How do the expectations of patients compare with their surgeons regarding outcomes of periacetabular osteotomy?

Our objective was to determine the frequency and strength of agreement between patients and their surgeons on preoperative expectations of the outcomes of periacetabular osteotomy (PAO) surgery. We also sought to determine whether patient preoperative function and pain levels were associated with patients' and surgeons' expectations and to identify the motivating factors for patients to undergo PAO. Two surgeons and their combined 68 patients preoperatively completed 4-point Likert-scales rating their expectations of improvement in six domains representing different hip symptoms after surgery. Domains included pain, stiffness, locking, stability, walking ability and athletic ability. Concordance between patient and surgeon expectation was evaluated by the percent of exact and partial agreement. Correlation analyses were performed to investigate associations between expectations of improvement and patient factors. Exact agreement between patients and surgeons ranged from 18.2% (stiffness) to 55.9% (pain) and partial agreement between patients and surgeons ranged from 48.5% (stiffness) to 100% (pain). Patients with higher UCLA scores tended to have lower surgeon expectations of improving walking ability (r = -0.34; P = 0.007) but higher expectations for improved athletic ability (r = 0.25; P = 0.04), and surgeons anticipated more improvement in walking for patients with higher stiffness (r = 0.31, P = 0.01) and pain (r = 0.38, P = 0.002). Similarly, patients with higher Short Form-12 physical component summary had lower surgeon expectations of improvement in walking ability (r = -0.40, P = 0.002) and stiffness (r = -0.35, P = 0.006). In the most domains there was frequent discrepancy between patient and surgeon expectations, with patients being more optimistic than their surgeons in every domain. For the pain domain, patients and surgeons had similar expectations.

Feasibility of a Randomized Clinical Trial for Treatment of Femoroacetabular Impingement of the Hip.

BACKGROUND: Symptomatic femoroacetabular impingement (FAI) is currently corrected by surgery. However, it is possible that nonsurgical treatment could resolve symptomatic FAI in some patients; thus, uncertainty about the necessity of surgical treatment exists. The current equipoise concerning FAI treatment presents an opportunity to conduct a randomized controlled trial (RCT) of surgical and nonsurgical treatment options. Given the unique challenge of adequate patient enrollment in RCTs, it is important that a preliminary study is done to appraise the feasibility of conducting an RCT. PURPOSE: To estimate enrollment rates of a planned future RCT to compare surgical and nonsurgical treatments for symptomatic FAI and to identify factors associated with patients' willingness to participate in the randomized trial. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: Patients diagnosed with FAI at 2 orthopaedic centers were presented with a hypothetical randomized trial comparing 2 treatment options for FAI. All patients completed forms providing information regarding their willingness to participate and treatment preferences. RESULTS: A total of 75 patients participated in the study: 53 and 22 from 2 centers, respectively. Twenty-eight percent indicated absolute willingness to participate in the trial, 40% were probably willing or unsure, and 32% were definitely not willing; 18.7% had a strong preference for surgery while 2.7% strongly preferred nonsurgical treatment. The majority (78.6%) had no strong preference for either treatment arm. There were correlations between treatment preferences and willingness to participate. Patients with a strong treatment preference and/or a preference for surgery were less likely to be willing to participate. CONCLUSION: The study findings suggest that sufficient patient accrual for a randomized trial of FAI treatment is currently feasible while equipoise still exists among patients and surgeons.

Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries.

BACKGROUND: The Lancet Commission on Global Surgery calls for universal access to safe, affordable, and timely surgical care. Two requisite components of timely access are (1) the ability to reach a surgical provider in a given timeframe, and (2) the ability to receive appropriately prompt care from that provider. We chose a threshold of 2 h in view of its relevance in time-to-death in post-partum haemorrhage. Here, we use geospatial mapping to enumerate the percentage of a nation's population living within 2 h of a surgeon and the surgeon-to-population ratio for each provider. METHODS: Geospatial mapping was used to identify the population living within a 2-h driving distance (access zone) of a health-care facility staffed by a surgeon. Surgeon locations were extracted from Ministries of Health, professional society databases, and published literature for countries which had available data. Data were reviewed by individuals knowledgeable of in-country distribution. Spatial distribution of providers was mapped with Google Maps engine. Access zones were constructed around every provider through estimation of driving times in Google Maps. The number of people living within zones was estimated with the Socioeconomic Data and Applications Center Population Estimation Service. Surgeon-to-population ratios were constructed for every individual access zone and averaged to report a single ratio. FINDINGS: Results (% country's population living within an access zone; average surgeon:population ratio within all access zones) are reported for nine countries with available data: Somaliland (16·9%; 1:118 306), Botswana (31·0%; 1:64 635), Ethiopia (39·6%; 1:229 696), Rwanda (41·3%; 1:158 484), Namibia (43·4%; 1:69 385), Zimbabwe (54%; 1:148 292), Mongolia (55·5%; 1:10 500), Sierra Leone (70·3%; 1:106 742), and Pakistan (84·4%, 1:139 299). Surgeon-to-population ratios vary substantially even within countries; in Sierra Leone, urban access zones have a ratio of 1:45 058 and rural access zones have a ratio of 1:467 929. INTERPRETATION: Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness. Living outside of an access zone makes timely access to surgical care highly unlikely, and in view of low surgeon-to-population ratios and poor prehospital transport, even living within a 2-h access zone might not confer 2-h access. Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery. FUNDING: None.