PROMIS Physical Function Correlates with KOOS, JR in Patients with Knee Pain.

Using Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computerized adaptive test instead of the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) could reduce question burden for patients with knee pain. We aimed to prospectively determine the correlation between PROMIS PF and KOOS, JR to assess whether PROMIS PF could be a useful alternative measure for both research and clinical care of patients with knee pain. This was a cross-sectional study of 88 patients. We assessed the correlation between PROMIS PF and KOOS, JR using a Pearson's correlation test. Two multivariable linear regression models were used to determine the amount of variation explained by various patient-level factors. There was a strong correlation between PROMIS PF and KOOS, JR (r = 0.74, p < 0.001). KOOS, JR was an independent predictor of PROMIS PF when controlling for patient-level factors (ß 0.26; p < 0.001). The results of this study support the idea of using PROMIS PF in place of joint-specific measures such as KOOS, JR for clinical care of patients with knee pain. The level of evidence for this study is Level III.

A Surgeon Scorecard Is Associated with Improved Value in Elective Primary Hip and Knee Arthroplasty.

BACKGROUND: Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. METHODS: We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. RESULTS: After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). CONCLUSIONS: The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. CLINICAL RELEVANCE: Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

Health Utility of Early Hemiarthroplasty vs Delayed Total Hip Arthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Markov Model.

BACKGROUND: Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates. METHODS: We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters. RESULTS: In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%. CONCLUSION: We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.

Mechanical testing of different knot types using high-performance suture material.

PURPOSE: This laboratory study aimed to evaluate the loop security, knot security, cyclic loading resistance and load-to-failure rate of three different knot types with establishing a new experimental set-up. Additionally, the mode of failure of each knot was evaluated. METHODS: With the use of nonabsorbable, braided polyethylene sutures, USP size No. 2 [Hi-Fi®; ConMed Linvatec], the arthroscopic knot types Dines, SMC as well as the surgeon's knot were tested using a material testing machine. The knots were tied openly as well as arthroscopically. The set-up enables testing of knot configurations while eliminating friction between knot loop and its suspension points. Including all test procedures, a total of 216 knots were tested. RESULTS: All openly tied knot types and ten of each type of arthroscopically tied knots resisted against cyclic loading of 1,000 cycles. With subsequent load-to-failure testing, openly tied knot types achieved significantly higher values of tensile strength than arthroscopically tied knots. Regarding clinical failure, defined as an elongation of 3 mm, Dines knot reached highest loop as well as knot security. Knot slippage was the most common failure mechanism at an elongation of 3 mm, whereas suture breakage was evaluated most at an elongation of 6 mm. CONCLUSIONS: The new experimental set-up confirms the loop security of arthroscopic knot types. Using a knot pusher clinically is a key factor to attain this as compared to openly hand-tied techniques. The Dines knot presented the highest reliability. It may provide a secure tissue healing during rehabilitation and consequently can be recommended for clinical application.

Subjective sexual well-being and sexual behavior in young women with breast cancer.

OBJECTIVES: The aim of this study was to systematically describe the nature and context of subjective sexual well-being and sexual behavior in young women with breast cancer. METHODS: Data on sexual behavior and subjective sexual well-being were collected through an internet questionnaire. Respondents were included if they had been diagnosed with breast cancer within the past 6 years and were currently 45 years of age or younger. Results were compared with a representative sample of the general Dutch population. RESULTS: In comparison with the general Dutch population of women, young women still undergoing breast cancer treatment are less sexually active and have a more negative experience of sexuality. While women who had already finished their treatment had more or less the same amount of sexual activity as the general Dutch population, there were still major differences in their experience of sexuality. Particularly strong associations were found between these women's sexual well-being in relation to their relationship satisfaction, and sexual interaction competence. CONCLUSION: In the wake of breast cancer treatment, young women have difficulty enjoying sex; it is evidently hard for them to resume their sex lives after breast cancer. In particular, women who find it hard to discuss sexual wishes and the possibilities and impossibilities associated with breast cancer with their partner experience negative consequences when trying to resume their sex lives.

Sexual dysfunction in young women with breast cancer.

