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Van der Weegen W, Van Egmond JC, Geuze RE, Gosens T, Snoeker B, Poolman RW. A simplified, 2-question grading system for evaluating abstracts in orthopedic scientific meetings: a serial randomization study. Acta Orthop 2024; 95:180-185. [PMID: 38629944 PMCID: PMC11022873 DOI: 10.2340/17453674.2024.40504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Efficient abstract scoring for congress presentation is important. Given the emergence of new study methodologies, a scoring system that accommodates all study designs is warranted. We aimed to assess the equivalence of a simplified, 2-question abstract grading system with a more complex currently used system in assessing abstracts submitted for orthopedic scientific meetings in a serial randomized study. METHODS Dutch Orthopedic Association Scientific Committee (DOASC) members were randomized to grade abstracts using either the current grading system, which includes up to 7 scoring categories, or the new grading system, which consists of only 2 questions. Pearson correlation coefficient and mean abstract score with 95% confidence intervals (CI) were calculated. RESULTS Analysis included the scoring of 195 abstracts by 12-14 DOASC members. The average score for an abstract using the current system was 60 points (CI 58-62), compared with 63 points (CI 62-64) using the new system. By using the new system, abstracts were scored higher by 3.3 points (CI 1.7-5.0). Pearson correlation was poor with coefficient 0.38 (P < 0.001). CONCLUSION The simplified abstract grading system exhibited a poor correlation with the current scoring system, while the new system offers a more inclusive evaluation of varying study designs and is preferred by almost all DOASC members.
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Affiliation(s)
| | | | - Ruth E Geuze
- Department of Orthopedics, Elisabeth-Tweesteden Ziekenhuis, Tilburg
| | - Taco Gosens
- Department of Orthopedics, Elisabeth-Tweesteden Ziekenhuis, Tilburg
| | - Barbara Snoeker
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Medical Center, University of Amsterdam
| | - Rudolf W Poolman
- Department of Orthopedics, Leiden University Medical Center, Leiden; Department of Orthopedics, Joint Research, OLVG, Amsterdam, the Netherlands
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Bernstein DN, Shin D, Poolman RW, Schwab JH, Tobert DG. Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores? Clin Orthop Relat Res 2024; 482:604-614. [PMID: 37882798 PMCID: PMC10937004 DOI: 10.1097/corr.0000000000002896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate. QUESTIONS/PURPOSES Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors? METHODS New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status-as measured by the SDoH indices-among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05. RESULTS There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively. CONCLUSION Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application. CLINICAL RELEVANCE We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - David Shin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Oosterhoff JHF, de Hond AAH, Peters RM, van Steenbergen LN, Sorel JC, Zijlstra WP, Poolman RW, Ring D, Jutte PC, Kerkhoffs GMMJ, Putter H, Steyerberg EW, Doornberg JN. Machine Learning Did Not Outperform Conventional Competing Risk Modeling to Predict Revision Arthroplasty. Clin Orthop Relat Res 2024:00003086-990000000-01528. [PMID: 38470976 DOI: 10.1097/corr.0000000000003018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 02/01/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Estimating the risk of revision after arthroplasty could inform patient and surgeon decision-making. However, there is a lack of well-performing prediction models assisting in this task, which may be due to current conventional modeling approaches such as traditional survivorship estimators (such as Kaplan-Meier) or competing risk estimators. Recent advances in machine learning survival analysis might improve decision support tools in this setting. Therefore, this study aimed to assess the performance of machine learning compared with that of conventional modeling to predict revision after arthroplasty. QUESTION/PURPOSE Does machine learning perform better than traditional regression models for estimating the risk of revision for patients undergoing hip or knee arthroplasty? METHODS Eleven datasets from published studies from the Dutch Arthroplasty Register reporting on factors associated with revision or survival after partial or total knee and hip arthroplasty between 2018 and 2022 were included in our study. The 11 datasets were observational registry studies, with a sample size ranging from 3038 to 218,214 procedures. We developed a set of time-to-event models for each dataset, leading to 11 comparisons. A set of predictors (factors associated with revision surgery) was identified based on the variables that were selected in the included studies. We assessed the predictive performance of two state-of-the-art statistical time-to-event models for 1-, 2-, and 3-year follow-up: a Fine and Gray model (which models the cumulative incidence of revision) and a cause-specific Cox model (which models the hazard of revision). These were compared with a machine-learning approach (a random survival forest model, which is a decision tree-based machine-learning algorithm for time-to-event analysis). Performance was assessed according to discriminative ability (time-dependent area under the receiver operating curve), calibration (slope and intercept), and overall prediction error (scaled Brier score). Discrimination, known as the area under the receiver operating characteristic curve, measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities; a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. A scaled version of the Brier score, 1 - (model Brier score/null model Brier score), can be interpreted as the amount of overall prediction error. RESULTS Using machine learning survivorship analysis, we found no differences between the competing risks estimator and traditional regression models for patients undergoing arthroplasty in terms of discriminative ability (patients who received a revision compared with those who did not). We found no consistent differences between the validated performance (time-dependent area under the receiver operating characteristic curve) of different modeling approaches because these values ranged between -0.04 and 0.03 across the 11 datasets (the time-dependent area under the receiver operating characteristic curve of the models across 11 datasets ranged between 0.52 to 0.68). In addition, the calibration metrics and scaled Brier scores produced comparable estimates, showing no advantage of machine learning over traditional regression models. CONCLUSION Machine learning did not outperform traditional regression models. CLINICAL RELEVANCE Neither machine learning modeling nor traditional regression methods were sufficiently accurate in order to offer prognostic information when predicting revision arthroplasty. The benefit of these modeling approaches may be limited in this context.
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Affiliation(s)
- Jacobien H F Oosterhoff
- Amsterdam UMC, University of Amsterdam, Department of Orthopedic Surgery and Sports Medicine, Amsterdam, the Netherlands
- Department of Engineering Systems and Services, Faculty of Technology Policy and Management, Delft University of Technology, Delft, the Netherlands
| | - Anne A H de Hond
- Clinical AI Implementation and Research Lab, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rinne M Peters
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | | | - Juliette C Sorel
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX, USA
| | - Paul C Jutte
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Gino M M J Kerkhoffs
- Amsterdam UMC, University of Amsterdam, Department of Orthopedic Surgery and Sports Medicine, Amsterdam, the Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Ewout W Steyerberg
- Clinical AI Implementation and Research Lab, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Job N Doornberg
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
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Van Beers LWAH, Scheijbeler E, Van Oldenrijk J, Geerdink CH, Niers BBAM, Willigenburg NW, Poolman RW. Short versus conventional straight stem in uncemented total hip arthroplasty: functional outcomes up to 5 years and survival up to 12 years: secondary results of a randomized controlled trial. Acta Orthop 2024; 95:99-107. [PMID: 38318961 PMCID: PMC10846089 DOI: 10.2340/17453674.2024.39964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/14/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND AND PURPOSE To date, the mid- and long-term outcomes of the Collum Femoris Preserving (CFP) stem compared with conventional straight stems are unknown. We aimed to compare physical function at a 5-year follow-up and implant survival at an average of 10-year follow-up in an randomized controlled trial (RCT). METHODS This is a secondary report of a double-blinded RCT in 2 hospitals. Patients aged 18-70 years with hip osteoarthritis undergoing an uncemented primary THA were randomized to a CFP or a Zweymüller stem. Patient-reported outcomes, clinical tests, and radiographs were collected at baseline, 2, 3, 4, and 5 years postoperatively. Primary outcome was the Hip disability and Osteoarthritis Outcome Score (HOOS) function in activities of daily living (ADL) subscale. Secondary outcomes were other patient-reported outcomes, clinical tests, adverse events, and implant survival. Kaplan-Meier and competing risk survival analyses were performed with data from the Dutch Arthroplasty Registry. RESULTS We included 150 patients. Mean difference between groups on the HOOS ADL subscale at 5 years was -0.07 (95% confidence interval -5.1 to 4.9). Overall survival was 92% for the CFP and 96% for the Zweymüller stem. No significant difference was found. CONCLUSION No significant differences were found in physical function at 5-year and implant survival at 10-year follow-up between the CFP and Zweymüller stems. When taking cup revisions into account, the CFP group showed clinically inferior survival.
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Affiliation(s)
- Loes W A H Van Beers
- Department of Orthopaedic Surgery, OLVG, Amsterdam; Department of Orthopaedic Surgery, St Antonius Hospital, Utrecht.
| | | | | | | | - Bob B A M Niers
- Department of Orthopedic Surgery, Ikazia Hospital, Rotterdam
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, OLVG, Amsterdam; Department of Orthopedic Surgery, LUMC, Leiden, The Netherlands
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Tol MCJM, Willigenburg NW, Rasker AJ, Willems HC, Gosens T, Heetveld MJ, Schotanus MGM, Eggen B, Kormos M, van der Pas SL, van der Vaart AW, Goslings JC, Poolman RW. Posterolateral or Direct Lateral Surgical Approach for Hemiarthroplasty After a Hip Fracture: A Randomized Clinical Trial Alongside a Natural Experiment. JAMA Netw Open 2024; 7:e2350765. [PMID: 38206628 PMCID: PMC10784859 DOI: 10.1001/jamanetworkopen.2023.50765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/20/2023] [Indexed: 01/12/2024] Open
Abstract
Importance Hip fractures in older adults are serious injuries that result in disability, higher rates of illness and death, and a substantial strain on health care resources. High-quality evidence to improve hip fracture care regarding the surgical approach of hemiarthroplasty is lacking. Objective To compare 6-month outcomes of the posterolateral approach (PLA) and direct lateral approach (DLA) for hemiarthroplasty in patients with acute femoral neck fracture. Design, Setting, and Participants This multicenter, randomized clinical trial (RCT) comparing DLA and PLA was performed alongside a natural experiment (NE) at 14 centers in the Netherlands. Patients aged 18 years or older with an acute femoral neck fracture were included, with or without dementia. Secondary surgery of the hip, pathological fractures, or patients with multitrauma were excluded. Recruitment took place between February 2018 and January 2022. Treatment allocation was random or pseudorandom based on geographical location and surgeon preference. Statistical analysis was performed from July 2022 to September 2022. Exposure Hemiarthroplasty using PLA or DLA. Main Outcome and Measures The primary outcome was health-related quality of life 6 months after surgery, quantified with the EuroQol Group 5-Dimension questionnaire (EQ-5D-5L). Secondary outcomes included dislocations, fear of falling and falls, activities of daily living, pain, and reoperations. To improve generalizability, a novel technique was used for data fusion of the RCT and NE. Results A total of 843 patients (542 [64.3%] female; mean [SD] age, 82.2 [7.5] years) participated, with 555 patients in the RCT (283 patients in the DLA group; 272 patients in the PLA group) and 288 patients in the NE (172 patients in the DLA group; 116 patients in the PLA group). In the RCT, mean EQ-5D-5L utility scores at 6 months were 0.50 (95% CI, 0.45-0.55) after DLA and 0.49 (95% CI, 0.44-0.54) after PLA, with 77% completeness. The between-group difference (-0.04 [95% CI, -0.11 to 0.04]) was not statistically significant nor clinically meaningful. Most secondary outcomes were comparable between groups, but PLA was associated with more dislocations than DLA (RCT: 15 of 272 patients [5.5%] in PLA vs 1 of 283 patients [0.4%] in DLA; NE: 6 of 113 patients [5.3%]) in PLA vs 2 of 175 patients [1.1%] in DLA). Data fusion resulted in an effect size of 0.00 (95% CI, -0.04 to 0.05) for the EQ-5D-5L and an odds ratio of 12.31 (95% CI, 2.77 to 54.70) for experiencing a dislocation after PLA. Conclusions and Relevance This combined RCT and NE found that among patients treated with a cemented hemiarthroplasty after an acute femoral neck fracture, PLA was not associated with a better quality of life than DLA. Rates of dislocation and reoperation were higher after PLA. Randomized and pseudorandomized data yielded similar outcomes, which suggests a strengthening of these findings. Trial Registration ClinicalTrials.gov Identifier: NCT04438226.
