Patient injury claims for posterior cruciate ligament injury: a nationwide registry study in Finland.

BACKGROUND AND PURPOSE: Posterior cruciate ligament (PCL) injuries usually occur in combination with other ligamentous knee injuries. The outcome varies and may be poor due to suboptimal treatment. We investigated claims following PCL injury treatment on a nationwide scale. PATIENTS AND METHODS: All patient PCL injury claims filed in Finland from 1997 to 2015 were collected from the Patient Insurance Centre (PIC) register. We reviewed and analyzed all records to determine the causes of claims. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO). RESULTS: We found out from HILMO background data that, during the 19-year study period, 1,891 PCL and 1,380 multiligament reconstructions were performed in 99 different hospitals. The number of PCL injuries treated conservatively is unknown. During this same period, 49 claims arrived at the PIC, and 39/49 of these patients were operated on. 12/49 claims were compensated. Of these 12 claims, 6 were compensated for technical errors and 4 were compensated for diagnostic delays. CONCLUSION: The number of patient injury claims was few, and compensated claims were even fewer. Technical errors and diagnostic delays were the most common reasons for reimbursement.

Structural and Construct Validity of the Foot and Ankle Ability Measure (FAAM) With an Emphasis on Pain and Functionality After Foot Surgery: A Multicenter Study.

The Foot and Ankle Ability Measure (FAAM) is a patient-reported outcome measure that is available in several languages. We aim to assess the structural and construct validity of the FAAM with an emphasis on pain and functionality after foot surgery. The activities of daily living (ADL) and Sports subscales of the Finnish version of the FAAM were completed by 182 patients who underwent operative treatment for disorders of the foot. Convergent validity was assessed by principal component analysis using Spearman's correlation coefficient between the FAAM subscales and the principal components (Function-PC and Pain-PC) derived from validated patient-reported outcome measures. Subscales were studied for floor and ceiling effects, internal consistency and unidimensionality. Internal consistency was examined with Cronbach's alpha and the subscale structure with exploratory factor analysis. FAAM-ADL had high correlation with the Function-PC (r = 0.87, 95% confidence interval [CI] 0.81-0.91) and the Pain-PC (r = 0.75, 95% CI 0.65-0.83). FAAM-Sports had moderate correlation (r = 0.64, 95% CI 0.50-0.74) with the Function-PC and high correlation (r = 0.74, 95% CI 0.64-0.82) with the Pain-PC. No floor or ceiling effects were observed. Cronbach's alpha was 0.97 (95% CI 0.96-0.98) for the ADL and 0.93 (95% CI 0.91-0.95) for the Sports subscales. The results supported the unidimensionality of the FAAM-Sports. Within the ADL subscale, 3 factors were identified, suggesting a 3-factor model for the FAAM overall. Results highlighted the inter-relationship of pain and physical function. Further research on longitudinal validity is needed.

Longitudinal Validity and Minimal Important Change for the Modified Lower Extremity Functional Scale (LEFS) in Orthopedic Foot and Ankle Patients.

The lower extremity functional scale (LEFS) is a patient-reported outcome measure for lower extremity disorders. Aim of this study was to assess the longitudinal validity including responsiveness and test-retest reliability of the revised 15-item version, and to define the minimal important change (MIC) of the modified LEFS in a generic sample of orthopedic foot and ankle patients who underwent surgery. Responsiveness, effect size, and standardized response mean were measured by determining the score change between the baseline and 6 months administration of the LEFS from 156 patients. There was no significant difference between preoperative (median 78, interquartile range [IQR] 64.2-90.3) and postoperative (median 75.0, IQR 61.7-95.0) scores. Both effect size and standardized response mean were low (0.06 and 0.06, respectively). Test-retest reliability of the LEFS was satisfactory. Intraclass correlation coefficient was 0.85 (95% confidence interval 0.81-0.88). MIC value could not be estimated due to the lack of significant score change. The modified LEFS presented with relatively low longitudinal validity in a cohort of generic orthopedic foot and ankle patients. The findings of this study indicate that the modified LEFS might not be the optimal instrument in assessing the clinical change over time for these patients.

