Quality of life: patients and doctors don't always agree: a meta-analysis

Minimum 19-Year Clinical Results and Patient Satisfaction After Total Knee Arthroplasty

BACKGROUND

Long-term (minimum 19-year) outcome data on clinical results and patient satisfaction after posterior-stabilized total knee arthroplasties (TKAs) are missing in the literature. The purpose of the study was to evaluate the clinical and radiographic results as well as patient satisfaction at a mean of 21.2 years after posterior-stabilized TKAs.

METHODS

This study included 756 patients (1,350 knees) who had undergone TKAs. There were 96 men and 660 women (mean age, 58 years; range, 40 to 84). The mean follow-up was 21.2 years (range, 19 to 23). At each follow-up visit, the patients were assessed radiographically and clinically. Furthermore, patient satisfaction was determined.

RESULTS

The Knee Society total, pain, function, and deformity scores were 42, 18, 33, and 5 points, respectively, at the final follow-up. The mean Western Ontario and McMaster Universities Arthritis Index score was 25 points at the final follow-up. With revision or aseptic loosening as the end point, the 23-year intimated survival for the implant was 96% (95% confidence interval, 91 to 100%). The overall patient satisfaction score at the final follow-up was 83.3 points (range, 81 to 86). Patient satisfaction scores with regard to pain, housework, recreation, and surgery were 84, 81, 82, and 86 points, respectively.

CONCLUSIONS

The findings of the present, mean 21-year follow-up clinical study suggest excellent results with regard to the revision rates and survivorship of the posterior-stabilized total knee implants. However, consistent with the literature, we found that about 80% of patients expressed overall satisfaction with their primary TKAs. About 8% of patients were either somewhat or very dissatisfied with the procedure.

Patient and healthcare practitioner evaluation of patient-reported outcomes in bariatric surgery - a modified Delphi study

BACKGROUND

Patient-reported outcomes are an important emerging metric increasingly utilised in clinical, research and registry settings. These outcomes, while vital, are underutilised and require refinement for the specific patient population of those undergoing bariatric surgery. This study aimed to investigate and compare how pre-surgical patients, post-surgical patients, and healthcare practitioners evaluate patient-reported outcomes of bariatric surgery to identify outcomes that are considered most important.

METHODS

A modified Delphi survey was distributed to patients pre- and post-surgery, and to a variety of healthcare practitioners involved in bariatric care. Across two rounds, participants were asked to rate a variety of physical and psychosocial outcomes of bariatric surgery from 0 (Not Important) to 10 (Extremely Important). Outcomes rated 8-10 by at least 70% of participants were considered highly important (prioritised). The highest-rated outcomes were compared between the three groups as well as between medical and allied health practitioner subgroups.

RESULTS

20 pre-surgical patients, 95 post-surgical patients, and 28 healthcare practitioners completed both rounds of the questionnaire. There were 58 outcomes prioritised, with 21 outcomes (out of 90, 23.3%) prioritised by all three groups, 13 (14.4%) by two groups, and 24 (26.7%) prioritised by a single group or subgroup. Unanimously prioritised outcomes included 'Co-morbidities', 'General Physical Health', 'Overall Quality of Life' and 'Overall Mental Health'. Discordant outcomes included 'Fear of Weight Regain', 'Suicidal Thoughts', 'Addictive Behaviours', and 'Experience of Stigma or Discrimination'.

CONCLUSION

While there was considerable agreement between stakeholder groups on many outcomes, there remain several outcomes with discordant importance valuations that must be considered. In particular, healthcare practitioners prioritised 20 outcomes that were not prioritised by patients, emphasising the range of priorities across stakeholder groups. Future work will consider these priorities to ensure resulting measures encompass all important outcomes and are beneficial and valid for end users.

Safety and quality of parenteral nutrition: Areas for improvement and future perspectives

PURPOSE

This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at Charleston, SC, and Bad Homburg, Germany) and aims to raise awareness concerning unresolved issues associated with the PN process and potential future directions, including a greater emphasis on patients' perspectives and the role of patient support.

SUMMARY

Ensuring that every patient in need receives adequate PN support remains challenging. It is important to have a standardized approach to identify nutritional risk and requirements using validated nutritional screening and assessment tools. Gaps between optimal and actual clinical practices need to be identified and closed, and responsibilities in the nutrition support team clarified. Use of modern technology opens up opportunities to decrease workloads or liberate resources, allowing a more personalized care approach. Patient-centered care has gained in importance and is an emerging topic within clinical nutrition, in part because patients often have different priorities and concerns than healthcare professionals. Regular assessment of health-related quality of life, functional outcomes, and/or overall patient well-being should all be performed for PN patients. This will generate patient-centric data, which should be integrated into care plans. Finally, communication and patient education are prerequisites for patients' commitment to health and for fostering adherence to PN regimes.

CONCLUSION

Moving closer to optimal nutritional care requires input from healthcare professionals and patients. Patient-centered care and greater emphasis on patient perspectives and priorities within clinical nutrition are essential to help further improve clinical nutrition.

Students and physicians differ in perception of quality of life in patients with tumors of the upper gastrointestinal tract

Health-related quality of life (HRQoL) has recently gained importance as treatment options for tumors of the upper GI tract lead to improved long-term survival. HRQoL is often estimated by physicians even though their reliability and the impact of outside factors such as contact time and level of medical education is unclear. Therefore, in this study we investigated the correlation between physicians', students', and patients' assessment of HRQoL. 54 patients presenting with tumors of the upper GI tract were included and asked to fill out the standardized HRQoL questionnaires EORTC QLQ-C30 and QLQ-OG25. Attending physicians and medical students filled out the same questionnaires through estimation of patients' HRQoL. Correlation was assessed through Pearson's and Kendall's τb coefficients. Physicians' and patients' assessments correlated for one out of six of the functional and a third of the symptom scores. Students' and patients' assessments correlated for one third of the functional and two thirds of the symptom scores. Students tended to underestimate patients' symptom burden while physicians tended to overestimate it. Physicians failed to correctly assess several pathognomonic symptoms in this study. Students showed higher correlation with patients' symptoms than physicians. Even so, this adds to mounting evidence that shows the benefit of using patient-reported outcomes as a gold standard regarding HRQoL.

Evaluating quality of life in pediatric palliative care: a cross-sectional analysis of children's and parents' perspectives

The patient's perspective is an essential component of understanding the individual experience of suffering in children with palliative needs, but it is a perspective that is often overlooked. The aim of this study was to compare the perception of quality of life (QoL) of children with life-limiting and life-threatening conditions expressed by the children themselves and their parents. Through a cross-sectional study, the responses of 44 parent-child dyads were obtained and the analysis was performed with the statistics based on Student's t distribution and non-parametric tests. Children value QoL more positively (mean = 6.95, SD = 1.85) than their parents (mean = 5.39, SD = 2.43). This difference exists even if we consider sociodemographic and disease variables. The presence of exacerbated symptoms is the situation in which both parents (mean = 3.70; SD = 1.95) and children (mean = 5.60; SD = 1.17) evaluate QoL more negatively.

CONCLUSIONS

Children have a more optimistic view than their parents. When the child is the one who reports a lower QoL score than their parent, the child should be carefully monitored. The voice of the child and that of the family members can be collected to create a "family voice" and can be complementary.

WHAT IS KNOWN

• Children with life-limiting conditions experience multiple and changing symptoms that affect their QoL. • The child's perspective is often overlooked.

WHAT IS NEW

• Children value QoL more positively than their parents do, even if we control for sociodemographic variables and the disease itself. • When the child is the one who reports a lower QoL score than their parent, the child should be carefully monitored.

Intra and inter-rater reproducibility of the Remote Static Posture Assessment (ARPE) protocol's Postural Checklist

With the enforcement of social distancing due to the pandemic, a need to conduct postural assessments through remote care arose. So, this study aimed to assess the intra- and inter-rater reproducibility of the Remote Static Posture Assessment (ARPE) protocol's Postural Checklist. The study involved 51 participants, with the postural assessment conducted by two researchers. For intra-rater reproducibility assessment, one rater administered the ARPE protocol twice, with an interval of 7-days between assessments (test-retest). A second independent rater assessed inter-rater reproducibility. Kappa statistics (k) and percentage agreement (%C) were used, with a significance level of 0.05. The intra-rater reproducibility analysis indicated high reliability, k values varied from 0.921 to 1.0, with %C ranging from 94% to 100% for all items on the ARPE protocol's Postural Checklist. Inter-rater reproducibility indicates reliability ranging from slight to good, k values exceeded 0.4 for the entire checklist, except for four items: waists in the frontal photograph (k = 0.353), scapulae in the rear photograph (k = 0.310), popliteal line of the knees in the rear photograph (k = 0.270), and foot posture in the rear photograph (k = 0.271). Nonetheless, %C surpassed 50% for all but the scapulae item (%C = 47%). The ARPE protocol's Postural Checklist is reproducible and can be administered by the same or different raters for static posture assessment. However, when used by distinct raters, the items waists (front of the frontal plane), scapulae, popliteal line of the knees, and feet (rear of the frontal plane) should not be considered.

Cancer symptoms: do patients, family caregivers and professionals agree?

OBJECTIVES

To assess the level of agreement among patients, their family caregivers and health professionals regarding the symptoms presented by patients with cancer.

METHODS

This is a cross-sectional study carried out in patients with cancer admitted to a hospital in Brazil from December 2019 to July 2020. One family caregiver for each patient was included in the study. In addition, nurses and physicians involved in patient care were included. Patients, family caregivers and health professionals responded to the Palliative Outcome Scale (POS).