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Affiliation(s)
- Maria C. J. M. Tol
- Department of Orthopedic Surgery, Joint Research, OLVG Hospital, Amsterdam, the Netherlands
| | - Nienke W. Willigenburg
- Department of Orthopedic Surgery, Joint Research, OLVG Hospital, Amsterdam, the Netherlands
| | - Ariena J. Rasker
- Department of Orthopedic Surgery, Joint Research, OLVG Hospital, Amsterdam, the Netherlands
| | - Hanna C. Willems
- Department of Internal Medicine and Geriatrics, Amsterdam UMC, Amsterdam, the Netherlands
| | - Taco Gosens
- Department of Orthopedics and Trauma Surgery, ETZ, Tilburg, the Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands
| | - Martin J. Heetveld
- Department of Trauma Surgery, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Martijn G. M. Schotanus
- Department of Orthopedic Surgery & Traumatology, Zuyderland Medical Center, Heerlen, Sittard-Geleen, the Netherlands
- School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Science, Maastricht University, the Netherlands
| | - Bart Eggen
- Delft University of Technology, Electrical Engineering, Mathematics and Computer Science, Delft, the Netherlands
| | - Mate Kormos
- Delft University of Technology, Electrical Engineering, Mathematics and Computer Science, Delft, the Netherlands
| | - Stéphanie L. van der Pas
- Amsterdam UMC location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Aad W. van der Vaart
- Delft University of Technology, Electrical Engineering, Mathematics and Computer Science, Delft, the Netherlands
| | - J. Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Rudolf W. Poolman
- Department of Orthopedic Surgery, Joint Research, OLVG Hospital, Amsterdam, the Netherlands
- Department of Orthopedic Surgery, LUMC, Leiden, the Netherlands
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Geurkink TH, Marang-van de Mheen PJ, Nagels J, Wessel RN, Poolman RW, Nelissen RG, van Bodegom-Vos L. Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study. Arthrosc Sports Med Rehabil 2023; 5:100819. [PMID: 38023445 PMCID: PMC10661501 DOI: 10.1016/j.asmr.2023.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors. Methods Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision. Results A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors. Conclusions Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important. Clinical Relevance There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.
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Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronald N. Wessel
- Department of Orthopaedics, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Willigenburg NW, Poolman RW. The difference between statistical significance and clinical relevance. The case of minimal important change, non-inferiority trials, and smallest worthwhile effect. Injury 2023; 54 Suppl 5:110764. [PMID: 37923502 DOI: 10.1016/j.injury.2023.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 11/07/2023]
Abstract
Clinical relevance and statistical significance are different concepts, linked via the sample size calculation. Threshold values for detecting a minimal important change over time are frequently (mis)interpreted as a threshold for the clinical relevance of a difference between groups. The magnitude of a difference between groups that is considered clinically relevant directly impacts the sample size calculation, and thereby the statistical significance in clinical study outcomes. Especially in non-inferiority trials the threshold for clinical relevance, i.e. the predefined margin for non-inferiority, is a crucial choice. A truly inferior treatment will be accepted as non-inferior when this margin is chosen too large. The magnitude of a clinically relevant difference between groups should be carefully considered, by determining the smallest effect for each specific study that is considered worthwhile. This means taking into account the (dis)advantages of both study interventions in terms of benefits, harms, costs, and potential side effects. This article clarifies common sources of confusion, illustrates the implications for clinical research with an example and provides specific suggestions to improve the design and interpretation of clinical research.
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Affiliation(s)
- Nienke W Willigenburg
- Joint Research, Department of Orthopaedic Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Rudolf W Poolman
- Joint Research, Department of Orthopaedic Surgery, OLVG Hospital, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Geurkink TH, Marang-van de Mheen PJ, Nagels J, Poolman RW, Nelissen RG, van Bodegom-Vos L. Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons. Int J Health Policy Manag 2023; 12:7710. [PMID: 38618816 PMCID: PMC10590240 DOI: 10.34172/ijhpm.2023.7710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 07/31/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers. METHODS We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion. RESULTS Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They [healthcare insurer] got it wrong," as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy. CONCLUSION The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.
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Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Schemitsch EH, Nowak LL, Schulz AP, Brink O, Poolman RW, Mehta S, Stengel D, Zhang CQ, Martinez S, Kinner B, Chesser TJS, Bhandari M. Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317164. [PMID: 37278998 DOI: 10.1001/jamanetworkopen.2023.17164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Importance Fractures of the hip have devastating effects on function and quality of life. Intramedullary nails (IMN) are the dominant implant choice for the treatment of trochanteric fractures of the hip. Higher costs of IMNs and inconclusive benefit in comparison with sliding hip screws (SHSs) convey the need for definitive evidence. Objective To compare 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS. Design, Setting, and Participants This randomized clinical trial was conducted at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopaedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patient recruitment occurred between January 2012 and January 2016, and patients were followed up for 52 weeks (primary end point). Follow-up was completed in January 2017. The analysis was performed in July 2018 and confirmed in January 2022. Interventions Surgical fixation with a Gamma3 IMN or an SHS. Main Outcomes and Measures The primary outcome was health-related quality of life (HRQOL), measured by the EuroQol-5 Dimension (EQ5D) at 1-year postsurgery. Secondary outcomes included revision surgical procedure, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score). Results In this randomized clinical trial, 850 patients were randomized (mean [range] age, 78.5 [18-102] years; 549 [64.6% female) with trochanteric fractures to undergo fixation with either the IMN (n = 423) or an SHS (n = 427). A total of 621 patients completed follow-up at 1 year postsurgery (304 treated with the IMN [71.9%], 317 treated with an SHS [74.2%]). There were no significant differences between groups in EQ5D scores (mean difference, 0.02 points; 95% CI, -0.03 to 0.07 points; P = .42). Furthermore, after adjusting for relevant covariables, there were no between-group differences in EQ5D scores (regression coefficient, 0.00; 95% CI, -0.04 to 0.05; P = .81). There were no between-group differences for any secondary outcomes. There were also no significant interactions for fracture stability (β [SE] , 0.01 [0.05]; P = .82) or previous fracture (β [SE], 0.01 [0.10]; P = .88) and treatment group. Conclusions and Relevance This randomized clinical trial found that IMNs for the treatment of trochanteric fractures had similar 1-year outcomes compared with SHSs. These results suggest that the SHS is an acceptable lower-cost alternative for trochanteric fractures of the hip. Trial Registration ClinicalTrials.gov Identifier: NCT01380444.
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Affiliation(s)
- Emil H Schemitsch
- London Health Sciences Centre, London, Ontario, Canada
- Western University, London, Ontario, Canada
| | - Lauren L Nowak
- London Health Sciences Centre, London, Ontario, Canada
- Western University, London, Ontario, Canada
| | | | | | | | | | - Dirk Stengel
- BG Kliniken: Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
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10
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Comeau-Gauthier M, Bzovsky S, Axelrod D, Poolman RW, Frihagen F, Bhandari M, Schemitsch E, Sprague S. Is the use of bipolar hemiarthroplasty over monopolar hemiarthroplasty justified? A propensity score-weighted analysis of a multicentre randomized controlled trial. Bone Jt Open 2023; 4:370-377. [PMID: 37203362 DOI: 10.1302/2633-1462.45.bjo-2023-0026.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Aims Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA). Methods This study is a secondary analysis of patients aged 50 years or older with a displaced femoral neck fracture who were enrolled in the HEALTH trial and underwent monopolar and bipolar HA. Scores from the Western Ontario and McMaster University Arthritis Index (WOMAC) and 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and (MCS) were compared between the two HA groups using a propensity score-weighted analysis. Results Of 746 HAs performed in the HEALTH trial, 404 were bipolar prostheses and 342 were unipolar. After propensity score weighting, adequate balance between the bipolar and unipolar groups was obtained as shown by standardized mean differences less than 0.1 for each covariable. A total of 24 months after HA, the total WOMAC score and its subcomponents showed no statistically significant difference between the unipolar and bipolar groups. Similarly, no statistically significant difference was found in the PCS and MCS scores of the SF-12 questionnaire. In participants aged 70 years and younger, no difference was found in any of the functional outcomes. Conclusion From the results of this study, the use of bipolar HA over unipolar design does not provide superior functional outcomes at 24 months postoperatively. The theoretical advantage of reduced acetabular wear with bipolar designs does not appear to influence functional outcomes in the first two years postoperatively.
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Affiliation(s)
- Marianne Comeau-Gauthier
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Axelrod
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, OLVG, Amsterdam and LUMC, Leiden, the Netherlands
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Emil Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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11
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Iken AR, Poolman RW, Nelissen RGHH, Gademan MGJ. Challenges in developing national orthopedic health research agendas in the Netherlands: process overview and recommendations. Acta Orthop 2023; 94:230-235. [PMID: 37194475 DOI: 10.2340/17453674.2023.12402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Indexed: 05/18/2023] Open
Abstract
Growing demand for clinical research to improve evidence-based medicine in daily medical practice led to healthcare evaluation, which assesses the effectiveness of the existing care. The first step is identifying and prioritizing the most important evidence uncertainties. A health research agenda (HRA) can be valuable and helps determine funding and resource allocation, aiding researchers and policymakers to design successful research programs and implement the results in daily medical practice. We provide an overview of the development process of the first 2 HRAs within orthopedic surgery in the Netherlands and the following research process. In addition, we developed a checklist with recommendations for the future development of an HRA. This perspective guides the development of highquality and widely supported nationwide HRAs, including preparatory actions. This improves the uptake of evidence uncertainties in a successful research program and disseminates evidence-based literature in daily medical practice to improve patient care.
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Affiliation(s)
- Annabelle R Iken
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden.
| | - Rudolf W Poolman
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden; Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden
| | - Maaike G J Gademan
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden; Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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12
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Bernstein DN, Lans A, Karhade AV, Heng M, Poolman RW, Schwab JH, Tobert DG. Are Detailed, Patient-level Social Determinant of Health Factors Associated With Physical Function and Mental Health at Presentation Among New Patients With Orthopaedic Conditions? Clin Orthop Relat Res 2023; 481:912-921. [PMID: 36201422 PMCID: PMC10097559 DOI: 10.1097/corr.0000000000002446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery. QUESTIONS/PURPOSES (1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation? METHODS New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 ± 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values < 0.05 designated statistical significance. The concept of minimum clinically important difference (MCID) was used to assess clinical importance. Regression coefficients represent the projected change in PROMIS physical or mental health symptom scores (that is, the dependent variable in our regression analyses) accounting for the other included variables. Thus, a regression coefficient for a given variable at or above a known MCID value suggests a clinical difference between those patients with and without the presence of that given characteristic. In this manuscript, regression coefficients at or above 4.2 (or at and below -4.2) for PROMIS Global Physical Health and at or above 5.1 (or at and below -5.1) for PROMIS Global Mental Health were considered clinically relevant. RESULTS Among the included patients, 8% (685 of 9057) were unemployed but seeking work, 4% (399 of 9057) reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, 4% (328 of 9057) reported trouble paying for medications, and 2% (181 of 9057) had no current housing. Lack of reliable transportation to attend doctor visits or pick up medications (β = -4.52 [95% CI -5.45 to -3.59]; p < 0.001), trouble paying for medications (β = -4.55 [95% CI -5.55 to -3.54]; p < 0.001), Medicaid insurance (β = -5.81 [95% CI -6.41 to -5.20]; p < 0.001), and workers compensation insurance (β = -5.99 [95% CI -7.65 to -4.34]; p < 0.001) were associated with clinically worse function at presentation. Trouble paying for medications (β = -6.01 [95% CI -7.10 to -4.92]; p < 0.001), Medicaid insurance (β = -5.35 [95% CI -6.00 to -4.69]; p < 0.001), and workers compensation (β = -6.07 [95% CI -7.86 to -4.28]; p < 0.001) were associated with clinically worse mental health at presentation. CONCLUSION Although transportation issues and financial hardship were found to be associated with worse presenting physical function and mental health, Medicaid and workers compensation insurance remained associated with worse presenting physical function and mental health as well even after controlling for these more detailed, patient-level SDoH factors. Because of that, interventions to decrease health disparities should focus on not only sociodemographic variables (for example, insurance type) but also tangible patient-specific SDoH characteristics. For example, this may include giving patients taxi vouchers or ride-sharing credits to attend clinic visits for patients demonstrating such a need, initiating financial assistance programs for necessary medications, and/or identifying and connecting certain patient groups with social support services early on in the care cycle. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Amanda Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Utrect, the Netherlands
| | - Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Oosterhoff JHF, Dijkstra H, Karhade AV, Poolman RW, Schipper IB, Nelissen RGHH, van Embden D, Jaarsma RL, Schwab JH, Doornberg JN, Heng M, Jadav B. Clockwise torque results in higher reoperation rates in left-sided femur fractures. Injury 2023:S0020-1383(23)00386-8. [PMID: 37164900 DOI: 10.1016/j.injury.2023.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. RESULTS In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05). CONCLUSION This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. LEVEL OF EVIDENCE Therapeutic level II.
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Affiliation(s)
- Jacobien H F Oosterhoff
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Engineering Systems and Services, Faculty Technology Policy Management, Delft University of Technology, Delft, the Netherlands
| | - Hidde Dijkstra
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Geriatric Medicine, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands.
