Improvement of Valgus Deviation of the Lesser Toes of Moderate to Severe Hallux Valgus After Proximal Chevron Metatarsal Osteotomy and Akin Osteotomy.

BACKGROUND: This study examines the correction of lesser toe valgus deviation following proximal chevron metatarsal osteotomy (PCMO) and Akin osteotomy in moderate to severe hallux valgus patients, while identifying influencing factors. METHOD: Among 89 patients (116 feet), those with moderate to severe hallux valgus underwent PCMO and Akin osteotomy. Radiologic assessments included preoperative metatarsus adductus angle (MAA), hallux valgus angle (HVA), intermetatarsal angle (IMA), valgus angles of the second to fourth metatarsophalangeal joints, and hallux valgus recurrence. Assessments included visual analog scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient satisfaction over an average follow-up of 30.6 ± 21.2 (range, 12-99) months. RESULTS: The mean preoperative HVA of 34.4 degrees decreased to 8.7 degrees at final follow-up. The valgus angles of the second, third, and fourth toes improved by 37.1%, 27%, and 44.5%, respectively. In metatarsus adductus patients, lesser toe valgus angles were significantly higher both preoperatively and at final follow-up. Hallux valgus recurrence patients had higher preoperative and final follow-up IMA and valgus angles in the second and third toes. Nonrecurrence patients showed greater decreases in these angles. A larger HVA correction corresponded to a greater decrease in lesser toe valgus deviation. VAS and AOFAS scores improved significantly at the last follow-up. CONCLUSION: The study found a significant reduction in the valgus angle of the second, third, and fourth toes after PCMO and Akin osteotomy in moderate to severe hallux valgus cases, without additional surgeries on lesser toes. The lesser toe angular reductions were less pronounced in patients with metatarsus adductus or with hallux valgus recurrence. LEVEL OF EVIDENCE: Level IV, case series.

Effects of safety and care services on psychological outcomes and housing satisfaction in Korean middle-aged and older adults living alone.

BACKGROUND: Korean society has witnessed a rapid increase in the number of single-person households at risk for loneliness or solitary deaths. This study aims to evaluate the effectiveness of safety and care services (SCS) on the psychological outcomes and housing satisfaction of Korean middle-aged and older adults living alone. METHODS: This study was a randomized controlled trial on residents of public rental housing. A total of 40 people underwent a 3-month intervention. For the experimental group, a caring service IoT solution was installed in participants' houses, and coordinators provided services using IoT information. The control group received only visits by coordinators. RESULTS: The experimental group showed significant positive changes in depressive symptoms. An interaction effect of time and condition was observed, indicating that the loneliness scores of the experimental group were significantly reduced, whereas those of their counterparts were negligible. Both groups showed significant decreases in suicidal thoughts. Housing satisfaction in both groups significantly increased over time, but group differences were observed. CONCLUSIONS: This study demonstrated the positive effects of SCS on depressive symptoms, suicidal thoughts and housing satisfaction for people living alone, suggesting that technology can be a useful tool for helping vulnerable people.

Psychometric Testing of a New Instrument for Assessing Cancer Patient Preparedness for the Survivorship Transition.

Purpose: This study aims to develop and examine the psychometric properties of the "Preparedness for Transition to Survivorship Care Instrument" (PTSCI) for cancer survivors. Methods: A cross-sectional study of cancer survivors in Korea was conducted to test the reliability and validity of the PTSCI. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and concurrent validity tests were conducted. Results: The EFA showed that the 7-factor structure of a 34-item PTSCI accounted for 61.5% of the total observed variance. In CFA, three competing models were created and compared to a seven-factor solution model. A 6-factor 31-item model showed the best fit and was chosen as the final PTSCI model. PTSCI is significantly associated with quality of life, psychological distress, and health promotion. Conclusions: PTSCI can be helpful in preparing for diverse psychosocial and behavioral issues faced by cancer survivors in the survivorship phase.

Evaluation of clinico-radiological outcome of fibular valgization osteotomy with supra-malleolar osteotomy in patients with ankle osteoarthritis.