RESULTS

Sixty-one patients with their family caregivers, 18 nurses and 8 physicians were included. Physicians reported a lower mean POS score than patients (p=0.008). In general, physicians and nurses underestimated the anxiety of the patient and the anxiety of the family caregivers and how much the patient feels that his or her life is worthwhile. Intraclass correlation coefficient showed moderate and good levels of agreement between patients' and family caregivers' responses (0.61). Agreement between patient and nurse (0.02) and physician (0.21) responses was poor.

CONCLUSIONS

The level of agreement between patients and healthcare professionals was very poor regarding patients' symptoms. However, the caregiver's perception of the patient's symptoms can be a reliable source of information.

Navigating the outcome maze: a scoping review of outcomes and instruments in clinical trials in genetic neurodevelopmental disorders and intellectual disability

Background

Individuals with genetic neurodevelopmental disorders (GNDs) or intellectual disability (ID) are often affected by complex neuropsychiatric comorbidities. Targeted treatments are increasingly available, but due to the heterogeneity of these patient populations, choosing a key outcome and corresponding outcome measurement instrument remains challenging.

Objectives

The aim of this scoping review was to describe the research on outcomes and instruments used in clinical trials in GNDs and ID.

Eligibility criteria

Clinical trials in individuals with GNDs and ID for any intervention over the past 10 years were included in the review.

Sources of evidence

MEDLINE, PsycINFO, and Cochrane CENTRAL were searched. Titles and abstracts were independently screened for eligibility with a subsample of 10% double-screening for interrater reliability. Data from full texts were independently reviewed. Discrepancies were discussed until consensus was reached.

Charting methods

Information was recorded on patient populations, interventions, designs, outcomes, measurement instruments, and type of reporter when applicable. Qualitative and descriptive analyses were performed.

Results

We included 312 studies reporting 91 different outcomes, with cognitive function most frequently measured (28%). Various outcome measurement instruments (n = 457) were used, with 288 in only a single clinical trial. There were 18 genetic condition-specific instruments and 16 measures were designed ad-hoc for one particular trial. Types of report included proxy-report (39%), self-report (22%), clinician-report (16%), observer-report (6%), self-assisted report (1%), or unknown (16%).

Conclusion

This scoping review of current practice reveals a myriad of outcomes and outcome measurement instruments for clinical trials in GNDs and ID. This complicates generalization, evidence synthesis, and evaluation. It underlines the need for consensus on suitability, validity, and relevancy of instruments, ultimately resulting in a core outcome set. A series of steps is proposed to move from the myriad of measures to a more unified approach.

Static Baropodometry for Assessing Short-Term Functional Outcome after Unilateral Total Knee Arthroplasty: Exploring Correlation between Static Plantar Pressure Measurements and Self-Reported Outcomes

This study aimed to investigate the association between objective baropodometric and radiological measurements and patient self-reported functional outcomes, assessed through the Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, it sought to evaluate the effectiveness of static baropodometry in predicting short-term KOOS results following unilateral total knee arthroplasty (TKA). We conducted a prospective single-center study involving 32 patients who underwent unilateral TKA for knee osteoarthritis (KOA). Patients were evaluated both preoperatively and six months postoperatively, utilizing objective measurements derived from static baropodometric analysis in a normal, relaxed, bipedal standing position using a multi-platform Plantar Pressure Analysis System (PPAS) and radiographic measurements of the femorotibial angle (FTA) and subjective assessments through the national validated version of the KOOS. The study found an insignificant average correction of -0.69° ± 4.12° in the preoperative FTA at the sixth month after TKA. Moreover, there were no significant differences in the KOOS based on different types of knee alignment (KA) both pre- and postoperatively (p > 0.05). No significant correlations were observed between the KOOS, and total average affected and unaffected plantar pressures (TAAPP and TAUPP) pre- and postoperatively, as well as KA pre- and postoperatively. However, significant changes were observed in TAAPP and TAUPP measurements after unilateral TKA. TAAPP demonstrated a significant increase postoperatively (mean change (SD) = 18.60 (47.71); p = 0.035). In conclusion, this study found no significant correlation between KA, static baropodometric measurements, including pre- and postoperative differences, and KOOS outcomes. Therefore, static plantar pressure measurements alone might not serve as a reliable predictor of short-term clinical outcomes after unilateral TKA, as reported by patients.

Patient-physician agreement on function and pain is associated with long-term outcomes in sarcoma: findings from a longitudinal study

PURPOSE

We aimed to describe the level of agreement between patients and physicians on the ratings of daily functioning and pain in a cohort of sarcoma patients and assess how (dis)agreement and its change over time predicted patient-reported outcomes in survivorship.

METHOD

We performed secondary analysis of longitudinal data from a sarcoma-specialty clinic in Montreal, Canada. Demographics, clinical characteristics and patient-physician agreement were summarized descriptively. Linear mixed models were used to assess the effects of time, baseline agreement, change in agreement over time, interaction of time and change in agreement and 12-month daily functioning, quality of life, and fatigue.

RESULTS

Data were available for 806 patients (57.7% male, x̄ = 53.3 years) who completed at least one questionnaire. Patient-physician disagreement was common on the level of function (43.4%) and pain (45.7%). Baseline physician-patient agreement was associated with better 12-month outcomes. Improvement in agreement on function over time was significantly associated with daily functioning (F(2, 212) = 3.18, p = 0.043) and quality of life (F(2, 212) = 3.17, p < 0.044). The pattern was similar though less pronounced for the agreement on pain.

CONCLUSIONS

Our study offers novel insights into the importance of patient-physician agreement and communication's role in long-term patient-reported outcomes in sarcoma.

IMPLICATIONS FOR CANCER SURVIVORS

The results emphasize the importance of mutual understanding of symptoms and patients' needs and suggest that further consultation in cases of discordance of ratings and opinions might be beneficial for optimal survivorship.

Back Pain and Body Posture Evaluation Instrument for Adults (BackPEI-A): Updating and an online application

INTRODUCTION

Back Pain and Body Posture Evaluation Instrument for Adults (BackPEI-A) lags the most recent literature, as it does not assess issues related to activity increasingly present in the daily lives of people of all ages.

PURPOSE

(1) to update the BackPEI-A by including four new questions regarding the use of mobile devices; (2) to present a new graphic design of the issues related to back and neck pain to facilitate understanding of the location of these pains; (3) to test the content validity and the reliability of the new questions; and (4) to identify whether the BackPEI-A version in online form has adequate reliability.

METHODS

The content validation by evaluation of eight experts, and the reliability of the new questions and of the online version were assessed. The new questions were translated to English. Content validation was assessed by the content validity index (CVI). Reliability was assessed using the agreement percentage (%C), the kappa statistic (k), and the intraclass correlation coefficient (ICC). k > 0.4 and %C > 0.5 were assumed to include new questions.

RESULTS

The new questions showed good agreement among the experts, k > 0.4 and %C > 0.5. Both forms applied presented an average kappa of total sample ranging from moderate to good, and moderate ICC values, showing an adequate reliability.

CONCLUSION

The updated BackPEI-A is valid and reliable and allows the identification of aspects related to back and neck pain, as well as possible risk factors.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients

Background  This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods  The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results  The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p  < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p  < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p  = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p  = 0.659, r  = - 0.041), and amount of limb volume reduction ( p  = 0.454, r  = - 0.070) showed no statistical significance. Conclusion  The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Understanding the impact of tuberous sclerosis complex: development and validation of the TSC-PROM

BACKGROUND

Tuberous sclerosis complex (TSC) is a rare and complex genetic disorder, associated with tumor growth in various organ systems, epilepsy, and a range of neuropsychiatric manifestations including intellectual disability. With improving patient-centered care and targeted therapies, patient-reported outcome measures (PROMs) are needed to measure the impact of TSC manifestations on daily functioning. The aim of this study was to develop a TSC-specific PROM for adults that captures the impact of TSC on physical functions, mental functions, activity and participation, and the social support individuals with TSC receive, called the TSC-PROM.

METHODS

COSMIN methodology was used to develop a self-reported and proxy-reported version. Development and validation consisted of the following studies: PROM development, content validity, structural validity, internal consistency, and construct validity. The International Classification of Functioning and Disability was used as a framework. Content validity was examined by a multidisciplinary expert group and cognitive interview study. Structural and construct validity, and internal consistency were examined in a large cohort, using confirmatory factor analysis, hypotheses testing, and Cronbach's alpha.

RESULTS

The study resulted in an 82-item self version and 75-item proxy version of the TSC-PROM with four subscales (physical functions 18 and 19 items, mental functions 37 and 28 items, activities and participation 13 and 14 items, social support 13 items, for self version and proxy version respectively). Sufficient results were found for structural validity with sufficient unidimensionality for each subscale. With regard to construct validity, 82% of the hypotheses were met for the self version and 59% for the proxy version. The PROM showed good internal consistency (Cronbach's alpha 0.78-0.97).

CONCLUSIONS

We developed a PROM for adults with TSC, named TSC-PROM, showing sufficient evidence for reliability and validity that can be used in clinical and research settings to systematically gain insight into their experiences. It is the first PROM in TSC that addresses the impact of specific TSC manifestations on functioning, providing a valuable, patient-centered addition to the current clinical outcomes.

Age-Related Differences in Pain, Function, and Quality of Life Following Primary Total Knee Arthroplasty: Results from a FORCE-TJR Cohort

INTRODUCTION

The impact of age on patient outcomes after total knee arthroplasty (TKA) remains controversial. Age has shown no effect on outcome in some studies, while others have reported better or worse outcome in younger patients. The aims of this study were to determine the differences in pain, function, and quality of life reported one-year after TKA across different age groups.