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Inger B Schipper
- Department of Surgery, Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daphne van Embden
- Department of Trauma Surgery, Amsterdam University Medical Centers, the Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedics & Trauma Surgery, Flinders Medical Centre and Flinders University, Adelaide, SA, Australia
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Job N Doornberg
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Orthopaedics & Trauma Surgery, Flinders Medical Centre and Flinders University, Adelaide, SA, Australia
| | - Marilyn Heng
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Bhavin Jadav
- Department of Orthopaedics & Trauma Surgery, Flinders Medical Centre and Flinders University, Adelaide, SA, Australia
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Dijkstra H, Oosterhoff JHF, van de Kuit A, IJpma FFA, Schwab JH, Poolman RW, Sprague S, Bzovsky S, Bhandari M, Swiontkowski M, Schemitsch EH, Doornberg JN, Hendrickx LAM. Development of machine-learning algorithms for 90-day and one-year mortality prediction in the elderly with femoral neck fractures based on the HEALTH and FAITH trials. Bone Jt Open 2023; 4:168-181. [PMID: 37051847 PMCID: PMC10032237 DOI: 10.1302/2633-1462.43.bjo-2022-0162.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making.
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Affiliation(s)
- Hidde Dijkstra
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Geriatric Medicine, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacobien H F Oosterhoff
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Engineering Systems and Services, Faculty Technology Policy Management, Delft University of Technology, Delt, Netherlands
| | - Anouk van de Kuit
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Orthopaedic Surgery, Onze Lieve Vrouw Gasthuis, Amsterdam, The Netherlands
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Marc Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Job N Doornberg
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Laurent A M Hendrickx
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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15
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van Loon J, Sierevelt IN, Spekenbrink-Spooren A, Opdam KTM, Poolman RW, Kerkhoffs GMMJ, Haverkamp D. Higher risk of 2-year cup revision of ceramic-on-ceramic versus ceramic-on-polyethylene bearing: analysis of 33,454 primary press-fit total hip arthroplasties registered in the Dutch Arthroplasty Register (LROI). Hip Int 2023; 33:280-287. [PMID: 34974763 PMCID: PMC9978866 DOI: 10.1177/11207000211064975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The influence of bearing on short-term revision in press-fit total hip arthroplasty (THA) remains under-reported. The aim of this study was to describe 2-year cup revision rates of ceramic-on-ceramic (CoC) and ceramic-on-polyethylene (CoPE). PATIENTS AND METHODS Primary press-fit THAs with one of the three most used cups available with both CoC or CoPE bearing recorded in the Dutch Arthroplasty Register (LROI) were included (2007-2019). Primary outcome was 2-year cup revision for all reasons. Secondary outcomes were: reasons for revision, incidence of different revision procedures and use of both bearings over time. RESULTS 2-year Kaplan-Meier cup revision rate in 33,454 THAs (12,535 CoC; 20,919 CoPE) showed a higher rate in CoC (0.67% [95% CI, 0.54-0.81]) compared to CoPE (0.44% [95% CI, 0.34-0.54]) (p = 0.004). Correction for confounders (age, gender, cup type, head size) resulted in a hazard ratio (HR) of 0.64 [95%CI, 0.48-0.87] (p = 0.019). Reasons for cup revision differed only by more cup revision due to loosening in CoC (26.2% vs.1 3.2%) (p = 0.030). For aseptic loosening a revision rate of 0.153% [95% CI, 0.075-0.231] was seen in CoC and 0.058% [95%CI 0.019-0.097] in CoPE (p = 0.007). Correction for head size resulted in a HR of 0.475 [95% CI, 0.197-1.141] (p = 0.096). Incidence of different revision procedures did not differ between bearings. Over time the use of CoPE has increased and CoC decreased. CONCLUSIONS A higher 2-year cup revision rate in press-fit THA was observed in CoC compared to CoPE. Cup loosening was the only significantly different reason for revision and seen more often in CoC and mostly aseptic. Future randomised controlled trials need to confirm causality, since the early cup revision data provided has the potential to be useful when choosing the bearing in press-fit THA, when combined with other factors like bone quality and patient and implant characteristics.
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Affiliation(s)
- Justin van Loon
- Xpert Clinics Orthopedie Amsterdam, The
Netherlands,Department of Orthopaedic Surgery,
Amsterdam Movement Sciences, Amsterdam UMC, Academic Medical Centre, University of
Amsterdam, Amsterdam, The Netherlands,Department of Orthopaedic Surgery,
Tergooi, Hilversum, The Netherlands
| | - Inger N Sierevelt
- Xpert Clinics Orthopedie Amsterdam, The
Netherlands,Department of Orthopaedic Surgery,
Spaarne Gasthuis Academy, TM Hoofddorp, The Netherlands
| | | | - Kim TM Opdam
- Department of Orthopaedic Surgery,
Amsterdam Movement Sciences, Amsterdam UMC, Academic Medical Centre, University of
Amsterdam, Amsterdam, The Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery,
Leiden University Medical Centre, Leiden, The Netherlands,Department of Orthopaedic Surgery,
OLVG, Amsterdam, The Netherlands
| | - Gino MMJ Kerkhoffs
- Department of Orthopaedic Surgery,
Amsterdam Movement Sciences, Amsterdam UMC, Academic Medical Centre, University of
Amsterdam, Amsterdam, The Netherlands
| | - Daniël Haverkamp
- Xpert Clinics Orthopedie Amsterdam, The
Netherlands,Daniël Haverkamp, Xpert Clinics Orthopedie
Amsterdam, Laarderhoogtweg 12, Amsterdam, North-Holland, 1101EA, The
Netherlands.
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16
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Wijn SRW, Hannink G, Østerås H, Risberg MA, Roos EM, Hare KB, van de Graaf VA, Poolman RW, Ahn HW, Seon JK, Englund M, Rovers MM. Arthroscopic partial meniscectomy vs non-surgical or sham treatment in patients with MRI-confirmed degenerative meniscus tears: a systematic review and meta-analysis with individual participant data from 605 randomised patients. Osteoarthritis Cartilage 2023; 31:557-566. [PMID: 36646304 DOI: 10.1016/j.joca.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify subgroups of patients with magnetic resonance imaging (MRI)-confirmed degenerative meniscus tears who may benefit from arthroscopic partial meniscectomy (APM) in comparison with non-surgical or sham treatment. METHODS Individual participant data (IPD) from four RCTs were pooled (605 patients, mean age: 55 (SD: 7.5), 52.4% female) as to investigate the effectiveness of APM in patients with MRI-confirmed degenerative meniscus tears compared to non-surgical or sham treatment. Primary outcomes were knee pain, overall knee function, and health-related quality of life, at 24 months follow-up (0-100). The IPD were analysed in a one- and two-stage meta-analyses. Identification of potential subgroups was performed by testing interaction effects of predefined patient characteristics (e.g., age, gender, mechanical symptoms) and APM for each outcome. Additionally, generalized linear mixed-model trees were used for subgroup detection. RESULTS The APM group showed a small improvement over the non-surgical or sham group on knee pain at 24 months follow-up (2.5 points (95% CI: 0.8-4.2) and 2.2 points (95% CI: 0.9-3.6), one- and two-stage analysis, respectively). Overall knee function and health-related quality of life did not differ between the two groups. Across all outcomes, no relevant subgroup of patients who benefitted from APM was detected. The generalized linear mixed-model trees did also not identify a subgroup. CONCLUSIONS No relevant subgroup of patients was identified that benefitted from APM compared to non-surgical or sham treatment. Since we were not able to identify any subgroup that benefitted from APM, we recommend a restrained policy regarding meniscectomy in patients with degenerative meniscus tears.
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Affiliation(s)
- S R W Wijn
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Medical Imaging, Nijmegen, the Netherlands.
| | - G Hannink
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Medical Imaging, Nijmegen, the Netherlands.
| | - H Østerås
- Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Department of Neuromedicine and Movement Science, Trondheim, Norway.
| | - M A Risberg
- Norwegian School of Sport Sciences, Department of Sport Medicine, and Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway.
| | - E M Roos
- University of Southern Denmark, Musculoskeletal Function and Physiotherapy and Centre for Muscle and Joint Health, Department of Sports and Clinical Biomechanics, Odense, Denmark.
| | - K B Hare
- University of Southern Denmark, Næstved-Slagelse-Ringsted Hospitals, Department of Orthopedics, Odense, Denmark.
| | - V A van de Graaf
- OLVG, Joint Research, Department of Orthopaedic Surgery, Amsterdam, the Netherlands; LUMC, Department of Orthopaedic Surgery, Leiden, the Netherlands.
| | - R W Poolman
- OLVG, Joint Research, Department of Orthopaedic Surgery, Amsterdam, the Netherlands; LUMC, Department of Orthopaedic Surgery, Leiden, the Netherlands.
| | - H-W Ahn
- Chonnam National University Bitgoeul Hospital, Department of Orthopedic Surgery, Gwangju, South Korea.
| | - J-K Seon
- Chonnam National University Bitgoeul Hospital, Department of Orthopedic Surgery, Gwangju, South Korea.
| | - M Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden.
| | - M M Rovers
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Medical Imaging, Nijmegen, the Netherlands; Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Health Evidence, Nijmegen, the Netherlands.
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17
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van de Kuit A, Oosterhoff JHF, Dijkstra H, Sprague S, Bzovsky S, Bhandari M, Swiontkowski M, Schemitsch EH, IJpma FFA, Poolman RW, Doornberg JN, Hendrickx LAM. Patients With Femoral Neck Fractures Are at Risk for Conversion to Arthroplasty After Internal Fixation: A Machine-learning Algorithm. Clin Orthop Relat Res 2022; 480:2350-2360. [PMID: 35767811 PMCID: PMC9653184 DOI: 10.1097/corr.0000000000002283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 05/31/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral neck fractures are common and are frequently treated with internal fixation. A major disadvantage of internal fixation is the substantially high number of conversions to arthroplasty because of nonunion, malunion, avascular necrosis, or implant failure. A clinical prediction model identifying patients at high risk of conversion to arthroplasty may help clinicians in selecting patients who could have benefited from arthroplasty initially. QUESTION/PURPOSE What is the predictive performance of a machine-learning (ML) algorithm to predict conversion to arthroplasty within 24 months after internal fixation in patients with femoral neck fractures? METHODS We included 875 patients from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial. The FAITH trial consisted of patients with low-energy femoral neck fractures who were randomly assigned to receive a sliding hip screw or cancellous screws for internal fixation. Of these patients, 18% (155 of 875) underwent conversion to THA or hemiarthroplasty within the first 24 months. All patients were randomly divided into a training set (80%) and test set (20%). First, we identified 27 potential patient and fracture characteristics that may have been associated with our primary outcome, based on biomechanical rationale and previous studies. Then, random forest algorithms (an ML learning, decision tree-based algorithm that selects variables) identified 10 predictors of conversion: BMI, cardiac disease, Garden classification, use of cardiac medication, use of pulmonary medication, age, lung disease, osteoarthritis, sex, and the level of the fracture line. Based on these variables, five different ML algorithms were trained to identify patterns related to conversion. The predictive performance of these trained ML algorithms was assessed on the training and test sets based on the following performance measures: (1) discrimination (the model's ability to distinguish patients who had conversion from those who did not; expressed with the area under the receiver operating characteristic curve [AUC]), (2) calibration (the plotted estimated versus the observed probabilities; expressed with the calibration curve intercept and slope), and (3) the overall model performance (Brier score: a composite of discrimination and calibration). RESULTS None of the five ML algorithms performed well in predicting conversion to arthroplasty in the training set and the test set; AUCs of the algorithms in the training set ranged from 0.57 to 0.64, slopes of calibration plots ranged from 0.53 to 0.82, calibration intercepts ranged from -0.04 to 0.05, and Brier scores ranged from 0.14 to 0.15. The algorithms were further evaluated in the test set; AUCs ranged from 0.49 to 0.73, calibration slopes ranged from 0.17 to 1.29, calibration intercepts ranged from -1.28 to 0.34, and Brier scores ranged from 0.13 to 0.15. CONCLUSION The predictive performance of the trained algorithms was poor, despite the use of one of the best datasets available worldwide on this subject. If the current dataset consisted of different variables or more patients, the performance may have been better. Also, various reasons for conversion to arthroplasty were pooled in this study, but the separate prediction of underlying pathology (such as, avascular necrosis or nonunion) may be more precise. Finally, it may be possible that it is inherently difficult to predict conversion to arthroplasty based on preoperative variables alone. Therefore, future studies should aim to include more variables and to differentiate between the various reasons for arthroplasty. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Anouk van de Kuit
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jacobien H. F. Oosterhoff
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hidde Dijkstra
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Sheila Sprague
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Marc Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, University Medical Center Leiden, Leiden University, Leiden, the Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia
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Willigenburg NW, Yesilkaya F, Rutgers M, Moojen DJF, Poolman RW, Kempen DH. Prosthetic Joint Infection and Wound Leakage After the Introduction of Intraoperative Wound Irrigation With a Chlorhexidine-Cetrimide Solution: A Large-Scale Before-After Study. Arthroplast Today 2022; 19:101053. [PMID: 36845287 PMCID: PMC9947967 DOI: 10.1016/j.artd.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage. Methods All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders. Results The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation. Conclusions Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference. Level of Evidence Level III-uncontrolled before and after the study.
