A comparison between patient recall and concurrent measurement of preoperative quality of life outcome in total hip arthroplasty

Exploring Quality of Life and Mortality in Pertrochanteric Fragility Hip Fractures in Northern Greece: A Single Tertiary Center Study

Background: Fragility-related pertrochanteric fractures have become a significant public health concern, with a rising incidence attributed to the expanding elderly demographic. Assessing patient-reported health-related quality of life (HRQoL), mortality, and factors correlated with them serves as a crucial metric in evaluating the effectiveness of hip fracture surgery. Methods: In a single-center retrospective study, 259 patients underwent surgical treatment with a cephalomedullary nail, with a mean follow-up of 21.7 months. Health-related quality of life (HRQoL) was assessed using SF-12 (12-item Short Form) and EQ-5D (EuroQoL-5 Dimensions) questionnaires. Mobility status was measured by the Crude Mobility Index (CMI). Surveys were administered during hospitalization and six months postoperatively. Statistical analysis involved descriptive statistics, non-parametric controls (Kendall, Mann-Whitney, and Wilcoxon), and Spearman correlation and logistic regression analysis, which were conducted using IBM SPSS version 28. Results: A statistically significant decrease was observed in the mean EQ-5D and SF-12 scores at 6 months post-op compared to the pre-fracture status. The ASA (American Society of Anaesthesiologists) score showed a significant correlation with the decrease in HRQoL measured by the SF-12 questionnaire. The 30-day post-operative mortality rate was 9.3%, increasing to 32.4% at 1 year. Notably, the 30-day mortality significantly rose during the pandemic era (5.0% vs. 12.0%; p = 0.003). Conclusions: Pertrochanteric hip fractures cause a lasting decline in quality of life. Annual mortality is high, and further investigations are needed to formulate policies that prevent hip fractures and reduce mortality rates.

Recall Bias in Client-Reported Outcomes in Canine Orthopaedic Patients Using Clinical Metrology Instruments

OBJECTIVE

 The aim of this study was to determine the accuracy of client recollection of their dogs' preconsultation status using clinical metrology instruments such as the Liverpool Osteoarthritis in Dogs (LOAD) and Canine Brief Pain Inventory (CBPI) questionnaires in dogs presenting to a referral orthopaedic clinic.

STUDY DESIGN

 This is a longitudinal prospective cohort study of client-owned dogs presenting for investigations of lameness (n = 217). LOAD and CBPI questionnaires were completed by the owners at the first consultation (T0). Owners were contacted at 2 (T1), 6 (T2), and 12 (T3) months and asked to recall their dogs' T0 status by completing another LOAD and CBPI questionnaire. The agreement between the T0 and recalled LOAD and CBPI scores was determined using the two-way mixed effects intraclass correlation coefficient (ICC). The Wilcoxon signed-rank test was used to determine the difference between scores.

RESULTS

 For the LOAD scores, there was moderate agreement between T0 and T1 (ICC: 0.64) and T0 and T2 (ICC: 0.53) scores and poor agreement between T0 and T3 (ICC: 0.496). For the CBPI Pain Severity Scores, there was poor agreement between T0 and all three subsequent time points (ICC < 0.5). For the CBPI Pain Interference Scores, there was moderate agreement between T0 and T1 (ICC: 0.57) and T2 (ICC: 0.56) scores and poor agreement between T0 and T3 (ICC: 0.43).

CONCLUSION

 The LOAD and CBPI questionnaires are subject to recall bias. Studies reporting retrospectively acquired CMI data should be interpreted with caution.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

Recall Bias in the Retrospective Collection of Common Patient-Reported Outcome Scores in Hip Arthroscopy

BACKGROUND

The use of patient-reported outcomes (PROs) is common practice in the treatment of patients undergoing hip arthroscopy. While the prospective collection of PROs is preferred, retrospective collection involving patient recall is not uncommon and may be subject to bias.

PURPOSE

To assess the presence of recall bias between prospectively and retrospectively collected PRO scores in hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients who underwent hip arthroscopy between 2015 and 2021 and provided preoperative baseline responses for the International Hip Outcome Tool-12 (iHOT-12), the Hip disability and Osteoarthritis Outcome Score-Physical Shortform (HOOS-PS), and the modified Harris Hip Score (mHHS) were eligible for recruitment. After surgery, participants were asked to complete a study-specific survey and the same preoperative PROs retrospectively. Agreements between the prospective and retrospective scores were assessed, and associations between score discrepancies and patient characteristics were identified.

RESULTS

A total of 94 patients (43.3% participation rate) completed study requirements and were included for analysis. The mean ± standard deviation duration of symptoms before surgery was 25.3 ± 32.8 months, and the mean duration to recall (from the day of surgery) for the PROs was 29.6 ± 22.2 months. The iHOT-12 (intraclass correlation coefficient [ICC], 0.409; P < .001) and HOOS-PS (ICC, 0.415; P < .001) scores had low agreement between prospectively and retrospectively collected scores. The mHHS showed moderate agreement (ICC, 0.598; P < .001). The mean scores for the iHOT-12 (41.4 ± 22.6 vs 34.6 ± 16.3; P < .01), HOOS-PS (29.7 ± 18.5 vs 40.9 ± 17.1; P < .001), and mHHS (62.7 ± 16.5 vs 54.5 ± 14.8; P < .001) were all significantly different prospectively versus retrospectively. The average changes in score for the iHOT-12, HOOS-PS, and mHHS were -6.8, 11.2, and -8.2, respectively. Duration to recall and female sex were predictors of the difference between prospectively and retrospectively collected iHOT-12 data, while no predictors were significant for the HOOS-PS or mHHS.

CONCLUSION

The retrospective collection of PROs for hip arthroscopy procedures is subject to bias. On average, retrospective (recalled) PROs reflected worse pain/function than their prospectively recorded counterpoints; therefore, retrospective patient recall is an unreliable source of clinical data, and the prospective collection of iHOT-12, mHHS, and HOOS-PS data should be prioritized.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty

INTRODUCTION

Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection.

METHODS

Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition.

RESULTS

A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (β = 0.275, P < 0.001).

CONCLUSION

Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention.

LEVEL OF EVIDENCE

III, diagnostic cohort study.

Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality

BACKGROUND

The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care.

OBJECTIVE

To assess the association of BPCI with patient-reported functional status and care experiences.

DESIGN

We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes.

PARTICIPANTS

Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%).

MAIN MEASURES

Patient-reported functional status, care experiences, and overall satisfaction with recovery.

KEY RESULTS

Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures).

CONCLUSIONS

The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.

Worse pre-admission quality of life is a strong predictor of mortality in critically ill patients

Objectives

In this study, we aimed to investigate whether quality of life (QoL) before intensive care unit (ICU) admission could predict ICU mortality in critically ill patients.

Patients and methods

Between January 2019 and April 2019, a total of 105 ICU patients (54 males, 51 females; mean age: 58 years; range, 18 to 91 years) from two ICUs of a tertiary care hospital were included in this cross-sectional, prospective study. Pre-admission QoL was measured by the Short Form (SF)-12- Physical Component Scores (PCS) and Mental Component Scores (MCS) and EuroQoL five-dimension, five-level scale (EQ-5D-5L) within 24 h of ICU admission and mortality rates were estimated.