Structural validity of the foot and ankle outcome score for orthopaedic pathologies with Rasch Measurement Theory.

BACKGROUND: The Foot and Ankle Outcome Score (FAOS) is one of the most frequently used patient-reported outcome measures for foot and ankle conditions. The aim is to test the structural validity of the Finnish version of the FAOS using Rasch Measurement Theory. METHODS: FAOS scores were obtained from 218 consecutive patients who received operative treatment for foot and ankle conditions. The FAOS data were fitted into the Rasch model and person separation index (PSI) calculated. RESULTS: All the five subscales provided good coverage and targeting. Three subscales presented unidimensional structure. Thirty-eight of the 42 items had ordered response category thresholds. Three of the 42 items had differential item functioning towards gender. All subscales showed sufficient fit to the Rasch model. PSI ranged from 0.73 to 0.94 for the subscales. CONCLUSIONS: The Finnish version of the FAOS shows acceptable structural validity for assessing complaints in orthopaedic foot and ankle patients.

Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint.

INTRODUCTION: Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus. METHODS AND ANALYSIS: Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. PROTOCOL VERSION: 21 June 2021 V.2.0. TRIAL REGISTRATION NUMBER: NCT04590313.

Traumatic Rupture and Herniation of the Peroneus Tertius Muscle Leading to Compartment Syndrome and Entrapment of the Superficial Peroneal Nerve: A Case Report.

We present a patient with compartment syndrome and entrapment of the superficial peroneal nerve due to a direct hit to the lateral part of the right lower extremity. The diagnosis of evolving compartment syndrome was made without delay and the patient was quickly taken to the operating theater. Intraoperatively, the entrapment of the superficial peroneal nerve caused by rupture and herniation of the peroneus tertius muscle was surprisingly observed at the site, where the nerve pierces the anterior compartment. The nerve was successfully released in conjunction with fasciotomies of the anterior and lateral compartments. Meticulous diagnosis of compartment syndrome is critical to prevent ischemic injury to muscles and nerves. Recognition of anatomy and anatomical variations is important to prevent iatrogenic injury in unusual circumstances.

Minimal important change for the visual analogue scale foot and ankle (VAS-FA).

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA) is a patient-reported outcome measure for foot and ankle disorders. The VAS-FA is validated into several languages and well adopted into use. Nonetheless, minimal important change (MIC) for the VAS-FA has not been estimated thus far. METHODS: The VAS-FA score was obtained from 106 patients undergoing surgery for various foot and ankle complaints. MIC was estimated using an anchor-based predictive method. RESULTS: The adjusted MIC was 6.8 for total VAS-FA score, and 9.3 for the Pain, 5.8 for the Function, and 5.7 for the Other complaints subscales. The VAS-FA score was found to separate improvement and deterioration in patients' foot and ankle condition. CONCLUSIONS: MIC was successfully defined for the VAS-FA in the current study. The VAS-FA can be used to evaluate foot and ankle patients' clinical foot and ankle status and its change. Further research on estimating disease-specific MICs is recommended.

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery.

BACKGROUND: Patient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments. METHODS: Altogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester-Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed. RESULTS: Based on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument. CONCLUSIONS: The ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.

Structural validity of the Finnish Manchester-Oxford Foot Questionnaire (MOXFQ) using the Rasch model.