METHODS

A prospective, multi-center cohort of 11,602 unilateral primary TKA patients was evaluated. Demographic data, comorbid conditions, and patient-reported outcome measures (PROMs) including the knee injury and osteoarthritis outcome score (KOOS), KOOS-12, KOOS JR, and Short-Form health survey (12-item) were collected pre- and at one-year postoperatively. Descriptive statistics were generated, stratified by age [< 55 years (younger adult), 55 to 64 years (older adult), 65 to 74 years (early elder), and ≥ 75 years (late elder)], and differences in pain, function, and quality of life among the four age groups were evaluated using Chi-square and Kruskal-Wallis tests. Multivariate regression models with 95% confidence interval (CI) were performed to determine if age was predictive for KOOS pain and function scores.

RESULTS

Prior to surgery, younger patients (< 55 years) reported worse KOOS pain (39), function (50), and quality of life (18) scores with poor mental health score (47) than other older patient groups. The mean pre-op score differences across the age groups in the KOOS total score (9.37), KOOS pain (11.61), KOOS-12 pain (10.14), and KOOS/KOOS-12 QoL (12.60) reached the calculated minimal clinically important difference (MCID). At one-year after TKA, younger patients (< 55 years) reported lower KOOS pain, function, and quality of life scores when compared to older patients (≥ 75 years). The differences in one-year postop scores among the 4 age groups (ranging from 4.0 to 12.2) reached the MCID for pain (10.4) and quality of life (12.2). Younger patients (< 55 years) achieved higher baseline to one-year pain (36.8 points), function (30.3 points), and quality of life (40.7 points) score changes when compared to older patients ≥ 75 years. Although statistically significant, the differences in score changes among the age groups were clinically irrelevant. The multivariate regression analyses showed that age was a significant predictor for pain, but not for function at one year where KOOS pain score was predicted to be higher (less pain) (β =6.17; 95% CI (4.12- 8.22) (P<0.001) in older patients (≥ 75 years) when compared to younger patients (< 55 years).

CONCLUSION

A TKA provides a dramatic improvement in pain, function, and quality of life in all age groups. However, there are age-related clinically significant differences in pre-operative pain, quality of life, and mental health and in final post-operative pain and quality of life scores with younger patients (< 55 years) reporting more pain, less quality of life, and worse pre-operative mental health. The PROM data presented here can be used clinically to improve shared decision making and patient expectations prior to TKA.

Quality of Life and Satisfaction in Patients Above and Under 65 Years Old Submitted to Total Knee Arthroplasty

Objective  To compare the level of quality of life and satisfaction after two years of total knee arthroplasties between individuals above and below 65 years of age and to identify predictor factors of poor clinical outcome and low level of satisfaction in patients undergoing arthroplasty.

Methods  This is a retrospective cohort with data from patients diagnosed with knee osteoarthritis submitted to primary total knee arthroplasty from 2014 to 2018 ( n  = 190). Clinical outcomes were assessed using the following scores: visual analog scale (VAS) of pain, EQ-5D-3L and EUROQOL-VAS (quality of life scales), patient satisfaction level, and functional scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), collected through a questionnaire applied preoperatively, as well as 1, 3, 12 and 24 months after surgery.

Results  Patients < 65 years old presented significantly lower values (clinical worsening) in KOOS-pain and KOOS-symptoms. There are no differences in the principal clinical scores that assess pain, function, and quality of life after the procedure, as well as in the rate of satisfaction with the procedure, among patients < 65 years old when compared with patients ≥ 65 years old. It was also observed that patients who were not satisfied with the procedure in the 24-month evaluation presented clinical results in some analyzed scores (KOOS-pain and EQ-VAS) similar to patients who declared themselves satisfied.

Conclusion  Scores that assess pain, function, quality of life, as well as satisfaction rate are similar between patients < 65 years old and those ≥ 65 years old.

Cross-cultural adaptation, validity and reliability of the Persian translation of the Western Ontario Shoulder Instability Index (WOSI)

PURPOSE

The Western Ontario Shoulder Instability Index (WOSI) is the most commonly used patient-reported outcome measure to record the quality of life in patients with shoulder instability. The current study aimed to translate the WOSI into the Persian language and evaluate its psychometric properties.

METHODS

The translation procedure of the WOSI was performed according to a standard guideline. A total of 52 patients were included in the study and responded to the Persian WOSI, Oxford shoulder score (OSS), Oxford shoulder instability score (OSIS), and disabilities of arm, shoulder and hand (DASH). A sub-group of 41 patients responded for the second time to the Persian WOSI after an interval of 1-2 weeks. The internal consistency, test-retest reliability using intraclass correlation coefficient (ICC), measurement error, minimal detectable change (MDC), and floor and ceiling effect were analyzed. The hypothesis testing method was used to assess construct validity by calculating Pearson correlation coefficient between WOSI and DASH, OSS, and OSIS.

RESULTS

Cronbach's alpha value was 0.93, showing strong internal consistency. Test-retest reliability was good to excellent (ICC = 0.90). There was no floor and ceiling effect. The standard error of measurement and MDC were 8.30% and 23.03%, respectively. Regarding construct validity, 83.3% of the results agreed with hypotheses. High correlations were observed between WOSI and DASH, OSS and OSIS (0.746, 0.759 and 0.643, respectively) indicating excellent validity for the Persian WOSI.

CONCLUSION

The current study results demonstrated that the Persian WOSI is a valid and reliable instrument and can be used in the clinic and research for Persian-speaking patients with shoulder instability.

Inter-Rater Reliability between Structured and Non-Structured Interviews Is Fair in Schizophrenia and Bipolar Disorders-A Systematic Review and Meta-Analysis

We aimed to find agreement between diagnoses obtained through standardized (SDI) and non-standardized diagnostic interviews (NSDI) for schizophrenia and Bipolar Affective Disorder (BD).

METHODS

A systematic review with meta-analysis was conducted. Publications from 2007 to 2020 comparing SDI and NSDI diagnoses in adults without neurological disorders were screened in MEDLINE, ISI Web of Science, and SCOPUS, following PROSPERO registration CRD42020187157, PRISMA guidelines, and quality assessment using QUADAS-2.

RESULTS

From 54231 entries, 22 studies were analyzed, and 13 were included in the final meta-analysis of kappa agreement using a mixed-effects meta-regression model. A mean kappa of 0.41 (Fair agreement, 95% CI: 0.34 to 0.47) but high heterogeneity (β = 92%) were calculated. Gender, mean age, NSDI setting (Inpatient vs. Outpatient; University vs. Non-university), and SDI informant (Self vs. Professional) were tested as predictors in meta-regression. Only SDI informant was relevant for the explanatory model, leaving 79% unexplained heterogeneity. Egger's test did not indicate significant bias, and QUADAS-2 resulted in "average" data quality.

CONCLUSIONS

Most studies using SDIs do not report the original sample size, only the SDI-diagnosed patients. Kappa comparison resulted in high heterogeneity, which may reflect the influence of non-systematic bias in diagnostic processes. Although results were highly heterogeneous, we measured a fair agreement kappa between SDI and NSDI, implying clinicians might operate in scenarios not equivalent to psychiatry trials, where samples are filtered, and there may be more emphasis on maintaining reliability. The present study received no funding.

Awareness About Total Knee Arthroplasty Among Hail Population

BACKGROUND

Knee joint osteoarthritis is the most common among older adults. The knee joint needs to be treated surgically. The prevalence of this disorder is believed to be higher than 40% among people over 60.

OBJECTIVE

To study public awareness about total knee replacement among the Hail population and to explore the relationship between the level of awareness and different socio-demographic factors.

METHODS

A cross-sectional study was carried out in Hail, Saudi Arabia, using an online self-administered questionnaire created via Google Forms. Collected data were coded, entered, and analyzed using the Statistical Package for Social Sciences (SPSS; Version 23).

RESULTS

A total of 431 participants enrolled in the study, of which 242 (56.15%) were males and 189 (43.9%) were females. Out of a total of 34 points, the average awareness score was 15 ± 6 (range: 5-33), with a mean percentage of awareness of 44.1%. The most reported causes of total knee replacement were overweight or obesity (82.6%), aging (61%), and rheumatoid arthritis (45.2%). The most known symptoms were pain (85.6%) and clicking sounds during movements (64.7%). Regarding the knowledge about the treatment, both physiotherapy and weight reduction were mentioned by 290 (67.3%), exercise by 244 (56.6%), and surgical intervention by 177 (41.1%) participants. The purpose of knee replacement surgery was to relieve pain according to 357 (82.8%) participants, improve walking quality according to 257 (59.6%) participants, and be able to do prayers (while kneeling) according to 215 (49.9%) participants. The most reported reasons that might prevent the participants from undergoing knee replacement surgery were the pain after surgery (59.4%), unavailability of surgeons (35.5%), and general complications from anesthesia (37.4%). Moreover, 188 (43.6%) participants thought that knee osteoarthritis is diagnosed using magnetic resonance imaging (MRI). Educational level was found to be associated with awareness score (p = .012). Conversely, gender, nationality, residence, and history of chronic disease were not found to be associated with awareness about total knee replacement (p = .548, .357, .734, and .639, respectively).

CONCLUSION

An average level of awareness and knowledge regarding total knee replacement was observed. Educational level was found to be significantly associated with this awareness.

Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes.

METHODS

A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery.

RESULTS

Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery.

CONCLUSION

Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.

Illness perspectives in patients with primary aldosteronism

OBJECTIVE

The burden of symptoms and treatment in patients with primary aldosteronism (PA), as well as the patients' experience of the health care is sparsely studied. The objectives of this study were to describe symptoms considered to be the most troublesome by patients with PA, and to explore health related worries and expectations following treatment.

