Reliability, validity, responsiveness, and minimal important change of the Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores in patients with a humeral shaft fracture

Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials

BACKGROUND

Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes.

AIM

To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures.

METHODS

We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3).

RESULTS

A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups.

CONCLUSION

This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.

Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities

OBJECTIVE

The purpose of this study was to perform a network meta-analysis of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSFs).

METHODS

DATA SOURCES

A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of MEDLINE, Embase, and Cochrane Library was screened from 2010 to 2023.

STUDY SELECTION

Inclusion criteria were evidence level I or II studies comparing nonoperative and/or operative repair techniques including open reduction internal fixation plate osteosynthesis (ORIF-Plate), minimally invasive percutaneous plating (MIPO), and intramedullary nail (IMN) fixation for the management of HSFs (OTA/AO 12A, B, C).

DATA EXTRACTION

The risk of bias and methodologic quality of evidence were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group.

DATA SYNTHESIS

Network meta-analysis was conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R.

RESULTS

A total of 25 studies (1908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared with ORIF-Plate (16.1%) [odds ratio (OR), 0.13; 95% confidence interval (CI), 0.04-0.49]. MIPO resulted in the lowest nonunion rate (0.65%) compared with all management techniques (OR, 0.28; 95% CI, 0.08-0.98), whereas Non-Op resulted in the highest (15.87%) (OR, 3.48; 95% CI, 1.98-6.11). MIPO demonstrated the lowest rate of postoperative radial nerve palsy overall (2.2%) and demonstrated a significantly lower rate compared with ORIF-Plate (OR, 0.22; 95% CI, 0.07-0.71, P = 0.02). IMN resulted in the lowest rate of deep infection (1.1%) when compared with ORIF-Plate (8.6%; P = 0.013). MIPO resulted in a significantly lower Disabilities of the Arm, Shoulder, and Hand score (3.86 ± 5.2) and higher American Shoulder and Elbow Surgeons score (98.2 ± 1.4) than ORIF-Plate (19.5 ± 9.0 and 60.0 ± 5.4, P < 0.05).

CONCLUSION

The results from this study support that surgical management results in better postoperative functional outcomes, leads to higher union rates, reduces fracture healing time, reduces revision rate, and decreases malunion rates in patients with HSFs. In addition, MIPO resulted in statistically higher union rates, lowest complication rate, lowest rate of postoperative radial nerve palsy, and lower intraoperative time while resulting in better postoperative Disabilities of the Arm, Shoulder, and Hand and American Shoulder and Elbow Surgeons scores when compared with nonoperative and operative (ORIF and IMN) treatment modalities.

LEVEL OF EVIDENCE

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

Modified Chinese disabilities of arm, shoulder and hand tool: Validity and reliability for upper extremity injuries

DESIGN

Clinimetric evaluation study.

INTRODUCTION

The Chinese Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has necessitated the development of a revised version to the specific needs of individuals with upper extremity injuries with the progress of times and lifestyle changes.

PURPOSE OF THE STUDY

This research aimed to evaluate the reliability and validity of Modified Chinese Disability of Arm, Shoulder and Hand (MC-DASH) questionnaire in individuals with upper extremity injuries.

METHODS

One hundred and one individuals with upper extremity injuries (UEI) were recruited. The function of upper extremity was measured using the electronic version of MC-DASH, and compared against the Chinese Disability of Arm, Shoulder and Hand. The MC-DASH was reassessed within three days in all individuals. We investigated the internal consistency, test-retest reliability, content validity, criterion validity, and construct validity of MC-DASH.

RESULTS

The internal consistency was deemed sufficient, as indicated by a Cronbach's alpha of 0.986 and an intraclass correlation coefficient of 0.957. Moreover, the mean total scores of MC-DASH on the first-test and retest were 37.86 and 38.19, respectively (ICC: 0.957, 95 %CI: 0.937-0.971, p < 0.001). Furthermore, the MC-DASH version exhibited satisfactory content validity evidenced by its strong correlation (R= 0.903, p < 0.001) with the Chinese DASH. Three major influencing factors were identified from 37 items. The cumulative variance contribution rate of the MC-DASH questionnaire was 75.76 %, confirming its construct validity.

CONCLUSION

The Modified Chinese Disability of Arm, Shoulder and Hand questionnaire has been shown to be a valid, reliable, and practical tool for use in patients with upper extremity injuries.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

BACKGROUND

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS

This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.

RESULTS

Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.

CONCLUSION

In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study

Background

About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes.

Methods

In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared.

Results

Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7).

Conclusion

Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial

BACKGROUND

Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking.

METHODS AND FINDINGS

The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely.

CONCLUSIONS

In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review

Background

Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae.

Methods

A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed.

Findings

Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%.

Conclusion

Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Responsiveness and Minimal Important Change of the Arabic Disabilities of the Arm, Shoulder and Hand (DASH) in Patients with Upper Extremity Musculoskeletal Disorders

The aim of this study was to examine the responsiveness of the Arabic Disabilities of the Arm, Shoulder and Hand (DASH) and to quantify its minimal important change (MIC) for improvement. People with upper extremity musculoskeletal problems who were receiving physical therapy were evaluated at baseline and again during a follow-up appointment, with a median time frame of 7 days between the two testing sessions (range of 6 to 72 days). The participants completed the Arabic DASH, Global Assessment of Function (GAF), Numeric Pain Rating Scale (NPRS) and Global Rating of Change Scale (GRC). The responsiveness of the Arabic DASH was assessed by examining the pre-specified hypotheses. The MIC for improvement was determined using the receiver operating characteristic method (MICROC) and the predictive modeling method (MICpred). As hypothesized, a change in the Arabic DASH demonstrated a significant positive correlation with changes in the GAF (r = 0.69), NPRS (r = 0.68) and GRC (r = 0.73). Consistent with our hypotheses, the DASH change scores could be used to differentiate between participants who improved and those who did not improve (area under the receiver operating characteristic curve = 0.87), and they showed a large magnitude of change (effect size = 1.53, standardized response mean = 1.42) in patients who improved. All the hypotheses specified a priori were supported by the results. The Arabic DASH MICROC and MICpred were estimated to be 14.22 and 14.85. The interaction between the DASH change and baseline score was not a significant predictor of status (improved vs. not improved) (p = 0.75), indicating that the DASH MIC was not baseline-dependent. The Arabic DASH demonstrated sufficient responsiveness, supporting the idea that the Arabic DASH is capable of detecting changes in upper extremity function over time. The value of the Arabic DASH MIC was similar when estimated using the predictive modeling and ROC methods, and the MIC was not dependent on baseline status.

