Structural validity of the Dutch version of the disability of arm, shoulder and hand questionnaire (DASH-DLV) in adult patients with hand and wrist injuries

Psychometric properties of the Disability of Arm Shoulder and Hand (DASH) in subjects with frozen shoulder: a reliability and validity study

BACKGROUND

Frozen Shoulder (FS) is a painful condition characterized by severe pain and progressive restriction of shoulder movement, leading to functional impairment and reduced quality of life. While different Patient Reported Outcome Measurements (PROMs) tools exist for assessing shoulder diseases, few specific PROMs are validated for FS patients.

PURPOSE

This study aims to assess the psychometric properties of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire in FS patients.

METHODS

One hundred and twenty-four subjects (mean ± SD age = 55.4 ± 7.9 years; 55.6% female) diagnosed with FS were included and completed the DASH questionnaire, the Numerical Pain Rating Scale (NPRS), the Shoulder Pain and Disability Index (SPADI), and the Short-Form Health Survey 36 (SF-36). Floor or ceiling effects were investigated. Structural validity was analysed through a unidimensional Confirmatory Factor Analysis (CFA), internal consistency through Cronbach's alpha, test-retest reliability through the Intraclass Correlation coefficient (ICC), measurement error through the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC), and construct validity through the hypothesis testing with the correlation with the other outcome measures used.

RESULTS

No floor or ceiling effects were observed. CFA confirmed a one-factor structure after addressing local item dependency (Root Mean Square Error of Approximation = 0.055; Standardized Root Mean Square Residual = 0.077; Comparative Fit Index = 0.970; Tucker-Lewis Index = 0.968). Cronbach's alpha was high (= 0.951), and test-retest reliability was excellent (ICC = 0.999; 95% CI: 0.998-1.000). SEM was equal to 0.5 points, and MDC to 1.5 points. Construct validity was considered satisfactory as 80% of the a-priori hypotheses were met.

CONCLUSION

The DASH questionnaire demonstrated good psychometric properties in FS patients, supporting its use as a valuable tool for assessing the impact of FS in clinical and research settings.

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.

Assessment of structural and cross-cultural validity of the Disabilities of the Arm, Shoulder and Hand questionnaire: a scoping review

Introduction

The Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire is a patient-reported outcome measure (PROM) that has been translated and cross-culturally adapted to at least 50 languages. Since the measure was developed in 1996, many researchers have reported on the construct validity (including structural and cross-cultural validity) of this instrument following translation and cross-cultural adaptation. The aim of this scoping review was to identify the methods used for the psychometric evaluation of structural and cross-cultural validity of the DASH questionnaire.

Methods

The updated methodological guidance for the conduct of scoping reviews and the PRISMA Extension for scoping reviews checklist was utilised. EBSCOHost (Academic Search Premier, Africa Wide, CINAHL, E-Journals and Medline), PubMed and Google Scholar were searched for articles (published between 1996-2022) and considered against the eligibility criteria.

Results

The scoping review collated evidence across 50 articles (37 language versions) of the evaluation of structural and cross-cultural validity of the DASH questionnaire. Three articles conducted confirmatory factor analysis (CFA) to assess structural validity, and none performed Multiple Group Confirmatory Factor Analysis (MGCFA) to assess cross-cultural validity.

Conclusion

The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) taxonomy propose that structural validity is best evaluated through CFA, with prior evidence of dimensionality. Additionally, cross-cultural validity (measurement invariance) is to be evaluated through MGCFA. This review identified that CFA is utilised infrequently and that to date cross-cultural validity has not been appropriately assessed for translations of the DASH questionnaire.

Structural and cross-cultural validity of the Afrikaans for the Western Cape Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire

BACKGROUND

The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire has been translated and cross-culturally adapted to Afrikaans for the Western Cape, within the public health service context of South Africa. The aim of this study was to evaluate structural validity, internal consistency, and cross-cultural validity/measurement invariance of this new translation to increase applicability and clinical utility in a public health service context.