PURPOSE: There are controversies about combining distal tibia medial opening-wedge osteotomy (DTMO) with fibular valgization osteotomy (FVO) when performing supramalleolar osteotomy (SMO) for medial ankle osteoarthritis. This study aimed to assess the effect of FVO on the coronal translation of the mechanical axis by comparing the improvement of radiological indices after DTMO with and without FVO. METHODS: Forty-three ankles (mean follow-up: 42.0 months) were reviewed after SMO. Among them, 35/43 (81.4%) underwent DTMO with FVO, while 8/43 (18.6%) underwent DTMO only. To evaluate the effect of FVO radiologically, the medial gutter space (MGS) and talus centre migration (TCM) were measured. RESULTS: Post-operatively, MGS and TCM were not significantly different after DTMO only and DTMO with FVO. However, the improvement of MGS was significantly higher in the combined FVO group (0.8 mm (standard deviation [SD] 0.8 mm) vs. 1.5 mm (SD 0.8 mm); p = 0.015). More lateral translation of the talus was achieved in the FVO group (5.1 mm (SD 2.3 mm) vs. 7.5 mm (SD 3.0 mm); p = 0.033). However, the changes in the MGS and TCM were not significantly correlated with the clinical outcomes (p > 0.05). CONCLUSION: Our radiological evaluation confirmed a significant medial gutter space widening and lateral talar translation after the addition of FVO. The SMO with fibular osteotomy allows greater shifting of the talus and, therefore, the weight-bearing axis.

Cognitive behavioral therapy for reducing fear of cancer recurrence (FCR) among breast cancer survivors: a systematic review of the literature.

BACKGROUND: Fear of cancer recurrence (FCR) has been addressed as a cause of emotional distress among breast cancer survivors (BCSs). This study aimed to systematically review the evidence on randomized controlled trials (RCTs) of cognitive behavioral therapy (CBT) designed to reduce FCR among BCSs. METHODS: A systematic review of published original research articles meeting the inclusion criteria was conducted. Five electronic databases, including the Cochrane Library, CINAHL, PubMed, PsycINFO, and Web of Science, were independently searched to identify relevant articles. The Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist was used to evaluate the quality of the eligible studies. RESULTS: Through a database search and a manual review process, seventeen quantitative studies with an RCT study design were included in the current systematic review. The interventions varied greatly in length and intensity, but the study designs and methodologies were similar. RCTs with face-to-face interventions of at least 1 month seemed to be more effective in reducing FCR outcomes and complying with than the CONSORT 2010 criteria than those with a brief online or telephone format of interventions; nevertheless, most RCT interventions appeared to be effective. CONCLUSIONS: These findings highlight the importance of conducting well-designed CBT interventions to reduce FCR in BCSs with diverse populations at multiple sites, thereby improving the quality of research in this area.

A high rate of talocalcaneal interosseous ligament tears was found in chronic lateral ankle instability with sinus tarsi pain.

PURPOSE: To evaluate the arthroscopic findings of subtalar joints, including interosseous talocalcaneal ligament (ITCL) tear, in patients with chronic lateral ankle instability (CLAI) and sinus tarsi pain. METHODS: A total of 118 ankles (109 patients) having CLAI with sinus tarsi pain who had undergone subtalar arthroscopy and lateral ankle ligament surgery were evaluated. The medical records, radiologic images, and the arthroscopic images and videos were reviewed. ITCL tears were classified into 4 grades: grade 0 (no tear), grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The efficacy of magnetic resonance imaging (MRI) in diagnosing ITCL tears was also evaluated by comparing preoperative official readings of MRI to arthroscopic findings. The pre- and postoperative functional scores were also assessed. RESULTS: The overall tear rate of ITCL was 107/118 (90.7%). There were 29 ankles (23.6%) with grade 1, 42 ankles (35.6%) with grade 2, and 36 ankles (30.5%) with grade 3 tears. Isolated lateral ankle instability (LAI) was diagnosed in 43 ankles (36.4%), subtalar instability (STI) in 30 ankles (25.4%), and LAI with STI in 45 ankles (38.1%). There was a statistically significant relationship between the ITCL tear grade and the final diagnosis. ITCL tear was confirmed or suspected in 81 ankles (68.6%) on preoperative MRI. Pain Visual Analog Score and functional outcome scores including the American Orthopaedic Foot & Ankle Society and Karlsson-Peterson scores showed significant improvement after the surgery. CONCLUSION: A high rate (90.7%) of ITCL tears was noted in CLAI patients with sinus tarsi pain. ITCL damage may play an important role in subtalar instability in patients with CLAI and sinus tarsi pain. Subtalar arthroscopic evaluation for ITCL tear is important for correct diagnosis for CLAI with sinus tarsi pain. LEVEL OF EVIDENCE: IV.