Functional and Clinical Outcomes After Plate Osteosynthesis Versus Intramedullary Nailing of a Humeral Shaft Fracture: The Results of the HUMMER Multicenter, Prospective Cohort Study

BACKGROUND

Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for humeral shaft fractures. However, it is undecided which treatment is more effective. This study aimed to compare functional and clinical outcomes of these treatment strategies. We hypothesized that plating would result in an earlier recovery of shoulder function and fewer complications.

METHODS

From October 23, 2012, to October 3, 2018, adults with a humeral shaft fracture, OTA/AO type 12A or 12B, were enrolled in a multicenter, prospective cohort study. Patients were treated with plating or nailing. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley score, ranges of motion of the shoulder and elbow, radiographic healing, and complications until 1 year. Repeated-measure analysis was done with correction for age, sex, and fracture type.

RESULTS

Of the 245 included patients, 76 were treated with plating and 169 were treated with nailing. Patients in the plating group were younger, with a median age of 43 years compared with 57 years for the nailing group (p < 0.001). The mean DASH score after plating improved faster over time, but did not differ significantly from the score after nailing at 12 months (11.7 points [95% confidence interval (CI), 7.6 to 15.7 points]) for plating and 11.2 points [95% CI, 8.3 to 14.0 points] for nailing). The Constant-Murley score and shoulder abduction, flexion, external rotation, and internal rotation displayed a significant treatment effect (p treatment ≤ 0.001), in favor of plating. The plating group had 2 implant-related complications, whereas the nailing group had 24, including 13 nail protrusions and 8 screw protrusions. Plating resulted in more postoperative temporary radial nerve palsy (8 patients [10.5%] compared with 1 patient [0.6%]; p < 0.001) and a trend toward fewer nonunions (3 patients [5.7%] compared with 16 patients [11.9%]; p = 0.285) than nailing.

CONCLUSIONS

Plating of a humeral shaft fracture in adults results in faster recovery, especially of shoulder function. Plating was associated with more temporary nerve palsies, but fewer implant-related complications and surgical reinterventions, than nailing. Despite heterogeneity in implants and surgical approach, plating seems to be the preferred treatment option for these fractures.

LEVEL OF EVIDENCE

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

Humeral shaft fracture: systematic review of non-operative and operative treatment

INTRODUCTION

Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.

METHODS

Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.

RESULTS

A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.

CONCLUSION

This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

Surgical Versus Nonsurgical Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis of Randomized Trials

INTRODUCTION

The aim was to compare surgical and nonsurgical management for adults with humeral shaft fractures in terms of patient-reported upper limb function, health-related quality of life, radiographic outcomes, and complications.

METHODS

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, International Clinical Trials Registry, and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomized trials comparing surgical and nonsurgical management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Pooled data were analyzed using a random-effects model.

RESULTS

The meta-analysis comprised 292 patients (mean age 41 [18 to 83] years, 67% male). Surgery was associated with superior Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores at 6 months (mean DASH difference 7.6, P = 0.01; mean Constant-Murley difference 8.0, P = 0.003), but there was no difference at 1 year (DASH, P = 0.30; Constant-Murley, P = 0.33). No differences in health-related quality of life or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, P = 0.004). The number needed to treat with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, P = 0.01) but not infection (OR 3.57, P = 0.13). Surgery was also associated with a lower risk of reintervention (1.4% versus 19.3%; OR 0.14, P = 0.04).

CONCLUSIONS

Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond 6 months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy.

LEVEL OF EVIDENCE

Level I.

Economic evaluation of operative versus nonoperative treatment of a humeral shaft fracture: economic analyses alongside a multicenter prospective cohort study (HUMMER)

PURPOSE

Operative treatment of a humeral shaft fracture results in faster recovery than nonoperative treatment. The cost-effectiveness, in terms of costs per Quality-Adjusted Life Year (QALY) gained (Dutch threshold €20,000-€80,000) or minimal important change (MIC) in disability reduced (DASH 6.7), is unknown. The aim of this study was to determine cost-utility and cost-effectiveness of operative versus nonoperative treatment in adults with a humeral shaft fracture type 12A or 12B.

METHODS

This study was performed alongside a multicenter prospective cohort study. Costs for health care and lost productivity until one year after trauma were calculated. The incremental cost-utility ratio (ICUR) was reported in costs per QALY (based on the EuroQoL-5D-3L (EQ-5D)) gained. The incremental cost-effectiveness ratio (ICER) was reported in costs per MIC (based on the DASH score at three months) reduced.

RESULTS

Overall, 245 patients were treated operatively and 145 nonoperatively. In the operative group, the mean total costs per patient (€11,925 versus €8793; p < 0.001) and QALYs (0.806 versus 0.778; p < 0.001) were higher. The ICUR of operative treatment was €111,860 per QALY gained (i.e., €3132/0.028). The DASH was 7.3 points (p < 0.001) lower in the operative group. The ICER of operative treatment was €2880 per MIC in disability reduced (i.e., €3132/7.3*6.7).

CONCLUSION

Due to the limited effect of treatment on quality of life measured with the EQ-5D, the ICUR of operative treatment (€111,860 per QALY gained) exceeds the threshold. However, the incremental costs of €2880 per clinically meaningful difference in DASH are much lower and suggest that operative treatment for a humeral shaft fracture is cost-effective.

Psychometric properties of patient-reported outcomes measures used to assess upper limb pathology: a systematic review

BACKGROUND

With the continued development of patient-centred healthcare models, patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients with upper limb pathology. The aim was to identify valid, reliable and responsive PROMs used to assess outcomes following upper limb pathology, and ascertain how their psychometric properties had been established. A secondary aim was to identify PROMs that have been validated to assess upper limb pathology in the paediatric population.

METHODS

A review of the Medline and EMBASE database was performed. Articles that analysed the validity of an established PROM used for upper limb pathology were included. Extracted study data included: author, country, PROM(s) investigated, year of publication, study type, sample size, demographics and duration of follow-up.

RESULTS

Twenty-five articles were included, which together investigated the psychometric properties of 23 different PROMs that have been used to assess outcomes in adults following upper limb pathology. No study evaluated the psychometric properties of PROMs used in the paediatric population. Among PROMs that have been used in adults, the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) had strong content- and construct-validity, reliability and responsiveness in comparison to others.

CONCLUSION

There are currently no studies that have analysed the content validity of PROMs used to assess upper limb pathology in the paediatric population. Prospective studies are required for the development of PROMs that can be utilized in children to assess upper limb pathology.

Minimal important difference and patient acceptable symptom state for common outcome instruments in patients with a closed humeral shaft fracture - analysis of the FISH randomised clinical trial data

Background

Two common ways of assessing the clinical relevance of treatment outcomes are the minimal important difference (MID) and the patient acceptable symptom state (PASS). The former represents the smallest change in the given outcome that makes people feel better, while the latter is the symptom level at which patients feel well.