Results

The overall mortality rate was 28.5%. Pre-admission QoL was worse in the non-survivors independent from age, sex, socioeconomic and education status, and comorbidities. During the hospitalization, the rate of sepsis and ventilator/hospital-acquired pneumonia were similar among the two groups (p>0.05). Logistic regression analysis adjusted for sex, age, education status, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores showed that pre-admission functional status as assessed by the SF-12 MCS (odds ratio [OR]: 14,2; 95% confidence interval [CI]: 2.5-79.0), SF-12 PCS (OR: 10.6; 95% CI: 1.8-62.7), and EQ-5D-5L (OR: 8.0; 95% CI: 1.5-44.5) were found to be independently associated with mortality.

Conclusion

Worse pre-admission QoL is a strong predictor of mortality in critically ill patients. The SF-12 and EQ-5D-5L scores are both valuable tools for this assessment. Not only the physical status, but also the mental status before ICU admission should be evaluated in terms of QoL to better utilize ICU resources.

Patient-reported outcome measures after hip fracture in patients with chronic cognitive impairment : results from 34,675 patients in the Norwegian Hip Fracture Register

Aims

Hip fracture patients have high morbidity and mortality. Patient-reported outcome measures (PROMs) assess the quality of care of patients with hip fracture, including those with chronic cognitive impairment (CCI). Our aim was to compare PROMs from hip fracture patients with and without CCI, using the Norwegian Hip Fracture Register (NHFR).

Methods

PROM questionnaires at four months (n = 34,675) and 12 months (n = 24,510) after a hip fracture reported from 2005 to 2018 were analyzed. Pre-injury score was reported in the four-month questionnaire. The questionnaires included the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, and information about who completed the questionnaire.

Results

Of the 34,675 included patients, 5,643 (16%) had CCI. Patients with CCI were older (85 years vs 81 years) (p < 0.001), and had a higher American Society of Anesthesiologists (ASA) classification compared to patients without CCI. CCI was unrelated to fracture type and treatment method. EQ-5D index scores were lower in patients with CCI after four months (0.37 vs 0.60; p < 0.001) and 12 months (0.39 vs 0.64; p < 0.001). Patients with CCI had lower scores for all dimensions of the EQ-5D-3L pre-fracture and at four and 12 months.

Conclusion

Patients with CCI reported lower health-related quality of life pre-fracture, at four and 12 months after the hip fracture. PROM data from hip fracture patients with CCI are valuable in the assessment of treatment. Patients with CCI should be included in future studies.

Cite this article: Bone Jt Open 2021;2(7):454–465.

Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population

Background:

Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients.

Methods:

Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis.

Results:

Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 (P = .045) and deformity recurrence requiring surgery OR of 23.15 (P = .032). Patient-reported outcomes were similar between comorbidity groups.

Conclusions:

This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction.

Level of Evidence:

Level III, retrospective comparative series.

What Is the Personal Impact of Recurrences of Low Back Pain? Subanalysis of an Inception Cohort Study

OBJECTIVE

To investigate (1) the impact of low back pain (LBP) over the course of 1 year in people recently recovered from an episode of LBP, (2) whether the impact differs in people who do and do not experience a recurrence, and (3) the impact of LBP based on 3 definitions of a recurrence of LBP.

DESIGN

Cohort study.

METHODS

In 250 individuals recently recovered from LBP, the impact of LBP over the previous 3 months was assessed with the impact score, a multidimensional measure (range, 8-50), at 3, 6, 9, and 12 months. Recurrence of LBP was assessed monthly and defined as a recurrence of an episode of LBP, a recurrence of activity-limiting LBP, or a recurrence of LBP causing patients to seek care.

RESULTS

The median impact over 1 year was 11.5 points (interquartile range, 9.5-14.8). The impact was 15.2 points (95% confidence interval [CI]: 13.9, 16.3) for those who reported any recurrence and 11.1 points (95% CI: 10.6, 11.5) for those who did not. When comparing definitions of recurrence, those who had a recurrence that did not cause moderate activity limitation or result in care seeking had an overall impact of 12.7 points (95% CI: 11.6, 13.8). Participants who had recurrences of activity-limiting LBP but did not seek care, had an overall impact of 15.5 points (95% CI: 13.5, 17.6), and those who had recurrences of LBP for which health care was sought had an overall impact of 16.9 points (95% CI: 15.3, 18.4).

CONCLUSION

The average impact due to recurrence of LBP was low and dependent on the definition of recurrence. J Orthop Sports Phys Ther 2020;50(6):294-300. Epub 16 Apr 2020. doi:10.2519/jospt.2020.9345.

Conventional and retrospective change in health-related quality of life of trauma patients: an explorative observational follow-up study

Background

Within trauma care measurement of changes in health-related quality of life (HRQL) is used in understanding patterns of recovery over time. However, conventionally-measured change in HRQL may not always reflect the change in HRQL as perceived by the patient. Recall bias and response shift may contribute to disagreement between conventional and retrospective change in HRQL. This study aimed to measure conventional and retrospective change of HRQL and assess to which extent recall bias and response shift contribute to disagreement between these two in a heterogeneous sample of adult trauma patients.

Methods

A sample of trauma patients (≥18 years) who attended the Emergency Department and were admitted to an Intensive Care unit or ward of one of ten Dutch hospitals received postal questionnaires 1 week (T1) and 3 months (T2) post-injury. At T1 and T2 participants completed the EQ-5D-3 L and EQ-VAS for their current health status. At T2 participants also filled out a recall and then-test regarding their health status at T1. The responses were used to assess conventional and retrospective change, recall bias and response shift. Wilcoxon signed rank tests were used to examine conventional and retrospective change on a group level. The intraclass correlation coefficient (ICC) was used to examine individual agreement between conventional and retrospective change. Uni- and multivariate linear regression analysis were used to investigate the association between background factors and recall bias and response shift.

Results

The EQ-5D-3 L, recall and then-test were completed by 550 patients. Mean EQ-5D-3 L summary score improved from 0.48 at T1 to 0.74 at T2. Mean EQ-VAS score improved from 56 at T1 to 73 at T2. Retrospective change was significantly higher than conventional change (EQ-5D-3 L: Z = -5.2, p < 0.05; EQ-VAS Z = -2.1, p < 0.05). Pairwise comparisons showed that agreement between conventional and retrospective change was fair (EQ-5D-3 L: ICC = 0.49; EQ-VAS: ICC = 0.48). For EQ-5-3 L response shift was significantly higher than recall bias (Z = − 4.5, p < 0.05). Patients with traumatic brain injury (TBI), severe injury and/or posttraumatic stress symptoms were more susceptible to recall bias and response shift.

Conclusions

We conclude that, compared to recall bias, response shift contributed more to the disagreement between conventional and retrospective change in EQ-5D-3 L summary score and EQ-VAS. Predictable subgroups of trauma patients were more susceptible to recall bias and response shift.