METHODS

During this cross-sectional study, exploratory factor analysis (EFA) was conducted with parallel analysis and oblimin rotation. Confirmatory factor analysis (CFA) and multiple group confirmatory factor analysis (MGCFA) to assess cross-cultural validity/measurement invariance, was employed to test model fit with X² goodness-of-fit statistic, root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR) and comparative fit index (CFI). Internal consistency was calculated using Cronbach's alpha.

RESULTS

109 women and 110 men (n = 219) completed the Afrikaans for the Western Cape and the South African English DASH questionnaire, used during the analysis. Unidimensionality of the Afrikaans for the Western Cape DASH questionnaire was not supported in the 218 questionnaires eligible for inclusion in the analysis [X² (df) = 1799.10 (405); p value = < 0.01; RMSEA (90% CI) = 0.126 (0.120-0.132); SRMR = 0.09 and CFI = 0.984]. EFA revealed a two-factor structure with Eigenvalues exceeding one explaining 55% and 7% of the variance. The two-factor structure of the Afrikaans for the Western Cape DASH questionnaire was supported during CFA. Cronbach's alpha revealed good internal consistency of both factors [factor 1 = 0.97 (0.96, 0.97) and factor 2 = 0.92 (0.90, 0.94)]. MGCFA conducted between 218 Afrikaans for the Western Cape DASH and 219 South African English DASH questionnaires (N = 437) revealed that the data supports configural, metric and scalar invariance models during initial model fit assessment. Subsequent hypotheses testing comparing the nested models revealed that scalar invariance holds.

CONCLUSION

The Afrikaans for the Western Cape DASH questionnaire revealed a two-factor structure with good internal consistency across the two factors and demonstrated measurement invariance with the South African English DASH questionnaire.

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.

Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients

BACKGROUND

Brachial plexus birth injury (BPBI) can lead to an imbalance of shoulder musculature that can lead to glenohumeral contractures, and joint and osseous deformities. Glenoid hypoplasia, lengthening of coracoid and acromion, protraction, lateral rotation and elevation of the scapula, and shortening of the clavicle can be observed. As a consequence, the trapezius, levator scapulae, rhomboid, and supraspinatus muscles are overloaded in daily activities causing pain, which can be difficult to treat conservatively. It is hypothesized that operative lengthening of the clavicle may lead to a more anatomic position of the scapula and periscapular muscles, which, as a consequence, may lead to less overloading pain. This study presents the results of this new technique in patients with BPBI.

MATERIALS AND METHODS

Seven patients (median age 20 years) were included and underwent a lengthening osteotomy of the clavicle at the affective side. Preoperatively, the osseous deformities were confirmed with a computed tomography scan. Patient-reported outcome measures, Disabilities of Arm, Shoulder and Hand score, and Mallet score were evaluated pre- and postoperatively.

RESULTS

After a median of 42 (interquartile range [IQR]: 8.0) months' follow-up, all patients were satisfied with the result. The median numeric rating scale for satisfaction was 8.0 (IQR: 2). Pain decreased from a median numeric rating scale of 7.0 (IQR: 2) preoperatively to 2.0 (IQR: 3) at the final follow-up. The median Mallet score was 14.5 (IQR: 1) preoperatively and 14 (IQR: 0) at the final follow-up. The median Disabilities of Arm, Shoulder and Hand score was 36.7 (IQR: 24.1) at the final follow-up. All patients returned to their normal work without changes in working conditions.

CONCLUSION

Short-term follow-up shows that in patients with BPBI with a short clavicle at the affected side and malposition of the scapula, a lengthening osteotomy of the clavicle is a safe and promising technique to reduce pain based on overloading, without deterioration of shoulder function.