Methods

We recruited 124 patients with a humeral shaft fracture to a randomised controlled trial comparing surgery to nonsurgical care. Outcome instruments included the Disabilities of Arm, Shoulder, and Hand (DASH) score, the Constant-Murley score, and two numerical rating scales (NRS) for pain (at rest and on activities). A reduction in DASH and pain scores, and increase in the Constant-Murley score represents improvement. We used four methods (receiver operating characteristic [ROC] curve, the mean difference of change, the mean change, and predictive modelling methods) to determine the MID, and two methods (the ROC and 75th percentile) for the PASS. As an anchor for the analyses, we assessed patients’ satisfaction regarding the injured arm using a 7-item Likert-scale.

Results

The change in the anchor question was strongly correlated with the change in DASH, moderately correlated with the change of the Constant-Murley score and pain on activities, and poorly correlated with the change in pain at rest (Spearman’s rho 0.51, -0.40, 0.36, and 0.15, respectively).

Depending on the method, the MID estimates for DASH ranged from -6.7 to -11.2, pain on activities from -0.5 to -1.3, and the Constant-Murley score from 6.3 to 13.5.

The ROC method provided reliable estimates for DASH (-6.7 points, Area Under Curve [AUC] 0.77), the Constant-Murley Score (7.6 points, AUC 0.71), and pain on activities (-0.5 points, AUC 0.68).

The PASS estimates were 14 and 10 for DASH, 2.5 and 2 for pain on activities, and 68 and 74 for the Constant-Murley score with the ROC and 75th percentile methods, respectively.

Conclusion

Our study provides credible estimates for the MID and PASS values of DASH, pain on activities and the Constant-Murley score, but not for pain at rest. The suggested cut-offs can be used in future studies and for assessing treatment success in patients with humeral shaft fracture.

Trial registration

ClinicalTrials.gov NCT01719887, first registration 01/11/2012.

Quantitative assessment of the course of distal radioulnar joint instability

Introduction

There is a lack of methods to objectively evaluate improvement in distal radioulnar joint (DRUJ) instability through treatment. We used ultrasonography to assess DRUJ instability and calculated the minimal detectable change (MDC) in healthy individuals. MDC was used to evaluate post-treatment changes in a patient with triangular fibrocartilage complex (TFCC) injury.

Methods

DRUJ instability was evaluated using force-monitor ultrasonography in eight healthy male participants to determine MDC and in a man in his 60s who underwent surgery and rehabilitation for TFCC injury (Palmer classification: type 2C). In the patient, DRUJ instability was measured pre-operatively, 3 months postoperatively, and 1 year post-operatively. Self-reported hand and upper limb functional ability were also recorded. The transducer of the force-monitor ultrasonographic system was used to apply cyclic compressions to the wrists automatically and measure DRUJ displacements. The amount of displacement was calculated using the distance between the radius and ulna before and during cyclic compression to the wrists. The applied pressure was measured as the force to the wrist, and the displacement-to-force ratio was calculated.

Results

The 95% confidence MDC95 for radioulnar displacement, displacement force, and displacement-to-force ratio were 0.27-0.31 mm, 0.30-0.59 N, and 0.12-0.15 mm/N, respectively. The patient's post-operative decrease in displacement exceeded the MDC95. DRUJ stability, pain, and use of the affected hand in daily life improved.

Discussion

Force-monitor ultrasonography can quantitatively evaluate post-treatment improvement in DRUJ stability over time. MDC for DRUJ instability can assess recovery after treatment or rehabilitation and determine changes resulting from interventions.

Evaluation of the Multiple Assessment Subjective Shoulder Score (MASSS). A pilot study

INTRODUCTION

This study compares an entirely patient reported modification of the Constant-Murley Score (CS) (the Multiple Assessment Subjective Shoulder Score [MASSS]), with the CS in symptomatic patients with non-instability shoulder pathology.

HYPOTHESIS

The hypothesis is that the sub scores and overall score of the MASSS will be well correlated and in high agreement to the corresponding scores of the CS.

MATERIALS AND METHODS

The MASSS, the CS and adjusted-CS (a-CS) were administered to 74 patients. The MASSS replaced the strength and ROM domains of the CS with SANE scores. Correlations, differences, agreement, test-retest reliability, and internal consistency were assessed using Pearson's R test, paired t-test, Bland-Altman method, intraclass correlations (ICC) and Cronbach's alpha.

RESULTS

Correlation between MASSS and CS (0.834) and a-CS (0.824) were excellent. Total MASSS (54.0) was higher than CS (41.8) (p<0.001) and a-CS (47.8) (p<0.05). MASSS strength and ROM domains were higher than those of the CS (Strength: 13.4 v 5.3 [p<0.001], ROM: 24.8 v 20.8 [p<0.001]. There was a floor effect for the strength domain of the CS (46.7% minimum score), but not the MASSS (0% minimum score). MASSS internal consistency (0.626-0.734) was better than the CS (0.401-0.643). Test re-test reliability of the total MASSS (ICC 0.93) and the strength (ICC 0.90) and ROM (ICC 0.86) domains was excellent.

DISCUSSION

The MASSS has several advantages over the CS. Although the correlation of the total MASSS with the CS and a-CS was high, there was poor agreement in the strength and the ROM domains and therefore the MASSS value is not interchangeable with the CS, but rather should be considered as an alternative.

LEVEL OF EVIDENCE

II; Prospective cohort study.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center

BACKGROUND

Upper-extremity injuries often lead to long-term problems in function and quality of life in patients. However, not much is known about the effects in polytrauma patients. This study aimed to describe the upper-extremity injuries in polytrauma patients and to compare self-reported disability and quality of life in polytrauma patients with vs. without upper-extremity injuries.

METHODS

We performed a retrospective cohort study of adult patients with an Injury Severity Score ≥ 16 admitted to Erasmus MC between January 1, 2007, and December 31, 2016. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand, Short Form 36, and EuroQol-5D questionnaires. Details on injuries, treatment, and clinical outcome were collected from the national trauma registry and medical files. Characteristics and self-reported outcomes of polytrauma patients with vs. without upper-extremity injuries were compared.

RESULTS

In a cohort of 3469 trauma patients, 1246 (36.5%) had upper-extremity injuries. Of these, 278 (22.0%) had severe injuries (Abbreviated Injury Scale score ≥ 3). Upper-extremity injuries were associated with a longer hospitalization (median, 12 days vs. 8 days; P < .001), longer intensive care unit stay (median, 5 days vs. 4 days; P = .005), and lower mortality rate (14.6% vs. 23.9%, P < .001). Among the 598 patients who completed the questionnaires, no differences in the physical component summary score (47 vs. 48, P = .181) and mental component summary score (54 vs. 53, P = .315) of the Short Form 36 questionnaire, as well as the utility score (0.82 vs. 0.85, P = .101) and visual analog scale score (80 vs. 80, P = .963) of the EuroQol-5D questionnaire, were found. However, patients with upper-extremity injuries showed a minor increase in disability in the Disabilities of the Arm, Shoulder and Hand score (9.2 vs. 4.2, P = .023).