OBJECTIVES: The objective of this study was to determine the prevalence of sexual dysfunction in young women with breast cancer in the Netherlands, and to assess the relationship between sexual dysfunction, treatment methods and treatment-related complaints. Also, the interest among women with breast cancer in receiving care for sexual dysfunction was determined. METHODS: Data on sexual functioning were collected through an internet questionnaire. Respondents were included if they had been diagnosed with breast cancer within the past 6 years and were currently 45 years of age or younger. Results were compared with a representative sample of the general Dutch population RESULTS: Of the women who were still undergoing treatment, 64 % had a sexual dysfunction. In women who had completed treatment, this was 45 %. All assessed dysfunctions were more common among these young women with breast cancer in comparison with women in the Dutch population. Particularly, early menopause and hormone therapy caused long-term occurence of genital arousal disorder. Radical mastectomy caused long-term occurrence of female orgasmic disorder, and early menopause dyspareunia. Half of the women reported that the topic "changes in sexual functioning" had been brought up during treatment, mostly on the initiative of the health professional. Six out of 10 women with a sexual dysfunction who felt a need for care did not consult a health professional. CONCLUSION: Sexual dysfunctions are highly prevalent among young women with breast cancer. This appears to improve after treatment has been completed, but women are far from recovered. The initiative to discuss sexuality should lie with the health professional. Including sexuality within treatment guidelines will prevent women with breast cancer from being deprived of care.

The Columbus Knee System: 4-Year Results of a New Deep Flexion Design Compared to the NexGen Full Flex Implant.

The Columbus knee system is designed as a standard knee implant to allow high flexion without additional bone resection. Between August, 2004 and March, 2010 we performed 109 total knee arthroplasties of the Columbus knee system in 101 consecutive patients suffering from primary arthrosis of the knee. Mean age was 72.4 years in women and 70.3 years in men. Mean followup was 47.3 months. The 4-year results of a group of patients who received the NexGen Full Flex implant operated by the same surgeon were used for comparison. Mean total knee score was Columbus: 175.6 and NexGen Flex: 183.4; P = 0.037. Mean operation time was 53 min for Columbus and 66 min for NexGen Flex; P < 0.001. With new streamlined instruments operative time became 60 min for the Columbus; P > 0.05. Radiological assessment showed no signs of loosening for both groups. Therefore, the Columbus knee system can be recommended for flexion angles up to 140°.

Posttraumatic stress disorder following preeclampsia and PPROM: a prospective study with 15 months follow-up.

OBJECTIVE: A prospective longitudinal evaluation of the prevalence of and risk factors for posttraumatic stress disorder (PTSD) in women with preeclampsia (PE) or preterm premature rupture of membranes (PPROM) compared to uncomplicated pregnancies. METHODS: Participating women completed PTSD and depression questionnaires during pregnancy, 6 weeks, and 15 months postpartum. Data regarding psychiatric history and indices of obstetric care were collected from patient charts. RESULTS: We included 57 PE, 53 PPROM, and 65 healthy pregnant women, of whom 137 also participated in the 15-month follow-up (PE 70%, PPROM 48%, and controls 95%; P < .001). At 6 weeks postpartum, the prevalence of PTSD, but not depression, following childbirth was significantly higher in patients than in controls (14% vs 3%; P = .023). A history of depression, depressive symptoms during pregnancy, and infant death were significantly associated with symptoms of postpartum PTSD. The maternal condition seems to be of less decisive value, as there was no difference between the prevalence of PTSD after PE and PPROM (11% vs 17%; P = .324). At 15 months postpartum, 11% of women with PE had PTSD, some of which did not have PTSD 6 weeks postpartum. The low response rate in the PPROM group at 15 months postpartum does not allow for definite conclusions. CONCLUSION: Pregnancies complicated by PE or PPROM are associated with PTSD in a substantial number of women. Especially women with proven vulnerability for psychological problems are at risk of developing PTSD postpartum, as are women whose children died in the perinatal period.

[Physiotherapeutic interventions on an outpatient basis for orthopaedic and trauma surgery: can success be recorded?]. / Ambulante Physiotherapie in Orthopädie und Unfallchirurgie: Kann der Erfolg überhaupt beurteilt werden?