METHODS

This was an explorative qualitative study where 25 patients with PA, diagnosed between 2017 and 2019, were included; 13 patients who had undergone adrenalectomy and 12 who were receiving medical treatment. Data was collected during six group interviews and analyzed using a thematic approach.

RESULTS

Three main themes were identified: 1) Distress of the past, where the most important issues were struggle to receive a correct diagnosis, impaired well-being and the consumption of a large number of tablets, 2) Satisfaction after receiving a correct diagnosis, both in patients with unilateral and bilateral disease, but also dissatisfaction with lack of information about the disease, and 3) Future concerns, where worries about the long-term effects of PA on health in general dominated.

CONCLUSIONS

Our findings illustrate several important issues related to PA where improvements in patient care are needed, including actions aiming at shortening the long diagnostic delay, a thorough information to the patients about the disease is of great importance, and that all patients with PA, regardless of treatment, would benefit from a structured long-term follow-up.

Patient-reported dissatisfaction following second side in staged bilateral total knee arthroplasty: A systematic review

BACKGROUND

Around one third of patients who undergo total knee arthroplasty (TKA) will eventually have the contralateral knee replaced. Overall patient satisfaction after staged bilateral total knee arthroplasty procedures performed on different days is reportedly similar to unilateral TKA. Nevertheless, in our anecdotal experience patients often report less satisfying outcomes following the second side. A cursory review of available literature tended to confirm that observation. We sought therefore to consolidate all of the available data on this issue to further investigate this phenomenon.

AIM

To consolidate available published data revealing satisfaction scores among patients following staged bilateral TKA, and to evaluate the phenomenon of less satisfying results following TKA2.

METHODS

A systematic review of available literature reporting on satisfaction with TKA1 and TKA2 after staged bilateral knee arthroplasty was undertaken using PubMed, Google Scholar, and Embase. From 427 records, five full-length articles met criteria for inclusion in the meta-analysis. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

A total of 1889 patients with an average age of 68 (range: 38–92) underwent staged bilateral TKA with outcomes reported at 1 year following each TKA with a mean 21.9 mo between surgeries (range: 2 d to 14.5 years). Overall satisfaction with both knees was 83.70% (1581) and dissatisfaction with both knees was 2.75% (52). In the remaining 13.56% (256) who were dissatisfied with one side, 61.0% were dissatisfied with TKA2, and 39.0% were dissatisfied with TKA1. Patient-reported outcome scores for TKA2 were frequently lower than TKA1 even in patients reporting overall satisfaction with both knees.

CONCLUSION

At 1-year follow-up, there was a 50% greater risk of dissatisfaction with TKA2 among the 13.56% of patients reporting dissatisfaction in one knee after staged bilateral TKA. Whether the interval between procedures or long-term follow-up changes these results requires further investigation.

Symptom Agreement Between Patients and Their Peer Caregivers in Prison

Peer caregivers are incarcerated people who provide adjunct, nonclinical support to other incarcerated people. We described patient-caregiver symptom agreement in prison and correlates of symptom agreement to explore peer caregivers' ability to understand their patients' experience. We found dyads were aligned closely (N = 52; k = .86; αbinary = .86), though patients and peer caregivers often reported no symptoms during the assessment period. Peer caregivers were capable of matching their patients' self-reported symptoms beyond chance alone, though few correlates of patient-caregiver symptom agreement in prison emerged. The role of reverence and social homophily are discussed as potential drivers of symptom agreement. Future examination of caregiver burden or measures that account for both patient and caregiver characteristics are encouraged.

Does obesity lead to lower rates of clinically meaningful improvement or satisfaction after total hip arthroplasty? A propensity score-matched study

BACKGROUND

Current literature lacks consensus regarding the impact of obesity on clinical outcomes of total hip arthroplasty (THA). The variability of results may reflect the lack of minimal clinically important difference (MCID) analysis, which helps to standardise the interpretation of patient-reported outcome measures (PROMs). We compared the PROMs, patient satisfaction and survivorship between obese and non-obese patients after THA.

METHODS

Prospectively collected registry data of 192 obese patients and 192 propensity score-matched controls who underwent primary THA at a single institution were reviewed. Clinical outcomes and satisfaction rates were assessed at 6 months and 2 years. Reoperations for surgical complications and revision rates were analysed.

RESULTS

Obese patients had a significantly poorer Oxford Hip Score (OHS) at 6 months and WOMAC-Function at 2 years. However, there was no difference in overall WOMAC, WOMAC-Pain, WOMAC-stiffness, SF-36 mental and physical component summary (PCS). A similar proportion of patients in each group achieved the MCID for OHS, WOMAC and SF-36 PCS. At 2 years, 90.3% of obese patients and 91.7% of controls were satisfied (p = 0.755). At a mean follow-up of 9 years, there were 5 reoperations (2.6%) for surgical complications in the obese group and 1 (0.5%) in the control group; whereas 12 revisions (6.3%) were recorded in the obese group and 3 (1.6%) in the control group (p = 0.021).

CONCLUSIONS

Despite a higher revision rate, obese patients undergoing THA may experience a similar level of clinical meaningful improvement and satisfaction as their non-obese counterparts. This study provides valuable prognostic information for obese patients and guides preoperative counselling.

Patient and Implant Performance of Satisfied and Dissatisfied Total Knee Arthroplasty Patients

BACKGROUND

Implant migration and altered kinematics have been thought to impact patient-reported outcome measures (PROMs) and postoperative patient satisfaction. In this study comparing satisfied and dissatisfied total knee arthroplasty (TKA) patients, we hypothesized that dissatisfied patients will have greater continuous implant migration and that there will be differences in joint kinematics, objective functional measurements, and PROMs between satisfied and dissatisfied patients.

METHODS

The Knee Society Score Satisfaction Subsection questions regarding satisfaction with function were used at least 6 months postoperation to split 50 patients into satisfied and dissatisfied groups. Patients underwent radiostereometric analysis to evaluate migration and kinematics. A wearable sensor system obtained objective measurements of patient function during timed up and go tests. PROMs were recorded preoperation and postoperation.

RESULTS

No statistically significant differences were found in migration between satisfied and dissatisfied groups. Statistical kinematic differences existed in lateral anteroposterior contact location at 20° and 40° of flexion at 1 year, where the dissatisfied group had more anteriorly located lateral contact. No statistically significant differences were present in objective functional measurements. Satisfied and dissatisfied groups had differing PROMs at 4 timepoints or greater for each questionnaire.

CONCLUSIONS

No differences were found in tibial component migration or objectively measured function between satisfied and dissatisfied patients. Functionally dissatisfied patients had more anteriorly positioned contact on the lateral condyle in early flexion and reported more pain and unmet expectations. These findings suggest that improving the functional satisfaction of TKA requires restoration of kinematics in early flexion and management of patient's pain and expectations.

The Prevalence and Predictors of Patient Dissatisfaction 5-years Following Primary Total Knee Arthroplasty

BACKGROUND

Previous studies have evaluated patient dissatisfaction after total knee arthroplasty (TKA) at 1 year, but there is no data about the prevalence of dissatisfaction among TKA patients after prolonged follow-up. The purpose of this study is to determine patient dissatisfaction 5-years after TKA and to identify patient factors predictive of dissatisfaction.

METHODS

Demographic and clinical data on 4402 patients undergoing primary unilateral TKA between 2012 and 2015 were collected prospectively through the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) comparative effectiveness consortium including diverse community and academic practices distributed across 23 states in the United States. Data collected at 1 year preoperatively and 5 years postoperatively included patient satisfaction (using a 5-point Likert satisfaction scale) and patient-reported outcome measures (PROMs) including the Knee injury and Osteoarthritis Outcome Score (KOOS) and Short-Form health survey (36-item). A univariate analysis of the difference between the satisfied and dissatisfied patients' groups was performed. A multivariate logistic regression model with 95% confidence interval (CI) was used to identify independent predictors of dissatisfaction at 5 years. The regression model was performed after adjusting the following variables: age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), marital status, smoking, education, and insurance type. The Receiver Operating Characteristic (ROC) analysis was performed with the measurement of area under curve (AUC). Hosmer-Lemeshow goodness of fit test was performed to evaluate the validity of the model.

RESULTS

A total of 12.7% patients (559/4402) reported dissatisfaction 5-years after TKA. Increased BMI, higher CCI, higher Oswestry disability index, and increased number of other painful lower extremities (LE) joints were significantly associated with dissatisfaction. Higher rates of dissatisfaction were present in young patients, patients with less education, and non-White patients. Patient dissatisfaction was significantly associated with poor preoperative and 5-year postoperative PROMs scores and less score improvement from baseline to 5 years (P < .001). The multivariate regression analysis showed that an increased number of other painful LE joints (OR = 1.81; 95% CI (1.14-2.88) (P = .01), increased Oswestry back disability index (OR = 1.40; 95% CI (1.07-1.82) (P = .01), non-White patients (OR = 1.74; 95% CI (1.26-2.40) (P = .001), and minimal preoperative functional disability with KOOS function in daily living (ADL) score ≥70 (OR = 0.64; 95% CI (0.43-0.95) (P = .02) were independent predictive factors for dissatisfaction at 5 years.

CONCLUSION

A total of 12.7% patients reported dissatisfaction 5-years after TKA. Clinical profiles of the satisfied and dissatisfied patients were captured 5-years after TKA with differences in the preoperative demographic and clinical characteristic variables identified. Risk factors for long-term patient dissatisfaction after TKA have been identified and should be considered during shared decision making while planning for TKA. Surgeons should use these identified risk factors to set realistic expectations for patients at an increased risk for dissatisfaction aiming to optimize their outcomes and increase their long-term satisfaction after TKA.

