[Implementation of standardized postoperative pain therapy for orthopaedic patients. Comparison between unsystematic and standardized pain therapy]. / Implementierung einer standardisierten Schmerztherapie bei postoperativen orthopädischen Patienten. Vergleich einer unsystematischen mit einer standardisierten Schmerztherapie.

BACKGROUND: The painless clinic and postoperative pain therapy are currently major issues in the management of surgical procedures. The aim of this study was to evaluate the benefit of a standardized pain therapy on the postoperative pain level after orthopaedic procedures. PATIENTS AND METHODS: We investigated two different groups of patients who underwent an orthopaedic surgical procedure. Group 1 (n = 249) received a pain therapy which was based on an individual and surgery-dependent concept whereas group 2 (n = 243) was treated with a standardized pain therapy concept. The effect of the treatment was monitored with a VAS-based protocol. RESULTS: Up to day 9 after surgery there was a significant difference between the two groups in regard to the postoperative pain. The patients of group 2 had less pain but had more unwanted side effects caused by the pain therapy during the first 3 days after surgery. Mobility and mental disposition were positively affected. CONCLUSION: The implementation of a standardized pain therapy is successful in reducing postoperative pain. Mobility and mental disposition are also influenced positively. As a consequence the incidence of unwanted side effects is rising.

[Comparative analysis of patient-centered outcome of total hip and knee arthroplasty]. / Vergleichende Analyse des patientenzentrierten Outcome nach totalendoprothetischem Ersatz von Hüft- und Kniegelenk.

AIM: The aim of the present study was a comparative investigation of the functional improvement reported by patients suffering from primary osteoarthritis of the knee or hip undergoing total joint replacement and assessed at 3 months. METHOD: In a prospective, controlled clinical trial, 56 patients with primary osteoarthritis of the hip and 59 patients with primary osteoarthritis of the knee undergoing total joint replacement were assessed at two measuring times (day of admission = t1 and 3-month follow-up = t2) using the XSMFA-D (Extra Short Musculoskeletal Function Assessment Questionnaire--German version), WOMAC (Western Ontario and McMasters Universities) arthrosis index and FFb-H OA (Function Assessment Questionnaire Hannover Osteoarthritis). The statistical analysis included effect sizes as standardised response mean, t-test and covariance analysis. RESULTS: Both groups of patients demonstrated significant improvements of the musculoskeletal functions measured. The effect sizes between baseline scores and 3-month follow-up scores range from 0.4 to 2.0 and can be considered as large effects. The covariance analysis showed significant differences between patients with osteoarthritis of the hip and knee for almost every score examined. Patients with hip replacement showed large improvements. A significant influence of the presurgery baseline score on the 3-month score was found consistently. Further analysis showed that patients with medium or strong degrees of disability according to the Function index of the XSMFA-D showed the strongest effects of change at 3 months. However, their scores at t2 were less than the scores of the less disabled patients at t1. CONCLUSION: We conclude that patients with hip replacement show more improvement 3 months after the surgery than patients with knee replacement. Furthermore, it was seen that patients who were more disabled before surgery achieved more improvement than the less-disabled patients. However, they did not achieve the level of the less disabled patients. Thus, the recommendation that total joint replacement should be performed as late as possible should be reviewed.

[A novel questionnaire to assess activity in patients after hip arthroplasties]. / Aktivitätsmessung von Patienten mit Hüfttotalendoprothesen.

BACKGROUND: Until now, the activity of the lower limb could only be exactly measured with expensive electronic pedometers. The aim of this study was to develop a feasible questionnaire to measure the activity of patients after arthroplasty. METHODS: The "Daily Activity Questionnaire" (DAQ) was developed in several steps and the evaluation was carried out in three groups of patients with osteoarthritis of the hip (160 patients and 855 investigated days). The psychometric characteristics were verified. RESULTS: The retest reliability (ICC) of the DAQ is in a range comparable to the electronic pedometer StepWatch. The testing of the criterion validity showed high correlations between the StepWatch and the DAQ (r=0.743). CONCLUSION: Because of its high correlations to the load changes actually performed, the DAQ is especially suited to answer arthroplasty-related questions. In all patient groups, projected load changes between 1.8 and 2.4 million per year were found, which by far exceed the generally accepted test standards for endoprostheses.