The Effect of Supramalleolar Osteotomy without Marrow Stimulation for Medial Ankle Osteoarthritis: Second-Look Arthroscopic Evaluation of 29 Ankles.

BACKGROUND: The effect of supramalleolar osteotomy without a bone marrow-stimulating procedure for articular cartilage regeneration in the ankle joint remains unknown. We investigated whether supramalleolar osteotomy yielded favorable clinical and radiographic outcomes. We also evaluated the joint tissue appearance after supramalleolar osteotomy without a bone marrow-stimulating procedure with use of second-look arthroscopy and its correlation with the outcome. METHODS: Twenty-nine ankles were retrospectively reviewed at a mean of 2.9 years after supramalleolar osteotomy without a bone marrow-stimulating procedure. All 29 ankles had had second-look arthroscopy to evaluate tibiotalar joint tissue regeneration at a minimum of 1 year postoperatively. A visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and patient satisfaction were used for functional evaluations. Ankle osteoarthritis was classified with the Takakura staging system, and the tibial anterior surface (TAS) angle and tibial lateral surface (TLS) angle were measured on radiographs. RESULTS: The mean VAS and AOFAS scores improved from 6.2 (95% confidence interval [CI], 5.7 to 6.8) preoperatively to 1.5 (95% CI, 0.9 to 2.1) postoperatively and from 60.5 (95% CI, 54.9 to 66.1) preoperatively to 88.3 (95% CI, 84.3 to 92.3) postoperatively, respectively. Patient satisfaction with the outcome of the procedure was classified as very satisfied or satisfied for 27 ankles (93.1%). Sixteen of 21 ankles that were classified as Takakura stage-IIIa and 2 of 3 ankles that were classified as stage-IIIb preoperatively improved to stage II postoperatively. The mean TAS and TLS angles significantly improved from 83.5° (95% CI, 82.2° to 84.7°) and 77.0° (95% CI, 75.4° to 78.7°) preoperatively to 94.2° (95% CI, 92.7° to 95.7°) and 80.4° (95% CI, 78.3° to 82.5°) postoperatively, respectively. On second-look arthroscopy, 26 ankles (89.7%) showed tissue regeneration of the medial compartment of the ankle joint and no patient showed cartilage deterioration. CONCLUSIONS: Medial tibiotalar tissue regeneration was identified in most patients with medial compartment ankle osteoarthritis following supramalleolar osteotomy without a bone marrow-stimulating procedure. The procedure results in satisfactory clinical and radiographic outcomes with high patient satisfaction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Metatarsus Adductus on Hallux Valgus Treated With Proximal Reverse Chevron Metatarsal Osteotomy.

BACKGROUND: This study aimed to compare clinical and radiographic outcomes and recurrence rates after reverse proximal chevron metatarsal osteotomy (PCMO) for patients with hallux valgus (HV) with or without metatarsus adductus (MA). We hypothesized that patients with MA would have poorer outcomes and a higher radiographic recurrence rate than those without MA. METHODS: This retrospective single-surgeon series comprised 144 patients (173 feet) with moderate to severe HV, treated with PCMO and Akin osteotomy without lesser metatarsal procedures, who were grouped according to the presence (MA group) or absence of MA (non-MA group). Clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score, pain visual analog scale (VAS), and patient satisfaction rating. Radiographic assessments included metatarsus adductus angle (MAA), HV angle (HVA), and intermetatarsal angle (IMA). RESULTS: The prevalence of the MA was 24.2%. The mean MAA was 23.1 ± 3.3 degrees in the MA group. There were no differences in the mean AOFAS score and pain VAS score at the final follow-up between the 2 groups (all P > .05). The patient satisfaction rate was 73.8% in the MA group vs 90.1% in the non-MA group (P = .017). The mean postoperative HVA and IMA significantly improved at the final follow-up in both groups, respectively (all P < .001). Preoperative and postoperative HVA were larger in the MA group vs non-MA group. However, no significant difference was found in the improvement of HVA and IMA after surgery between the 2 groups (all P > .05). The recurrence rate was 28.6% in the MA group and 6.1% in the non-MA group (P < .001). CONCLUSION: HV patients associated with the MA had a higher degree of preoperative HV, lower correction of the HVA, higher radiographic recurrence rate, and poorer patient satisfaction than those without MA post-PCMO without lesser metatarsal procedures. Therefore, a more extensive HV correction procedure or the addition of a lesser metatarsal realignment procedure may need to be considered. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Effect of Manipulation under Anesthesia of the First Knee in Staged Bilateral Total Knee Arthroplasty on Clinical Outcome and Satisfaction.