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Affiliation(s)
- Nienke W. Willigenburg
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Fatih Yesilkaya
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Marijn Rutgers
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Dirk Jan F. Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands,Department of Orthopaedic Surgery, LUMC, Leiden, the Netherlands
| | - Diederik H.R. Kempen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands,Corresponding author. Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, P.O. Box 95500, 1090 HM Amsterdam, the Netherlands. Tel.: +31 20 599 2415.
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19
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Peters RM, Ten Have BLEF, Rykov K, Van Steenbergen L, Putter H, Rutgers M, Vos S, Van Steijnen B, Poolman RW, Vehmeijer SBW, Zijlstra WP. The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register. Acta Orthop 2022; 93:775-782. [PMID: 36173140 PMCID: PMC9521054 DOI: 10.2340/17453674.2022.4802] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/25/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI). PATIENTS AND METHODS We identified all patients who received a primary THA using the DAA in several high-volume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26-50, 51-100, 101-150, 151-200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis. RESULTS Patients operated on in group 1-25 (hazard ratio [HR] 1.6; 95% CI 1.1-2.4) and 26-50 (HR 1.6; CI 1.1-2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9-1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6-1.6) and 0.8 (CI 0.5-1.4) for patients in operation groups 101-150 and 151-200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%). INTERPRETATION We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases.
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Affiliation(s)
- Rinne M Peters
- Department of Orthopedic Surgery, Medical Center Leeuwarden; Department of Orthopedic Surgery, University Medical Center Groningen.
| | | | - Kyrill Rykov
- Department of Orthopedic Surgery, Martini Hospital, Groningen
| | | | - Hein Putter
- Department of Medical Statistics and Bioinformatics Statistics, Leiden University Medical Center
| | - Marijn Rutgers
- Department of Orthopedic Surgery, HAGA Hospital, The Hague
| | - Stan Vos
- Department of Orthopedic Surgery, Noordwest Ziekenhuisgroep, Alkmaar
| | | | - Rudolf W Poolman
- Department of Orthopedic Surgery, OLVG, Amsterdam; Department of Orthopedic Surgery, Leiden University Medical Center
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20
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Sorel JC, Oosterhoff JHF, Broekman BFP, Jaarsma RL, Doornberg JN, IJpma FFA, Jutte PC, Spekenbrink-Spooren A, Gademan MGJ, Poolman RW. Do symptoms of anxiety and/or depression and pain intensity before primary Total knee arthroplasty influence reason for revision? Results of an observational study from the Dutch arthroplasty register in 56,233 patients. Gen Hosp Psychiatry 2022; 78:42-49. [PMID: 35853417 DOI: 10.1016/j.genhosppsych.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Anxiety, depression and greater pain intensity before total knee arthroplasty (TKA) may increase the probability of revision surgery for remaining symptoms even without clear pathology or technical issues. We aimed to assess whether preoperative anxiety/depression and pain intensity are associated with revision TKA for less clear indications. METHODS Less clear indications for revision were defined after a Delphi process in which consensus was reached among 59 orthopaedic knee experts. We performed a cox regression analyses on primary TKA patients registered in the Dutch Arthroplasty Registry (LROI) who completed the EuroQol 5D 3 L (EQ5D-3 L) anxiety/depression score to examine associations between preoperative anxiety/depression and pain (Numeric Rating Scale (NRS)) with TKA revision for less clear reasons. These analyses were adjusted for age, BMI, sex, smoking, ASA score, EQ5D-3 L thermometer and OKS score. RESULTS In total, 25.9% patients of the 56,233 included patients reported moderate or severe symptoms of anxiety/depression on the EQ5D-3 L anxiety/depression score. Of those, 615 revisions (45.5%) were performed for less clear reasons for revision (patellar pain, malalignment, instability, progression of osteoarthritis or arthrofibrosis). Not EQ5D-3 L anxiety/depression score, but higher NRS pain at rest and EQ5D-3 L pain score were associated with revision for less clear reason (HR: 1.058, 95% CI 1.019-1.099 & HR: 1.241, 95% CI 1.044-1.476, respectively). CONCLUSION Our findings suggest that pain intensity is a risk factor for TKA revision for a less clear reason. The finding that preoperative pain intensity was associated with reason for revision confirms a likely influence of subjective, personal factors on offer and acceptance of TKA revision. The association between anxiety/depression and reason for revision after TKA may also be found when including more specific outcome measures to assess anxiety/depression and we therefore hope to encourage further research on this topic with our study, ideally in a prospective setting. STUDY DESIGN Longitudinal Cohort Study Level III, Delphi Consensus.
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Affiliation(s)
- Juliette C Sorel
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
| | | | - Birit F P Broekman
- Department of Psychiatry and Medical Psychology, OLVG Hospital / Amsterdam UMC, VU University, Amsterdam, the Netherlands.
| | - Ruurd L Jaarsma
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia.
| | - Job N Doornberg
- Department of Orthopaedic Surgery, University Medical Centre Groningen, the Netherlands.
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, the Netherlands.
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Centre Groningen, the Netherlands.
| | | | - Maaike G J Gademan
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands; Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG Hospital, Amsterdam, the Netherlands.
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Noorduyn JCA, van de Graaf VA, Willigenburg NW, Scholten-Peeters GGM, Kret EJ, van Dijk RA, Buchbinder R, Hawker GA, Coppieters MW, Poolman RW. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2220394. [PMID: 35802374 PMCID: PMC9270699 DOI: 10.1001/jamanetworkopen.2022.20394] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There is a paucity of high-quality evidence about the long-term effects (ie, 3-5 years and beyond) of arthroscopic partial meniscectomy vs exercise-based physical therapy for patients with degenerative meniscal tears. OBJECTIVES To compare the 5-year effectiveness of arthroscopic partial meniscectomy and exercise-based physical therapy on patient-reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscal tear. DESIGN, SETTING, AND PARTICIPANTS A noninferiority, multicenter randomized clinical trial was conducted in the orthopedic departments of 9 hospitals in the Netherlands. A total of 321 patients aged 45 to 70 years with a degenerative meniscal tear participated. Data collection took place between July 12, 2013, and December 4, 2020. INTERVENTIONS Patients were randomly allocated to arthroscopic partial meniscectomy or 16 sessions of exercise-based physical therapy. MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported knee function (International Knee Documentation Committee Subjective Knee Form (range, 0 [worst] to 100 [best]) during 5 years of follow-up based on the intention-to-treat principle, with a noninferiority threshold of 11 points. The secondary outcome was progression in knee osteoarthritis shown on radiographic images in both treatment groups. RESULTS Of 321 patients (mean [SD] age, 58 [6.6] years; 161 women [50.2%]), 278 patients (87.1%) completed the 5-year follow-up with a mean follow-up time of 61.8 months (range, 58.8-69.5 months). From baseline to 5-year follow-up, the mean (SD) improvement was 29.6 (18.7) points in the surgery group and 25.1 (17.8) points in the physical therapy group. The crude between-group difference was 3.5 points (95% CI, 0.7-6.3 points; P < .001 for noninferiority). The 95% CI did not exceed the noninferiority threshold of 11 points. Comparable rates of progression of radiographic-demonstrated knee osteoarthritis were noted between both treatments. CONCLUSIONS AND RELEVANCE In this noninferiority randomized clinical trial after 5 years, exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for patient-reported knee function. Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01850719.
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Affiliation(s)
- Julia C. A. Noorduyn
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, the Netherlands
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Victor A. van de Graaf
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, St Antonius Hospital Nieuwegein, the Netherlands
| | - Nienke W. Willigenburg
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, the Netherlands
| | - Gwendolyne G. M. Scholten-Peeters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Esther J. Kret
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, the Netherlands
| | | | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Victoria, Australia
| | - Gillian A. Hawker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michel W. Coppieters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Menzies Health Institute Queensland, Griffith University, Brisbane & Gold Coast, Queensland, Australia
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Bernstein DN, van de Graaf VA, Meijers I, Portengen A, Klaassen A, Scholtes VAB, Poolman RW, Kempen DHR. Digital medical history implementation to triage orthopaedic patients during COVID-19: Findings from a rapid cycle, semi-randomised A/B testing quality improvement project. Musculoskeletal Care 2022; 20:390-395. [PMID: 34846805 PMCID: PMC9015220 DOI: 10.1002/msc.1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The COVID-19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised. METHODS We analysed 640 patients using a rapid cycle, semi-randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion. ETHICAL APPROVAL N/A (Quality Improvement Project) RESULTS: Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients [63 out of 81 patients]). Across all patients, increasing age (odds ratio [OR]: 0.985 (95% CI: 0.976-0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234-0.666), p = 0.001), and patients with non-specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176-0.623), p = 0.001) were associated with decreased odds of DMH completion. DISCUSSION AND CONCLUSION DMHs can be valuable in helping triage orthopaedic patients in resource-strapped settings, times of crisis, or as we transition towards value-based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic SurgeryHarvard Combined Orthopaedic Residency Program (HCORP)Massachusetts General HospitalBostonMassachusettsUSA,Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Victor A. van de Graaf
- Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands,Department of Orthopaedic SurgerySt Antonius ZiekenhuisNieuwegeinThe Netherlands
| | - Irina Meijers
- Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands
| | - Anne Portengen
- Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands
| | - Amanda Klaassen
- Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands
| | | | - Rudolf W. Poolman
- Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands,Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands
| | - Diederik H. R. Kempen
- Department of Orthopaedic SurgeryJoint ResearchOLVG AmsterdamAmsterdamThe Netherlands
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23
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Noorduyn JCA, van de Graaf VA, Willigenburg NW, Scholten-Peeters GGM, Mol BW, Heymans MW, Coppieters MW, Poolman RW. An individualized decision between physical therapy or surgery for patients with degenerative meniscal tears cannot be based on continuous treatment selection markers: a marker-by-treatment analysis of the ESCAPE study. Knee Surg Sports Traumatol Arthrosc 2022; 30:1937-1948. [PMID: 35122496 PMCID: PMC9165275 DOI: 10.1007/s00167-021-06851-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears. METHODS Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments. RESULTS Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. While some marker-based thresholds could be identified at 3, 12, and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. CONCLUSION This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Julia C A Noorduyn
- Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Victor A van de Graaf
- Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
- Department of Orthopedic Surgery, St. Antonius Ziekenhuis, Utrecht, The Netherlands
| | - Nienke W Willigenburg
- Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Gwendolyne G M Scholten-Peeters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynecology, School of Medicine, Monash University, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Michel W Coppieters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
- Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands
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24
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Ter Meulen DP, Mulders MAM, Kruiswijk AA, Kret EJ, Slichter ME, van Dongen JM, Kerkhoffs GMMJ, Goslings JC, Kleinlugtenbelt YV, Willigenburg NW, Schep NWL, Poolman RW. Effectiveness and cost-effectiveness of surgery versus casting for elderly patients with Displaced intra- Articular type C distal Radius fractures: protocol of a randomised controlled Trial with economic evaluation (the DART study). BMJ Open 2022; 12:e051658. [PMID: 35365511 PMCID: PMC8977782 DOI: 10.1136/bmjopen-2021-051658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Current literature is inconclusive about the optimal treatment of elderly patients with displaced intra-articular distal radius fractures. Cast treatment is less invasive and less expensive than surgical treatment. Nevertheless, surgery is often the preferred treatment for this common type of distal radius fracture. Patients with a non-acceptable position after closed reduction are more likely to benefit from surgery than patients with an acceptable position after closed reduction. Therefore, this study aims to assess non-inferiority of functional outcomes after casting versus surgery in elderly patients with a non-acceptable position following a distal radius fracture. METHODS AND ANALYSIS This study is a multicentre randomised controlled trial (RCT) with a non-inferiority design and an economic evaluation alongside. The population consists of patients aged 65 years and older with a displaced intra-articular distal radius fracture with non-acceptable radiological characteristics following either inadequate reduction or redisplacement after adequate reduction. Patients will be randomised between surgical treatment (open reduction and internal fixation) and non-operative treatment (closed reduction followed by cast treatment). We will use two age strata (65-75 and >75 years of age) and a web-based mixed block randomisation. A total of 154 patients will be enrolled and evaluated with the patient-rated wrist evaluation as the primary outcome at 1-year follow-up. Secondary outcomes include the Disabilities of the Arm, Shoulder and Hand questionnaire, quality of life (measured by the EQ-5D), wrist range of motion, grip strength and adverse events. In addition, we will perform a cost-effectiveness and cost-utility analysis from a societal and healthcare perspective. Incremental cost-effectiveness ratios, cost-effectiveness planes and cost-effectiveness acceptability curves will be presented. ETHICS AND DISSEMINATION The Research and Ethics Committee approved this RCT (NL56858.100.16). The results of this study will be reported in a peer-reviewed journal. We will present the results of this study at (inter)national conferences and disseminate the results through guideline committees. TRIAL REGISTRATION NUMBER Clinicaltrials.gov (NCT03009890). Dutch Trial Registry (NTR6365).