CONCLUSION

Upper-extremity injuries in polytrauma patients are associated with a longer hospitalization, longer intensive care unit stay, and reduced mortality rate, as well as a minor increase in long-term disability.

Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study

Purpose

The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods

From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results

Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion

Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial registration

NTR3617 (registration date 18-SEP-2012).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01890-6.

Using autograft in the surgical treatment of isolated distal ulna fractures with open reduction internal fixation improves short-term clinical outcomes: 11 years of experience

BACKGROUND

Most of the studies on ulna fractures assess the treatment of fractures accompanied by other tissue injuries; thus, the number of studies focused directly on isolated distal ulna fractures are very few. In this study, it was aimed to evaluate the short-term results of open reduction internal fixation (ORIF) and autograft+ORIF approaches in the treatment of isolated distal ulna fractures.

HYPOTHESIS

Using autograft in the surgical treatment of isolated distal ulna fractures with open reduction internal fixation improves short-term clinical outcomes.

PATIENTS AND METHODS

The records of isolated distal ulna fractures (distal one-third) operated at the Maltepe University Hospital Orthopedics and Traumatology Clinic between January 2009 and December 2019 were retrospectively reviewed. The cases were divided into two groups according to surgical approach, ORIF (n=40) or autograft+ORIF (n=34).

RESULTS

The mean age was 41.55±12.42 years. 52.7% of the cases were female, 67.6% of the fractures were right-sided, and 37.8% of the traumas causing the fracture were high-energy trauma. There was no significant difference between the ORIF and autograft+ORIF groups in terms of age, gender, side and severity of trauma (p>0.05). It was found that pseudoarthrosis development was significantly more prevalent in the ORIF group (25%) compared to the autograft+ORIF group (5.9%) (p=0.026). The median (1st quartile-3rd quartile) time to union was 16 (14-17) weeks in the ORIF group, and 9.5 (8.5-12) weeks in the autograft+ORIF group. Compared to ORIF, the time to union was significantly shorter with the autograft+ORIF procedure (p<0.001). At both the 3rd and 12th month follow-up examinations, the autograft+ORIF group was found to have significantly higher MAYO score and grip strength, and lower DASH score, compared to the ORIF group.

DISCUSSION

When an autograft is used in addition to ORIF in the surgical treatment of isolated distal ulna fractures, the bone heals faster, pseudoarthrosis develops less frequently, and short-term (3rd and 12th months) functional results are better.

LEVEL OF EVIDENCE

III; therapeutic study.

Psychometric evaluation of the disabilities of the arm, shoulder and hand (DASH) in patients with orthopedic shoulder impairments seeking outpatient rehabilitation

STUDY DESIGN

This is a cross-sectional, observational study.

INTRODUCTION

The disability of the arm, shoulder and hand (DASH) questionnaire is an upper-extremity specific outcome measure commonly used in routine clinical care and clinical trials.

PURPOSE OF THE STUDY

Our purposes were to: (1) examine the psychometric properties of the DASH questionnaire using factor analysis, one- and two-parameter item response theory models, and (2) develop a functional staging map illustrating the relationships between the item difficulty hierarchy of the DASH items and the patient's DASH total score.

METHODS

Data from 2724 patients with orthopedic shoulder impairments seeking outpatient physical therapy in 79 clinics in the US were analyzed.

RESULTS

Factor analysis supported a general factor, explaining 62.2% of the total variance. The coverage of DASH items was suitable for patients with shoulder impairments with no ceiling or floor effect. Endorsed items representing the most difficult items were related to feeling less capable, executing recreational activities with force or impact, and performing recreational activities in which you move your arm freely. Items with higher discriminating abilities were those related to do heavy household chores, garden/yard work, and change a light bulb overhead. With a separation index equaled to 4.94, the DASH can differentiate persons into at least 6 statistically distinct person strata. None of the DASH items exhibited differential item functioning by gender or symptom acuity, except two items by age group.

DISCUSSION

Besides a total (summed) final score obtained from a specific measure, the keyform and functional staging plots/maps can be used to assist clinicians in clinical interpretation of the scores.

CONCLUSIONS

Results supported the clinical usage of the DASH questionnaire in patients with orthopedic shoulder impairments seeking outpatient rehabilitation.

Responsiveness of five shoulder outcome measures at follow-ups from 3 to 24 months

Background

To assess responsiveness of five outcome measures at four different follow-ups in patients with SLAP II lesions of the shoulder.

Methods

119 patients with symptoms and signs, MRI arthrography and arthroscopic findings were included. The Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Shoulder Score (OISS), EuroQol (EQ-5D3L), Rowe Score and Constant-Murley Score (CMS) were assessed at baseline, 3, 6, 12 and 24 months. The analysis contains both anchor-based and distribution-based methods, and hypothesis testing.

Results

Confidence intervals for ROC cut-off values, representing MID, for OISS, CMS and EQ-5D3L crossed zero at 3 months. Cut-off values were stable between 6- and 24-months follow-up. At 24-months ROC cut-off values (95% CI) were: Rowe 18 (13 to 24); WOSI 331 (289 to 442); OISS 9 (5 to 14); CMS 11 (9 to 15) and EQ-5D3L 0.123 (0.035 to 0.222). MID_95%limit estimates were substantially higher than ROC cut-off values and MID_MEAN at all follow-ups for all instruments. The reliable change proportion (RCP) values in the improved group were highest for WOSI and the Rowe Score (ranging from 68 to 87%) and significantly lower for CMS. EQ-5D3L had the lowest values (13 to 16%). We found a moderate correlation between mean change scores of the outcome measures and the anchor, except for the EQ-5D3L.

Conclusions

In patients with SLAP II-lesions the patient reported OISS and WOSI and the clinical Rowe score had best responsiveness. Our results suggest that 3 months follow-up is too early for outcome evaluation.