Cross-Cultural Adaption and Validation of the Dutch Version of the Kerlan-Jobe Orthopaedic Clinic Questionnaire in Juvenile Baseball Pitchers

Monitoring the performance and functional status of baseball pitchers' upper extremity is important in maintaining the athlete's health and performance. This study validated a Dutch translation of the original English Kerlan-Jobe Orthopaedic Clinic (KJOC) against the previously validated Disabilities of the Arm, Shoulder and Hand (DASH) and Western Ontario Shoulder Instability Index (WOSI) questionnaires in a group of talented juvenile Dutch baseball pitchers. Three times, from 2014-2016, 107 pitchers completed the Dutch KJOC, DASH and WOSI questionnaires. Participants' questionnaire scores were analysed for the whole group and the symptomatic player subgroup separately. Internal consistency, construct validity and ceiling and floor effects were examined. Cronbach's alpha was consistently above 0.8 for the three time periods for the whole group, and ranged between 0.62 and 0.86 for the symptomatic subgroup. Spearman's rank correlation coefficients ranged from 0.47 to 0.67 for the whole group and 0.32 to 0.99 for the symptomatic subgroup. No floor effects were observed in the scores of the KJOC and only a ceiling effect for the whole group (15.2%) at one time period. The Dutch version of the KJOC has shown acceptable internal consistency and construct validity and can be used to assess overhead athletes' shoulder and elbow functionality.

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.

Work ability and percentage of hours worked related to limitations in patients with upper extremity musculoskeletal disorders: a cross-sectional cohort study

Background

The aim of this study was to assess the relationship between self-reported work ability and hours worked at the current time in Upper Extremity Musculoskeletal Disorders (UEMSD) patients. To further investigate this relationship, the association of work ability and working hours with several limitations in daily and working life were explored.

Methods

In this cross-sectional cohort study, a questionnaire was sent out to members of the UEMSD patient organisation, containing self-reported work ability, questions on working hours and limitations in work due to UEMSD. Limitations were measured with the Disabilities of Arm Shoulder and Hand questionnaire, ShortForm-36 subscales, and common hand grasps or grips. Work ability was measured with the work ability score, while worked hours were operationalised as the percentage of hours worked compared to fulltime. The correlation between worked hours and work ability was tested with the Pearson correlation coefficient. Variance in work ability and the hours worked were explained by limitations and assessed with two linear regression analyses.

Results

Based on data of 794 respondents a moderate correlation was found between work ability and worked hours r = 0.46; 95% CI [0.40, 0.53]. Models including limitations explained 52 and 21% of total variance in work ability and worked hours, respectively. Variance in both can be explained by the degree of difficulties performing daily activities at work, limitations in daily activities as a consequence of health issues and the ability to perform a precision grip. Additionally, work ability can be explained by limitations at work and other daily activities due to physical health issues, while the percentage of hours can additionally be explained by the ability to grasp a large object with one hand, the ability to use a keyboard, and the subject’s gender.

Conclusions

The number of worked hours does not fully match the work ability. Although they share three predictors, work ability and worked hours seem to be based on different aspects. Compared to work hours, work ability is more strongly related to limitations in daily activities and work. Taking self-reported work ability into account can improve the fit between work limitations and work hours.

The evolution of radiological measurements and the association with clinician and patient reported outcome following distal radius fractures in non-osteoporotic patients: what is clinically relevant?