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Affiliation(s)
- D P Ter Meulen
- Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
- Orthopedic Surgery, LUMC, Leiden, The Netherlands
| | - M A M Mulders
- Trauma Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - A A Kruiswijk
- Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
| | - E J Kret
- Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
| | - M E Slichter
- Orthopedic Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | - J M van Dongen
- Department of Health Sciences, Faculty of Science, and the Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G M M J Kerkhoffs
- Orthopedic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - J C Goslings
- Trauma Surgery, OLVG, Amsterdam, The Netherlands
| | | | | | - N W L Schep
- Trauma Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - R W Poolman
- Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
- Orthopedic Surgery, LUMC, Leiden, The Netherlands
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O'Connor D, Johnston RV, Brignardello-Petersen R, Poolman RW, Cyril S, Vandvik PO, Buchbinder R. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev 2022; 3:CD014328. [PMID: 35238404 PMCID: PMC8892839 DOI: 10.1002/14651858.cd014328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Arthroscopic knee surgery remains a common treatment for symptomatic knee osteoarthritis, including for degenerative meniscal tears, despite guidelines strongly recommending against its use. This Cochrane Review is an update of a non-Cochrane systematic review published in 2017. OBJECTIVES To assess the benefits and harms of arthroscopic surgery, including debridement, partial menisectomy or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscal tears, or both). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers up to 16 April 2021, unrestricted by language. SELECTION CRITERIA We included randomised controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, comparing arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, drug therapy, and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscal tears or both). Major outcomes were pain, function, participant-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events and knee surgery (replacement or osteotomy). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was arthroscopic surgery compared to placebo surgery for outcomes that measured benefits of surgery, but we combined data from all control groups to assess harms and knee surgery (replacement or osteotomy). MAIN RESULTS Sixteen trials (2105 participants) met our inclusion criteria. The average age of participants ranged from 46 to 65 years, and 56% of participants were women. Four trials (380 participants) compared arthroscopic surgery to placebo surgery. For the remaining trials, arthroscopic surgery was compared to exercise (eight trials, 1371 participants), a single intra-articular glucocorticoid injection (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-steroidal anti-inflammatory drugs (one trial, 80 participants) and weekly hyaluronic acid injections for five weeks (one trial, 120 participants). The majority of trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting (75%) biases. The placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. Here we limit reporting to the main comparison, arthroscopic surgery versus placebo surgery. High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates there is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery. Mean post-operative pain in the placebo group was 40.1 points on a 0 to 100 scale (where lower score indicates less pain) compared to 35.5 points in the arthroscopic surgery group, a difference of 4.6 points better (95% confidence interval (CI) 0.02 better to 9 better; I2 = 0%; 4 trials, 309 participants). Mean post-operative function in the placebo group was 75.9 points on a 0 to 100 rating scale (where higher score indicates better function) compared to 76 points in the arthroscopic surgery group, a difference of 0.1 points better (95% CI 3.2 worse to 3.4 better; I2 = 0%; 3 trials, 302 participants). Mean post-operative knee-specific health-related quality of life in the placebo group was 69.7 points on a 0 to 100 rating scale (where higher score indicates better quality of life) compared with 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI 0.36 better to 10.68 better; I2 = 0%; 2 trials, 188 participants). We downgraded this evidence to moderate certainty as the 95% confidence interval does not rule in or rule out a clinically important change. After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery at up to five years (risk ratio (RR) 1.11, 95% CI 0.66 to 1.86; I2 = 53%; 3 trials, 189 participants). We downgraded this evidence to low certainty due to serious indirectness (diversity in definition and timing of outcome measurement) and serious imprecision (small number of events). We are less certain if the risk of serious or total adverse events increased with arthroscopic surgery compared to placebo or non-surgical interventions. Serious adverse events were reported in 6 out of 100 people in the control groups and 8 out of 100 people in the arthroscopy groups from eight trials (RR 1.35, 95% CI 0.64 to 2.83; I2 = 47%; 8 trials, 1206 participants). Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery at up to five years (RR 1.15, 95% CI 0.78 to 1.70; I2 = 48%; 9 trials, 1326 participants). The certainty of the evidence was low, downgraded twice due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcome across studies). Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis and deep infection. Subsequent knee surgery (replacement or high tibial osteotomy) was reported in 2 out of 100 people in the control groups and 4 out of 100 people in the arthroscopy surgery groups at up to five years in four trials (RR 2.63, 95% CI 0.94 to 7.34; I2 = 11%; 4 trials, 864 participants). The certainty of the evidence was low, downgraded twice due to the small number of events. AUTHORS' CONCLUSIONS Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.
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Affiliation(s)
- Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Sheila Cyril
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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Noorduyn JCA, Teuwen MMH, van de Graaf VA, Willigenburg NW, Schavemaker M, van Dijk R, Scholten-Peeters GGM, Heymans MW, Coppieters MW, Poolman RW. In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery. Knee Surg Sports Traumatol Arthrosc 2022; 30:231-238. [PMID: 33550450 PMCID: PMC8800906 DOI: 10.1007/s00167-021-06468-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Although physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscal tear, 24% still opt for meniscal surgery. The aim was to identify those patients with a degenerative meniscal tear who will undergo surgery following physical therapy. METHODS The data for this study were generated in the physical therapy arm of the ESCAPE trial, a randomized clinical trial investigating the effectiveness of surgery versus physical therapy in patients of 45-70 years old, with a degenerative meniscal tear. At 6 and 24 months patients were divided into two groups: those who did not undergo surgery, and those who did undergo surgery. Two multivariable prognostic models were developed using candidate predictors that were selected from the list of the patients' baseline variables. A multivariable logistic regression analysis was performed with backward Wald selection and a cut-off of p < 0.157. For both models the performance was assessed and corrected for the models' optimism through an internal validation using bootstrapping technique with 500 repetitions. RESULTS At 6 months, 32/153 patients (20.9%) underwent meniscal surgery following physical therapy. Based on the multivariable regression analysis, patients were more likely to opt for meniscal surgery within 6 months when they had worse knee function, lower education level and a better general physical health status at baseline. At 24 months, 43/153 patients (28.1%) underwent meniscal surgery following physical therapy. Patients were more likely to opt for meniscal surgery within 24 months when they had worse knee function and a lower level of education at baseline at baseline. Both models had a low explained variance (16 and 11%, respectively) and an insufficient predictive accuracy. CONCLUSION Not all patients with degenerative meniscal tears experience beneficial results following physical therapy. The non-responders to physical therapy could not accurately be predicted by our prognostic models. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Julia C A Noorduyn
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
| | - M M H Teuwen
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - V A van de Graaf
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
- Department of Orthopeadic surgery, Antonius ziekenhuis, Nieuwegein, The Netherlands
| | - N W Willigenburg
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - M Schavemaker
- Department of Radiology, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - R van Dijk
- Department of Radiology, Isala, Zwolle, The Netherlands
| | - G G M Scholten-Peeters
- Faculty of Behavioural and Movement Sciences, Department of Human Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - M W Coppieters
- Faculty of Behavioural and Movement Sciences, Department of Human Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Menzies Health Institute Queensland, Griffith University, Brisbane & Gold Coast, Australia
| | - R W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG Amsterdam, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
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van Dijk LA, Vervest AMJS, Baas DC, Poolman RW, Haverkamp D. Decision aids can decrease decisional conflict in patients with hip or knee osteoarthritis: Randomized controlled trial. World J Orthop 2021; 12:1026-1035. [PMID: 35036345 PMCID: PMC8696597 DOI: 10.5312/wjo.v12.i12.1026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/21/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The interest in shared decision making has increased considerably over the last couple of decades. Decision aids (DAs) can help in shared decision making. Especially when there is more than one reasonable option and outcomes between treatments are comparable.
AIM To investigate if the use of DAs decreases decisional conflict in patients when choosing treatment for knee or hip osteoarthritis (OA).
METHODS In this multi-center unblinded randomized controlled trial of patients with knee or hip OA were included from four secondary and tertiary referral centers. One-hundred-thirty-one patients who consulted an orthopedic surgeon for the first time with knee or hip OA were included between December 2014 and January 2016. After the first consultation, patients were randomly assigned by a computer to the control group which was treated according to standard care, or to the intervention group which was treated with standard care and provided with a DA. After the first consultation, patients were asked to complete questionnaires about decisional conflict (DCS), satisfaction, anxiety (PASS-20), gained knowledge, stage of decision making and preferred treatment. Follow-up was carried out after 26 wk and evaluated decisional conflict, satisfaction, anxiety, health outcomes (HOOS/KOOS), quality of life (EQ5D) and chosen treatment.
RESULTS After the first consultation, patients in the intervention group (mean DCS: 25 out of 100, SD: 13) had significantly (P value: 0.00) less decisional conflict compared to patients in the control group (mean DCS: 39 out of 100, SD 11). The mean satisfaction score for the given information (7.6 out of 10, SD: 1.8 vs 8.6 out of 10, SD: 1.1) (P value: 0.00), mean satisfaction score with the physician (8.3 out of 10, SD: 1.7 vs 8.9 out of 10, SD: 0.9) (P value: 0.01) and the mean knowledge score (3.3 out of 4, SD: 0.9 vs 3.7 out of, SD: 0.6) (P value: 0.01) were all significantly higher in the intervention group. At 26-wk follow-up, only 75 of 131 patients (57%) were available for analysis. This sample is too small for meaningful analysis.
CONCLUSION Providing patients with an additional DA may have a positive effect on decisional conflict after the first consultation. Due to loss to follow-up we are unsure if this effect remains over time.
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Affiliation(s)
- Lode A van Dijk
- Department of Orthopedic Surgery, Tergooi Hospital, Hilversum 1213 XZ, Noord-Holland, Netherlands
| | - Antonius MJS Vervest
- Department of Orthopedic Surgery, Tergooi Hospital, Hilversum 1213 XZ, Noord-Holland, Netherlands
| | - Dominique C Baas
- Department of Orthopedic Surgery, Tergooi Hospital, Hilversum 1213 XZ, Noord-Holland, Netherlands
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam 1091 AC, Netherlands
- Department of Orthopedic Surgery, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Daniel Haverkamp
- Department of Orthopedic Surgery, Xpert Orthopedie Amsterdam/SCORE (Specialized Center of Orthopedic Research and Education), Amsterdam 1101 EA, Netherlands
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Abstract
Background and purpose - Gaining experience in the surgery room during residency is an important part of learning the skills needed to perform arthroplasties. However, in practice, patients are often not fully comfortable with trainee involvement in their own surgery. Therefore, we investigated complications, revision rates, mortality, and operative time of orthopedic surgeons and residents as primary surgeon performing total knee arthroplasties (TKAs) or total hip arthroplasties (THAs).Patients and methods - In this multi-center retrospective cohort study, 3,098 TKAs and 4,027 THAs performed between 2007 and 2013 were analyzed. Complications, revisions, mortality, and operative time were compared for patients operated on by the orthopedic surgeon or a resident as primary surgeon. An additional analysis was performed to determine whether the complication risk was affected by the postgraduate year of the resident.Results - Orthopedic complication rates were similar (TKA: orthopedic surgeon: 10%, resident: 11%; THA: 9% and 8%), revision rates (TKA: 3% and 2%, THA: 3% and 2%), or mortality rates (TKA: 0.1% and 0.3%, THA: 0.2% and 0.3%). For both procedures a higher non-orthopedic complication rate was found in the resident group (TKA: 8% and 10%; p = 0.03, THA: 8% and 10%; p = 0.01) and a slightly longer operative time (TKA: mean difference 9.0 minutes (8%); THA: 11.3 minutes (11%)).Interpretation - Complications, revisions, and mortality were similar in TKAs or THAs performed by the resident as primary surgeon compared with surgeries performed by an orthopedic surgeon. This data can be used in teaching hospitals and may help to reassure patients.