Recall Bias in Retrospective Assessment of Preoperative Patient-Reported American Shoulder and Elbow Surgeons Scores in Arthroscopic Rotator Cuff Repair Surgery

BACKGROUND

The gold-standard method for collecting patient-reported outcomes (PROs) is the prospective assessment of preoperative to postoperative change. However, this method is not always feasible because of unforeseen cases or emergencies, logistical and infrastructure barriers, and cost issues. In such cases, a retrospective approach serves as a potential alternative, but there are conflicting conclusions regarding the reliability of the recalled preoperative PROs after orthopaedic procedures.

PURPOSE

To assess the agreement between prospectively and retrospectively collected PROs for a common, low-risk procedure.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Patients who underwent arthroscopic rotator cuff repair between May 2012 and September 2017 at the study institution were identified. All of the patients completed the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form preoperatively at their preassessment appointment. Patients were then contacted in the postoperative period and asked to recall their preoperative condition while completing another ASES form.

RESULTS

A total of 84 patients completed the telephone survey and were included in this analysis (mean age, 57.40 ± 9.96 years). The mean duration of time from onset of shoulder symptoms to surgery was 9.13 ± 9.08 months. The mean duration of time between surgery and recall ASES administration was 39.12 ± 17.37 months. The mean recall ASES score was significantly lower than the preoperative ASES score (30.69 ± 16.93 vs 51.42 ± 19.14; P < .001). There was poor test-retest reliability between preoperative ASES and recall ASES (intraclass correlation coefficient, 0.292; 95% CI, -0.07, 0.57; P = .068). Greater age at the time of recall, a shorter symptomatic period before surgery, and less severe preoperative shoulder dysfunction were associated with a greater difference between preoperative ASES and recall ASES.

CONCLUSION

Retrospectively reported PROs are subject to significant recall bias. Recalled PROs were almost always lower than their prospectively recorded counterparts. Recalled PROs are more likely to be accurate when reported by younger patients, those with a longer duration of symptoms, and those with more severe preoperative conditions.

Cemented or Uncemented Hemiarthroplasty for Femoral Neck Fracture? Data from the Norwegian Hip Fracture Register

BACKGROUND

A displaced femoral neck fracture in patients older than 70 years is a serious injury that influences the patient's quality of life and can cause serious complications or death. Previous national guidelines and a Cochrane review have recommended cemented fixation for arthroplasty to treat hip fractures in older patients, but data suggest that these guidelines are inconsistently followed in many parts of the world; the effects of that must be better characterized.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate a large group of patients in the Norwegian Hip Fracture Register to investigate whether the fixation method in hemiarthroplasty is associated with (1) the risk of reoperation; (2) the mortality rate; and (3) patient-reported outcome measures (PROMs).

METHODS

Longitudinally maintained registry data from the Norwegian Hip Fracture Register with high completeness (93%) and near 100% followup of deaths were used for this report. From 2005 to 2017, 104,993 hip fractures were registered in the Norwegian Hip Fracture Register. Fractures other than intracapsular femoral neck fractures and operative methods other than bipolar hemiarthroplasty, such as osteosynthesis or THA, were excluded. The selection bias risk on using cemented or uncemented hemiarthroplasty is small in Norway because the decision is usually regulated by tender processes at each hospital and not by surgeon. A total of 7539 uncemented hemiarthroplasties (70% women, mean age, 84 years [SD 6] years) and 22,639 cemented hemiarthroplasties (72% women, mean age, 84 years [SD 6] years) were eligible for analysis. Hazard risk ratio (HRR) on reoperation and mortality was calculated in a Cox regression model adjusted for age, sex, comorbidities (according to the American Society of Anesthesiologists classification), cognitive function, surgical approach, and duration of surgery. At 12 months postoperatively, 65% of patients answered questionnaires regarding pain and quality of life, the results of which were compared between the fixation groups.

RESULTS

A higher overall risk of reoperation for any reason was found after uncemented hemiarthroplasty (HRR, 1.5; 95% CI, 1.4-1.7; p < 0.001) than after cemented hemiarthroplasty. When assessing reoperations for specific causes, higher risks of reoperation because of periprosthetic fracture (HRR, 5.1; 95% CI, 3.5-7.5; p < 0.001) and infection (HRR, 1.2; 95% CI, 1.0-1.5; p = 0.037) were found for uncemented hemiarthroplasty than for cemented procedures. No differences were found in the overall mortality rate after 1 year (HRR, 1.0; 95% CI, 0.9-1.0; p = 0.12). Hemiarthroplasty fixation type was not associated with differences in patients' pain (19 versus 20 for uncemented and cemented hemiarthroplasties respectively, p = 0.052) or quality of life (EuroQol [EQ]-VAS score 64 versus 64, p = 0.43, EQ5D index score 0.64 versus 0.63, p = 0.061) 1 year after surgery.

CONCLUSIONS

Our study found that the fixation method was not associated with differences in pain, quality of life, or the 1-year mortality rate after hemiarthroplasty. Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures because there is an increased reoperation risk.Level of Evidence Level III, therapeutic study.

Correspondence of directly reported and recalled health-related quality of life in a large heterogeneous sample of trauma patients

Purpose

To evaluate the correspondence of directly reported and recalled health-related quality of life (HRQL) in a heterogeneous sample of trauma patients.

Methods

Adult trauma patients who attended the Emergency Department and were admitted between 03/2016 and 11/2016 were invited to participate. Postal surveys were sent 1 week (T1), 3 months (T2), and 12 months (T3) post-trauma. The EQ-5D-3L and Visual Analogue Scale (EQ-VAS) were used to assess directly reported and recalled HRQL.

Results

The EQ-5D was completed by 446 patients at T1, T2, and T3. Directly reported mean T1 EQ-5D summary score was 0.482, whereas recalled T1 EQ-5D summary score was 0.453 (p < 0.05) at T2 and 0.363 (p < 0.001) at T3. Directly reported mean T2 EQ-5D summary score was 0.737 and mean recalled T2 EQ-5D summary score was 0.713 (p < 0.05) at T3. Directly reported mean T1 EQ-VAS was 56.3, whereas mean recalled T1 EQ-VAS at T2 and T3 was 55.4 (p = 0.304) and 53.3 (p < 0.05), respectively. Directly reported mean T2 EQ-VAS was 72.5 and recalled T2 EQ-VAS at T3 was 68.0 (p < 0.001). The correspondence between all directly reported and recalled HRQL (both EQ-5D summary and EQ-VAS) was fair (ICC = 0.518–0.598). Lowest correspondence was seen in patients with major trauma (injury severity score ≥ 16) and in patients with middle-level education.

Conclusions

Recalled HRQL measured by the EQ-5D-3L and EQ-VAS was systematically lower compared to the directly reported HRQL. Patient characteristics, injury severity, subjectivity of the dimension, and time interval appear to influence correspondence between directly reported and recalled HRQL.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02256-z) contains supplementary material, which is available to authorized users.

Patients Undergoing Shoulder Stabilization Procedures Do Not Accurately Recall Their Preoperative Symptoms at Short- to Midterm Follow-up

Background:

A patient’s ability to recall symptoms is poor in some elderly populations, but we considered that the recall of younger patients may be more accurate. The accuracy of recall in younger patients after surgery has not been reported to date.