Introduction: Following distal radius fractures in young non-osteoporotic patients, clinical relevancy of outcome has been scarcely reported. Outcome can be put in perspective by using measurement errors of radiological measurements and Minimal Important Change when reporting on clinician and patient reported outcome. Aim of this study was to assess the clinical relevance of radiological measurements, clinician and patient reported outcomes following distal radius fractures in young non-osteoporotic patients.Methods: Retrospective cohort study. Non-osteoporotic patients following a distal radius fracture were selected. Radiographs of both wrists were obtained at baseline, 6 weeks and at follow-up. Active range of motion and grip strength measurements were obtained at the follow-up visit and 4 questionnaires were answered to assess pain, upper extremity functioning, and health status.Results: Seventy-three patients (32 women, 41 men) with a mean age of 33.5 (SD 9.2) years at the time of injury were included. Median follow up was 62 months (IQR 53.0-84.5). Several radiological measurements evolved statistically significantly over time, however none exceeded measurement errors. Flexion/extension difference of injured compared to uninjured wrist (mean difference 11.2°, t = -7.5, df = 72, p < 0.001), exceeded Minimal Important Change, while grip strength differences did not. When comparing patients with DRFs to healthy controls, only the differences on Patient Reported Wrist Evaluation subscales "pain", "function" and total scores exceeded minimal important change (8, 10 and 13 points, respectively). Multivariable regression analysis revealed statistically significant relationships between residual step-off and respectively diminished flexion/extension (B = -36.8, 95% CI -62; -11.1, p  =  0.006), diminished radial/ulnar deviation (B = -17.9, 95% CI -32.0; -3.9, p  =  0.013) and worse ShortForm-36 "mental component score" (B = -15.4, 95% CI -26.6; -4.2, p < 0.001).Conclusion: Radiological measurements following distal radius fractures seem to evolve over time, but differences were small and were probably not clinically relevant. Range of motion, in particular flexion/extension, was impaired to such extend that it was noticeable for a patient, whereas grip strength was not impaired. The Patient Reported Wrist Evaluation was clinically relevantly diminished. Residual articular incongruency seems to influence range of motion.Implications for rehabilitationReporting Minimal Important Change regarding clinician and patient reported outcome following distal radius fractures is of more clinical value than reporting on statistical significance.Following distal radius fractures, the changes in radiological measurements do not seem to reflect a clinical relevant change.Range of motion, in particular flexion/extension, should be measured following distal radius fractures, as this might be impaired in a clinically relevant way.Measuring grip strength is of less importance following distal radius fractures, because grip strength does not seem to be affected.Residual articular incongruency seems to influence range of motion and therefore should be reduced to a minimum when treating non-osteoporotic patients.

Graded response model fit, measurement invariance and (comparative) precision of the Dutch-Flemish PROMIS® Upper Extremity V2.0 item bank in patients with upper extremity disorders

BACKGROUND

The Dutch-Flemish PROMIS® Upper Extremity (DF-PROMIS-UE) V2.0 item bank was recently developed using Item Response Theory (IRT). Unknown for this bank are: (1) if it is legitimate to calculate IRT-based scores for short forms and Computerized Adaptive Tests (CATs), which requires that the items meet the assumptions of and fit the IRT-model (Graded Response Model [GRM]);(2) if it is legitimate to compare (sub) groups of patients using this measure, which requires measurement invariance; and (3) the precision of the estimated patients' scores for patients with different levels of functioning and compared to legacy measures. Aims were to evaluate (1) the assumptions of and fit to the GRM, (2) measurement invariance and (3) (comparative) precision of the DF-PROMIS-UE v2.0.

METHODS

Cross-sectional data were collected in Dutch patients with upper extremity disorders. Assessed were IRT-assumptions (unidimensionality [bi-factor analysis], local independence [residual correlations], monotonicity [coefficient H]), GRM item fit, measurement invariance (absence of Differential Item Functioning [DIF] due to age, gender, center, duration, and location of complaints) and precision (standard error of IRT-based scores across levels of functioning). To study measurement invariance for language [Dutch vs. English], additional US data were used. Legacy instruments were the Disability of the Arm, Shoulder and Hand (DASH), the QuickDASH and the Michigan Hand Questionnaire (MHQ).