A Patient and Public Involvement Study to Explore the Need for Further Research into the Experience of Younger Patients Undergoing Total Hip Arthroplasty

Background: Total Hip Arthroplasty (THA) is one of the most commonly performed operations in orthopaedics. It is an operation usually performed in older patients, however the need for THA in younger patients is increasing. There is a lack of literature examining whether current recovery pathways address the specific needs of younger patients. Public and Patient Involvement (PPI) is a core aspect of good research practice and is recommended throughout the research process, including the formulation and refinement of pertinent research questions. Therefore, the explicit aim of this PPI study was to collect qualitative data from patients on the feasibility and requirement for further research into the experience of younger hip arthroplasty patients. Methods: Qualitative data was collected via an online questionnaire that was advertised on social media, requesting the input of anybody who had experienced a lower limb musculoskeletal injury or condition before the age of 50. The survey asked the respondents to describe their experiences and reflect on their priorities and goals throughout their recovery. Results: There were 71 respondents, of which 90% were female, with an average age of 43. Qualitative responses identified many concerns that were issues that could be translated across all patient ages. However, other priorities were raised that are not always recognised as important when measuring successful outcomes after a THA. Furthermore, many respondents described not feeling listened to by clinicians or treatment options not being sufficiently addressed and explored. Multiple respondents reported being told they were too young to have anything serious or that nothing could be done until they were older. Conclusions: The responses to the survey indicate that current care pathways are not fulfilling the needs and priorities in younger patients. Further research is required to explore these priorities and goals in more depth in order to understand how healthcare professionals can address them.

Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus

BACKGROUND

This study aimed to evaluate the reliability and validity of the American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) score in patients with hallux valgus in Singapore.

METHOD

A total of 121 English-literate patients with hallux valgus identified between October 2017 and May 2020 were analyzed. Reliability was assessed via Cronbach α. Construct validity was evaluated through 20 a priori hypotheses by correlating the AOFAS MTP-IP score for hallux and lesser toes with other patient-reported outcome measures (PROMs). Standardized response means (SRMs) were calculated to evaluate responsiveness at 6 months postoperative. Structural validity was evaluated via confirmatory factor analysis (CFA) whereby a good fit was indicated when comparative fit index (CFI) is >0.95, Tucker-Lewis index (TLI) is >0.95 and standardized root mean residual (SRMR) is <0.08.

RESULTS

The AOFAS MTP-IP score demonstrated reliability with a Cronbach α of 0.837. Convergent construct validity was confirmed when all a priori hypotheses were fulfilled. Structural validity was established with our AOFAS MTP-IP score model that displayed good fit for a 1-factor structure (CFI = 0.988, TLI = 0.960, SRMR = 0.034). Responsiveness of the AOFAS MTP-IP score for hallux was demonstrated by an SRM score of 1.28.

CONCLUSION

The AOFAS MTP-IP score displayed adequate reliability and validity among English-literate patients in Singapore with an operatively managed hallux valgus.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Back Pain and Body Posture Evaluation Instrument for Children and Adolescents (BackPEI-CA): Expansion, Content Validation, and Reliability

The Back Pain and Body Posture Evaluation Instrument (BackPEI) was created in 2013 to assess back pain and its risk factors in school children. However, it does not assess neck pain or the habits of mobile device usage, which are aspects that are often part of school children’s lives. Therefore, we aimed to update the BackPEI questionnaire to include new questions assessing aspects related to neck pain and the use of mobile devices and to test the content validity and reliability of the new questions. The updated questionnaire was named Back Pain and Body Posture Evaluation Instrument for Children and Adolescents (BackPEI-CA). The content was validated by eight experts using the content validity index (CVI). To assess reliability, the BackPEI-CA questionnaire was applied at two different times in 105 school children, and Cohen’s kappa (k) and intraclass correlation coefficient (ICC) were calculated. All aspects assessed regarding content validity had a CVI higher than 0.8. The new questions presented moderate and good kappa values and excellent ICC values. The updated version of BackPEI-CA can be used as a clinic tool for assessing the presence, frequency, and intensity of back and neck pain and their risk factors.

Health Related Quality of Life of Rosacea Patients in China Assessed by Dermatology Life Quality Index and Willingness to Pay

PURPOSE

Rosacea is a chronic inflammatory dermatosis mainly involving facial skin, leading to physical and emotional problems, which greatly affect the quality of life (QoL) of patients. Dermatology Life Quality Index (DLQI) and willingness to pay (WTP) are well-established instruments assessing the health-related quality of life (HRQoL), while very few studies have been focused on this topic about rosacea in China. The present study investigated HRQoL in Chinese rosacea patients.

PATIENTS AND METHODS

This cross-sectional study was conducted on 973 patients with rosacea. Sociodemographic data, clinical features and DLQI were collected, and WTP was assessed by three standardized items. Multivariable logistic analysis was performed to investigate independent factors influencing QoL.

RESULTS

A total of 921 questionnaires were accomplished by participants. The mean DLQI score was 11.6 (median 11). Patients were willing to pay an average of € 896.2 (median € 368.1) for complete cure. 33.3% would like to pay more than 20% of their monthly income to achieve sustainable control. There were positive correlations between WTP with DLQI (P < 0.05). DLQI could be independently impacted by age (21-30 and 31-40 relative to > 50, OR = 3.242 and 3.617, respectively), the occupational requirement of appearance (high, OR = 4.410), disease duration (< 2 years, OR = 1.582), edema (OR = 1.844) and severity of flushing, burning, stinging and pruritus (severe, OR = 2.003, 1.981, 2.491, 2.249, respectively). There were no significant associations between WTP and most of the clinical factors.

CONCLUSION

The QoL was greatly impaired and should not be ignored among rosacea patients in China. Patients aged 21-40y, having occupational requirement of appearance, with the disease duration less than 2 years, and suffering severe flushing and related sensitive symptoms were more likely to have severe or very severe limitation of QoL.

Experienced Well-Being in the Rural Areas of the Srem Region (Serbia): Perceptions of the Local Community

The sustainability of rural settlements in Serbia has become the main focus of strategic rural development planning. Although it is still difficult to measure the quality of life of the citizens of the Republic of Serbia, preliminary results show that it is necessary to go beyond the GDP as the only or one of its most important indicators. A multidimensional approach and analysis at the local level is necessary for more comprehensive insight into quality of life in order to avoid erroneous or simplified conclusions. Striving to provide more detailed insight into the attitudes and needs of the local population, this research uses a qualitative approach. Subjective measures of how people feel and function in everyday life can predict future reactions, many of which are in the domain of the interests of local public services. The aim of the research is to apply measurement indicators through six dimensions of well-being in order to determine to what extent the inhabitants of rural communities are satisfied with some indicators and how they assess their own well-being. The research results illustrate the importance of understanding the needs of the local population and the perception of overall life experience in monitoring balanced rural development. The research can be adapted and applied to any rural community. Thus, only by developing a participatory approach can one strive for community-based rural development.

Preoperative Flexion Contracture Does Not Compromise the Outcomes and Survivorship of Medial Fixed Bearing Unicompartmental Knee Arthroplasty

BACKGROUND

Despite the expanding indications for unicompartmental knee arthroplasty (UKA), the classic indication that limits flexion contracture to <5° in fixed bearing UKA excludes most patients with arthritic knees and has not been challenged in modern literature. This study compared the clinical outcomes between patients with severe flexion contracture and controls undergoing UKA.

METHODS

Eighty seven medial fixed bearing UKAs performed in patients with severe (≥15°) flexion contracture were matched 1:1 with 87 controls without flexion or recurvatum deformity (-5°<extension<5°) using propensity scores to control for age, sex, BMI, Charlson comorbidity index, ASA class, and baseline patient-reported outcome measures (PROMs). Perioperative outcomes were recorded. Range of motion, Knee Society Score, Oxford Knee Score, SF-36, and patient satisfaction were assessed at 6 months and 2 years. Survivorship was recorded at mean 11.5 ± 3.2 years.

RESULTS

Preoperative knee extension in the control and contracture groups was 0.9° ± 1.9° and 18.0° ± 3.5° (P < .001), respectively, whereas flexion was 122.8° ± 27.9° and 120.6° ± 13.6° (P = .502). The contracture group had poorer Knee Society functional (P = .023) and SF-36 physical score (P = .010) at 6 months. However, there was no difference in PROMs at 2 years. A similar proportion achieved the minimal clinically important difference for each PROM and was satisfied with surgery. Range of motion remained poorer in the contracture group and a higher percentage had residual contractures (P < .001). Ten-year survivorship was 94% and 97% in the control and contracture groups, respectively (P = .145).

CONCLUSION

Although patients with severe flexion contractures had a poorer range of motion and postoperatively, these patients attained comparable PROMs, satisfaction rates, and mid-term survivorship after UKA.

LEVEL OF EVIDENCE

III, therapeutic study.

Construct validity and reliability of tests for sacroiliac dysfunction: standing flexion test (STFT) and sitting flexion test (SIFT)

CONTEXT

Sacroiliac dysfunction is characterized by a hypomobility of the range of motion of the joint, followed by a positional change regarding the relationship between the sacrum and the iliac. In general, the clinical tests that evaluate the sacroiliac joint (SIJ) and its dysfunctions lack validity and reliability values.

OBJECTIVES

This article aims to evaluate the construct validity and intra- and inter-rater reliability of the standing flexion test (STFT) and sitting flexion test (SIFT).