Purpose:

To assess younger patients’ abilities to recall their preoperative symptoms after having undergone shoulder stabilization surgery. We used 2 disease-specific, patient-reported outcome measures (PROMs)—the Western Ontario Shoulder Instability Index (WOSI) and the Melbourne Instability Shoulder Score (MISS)—at a period of up to 2 years postoperatively.

Study Design:

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

Methods:

Participants (N = 119) were stratified into 2 groups: early recall (at 6-8 months postoperatively; n = 58) and late recall (at 9-24 months postoperatively; n = 61). All patients completed the PROMs with instructions to recall preoperative function. The mean and absolute differences between the preoperative scores and recalled scores for each PROM were compared using paired t tests. Correlations between the actual and recalled scores of the subsections for each PROM were calculated using an intraclass correlation coefficient (ICC). The number of individuals who recalled within the minimal detectable change (MDC) of each PROM was calculated.

Results:

Comparison between the means of the actual and recalled preoperative scores for both groups did not demonstrate significant differences (early recall differences, MISS 1.05 and WOSI –38.64; late recall differences, MISS –0.25 and WOSI –24.02). Evaluation of the absolute difference, however, revealed a significant difference between actual and recalled scores for both the late and early groups (early recall absolute differences, MISS 12.26 and WOSI 216.71; late recall absolute differences, MISS 12.84 and WOSI 290.08). Average absolute differences were above the MDC scores of both PROMs at both time points. Subsections of each PROM demonstrated weak to moderate correlations between actual and recalled scores (ICC range, 0.17-0.61). Total scores for the PROMs reached moderate agreement between actual and recalled scores.

Conclusion:

Individual recall after shoulder instability surgery was not accurate. However, the mean recalled PROM scores of each group were not significantly different from the actual scores collected preoperatively, and recall did not deteriorate significantly over 2 years. This suggests that recall of the individual, even in this younger group, cannot be considered accurate for research purposes.

Agreement between retrospectively assessed health-related quality of life collected 1 week and 12 months post-injury: an observational follow-up study

Background

Retrospective assessment of pre-injury health-related quality of life (HRQL) is frequently used to measure change from pre- to post-injury HRQL. However, retrospective measurement may be confounded by recall bias. It is assumed that presence of recall bias is influenced by several factors, such as the measurement scale or the instrument that is used, the measurement schedule, and the presence of a substantial health event during the follow up period. This study empirically tests these assumptions by comparing pre-injury EQ-5D summary scores, EQ-5D profiles and visual analogue scale (EQ-VAS) scores of trauma patients, as recorded 1 week and 12 months post-injury, respectively.

Methods

A sample of 5371 adult trauma patients who attended the Emergency Department (ED) followed by hospital admission, received postal questionnaires 1 week (T1) and 12 months (T2) post-injury. The questionnaires contained items on pre-injury health, in terms of EQ-5D3L and EQ-VAS.

Results

One thousand one hundred sixty-six completed data pairs with T1 and T2 pre-injury data were available. Mean pre-injury EQ-5D summary scores were 0.906 (T1) and 0.905 (T2), respectively, with moderate intertemporal agreement (intraclass correlation coefficient (ICC) T1T2 = 0.595). In absolute terms, 442 (37.9%) respondents reported a different pre-injury EQ-5D profile at T2 compared to T1. The least stable EQ-5D dimension was pain/discomfort (20.2% reported a change). Mean T2 pre-injury EQ-VAS score was significantly higher than mean T1 pre-injury EQ-VAS score (T2 84.6 versus T1 83.3). Multivariable logistic regression analysis indicated that lower educational level, comorbid disease and having PTSD symptoms were independent predictors of change of pre-injury EQ-5D profile.

Conclusions

Despite one third of respondents reported a different pre-injury health level, if asked for on two interview occasions separated by 1 year, on the group level this difference was nil (EQ-5D summary score) to small (EQ-VAS). The consistent symmetrical pattern of change suggests random error to play the largest role. Intertemporal reliability was the same in EQ-5D profiles vs. EQ-VAS scores, ruling out scale effects. Particularly certain trauma subgroups showed highest distortion. While group comparisons may be trusted, in pre-post analysis and repeated measure analysis the individual injury impact and recovery pattern may be wrongly estimated.

Short-Term Outcomes of Interdisciplinary Hip Fracture Rehabilitation in Frail Elderly Inpatients

Objective

To investigate short-term outcomes of an interdisciplinary rehabilitation program for elderly inpatients who underwent surgical treatment for hip fractures.

Methods

This is a prospective cohort study of fifty older inpatients who were admitted to a geriatric rehabilitation unit. Clinical and functional outcomes were assessed at admission, at discharge, and one month postdischarge.

Results

Patients mean age was 84.1 ± 4.7 years. Proportions of study population with risk factors of frailty were cognitive impairment (64%), Charlson comorbidity index > 1 (72%), and protein malnutrition (59.2%). Before fracture, Barthel median was 90 (IQR 85, 100), and functional ambulation classification (FAC) score was ≥ 4 for 90% of study participants. One month after concluding rehabilitation, Barthel median was 80, 1 month postdischarge FAC ≥ 4 – prefracture FAC ≥ 4 mean change was – 8% (95% CI, -21.5%, 3.4%), and average for gait speed was 0.48 ± 0.18 m/s (95% CI, 0.43, 0.54). Significant correlation was found between admission Barthel score and 1 month postdischarge Barthel score (ρ= 0.27, p=0.05), and between prefracture FAC score and FAC score 1 month postdischarge (ρ = 0.57, p = 0.05). According to regression analysis, age, cognitive status, prefracture Barthel, prefracture FAC, type of surgery, and length of stay were associated with short-term recovery outcomes.

Conclusion

An early interdisciplinary rehabilitation management was insufficient to recover prefracture functional status. Future studies should investigate the best therapeutic strategies to optimize functional recovery, according to clinical and prefracture frail conditions of these patients.

Do Cervical Spine Surgery Patients Recall Their Preoperative Status?: A Cohort Study of Recall Bias in Patient-reported Outcomes

STUDY DESIGN

This is a prospective cohort study.

OBJECTIVE

To characterize the accuracy of patient recollection of preoperative symptoms after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Recall bias is a well-known source of systematic error. The accuracy of patient recall after cervical spine surgery remains unknown.

METHODS

Consecutive patients undergoing cervical spine surgery for myelopathy or radiculopathy were enrolled. Neck and arm numeric pain scores and Neck Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at either short (<1 y) or long-term (≥1 y) follow-up. Actual and recalled scores were compared using paired t tests and relations were quantified using the Pearson correlation coefficients. Multivariable linear regression was used to identify factors impacting recollection.