BACKGROUND: The 16-item patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ) with subscales of pain, social interactions, and walking/standing has been claimed for strongest scientific evidence in measuring foot and ankle complaints. This study tests the validity of the Finnish MOXFQ for orthopaedic foot and ankle population using the Rasch analysis. METHODS: We translated the MOXFQ into Finnish and used that translation in our study. MOXFQ scores were obtained from 183 patients. Response category distribution, item fit, coverage, targeting, item dependency, ability to measure latent trait (unidimensionality), internal consistency (Cronbach's alpha), and person separation index (PSI) were analyzed. RESULTS: Fifteen of the items had ordered response categories and/or sufficient fit statistics. The subscales provided coverage and targeting. Some residual correlation was noted. Removing one item in the pain subscale led to a unidimensional structure. Alphas and PSIs ranged between 0.68-0.90 and 0.67-0.92, respectively. CONCLUSIONS: Despite some infractions of the Rasch model, the instrument functioned well. The subscales of the MOXFQ are meaningful for assessing patient-reported complaints and outcomes in orthopaedic foot and ankle population.

Anterior cruciate ligament reconstruction-related patient injuries: a nationwide registry study in Finland.

Background and purpose - Treatment outcomes of anterior cruciate ligament (ACL) injuries are generally good, but complications after ACL reconstruction (ACLR) can result in long-lasting problems. Patient injury claims usually fall on the more severe end of the complication spectrum. They are important to investigate because they may reveal the root causes of adverse events, which are often similar regardless of the complication's severity. Therefore, we analyzed ACL-related patient injuries in Finland, the reasons for these claims, causes of complications, and grounds for compensation.Patients and methods - We analyzed all claims filed at the Patient Insurance Centre (PIC) between 2005 and 2013 in which the suspected patient injury occurred between 2005 and 2010. This study also reviewed all original patient records and available imaging studies. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).Results - There were 248 patient injury claims, and 100 of these were compensated. Compensated claims were divided into 4 main categories: skill-based errors (n = 46), infections (n = 34), knowledge-based errors (n = 6), and others (n = 14). Of the compensated skill-based errors, 34 involved graft malposition, 26 of them involved the femoral-side tunnel. All compensated infections were deep surgical site infections (DSSI).Interpretation - This is the first nationwide study of patient injuries concerning ACLRs in Finland. The most common reasons for compensation were DSSI and malposition of the drill tunnel. Therefore, it would be possible to decrease the number of serious complications by concentrating on infection prevention and optimal surgical technique.

Validation of the Western Ontario and McMaster Universities Osteoarthritis Index in Patients Having Undergone Ankle Fracture Surgery.

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a patient-reported outcome measure (PROM) that is widely used to evaluate the pain, stiffness, and physical function of patients with osteoarthritis of the hip and knee. Although the WOMAC has also been used for patients after foot and ankle surgery, it has not been validated for this purpose. A total of 130 patients with surgically treated ankle fractures completed the WOMAC, Visual Analogue Scale Foot and Ankle (VAS FA), Lower Extremity Functional Scale (LEFS), 15D Health-Related Quality-of-Life Questionnaire (15D), and Visual Analog Scale for General Health (VAS general health) after foot and ankle surgery. The structural validity of the WOMAC was assessed by using Cronbach's α, and convergent validity was tested between the WOMAC and reference outcome measures. Cronbach's α for the index score was 0.98 and 0.95, 0.86, and 0.98 for the Pain, Stiffness, and Physical Function subscales, respectively. The Spearman correlation coefficients were ‒0.84, ‒0.74, ‒0.58, and 0.55 for the VAS-FA, LEFS, 15D, and VAS general health, respectively. The relationships with the VAS-FA, LEFS, 15D, and VAS general health were strong. All relationships were statistically significant (p < .001). The WOMAC provides valid scores for assessing pain, stiffness, and physical function in patients having undergone ankle fracture surgery.

Rasch analysis of the Lower Extremity Functional Scale for foot and ankle patients.