METHODS

In this prospective study, the sample consisted of 30 individuals of both sexes, and the evaluation team was composed of five researchers. The evaluations took place on two different days: first day, inter-rater reliability and construct validity; and second day, intra-rater reliability. The reference standard for the construct validity was 3-dimensional measurements obtained utilizing the BTS SMART-DX system. For statistical analysis, the percentage (%) agreement and the kappa statistic (K) were utilized.

RESULTS

The construct validity was determined for STFT (70% agreement; K=0.49; p<0.01) and SIFT (56.7% agreement; K=0.29; p<0.05). The intra-rater reliability was determined for STFT (66.3% agreement; K=0.43; p<0.01) and SIFT (56.7% agreement; K=0.38; p<0.01). The inter-rater reliability was determined for STFT (10% agreement; K=-0.02; p=0.825) and SIFT (13.3% agreement; K=0.01; p=0.836).

CONCLUSIONS

The STFT confirmed the construct validity and was reliable when applied by the same rater to healthy people, even if the rater had no experience. It was not possible to achieve minimum scores using the SIFT either for construct validity or reliability. We suggest that further studies be conducted to investigate the measurement properties of palpatory clinical tests for SIJ mobility, especially in symptomatic patients.

Can patients with psychological distress achieve comparable functional outcomes and satisfaction after hallux valgus surgery? A 2-year follow-up study

BACKGROUND

This study assessed the influence of preoperative mental health on functional outcomes and satisfaction, and the change in mental health after hallux valgus surgery.

METHODS

383 patients who underwent scarf osteotomy were analyzed. Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society score (AOFAS) and SF-36 were assessed at 6 months and 2 years. The cohort was stratified into patients with and without psychological distress (i.e. SF-36 Mental Component Summary [MCS] <50 vs ≥50).

RESULTS

After adjusting for demographics and baseline scores, VAS and AOFAS were poorer in the distressed group at 6 months. However, there was no difference in scores at 2 years and a similar proportion of patients were satisfied. SF-36 MCS in distressed patients significantly improved, but remained lower compared to non-distressed patients at follow-up.

CONCLUSIONS

Patients with psychological distress undergoing hallux valgus surgery had poorer short-term outcomes, but these differences resolved at 2 years.

Preoperative Mental Health Influences Patient-Reported Outcome Measures and Satisfaction After Revision Total Knee Arthroplasty

BACKGROUND

A higher prevalence of mental health conditions has been reported in patients undergoing revision total knee arthroplasty (rTKA). This study investigated the effect of preoperative mental health on patient-reported outcome measures (PROMs) and satisfaction after rTKA.

METHODS

A total of 245 patients who underwent rTKA in 2004-2018 were identified from our institutional joint registry. The most common indications were aseptic loosening (n = 111), infection (n = 70), and instability (n = 35). 36-item Short-Form health survey (SF-36) mental component summary (MCS) was used to stratify the cohort into: Low-MCS (SF-36 MCS <50; n = 112) and control (SF-36 MCS ≥50; n = 133) groups. Knee Society score, Oxford knee score, SF-36 physical score, and a satisfaction questionnaire were used to compare the low-MCS and control at 6 months and 2 years.

RESULTS

All PROMs were poorer in the low-MCS group at 6 months and 2 years. However, both groups demonstrated a comparable improvement in each PROM and a similar proportion attained the minimal clinically important difference. Fewer patients in the low-MCS group were satisfied at 2 years (72.2% vs 84.5%, P = .045). Lower preoperative SF-36 MCS was independently associated with increased odds of dissatisfaction (OR 1.037, 95% CI 1.004-1.070, P = .027). Although the change in SF-36 MCS was greater in the low-MCS group, the final value remained lower at 2 years.

CONCLUSION

While patients with poor mental health had inferior PROMs preoperatively and postoperatively, a similar percentage experienced a clinically meaningful improvement at 2 years. Perioperative optimization of psychological factors should still be emphasized as these patients were at a higher risk of dissatisfaction after rTKA.

Effect of Age on Clinical and Radiological Outcomes of Hallux Valgus Surgery

BACKGROUND

The prevalence of hallux valgus increases with age. However, no studies have compared the effectiveness of surgical correction among different age groups. This study investigated the influence of age on clinical and radiological outcomes following hallux valgus surgery.

METHODS

Patients who underwent correction for hallux valgus at an academic hospital were stratified into 3 age groups: younger (<50 years), middle-aged (50-59 years), and older (≥60 years). Functional outcomes and satisfaction questionnaires were collected preoperatively and at 6 months and 2 years postoperatively. Radiological recurrence and reoperations were recorded at follow-up. There were 193 patients (93% female): 34 younger, 74 middle-aged, and 85 older.

RESULTS

The preoperative hallux valgus angle was significantly greater in older patients (P < .001). The older group had 3 perioperative complications (P = .144) and showed a trend toward a longer hospital stay (P = .083). There was no difference in visual analog scale, American Orthopaedic Foot & Ankle Society score, or SF-36 among the groups at 6 months or 2 years. Using multiple regression, age was not associated with any outcome score. The satisfaction rates were 82%, 78%, and 83% in the young, middle-aged, and older groups, respectively (P = .698). There was no difference in the number of reoperations at a mean follow-up of 9.2 ± 2.2 years (P = .778), and no patients underwent reoperation for recurrent hallux valgus. The risk of recurrence was 5 times higher in older patients compared with younger patients (OR, 5.15; 95% CI, 1.10-24.03; P = .037).

CONCLUSION

Age did not influence the perioperative, functional, or subjective outcomes following hallux valgus surgery. However, older patients should be counseled on the higher risk of recurrence following surgical correction.

LEVEL OF EVIDENCE

Therapeutic, level III, retrospective comparative series.

Factors that influence quality of life in patients with multiple sclerosis in Saudi Arabia

PURPOSE

To study the factors which may contribute to quality of life (QOL) in patients with multiple sclerosis (pwMS) in Saudi Arabia.

METHODS

175 pwMS and 71 age-, gender-, and BMI-matched healthy subjects participated in this cross-sectional study. QOL was studied by the multiple sclerosis quality of life-54 (MSQOL-54) while depression, disability, and fatigue were measured by the beck depression inventory-II (BDI-II), the expanded disability status scale (EDSS), and the modified fatigue impact scale (MFIS), respectively. The effects of demographic and clinical characteristics on MSQOL-54 were studied.

RESULTS

QOL was worse in pwMS. A better QOL in pwMS was linked to being male, having relapsing-remitting MS, having lower BMI, being employed, having a low disability, having no or minimal depression, and not fatigued. Age, disease duration, marital status, living status, and level of education did not affect the QOL. QOL showed a moderate to strong correlation with depression and fatigue and a weak correlation with EDSS. Depression and fatigue were the strongest predictors of QOL. Other predictors included gender and BMI but not EDSS.

CONCLUSIONS

Many of the factors which seem to influence QOL in pwMS are modifiable. Evaluation and management of such factors may improve QOL in pwMS.Implications for rehabilitationAssessment of QOL (using a proper tool) should be part of every pwMS evaluation.Depression and fatigue are the main predictors of QOL in pwMs, therefore, attention should be paid for their evaluation and management.Sexual dysfunction and pain should be assessed and managed early in the course of the disease.

Validity and Reliability of Palpatory Clinical Tests of Sacroiliac Joint Mobility: A Systematic Review and Meta-analysis

OBJECTIVE

The primary objective of this review was to investigate the reliability and validity of palpatory clinical tests of sacroiliac mobility. The secondary objective was to investigate which palpatory clinical tests of sacroiliac mobility exist in the literature.

METHODS

PubMed, Embase, Scopus, Medline, and the Physiotherapy Evidence Database were searched. There was no restriction on the study design or participants. The data extracted from each study were sample size, study deign, and clinical test used. If there was information on reliability values, number of examiners, concurrent validity values, gold standard used, or inferential statistical test used, that was also extracted. For intraexaminer reliability, the data were expressed as κ values that were meta-analyzed using random effects.

RESULTS

Fifteen palpatory clinical tests of sacroiliac mobility were identified from 28 studies; 14 studies performed inferential statistical analysis, all including analysis of interexaminer reliability, with κ values ranging from -0.05 to 0.77. Analysis of intraexaminer reliability was performed in 8 studies, with κ values ranging from 0.08 to 0.73. No study included in this systematic review verified the concurrent validity of the tests. Our meta-analysis of intraexaminer reliability showed moderate to good agreement results for the Gillet test (κ = 0.46), the standing flexion test (κ = 0.61), and the sitting flexion test (κ = 0.68).

CONCLUSION

We found 15 palpatory clinical tests of sacroiliac mobility in this systematic review. According to our meta-analysis, only the sitting flexion test obtained a good and statistically significant intraexaminer agreement. Further studies are necessary to evaluate the reliability and validity of these tests.

A qualitative study on experiences of persons with schizophrenia in oral-health-related quality of life

Our study aimed to explore the views and experiences in oral health and oral-health-related quality of life (OHRQoL) of persons with schizophrenia (PWS) in order to expand the understanding of the factors that either limit or facilitate their healthcare pathway, which can ultimately optimize their oral health and/or OHRQoL. A qualitative study was conducted in France in the Côte d'Or department (530 000 in habitants) centered on PWS's perceived meanings regarding oral health or OHRQoL, and semi-structured individual interviews were used. A conventional content analysis approach was chosen in order to highlight unrevealed themes. A sample of 20 PWS (12 males; 8 females) with a median age was 45.8 (± 9.5) were recruited to assess views and experiences regarding OHRQoL, which were focused on three dimensions: an individual dimension related to experience of "oral symptoms", a second dimension related to experience of "stress and its management", and a third related to "Autonomy dimension in oral health". We showed that PWS clearly expressed their mental representations of oral health and OHRQoL. This study supports that PWS were able to define their needs and had the ability to discuss their oral health and OHRQoL. These finding could be used to support specific interventions for this population to better manage the negative impact of antipsychotics and help them to consult dentists on a regular basis.