How to Assess Shoulder Functionality: A Systematic Review of Existing Validated Outcome Measures

The objective of this review was to compile validated functional shoulder assessment tools and analyse the methodological quality of their validations. Secondarily, we aimed to provide a comparison of the tools, including parameter descriptions, indications/applications, languages and operating instructions, to choose the most suitable for future clinical and research approaches. A systematic review (PRISMA) was conducted using: PubMed, WoS Scopus, CINHAL, Dialnet and reference lists until 2020. The main criteria for inclusion were that papers were original studies of validated tools or validation studies. Pre-established tables showed tools, validations, items/components, etc. The QUADAS-2 and COSMIN-RB were used to assess the methodological quality of validations. Ultimately, 85 studies were selected, 32 tools and 111 validations. Risk of bias scored lower than applicability, and patient selection got the best scores (QUADAS-2). Internal consistency had the highest quality and PROMs development the lowest (COSMIN-RB). Responsiveness was the most analysed metric property. Modified UCLA and SST obtained the highest quality in shoulder instability surgery, and SPADI in pain. The most approached topic was activities of daily living (81%). We compiled 32 validated functional shoulder assessment tools, and conducted an analysis of the methodological quality of 111 validations associated with them. Modified UCLA and SST showed the highest methodological quality in instability surgery and SPADI in pain.

Comparison of reliability, validity and responsiveness of the Japanese Orthopaedic Association Shoulder 36 Ver. 1.3 among different diagnoses of shoulder lesions

BACKGROUND

Shoulder 36 (Sh-36) is an original quality of life measure for shoulder lesions with high reliability and validity; however, in some cases, especially in those with a Bankart lesion, we observed no improvement in Sh-36 during the postoperative follow-up. Sh-36 may be less effective for a certain shoulder lesion. This study aimed to compare the reliability, validity, and responsiveness of Sh-36 among different representative diagnoses of shoulder lesions.

METHODS

Sh-36 and the Disability of the Arm, Shoulder and Hand (DASH) were measured in 192 patients with a Bankart lesion (Bankart group), rotator cuff tear (Cuff group), and SLAP lesion (SLAP group) who underwent arthroscopic surgery. Both measures were evaluated before surgery, and at 3, 6, 9, 12, 18, and 24 months postoperatively, and reliability, validity, and responsiveness of Sh-36 and the DASH were compared among the three groups.

RESULTS

Significant postoperative improvement was observed in the three groups (p < 0.0001) within 9 months. No marked improvement was observed after 9 months in the Bankart and SLAP groups due to the ceiling effect; however, most domains of Sh-36 increased continuously in the Cuff group during the whole follow-up period. Reliability and construct validity were sufficient in all the groups. The longitudinal validity was sufficient in most domains for the three groups; however, the standardized response mean in the Bankart group was lower than that in other two groups, indicating low responsiveness in this group because of the ceiling effect.

CONCLUSIONS

Sh-36 was a valid and reliable instrument in patients who have undergone arthroscopic shoulder surgery, especially for patient with a rotator cuff tear with high responsiveness. However, Sh-36 had lower standard response mean representing lower responsiveness in the Bankart group due to the ceiling effect and may not be ideal for longitudinal follow-up in patients with a Bankart lesion.

Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial

OBJECTIVES

To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population.

DESIGN

Prospective multicenter randomized controlled trial.

SETTING

Three Level-1 trauma centers.

PATIENTS/PARTICIPANTS

This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group.

INTERVENTION

Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA.

MAIN OUTCOME MEASUREMENTS

Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes.

RESULTS

After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups.

CONCLUSION

RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up.

LEVEL OF EVIDENCE

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

Interchangeability of Diverse Analog Scales Used Within the Constant-Murley Score

Purpose

To assess the interchangeability of various existing answering scales within the subjective part of the Constant–Murley Score (CMS) and to determine the effect of the different answering scales on the inter- and intraobserver reliability.

Methods

In this prospective, single-center, cross-sectional trial, patients with shoulder problems were included from June to September 2018. Subjects recruited were 18 years or older, presented various shoulder complaints, e.g., diagnosis of osteoarthritis, subacromial pain syndrome, rotator cuff or biceps tendon problems, or frozen shoulder. An extended version of the CMS was prepared including the same questions multiple times but with varying answer scales. Six versions were made with random order of the questions. The answering scales were a verbal and paper based visual analog scale (VAS), smiley face scale, Numeric Rating Scale (NRS), and categories. Internal consistency of the various CMS, Spearman correlation coefficients, intraobserver, and interobserver agreement was assessed (ICC).

Results

In total, 93 patients were included. The total CMS using the paper-based VAS, smiley face score, and NRS were 46.9 ± 19.4, 45.2 ± 18.5, and 45.0 ± 18.7. Correlations of the total scores of the different versions varied from 0.98 to 0.99. CMS-category versus CMS-smiley face score and CMS-category versus CMS-NRS pain were significantly different (P = .02 and P = .01). Good internal consistency (0.76-0.79) and acceptable inter- and intraobserver reliability were found (ICC: 0.89-0.97, 0.98-0.99; P < .001).

Conclusions

The different answering scales for the subjective subscales within the CMS for pain, work, and recreational activity were not interchangeable on item level and significantly influenced the total CMS score. Differences were below the smallest detectable change and interpreted as not clinically relevant. Particularly on item level, data from different studies cannot be pooled and compared when different answering scales are being used. The inter- and intraobserver reliability were excellent.

Level of Evidence

Level I, prospective cross-sectional study.

Comparability of Patient-reported Outcome Measures and Clinical Assessment Tools for Shoulder Function in Patients with Proximal Humeral Fracture

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining increasing importance in the context of quality management. Different PROMs and scoring tools are available to assess shoulder function after proximal humeral fracture (PHFx). In Europe, these include the Constant-Murley Score (CS), Neer Score (NS), Oxford Shoulder Score (OSS), University of California at Los Angeles Score (UCLA) and Disabilities of the Arm, Shoulder and Hands Score (DASH). In addition, the health-related quality of life can be assessed by the PROMs Short Form 36 (SF-36) and EuroQol (EQ-5D). Although all these test instruments assess shoulder function, the components to be answered objectively and subjectively vary and thus the possibility of independent assessment. The aim of the present study is to compare the correlation between the results of the different PROMs and the clinical screening tools in patients with PHFx.

METHODS

76 patients who were treated with angular stable plate osteosynthesis for a proximal humeral fracture between 01/2001 and 12/2005 were included in this trial. The outcome was measured with PROMs or clinical scoring tools such as CS, NS, OSS, UCLA, DASH, SF-36 and EQ-5D and a correlation coefficient between those evaluation tools was calculated. In addition, a distinction was made between the two force measurement methods (wrist [HG] vs. deltoid muscle [DM]) for CS.

RESULTS

The correlation of the results of CS and NS (HG: r = 0.85; p < 0.001/DM: r = 0.93; p < 0.001), CS and UCLA (HG: r = 0.83; p < 0.001/DM: r = 0.86; p < 0.001), NS and UCLA (r = 0.91; p < 0.001) as well as DASH and OSS (r = 0.88; p < 0.001) was strongly expressed. A good comparability of the results was demonstrated between CS and OSS (HG: r = 0.63; p < 0.001/DM: r = 0.66; p < 0.001) and between CS and DASH (HG: r = 0.62; p < 0.001/DM: r = 0.61; p < 0.001). The correlation of CS (HG/DM) and UCLA with the EQ-5D index was also good. Assessment of the physical components of SF-36 with CS, NS, OSS, UCLA and DASH showed a moderate to good association, while the mental components of SF-36 showed a low correlation (p > 0.05).

