[Structured assessment for orthopaedic patients - method, results, and diagnostic potential]. / Strukturierte Anamnese bei orthopädischen Patienten - Methode, Resultate und diagnostisches Potenzial.

BACKGROUND: Review of medical records demonstrates a moderate to low correlation (r = 0.57 to 0.22) between daily limitations and symptoms based upon patient history. This correlation could be improved with the ideal questionnaire which would assess patients using the same questions with the same response options in the same order. Therefore, a simple patient questionnaire for orthopaedic patients was developed and validated to assess 10 symptoms, 12 limitations of daily life and patients' well-being. The concept was to provide a universal questionnaire that could be used for all patients and provide the basis for a structured assessment that would then provide standardised and comparable patient information. Additional localisation of symptoms would allow a differential diagnosis. For example, pain in the groin/thigh while standing and walking may be caused by osteoarthritis of the hip or osteochondrosis of the lumbar spine. Further physical investigation and diagnostic imaging may lead to the diagnosis. PATIENTS AND METHODS: This method was employed as part of routine quality control from November 2006 to October 2008 by two orthopaedic surgeons in their outpatient clinic in a tertiary health care hospital. Structured assessment was performed in all patients regardless of their pathology (hip, knee, shoulder, cervical spine, lumbar spine, foot) or situation (before/after surgery, conservative therapy). The completeness, symptom score, daily limitation score, and well-being as well as the relationships between symptom score, daily limitation score, and well-being were calculated. Answers regarding walking capacity and effective walking capacity could be compared. Several patients with combined orthopaedic pathologies were closely analysed. RESULTS: Data of 2642 structured assessments in 1777 patients (957 women, 53.9 %) were evaluated. The average age was 64.4 years. The data completeness on the front page was 96.2 and 86.3 % on the back page. The mean value for symptoms (daily limitations) was 34.31 (27.45), and the median was 32.5 (25.0). The distributions of the symptom score and daily limitation score were asymmetrical; 80 % of the patients were below 50 and 38, respectively. Well-being was excellent in 21.4 %, good in 24 %, moderate in 24.2 %, poor in 11.4 %, and very poor in 16.7 %. The main symptom was pain on movement/walking, with an average of 60.32. The symptom score, daily limitation score, and well-being were found to have a correlation to each other (Spearman's r between 0.55 and 0.63). Thirty-nine patients reported an inability to walk, although 36 could walk in the office (1 had paraplegia and 2 had paraparesis caused by lumbar stenosis). Combined pathologies in orthopaedic patients were found for cervical-shoulder, lumbar-hip, and lumbar-knee pathologies. CONCLUSIONS: A routine structured assessment can be performed with extra effort. A structured assessment provides patient information in a standardised form so that such information can be compared as well as allow a differential diagnosis. It is possible that answers to the questionnaire represent patients' subjective assessment rather than reality.

[Relative effect per patient (REPP)--outcome groups for total hip replacement and total knee replacement]. / Relativer Effekt pro Patient (REPP)--Ergebnisgruppen am Beispiel der Hüfttotalendoprothese und Knietotalendoprothese.