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Affiliation(s)
- Daphne M Bron
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;
| | - Nienke Wolterbeek
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;;,Correspondence:
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, JointResearch OLVG, Amsterdam;;,Department of Orthopedic Surgery, LUMC, Leiden, The Netherlands
| | | | - Diyar Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;
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29
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Bernstein DN, Reitblat C, van de Graaf VA, O’Donnell E, Philpotts LL, Terwee CB, Poolman RW. Is There An Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review. Clin Orthop Relat Res 2021; 479:2430-2443. [PMID: 33942797 PMCID: PMC8509989 DOI: 10.1097/corr.0000000000001792] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists. QUESTIONS/PURPOSES In this systematic review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure? METHODS This systematic review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis. RESULTS Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001). CONCLUSION In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.
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Affiliation(s)
- David N. Bernstein
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Harvard Medical School, Boston, MA, USA
| | - Chanan Reitblat
- Harvard Medical School, Boston, MA, USA
- Harvard Business School, Boston, MA, USA
| | | | - Evan O’Donnell
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Caroline B. Terwee
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
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30
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Comeau-Gauthier M, Zura RD, Bzovsky S, Schemitsch EH, Axelrod D, Avram V, Manjoo A, Poolman RW, Frihagen F, Heels-Ansdell D, Bhandari M, Sprague S. Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture. J Bone Joint Surg Am 2021; 103:1328-1334. [PMID: 33764913 PMCID: PMC8388546 DOI: 10.2106/jbjs.20.01586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes. METHODS We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months. RESULTS Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II. CONCLUSIONS The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Robert D. Zura
- Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Sofia Bzovsky
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Daniel Axelrod
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Victoria Avram
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ajay Manjoo
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, and OLVG (Onze Lieve Vrouwe Gasthuis), Amsterdam, the Netherlands
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Sprague
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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31
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Tol MCJM, van Beers LWAH, Willigenburg NW, Gosens T, Heetveld MJ, Willems HC, Bhandari M, Poolman RW. Posterolateral or direct lateral approach for hemiarthroplasty after femoral neck fractures: a systematic review. Hip Int 2021; 31:154-165. [PMID: 32552010 DOI: 10.1177/1120700020931766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The posterolateral approach (PLA) and direct lateral approach (DLA) are the most commonly used approaches for inserting a hemiarthroplasty in the treatment of femoral neck fractures. A recent review concluded that the routine use of PLA should be questioned, but this conclusion itself can be questioned. The aim of this study is to provide an updated overview and critical appraisal of the available evidence, focussing on outcomes most relevant for patients. METHODS We conducted a comprehensive search of literature in the MEDLINE and EMBASE databases and Cochrane Library. Studies (till June 2018) to identify hip fracture clinical trials/comparative studies comparing alternative surgical approaches (PLA and DLA). We explored sources of heterogeneity and conducted pooled analyses when appropriate. RESULTS 264 potentially eligible studies were identified of which 1 RCT, 3 prospective, 3 registry data and 5 retrospective studies were included. The RCT consisted performance and attrition bias. The mean MINORS score of the prospective/register studies was 17.3 (SD 3.5) and 13.8 (SD 1.9) of the 5 retrospective studies. The GRADE score for all the outcomes was very low. Due to the high and various types of biases across the included studies, we did not pool the data. None of studies assessed the activities of daily living functionality. 6 studies reported significantly more dislocations or reoperations due to dislocation in the PLA group, 6 other studies found no differences. DLA patients were more likely to develop abductor insufficiency leading to limping and more need for walking aids. The PLA patients tended to have better quality of life, less pain and more satisfaction compared to the DLA patients. CONCLUSION Based on low-quality studies, PLA may be associated with more dislocations, but patients had less walking problems and a lower tendency to abductor insufficiency compared with DLA. Further clinical trials with methodology rigor are needed to determine which approach is more effective in terms of outcomes relevant to patients.
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Affiliation(s)
- Maria C J M Tol
- Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
| | | | | | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Martin J Heetveld
- Department of Trauma Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Hanna C Willems
- Department of Internal Medicine and Geriatrics, AMC, Amsterdam, The Netherlands
| | - Mohit Bhandari
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands.,Department of Orthopaedic Surgery, LUMC, Leiden, The Netherlands
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32
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Veltman ES, Moojen DJF, Poolman RW. Improved patient reported outcomes with functional articulating spacers in two-stage revision of the infected hip. World J Orthop 2020; 11:595-605. [PMID: 33362995 PMCID: PMC7745492 DOI: 10.5312/wjo.v11.i12.595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Two-stage revision arthroplasty with an antibiotic-loaded spacer is the treatment of choice in chronically infected total hip arthroplasties. Interval spacers can be functional articulating or prefabricated. Functional results of these spacers have scarcely been reported.
AIM To compare retrospectively the patient reported outcome and infection eradication rate after two-stage revision arthroplasty of the hip with the use of a functional articulating or prefabricated spacer.
METHODS All patients with two-stage revision of a hip prosthesis at our hospital between 2003 and 2016 were included in this retrospective cohort study. Patients were divided into two groups; patients treated with a functional articulating spacer or with a prefabricated spacer. Patients completed the Hip Osteoarthritis Outcome Score and the EQ-5D-3L (EQ-5D) and the EQ-5D quality of life thermometer (EQ-VAS) scores. Primary outcomes were patient reported outcome and infection eradication after two-stage revision. The results of both groups were compared to the patient acceptable symptom state for primary arthroplasty of the hip. Secondary outcomes were complications during spacer treatment and at final follow-up. Descriptive statistics, mean and range are used to represent the demographics of the patients. For numerical variables, students’ t-tests were used to assess the level of significance for differences between the groups, with 95% confidence intervals; for binary outcome, we used Fisher’s exact test.
RESULTS We consecutively treated 55 patients with a prefabricated spacer and 15 patients with a functional articulating spacer of the hip. The infection eradication rates for functional articulating and prefabricated spacers were 93% and 78%, respectively (P > 0.05). With respect to the functional outcome, the Hip Osteoarthritis Outcome Score (HOOS) and its subscores (all P < 0.01), the EQ-5D (P < 0.01) and the EQ-VAS scores (P < 0.05) were all significantly better for patients successfully treated with a functional articulating spacer. More patients in the functional articulating spacer group reached the patient acceptable symptom state for the HOOS pain, HOOS quality of life and EQ-VAS. The number of patients with a spacer dislocation was not significantly different for the functional articulating or prefabricated spacer group (P > 0.05). However, the number of dislocations per patient experiencing a dislocation was significantly higher for patients with a prefabricated spacer (P < 0.01).
CONCLUSION Functional articulating spacers lead to improved patient reported functional outcome and less perioperative complications after two-stage revision arthroplasty of an infected total hip prosthesis, while maintaining a similar infection eradication rate compared to prefabricated spacers.
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic and Trauma Surgery, OLVG, Amsterdam 1091AC, Netherlands
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery and Joint Research, OLVG, Amsterdam 1091AC, Netherlands
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33
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Veltman ES, Lenguerrand E, Moojen DJF, Whitehouse MR, Nelissen RGHH, Blom AW, Poolman RW. Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients. Acta Orthop 2020; 91:794-800. [PMID: 32698642 PMCID: PMC8023957 DOI: 10.1080/17453674.2020.1794096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.
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MESH Headings
- Anti-Bacterial Agents/administration & dosage
- Antibiotic Prophylaxis/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Cefazolin/administration & dosage
- Cefuroxime/administration & dosage
- Dose-Response Relationship, Drug
- Duration of Therapy
- Female
- Humans
- Male
- Middle Aged
- Netherlands/epidemiology
- Outcome and Process Assessment, Health Care
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/epidemiology
- Prosthesis-Related Infections/prevention & control
- Prosthesis-Related Infections/surgery
- Reoperation/methods
- Reoperation/statistics & numerical data
- Risk Adjustment/methods
- Risk Adjustment/statistics & numerical data
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dirk Jan F Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rudolf W Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
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34
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Noorduyn JCA, Glastra van Loon T, van de Graaf VA, Willigenburg NW, Butter IK, Scholten-Peeters GGM, Coppieters MW, Poolman RW, Scholtes VAB, Mutsaerts ELAR, Krijnen MR, Moojen DJF, van Deurzen DFP, Bloembergen CH, Wolkenfelt J, de Gast A, Snijders T, Saris DBF, Wolterbeek N, Neeter C, Kerkhoffs GMMJ, Peters RW, van den Brand ICJB, de Vos-Jakobs S, Spoor AB, Gosens T, Rezaie W, Hofstee DJ, Burger BJ, Haverkamp D, Vervest AMJS, van Rheenen TA, Wijsbek AE, van Arkel ERA, Thomassen BJW, Sprague S, van Tulder MW, Schavemaker M, van Dijk R, van der Kraan J. Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120954392. [PMID: 33195707 PMCID: PMC7607803 DOI: 10.1177/2325967120954392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 02/04/2023] Open
Abstract
Background It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. Purpose To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome. Study Design Randomized controlled trial; Level of evidence, 1. Methods This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. Results After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. Conclusion Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. Registration NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).
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Affiliation(s)
| | | | | | | | - Ise K Butter
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Gwendolyne G M Scholten-Peeters
- Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michel W Coppieters
- Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Vanessa A B Scholtes
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Eduard L A R Mutsaerts
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Matthijs R Krijnen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Dirk Jan F Moojen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Derek F P van Deurzen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Coen H Bloembergen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Julius Wolkenfelt
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Arthur de Gast
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Thom Snijders
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Daniel B F Saris
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Nienke Wolterbeek
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Camille Neeter
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Rolf W Peters
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Igor C J B van den Brand
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Suzanne de Vos-Jakobs
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Andy B Spoor
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Wahid Rezaie
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Dirk Jan Hofstee
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Bart J Burger
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Daniel Haverkamp
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Anton M J S Vervest
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Thijs A van Rheenen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Anne E Wijsbek
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Ewoud R A van Arkel
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Bregje J W Thomassen
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Sheila Sprague
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Maurits W van Tulder
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Mirjam Schavemaker
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Rogier van Dijk
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - J van der Kraan
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.,Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Investigation performed at the Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
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35
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Van Beers LWAH, Van Der Wal BCH, Van Loon TG, Moojen DJF, Van Wier MF, Klaassen AD, Willigenburg NW, Poolman RW. Study protocol: Effectiveness of dual-mobility cups compared with uni-polar cups for preventing dislocation after primary total hip arthroplasty in elderly patients - design of a randomized controlled trial nested in the Dutch Arthroplasty Registry. Acta Orthop 2020; 91:514-519. [PMID: 32746668 PMCID: PMC8023924 DOI: 10.1080/17453674.2020.1798658] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Dislocation is the leading reason for early revision surgery after total hip arthroplasty (THA). The dual-mobility (DM) cup was developed to provide more stability and mechanically reduce the risk of dislocation. Despite the increased use of DM cups, high-quality evidence of their (cost-)effectiveness is lacking. The primary objective of this randomized controlled trial (RCT) is to investigate whether there is a difference in the number of hip dislocations following primary THA, using the posterolateral approach, with a DM cup compared with a unipolar (UP) cup in elderly patients 1 year after surgery. Secondary outcomes include the number of revision surgeries, patient-reported outcome measures (PROMs), and cost-effectiveness.Methods and analysis - This is a prospective multicenter nationwide, single-blinded RCT nested in the Dutch Arthroplasty Registry. Patients ≥ 70 years old, undergoing elective primary THA using the posterolateral approach, will be eligible. After written informed consent, 1,100 participants will be randomly allocated to the intervention or control group. The intervention group receives a THA with a DM cup and the control group a THA with a UP cup. PROMs are collected preoperatively, and 3 months, 1 and 2 years postoperatively. Primary outcome is the difference in number of dislocations between the UP and DM cup within 1 year, reported in the registry (revisions), or by the patients (closed or open reduction). Data will be analyzed using multilevel models as appropriate for each outcome (linear/logistic/survival). An economic evaluation will be performed from the healthcare and societal perspective, for dislocation and quality adjusted life years (QALYs).Trial registration - This RCT is registered at www.clinicaltrials.gov with identification number NCT04031820.