CONCLUSION

The assessment of shoulder function after proximal humerus fracture showed a very strong correlation within the clinical questionnaires (CS/NS/UCLA) and the PROMs (OSS/DASH). A strong correlation also exists between the clinical questionnaires and the PROMs. There was only a moderate correlation with the EQ-5D. The moderate to strong correlation between the physical components of SF-36, with almost no correlation between the mental components of SF-36, indicates that the quality of life restriction is based on a physical, but not on a mental impairment.

Quantifying the minimal and substantial clinical benefit of the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff

Background

To aid the interpretation of clinical outcome scores, it is important to determine the measurement properties. The aim of this study was to establish the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score in patients with long-lasting rotator cuff calcific tendinitis treated with high-energy extracorporeal shockwave therapy and ultrasound guided needling. The secondary purpose was to assess the responsiveness of both questionnaires and to identify variables associated with achieving the MCID and SCB.

Methods

A prospective cohort of 80 patients with rotator cuff calcific tendinitis was analyzed. Two anchor-based methods were used to calculate the MCID and SCB. Effect sizes and standardized response means were calculated to assess the responsiveness. Additional univariate logistic regression analyses were performed to identify factors associated with the achievement of the MCID and SCB.

Results

For the Constant-Murley score, we found an MCID and SCB of 9.8 and 19.9, respectively, based on the mean change method and 5.5 and 10.5, respectively, based on receiver operating characteristic analysis. For the Disabilities of the Arm, Shoulder and Hand score, we found an MCID and SCB of –8.2 and –19.6, respectively, with the former and –11.7 and –12.5, respectively, with the latter. The responsiveness of both outcome measures was good, with large effect sizes and standardized response means. The radiographic resorption after 6 weeks and after 6 months appeared to be the most important positive predictor for achieving the MCID and SCB after 6 months.

Conclusion

This study established the MCID, SCB, and responsiveness for patients with long-lasting rotator cuff calcific tendinitis who were treated with minimally invasive treatment options. With this information, physicians can distinguish between a statistically significant difference and a clinically relevant benefit. Successful radiographic resorption after 6 weeks and after 6 months was associated with achieving clinically significant improvement after treatment.

No need to use both Disabilities of the Arm, Shoulder and Hand and Constant-Murley score in studies of midshaft clavicular fractures

Background and purpose - Most newer randomized studies examining plate fixation and nonoperative treatment of midshaft clavicular fractures utilize both Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley score (CS) in the evaluation of patient outcomes. Compared with DASH, the use of CS requires on-site trained personnel and patient visits to obtain the score. The use of both DASH and CS should provide extra value compared with the use of a single functional outcome score; if this value is not provided, the combined use is not necessary. We evaluated the agreement between DASH and CS in patients with displaced midshaft clavicular fractures.Patients and methods - We used prospectively collected data from 146 patients enrolled in a randomized study comparing operative and nonoperative treatment of midshaft clavicular fractures. We determined correlation between DASH and CS at all follow-up points and calculated mean bias in the Bland-Altman plot.Results - We found moderate to high correlation (from 0.82 at 6 weeks' follow-up to 0.58 at 1-year follow-up) between DASH and CS score, and a small bias (2.21 [95% CI 0.22-4.20]) in the Bland-Altman plot.Interpretation - In patients with displaced midshaft clavicular fractures DASH and CS measures the same degree of disability. Unless specifically studying strength and range of motion, we recommend the sole use of DASH as it would eliminate potential observer-induced bias along with removing the economic and logistic burden of obtaining CS without compromising the value of the collected data.

Is PROMIS the new standard for patient-reported outcomes measures in orthopaedic trauma research?

This review describes some of the benefits of the Patient-Reported Outcomes Measurement Information System (PROMIS) architecture, determined how frequently PROMIS measures were used in the current orthopaedic trauma literature, and compared the features of PROMIS instruments with other frequently used patient-reported outcomes measures (PROMs). PROMIS instruments have several unique elements to their architecture, such as item response theory, computerized adaptive testing options, and scaling using T-scores, that differentiate the instruments from many other PROMs. Over the past five years, 108 different PROMs were reported in 319 studies published in high-impact orthopaedic journals. PROMIS measures, including PROMIS Physical Function, Pain Interference, and Upper Extremity Function, were only used in seven studies (2%). PROMIS measures were found to be comparable to other more common PROMs with respect to respondent burden, administration options, and psychometric assessments specific to fracture patients. Likely, the limited familiarity and interpretability of PROMIS measures in the fracture population remain the most substantial barriers to broader adoption in orthopaedic trauma research.

Rasch analysis of the Disabilities of the Arm, Shoulder and Hand (DASH) instrument in patients with a humeral shaft fracture

BACKGROUND

The Disabilities of the Arm, Shoulder and Hand (DASH) instrument was developed to assess the disability experienced by patients with any musculoskeletal condition of the upper extremity and to monitor change in symptoms and upper-limb function over time. The 30 items are scored on a 5-point rating scale. The Dutch-language version of the DASH instrument (DASH-DLV) has been examined with the classical test theory in patients with a humeral shaft fracture. This study aimed to examine the DASH-DLV with a more rigorous and extensive analysis by applying the Rasch model.

METHODS

Data of 400 patients included in a multicenter, prospective study comparing operative and nonoperative treatment of adult patients with a humeral shaft fracture were used. The person-item map, item fit statistics, reliability, response category ordering, and dimensionality were examined. Raw data were converted to linear measures using the Rasch model.

RESULTS

The DASH-DLV showed a good fit to the Rasch model, except for item 26 ("Tingling [pins and needles] in your arm, shoulder or hand"). The person reliability was 0.92. In general, the category functioning of the 5-point rating scale was working well. Dimensionality analysis revealed that the DASH-DLV is a unidimensional scale. Differential item functioning for sex was not detected, and only item 26 exhibited differential item functioning as a function for age.

CONCLUSION

The DASH-DLV fits the stringent Rasch model in a clinical situation with a group of adult patients with a humeral shaft fracture. Adequate measurement for scientific research can be obtained to evaluate longitudinal intervention research.

Which study outcomes change practice

The use of evidence based medicine to guide treatment decision making is widely supported by clinicians as a method to improve patient care and outcomes. Surgeons and physicians play a key role in both the design of clinical and translational research studies, as well as the implementation of the results. With the massive volume of published studies, it is increasingly difficult for clinicians to evaluate the literature and appropriately integrate novel findings into practice. With a focus on research studies in the field of orthopaedic surgery, the purpose of this review is to discuss which factors lead to impactful conclusions and clinical change, including the role of outcome selection, study design, presentation of results, and stakeholder involvement.