BACKGROUND: The outcome of orthopaedic surgery such as total hip replacement (THR) or total knee replacement (TKR) is commonly given by the change in mean scores on patient-reported outcome measures (Prom's). This may give the impression that all enrolled patients have experienced an improvement. But the Swedish hip registry and other studies report a reduction of complaints in 80-85 % of patients ("responders"), with the remainder (approximately one in six) remaining unchanged or reporting worse complaints ("non-responders"). According to Cohen, the degree of success in the "responders" group can be subdivided into excellent, good and moderate. For a given treatment, a total of 5 different outcome groups can therefore be defined: excellent, good, moderate, unchanged and worse. Allocation to the groups is based on the "relative effect per patient" (REPP). The REPP is calculated as the base-line score minus the post-treatment score divided by the baseline score. The maximum possible REPP is 1; a REPP of 0 means no effect and a negative REPP means deterioration. Allocation to the outcome groups is as follows: excellent 0.95 to 1 REPP, good 0.5 to 0.95 REPP, moderate over 0.2 to 0.5 REPP, unchanged -0.2 to 0.2 REPP and worse below -0.2 REPP. PATIENTS AND METHODS: Our local arthroplasty register was used to evaluate the 1-year outcomes of THR and TKR patients operated between March 2003 and November 2008, using WOMAC scores and EuroQoL scores. Only patients with complete data sets and unilateral THR/TKR were included. The success rate given by the REPP method was compared with that of the "responder rate" method defined by the OMERACT-OARSI criteria. RESULTS: With the WOMAC questionnaire, outcomes were as follows (THR/TKR): excellent 29/14 %, good 51/54 %, moderate 11/13 %, unchanged at 5/12 %, worse 4/7 %. The corresponding values for the EuroQoL were (THR/TKR): excellent 16/6 %, good 41/42 %, moderate 25/28 %, unchanged 12/16 %, worse 6/8 %. For THR, success rates were 92 % using the "responder rate" method (OMERACT-OARSI criteria) and 91 % using the REPP method with the WOMAC. CONCLUSION: Calculation of the REPP and the subsequent allocation to outcome groups is simple. The distribution of outcomes depends on the intervention (THR results better than TKR) and the patient questionnaire used (better results with a condition-specific than a generic questionnaire). The proportion of "unchanged" and "moderate" outcomes was greater with the generic questionnaire than with the condition-specific questionnaire, while the proportion of "worse" outcomes was similar for the two instruments. Partitioning of the degree of success into sub-groups, based on the REPP, provides more information for both the patient and the orthopaedic surgeon.

[A simple orthopaedic patient questionnaire to measure symptoms and disabilities--validation and experience]. / Ein einfacher orthopädischer Patientenfragebogen für die Messung von Beschwerden und Behinderungen (Pationnaire) - Validierung, Erfahrungen.

AIM: The aim of this study was to measure musculoskeletal symptoms and disabilities in a structured and objective manner. For this purpose, we have developed a simple patient questionnaire (Pationnaire). This includes the most important symptoms and signs of the entire musculoskeletal system including the vertebrae. METHODS: The questionnaire was tested for construct validity and reliability. The experiences were gathered in separate centres within an outcome study after total hip arthroplasty and routine consultations. RESULTS: Construct validity was tested in 71 patients by comparing the questionnaire answers with details given by personal interview. Concordance was total in 95 %, partial in 3 %, and inadequate in 2 % (older patients with poly-morbidity). Concordance was improved by discussion, completion and correction of questionnaire answers together with the patient. Participants required an average of 9.9 minutes to complete the questionnaire. The test-retest reliability of the Pationnaire yielded, compared to the SF-36, more questions with a higher intraclass correlation coefficient (ICC); the mean ICC for all Pationnaire questions was 0.76 versus 0.57 for the SF-36. The percentage of identical answers was between 69.7 % and 99.4 % with the Pationnaire and between 52.2 % and 96.8 % with SF-36. User experience showed that the questionnaire can be used for initial and differential diagnosis, for improved communication with the patient, and to measure outcome. The questionnaire proved valuable in the differential diagnosis of symptoms after endoprosthesis. Information on type and location are particularly valuable in differentiating mechanical, inflammatory or other causes. The questionnaire can be used for outcome measurements in endoprosthesis. In 66 patients, 6 months after total hip prosthesis, pain scores were reduced from 47.8 to 29.5, symptom scores from 30.8 to 11.6, and disability scores from 22.5 to 10.5 (all changes statistically significant, p < 0.05). CONCLUSION: The questionnaire reliably measures symptoms and disabilities in orthopaedic disease. Interactive collection of patient history renders it more objective. The questionnaire can be used in outpatient consultations, for initial and differential diagnosis, to improve communication, and to measure outcome.