This study aimed to evaluate whether manipulation under anesthesia (MUA) affect clinical outcome including range of motion (ROM) and patient satisfaction after total knee arthroplasty (TKA). It is hypothesized that MUA improves clinical outcomes and patient satisfaction after primary TKA. This retrospective study analyzed 97 patients who underwent staged bilateral primary TKA. MUA of knee flexion more than 120 degrees was performed a week after index surgery just before operation of the opposite site. The first knees with MUA were classified as the MUA group and the second knees without MUA as the control group. ROM, Knee Society Knee Score, Knee Society Functional Score, Western Ontario and McMaster Universities (WOMAC) score, and patient satisfaction were assessed. Postoperative flexion was significantly greater in the MUA group during 6 months follow-up (6 weeks: 111.6 vs. 99.8 degrees, p < 0.001; 3 months: 115.9 vs. 110.2 degrees, p = 0.001; 6 months: 120.2 vs. 117.0 degrees, p = 0.019). Clinical outcomes also showed similar results with knee flexion during 2 years follow-up. Patient satisfaction was significantly high in the MUA group during 12 months (3 months: 80.2 vs. 71.5, p < 0.001; 6 months: 85.8 vs. 79.8, p < 0.001; 12 months: 86.1 vs. 83.9, p < 0.001; 24 months: 86.6 vs. 85.5, p = 0.013). MUA yielded improvement of clinical outcomes including ROM, and patient satisfaction, especially in the early period after TKA. MUA in the first knee could be taken into account to obtain early recovery and to improve patient satisfaction in staged bilateral TKA.

Slight under-correction using individualized intentional varus femoral cutting leads to favorable outcomes in patients with lateral femoral bowing and varus knee.

PURPOSE: Restoration of neutral alignment is considered key in total knee arthroplasty (TKA). However, this may be undesirable and can result in medial soft-tissue over-release in patients with varus knee and lateral femoral bowing. This study aimed to determine whether individualized intentional varus distal femoral cutting yielded satisfactory clinical and radiological outcomes. METHODS: A total of 77 patients (91 knees) with varus knee (hip-knee-ankle axis ≥ 10°) and lateral femoral bowing > 5° underwent navigation-assisted primary TKA using individualized intentional varus distal femoral cutting. Knee Society scores, Western Ontario and McMaster Universities scores, and radiographs for limb alignment, implant alignment, and aseptic loosening were evaluated. Subgroup analyses were performed according to the limb alignment and coronal femoral component alignment (0° ± 3° vs. varus of > 3°). RESULTS: All clinical outcomes significantly improved at the final follow-up (p < 0.05 in all). The mechanical axis angle changed from 13.1° ± 2.7° to 2.8° ± 1.5°. The coronal femoral component angle at the final follow-up was 2.8° ± 1.3°. Radiolucent lines were observed in 6 cases (6.6%) and were less than 2 mm in all cases without progression. In subgroup analyses, no significant differences were observed in clinical outcomes (n.s. in all) and in the incidence of radiolucent lines (n.s. in limb alignment, n.s. in coronal femoral component alignment). CONCLUSIONS: Individualized intentional varus distal femoral cutting yielded favorable clinical outcomes without complications at 5-year follow-up. Slight under-correction using intentional varus distal femoral cutting could be a viable option in patients with varus knee and lateral femoral bowing during navigation-assisted TKA. LEVEL OF EVIDENCE: IV.

Stress radiography at 30° of knee flexion is a reliable evaluation tool for high-grade rotatory laxity in complete ACL-injured knees.