RESULTS

In total 521 Dutch (mean age ± SD = 51 ± 17 years, 49% female) and 246 US patients (mean age ± SD = 48 ± 14 years, 69% female) participated. The DF-PROMIS-UE v2.0 item bank was sufficiently unidimensional (Omega-H = 0.80, Explained Common Variance = 0.68), had negligible local dependence (four out of 1035 correlations > 0.20), good monotonicity (H = 0.63), good GRM fit (no misfitting items) and demonstrated sufficient measurement invariance. Precise estimates (Standard Error < 3.2) were obtained for most patients (7-item short form, 88.5%; standard CAT, 91.3%; and, fixed 7-item CAT, 87.6%). The DASH displayed better reliability than the DF-PROMIS-UE short form and standard CAT, the QuickDASH displayed comparable reliability. The MHQ-ADL displayed better reliability than the DF-PROMIS-UE short form and standard CAT for T-scores between 28 and 50. For patients with low function, the DF-PROMIS-UE measures performed better.

CONCLUSIONS

The DF-PROMIS-UE v2.0 item bank showed sufficient psychometric properties in Dutch patients with UE disorders.

Structural validity and construct validity of the Dutch-Flemish PROMIS® physical function-upper extremity version 2.0 item bank in Dutch patients with upper extremity injuries

INTRODUCTION

Aim of this study was to validate the Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank in patients with upper extremity injuries.

MATERIALS AND METHODS

Cross-sectional study. Structural validity was assessed using Confirmatory Factor Analysis examining unidimensionality. In addition, a bi-factor model was fitted. Internal consistency was assessed by Cronbach's alpha. Construct validity was examined by assessing correlations with legacy instruments Disability of Arm Shoulder and Hand, Patient Reported Wrist Evaluation and Michigan Hand Questionnaire subscale Activities in Daily Life.

RESULTS

A total of 303 patients (144 female) with mean age of 50 years (standard deviation 18) were included. Confirmatory Factor Analysis showed Comparative Fit Index of 0.94, a Tucker Lewis Index of 0.93, a Root Mean Square Error of Approximation of 0.12 and a Standardized Root Mean Residual of 0.09. Factor loadings were all above 0.70. Bifactor analysis showed an omega-H of 0.79 and Explained Common Variance of 0.67. The correlations with the legacy instruments were as expected or higher than expected.

CONCLUSION

The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and sufficient construct validity was found.IMPLICATIONS FOR REHABILITATIONCompleting Patient Reported Outcomes is time-consuming for patients and interpretability of outcomes is sometimes unclear due to some variation in psychometric properties.Computerized Adaptive Testing reduces the burden for patients by using an algorithm which decreases the amount of questions that need to be answered to 4 to 7 items.The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and has sufficient structural validity, internal consistency and construct validity.After calibration of the Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0, the item bank is operable to use with Computerized Adaptive Testing.

Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome

Background:

Pain and functional impairment of the ipsilateral shoulder girdle in patients who underwent surgery and radiotherapy for breast cancer (BC) is a late complication reported in the literature. We analyze a correlation with dosimetric parameters and propose an algorithm for sparing strategies.

Methods:

A total of 111 patients treated for BC were included in this observational analysis during follow-up protocol visits. Exclusion criteria were the presence of moderate or severe arthrosis history and/or rheumatologic diseases. All the patients had complete physical and multidimensional examinations during joint (physiatrist and radiotherapy oncology) follow-up visits. A scapula–humeral articulation (SHA) standardized contouring was performed retrospectively on Eclipse® treatment plans. A possible correlation between patients’ characteristics, radiotherapy, and dosimetry analysis and functional impairment was investigated at statistical analysis. Results of analysis were summarized into a proposal of algorithm for sparing SHA.

