Patient-reported outcome measures for hip preservation surgery-a systematic review of the literature.

Hip preservation surgery is rapidly advancing and patient-reported outcome (PRO) measures are becoming an integral part of measuring treatment effectiveness. Traditionally the modified Harris hip score has been used as the main outcome measure. More recently, new PRO tools in the field have been developed. We performed a systematic review of the English literature from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and SPORTDiscus databases to identify the PRO tools used in hip preservation surgery. Our aim was to critically appraise the quality of the questionnaire properties in order to recommend the most appropriate PRO tool for future use. Measurement properties of each PRO questionnaire were rated from excellent to poor, based on Terwee criteria and the results from the included studies. Six PRO tools were identified with description or comparison of their measurement properties in 10 articles. While, most recently developed PRO tools, the hip outcome score (HOS), the Copenhagen hip and groin outcome score (HAGOS) and the international hip outcome tool (iHOT-33) scored better than the others in their measurement properties, iHOT-33 scored the best of all the PRO tools and is recommended for future use in hip preservation surgery.

Pulmonary embolism after hip arthroscopy.

A case of pulmonary embolus after elective hip arthroscopy is reported. The incidence of thromboembolic events after such procedures is currently unknown, and the decision regarding whether to provide prophylaxis rests on anecdotal evidence.

Rupture of the pectoralis major muscle: surgical treatment in athletes.

Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50% of these injuries occur in athletes, classically in weight-lifters during the 'bench press' manoeuvre. We present 13 cases of distal rupture of the pectoralis major muscle in athletes. All patients underwent open surgical repair. Magnetic resonance imaging was used to confirm the diagnosis in all patients. The results were analysed using (1) the visual analogue pain score, (2) functional shoulder evaluation and (3) isokinetic strength measurements. At the final follow-up of 23.6 months (14-34 months), the results were excellent in six patients, good in six and one had a poor result. Eleven patients were able to return to their pre-injury level of sports. The mean time for a return to sports was 8.5 months. The intraoperative findings correlated perfectly with the reported MRI scans in 11 patients and with minor differences in 2 patients. We wish to emphasise the importance of accurate clinical diagnosis, appropriate investigations, early surgical repair and an accelerated rehabilitation protocol for the distal rupture of the pectoralis major muscle as this allows complete functional recovery and restoration of full strength of the muscle, which is essential for the active athlete.

A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160].

BACKGROUND: The shoulder is the most frequently dislocated joint in the body. Multiple causes and pathologies account for the various types of shoulder instability. Multi-directional instability (MDI) and multi-directional laxity with antero-inferior instability (MDL-AII) are similar in pathology, less common and more difficult to treat. These instabilities are caused by ligamentous capsular redundancy. When non-operative management fails for these patients, quality of life is significantly impaired and surgical treatment is required to tighten the ligaments and joint capsule. The current reference (gold) standard treatment for MDI/MDL-AII is an open inferior capsular shift (ICS) surgical procedure. An alternative treatment involves arthroscopic thermal shrinkage of redundant capsular tissue to tighten the joint. However, there is a lack of scientific evidence to support the use of this technique called, electrothermal arthroscopic capsulorrhaphy (ETAC). This trial will compare the effectiveness of ETAC to open ICS in patients with MDI and MDL-AII, using patient-based quality of life outcome assessments. METHODS: This study is a multi-centre randomized clinical trial with a calculated sample size of 58 patients (p = 0.05, 80% power). Eligible patients are clinically diagnosed with MDI or MDL-AII and have failed standardized non-operative management. A diagnostic shoulder arthroscopy is performed to confirm eligibility, followed by intra-operative randomization to the ETAC or ICS surgical procedure. The primary outcome is the disease-specific quality of life questionnaire (Western Ontario Shoulder Instability Index), measured at baseline, 3, 6, 12 and 24 months. Secondary outcomes include shoulder-specific measures (American Shoulder and Elbow Surgeons Score and Constant Score). Other outcomes include recurrent instability, complications and operative time. The outcome measurements will be compared on an intention-to-treat basis, using two-sample independent t-tests to assess statistical significance. A Generalized Estimated Equations (GEE) analysis will determine whether there is an effect over time. DISCUSSION: This ongoing trial has encountered unexpected operational and practical issues, including slow patient enrollment due to high intra-operative exclusion rates. However, the authors have a greater understanding of multi-directional laxity in the shoulder and anticipate the results of this trial will provide the medical community with the best scientific clinical evidence on the efficacy of ETAC compared to open ICS.

Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature.

OBJECTIVE: Hamstring strains are one of the most common muscle strains in athletes; however, complete rupture of the proximal hamstring origin is rare and results from significant trauma. The objective of this paper is to present our experience of management of complete ruptures where surgical repair resulted in good results in both acute and delayed cases. METHODS: Two water skiers and two bull riders sustained complete rupture of the proximal origin of the hamstring muscles. All underwent repair of the hamstring origin and sciatic nerve neurolysis. A post operative hamstring rehabilitation programme was instituted. Regular follow up was performed at 2, 3, 6, 9, and 12 months. RESULTS: At a minimum final follow up of 12 months all patients had regained functional knee flexion strength with no pain and a near normal range of knee flexion. All four individuals were able to return to their previous line of work and three were able to return to their pre-injury level of sport. CONCLUSION: Complete rupture of the hamstring origin is a potentially devastating sports injury that has implications affecting the individual's activities of daily living as well as potential as a sportsperson. Surgical repair restores the distorted anatomy, allows early functional rehabilitation, and avoids the potential debilitating neurological problem of gluteal sciatica.

Evidence-based review of sport-related concussion: basic science.

The evidence base for sport-related concussive brain injury is reviewed in this paper. In the past, pathophysiological understanding of this common condition has been extrapolated from studies of severe brain trauma. More recent scientific study demonstrates that this approach is unsatisfactory, and the clinical features of concussion represent a predominantly functional brain injury rather than manifest by structural or neuropathological damage. Such understanding of this condition remains incomplete at this stage.

Evidence-Based review of sport-related concussion: clinical science.

The clinical nature of sport-related concussion is discussed in this paper. Particularly highlighted are the difficulties with definition, injury severity grading, classification, and understanding of clinical symptoms. In addition, the well-recognized sequelae of concussion including the motor and convulsive manifestations are discussed in detail. Where possible, an evidence-based approach is adopted to assist the understanding of the literature in this complex area.

The effect of exercise on anterior-posterior translation of the normal knee and knees with deficient or reconstructed anterior cruciate ligaments.

Exercise may result in increased laxity in the knee. Anterior translation in 40 normal knees, 33 consecutive anterior cruciate ligament-deficient knees, and 30 randomly chosen anterior cruciate ligament-reconstructed knees was measured using the KT-1000 arthrometer before and after the participants ran for 15 minutes on a neutral-incline treadmill. A single observer blinded to the status of each knee tested all participants. There was a significant increase in anterior translation in the normal (mean, 0.75 mm), anterior cruciate ligament-deficient (mean, 0.62 mm), and anterior cruciate ligament-reconstructed knees (mean, 0.25 mm) after exercise. In addition, the amount of anterior translation after exercise was significantly different when these groups were compared with each other. Post hoc analysis using Tukey's procedure indicated that anterior translation in the anterior cruciate ligament-reconstructed knee was significantly less than in the normal and anterior cruciate ligament-deficient knees. Therefore, repetitive loading exercise contributes to an increase in anterior translation in normal, anterior cruciate ligament-deficient, and anterior cruciate ligament-reconstructed knees, and the anterior cruciate ligament-reconstructed knee does not respond to repetitive loading in the same manner as a normal knee.

Two 6-year follow-up studies of large and massive rotator cuff tears: comparison of outcome measures.

The purposes of this report are (1) to describe the development of a quality-of-life outcome measure for rotator cuff disease (RC-QOL) and a new simple test of rotator cuff function, the Functional Shoulder Elevation Test (FSET), and (2) to compare these with the SF-36 and the American Shoulder and Elbow Surgeons Assessment (ASESA) in a cohort of 86 patients with surgically treated large and massive rotator cuff tears. The RC-QOL is a 34-item self-administered questionnaire that has demonstrated excellent reliability, face validity, and ability to discriminate between large and massive cuff tears; it has also confirmed the construct of higher correlations with the other shoulder outcome measures than with the SF-36. The FSET is a simple test of rotator cuff function that uses 5% body weight and measurement of pain and discomfort on a 100-point visual analog scale. It was highly correlated with the RC-QOL and ASESA and discriminated between large and massive cuff tears. The study achieved an 82% follow-up at an average of 3.5 years. Large cuff tears had statistically significantly improved outcome scores in comparison with massive cuff tears on these 3 outcome measures. The SF-36, however, was not able to discriminate between tear sizes. The RC-QOL and the FSET are recommended outcome measures for rotator cuff disease.

Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg.

OBJECTIVE: To evaluate outcomes in patients who had a fasciotomy performed on their leg(s) for chronic exertional compartment syndrome (CECS). DESIGN: A retrospective descriptive cohort study. SETTING: Tertiary care sport medicine referral practice. PATIENTS: A consecutive series of 62 patients surgically treated for CECS from January 1991 to December 1997. MAIN OUTCOME MEASURES: A questionnaire was designed and developed to assess pain (using a 100 mm visual analogue scale), level of improvement, level of maximum activity, satisfaction level, and the occurrence of reoperations. RESULTS: Fifty patients had anterior/lateral compartment involvement, 8 patients had deep posterior compartment involvement, and 4 patients had anterior/lateral/deep posterior compartment involvement. The demographics of the 39 respondents and 23 nonrespondents were similar. The mean percent pain relief of respondents was 68% (95% CI [confidence interval] = 54% to 82%). There was no relationship between percent pain relief and the documented immediate post exercise compartment pressures. A clinically significant improvement was reported by 26 of 32 (81%) anterior/lateral compartment patients and 3 of 6 (50%) patients with deep posterior compartment involvement. Patient level of activity after fasciotomy was classified as equal to or higher than before the operation with a lesser degree of pain by 28 of 36 (78%) patients, while 8 of 36 (22%) patients reported lower activity levels than before the operation. Of the patients reporting lower activity, seven were due to exercise related pain in the post operative leg(s) and one was due to lifestyle changes. Thirty of 38 patients (79%) were satisfied with the outcome of the operation. Four of 62 patients (6%) failed the initial surgical procedure and required revision surgery for exercise-induced pain. In addition, one of these individuals also had a sympathectomy and another had a neurolysis performed at the time of revision surgery. Three of the 62 (5%) patients had subsequent operations for exercise-induced pain on different compartments than the initial surgical procedure. One individual had an unsuccessful operative repair of a posttraumatic neuroma. Postoperative complications were reported by 5 of 39 (13%) patients in the additional comments section of the questionnaire. CONCLUSIONS: The majority of patients surgically treated for CECS experience a high level of pain relief and are satisfied with the results of their operation. The level of pain relief experienced by patients is not related to the magnitude of the immediate post exercise compartment pressures. Despite the possibility that some patients have less favorable outcomes, experience complications, or need subsequent operations, fasciotomy is recommended for patients with CECS as there is no other treatment for this condition.

The distribution of injuries in men's Canada West university football. A 5-year analysis.

We conducted a prospective cohort study from 1993 to 1997 to determine the frequency and severity of injury in men's Canada West university football. The Canadian Intercollegiate Sport Injury Registry was used to document baseline preseason data, daily athlete participation, and subsequent injury from five varsity football teams. An injury was defined as "any injury resulting in one or more complete or partial sessions of time loss" or "any concussion or transient neck neurologic injury." The annual proportion of injured athletes ranged from 53.5% to 60.4%, with a 5-year total of 1,811 injuries. Regression analysis indicated that the rate of nonconcussion, nonneck neurologic injuries increased. Concussion (N = 110), hamstring strain (N = 88), and brachial plexus (N = 84) injuries were the most common, specific injury diagnoses. Knee injuries resulted in the highest rate of severe (greater than or equal to 7 sessions of time loss) injury and resulted in the most time loss (3,350.5 sessions). Ligament sprains and muscle strains and spasms accounted for approximately half of all injury diagnoses. A total of 1,173 injuries (65%) were related to contact between players or between players and other obstacles. Future studies should be conducted to identify risk factors for the ultimate purpose of implementing injury prevention strategies.

Head and neck injuries among ice hockey players wearing full face shields vs half face shields.