[Evaluation of the Extra Short Musculoskeletal Function Assessment questionnaire XSMFA-D in patients with musculoskeletal disorders and surgical or medical in-patient treatment]. / Evaluierung des XSMFA-D an Patienten mit Erkrankungen des Bewegungsapparates und operativer oder konservativer stationärer Therapie.

AIM: The present study had the objective of evaluating the psychometric characteristics of the shortened 16-item version of the German Short Musculoskeletal Function Assessment questionnaire (XSMFA-D), which was designed for routine assessment of functional capacity in patients with various orthopaedic disorders treated either surgically or medically. METHODS: A total of 382 patients from seven different samples with either osteoarthritis of the knee, osteoarthritis of the hip, rheumatoid arthritis or rotator cuff tear treated either in surgical hospitals or rehabilitation settings were assessed both before and after treatment. The XSMFA-D was compared with both questionnaires measuring similar constructs and widely accepted indicators of health status in musculoskeletal disorders. Psychometric characteristics were computed. RESULTS: The internal consistency (Cronbach's alpha) exceeded 0.90 in most cases for the function index and was between 0.80 and 0.90 in most cases for the bother index of the XSMFA-D. Retest-reliability was between 0.80 and 0.95 for the function index and between 0.60 and 0.92 for the bother index. Correlations between the XSMFA-D subscales and the other questionnaires were substantial, showing construct validity. Criterion validity was also demonstrated as significant relationships with accepted external parameters such as function tests, judgements by physicians, pain self-ratings by patients and disease severity scores were found. Sensitivity to change was as high as for the other assessment instruments used in this study. CONCLUSIONS: The XSMFA-D, a very short assessment instrument, proved to be practical, reliable, valid and sensitive to change among the various patient samples studied. It may be recommended for the assessment of patients' state as well as the evaluation of treatments.

[Evaluation of a simple test for shoulder function in patients with surgically treated rotator cuff injuries]. / Prüfung eines einfachen Schulterfunktionstests an operativ behandelten Patienten mit Rotatorenmanschettendefekt.

INTRODUCTION: To assess overall shoulder function a simple examination of the range of motion and strength may not be sufficiently representative. because the shoulder in its daily use is often required for repetitive activities, fatigue at an early stage could be a sign of disturbed shoulder function. Therefore the shoulder function test (SFT) was created to incorporate the factor time into shoulder assessment. With this study the SFT was evaluated for its clinical use in the prospective follow-up of a series of patients operated on for rotator cuff tears. METHODS: Using forward flexion, the patient had to lift a 500-g weight onto a shelf placed at a height which he could reach with his extended arm. The achieved height (5 levels possible) and the time he needed for 5 repetitions were recorded. The SFT value was calculated by division of the time required by the level of the reached shelf. Thus, a lower SFT score represents a better shoulder function. This was tested on 45 patients prior to rotator cuff repair and at 3, 6 and 12 months postoperatively. As validation the SF-36 and the Constant score were evaluated in parallel. Construct, criterion, content and discriminative validity and responsiveness were calculated Results: At all assessments the SFT correlated with the Constant score (r = - 0.47 to r = - 0.62) and the SF-36 (r = - 0.26 to r = - 0.61) demonstrating construct validity. As criterion validity the SFT correlated with the reported pain (r = 0.34 to r = 0.61), patients' self-estimation (r = 0.38 to r = 0.59) and doctors' estimation of the patients shoulder function (r = 0.36 to r = 0.54). Known groups validity was positive as the SFT could differentiate between shoulders with and without rotator cuff tears. The SFT demonstrated a good responsiveness with significant improvement (p = 0.01) after rotator cuff repair. CONCLUSION: Repetitive forward flexion is an important function of the shoulder in daily activities. The SFT allows a reliable and valid quantitative measurement of this function. In order to improve functional assessment of the shoulder and scoring we would recommend using this patient- and function-orientated test in combination with the Constant score to document the current status of shoulder function.

The German Short Musculoskeletal Function Assessment questionnaire: reliability, validity, responsiveness, and comparison with the Short Form 36 and Constant score--a prospective evaluation of patients undergoing repair for rotator cuff tear.