PURPOSE: To evaluate the diagnostic value of stress radiography and determine the cutoff values for high-grade anterolateral rotatory laxity in complete anterior cruciate ligament (ACL)-deficient knees at different positions. METHODS: Forty-two patients with complete ACL rupture (group 1) and 37 normal subjects (group 2) were prospectively enrolled. The amount of anterior translation in the medial (MM) and lateral (LL) distance compartments and the difference between them (LL-MM distance) were measured using stress radiography at 30°, 45°, 60°, and 90° positions. The area under the receiver operating characteristic curve (AUC) was assessed for the presence of a high-grade (grade > 2) pivot shift. RESULTS: The MM and LL distances in group 1 were significantly different at 30° and 45° positions (P < 0.05). The AUC of the MM (AUC, 0.903) and LL (AUC, 0.901) distances at the 30° position was significantly higher than that of the other positions (P = 0.000); however, the cutoff values were different to diagnose ACL injury (MM vs. LL, 3.1 mm vs. 5.4 mm). A 2.1-mm cutoff for the LL-MM distance showed 78.4% sensitivity and 90.3% specificity for detecting the presence of a high-grade pivot shift (AUC = 0.905, P = 0.000). CONCLUSION: The cutoff values of stress radiography differed according to anatomical references and knee flexion positions. Stress radiography of a 2.1 mm difference in LL-MM distance at 30° of knee flexion can be a reliable method for high-grade rotatory laxity in complete ACL-injured knees. LEVEL OF EVIDENCE: Level 1, diagnostic study.

Physical and psychological symptoms and psychological distress among the spouses of cancer survivors: The mediating effect of family communication and coping.

OBJECTIVE: The current study examined the relationships among physical and psychological symptoms, family communication, family coping and psychological distress for the spouses of cancer survivors. METHODS: A total of 91 spouses of cancer survivors who were diagnosed with breast, colorectal or prostate cancer who were recruited from the University Hospital registry in Cleveland, Ohio, participated in this study. Standardised questionnaires that assessed family communication, family coping and psychological distress were used. RESULTS: The results indicate that the relationships among variables of interests varied by the depression, anxiety and somatisation subscales of psychological distress. For example, depression was negatively associated with family communication, while somatisation was negatively associated with reframing coping. Mediating effects of family communication and family coping were observed only for the somatisation and depression subscales. CONCLUSION: Findings suggest that spouses of cancer survivors may experience different psychological distress symptoms in the survivorship period according to how well the family communicates and how it copes when facing a crisis situation. Spouses may benefit from psychosocial interventions that facilitate their ability to effectively communicate and cope with the challenges of life, which may reduce psychological distress.

The role of post-traumatic growth in promoting healthy behavior for couples coping with cancer.

OBJECTIVE: Post-traumatic growth (PTG) could be beneficial to cancer survivors who translate growth cognitions or emotional processes into positive behavior changes. The current study aimed to determine how post-traumatic growth (PTG) is associated with health behaviors in couples coping with cancer. Specifically, five hypothetical models based on PTG domains were created to better understand the dyadic relationship between PTG domain and health behaviors. METHODS: A total of 91 breast, colorectal, and prostate cancer survivor-spouse dyads were collected from the University Hospital Registry in Cleveland, Ohio. Standardized questions regarding PTG and health behaviors including eating and exercise were used. The actor-partner interdependence model with the use of structural equation modeling was utilized to analyze dyadic data. RESULTS: Findings indicated that survivor actor effects of PTG on health behaviors were observed for survivors only. In the spiritual change and appreciation of life PTG models, the survivor or the spouse partner effects were observed, respectively. The spiritual change model produced the best fit of all of the other models, indicating both a survivor actor effect and survivor partner effect of spiritual change PTG on health behaviors. Thus, the relationships between PTG and health behavior at the dyadic level differed by five domains of PTG. CONCLUSIONS: The findings reveal valuable insight into the nature of relationships between PTG and health behaviors at the individual and dyadic levels. The changed philosophies of life for cancer survivor-spouse dyads can specifically encourage healthy behaviors of couples coping with cancer.

Reliability and Validity of the Femorotibial Mechanical Axis Angle in Primary Total Knee Arthroplasty: Navigation versus Weight Bearing or Supine Whole Leg Radiographs.

