outcome was slightly lower and the association with physician empathy was weaker. Compared to patients who rated the empathy of their surgeon lower than 31 points, patients with ratings of 41 points or higher had a 4.2-fold higher probability to be in the group with a better medical treatment outcome (3.5 and above) on the Cologne Patient Questionnaire scale 12 months after discharge from hospital (P=0.009, R (2)=33.5, 95% confidence interval: 1.440-12.629).

CONCLUSION

Physician empathy is the strongest predictor for a higher level of trauma patients' subjective evaluation of treatment outcome 6 weeks and 12 months after discharge from the hospital. Interpersonal factors between surgeons and their patients are possible key levers for improving patient outcomes in an advanced health system. Communication trainings for surgeons might prepare them to react appropriately to their patients' needs and lead to satisfactory outcomes for both parties.

External fixation devices in the treatment of fractures of the tibial plafond

We have compared the outcomes of the use of external fixation devices for spanning or sparing the ankle joint in the treatment of fractures of the tibial plafond, focusing on the complications and the rates of healing. We have devised a scoring system for the quality of reporting of clinical outcomes, to determine the reliability of the results.

We conducted a search of publications in English between 1990 and 2006 using the Pubmed search engine. The key words used were pilon, pylon, plafond fractures, external fixation. A total of 15 articles, which included 465 fractures, were eligible for final evaluation.

There were no statistically significant differences between spanning and sparing fixation systems regarding the rates of infection, nonunion, and the time to union. Patients treated with spanning frames had significantly greater incidence of malunion compared with patients treated with sparing frames. In both groups, the outcome reporting score was very low; 60% of reports involving infection, nonunion or malunion scored 0 points.

The mind does matter: Psychological and physical recovery after musculoskeletal trauma

BACKGROUND

Posttraumatic psychopathology (PTP) is important to the orthopedic surgeon because it appears to be much more common than might have been suspected and may complicate the recovery from musculoskeletal injury. We have investigated the relationship between physical and psychological recovery in victims of musculoskeletal trauma.

METHODS

A prospective cohort of 200 patients with musculoskeletal injuries were studied, correlating development of psychopathology (measured by the General Health Questionnaire) and functional outcome (measured by Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment) 2 and 6 months after their injuries.

RESULTS

Pre-existing psychological disturbance was found in 11% of our patients; this figure rose to 46% of patients at 2 months but fell to 22% at 6 months. The posttraumatic disturbance correlated strongly with impaired functional outcome as measured by all three outcomes measures (total and category scores) (p < 0.05).

CONCLUSIONS

The strong correlation of PTP with impaired functional outcome after musculoskeletal trauma stresses that it is a significant problem. Further research is required to determine whether an approach that combines physical and psychological treatment can improve patient outcomes.

Classifying health-related quality of life outcomes of total hip arthroplasty

BACKGROUND

Primary total hip arthroplasty (THA) is an effective treatment for hip osteoarthritis, assessed by whatever distribution-based measures of responsiveness. Yet, the group level evaluation has provided very little evidence contributes to our understanding of the large variation of treatment outcome. The objective is to develop criteria that classify individual treatment health related quality of life (HRQOL) outcome after primary THA, adjusted by preoperative scores.

METHODS

We prospectively measured 147 patients' disease specific HRQOL on the date of consultation and 12 months post operation by Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). Regression models were used to determine the "expected" outcome for a certain individual baseline score. The ceiling effect of WOMAC measurement is addressed by implementing a left-censoring method.

RESULTS

The classification criteria are chosen to be the lower boundary of the 95% confidence interval (CI) of the estimated median from the regression. The robustness of the classification criteria was demonstrated using the Monte-Carlo simulation.

CONCLUSION

The classification criteria are robust and can be applied in general orthopaedic research when the sample size is reasonable large (over 500).

Functional Outcome After Treatment of Lower-Extremity Nonunions

BACKGROUND

The results for nonunion surgery usually have been judged in terms of bony union, time to union, infection rate, range of motion for the adjacent joints, and muscle strength. The goal of this study was to assess the improvement of patient-oriented physical and mental functional outcomes.

METHODS

The functional status of 23 patients with nonunion of the lower extremity was assessed using the Short-Form Health Survey (SF-36) questionnaire. The SF-36 subscores were compared with preoperative values and with the average values for the U.S. population.

RESULTS

Of the 23 patients, 21 healed. The functional status for nonunions of the lower extremity was greatly improved 1 year after operative intervention in this study. Nevertheless, the results show that it did not reach the level of the average U.S. population.

CONCLUSION

The results of this study can be used to guide patients' expectations regarding the functional outcome of treatment for a nonunion of the lower extremity.

Measures of health-related quality of life and physical function

Outcome measures may be seen as windows, each of which provides a different perspective on a single view, the impact of a disease or disorder on the patient concerned. A comparison of the orthopaedic literature in 1991 with that in 2001 suggests that the intervening decade saw an increasing interest in the use of patient-based measures in clinical outcome studies, particularly randomized controlled trials. The tool most commonly used to determine the patient's point of view was the generic Short Form-36 (SF-36). Other measures included regional assessments such as the Musculoskeletal Functional Assessment, or the Disability of the Arm, Shoulder and Hand. The Western Ontario McMaster Osteoarthritis Index (WOMAC) (hip and knee), the Simple Shoulder Test (shoulder) and the Roland-Morris Questionnaire or Oswestry Disability Index (low back) were the most common joint-specific measures. Each of the questionnaires reported was supported by evidence of reliability and validity, and in most cases one or more studies had shown responsiveness in at least musculoskeletal disorders. We provide a brief description of the most common tools, and review the evidence that orthopaedic research is making increased use of measures of health status and function.