Purpose: The Lower Extremity Functional Scale (LEFS) is a widely used 20-item patient-reported outcome instrument with five response categories. We investigated the measurement properties of the Finnish version of the LEFS among foot and ankle patients to refine the scale to measure more accurately what is relevant for patients.Materials and methods: Data were obtained from 182 patients who had undergone foot and ankle surgery for various reasons. The Rasch Measurement Theory and Cronbach's alpha were employed for analyses of model and item fit, response category thresholds, targeting, person separation index, and internal consistency.Results: Threshold misfit was noted in 13 of the 20 items. After collapsing the response categories 1 ("Quite a bit of difficulty") and 2 ("Moderate difficulty"), five items were removed one by one to make the scale fit the model. This new 15-item scale with four response categories had a unidimensional structure with good item fit, ordered thresholds, and good coverage/targeting. The person separation index and Cronbach's alpha were 0.85 and 0.95, respectively.Conclusions: This study provides a new 15-item LEFS with four response categories for clinicians and researchers to measure function in foot and ankle patients in a relevant way.Implications for rehabilitationAssessing foot and ankle function and rehabilitation effectiveness is of high importance.The Lower Extremity Functional Scale (LEFS) is a widely used 20-item patient-reported outcome instrument with five response categories.The Finnish LEFS was revised to better fit into the Rasch model.The new LEFS with 15 items and four response categories for foot and ankle patients is a psychometrically sound, meaningful, and operable instrument.

Patient injury claims involving fractures of the distal radius.

Background and purpose - Optimal treatment for distal radius fractures remains controversial, with a significant number of fractures resulting in complications and long-term morbidity. We investigated patient injury claims related to distal radius fractures to detect the critical steps in the treatment leading to avoidable adverse events Patients and methods - We analyzed all compensated patient injury claims in Finland between 2007 and 2011. Claims were collected from the Patient Insurance Center's (PIC) nationwide claim register. Patients of all ages were included. Each claim decision, original patient records, and radiographs related to treatment were reviewed. Results - During the study period, the PIC received 584 claims regarding distal radius fractures, of which 208 (36%) were compensated. Pain and impaired wrist function were the most common subjective reasons to file claims among compensated patients. In 66/208 patients, more than 1 adverse event leading to patient injury was detected. The detected adverse events could be divided into 3 main groups: diagnostic errors (36%, n = 103), decision/planning errors (30%, n = 87), and insufficient technical execution (32%, n = 91). Issues related to malalignment were the main concerns in each group. Diagnostic errors were often related to incorrect assessment of the fracture (re)displacement (75%, n = 78). All of the decision-making errors concerned physicians' decisions to accept unsatisfactory fracture alignment. The most common technical error was insufficient reduction (29%, n = 26). Interpretation - We identified avoidable adverse events behind patient injuries related to distal radius fracture treatment. This study will help physicians to recognize the critical steps in the treatment of this common fracture and enhance patient safety.

[Luxatio erecta: two case reports and review of the literature]. / Luxatio erecta--harvinainen vamma koiranulkoiluttajillakin.

Luxatio erecta, inferior dislocation of the glenohumeral joint, is a rare type of injury (1% of shoulder dislocations). In most cases the injury is caused by falling while the upper extremity is hyperabducted. We introduce two cases of consecutive patients with the same rare type of injury--walking the dog. According to the literature, the most frequently used method for the reduction of inferior shoulder dislocation is tractioncountertraction under sedation. If the patient has no other reason to be under general anesthesia or sedation, we recommend, however, administration of local anesthetics and using a less traumatic two-step manoeuvre to reduce inferior shoulder dislocation--luxatio erecta.

[Diaphragmatic rupture: case report of a rare complication of labor]. / Synnyttäjän pallearuptuura.

A diaphragmatic rupture associated with labor is a rare complication of pregnancy with high fetal and maternal mortality. Due to non-specific symptoms and rareness of the disease the diagnosis can be challenging. We present a case of a healthy 26-year old woman with one previous childbirth who presented upper abdominal pain, tachycardia and dyspnea during labor. Immediately after labor, a left-sided diaphragmatic rupture complicated with ventricle perforation was diagnosed. After prompt diagnosis and immediate surgical care, including thoracotomy and laparotomy, both patient and child experienced a full recovery.