AIM: This prospective study analyses the quality and number of physiotherapy reports, cooperation between physiotherapist and orthopaedic surgeons as well as correctness of the physiotherapy in relation to the prescription within the German medical health system. We pose the question to whether or not the reported information is sufficient to evaluate outpatient physiotherapy. METHOD: In 264 physiotherapeutic prescriptions, given to the patients for conservative treatment or during postoperative rehabilitation by an orthopaedic outpatient clinic, we prospectively evaluated the report quality. The types of prescription and performed physiotherapy were compared. The ability of the patient to demonstrate or to verbalise exercises, as has to be learned during therapy, was analysed and the number of questioned follow-up forms documented. We also tried to evaluate the efficiency of different types of physiotherapy. RESULTS: We received 33 reports in 264 prescriptions, i.e., the obligation to report was only followed in 12.5 % of the cases. Depending on the type of physiotherapy, there was a range between 0 % in electric field treatment, 0 % in active muscle training with weights and resistant exercises as well as in thermo- and swimming therapy, 10.8 % in passive mobilisation, 16.8 % in regular physical therapy and 33 % in classic massage treatment. In 261 cases, i.e., in 98.8 % of the prescriptions, the physiotherapist was asked via the patient for another prescription. Only in one patient did the physiotherapist call the doctor personally to ask for a variation of the treatment during the prescribed series. In 193 prescriptions the patients should have learned to do the exercises by themselves as a home therapy programme. Only 5 patients were able to demonstrate this at the reassessment appointment. The allover complication rate was 2.3 % including nausea, vertigo or increasing pain. In all these cases the type of prescription was not followed. CONCLUSION: In the outpatient treatment of orthopaedic or trauma patients there is not sufficient cooperation between physiotherapists and surgeons. This may lead to prolonged postoperative rehabilitation time or may question the success of conservative treatment completely. The efficiency of physiotherapy could not be evaluated due to lack of prescription reports. Therefore, a new control mechanism to support the patient and the responsible outpatient surgeons should be introduced.

Efficacy of sexological healthcare for people with chronic diseases and physical disabilities.

The purpose of this study was to determine whether participation in a short and well-structured psychosexual therapy was effective for people with a broad range of physical impairments and chronic diseases. Data were collected from 37 men and 10 women (between 30 and 70 years of age). The results demonstrated that psychosexual therapy has a positive effect on several areas of sexual well-being: less relational stress and sexual stress and an increase in sexual satisfaction, sexual esteem, sexual interaction competence, and a higher frequency in sexual contact. Although based on a relatively small sample, these findings clearly indicate that people with physical impairments can benefit from psychosexual therapy.

18-year experience in the management of men with a complaint of a small penis.

In many cultures, the erect penis has been a symbol of masculine qualities. Because of this symbolism, a penis that is less than average size can cause insecurity or embarrassment. This series reports the authors' 18-year experience in the management of 60 men with a complaint of a small penis. For 44 of these 60 men, counseling was sufficient; the other 16 had surgery, and of these, 9 were satisfied with the result. Despite limitations, the authors conclude that those men who already achieve a penis length of no less than 7.5 cm (2.95 in) in erection, have only limited benefit from penis-enhancing surgery. This particular patient category should therefore be dissuaded from surgery.

Penile enlargement: from medication to surgery.

Penis lengthening pills, stretch apparatus, vacuum pumps, silicone injections, and lengthening and thickening operations are available for men who worry about their penis size. Surgery is thus far the only proven scientific method for penile enlargement. In this article, we consider patient selection, outcome evaluation, and techniques applied. In our view, sexological counseling and detailed explanation of risks and complications are mandatory before any operative intervention.

Initial load-to-failure and failure analysis in single- and double-row repair techniques for rotator cuff repair.