CONTEXT: Speculation exists that use of a full face shield by ice hockey players may increase their risk of concussions and neck injuries, offsetting the benefits of protection from dental, facial, and ocular injuries, but, to our knowledge, no data exist regarding this possibility. OBJECTIVE: To determine the risk of sustaining a head or neck injury among intercollegiate ice hockey players wearing full face shields compared with those wearing half shields. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted during the 1997-1998 Canadian Inter-University Athletics Union hockey season of 642 male hockey players (mean age, 22 years) from 22 teams. Athletes from 11 teams wore full face shields and athletes from 11 teams wore half face shields during play. MAIN OUTCOME MEASURE: Reportable injury, defined as any event requiring assessment or treatment by a team therapist or physician or any mild traumatic brain injury or brachial plexus stretch, categorized by time lost from subsequent participation and compared by type of face shield. RESULTS: Of 319 athletes who wore full face shields, 195 (61.6%) had at least 1 injury during the study season, whereas of 323 who wore half face shields, 204 (63.2 %) were injured. The risk of sustaining a facial laceration and dental injury was 2.31 (95% confidence interval [CI], 1.53-3.48; P<.001) and 9.90 (95% CI, 1.88-52.1; P = .007) times greater, respectively, for players wearing half vs full face shields. No statistically significant risk differences were found for neck injuries, concussion, or other injuries, although time lost from participation because of concussion was significantly greater in the half shield group (P<.001), than in the group wearing full shields. CONCLUSIONS: These data provide evidence that the use of full face shields is associated with significantly reduced risk of sustaining facial and dental injuries without an increase in the risk of neck injuries, concussions, or other injuries.

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder.

Our purpose was to compare the effectiveness of traditional treatment with immediate arthroscopic stabilization in young patients who have sustained a first traumatic anterior dislocation of the shoulder. Forty skeletally mature patients younger than 30 years of age were randomly allocated to immobilization for 3 weeks followed by rehabilitation (group T) or arthroscopic stabilization (within 4 weeks of injury) followed by an identical immobilization and rehabilitation protocol (group S). A blinded research assistant performed all follow-up evaluations. The dominant arm was involved in 35% of subjects. The injury occurred in a sporting event in 70% of subjects. At 24 months, there was a statistically significant difference in the rate of redislocation (T = 47%, S = 15.9%, P = .03). An intention-to-treat analysis comparing disease-specific quality of life using the validated Western Ontario Shoulder Instability (WOSI) index showed statistically significantly better results in the surgically treated group at the 33 months (T = 633.93 v S = 287.1, P = .03) and no significant difference in range of motion. At an average 32 months follow-up, a significant reduction in redislocation and improvement in disease-specific quality of life is afforded by early arthroscopic stabilization in patients less than 30 year of age with a first, traumatic, anterior dislocation of the shoulder.

Skiing and snowboarding injuries in the children and adolescents of Southern Alberta.

OBJECTIVE: To identify injuries and profile the characteristics of injured skiers and snowboarders younger than 18 years of age in Southern Alberta, Canada. DESIGN: Case-series over one year. PARTICIPANTS: Injured skiers and snowboarders younger than 18 years of age presenting to the ski patrol members at each of seven ski areas in Southern Alberta. MAIN OUTCOME MEASURES: Information on injured individuals reporting to the ski patrol at the involved areas was documented on a standardized injury reporting form. Anonymous information was then copied and sent to the University of Calgary Sport Medicine Centre, where the data were analyzed. Proportions of injured skiers and snowboarders with specific characteristics or participating in specific environmental conditions are presented. RESULTS: There were a total of 832 (60.0%) injury reports filed for skiers and 557 (40.1%) for snowboarders, reflecting 1,635 separate injuries. Head injuries were the most frequently reported (19.1% of all regional injuries). The most commonly injured region was the knee among skiers (n = 213; 22.8%) and the wrist among snowboarders (n = 173; 27.8%). Lower extremity injuries in skiers and upper extremity injuries in snowboarders were most common. Younger male skiers and snowboarders reported high proportions of head, neck, and back injuries. CONCLUSION: The lower extremity in skiers and the upper extremity in snowboarders were most susceptible to injury. A cause for concern is the high proportion of head injuries reported for both male skiers and snowboarders of younger age groups. Further study into protective equipment design and function is required.

Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency.

A patient-based, subjective outcome measure for chronic anterior cruciate ligament deficiency was developed, pretested, and validated. The development of the outcome measure was completed in four stages: 1) item generation (167 items), 2) item reduction (by surveying 79 patients), 3) questionnaire formation and pretesting (20 patients), and 4) reliability, responsiveness, and validity assessment (100 patients). This disease-specific quality of life measure is a 32-item questionnaire using a 100-mm visual analog scale response format. Face validity was derived from extensive direct patient input. Content validity was determined by consensus among 20 knee surgeons. There was no significant difference on test-retest reliability, with an overall average error of 6%. The outcome measure demonstrated responsiveness to clinical change correctly in 21 of 25 patients (84%). Construct validity was shown by the ability of the questionnaire to measure the full spectrum of disease; scores ranged from 8 to 99 out of a maximum score of 100. The questionnaire was able to distinguish patients who went on to have surgery (average score, 31) from those who would be treated nonoperatively (average score, 79). The quality of life outcome measure for chronic anterior cruciate ligament deficiency is the first subjective knee scale of its kind to be validated to measure quality of life in patients with chronic anterior cruciate ligament deficiency.

Survey of competitive distance runners in Alberta: satisfaction with health care services with respect to running injuries.

OBJECTIVE: To measure the level of satisfaction of competitive runners with health care services provided for injury management. Secondary objectives were to identify the injury frequency and the rate of utilization of health care services. DESIGN: Descriptive survey. PARTICIPANTS: Cohort of all competitive distance runners in Alberta. MAIN OUTCOME MEASURES: A questionnaire was designed based upon a literature review, standardized questionnaire methodology, and pretesting and evaluation. The questionnaire was mailed to all competitive runners in Alberta. A follow-up letter was mailed to maximize the return rate. The main focus of the questionnaire was to evaluate the athletes' level of satisfaction with health care services, as well as reasons for dissatisfaction with health care. RESULTS: The survey was sent to 306 athletes. A 79% response rate was achieved. There were a number of clinically important trends in the data: (a) 75% of athletes experienced one or more injuries in a 2-year period, (b) 93% of injured athletes utilized health care services for their injuries, and (c) 62% of athletes were satisfied with this health care. The level of satisfaction with health care (62%) was found to be lower than typical levels of satisfaction with health care in the literature. Several reasons for dissatisfaction with health care were identified. CONCLUSIONS: High rates of injury and health care utilization, and a low level of satisfaction with health care were found amongst competitive distance runners. A prospective study is required to confirm these findings.

The effect of bicycling helmets in preventing significant bicycle-related injuries in children.

OBJECTIVE: To identify bicycle-related injuries in children and the effect of helmet use on injury patterns and prevention. DESIGN: A prospective cohort of injured children with case-control design looking at serious head injuries and helmet use. SETTING: A tertiary care childrens' hospital emergency room. PATIENTS: All patients presenting between April 1, 1991 and September 30, 1993, between the ages of 3 and 16 years, with bicycle-related injuries were included. INTERVENTION: The Childrens' Hospital Injury Research and Prevention Program (CHIRPP) Database was used. Standardized information collected on each child included age and sex of the child; nature, location, and time of accident/injury; whether any safety devices were being used at the time of the accident; and the attending physician's determination of the injury(s) and treatment rendered. MAIN OUTCOME MEASURES: Injuries were categorized as major or minor, based upon a consensus of the authors, in a retrospective fashion. RESULTS: Separate bicycle accidents (n = 699) were recorded resulting in 856 injuries. Only 13.7% of the children were wearing helmets at the time of their accidents. Seventy-six serious head injuries were recorded. The risk of serious head injury was significantly greater when a helmet was not worn (chi 2 0.01 < p < 0.05) This represents an odds ratio of 3.12 [confidence interval (CI) = 95% 1.13-8.75]. There was no significant difference in terms of serious injuries overall comparing helmeted and nonhelmeted children (odds ratio = 1.11, 95% CI = 0.72-1.72). CONCLUSIONS: Helmets afford a protective effect with respect to serious head injuries.