[Traumatic pseudoaneurysm of the superficial temporal artery]. / Sykkivä sarvi otsalla.

Pseudoaneurysms of the superficial temporal artery (STA) are uncommon vascular lesions. Approximately 75% of them result from blunt trauma. Other etiological factors include penetrating wounds, iatrogenic trauma such as hair grafting and neurosurgical procedures. Thorough history and physical examination are often sufficient to make the diagnosis. Imaging studies are recommended for closer morphology and to rule out intracranial vascular communications and other possibilities in the differential diagnosis. We present successful treatment of a traumatic STA pseudoaneurysm with ultrasound-guided percutaneuous thrombin injection.

Targeting lymphatic vessel activation and CCL21 production by vascular endothelial growth factor receptor-3 inhibition has novel immunomodulatory and antiarteriosclerotic effects in cardiac allografts.

BACKGROUND: Lymphatic network and chemokine-mediated signals are essential for leukocyte traffic during the proximal steps of alloimmune response. We aimed to determine the role of lymphatic vessels and their principal growth signaling pathway, vascular endothelial growth factor (VEGF)-C/D/VEGFR-3, during acute and chronic rejection in cardiac allografts. METHODS AND RESULTS: Analysis of heterotopically transplanted rat cardiac allografts showed that chronic rejection increased VEGF-C(+) inflammatory cell and hyaluronan receptor-1 (LYVE-1)(+) lymphatic vessel density. Allograft lymphatic vessels were VEGFR-3(+), contained antigen-presenting cells, and produced dendritic cell chemokine CCL21. Experiments with VEGFR-3/LacZ mice or mice with green fluorescent protein-positive bone marrow cells as cardiac allograft recipients showed that allograft lymphatic vessels originated almost exclusively from donor cells. Intraportal adenoviral VEGFR-3-Ig (Ad.VEGFR-3-Ig/VEGF-C/D-Trap) perfusion was used to inhibit VEGF-C/D/VEGFR-3 signaling. Recipient treatment with Ad.VEGFR-3-Ig prolonged rat cardiac allograft survival. Ad.VEGFR-3-Ig did not affect allograft lymphangiogenesis but was linked to reduced CCL21 production and CD8(+) effector cell entry in the allograft. Concomitantly, Ad.VEGFR-3-Ig reduced OX62(+) dendritic cell recruitment and increased transcription factor Foxp3 expression in the spleen. In separate experiments, treatment with a neutralizing monoclonal VEGFR-3 antibody reduced arteriosclerosis, the number of activated lymphatic vessels expressing VEGFR-3 and CCL21, and graft-infiltrating CD4(+) T cells in chronically rejecting mouse cardiac allografts. CONCLUSIONS: These results show that VEGFR-3 participates in immune cell traffic from peripheral tissues to secondary lymphoid organs by regulating allograft lymphatic vessel CCL21 production and suggest VEGFR-3 inhibition as a novel lymphatic vessel-targeted immunomodulatory therapy for cardiac allograft rejection and arteriosclerosis.

Angiogenic growth factors in cardiac allograft rejection.

Normal adult vasculature is in a quiescent state. In transplanted hearts, peri- and postoperative ischemic and alloimmune stimuli may be interpreted as inadequate tissue perfusion leading to activation of angiogenic signaling. Although this may have protective functions, improper activation of cardiac allograft endothelial cells and smooth muscle cells may actually result in impaired survival of cardiac allografts. In this paper, we review the current knowledge on angiogenic growth factors, vascular endothelial growth factor, angiopoietins, and platelet-derived growth factor in cardiac allografts. We also discuss the potential for therapies aimed at angiogenic growth factors in preventing and treating cardiac allograft rejection and transplant coronary artery disease.