Results:

A total of 111 patients were selected during follow-up visits. Mean age of patients was 60 years (range 41–85 years). A total of 103 patients (93%) underwent conservative surgery, with 110 patients (99%) undergoing axilla surgery as well. Fifty-two patients (46.8%) presented a reduction of range of motion (ROM) abduction on the treated side at the observational analysis. Mean ROM abduction reduction was 13°06’ (range 0°–100°). Disability of the Arm, Shoulder and Hand questionnaire (DASH) score results were excellent in 79 patients (71.2%), discrete in 15 patients (13.5%), good in 15 patients (13.5%), and sufficient in 2 patients (1.8%). Median EQD2Dmaxat SHA was 18 Gy (range 0.22–51.9 Gy) and median EQD2mean dose at SHA was 2 Gy (range 0.04–24.32 Gy). Univariate analysis showed a linear correlation between DASH score and ROM of abduction of treated side (ρ=−0.7), ROM of abduction and ROM of flexion in ipsilateral arm (ρ=0.8), or ROM of abduction and ROM of flexion in contralateral arm (ρ=0.8). A statistically significant difference in ROM abduction between the 2 arms was found at χ2test ( P<0.05 at χ2confidence interval = 95%). Cox linear regression analysis showed ROM abduction on treated arm as a predictive factor of DASH score ( P<0.0001). Age ( P<0.05), DASH score ( P=0.006), and ROM abduction on treated arm ( P=0.005) were found as independent predictive factors of mean dose at multivariate analysis. A mean dose higher than 7 Gy and ROM abduction reduction more than 30° were related to DASH score level reduction.

Conclusions:

This hypothesis-generating study introduces an algorithm to be validated for management of sparing SHA and improving quality of survivorship. ROM evaluation after surgery, early physiotherapy, standard contouring, and planning adaptation represent possible indications to preserve shoulder impairment. Further prospective studies are needed to discriminate impairment of surgery and radiotherapy in order to personalized therapeutic plan programs.

Pain, impaired functioning, poor satisfaction and diminished health status eight years following perilunate (fracture) dislocations

Purpose: Perilunate (fracture) dislocations are rare injuries and diminished functional outcomes are reported. However, Patient Reported Outcomes (PROs) following these injuries are rarely described. The aim of this study was to investigate the long-term impact of perilunate (fracture) dislocations using a range of measures, including pain, function, and quality of life.Materials and Methods: This cross-sectional study was conducted from January 2016 until March 2016. Eleven patients who had suffered from perilunate (fracture) dislocations between August 1996 and January 2014 were matched on age and gender with 22 healthy controls. Functional outcome included range of motion and grip strength measurements. The Patient Reported Outcomes included: Patient Reported Wrist Evaluation, Disability of Arm, Shoulder and Hand questionnaire, Michigan Hand Questionnaire and the Short Form-36.Results: The 11 patients that were included (9 males) had a median age at injury of 38 years (IQR 33; 54) and median follow up of 97 months (IQR 84-193). Flexion/extension (mean difference -60°, 95% CI -76, -43, p < 0.001) and ulnar/radial deviation (mean difference -28°, 95% CI -38, -18, p < 0.001) were significantly diminished in patients following perilunate (fracture) dislocations. Grip strength was not affected. The patients experienced significantly more pain as assessed on all pain subscales. Physical functioning was significantly worse in the group with perilunate (fracture) dislocations as assessed on all function subscales, except the PRWE function score and the subscale physical functioning of the Short Form-36. Satisfaction as measured with the Michigan Hand Questionnaire satisfaction subscale (mean difference -36, 95% CI -57, -16, p = 0.002) was also reported poorer. No difference was found regarding work participation.Conclusions: A perilunate (fracture) dislocation has a significant impact on everyday life, as patients experience diminished range of motion, pain, diminished physical functioning, diminished satisfaction and report lower general health status than healthy controls. However, no consequences for work participation were found in this study. Level of evidence 3.Implications for rehabilitationFlexion/extension and ulnar/radial deviation remains limited following perilunate (fracture) dislocations.Grip strength is not diminished in patients with perilunate (fracture) dislocations.Pain, restrictions in physical functioning, diminished satisfaction and lower general health status are likely to be present following perilunate (fracture) dislocations.If conservative treatment including pain medication and rehabilitation strategies do not relief pain following perilunate (fracture) dislocations, surgical treatment options such as wrist denervation or arthrodesis should be considered.