RESULTS

In total, 73 patients with a mean age of 58.2 years were included. Compared with their preoperative scores, patients showed significant improvement in neck pain [mean difference (MD)=-2.9; 95% confidence intervals (CIs), -3.5 to -2.3], arm pain (MD, -3.4; 95% CI, -4.0 to -2.8), and disability (MD, -12.4%; 95% CI, -16.9 to -7.9). Patient recollection of preoperative status was significantly more severe than actual for neck pain (MD, +1.5; 95% CI, 0.8-2.2), arm pain (MD, +2.3; 95% CI, 1.6-3.0), and disability (MD, +5.8%; 95% CI, 2.4-9.2). Moderate correlation between actual and recalled scores with regard to neck (r=0.41), arm (r=0.50) pain, and disability (r=0.67) was seen. This was maintained across age, sex, and time between date of surgery and recollection. Over 30% of patients switched their predominant symptom from neck-to-arm pain or vice versa on recall of their preoperative symptoms.

CONCLUSIONS

Relying on patient recollection does not provide an accurate measure of preoperative status after cervical spine surgery. Prospective and not retrospective collection of patient-reported outcomes remain the gold standard to measure and interpret outcomes after cervical spine surgery. Recall bias has the potential to affect patient satisfaction and requires further study.

Patients Discharged to Inpatient Rehabilitation Facilities Undergo More Diagnostic Interventions With No Improvement in Outcomes

The purpose of this study was to determine if there is a difference in the number of diagnostic tests and interventions, pain and function scores, or satisfaction of patients discharged to inpatient rehabilitation facilities vs to home. From February to May 2015, 171 consecutive patients were prospectively recruited following primary total knee arthroplasty. Six weeks postoperatively, based on the patients' recollections, the number and types of diagnostic imaging tests, number of blood transfusions, and overall satisfaction whether discharged to inpatient rehabilitation facilities (n=85) or to home (n=86) were assessed. A significantly greater proportion of patients discharged to inpatient rehabilitation facilities reported undergoing at least 1 diagnostic imaging test compared with patients discharged to home (25.9% vs 8.1%; P=.013). Multivariate logistic regressions revealed that patients discharged to an inpatient rehabilitation facility were more likely to have a greater number of diagnostic tests (odds ratio, 5.01; 95% confidence interval, 1.69-14.92; P=.004) and radiographs (odds ratio, 16.10; 95% confidence interval, 1.54-169.70; P=.020) performed. There was no significant difference in readmission rates for patients discharged to home (2.3%) vs to an inpatient rehabilitation facility (0%) (P=.246). No significant differences were observed in postoperative Knee Society pain or function scores (P=.083 and P=.057, respectively) or visual analog scale satisfaction scores (P=.206). Twenty-nine (34.1%) patients were discharged under the care of the visiting nurse service after leaving the rehabilitation facility. Patients discharged to an inpatient rehabilitation facility underwent more diagnostic testing, especially radiographs, than patients discharged to home. There were no clinically relevant differences in Knee Society pain or function scores or patient satisfaction. [Orthopedics. 2018; 41(6):e841-e847.].

Recall of preoperative Oxford Hip and Knee Scores one year after arthroplasty is an alternative and reliable technique when used for a cohort of patients

Objectives

The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient's recollection of their own preoperative OHS and OKS one year following surgery.

Methods

A total of 335 patients (mean age 72.5; 22 to 92; 53.7% female) undergoing total hip arthroplasty (n = 178) and total knee arthroplasty (n = 157) were prospectively assessed. Patients undergoing hip and knee arthroplasty completed an OHS or OKS, respectively, preoperatively and were asked to recall their preoperative condition while completing the same score one year after surgery.

Results

A mean difference of 0.04 points (95% confidence intervals (CI) -15.64 to 15.72, p = 0.97) between the actual and the recalled OHS was observed. The mean difference in the OKS was 1.59 points (95% CI -11.57 to 14.75, p = 0.10). There was excellent reliability for the 'average measures' intra-class correlation for both the OHS (r = 0.802) and the OKS (r = 0.772). However, this reliability was diminished for the individuals OHS (r = 0.670) and OKS (r = 0.629) using single measures intra-class correlation. Bland-Altman plots demonstrated wide variation in the individual patient's ability to recall their preoperative score (95% CI ± 16 for OHS, 95% CI ± 13 for OKS).

Conclusion

Prospective preoperative collection of OHS and OKS remains the benchmark. Using recalled scores one year following hip and knee arthroplasty is an alternative when used to assess a cohort of patients. However, the recall of an individual patient's preoperative score should not be relied upon due to the diminished reliability and wide CI.Cite this article: T. F. M. Yeoman, N. D. Clement, D. Macdonald, M. Moran. Recall of preoperative Oxford Hip and Knee Scores one year after arthroplasty is an alternative and reliable technique when used for a cohort of patients. Bone Joint Res 2018;7:351-356. DOI: 10.1302/2046-3758.75.BJR-2017-0259.R1.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients

BACKGROUND

Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities.

METHODS

Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort.

RESULTS

Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively.

CONCLUSIONS

Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients.

LEVEL OF EVIDENCE

Level, III comparative series.

Can We Assess the Success of Surgery for Degenerative Spinal Diseases Using Patients' Recall of Their Preoperative Status?

BACKGROUND

Patients' recall of their preoperative status is seldom used to assess surgical outcomes because of concerns about inaccuracy and bias. The present study aimed to measure the significance of this recall bias and its repercussion on patients' recollection of their preoperative status.

METHODS

Patients submitted to surgery due to degenerative spine diseases over a 1-year period (n = 198) were included in this study. Each patient completed the EuroQol Five-Dimensional Questionnaire (including a visual analog scale), Core Outcome Measures Index (COMI) for neck (including neck pain and shoulder/arm pain numeric rating scale [NRS]), COMI back (including back pain and buttock/leg pain NRS), Neck Disability Index, and Oswestry Disability Index preoperatively. At 1 year after surgery, the patients were asked to complete 2 sets of the same questionnaires, one set regarding their postoperative status and the other set regarding their recall of their preoperative status.

RESULTS

There was poor to moderate agreement between recalled and collected preoperative scores for all patient-reported outcome measures. Patients' recollection of their preoperative status was accurate for patients who underwent cervical spine surgery, but not for those who underwent lumbar spine surgery. Patients satisfied with the outcome after lumbar spine surgery recalled significantly worse scores compared with the actual preoperative scores.

CONCLUSIONS

Using patients' recall of their preoperative status may lead to overestimation of the effectiveness of surgery, particularly for lumbar spine surgery. The self-assessed effectiveness of surgery interferes with the recollection of baseline status.

Agreement between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) in hip and knee replacement patients

Purpose

To investigate the relationship between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) and the influence on this relationship of patients’ age and socio-economic status and the length of time.

Methods

Patients undergoing hip or knee replacement in four hospitals who had completed a pre-operative questionnaire were invited to recall their pre-operative health status shortly after surgery. The questionnaires included a disease-specific (Oxford Hip Score; Oxford Knee Score) and generic (EQ-5D-3L) PROM. Consistency and absolute agreement between contemporary and retrospective reports were investigated using intraclass correlations (ICCs). Differences were visualised using Bland–Altman plots. Linear regression analysis explored whether retrospective can predict contemporary PROMs.