PURPOSE: To evaluate the reliability and validity of the femorotibial mechanical axis angle from radiographs in the weight bearing (WB) and supine positions compared with navigation-measured values. MATERIALS AND METHODS: Sixty-eight cases of navigation-assisted total knee arthroplasty (TKA) were included. The pre- and postoperative whole leg radiographs (WLRs) in WB and supine positions were compared with the initial and final navigation values. RESULTS: The mean mechanical axis angle from the preoperative WBWLR and navigation were not statistically different (p=0.079) and were correlated strongly with each other (intraclass correlation [ICC], 0.818). However, on postoperative measurements, although the WBWLR and navigation values were not different (p=0.098), they were not correlated with each other (ICC, 0.093). The standard error of measurement was 1.8°±3.6° for the preoperative WBWLR and 2.5°±4.8° for the postoperative WBWLR. The validity that was determined by the Bland-Altman plot was not acceptable for both pre- and postoperative measurements. CONCLUSIONS: The preoperative WBWLR could provide accurate but not precise measurement value of the femorotibial mechanical axis angle for navigation-assisted TKA, and postoperative measurements in navigation were not comparable with radiographic measurements. The lack of agreement was found between the radiographic and navigation measurements of the coronal alignment regardless of pre- or postoperative evaluation although the accuracy was found acceptable. LEVEL OF EVIDENCE: Level 4.

The Dyadic Effects of Family Cohesion and Communication on Health-Related Quality of Life: The Moderating Role of Sex.

BACKGROUND: Spouses' ability to care for survivors can be particularly challenging because patients and spouses are interdependent and mutually influence one another. Family functioning such as family cohesion and communication may play a primary role in improving the health-related quality of life (HRQOL) of couples, given that cancer can influence family dynamics. OBJECTIVE: The aims of this study were to investigate the mediating effect of family communication on the relationship between family cohesion and HRQOL and examine the moderating effect of sex on this relationship among cancer survivor-spouse dyads. METHODS: A total of 91 cancer survivors with a diagnosis of breast, colorectal, or prostate cancer and their spouses were recruited from the University Hospital Registry in Cleveland, Ohio. The dyadic data were analyzed using structural equation modeling with the actor-partner interdependence mediation model. RESULTS: Findings demonstrated that the spouses' own perceived family communication mediated the associations between their own family cohesion and physical HRQOL and between the survivors' family cohesion and physical HRQOL. The spouse actor effects between family communication and HRQOL significantly differed by sex. CONCLUSIONS: Enhancing family cohesion and communication within the family can improve the spouses' HRQOL. Findings regarding sex differences serve as a rationale for gender-based approaches to improving HRQOL in survivorship care in the family context. IMPLICATIONS FOR PRACTICE: Couple- and/or family-based interventions should be designed to enhance family cohesion and improve family communication skills for effective adjustments within couples and families. Supportive care within the family context can be promoted to address the diverse challenges of survivorship care.

The impact of comorbidity on the relationship between life stress and health-related quality of life for Chinese- and Korean-American breast cancer survivors.

OBJECTIVE: The current study aimed to (1) identify the occurrence of comorbidities among Chinese- and Korean-American breast cancer survivors (BCS), (2) examine whether health-related quality of life (HRQOL) scores varied with the occurrence of specific comorbidities, and (3) investigate the mediating effect of comorbidities on the relationship between life stress and HRQOL. DESIGN: Data were drawn from the parent study, a cross-sectional study investigating HRQOL in 86 Chinese- and 71 Korean-American BCS in Southern California. Two comorbidity-related variables, the occurrence of the specific comorbidity and the total number of comorbidities, were used to comprehensively reflect the characteristics of comorbidity. RESULTS: Approximately 60% of participants had at least one comorbid disease, and osteoporosis was the most prevalent comorbidity. HRQOL differences based on the occurrence of a specific comorbidity were evident for arthritis, eye/vision problems, dental and gum problems, lymphedema, and psychological difficulties. Structural equation modeling demonstrated that the nature of the outcome variable, either physical or mental HRQOL, influenced the overall patterns of the findings. For example, life stress was significantly associated with the total number of comorbidities and in turn influenced physical HRQOL. In terms of mental HRQOL, arthritis, dental and gum problems, chronic pain, heart disease, lymphedema, and psychological difficulties mediated the relationship between life stress and mental HRQOL. CONCLUSION: The current study adds to the existing literature by examining the mediating effects of comorbidity on the relationship between life stress and HRQOL. The findings support the need for health care professionals to clearly assess physical and psychological comorbidities when providing survivorship care for cancer survivors.

Influence of soft tissue balancing and distal femoral resection on flexion contracture in navigated total knee arthroplasty.