AIM: This experimental study aimed to compare the load-to-failure rate and stiffness of single- versus double-row suture techniques for repairing rotator cuff lesions using two different suture materials. Additionally, the mode of failure of each repair was evaluated. METHOD: In 32 sheep shoulders, a standardized tear of the infraspinatus tendon was created. Then, n = 8 specimen were randomized to four repair methods: (1) Double-row Anchor Ethibond coupled with polyester sutures, USP No. 2; (2) Double-Row Anchor HiFi with polyblend polyethylene sutures, USP No. 2; (3) Single-Row Anchor Ethibond coupled with braided polyester sutures, USP No. 2; and (4) Single-Row Anchor HiFi with braided polyblend polyethylene sutures, USP No. 2. Arthroscopic Mason-Allen stitches were placed (single-row) and combined with medial horizontal mattress stitches (double-row). All specimens were loaded to failure at a constant displacement rate on a material testing machine. RESULTS: Group 4 showed lowest load-to-failure result with 155.7 +/- 31.1 N compared to group 1 (293.4 +/- 16.1 N) and group 2 (397.7 +/- 7.4 N) (P < 0.001). Stiffness was highest in group 2 (162 +/- 7.3 N/mm) and lowest in group 4 (84.4 +/- 19.9 mm) (P < 0.001). In group 4, the main cause of failure was due to the suture cutting through the tendon (n = 6), a failure case observed in only n = 1 specimen in group 2 (P < 0.001). CONCLUSIONS: A double-row technique combined with arthroscopic Mason-Allen/horizontal mattress stitches provides high initial failure strength and may minimize the risk of the polyethylene sutures cutting through the tendon in rotator cuff repair when a single load force is used.

Inattention, hyperactivity-impulsivity, academic skills and psychopathology in boys with and without haemophilia.

The aim of this study was to determine if symptoms of inattention (IN) and hyperactivity-impulsivity (HI) differ for boys with and without haemophilia and to determine if IN and HI are the essential behavioural dimensions on which the two groups differ. Using a quasi-experimental design, parents' and teachers' ratings of IN and HI for boys with and without haemophilia (ages 6-14 years) were compared. IN and HI were also assessed with a psychometric task, as were reading and math, psychopathology, and educational status via various techniques. Boys with haemophilia (n = 19) were rated higher on dimensions of HI and IN by teachers (P = 0.01, P = 0.02, respectively) but only on HI by parents (P = 0.01). In addition, the haemophilia group committed more impulsivity errors on a psychometric task (P = 0.01). Trends, but not statistically significant differences, were found on reading and math scores, and the haemophilia group had more special education participation. Compared to national norms, borderline range scores on the attention-deficit/hyperactivity disorder (ADHD)-related dimensions of HI and psychometrically measured impulsivity characterized the boys with haemophilia. Although not addressing formal diagnoses, this study found that boys with haemophilia risk ADHD-spectrum problems, especially HI, and special education participation, but not frank academic deficits.

Comparative evaluation of the tendon-bone interface contact pressure in different single- versus double-row suture anchor repair techniques.

The aim of the study was to evaluate the time zero contact pressure over a defined rotator cuff footprint using different repair and stitch techniques in an established sheep model. Forty fresh-frozen sheep shoulders were randomly assigned to five repair groups: single-row repair using simple stitches (SRA-s), single-row repair using horizontal mattress stitches (SRA-m), and single-row repair using arthroscopic Mason-Allen stitches (SRA-ama). Double-row repair was either performed with a combination of simple and horizontal mattress stitches (DRA-sm) or with arthroscopic Mason-Allen/horizontal mattress stitches (DRA-amam). Investigations were performed using a pressure-sensitive film system. The average contact pressure and pressure pattern were measured for each group. Contact pressure was lowest in SRA-m followed by SRA-s. SRA-ama showed highest contact pressure of all single-row treatment groups (P < 0.05). DRA-amam presented the highest overall contact pressure (P < 0.05), whereas DRA-sm exerted contact pressure equal to that of SRA-ama. Both double-row techniques showed the most expanded pressure pattern. Average contact pressures for the more complex single- and double-row techniques utilizing arthroscopic Mason-Allen stitches were greater than were those of the repair techniques utilizing simple and horizontal mattress stitches. However, the contact pattern between the anchors could be increased by using the double-row technique, resulting in more footprint coverage compared to patterns utilizing the single-row techniques. These results support the use of the more complex arthroscopic Mason-Allen stitches and may improve the environment for healing of the repaired rotator cuff tendon.

Prevalence and risk factors associated with decreased bone mineral density in patients with haemophilia.