Results

Patients’ recalled health statuses were similar to their contemporaneous reports, with no significant systematic bias. Absolute agreement for disease-specific PROMs was very strong (ICC 0.82) and stronger than for the generic PROM (ICC 0.60, 0.62). Agreement was consistently strong across the range of severity of a patient’s condition, age and socio-economic status. Patients’ age and socio-economic status had no significant influence on size of difference and direction of recall, although reliability of recall was slightly worse among the over-75s versus under-60s for hips (Oxford Hip Score ICC 0.88 vs. 0.78). Mean retrospective PROMs for groups or populations of patients can reliably predict what mean contemporary reports of PROMs would have been.

Conclusion

Retrospective PROMs can be used to obtain a baseline assessment of health status when contemporary collection is not feasible or cost effective. Research is needed to determine the feasibility of retrospective PROMs in emergency admissions.

Patients recall worse preoperative pain after shoulder arthroplasty than originally reported: a study of recall accuracy using the American Shoulder and Elbow Surgeons score

BACKGROUND

Patient-reported outcome measures (PROMs) are valuable tools for quantifying outcomes of orthopedic surgery. However, when baseline scores are not obtained, there is considerable controversy about whether PROMs can be administered retrospectively for patients to recall their preoperative state. We investigated the accuracy of patient recall after total shoulder arthroplasty (TSA) using the American Shoulder and Elbow Surgeons (ASES) assessment score.

METHODS

Recalled ASES scores were collected postoperatively at 6 weeks, 3 months, 6 months, and 12 months from 169 patients who previously completed baseline scores before TSA. The ASES total score was divided into its two subcomponents: functional ability and visual analog scale (VAS) for pain. We compared preoperative and recalled scores for each subcomponent and the total ASES score.

RESULTS

Recalled ASES function scores were comparable to corresponding preoperative scores across all time points (analysis of variance, P = .21), but recalled VAS pain was significantly higher at all time points beyond 6 weeks after surgery (P = .0001 at 3 months; P = .005 at 6 months; and P = .001 at 12 months). As a result, the ASES total score was only comparable at 6 weeks after surgery (P = .39) and differed at all time points thereafter.

CONCLUSION

Patients are able to recall preoperative function with considerable accuracy for up to 12 months after TSA. However, beyond 6 weeks postoperatively, patients recall having worse pain than they originally reported, and recalled ASES total scores are unreliable as a result.

Posterior approach compared to direct lateral approach resulted in better patient-reported outcome after hemiarthroplasty for femoral neck fracture

Background and purpose - Hemiarthroplasty (HA) is the most common treatment for displaced femoral neck fractures in many countries. In Norway, there has been a tradition of using the direct lateral surgical approach, but worldwide a posterior approach is more often used. Based on data from the Norwegian Hip Fracture Register, we compared the results of HA operated through the posterior and direct lateral approaches regarding patient-reported outcome measures (PROMs) and reoperation rate. Patients and methods - HAs due to femoral neck fracture in patients aged 60 years and older were included from the Norwegian Hip Fracture Register (2005-2014). 18,918 procedures were reported with direct lateral approach and 1,990 with posterior approach. PROM data (satisfaction, pain, quality of life (EQ-5D), and walking ability) were reported 4, 12, and 36 months postoperatively. The Cox regression model was used to calculate relative risk (RR) of reoperation. Results - There were statistically significant differences in PROM data with less pain, better satisfaction, and better quality of life after surgery using the posterior approach than using the direct lateral approach. The risk of reoperation was similar between the approaches. Interpretation - Hemiarthroplasty for hip fracture performed through a posterior approach rather than a direct lateral approach results in less pain, with better patient satisfaction and better quality of life. The risk of reoperation was similar with both approaches.

Do Lumbar Decompression and Fusion Patients Recall Their Preoperative Status?: A Cohort Study of Recall Bias in Patient-Reported Outcomes

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To characterize the accuracy of patient recollection of preoperative symptoms after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Although patient-reported outcomes have become important in the evaluation of spine surgery patients, the accuracy of patient recall remains unknown.

METHODS

Patients undergoing lumbar decompression with or without fusion were enrolled. Back and leg Numeric Pain Scores and Oswestry Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at a minimum of 1 year after surgery. Actual and recalled scores were compared using paired t tests and relations were quantified using Pearson correlation coefficients. Multivariable linear regression was used to identify factors that affected recollection.

RESULTS

Sixty-two patients with a mean age of 66.1 years were included. Compared to their preoperative scores, patients showed significant improvement in back pain (mean difference [MD] = -3.2, 95% CI -4.0 to -2.4), leg pain (MD -3.3, 95% CI -4.3 to -2.2), and disability (MD -25.0%, 95% CI -28.7 to -19.6). Patient recollection of preoperative status was significantly more severe than actual for back pain (MD +2.3, 95% CI 1.5-3.2), leg pain (MD +1.8, 95% CI 0.9-2.7), and disability (MD +9.6%, 95% CI 5.6-14.0). No significant correlation between actual and recalled scores with regards to back (r = 0.18) or leg (r = 0.24) pain and only moderate correlation with disability (r = 0.44) were seen. This was maintained across age, sex, and time between date of surgery and recollection. More than 40% of patients switched their predominant symptom from back pain to leg pain or leg pain to back pain on recall.

CONCLUSION

Relying on patient recollection does not provide an accurate measure of preoperative status after lumbar spine surgery. Recall bias indicates the importance of obtaining true baseline scores and patient-reported outcomes prospectively and not retrospectively.

LEVEL OF EVIDENCE

2.

Retrospectively patient-reported pre-event health status showed strong association and agreement with contemporaneous reports

OBJECTIVE

The unpredictability of the occurrence of illnesses and injuries leading to most emergency admissions to hospital makes it impossible prospectively to collect preadmission patient-reported outcome measures (PROMs). Our aims were to review the evidence for using retrospective PROMs to determine pre-event health status and the validity of using general population norms instead of retrospective PROMs.

STUDY DESIGN AND SETTING

Searches of Medline, PsycINFO, Embase, Global Health, and Health Management information. Six studies met the inclusion criteria for the first aim, and 11 studies addressed the second aim. Narrative syntheses were conducted.

RESULTS

Strong associations were found between retrospective and contemporary PROMs in 21 of 30 comparisons (correlation coefficients over 0.68) and 20 of 24 showed strong agreement for continuous measures (intraclass correlations over 0.75). Categorical measures revealed only fair to moderate levels of agreement (kappa 0.3-0.6). Associations were stronger for indices than for individual items and for shorter time intervals. The direction of differences was inconsistent. Retrospective PROMs reported by elderly patients were similar to the general population but younger adults had been healthier.

CONCLUSION

Retrospective collection offers a means of assessing PROMs in unexpected emergency admissions. However, further research is needed to establish the best policy for their use.

Quality of life following hip fractures: results from the Norwegian hip fracture register

BACKGROUND

Patient-reported health-related quality of life is an important outcome measure when assessing the quality of hip fracture surgery. The frequently used EQ-5D index score has unfortunately important limitations. One alternative can be to assess the distribution of each of the five dimensions of the patients' descriptive health profile. The objective of this paper was to investigate health-related quality of life (HRQoL) after hip fractures.