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Affiliation(s)
| | | | | | | | | | | | | | - Rudolf W Poolman
- OLVG, Amsterdam; ,LUMC, Leiden, the Netherlands,Correspondence:
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36
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Bhandari M, Schemitsch EH, Karachalios T, Sancheti P, Poolman RW, Caminis J, Daizadeh N, Dent-Acosta RE, Egbuna O, Chines A, Miclau T. Romosozumab in Skeletally Mature Adults with a Fresh Unilateral Tibial Diaphyseal Fracture: A Randomized Phase-2 Study. J Bone Joint Surg Am 2020; 102:1416-1426. [PMID: 32358413 DOI: 10.2106/jbjs.19.01008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Romosozumab is an antibody that binds and inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption. A double-blinded, randomized, phase-2, dose-finding trial was performed to evaluate the effect of romosozumab on the radiographic and clinical outcomes of surgical fixation of tibial diaphyseal fractures. METHODS Patients (18 to 82 years old) were randomized 3:1:1:1:1:1:1:1:1:1 to a placebo or 1 of 9 romosozumab treatment groups. Patients received subcutaneous injections of romosozumab or the placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary outcome was the time to radiographic evidence of healing ("radiographic healing") analyzed after the week-24 assessments had been completed for all patients. RESULTS A total of 402 patients were randomized: 299 to the romosozumab group and 103 to the placebo group. The median time to radiographic healing (the primary outcome) ranged from 14.4 to 18.6 weeks in the romosozumab groups and was 16.4 weeks (95% confidence interval [CI]: 14.6 to 18.0 weeks) in the placebo group, which was not a significant difference. There was also no significant difference in the median time to clinical healing, no relationship between romosozumab dose/frequency and unplanned revision surgery, and no apparent treatment benefit in terms of physical function. The safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS Romosozumab did not accelerate tibial fracture-healing in this patient population. Additional studies of patients at higher risk for delayed healing are needed to explore the potential of romosozumab to accelerate tibial fracture-healing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Theofilos Karachalios
- Orthopaedic Department UGHL, School of Health Sciences, University of Thessalia, Larissa, Greece
| | - Parag Sancheti
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
| | | | | | | | | | | | | | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.,Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, California
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37
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van den Bekerom MPJ, Poolman RW. No Indications for Subacromial Decompression in Rotator Cuff Tendinopathy: A Level I Evidence Clinical Guideline. Arthroscopy 2020; 36:1492-1493. [PMID: 32503763 DOI: 10.1016/j.arthro.2020.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/20/2020] [Indexed: 02/02/2023]
Affiliation(s)
| | - R W Poolman
- OLVG, Amsterdam, the Netherlands; LUMC, Leiden, the Netherlands
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38
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Jonker RC, van Beers LWAH, van der Wal BCH, Vogely HC, Parratte S, Castelein RM, Poolman RW. Can dual mobility cups prevent dislocation without increasing revision rates in primary total hip arthroplasty? A systematic review. Orthop Traumatol Surg Res 2020; 106:509-517. [PMID: 32278733 DOI: 10.1016/j.otsr.2019.12.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Dislocation is one of the leading causes for early revision surgery after total hip arthroplasty (THA). To address this problem, the dual mobility (DM) cup was developed in the 1970s by the French. Despite the increased and, in some countries, broad use of DM cups, high quality evidence of their effectiveness compared to traditional unipolar (UP) cups is lacking. There are a few well-conducted literature reviews, but the level of evidence of the included studies was moderate to low and the rates of revision were not specifically investigated. Therefore, we did a systematic review to investigate whether there is a difference in the rate of dislocations and revisions after primary THA with a DM cup or a UP cup. METHODS We conducted a systematic literature search in PubMed, Embase and Cochrane databases in July 2019. The articles were selected based upon their quality, relevance and measurement of the predictive factor. We used the MINORS criteria to determine the methodological quality of all studies. RESULTS The initial search resulted in 702 citations. After application of the inclusion and exclusion criteria, eight articles met our eligibility criteria and were graded. Included studies were of medium to low methodological quality with a mean score of 14/24 (11-16) points following the MINORS criteria. In the case-control studies, a total of 549 DM cups and 649 UP cups were included. In the registry studies, a total of 5.935 DM cups and 217.362 UP cups were included. In the case-control studies, one (0.2%) dislocation was reported for the DM cups and 46 (7.1%) for the UP cup (p=0.009, IQR=0.00-7.00). Nine (1.6%) revisions, of which zero due to dislocation, were reported for the DM cup and 39 (6.0%), of which 30 due to dislocation, for the UP cup (p=0.046, CI=-16.93-5.73). In the registry studies 161 (2.7%) revisions were reported for the DM cup, of which 14 (8.7%) due to dislocation. For the UP cup, 3.332 (1.5%) revisions were reported (p=0.275, IQR=41.00-866.25), of which 1.093 (32.8%) due to dislocation (p=0.050, IQR=3.50-293.25). CONCLUSION This review suggests lower rates of dislocation and lower rates of revision for dislocation in favor of the DM cups. Concluding, DM cups might be an effective solution to reduce dislocation in primary THA. To evaluate the efficacy of DM cups compared to UP cups, an economic evaluation alongside a randomized controlled trial is needed focusing on patient important endpoints. LEVEL OF EVIDENCE III, systematic review of level III studies.
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Affiliation(s)
- Ragna C Jonker
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Loes W A H van Beers
- Department of Orthopaedic Surgery, OLVG, PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Bart C H van der Wal
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - H Charles Vogely
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Sebastien Parratte
- Department of Orthopedic Surgery and Traumatology, St. Marguerite Hospital Marseille, 270 Boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - René M Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, OLVG, PO Box 95500, 1090 HM Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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39
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Schemitsch EH, Miclau T, Karachalios T, Nowak LL, Sancheti P, Poolman RW, Caminis J, Daizadeh N, Dent-Acosta RE, Egbuna O, Chines A, Maddox J, Grauer A, Bhandari M. A Randomized, Placebo-Controlled Study of Romosozumab for the Treatment of Hip Fractures. J Bone Joint Surg Am 2020; 102:693-702. [PMID: 31977817 PMCID: PMC7508283 DOI: 10.2106/jbjs.19.00790] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Romosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures. METHODS Patients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed "Up & Go" (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH). RESULTS A total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada,Email address for E.H. Schemitsch:
| | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California,Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Theofilos Karachalios
- Orthopaedic Department UGHL, School of Health Sciences, University of Thessalia, Larissa, Greece
| | - Lauren L. Nowak
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Parag Sancheti
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
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40
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Wijn SRW, Rovers MM, Rongen JJ, Østerås H, Risberg MA, Roos EM, Hare KB, van de Graaf VA, Poolman RW, Englund M, Hannink G. Arthroscopic meniscectomy versus non-surgical or sham treatment in patients with MRI confirmed degenerative meniscus lesions: a protocol for an individual participant data meta-analysis. BMJ Open 2020; 10:e031864. [PMID: 32152157 PMCID: PMC7064080 DOI: 10.1136/bmjopen-2019-031864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Arthroscopic partial meniscectomy (APM) after degenerative meniscus tears is one of the most frequently performed surgeries in orthopaedics. Although several randomised controlled trials (RCTs) have been published that showed no clear benefit compared with sham treatment or non-surgical treatment, the incidence of APM remains high. The common perception by most orthopaedic surgeons is that there are subgroups of patients that do need APM to improve, and they argue that each study sample of the existing trials is not representative for the day-to-day patients in the clinic. Therefore, the objective of this individual participant data meta-analysis (IPDMA) is to assess whether there are subgroups of patients with degenerative meniscus lesions who benefit from APM in comparison with non-surgical or sham treatment. METHODS AND ANALYSIS An existing systematic review will be updated to identify all RCTs worldwide that evaluated APM compared with sham treatment or non-surgical treatment in patients with knee symptoms and degenerative meniscus tears. Time and effort will be spent in contacting principal investigators of the original trials and encourage them to collaborate in this project by sharing their trial data. All individual participant data will be validated for missing data, internal data consistency, randomisation integrity and censoring patterns. After validation, all datasets will be combined and analysed using a one-staged and two-staged approach. The RCTs' characteristics will be used for the assessment of clinical homogeneity and generalisability of the findings. The most important outcome will be the difference between APM and control groups in knee pain, function and quality of life 2 years after the intervention. Other outcomes of interest will include the difference in adverse events and mental health. ETHICS AND DISSEMINATION All trial data will be anonymised before it is shared with the authors. The data will be encrypted and stored on a secure server located in the Netherlands. No major ethical concerns remain. This IPDMA will provide the evidence base to update and tailor diagnostic and treatment protocols as well as (international) guidelines for patients for whom orthopaedic surgeons consider APM. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017067240.
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Affiliation(s)
- Stan R W Wijn
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan J Rongen
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Håvard Østerås
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - May A Risberg
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo University Hospital, Oslo, Norway
- Division of Orthopedic Surgery, Norwegian School of Sport Sciences, Oslo University Hospital, Oslo, Norway
| | - Ewa M Roos
- Department of Sports and Clinical Biomechanics, Musculoskeletal Function and Physiotherapy and Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Kristoffer B Hare
- Department of Orthopedics, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Martin Englund
- Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Faculty of Medicine, Lund University, Lund, Sweden
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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41
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Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ. Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. N Engl J Med 2019; 381:2199-2208. [PMID: 31557429 DOI: 10.1056/nejmoa1906190] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty. METHODS We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points. RESULTS The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty. CONCLUSIONS Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).
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Affiliation(s)
- Mohit Bhandari
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Thomas A Einhorn
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Gordon Guyatt
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Emil H Schemitsch
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Robert D Zura
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Sheila Sprague
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Frede Frihagen
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Ernesto Guerra-Farfán
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Ydo V Kleinlugtenbelt
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Rudolf W Poolman
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Amar Rangan
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Sofia Bzovsky
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Diane Heels-Ansdell
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Lehana Thabane
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - Stephen D Walter
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
| | - P J Devereaux
- The affiliations of the members of the writing committee are as follows: the Division of Orthopaedic Surgery, Department of Surgery (M.B., S.S., S.B.), the Department of Health Research Methods, Evidence, and Impact (M.B., G.G., S.S., D.H.-A., L.T., S.D.W., P.J.D.), the Department of Medicine (G.G., P.J.D.), and the Population Health Research Institute (P.J.D.), McMaster University, Hamilton, and the Department of Surgery, University of Western Ontario, London (E.H.S.) - all in Ontario, Canada; the Department of Orthopedic Surgery, New York University Langone Medical Center, New York (T.A.E.); the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans (R.D.Z.); the Division of Orthopedic Surgery, Oslo University Hospital, Oslo (F.F.); the Department of Traumatology, Orthopedic Surgery, and Emergency, Hospital Vall d'Hebrón, Barcelona (E.G.-F.); the Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer (Y.V.K.), and the Department of Orthopedic Surgery, OLVG, Amsterdam (R.W.P.) - both in the Netherlands; and the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, the Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, and the Department of Health Sciences, University of York, York - all in the United Kingdom (A.R.)
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Peter WF, Poolman RW, Scholtes VAB, de Vet HCW, Terwee CB. Responsiveness and interpretability of the Animated Activity Questionnaire for assessing activity limitations of patients with hip or knee osteoarthritis. Musculoskeletal Care 2019; 17:327-334. [PMID: 31402572 DOI: 10.1002/msc.1418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 06/10/2023]
Abstract
PURPOSE The aim of the study was to determine the responsiveness and interpretability of the Animated Activity Questionnaire (AAQ), an online questionnaire in which osteoarthritis patients select animations that best match their performance of daily activities. METHODS A longitudinal study was carried out, in which 94 patients with hip or knee osteoarthritis were assessed at baseline, and 3 and 6 months after treatment (conservative and surgical). Responsiveness was assessed by means of testing hypotheses about expected correlations between change in AAQ, a Global Rating Scale of change (GRS) and change in the Activities of Daily Living subscale of the Hip disability or Knee injury and Osteoarthritis Outcome Score (H/KOOS), and a combination of performance-based tests (the 30 s chair-stand test, the timed up-and-go test and the nine-step stair climbing test). The minimal important change (MIC) was estimated by means of the receiving operating characteristics (ROC) method. RESULTS The correlations of the AAQ with the H/KOOS were as expected, but other correlations were lower than anticipated. The area under the ROC curve was 0.74 at 6 months. At 3 months' follow-up, the correlations were too low to calculate a MIC. A total of 20% of the results at 3 months and 80% of the results at 6 months were in accordance with the hypotheses. The MIC was 9 points at 6 months. CONCLUSIONS The AAQ was sufficiently responsive at the six-months follow-up, but not at the three-month follow-up. The MIC at the 6-month follow-up (9 points) was slightly lower than the smallest detectable change of 14 points found in a previous study.