Minimal important change in physical function in trauma patients: a study using the short musculoskeletal function assessment

Purpose

The Short Musculoskeletal Function Assessment (SMFA) questionnaire can be used to evaluate physical functioning in patients with traumatic injuries. It is not known what change in score reflects a meaningful change to patients. The aim was to determine minimal important change (MIC) values of the subscales (0–100) of the Dutch SMFA-NL in a sample of patients with a broad range of injuries.

Methods

Patients between 18 and 65 years of age completed the SMFA-NL and the Global Rating of Effect (GRE) questions at 6-week and 12-month post-injury. Anchor-based MIC values were calculated using univariable logistic regression analyses.

Results

A total of 225 patients were included (response rate 67%). The MIC value of the Upper Extremity Dysfunction (UED) subscale was 8 points, with a misclassification rate of 43%. The Lower Extremity Dysfunction subscale MIC value was 14 points, with a misclassification rate of 29%. The MIC value of the Problems with Daily Activities subscale was 25 points, with a misclassification rate of 33%. The MIC value of the Mental and Emotional Problems (MEP) subscale was 7 points, with a misclassification rate 37%.

Conclusion

MIC values of the SMFA-NL were determined. The MIC values aid interpreting whether a change in physical functioning can be considered clinically important. Due to the considerable rates of misclassification, the MIC values of the UED and MEP subscales should be used with caution.

Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers

BACKGROUND

Despite the importance of assessing patient outcomes during patient care, current evidence suggests relatively limited use of patient-reported outcome measures (PROMs) by athletic trainers (ATs). Major barriers to PROM use include lack of knowledge, navigating the intricate process of assessing a wide variety of PROMs, and selecting the most appropriate PROM to use for care. A concise resource for ATs to consult when selecting and implementing PROMs may help facilitate the use of PROMs in athletic health care.

OBJECTIVE

To review the instrument essentials and clinical utility of PROMs used by ATs.

METHODS

We studied 11 lower extremity region-specific, 10 upper extremity region-specific, 6 generic, and 3 single-item PROMs based on the endorsement of at least 10% of ATs who use PROMs, as reported in a recent investigation of PROM use in athletic training. A literature search was conducted for each included PROM that focused on identifying and extracting components of the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and clinical utility (ie, acceptability, feasibility, and appropriateness). Through independent review and group consensus, we also classified each PROM question by International Classification of Functioning, Disability and Health domain and health-related quality-of-life dimensions.

KEY FINDINGS

The PROMs contained in this report generally possessed appropriate instrument essentials and clinical utility. Moreover, the PROMs generally emphasized body structure and function as well as the physical functioning of the patient. Athletic trainers aiming to assess patients via a whole-person approach may benefit from combining different PROMs for use in patient care to ensure broader attention to disablement health domains and health-related quality-of-life dimensions.

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients-which scores can be evaluated by a telephone-based assessment?

BACKGROUND

The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.

METHODS

Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.

RESULTS

In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).

CONCLUSION

Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.

TRIAL REGISTRATION

(250/2011BO2).

A prospective randomised controlled trial of operative versus non-operative management of fractures of the humeral diaphysis: the HUmeral Shaft Fracture FIXation (HU-FIX) Study protocol

BACKGROUND

Humeral shaft fractures constitute around 1% of adult fractures in the UK, with an annual incidence of approximately 13 per 100,000 population. Historically, these injuries have been primarily managed non-operatively, with operative fixation reserved for specific indications. Although some recent retrospective studies have suggested there are potential benefits of operative fixation over humeral bracing, there is a deficiency in level 1 evidence to support operative management as the primary treatment for humeral shaft fractures.

METHODS/DESIGN

This single-centre prospective randomised controlled trial aims to recruit 70 adult patients with an isolated closed fracture of the humeral diaphysis into one of two treatment arms: operative (n = 35) or non-operative (n = 35). The operative arm will undergo open reduction and internal fixation (ORIF) of the fracture using a standard fixation technique (plate and screws). The non-operative arm will be fitted with a prefabricated humeral brace until fracture union. All patients will be followed up for 1 year post-intervention. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3 months post-intervention. Secondary outcome measures will include pain, treatment complications, return to work or sporting activities, shoulder and elbow range of motion, radiographic assessment, EuroQol (EQ-5D) Health Outcome score and 12-item Short Form (SF-12) Health Survey score. A health economic analysis will be performed to compare the cost implications of each treatment strategy.

DISCUSSION

This randomised controlled trial will provide level 1 evidence comparing a standard ORIF technique against functional bracing for isolated closed humeral shaft fractures. The investigators hope that the study results will assist surgeons in their decision-making when managing patients with these injuries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03689335 . Registered on 28 September 2018 (retrospectively).

Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a BMJ Rapid Recommendation

OBJECTIVES

To identify credible anchor-based minimal important differences (MIDs) for patient-reported outcome measures (PROMs) relevant to a BMJ Rapid Recommendations addressing subacromial decompression surgery for shoulder pain.

DESIGN

Systematic review.

OUTCOME MEASURES

Estimates of anchor-based MIDs, and their credibility, for PROMs judged by the parallel BMJ Rapid Recommendations panel as important for informing their recommendation (pain, function and health-related quality of life (HRQoL)).

DATA SOURCES

MEDLINE, EMBASE and PsycINFO up to August 2018.

STUDY SELECTION AND REVIEW METHODS

We included original studies of any intervention for shoulder conditions reporting estimates of anchor-based MIDs for relevant PROMs. Two reviewers independently evaluated potentially eligible studies according to predefined selection criteria. Six reviewers, working in pairs, independently extracted data from eligible studies using a predesigned, standardised, pilot-tested extraction form and independently assessed the credibility of included studies using an MID credibility tool.

RESULTS

We identified 22 studies involving 5562 patients that reported 74 empirically estimated anchor-based MIDs for 10 candidate instruments to assess shoulder pain, function and HRQoL. We identified MIDs of high credibility for pain and function outcomes and of low credibility for HRQoL. We offered median estimates for the systematic review team who applied these MIDs in Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence summaries and in their interpretations of results in the linked systematic review addressing the effectiveness of surgery for shoulder pain.

CONCLUSIONS

Our review provides anchor-based MID estimates, as well as a rating of their credibility, for PROMs for patients with shoulder conditions. The MID estimates inform the interpretation for a linked systematic review and guideline addressing subacromial decompression surgery for shoulder pain, and could also prove useful for authors addressing other interventions for shoulder problems.

PROSPERO REGISTRATION NUMBER

CRD42018106531.