METHODS

Data from hip fracture operations from 2005 through 2012 were obtained from The Norwegian Hip Fracture Register. Patient reported HRQoL, (EQ-5D-3L) was collected from patients preoperatively and at four and twelve months postoperatively n = 10325. At each follow-up the distribution of the EQ-5D-3L and mean pain VAS was calculated.

RESULTS

Generally, a higher proportion of patients reported problems in all 5 dimensions of the EQ-5D-3L at all follow-ups compared to preoperative. Also a high proportion of patients with no preoperative problems reported problems after surgery; At 4 and 12 months follow-ups 71 % and 58 % of the patients reported walking problems, and 65 % and 59 % of the patients reported pain respectively. Patients with femoral neck fractures and the youngest patients (age < 70 years) reported least problems both preoperatively and at all follow-ups.

CONCLUSIONS

A hip fracture has a dramatic impact on the patients' HRQoL, and the deterioration in HRQoL sustained also one year after the fracture. Separate use of the descriptive profile of the EQ-5D is informative when assessing quality of life after hip fracture surgery.

Outcomes of Unicompartmental Knee Arthroplasty After Aseptic Revision to Total Knee Arthroplasty: A Comparative Study of 768 TKAs and 578 UKAs Revised to TKAs from the Norwegian Arthroplasty Register (1994 to 2011)

BACKGROUND

The general recommendation for a failed primary unicompartmental knee arthroplasty (UKA) is revision to a total knee arthroplasty (TKA). The purpose of the present study was to compare the outcomes, intraoperative data, and mode of failure of primary UKAs and primary TKAs revised to TKAs.

METHODS

The study was based on 768 failed primary TKAs revised to TKAs (TKA→TKA) and 578 failed primary UKAs revised to TKAs (UKA→TKA) reported to the Norwegian Arthroplasty Register between 1994 and 2011. Patient-reported outcome measures (PROMs) including the EuroQol EQ-5D, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and visual analog scales assessing satisfaction and pain were used. We performed Kaplan-Meier and Cox regression analyses adjusting for propensity score to assess the survival rate and the risk of re-revision and multiple linear regression analyses to estimate the differences between the two groups in mean PROM scores.

RESULTS

Overall, 12% in the UKA→TKA group and 13% in the TKA→TKA group underwent re-revision between 1994 and 2011. The ten-year survival percentage of UKA→TKA versus TKA→TKA was 82% versus 81%, respectively (p = 0.63). There was no difference in the overall risk of re-revision for UKA→TKA versus TKA→TKA (relative risk [RR] = 1.2; p = 0.19), or in the PROM scores. However, the risk of re-revision was two times higher for TKA→TKA patients who were greater than seventy years of age at the time of revision (RR = 2.1; p = 0.05). A loose tibial component (28% versus 17%), pain alone (22% versus 12%), instability (19% versus 19%), and deep infection (16% versus 31%) were major causes of re-revision for UKA→TKA versus TKA→TKA, respectively, but the observed differences were not significant, with the exception of deep infection, which was significantly greater in the TKA→TKA group (RR = 2.2; p = 0.03). The surgical procedure of TKA→TKA took a longer time (mean of 150 versus 114 minutes) and more of the procedures required stems (58% versus 19%) and stabilization (27% versus 9%) compared with UKA→TKA.

CONCLUSIONS

Despite TKA→TKA seeming to be a technically more difficult surgical procedure, with a higher percentage of re-revisions due to deep infection compared with UKA→TKA, the overall outcomes of UKA→TKA and TKA→TKA were similar.

Secondary patella resurfacing in painful non-resurfaced total knee arthroplasties : A study of survival and clinical outcome from the Norwegian Arthroplasty Register (1994-2011)

PURPOSE

In Norway, 19 % of revisions of non-resurfaced total knee arthroplasties done for knee pain between 1994 and 2011 were Secondary Patella Resurfacing (SPR). It is, however, unclear whether SPR actually resolves the pain. The aim was to investigate prostheses survival and clinical outcomes following SPR.

METHOD

A total of 308 knees (301 patients) with SPR were used to assess implant survival, and a sub-cohort (n = 114 out of 301 patients) with Patient Reported Outcome Measures (PROMs) data were used to assess the clinical outcomes. The EuroQol (EQ-5D), the Knee Injury and Osteoarthritis Outcome Score, and Visual Analogue Scales on satisfaction and pain were used to collect PROM data. Outcomes were analysed by Kaplan-Meier, Cox regression, and multiple linear regression.

RESULTS

The five- and ten-year Kaplan-Meier survival percentages were 91 % and 87 %, respectively. Overall, 35 knees were re-revised at a median follow-up of eight years and pain alone (10 knees) was the main cause of re-revision. Younger patients (<60 years) had nearly nine times higher risk of re-revision compared to older patients (>70 years) (RR = 8.6; p < 0.001). Mean EQ-5D index score had improved from 0.41 (SD 0.21) preoperative to 0.56 (SD 0.25) postoperative following SPR. A total of 63 % of patients with PROM data were satisfied with the outcomes of SPR.

CONCLUSION

The long-term prostheses survival following SPR was satisfactory, although not as good as for primary knee replacement. Patients' health related quality of life improved significantly following SPR. Still, more than a third of patients with PROMs data were dissatisfied with the outcomes of the SPR procedure.

A patient’s recollection of pre-operative status is not accurate one year after arthroplasty of the hip or knee

If patients could recall their physical status before total hip (THA) or knee arthroplasty (TKA) accurately it could have valuable applications both clinically and for research. This study evaluated the accuracy of a patient’s recollection one year after either THA or TKA using the Oxford hip or knee scores (OHS and OKS). In total, 113 patients (59 THA, 54 TKA) who had completed the appropriate score pre-operatively were asked to complete the score again at a mean of 12.4 months (standard deviation (sd) 0.8) after surgery, recalling their pre-operative state.

While there were no significant differences between the actual and recalled pre-operative scores (OHS mean difference 0.8, sd 6.21, 95% confidence interval (CI) -0.82 to 2.42, p = 0.329; OKS mean difference -0.11, sd 7.34, 95% CI -2.11 to 1.89, p = 0.912), absolute differences were relatively large (OHS, 5.24; OKS, 5.41), correlation was weak (OHS r = 0.7, OKS r = 0.61) and agreement between actual and recalled responses for individual questions was poor in half of the OHS and two thirds of the OKS.

A patient’s recollection of pre-operative pain and function is inaccurate one year after THA or TKA.

Cite this article: Bone Joint J 2015;97-B:1070–5.

Accuracy of patient recall of hand and elbow disability on the QuickDASH questionnaire over a two-year period

BACKGROUND

Patient self-reporting questionnaires such as the QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, are critical to current orthopaedic outcomes research. The use of these questionnaires could introduce recall bias in retrospective, case-control, and cross-sectional studies if no preoperative data has been collected prior to study inception. The purpose of this study was to quantify recall accuracy on the QuickDASH questionnaire as a function of the duration of the recall interval.