Osteoporosis in adult males is an under-recognized problem. Patients with haemophilia have several predisposing factors for developing decreased bone mineral density (BMD) including prolonged periods of immobility, reduced weight bearing and co-morbidities associated with bone loss. To establish prevalence and risk factors associated with decreased BMD in patients with haemophilia. Adults with moderate or severe haemophilia A or B underwent dual-energy X-ray absorptiometry (DXA). BMD was correlated to laboratory values, joint mobility measurements and physical activity questionnaires. Thirty patients completed evaluations. The median age was 41.5 years (range 18-61). Median lowest T-score by DXA was -1.7 (range: -5.8 to +0.6), with the femoral neck being the site of the lowest T-scores. Based on World Health Organization criteria, 70% of patients had decreased BMD. Twenty-seven per cent of the participants (n = 8) had osteoporosis and 43% (n = 13) had osteopenia. Variables associated with increased bone loss included lower serum 25-hydroxyvitamin D levels (P = 0.03), lower body mass index (P = 0.047), lower activity scores (P = 0.02), decreased joint range of motion (P = 0.046), HIV (P = 0.03), HCV (P = 0.02), history of inhibitor (P = 0.01) and age (P = 0.03). Adults with haemophilia are at increased risk for developing osteoporosis. A history of HCV and HIV infections, decreased joint range-of-motion, decreased activity levels, history of an inhibitor and low body weight predict bone loss and suggest a population to target for screening. A high prevalence of vitamin D insufficiency was observed. Future studies should investigate interventions, including vitamin D supplementation, to prevent bone loss and fractures for this at-risk population.

Improved bleeding profile and tolerability of tibolone versus transdermal E2/NETA treatment in postmenopausal women with female sexual dysfunction.

OBJECTIVES: To compare the incidence of vaginal spotting/bleeding events and breast pain between therapy with tibolone 2.5 mg and continuous combined transdermal estradiol (E(2))/norethisterone acetate (NETA) 50 microg/140 microg after 24 weeks of treatment. METHODS: A double-blind, double-dummy, randomized, controlled trial was performed and assessments were performed at baseline, week 12 and week 24. Bleeding/spotting events were recorded in a daily diary. Breast signs and symptoms were collected as adverse events. RESULTS: A total of 403 women (mean age 56 years) were randomized. Bleeding/spotting events during weeks 1-12 with tibolone and E(2)/NETA were experienced by 16% and 56% of women, respectively (p < 0.001). The corresponding percentages during weeks 13-24 were 12% and 51%, respectively (p < 0.001). E(2)/NETA was significantly more likely than tibolone to be associated with vaginal hemorrhage (11% vs. 0%; p < 0.001) and breast signs and symptoms (11% vs. 4%; p = 0.015). Early discontinuations resulting from adverse events were significantly more common in the E(2)/NETA group than in the tibolone group (20% vs. 12%), primarily related to withdrawal due to vaginal hemorrhage (8% vs. 0%). CONCLUSIONS: Tibolone has a significantly better tolerability profile than transdermal E(2)/NETA as measured by vaginal bleeding, breast pain and treatment continuation.

Cell biological and biomechanical evaluation of two different fixation techniques for rotator cuff repair.

Our objective was to evaluate the cell biology and biomechanical aspects of the healing process after two different techniques in open rotator cuff surgery - double-loaded bio-absorbable suture anchors combined with so-called arthroscopic Mason-Allen stitches (AAMA) and a trans-osseous suture technique combined with traditional modified Mason-Allen stitches (SMMA). Thirty-six mature sheep were randomized into two repair groups. After 6, 12, or 26 weeks, evaluation of the reinsertion site of the infraspinatus tendon was performed. The mechanical load-to-failure and stiffness results did not indicate a significant difference between the two groups. After 26 weeks, fibrocartilage was sparse in the AAMA group, whereas the SMMA group showed the most pronounced amount of fibrocartilage. We found no ultrastructural differences in collagen fiber organization between the two groups. The relative expression of collagen type II mRNA in the normal group was 1.11. For the AAMA group, 6 weeks after surgery, the relative expression was 55.47, whereas for the SMMA group it was 1.90. This in vivo study showed that the AAMA group exhibited a tendon-to-bone healing process more favorable in its cell biology than that of the traditional SMMA technique. Therefore, the AAMA technique might also be more appropriate for arthroscopic repair.