Effect of osteoarthritis severity on survival and clinical outcomes after high tibial osteotomy

BACKGROUND

This study aimed to evaluate the effect of osteoarthritis severity on clinical outcomes using the 2011 Knee Society Score (KSS2011) and survival rates after closed wedge high tibial osteotomy (CWHTO).

METHODS

In this retrospective study, KSS2011 questionnaires were mailed to patients who had undergone CWHTO between January 1991 and December 2011. The completed questionnaires returned by the patients were analyzed. Preoperative osteoarthritis severity was evaluated by Kellgren-Lawrence (K-L) grade. KSS2011 was compared between the K-L grade groups. To determine the effect of K-L grade for revision surgery, Kaplan-Meier survival curves were created using the need for total knee arthroplasty (TKA) as the endpoint to estimate the probability of failure.

RESULTS

There were 16, 81, and 47 knees with preoperative K-L 2, 3, and 4, respectively. Among the KSS2011 sub-scores, the symptom score showed significant differences between the groups (p = 0.006). However, no significant difference was found regarding satisfaction, expectation, and functional activity scores. No significant difference in the symptom score was found between the K-L 2 and 3 groups (p > 0.05). Eighteen knees were treated with TKA at a mean of 9 years after CWHTO. Using the Kaplan-Meier survival estimates, the K-L 4 group showed a significantly higher rate of total knee arthroplasty conversion than the K-L 2 and 3 groups (p < 0.001).

CONCLUSIONS

Osteoarthritis severity affects clinical outcomes and survival rates during long-term follow-up after CWHTO. Surgeons should consider the preoperative osteoarthritis grade for long-term outcomes when considering CWHTO for patients with varus knees.

Patients and neurologists have different perceptions of multiple sclerosis symptoms, care and challenges

BACKGROUND

Basic steps in the management of patients with Multiple Sclerosis (MS), such as good patient understanding of the disease and active participation in its management are extremely important, as they directly influence treatment adherence and success. Therefore, this study aimed to evaluate the perception of MS patients and neurologists pertaining to the most common disease symptoms, disabilities that impact on quality of life, and patient concerns and difficulties during medical visits, as information that can be used to improve the doctor-patient relationship.

METHODS

A cross-sectional study involving two groups: the first composed of neurologists and the second of patients. Participants of the first group were selected by a Steering Committee (15 predetermined neurologists representing each region of Brazil and specialized in MS and neuroimmunological disorders, who also assumed the role of creating the survey and questionnaire). Participants of the second group were selected following dissemination of a questionnaire on the AME's social networks (Amigos Múltiplos pela Esclerose, a non-governmental organization to support patients with MS). Questions about sociodemographic data, disease impact on quality of life, symptoms perception, and concerns and issues regarding disease care were put to both groups.

RESULTS

A total of 317 patients and 182 neurologists answered the questionnaires. Significant divergences were found between the perceptions of patients and neurologists in relation to orientation and information given during medical appointments, and also regarding patient participation in treatment and therapy choice. Considering the topic assessing impact on quality of life, more than 70% of neurologists perceived that autonomy to work and travel, and future planning were aspects that most affected patient lives, however, almost 50% of patients reported that disease monitoring did not affect their life in any way. Analysis of data regarding MS symptoms revealed neurologists to consider physical symptoms, such as ambulation issues, imbalance, falls and urinary incontinence, to be those most interfering with patient quality of life, whereas patients considered non-physical symptoms, such as fatigue, pain, cognitive and memory problems to be more significant. Patients with primary progressive MS complained more about ambulation issues, imbalance and falls (p<0.05), when compared to patients with other disease phenotypes.

CONCLUSION

Significant differences in disease perception were found in this study. While neurologists tended to overestimate the consequences and symptoms of the disease, for most patients, the disease impact on activities did not appear to be as significant, with more complaints regarding non-physical symptoms. Although neurologists described involving patients in treatment decisions and providing them with appropriate orientation during medical appointments, the opposite was reported by patients. These results may help to improve treatment adherence and disease outcomes by redefining the doctor-patient relationship.

Do Knee Osteoarthritis Patterns Affect Patient-Reported Outcomes in Total Knee Arthroplasty? Results From an International Multicenter Prospective Study With 3-Year Follow-Up

BACKGROUND

The aim of this multicenter study is to answer (1) Does patellofemoral osteoarthritis (OA) affect preoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) scores in total knee arthroplasty (TKA)? and (2) Do different OA patterns affect preoperative and postoperative KOOS scores in TKA?

METHODS

This international, multicenter prospective study examined 384 TKA patients. Compartmental OA was divided into (1) medial, (2) medial + patellofemoral, (3) lateral, (4) lateral + patellofemoral, (5) medial + lateral (bicompartmental), and (6) medial + lateral + patellofemoral (tricompartmental), based on preoperative anterior-posterior and lateral ± skyline radiographs with Kellgren-Lawrence grade III-IV and joint space width <2.5 mm. KOOS was collected preoperatively, 1 year postoperatively, and 3 years postoperatively. Higher KOOS score represented better clinical state, for example, higher KOOS Pain score indicated less pain.

RESULTS

Patellofemoral OA had no effect on preoperative KOOS scores (P > .15). Compared to medial ± patellofemoral OA patients, bicompartmental/tricompartmental OA patients had less preoperative pain (KOOS Pain 7.4, P = .03) and higher daily function (KOOS-ADL [Activities of Daily Living] 7.1, P = .05), and higher 1-year postoperative daily function (KOOS-ADL 9.2, P = .03) and sports activity (KOOS Sports & Recreation Function 15.0, P = .04), while lateral ± patellofemoral OA patients had more symptoms (KOOS-Symptoms 7.0, P < .01), more pain (KOOS-Pain 7.5, P = .01), lower daily function (KOOS-ADL 9.3, P < .01), and lower quality of life (KOOS-QOL 9.0, P = .04), at 3 years postoperatively.

CONCLUSION

Patellofemoral OA does not affect medial ± lateral OA patients' preoperative KOOS scores, challenging the importance of patellofemoral OA in TKA. Lateral ± patellofemoral OA patients have lower postoperative KOOS scores than medial/more progressed compartmental OA patients, indicating that patients with less common OA patterns present with unique surgical challenges. Further development of indications for and correct timing of TKA surgery in different patient subgroups is needed.

Early post-operative oxford knee score and knee society score predict patient satisfaction 2 years after total knee arthroplasty

BACKGROUND

There is poor correlation between functional outcomes and patient satisfaction following total knee arthroplasty (TKA). We asked if early post-operative scores at 6 months or the pre- to post-operative change in scores are predictive of patient satisfaction 2 years after TKA.

METHODS

We conducted a retrospective review of prospectively collected registry data of 4359 TKAs performed at a single institution. At 6 months and 2 years, the Knee Society Score (KSS), Oxford Knee Score (OKS), and Short-Form 36 scores were assessed. A satisfaction questionnaire was also completed. Logistic regression was used to generate receiver-operating characteristic (ROC) curves to assess the ability of each scoring system in predicting satisfaction at 2 years.

RESULTS

At 2 years, 91.1% of patients were satisfied. For the absolute post-operative OKS at 6 months, an AUC of 0.762 (95% CI 0.736-0.788) and a threshold of ≤ 21.5 points (or ≥ 38.5 points on the new scale) were obtained. For the KSS knee score, an AUC of 0.704 (95% CI 0.674-0.734) and a threshold of ≥ 80.5 points were identified. The OKS performed significantly better than the KSS knee score (p = 0.03) and the other post-operative scores (p < 0.001). When analysing the change in scores pre-operatively to 6 months, the AUC was < 0.7 for all scales.

CONCLUSIONS

Early post-operative scores, specifically the OKS and KSS knee score, can predict patient satisfaction at 2 years after TKA with good accuracy. The threshold values offer surgeons an additional tool to identify patients at risk of dissatisfaction at 2 years, enabling them to intervene earlier to ensure good patient satisfaction.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Differences in patient-reported outcomes between medial opening-wedge high tibial osteotomy and total knee arthroplasty

PURPOSE

To compare patient subjective satisfaction between medial opening-wedge high tibial osteotomy (HTO) and total knee arthroplasty (TKA).

METHODS

This study enrolled 110 knees, including comprising 49 knees in the HTO group, and 61 knees in the TKA group. We assessed the overall satisfaction using a three-point questionnaire. The satisfaction questionnaire included three questions: (1) How satisfied are you with the results of your knee surgery? (2) How satisfied are you with your most recent knee surgery for reducing your pain? and (3) How satisfied are you with your most recent knee surgery for improving your ability to perform functions? Furthermore, we assessed knee pain and function by using the Knee Society Function Score (KSS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) systems.

RESULTS

Overall, 93.8% of patients from the HTO group and 95.1% from the TKA group indicated subjective satisfaction (very satisfied and satisfied) with their surgeries. For pain relief, the HTO group showed significantly better outcomes for overall satisfaction (p = 0.04 in walking on a flat surface and p = 0.02 in going upstairs or downstairs). For restored function, the HTO group scored significantly better on ascending stairs than the TKA group (p = 0.007). Functional outcomes using the KSS scoring system did not show significant differences between the two groups. The KOOS pain score was significantly higher in the TKA group (89.9 ± 6.4) than in the HTO group (80.3 ± 12.5).