PURPOSE: The purpose of this study was to evaluate the influence of intra-operative soft tissue balancing and distal femoral cutting on flexion contracture in navigated TKA. METHODS: This was a prospective cohort study. Fifty-nine patients of primary navigation-assisted TKA were included with over 15° of flexion contracture and excluded valgus knees. Among the cases, 43 cases were performed with soft tissue balancing procedures only, and 16 cases were performed with soft tissue balancing and additional distal femoral bone cutting. The mean preoperative flexion contracture was 17.5° ± 2.7°. The angles of flexion contracture were recorded at each surgical step with navigation. RESULTS: The mean difference in flexion contracture angle between initial angle and angle after medial release was 5.2° ± 2.8°. The mean difference in flexion contracture angle between medial release step and after posterior cruciate ligament (PCL) release was 2.5° ± 2.2°. The mean difference in flexion contracture angle between PCL release step and after routine bone cutting was 3.1° ± 3.2°. The mean difference in flexion contracture angle between after trial insertion and after posterior clearing procedure was 2.7° ± 1.9°. Among the cases, TKA with 2 mm additional bone cutting were performed in 16 cases. The mean difference in flexion contracture angle after additional femoral bone cutting was 4.8° ± 2.1°. CONCLUSION: The medial release and 2 mm additional bone cutting could correct flexion contracture by 5°. The appropriate soft tissue balancing and bone cutting could correct flexion contracture intra-operatively up to 5° in each step. LEVEL OF EVIDENCE: II.

Decisional Conflict: Relationships Between and Among Family Context Variables in Cancer Survivors.

PURPOSE/OBJECTIVES: To investigate the relationships among life stress, family functioning, family coping, reliance on formal and informal resources, and decisional conflict in cancer survivors. 
. DESIGN: Cross-sectional.
. SETTING: Participants were recruited from the California Cancer Surveillance Program, hospital registries, and community agencies in southern California and Cleveland, Ohio. 
. SAMPLE: 243 European American, African American, Chinese American, and Korean American cancer survivors diagnosed with breast, colorectal, or prostate cancer.
. METHODS: The merged data from an ethnically diverse cohort of cancer survivors participating in the two survey studies were used. Standardized measures were used to identify family context variables and decisional conflict. 
. MAIN RESEARCH VARIABLES: Life stress, family functioning, family coping, reliance on formal and informal resources, and decisional conflict.
. FINDINGS: Structural equation modeling demonstrated that life stress was significantly associated with decisional conflict. Family functioning significantly mediated the impact of life stress on decisional conflict through family coping. Reliance on formal and informal resources moderated the relationships among the study variables. 
. CONCLUSIONS: The role of the family context, which includes family functioning and coping, on decisional conflict is important in the adjustment process to make high-quality decisions in cancer survivorship care. 
. IMPLICATIONS FOR NURSING: Findings present nursing practice and research implications that highlight the need for efforts to encourage and support family involvement in the decision-making process and to enhance cancer survivors' adjustment process.

Comparison of ultra-congruent mobile- and fixed-bearing navigation-assisted total knee arthroplasty with minimum 5-year follow-up.

PURPOSE: The purpose of this study was to compare the midterm outcomes between fixed and mobile ultra-congruent (UC) bearings in total knee arthroplasty (TKA). METHODS: This is a retrospective matched-pairs case-control study of patients who underwent primary navigation-assisted TKA with a minimum 5-year follow-up. A total of 182 cases involved the fixed UC bearing system as Group 1 and 101 cases involved mobile UC bearing system group as Group 2. After 1:1 matching, 73 knees in each group were enrolled. Clinical and radiographic outcomes were evaluated. RESULTS: The overall survival was 143 of 146 cases (97.9 %) at final follow-up, and 72 of 73 cases (96.3 %) in Group 1 and 71 of 73 cases (95.8 %) in Group 2 at final follow-up based on an endpoint of revision surgery. The reasons of revision TKA were periprosthetic fracture in Group 1, infection and bearing dislocation in Group 2. There was no statistical difference in Hospital for Special Surgery (HSS) scores, Knee Society Scores (KSS), WOMAC index score evaluations between groups. CONCLUSIONS: This study demonstrated that the fixed-bearing UC prosthesis could provide satisfactory performance compared with that of the mobile-bearing UC prosthesis with minimum 5-year follow-up. The fixed-bearing UC prosthesis could be considered in navigation-assisted TKA with theoretical advantages of UC design. LEVEL OF EVIDENCE: IV.