Constant-Murley Score: systematic review and standardized evaluation in different shoulder pathologies

PURPOSE

The objective of this study was to evaluate the psychometric properties of the Constant-Murley Score (CMS) in various shoulder pathologies, based on a systematic review and expert standardized evaluations.

METHODS

A systematic review was performed in MEDLINE and EMBASE databases. Titles and abstracts were reviewed and finally the included articles were grouped according to patients' pathologies. Two expert evaluators independently assessed the CMS properties of reliability, validity, responsiveness to change, interpretability and burden score in each group, using the EMPRO (Evaluating Measures of Patient Reported Outcomes) tool. The CMS properties were assessed per attribute and overall for each considered group. Only the concept and measurement model was assessed globally.

RESULTS

Five individual pathologies (i.e. subacromial, fractures, arthritis, instability and frozen shoulder) and two additional groups (i.e. various pathologies and healthy subjects) were considered. Overall EMPRO scores ranged from 58.6 for subacromial to 30.6 points for instability. Responsiveness to change was the only quality to obtain at least 50 points across all groups, but for frozen shoulder. Insufficient information was obtained in relation to the concept and measurement model and great variability was seen in the other evaluated attributes.

CONCLUSIONS

The current evidence does not support the CMS as a gold standard in shoulder evaluation. Its use is advisable for subacromial pathology; but data are inconclusive for other shoulder conditions. Prospective studies exploring the psychometric properties of the scale, particularly for fractures, arthritis, instability and frozen shoulder are needed.

LEVEL OF EVIDENCE

Systematic review.

Validation of the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale Dutch language version in patients with hindfoot fractures

OBJECTIVES

The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale is among the most used questionnaires for measuring functional recovery after a hindfoot injury. Recently, this instrument was translated and culturally adapted into a Dutch version. In this study, the measurement properties of the Dutch language version (DLV) were investigated in patients with a unilateral hindfoot fracture.

DESIGN

Multicentre, prospective observational study.

SETTING

This multicentre study was conducted in three Dutch hospitals.

PARTICIPANTS

In total, 118 patients with a unilateral hindfoot fracture were included. Three patients were lost to follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were asked to complete the AOFAS-DLV, the Foot Function Index and the Short Form-36 on three occasions. Descriptive statistics (including floor and ceiling effects), reliability (ie, internal consistency), construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change (SDC)) and responsiveness were determined.

RESULTS

Internal consistency was inadequate for the AOFAS-DLV total scale (α=0.585), but adequate for the function subscale (α=0.863). The questionnaire had adequate construct validity (82.4% of predefined hypotheses were confirmed), but inadequate longitudinal validity (70.6%). No floor effects were found, but ceiling effects were present in all AOFAS-DLV (sub)scales, most pronounced from 6 to 24 months after trauma onwards. Responsiveness was only adequate for the pain and alignment subscales, with a SDC of 1.7 points.

CONCLUSIONS

The AOFAS Ankle-Hindfoot Scale DLV has adequate construct validity and is reliable, making it a suitable instrument for cross-sectional studies investigating functional outcome in patients with a hindfoot fracture. The inadequate longitudinal validity and responsiveness, however, hamper the use of the questionnaire in longitudinal studies and for assessing long-term functional outcome.

TRIAL REGISTRATION NUMBER

NTR5613; Post-results.

Minimal important change and other measurement properties of the Oxford Elbow Score and the Quick Disabilities of the Arm, Shoulder, and Hand in patients with a simple elbow dislocation; validation study alongside the multicenter FuncSiE trial

Study design

Validation study using data from a multicenter, randomized, clinical trial (RCT).

Objectives

To evaluate the reliability, validity, responsiveness, and minimal important change (MIC) of the Dutch version of the Oxford Elbow Score (OES) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) in patients with a simple elbow dislocation.

Background

Patient-reported outcome measures are increasingly important for assessing outcome following elbow injuries, both in daily practice and in clinical research. However measurement properties of the OES and Quick-DASH in these patients are not fully known.

Methods

OES and Quick-DASH were completed four times until one year after trauma. Mayo Elbow Performance Index, pain (VAS), Short Form-36, and EuroQol-5D were completed for comparison. Data of a multicenter RCT (n = 100) were used. Internal consistency was determined using Cronbach’s alpha. Construct and longitudinal validity were assessed by determining hypothesized strength of correlation between scores or changes in scores, respectively, of (sub)scales. Finally, floor and ceiling effects, MIC, and smallest detectable change (SDC) were determined.

Results

OES and Quick-DASH demonstrated adequate internal consistency (Cronbach α, 0.882 and 0.886, respectively). Construct validity and longitudinal validity of both scales were supported by >75% correctly hypothesized correlations. MIC and SDC were 8.2 and 12.0 point for OES, respectively. For Quick-DASH, these values were 11.7 and 25.0, respectively.

Conclusions

OES and Quick-DASH are reliable, valid, and responsive instruments for evaluating elbow-related quality of life. The anchor-based MIC was 8.2 points for OES and 11.7 for Quick-DASH.

The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale; translation and validation of the Dutch language version for ankle fractures

OBJECTIVES

The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale is among the most commonly used instruments for measuring outcome of treatment in patients who sustained a complex ankle or hindfoot injury. It consists of a patient-reported and a physician-reported part. A validated, Dutch version of this instrument is currently not available. The aim of this study was to translate the instrument into Dutch and to determine the measurement properties of the AOFAS Ankle-Hindfoot Scale Dutch language version (DLV) in patients with a unilateral ankle fracture.

SETTING

Multicentre (two Dutch hospitals), prospective observational study.

PARTICIPANTS

In total, 142 patients with a unilateral ankle fracture were included. Ten patients were lost to follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients completed the subjective (patient-reported) part of the AOFAS Ankle-Hindfoot Scale-DLV. A physician or trained physician-assistant completed the physician-reported part. For comparison and evaluation of the measuring characteristics, the Foot Function Index and the Short Form-36 were completed by the patient. Descriptive statistics (including floor and ceiling effects), reliability (ie, internal consistency), construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change) and responsiveness were determined.

RESULTS

The AOFAS-DLV and its subscales showed good internal consistency (Cronbach's α >0.90). Construct validity and longitudinal validity were proven to be adequate (76.5% of predefined hypotheses were confirmed). Floor effects were not present. Ceiling effects were present from 6 months onwards, as expected. Responsiveness was adequate, with a smallest detectable change of 12.0 points.

CONCLUSIONS

The AOFAS-DLV is a reliable, valid and responsive measurement instrument for evaluating functional outcome in patients with a unilateral ankle fracture. This implies that the questionnaire is suitable to compare different treatment modalities within this population or to compare outcome across hospitals.

TRIAL REGISTRATION

The Netherlands Trial Register (NTR5613; 05-jan-2016).