CONCLUSION

HTO and TKA have comparable outcomes with respect to overall patient satisfaction.

LEVEL OF EVIDENCE

Level III, therapeutic case series.

Predictors of Outcomes After Single-level Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy: A Multivariate Analysis

STUDY DESIGN

This was a retrospective study that was carried out using prospectively collected registry data.

OBJECTIVE

The objective of this study was to identify preoperative predictors of outcomes after anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

Proper patient selection is paramount to achieving good surgical results. Identifying predictors of outcomes may aid surgical decision-making and facilitate counseling of patients to manage expectations.

METHODS

Prospectively collected registry data of 104 patients who underwent single-level ACDF for cervical spondylotic myelopathy were reviewed. Outcomes assessed at 2 years were the presence of residual neck pain/arm pain (AP), and attainment of a minimal clinically important difference (MCID) for Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) score, and Physical Component Score (PCS) of SF-36, as well as patient satisfaction, fulfilment of expectations, willingness to undergo same surgery again, return to work (RTW), and return to function (RTF). Receiver operating characteristic curves and multivariate stepwise logistical regression were performed to identify independent predictors of each outcome using 22 covariates including demographics, comorbidities, and preoperative disease state.

RESULTS

Lower preoperative NDI was predictive of the absence of residual neck pain/AP at 2 years. Higher preoperative JOA score was predictive of MCID attainment for PCS, satisfaction, expectation fulfilment, willingness to undergo the same surgery for same condition, and RTF. Poorer preoperative scores of NDI, JOA, and PCS were predictors of attaining MCID of the respective scores. Older patients were less likely to attain MCID for JOA. Higher preoperative AP was a risk factor for unsuccessful RTW.

CONCLUSIONS

In general, the preoperative JOA score was the best predictor of outcomes after ACDF. A preoperative JOA cutoff value of 9.25-10.25 predicted satisfaction, expectation fulfilment, willingness to undergo same surgery, and RTF with at least 70% sensitivity and 50% specificity. These findings may aid surgeons in identifying patients at risk of a poor outcome and guide preoperative counseling to establish realistic expectations of the surgical outcome.

LEVEL OF EVIDENCE

Level III-Non-randomized controlled cohort/follow-up study.

Determination of the patient acceptable symptom state for the Japanese Orthopaedic Association Score in patients undergoing anterior cervical discectomy and fusion for cervical spondylotic myelopathy

BACKGROUND CONTEXT

The patient acceptable symptom state (PASS) has gained attention as a valuable interpretation tool in spine research. While the PASS for the Japanese Orthopaedic Association (JOA) score has been recently proposed, previous analyses demonstrated a weak discriminative ability for the suggested threshold.

PURPOSE

To define the PASS for the JOA score in patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

STUDY DESIGN

Retrospective review of prospectively collected registry data.

PATIENT SAMPLE

378 patients who underwent ACDF for cervical myelopathy between 2005 and 2014.

OUTCOME MEASURES

The main outcome measure was the JOA score. The PASS anchor question was adapted from the NASS questionnaire, "How would you rate the overall results of your treatment?" and the validation question was adapted from same questionnaire, "Has the surgery for your neck condition met your expectation so far?"

METHODS

Patients were assessed preoperatively, 6 months and 2 years postoperatively using the JOA. Responses to the anchor question were dichotomized and used as the external criterion in receiver operating characteristics (ROC) analysis to define thresholds on the JOA that corresponded to a PASS at 2 years postoperatively. Sensitivity analyses were carried out for various subgroups (based on age, gender, body mass index, comorbidities), preoperative myelopathy severity, time of follow-up (6 months and 2 years) and an alternate definition of PASS.

RESULTS

Of the 378 patients, 312 (83%) completed 2-year follow-up, of which, 78.5% reported their current state as acceptable. The areas under the curve (AUC) for the ROCs were 0.72 to 0.83 for all analyses, indicating a good discriminative ability of the JOA when assessing if a satisfactory state was attained. The PASS threshold was ≥13.25 points at 6 months (AUC 0.74, sensitivity 78%, specificity 59%) and ≥14.25 points at 2 years (AUC 0.76, sensitivity 74%, specificity 66%). Sensitivity analyses revealed that the 14.25-point threshold on the JOA was robust. PASS responders were approximately 6 times more likely to be satisfied (adjusted OR 6.18, 95% CI 2.87-13.30) and 8 times more likely to have their expectation fulfilled (adjusted OR 8.23, 95% CI 3.81-17.77) compared with non-responders.

CONCLUSIONS

This study validates the PASS threshold of 14.25 on the JOA in a robust analysis of a large cohort undergoing ACDF. This knowledge will enable clinicians to identify patients who have attained a satisfactory functional status after surgery for CSM and allow researchers to interpret studies utilizing the JOA from a patient-centered perspective.

Decision-Making About Tracheostomy for Children With Medical Complexity: Caregiver and Health Care Provider Perspectives

OBJECTIVE

Caregivers of children with medical complexity (CMC) face decisions about tracheostomy. The objectives of this paper are to identify facilitators and barriers to tracheostomy decision-making (TDM) process for CMC.

METHODS

Using phenomenology as its methodologic orientation, this qualitative study conducted in North Carolina between 2013 and 2015 consists of semistructured interviews with 56 caregivers of 41 CMC who received tracheostomies, and 5 focus groups of 33 health care providers (HCP) at a tertiary care children's hospital involved in TDM for CMC. Participants were asked to share their experiences and perspectives on the TDM process. Qualitative data were transcribed, coded, and organized into themes as is consistent with thematic content analysis.

RESULTS

Five themes were identified. 1) Caregivers perceived decision about tracheostomy for their children was theirs to make. 2) Strategies that increased caregivers' active participation in the TDM process facilitated the TDM process. 3) Caregiver emotional stress and lack of understanding about tracheostomy were barriers. 4) Good HCP communication during the TDM process was valued; poor communication was a barrier. 5) Collaboration among HCP-facilitated TDM, especially when nurses were involved, whereas fragmentation in care was a barrier.

CONCLUSIONS

Caregivers take a primary role in the TDM process. Many caregiver and HCP-level facilitators and barriers for TDM exist. Augmenting the facilitators and reducing the barriers identified in this study could improve the TDM process for CMC.

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.

METHODS

PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.

RESULTS

Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.

CONCLUSION

ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.

A High Proportion of Patients Have Unfulfilled Sexual Expectations After TKA: A Prospective Study

BACKGROUND

Most patients have high expectations about restoration of the knee function after TKA, expecting a more active life after retirement. However, 20% to 30% of patients report that their expectations are not met postoperatively. Among those unmet expectations may be the anticipation to engage in sexual activity after surgery, but few studies have evaluated sexual activity after arthroplasty.

QUESTIONS/PURPOSES

In this study, our purposes were (1) to evaluate the anticipation and the fulfillment of sexual activity after TKA in men and women, and (2) to identify prognostic factors for the fulfillment of anticipated postoperative sexual activity.

METHODS

This was a prospective, multicenter study of all 1371 patients scheduled for TKA between June 2012 and July 2015. The study was part of the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS). After screening according to LOAS inclusion criteria, 1213 respondents remained. Our primary study endpoint was whether sexual expectations were met 1 year after TKA; we used the sexual-activity-expectation question from the Hospital for Special Surgery (HSS) Knee Replacement Expectations Survey, which allows the patient to score the result on a 5-point scale. To assess postoperative fulfillment of sexual activity 1 year after TKA, we asked the patient to score the current status of sexual activity on the same 5-point scale: 1 (back to normal), 2 (large improvement), 3 (moderate improvement), 4 (slight improvement), and 5 (does not apply). Patients with incomplete data on the preoperative expectation- and postoperative fulfillment-question of sexual activity were excluded, leaving 71% (866 of 1213) patients for analysis. The difference between the pre- and postoperative scores determined whether expectations of sexual activity were unfulfilled (lower than expected) or fulfilled/exceeded (neutral or higher than expected). Pre- and postoperatively, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Short Form-12 Mental and Physical Component Summary scores (SF-12 MCS and SF-12 PCS), the EuroQoL-5 Dimensions (EQ-5D), and the EQ-5D VAS scale were used. Multivariate regression models were used for analysis.

RESULTS

Preoperatively, 54% patients (467 of 866) anticipated postoperative sexual activity after recovery from surgery. Both genders showed that the proportion who anticipated "back to normal" sexual activity decreased with higher age. Likewise, postoperative fulfillment of anticipated sexual activity was found in 58% (111 of 191 for men; 159 of 276 for women). Younger women (younger than 65 years of age) experienced fulfillment more often compared with younger men. A positive postoperative change in functional and health status was associated with fulfilled/exceeded scores of patients anticipating postoperative sexual activity. A better preoperative health status, the EQ-5D VAS score (odds ratio [OR] 1.02 [95% CI 1.01 to 1.03]; p = 0.006), was associated with a higher likelihood of fulfillment of anticipated postoperative sexual activity.

CONCLUSION

In both men and women, two of five patients who anticipated postoperative sexual activity indicated that their expectation of sexual activity was not met 1 year after TKA. These patients had worse functional recovery scores compared with patients who achieved the anticipated level of sexual activity. The latter is associated with functional recovery. Surgeons should be aware that many patients anticipate restoration of normal sexual activity, and that this may be the expectation for patients of all ages and for women and men alike. The results underscore the need for more qualitative research to understand this topic in greater depth.

LEVEL OF EVIDENCE

Level II, therapeutic study.