Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Classification and surgical treatment of incisional hernia. Results of an experts' meeting

BACKGROUND

The treatment of incisional hernia (IH) is a current problem in modern surgery. Many important aspects of incisional hernia surgery are yet to be answered, especially the choice of surgical technique and its adaptation to the individual patient. The aim of this experts' meeting was to resolve some current questions in incisional hernia surgery and to organise an international hernia register.

METHODS

An international panel of ten experts met under the auspices of the European Hernia Society (GREPA) to investigate the classification and therapeutic alternatives for incisional hernia. Prior to the conference, all experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The information from this correspondence was used as a basis for panel discussion. The personal experiences of the participants and other aspects of individualised therapy were also considered.

RESULTS

The expert panel suggested a new classification of incisional hernia based on localisation, size, recurrences and symptoms. All experts agreed that the fascia duplication and the fascia adaptation should only be used for small incisional hernias. Fascia duplication is of value only in the horizontal direction. The technical details and the pros and cons of each procedure were discussed for prosthetic implantation using onlay and sublay techniques and the technique of autodermal hernioplasty.

CONCLUSIONS

The management of incisional hernia is currently not standardised. In order to answer relevant questions of incisional hernia surgery, an international hernia register should be established.

The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures

Currently available intramedullary devices for the treatment of unstable pertrochanteric femoral fractures are technically demanding and show a considerable failure rate due to their massiveness and the persistent rotational instability of the head-neck fragment. The Arbeitsgemeinschaft für Osteosynthesefragen (AO/ASIF) therefore designed a new intramedullary device, the proximal femoral nail (PFN), which during a handling study was tested in 4 European clinics. Within one year 191 proximal femoral fractures were treated with the PFN. After a follow up period of at least 4 months technical failures (poor reduction, malrotation or wrong choice of screws) were seen in just 4.6% of the cases. One patient showed a cut-out of the implant but there were no mechanical failures (bending, breaking of the implant) or ipsilateral fractures of the femoral shaft at the tip of the implant. It is therefore concluded that the results of this new implant compare favourably to the currently available implants for the treatment of the unstable pertrochanteric femoral fracture.

Reherniation after repair of the abdominal wall with expanded polytetrafluoroethylene

Defects of the abdominal wall that are not amendable to primary closure have to be bridged by synthetic materials. The use of a nonabsorbable expanded polytetrafluoroethylene (ePTFE) soft-tissue patch is advocated for this purpose. To investigate the suitability of the ePTFE patch, abdominal wall defects in 30 rats were repaired with ePTFE and compared with polypropylene (PP) mesh. Herniations and adhesions were scored, qualitatively and quantitatively, eight weeks after implantation and the patches were histologically examined. Herniations, all observed at the fascia and patch interface, were significantly more frequent in abdominal wall defects repaired with ePTFE (60 percent) than with PP (zero percent) (p < 0.001, chi-square test). Adhesion formation was less frequently found in rats treated with ePTFE and adhesions were less strongly attached. Histologic examination revealed no ingrowth of fibro-collagenous tissue into the ePTFE patch, whereas the PP mesh was completely incorporated into fibrocollagenous tissue, which was continuous with the adjacent fascia. We conclude that this study confirms our clinical experience that reherniations at the fascia and patch interface in abdominal wall defects closed with an ePTFE soft-tissue patch are the result of insufficient ingrowth of fibrocollagenous tissue into the patch, which results in an insufficient anchorage of the patch to the fascia.

Expanded polytetrafluoroethylene patch versus polypropylene mesh for the repair of contaminated defects of the abdominal wall

Contaminated defects of the abdominal wall continue to be a significant problem for patients and surgeons. The lack of sufficient tissue may require the insertion of a prosthetic material. Polypropylene (PP) mesh is still the most widely used material for this purpose, although the propensity to induce extensive visceral adhesions and erosion of the skin or intestine is a well-known drawback. Expanded polytetrafluoroethylene (PTFE) patch has better mechanical properties and has a low potential for infection. Therefore, we used expanded PTFE patch to repair contaminated abdominal wall defects in three patients. In one patient, the postoperative course was uneventful. In the other two patients, the patch had to be removed for ongoing wound sepsis and because the patch disintegrated. In an experimental study, contaminated abdominal wall defects created in Wistar rats were repaired with expanded PTFE patch (PTFE group, n = 21) or PP (PP group, n = 21). Wound infection occurred in 16 rats in the PTFE group and in 14 rats in the PP group. Two rats in each group died. Two rats in the PTFE group died as a result of peritonitis, one rat in the PP group died as a result of ileus and one as a result of peritonitis. Incisional hernia was found to be significantly more frequent in the PTFE group (n = 13) than in the PP group (n = 3). Fistula formation was only found in three rats in the PP group. Adhesion formation was more pronounced in rats in the PP group. It is concluded that the expanded PTFE is unsuitable for the reconstruction of contaminated abdominal wall defects and that PP mesh is more suitable, although this material has a high risk of complications.

[Treatment strategy and results in primary inoperable rectal cancer]

The authors report their experience with laparotomy in patients with rectal carcinoma to identify those patients with locally non-resectable primary cancer of the rectum who may be treated initially by high-dose radiotherapy. The goal of this so-called "staging laparotomy" is to assess mobility and tumor size by means of bimanual palpation, to stage the abdominal cavity and to create total fecal diversion by performing an endcolostomy in order to condition these patients for maximum tolerance during the protracted radiotherapy course (greater than 50 Gy/5-6 weeks). The formation of an endcolostomy seems to avoid severe morbidity and even mortality of high-dose radiotherapy without delay of further surgery. Twenty-two patients with locally advanced rectal carcinoma were treated in this way. The tumor was resectable in 18 of the 20 patients who underwent relaparotomy after high-dose radiotherapy. Six out of the 13 patients with a radical resection died with evidence of disease during the follow-up (2 with local disease). One patient died with no evidence of disease after 5 years and 6 patients are still alive without disease after an average of 37 months (15-67 months).

Improved tissue ingrowth and anchorage of expanded polytetrafluoroethylene by perforation: an experimental study in the rat

Although an expanded polytetrafluoroethylene patch is a suitable synthetic material to repair large abdominal wall defects, lack of tissue ingrowth into the patch may give rise to herniation at the fascia-patch interface. This study was undertaken to determine whether perforations and/or ethanol pretreatment improved tissue ingrowth into the polytetrafluoroethylene patch. Patches were implanted subcutaneously in 12 rats and evaluated 6 wk (n = 4) or 12 wk (n = 8) after implantation. Tissue ingrowth was only demonstrated into perforated patches. Stress-strain measurements showed that perforation caused a 25% decrease in the mechanical strength of the material. It was concluded that perforation might improve the anchorage of the polytetrafluoroethylene patch to the adjacent aponeurosis and thereby prevent herniation when the polytetrafluoroethylene soft tissue patch was used for the repair of abdominal wall defects.

Expanded polytetrafluoroethylene patch for the repair of large abdominal wall defects

Expanded polytetrafluoroethylene (ePTFE) was used to repair 11 large abdominal wall defects in ten patients. Three patches were fixed to the adjacent abdominal aponeurosis with a single row of sutures; seven patches were implanted with a 1-2 cm overlap of patch and aponeurosis and a double row of sutures. Recurrent buttonhole hernias were found in two patients, in both of whom a single row of sutures had been used. This reherniation was due to insufficient anchorage of the patch to the fascia. It is concluded that ePTFE is a useful material to repair large abdominal wall defects provided the patch is fixed to the aponeurosis with an overlap and a double row of sutures to prevent buttonhole hernias.