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Affiliation(s)
- Wilfred F Peter
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
- Amsterdam Rehabilitation Research Center|Reade, Amsterdam, the Netherlands
| | - Rudolf W Poolman
- Department of Orthopedics, Joint Research, OLVG, Amsterdam, the Netherlands
| | | | - Henrika C W de Vet
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Caroline B Terwee
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Kempen DHR, Delawi D, Altena MC, Kruyt MC, van den Bekerom MPJ, Oner FC, Poolman RW. Neurological Outcome After Traumatic Transverse Sacral Fractures: A Systematic Review of 521 Patients Reported in the Literature. JBJS Rev 2019; 6:e1. [PMID: 29870419 DOI: 10.2106/jbjs.rvw.17.00115] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The purpose of this study was to determine the neurological outcome after transverse sacral fractures in patients with neurological impairment. METHODS A systematic review of the English, French, German, and Dutch literature was conducted. All study designs, including retrospective cohort studies and case reports, describing transverse sacral fractures were included. Two authors independently extracted the predefined data and scored the neurological impairment according to the Gibbons classification after the trauma and at the time of follow-up. The neurological outcomes were pooled according to the Gibbons classification. RESULTS No randomized controlled trials or prospective case series were found. A total of 139 articles were included, consisting of 81 case reports and 58 retrospective case series involving 521 patients. Regardless of the type of management, neurological recovery of at least 1 Gibbons category was reported in 62% of these patients. A comparison of the neurological outcome of nonoperatively treated patients and surgically treated patients showed similar neurological recovery rates. For the surgically treated patients, fixation of the fracture resulted in a better neurological improvement compared with an isolated decompression. CONCLUSIONS This review could not provide evidence of improved neurological recovery after surgical treatment compared with nonoperative treatment. When surgical treatment was considered, there was a low level of evidence that fixation of the fracture results in better neurological improvement compared with isolated decompression. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- D H R Kempen
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - D Delawi
- Department of Orthopaedic Surgery, Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - M C Altena
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - M C Kruyt
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M P J van den Bekerom
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - F C Oner
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
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Thiel B, Mooijer BC, Kolff-Gart AS, Kerklaan BM, Poolman RW, de Haan P, Siepel MAM. Is preoperative forced-air warming effective in the prevention of hypothermia in orthopedic surgical patients? A randomized controlled trial. J Clin Anesth 2019; 61:109633. [PMID: 31706739 DOI: 10.1016/j.jclinane.2019.109633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Bram Thiel
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands.
| | - Bart C Mooijer
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands
| | - Anna S Kolff-Gart
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands; Department of Radiology, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Bojana Milojkovic Kerklaan
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands; Medical Center Dupont, 's Heeren Loo, Ermelo, the Netherlands
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Peter de Haan
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands
| | - Muriel A M Siepel
- Department of Anesthesiology, OLVG Hospital, Amsterdam, the Netherlands
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Bloembergen CH, van de Graaf VA, Virgile A, Willigenburg NW, Noorduyn JCA, Saris DB, Harris I, Poolman RW. Infographic. Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. Br J Sports Med 2019; 54:556-557. [PMID: 31653776 DOI: 10.1136/bjsports-2019-101502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Coen H Bloembergen
- Centre for Orthopaedic Research (CORAL), Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | | | | | | | - Julia C A Noorduyn
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Daniel Bf Saris
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian Harris
- Ingham Institute for Applied Medical Research, Whitlam Orthopaedic Research Centre, University of New South Wales, Australia, Liverpool, New South Wales, Australia.,Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
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Veltman ES, Moojen DJF, van Ogtrop ML, Poolman RW. Two-stage revision arthroplasty for coagulase-negative staphylococcal periprosthetic joint infection of the hip and knee. World J Orthop 2019; 10:348-355. [PMID: 31750083 PMCID: PMC6854054 DOI: 10.5312/wjo.v10.i10.348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/14/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) are frequently caused by coagulase-negative Staphylococci (CoNS), which is known to be a hard-to-treat microorganism. Antibiotic resistance among causative pathogens of PJI is increasing. Two-stage revision is the favoured treatment for chronic CoNS infection of a hip or knee prosthesis. We hypothesised that the infection eradication rate of our treatment protocol for two-stage revision surgery for CoNS PJI of the hip and knee would be comparable to eradication rates described in the literature.
AIM To evaluate the infection eradication rate of two-stage revision arthroplasty for PJI caused by CoNS.
METHODS All patients treated with two-stage revision of a hip or knee prosthesis were retrospectively included. Patients with CoNS infection were included in the study, including polymicrobial cases. Primary outcome was infection eradication at final follow-up.
RESULTS Forty-four patients were included in the study. Twenty-nine patients were treated for PJI of the hip and fifteen for PJI of the knee. At final follow-up after a mean of 37 mo, recurrent or persistent infection was present in eleven patients.
CONCLUSION PJI with CoNS can be a difficult to treat infection due to increasing antibiotic resistance. Infection eradication rate of 70%-80% may be achieved.
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic and Trauma Surgery, OLVG, Joint Research OLVG, Amsterdam 1091AC, Netherlands
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden 2333ZA, Netherlands
| | - Dirk Jan F Moojen
- Department of Orthopaedic and Trauma Surgery, OLVG, Joint Research OLVG, Amsterdam 1091AC, Netherlands
| | - Marc L van Ogtrop
- Department of Medical Microbiology, OLVG, Amsterdam 1091AC, Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic and Trauma Surgery, OLVG, Joint Research OLVG, Amsterdam 1091AC, Netherlands
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Veltman ES, Moojen DJF, Ogtrop MLV, Poolman RW. Two-stage revision arthroplasty for coagulase-negative staphylococcal periprosthetic joint infection of the hip and knee. World J Orthop 2019. [DOI: 10.5312/wjo.v10.i10.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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van de Graaf VA, Bloembergen CH, Willigenburg NW, Noorduyn JCA, Saris DB, Harris IA, Poolman RW. Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. Br J Sports Med 2019; 54:354-359. [PMID: 31371339 PMCID: PMC7057800 DOI: 10.1136/bjsports-2019-100567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2019] [Indexed: 12/28/2022]
Abstract
Objectives To examine the ability of surgeons to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy (APM) and exercise therapy in middle-aged patients. Design and setting Electronic survey. Orthopaedic surgeon survey participants were presented 20 patient profiles. These profiles were derived from a randomised clinical trial comparing APM with exercise therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. From each treatment group (APM and exercise therapy), we selected five patients with the best (responders) and five patients with the worst (non-responders) knee function after treatment. 1111 orthopaedic surgeons and residents in the Netherlands and Australia were invited to participate in the survey. Interventions For each of the 20 patient profiles, surgeons (unaware of treatment allocation) had to choose between APM and exercise therapy as preferred treatment and subsequently had to estimate the expected change in knee function for both treatments on a 5-point Likert Scale. Finally, surgeons were asked which patient characteristics affected their treatment choice. Main outcomes The primary outcome was the surgeons’ percentage correct predictions. We also compared this percentage between experienced knee surgeons and other orthopaedic surgeons, and between treatment responders and non-responders. Results We received 194 (17%) complete responses for all 20 patient profiles, resulting in 3880 predictions. Overall, 50.0% (95% CI 39.6% to 60.4%) of the predictions were correct, which equals the proportion expected by chance. Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons (50.4% vs 49.5%, respectively; p=0.29). The percentage correct predictions was lower for patient profiles of non-responders (34%; 95% CI 21.3% to 46.6%) compared with responders (66.0%; 95% CI 57.0% to 75.0%; p=0.01). In general, bucket handle tears, knee locking and failed non-operative treatment directed the surgeons’ choice towards APM, while higher level of osteoarthritis, degenerative aetiology and the absence of locking complaints directed the surgeons’ choice towards exercise therapy. Conclusions Surgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears. Clinical trial registration ClinicalTrials.gov Identifier: NCT03462134.
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Affiliation(s)
- Victor A van de Graaf
- Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands .,Orthopaedic Surgery, University Medical Centre, Utrecht, The Netherlands
| | - Coen H Bloembergen
- Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands.,Department of Orthopaedics, CORAL - Center for Orthopaedic Research Alkmaar, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | | | | | - Daniel Bf Saris
- Orthopaedic Surgery, University Medical Centre, Utrecht, The Netherlands.,Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian A Harris
- Injury and Rehabilitation Research Department, Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rudolf W Poolman
- Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
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van de Graaf VA, van Dongen JM, Willigenburg NW, Noorduyn JCA, Butter IK, de Gast A, Saris DBF, van Tulder MW, Poolman RW. How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study. Br J Sports Med 2019; 54:538-545. [PMID: 31227493 PMCID: PMC7212930 DOI: 10.1136/bjsports-2018-100065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2019] [Indexed: 11/07/2022]
Abstract
Objectives To examine whether physical therapy (PT) is cost-effective compared with arthroscopic partial meniscectomy (APM) in patients with a non-obstructive meniscal tear, we performed a full trial-based economic evaluation from a societal perspective. In a secondary analysis—this paper—we examined whether PT is non-inferior to APM. Methods We recruited patients aged 45–70 years with a non-obstructive meniscal tear in nine Dutch hospitals. Resource use was measured using web-based questionnaires. Measures of effectiveness included knee function using the International Knee Documentation Committee (IKDC) and quality-adjusted life-years (QALYs). Follow-up was 24 months. Uncertainty was assessed using bootstrapping techniques. The non-inferiority margins for societal costs, the IKDC and QALYs, were €670, 8 points and 0.057 points, respectively. Results We randomly assigned 321 patients to PT (n=162) or APM (n=159). PT was associated with significantly lower costs after 24 months compared with APM (−€1803; 95% CI −€3008 to −€838). The probability of PT being cost-effective compared with APM was 1.00 at a willingness to pay of €0/unit of effect for the IKDC (knee function) and QALYs (quality of life) and decreased with increasing values of willingness to pay. The probability that PT is non-inferior to APM was 0.97 for all non-inferiority margins for the IKDC and 0.89 for QALYs. Conclusions The probability of PT being cost-effective compared with APM was relatively high at reasonable values of willingness to pay for the IKDC and QALYs. Also, PT had a relatively high probability of being non-inferior to APM for both outcomes. This warrants further deimplementation of APM in patients with non-obstructive meniscal tears. Trial registration numbers NCT01850719 and NTR3908.
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Affiliation(s)
- Victor A van de Graaf
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands .,Department of Orthopaedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | | | - Julia C A Noorduyn
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Ise K Butter
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Arthur de Gast
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Centre - mN, Diakonessenhuis, Utrecht, The Netherlands
| | - Daniel B F Saris
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
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Gielis WP, van Oldenrijk J, Ten Cate N, Scholtes VAB, Geerdink CH, Poolman RW. Increased Persistent Mid-Thigh Pain After Short-Stem Compared With Wedge-Shaped Straight-Stem Uncemented Total Hip Arthroplasty at Medium-Term Follow-Up: A Randomized Double-Blinded Cross-Sectional Study. J Arthroplasty 2019; 34:912-919. [PMID: 30773357 DOI: 10.1016/j.arth.2019.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/06/2018] [Accepted: 01/06/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Femoral prosthesis design may impact the frequency of mid-thigh pain. We compared current, incidental, and persistent mid-thigh pain between the short-stem, Collum Femoris femur prosthesis, and the wedge shaped straight-stem, Zweymüller femur prosthesis and studied the associations between demographics, radiographic measurements, and mid-thigh pain. METHODS We contacted patients from a randomized controlled trial who underwent uncemented total hip arthroplasty (THA) for hip osteoarthritis at a mean follow-up of 44 months (range 24-64 months). Patients were specifically assessed for current (during assessment), incidental (any time postoperatively for >1 week) mid-thigh pain, and persistent (any time postoperatively for >2 years) mid-thigh pain. Furthermore, we used regression analysis to study associations between demographics, radiographic measurements, and mid-thigh pain. RESULTS One hundred forty of 150 patients (93%) responded to our assessment. Mean age at the time of operation was 62 years (±7.0). Current mid-thigh pain occurred in 16 patients (23%) in the Collum Femoris Preserving (CFP) group compared with 10 patients (14%) in the Zweymüller group (P = .192). Incidental mid-thigh pain occurred in 24 patients (34%) in the CFP group compared with 15 patients (21%) in the Zweymüller group (P = .090). Persistent mid-thigh pain was found in 13 patients (19%) in the CFP group compared with five patients (7%) in the Zweymüller group (P = .043). Varus malalignment (odds ratio 1.819 [95% confidence interval 1.034-3.200]) and leg lengthening (odds ratio 1.107 per cm lengthening [95% confidence interval 1.026-1.195]) showed significant associations with mid-thigh pain. CONCLUSIONS We found more persistent mid-thigh pain after short-stem uncemented THA compared to wedge-shaped straight-stem uncemented THA during medium-term follow-up. Varus malalignment and leg lengthening were associated with mid-thigh pain.
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Affiliation(s)
- Willem Paul Gielis
- Department of Orthopedic Surgery, Joint Research, Amsterdam, The Netherlands; Department of Orthopedic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Jakob van Oldenrijk
- Department of Orthopedic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Nick Ten Cate
- Department of Orthopedic Surgery, Joint Research, Amsterdam, The Netherlands
| | | | - Carel H Geerdink
- Department of Orthopedic Surgery, Ikazia Hospital, Rotterdam, The Netherlands
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, Joint Research, Amsterdam, The Netherlands
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