METHODS

This cross-sectional study enrolled 140 patients with nontraumatic hand and elbow diseases. Patients were stratified into groups of thirty-five based on the time since their initial office visit (three months, six months, twelve months, or twenty-four months). All patients had completed the QuickDASH as part of a standard intake form at the time of the initial office visit (actual baseline score). Patients were contacted by phone and asked to recall their upper extremity disability from the time of the initial office visit with use of the QuickDASH questionnaire. Patients also completed the QuickDASH to rate their current disability. Actual and recalled QuickDASH scores for each group were statistically compared. Kruskal-Wallis analysis was used to determine any differences in recall accuracy between the groups. Pearson correlation coefficients quantified relations between recall accuracy and patient age and current function (absolute QuickDASH scores).

RESULTS

Mean differences between recalled QuickDASH scores and actual scores were all less than the QuickDASH minimal clinically important difference (MCID) of 13 points at different time points: three months (-7.1, p < 0.01), six months (0.8, p = 0.79), twelve months (-2.3, p = 0.43), and twenty-four months (-2.8, p = 0.26). There were no significant differences in recall accuracy across the four groups (p = 0.77). Recalled QuickDASH scores were highly correlated with actual baseline values (rp ≥ 0.74). Recall accuracy was neither correlated with patient age nor current QuickDASH scores (rp ≤ 0.04).

CONCLUSIONS

Patients with a nontraumatic hand or elbow diagnosis are able to recall prior level of function accurately for up to two years with the QuickDASH questionnaire. Although data collected prospectively remain optimal, our data suggest that research conducted with use of recalled QuickDASH scores produces reliable assessment of disability from common upper extremity diagnoses with acceptable recall bias.

Outcome of periprosthetic distal femoral fractures following knee arthroplasty

INTRODUCTION

The majority of periprosthetic fractures around the knee occur at the supracondylar region of the distal femur. Fixation of distal femoral fractures in osteoporotic bone with short segment remains a challenge, especially after total knee arthroplasty (TKA). Internal fixation of these fractures using locking plates has become popular. The purpose of this study was to evaluate a consecutive series of periprosthetic supracondylar femoral fractures treated with locked periarticular plate fixation with regard to surgical procedure, complications and clinical outcome.

MATERIALS AND METHODS

From two academic trauma centres, 55 consecutive periprosthetic distal femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association, AO/OTA 33) were retrospectively identified as having been treated with locked plate fixation. Of these, 36 fractures in 35 patients (86.1% female) met the inclusion criteria. Patients had an average age of 73.2 years (range 54-95 years). Fixation constructs for plate length and working length were delineated. Nonunion, infection and implant failure were used as complication variables. Demographics were assessed. Outcome was addressed radiographically and clinically according to Kristensen et al.(1) by range of motion and pain.

RESULTS

Twenty-five of 36 fractures (69.4%) healed after the index procedure. Eight of 36 fractures (22.2%) developed a nonunion with three fractures (8.3%) leading to hardware failure. Nine of the 36 patients (25%) were radiographically diagnosed with notching of the anterior femoral cortex. Regarding technical aspects, distance from the anterior flange of the femoral component to fracture was significantly shorter in patients with compared to without anterior notching (t=3.68, p=0.02). Patients who underwent submuscular plate insertion compared to an extensive lateral approach had a reduced nonunion risk (χ(2)=0.05). No difference in infection rate was found for submuscular procedures compared with open procedures (χ(2)=0.85). Range of motion was reduced in most of the patients and 13.5% had a persistent loss of extension of 5°. More than 77% of the patients reported no or only mild pain during the last office visit. Range of motion loss did not influence pain. Successful treatment according to Cain et al.(2) was achieved in 83%. Using Kristensen's(1) criteria, 56% of the knees had acceptable flexion.

CONCLUSION

Operative fixation of periprosthetic distal femoral fractures after TKA continues to be challenging. Notching of the anterior femoral cortex should be avoided. Loss of reduction and high failure rates still occur with locked plating and may be related to underlying factors. Indirect reduction and submuscular plate insertion technique reduce nonunion risk.

Patient perspective survey of total hip vs total knee arthroplasty surgery

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.

Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients

BACKGROUND

Internal fixation and arthroplasty are the two main options for the treatment of displaced femoral neck fractures in the elderly. The optimal treatment remains controversial. Using data from the Norwegian Hip Fracture Register, we compared the results of hemiarthroplasty and internal screw fixation in displaced femoral neck fractures.

METHODS

Data from 4335 patients over seventy years of age who had internal fixation (1823 patients) or hemiarthroplasty (2512 patients) to treat a displaced femoral neck fracture were compared at a minimum follow-up interval of twelve months. One-year mortality, the number of reoperations, and patient self-assessment of pain, satisfaction, and quality of life at four and twelve months were analyzed. Subanalyses of patients with cognitive impairment and reduced walking ability were done.

RESULTS

In the arthroplasty group, only contemporary bipolar prostheses were used and uncemented prostheses with modern stems and hydroxyapatite coating accounted for 20.8% (522) of the implants. There were no differences in one-year mortality (27% in the osteosynthesis group and 25% in the arthroplasty group; p = 0.76). There were 412 reoperations (22.6%) performed in the osteosynthesis group and seventy-two (2.9%) in the hemiarthroplasty group during the follow-up period. After twelve months, the osteosynthesis group reported more pain (mean score, 29.9 compared with 19.2), higher dissatisfaction with the operation result (mean score, 38.9 compared with 25.7), and a lower quality of life (mean score, 0.51 compared with 0.60) than the arthroplasty group. All differences were significant (p < 0.001). For patients with cognitive impairment, hemiarthroplasty provided a better functional outcome (less pain, higher satisfaction with the result of the operation, and higher quality of life as measured on the EuroQol visual analog scale) at twelve months (p < 0.05).

CONCLUSIONS

Displaced femoral neck fractures in the elderly should be treated with hemiarthroplasty.

Optimal recall periods for patient-reported outcomes: challenges and potential solutions

OBJECTIVES

As the role and importance of patient-reported outcomes (PROs) increase, the validity and reliability of PRO measures come under greater scientific and regulatory scrutiny. One key issue is selecting the 'most appropriate' recall period for capturing PROs in clinical trials. This paper draws on survey research, health-specific literature, and results from clinical trials to summarize factors that can influence recall and provide guidance on selecting an optimal recall period.

METHODS

We conducted a systematic review of six databases and additional literature drawn from bibliographies of the selected articles.

RESULTS

Six major factors can influence recall; these can be classified into two broad areas: characteristics of the recalled phenomenon (recency, attributes, complexity) and context or meaning of the recalled phenomenon (salience, patient experience, mood). Results of different recall periods for three classes of PROs are presented: health behaviors, symptoms, and health-related quality of life. We present findings on the effect of alternative recall periods for three commonly used PROs. Finally, we propose a heuristic model to link the concept under investigation with an optimal recall period.

CONCLUSIONS

No single recall period is best for all measures or all phenomena. The recall period must correspond to the characteristics of the phenomenon of interest and the purpose of the assessment. Recall period is an issue of internal validity. An incorrect recall period introduces measurement error that may reduce the chances of detecting a treatment effect. Researchers should consider recall period as seriously as they do other measurement properties.