In a prospective clinical trial, first the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D) was tested for reliability, validity, and responsiveness in 23 patients with rotator cuff tears, and secondly the Short Form (SF)-36, and the Constant score were evaluated comparatively in 45 patients with rotator cuff tear undergoing open repair. Retest reliability was excellent for the functional index of the SMFA-D and satisfactory for the bother index. The SMFA-D showed good validity and responsiveness. All three instruments demonstrated significantly the positive effect of rotator cuff repair at 12-month follow-up. Using comparable scales, effect sizes were bigger with the SMFA-D than with the SF-36 and as big as the Constant score. Significant correlations of the SMFA-D indices with the SF-36 scales and the Constant score could be shown preoperatively. At 12-month follow-up, all correlations between SMFA-D indices, SF-36 scales, and Constant score function scales were still significant. We recommend use of the SMFA-D to assess changes in functional status concerning patients with rotator cuff tear undergoing open repair.

Knee arthroplasty for spontaneous osteonecrosis of the knee: unicompartimental vs bicompartimental knee arthroplasty.

Spontaneous osteonecrosis of the knee (SON) is an osteonecrosis that mainly affects the medial femoral condyle. In endstage SON, knee arthroplasty is the therapy of choice. Because of the unicompartimental nature of the knee, unicondylar knee arthroplasty is considered an ideal implant for treatment of this condition. The purpose of this study was to prove that the long-term results of unicondylar implants are better than the results of bicondylar implants for the treatment of SON. All patients treated for SON between 1984 and 2000 have been recorded. Two groups were formed according to the implant used. In all patients the preoperative radiograph was analyzed according to stage and size of the osteonecrotic lesion and the osteoarthritic changes. Postoperatively, the Knee Society Score and the radiograph were recorded. Thirty-nine patients were included in this study, of which 23 patients were treated by a unicondylar implant and 16 by a bicondylar implant. On a short-term basis, unicondylar implants had better clinical results; however, on a long-term basis bicondylar implants were better. In comparison, only unicondylar implants had to be revised. Radiolucency lines were mainly observed in patients with unicondylar impants and large areas of osteonecrosis. Our long-term results suggest that patients with SON are better treated by bicondylar implants. The reasons for the higher failure rate for unicondylar implants are poor bone stock and secondary arthritic changes.

[Evaluating the reliability, validity and responsiveness of the german short musculoskeletal function assessment questionnaire, SMFA-D, in inpatient rehabilitation of patients with conservative treatment for hip osteoarthritis]. / Reliabilitäts-, Validitäts- und Anderungssensitivitätsprüfung des Funktionsfragebogens Bewegungsapparat (SMFA-D) in der stationären Rehabilitation von Patienten mit konservativ behandelter Coxarthrose.

BACKGROUND: Modern patient based outcome measures like the SMFA-D (German Short Musculoskeletal Function Assessment Questionnaire) are able to detect the impairment and functional capacity of patients with musculoskeletal extremity disorders. The SMFA-D was successfully evaluated in several cohorts treated operatively for osteoarthritis of the knee and hip, rotator cuff tears and rheumatoid arthritis. The aim of the present study was the evaluation of the SMFA-D in patients with conservative treatment for hip osteoarthritis. PATIENTS AND METHODS: 69 patients with osteoarthritis of the hip were enrolled in a prospective controlled clinical trial. All patients completed the SMFA-D, SF-36, WOMAC, FFbH-OA. A standardized test of walking speed and the functional status of the patient as judged by the physician were recorded. Statistical analysis were done for the following: re-test reliability (ICC), internal consistency (Cronbach's alpha), validity and responsiveness. RESULTS: Internal consistency (Cronbach's alpha) was alpha = 0.89 and alpha = 0.97 for the SMFA-D scales. The retest reliability (ICC, unjust, mixed effect) was 0.91 (p < 0.001) for the function index and 0.73 (p < 0.001) for the bother index. Both indices correlated significantly with the FFbH-OA (r = 0.66 to r = 0.84), the WOMAC (r = 0.55 to r = 0.86) and the scales of the SF-36 (r = - 0.34 to r = - 0.85) on all three time points, which supports construct validity. There was mainly a significant correlation between the SMFA-D scales and the functional status of the patient (r = 0.21 to r = 0.44), pain reported by the patient (r = 0.43 to = 0.54) and the self selected walking speed (r = 0.28 to r = 0.51), which supports external validity. We were able to differentiate operatively and conservatively treated patients (discriminant construct validity). At the end of the rehabilitation program we were able to demonstrate small to medium treatment effects in SMFA-D and SF-36. The WOMAC and FFbH-OA were not able to demonstrate these treatment effects. CONCLUSION: Even in patients with conservative treatment of hip osteoarthritis the SMFA-D represents a reliable, valid and responsive measure. The use of the SMFA-D can be recommended as a patient based outcome measure.

[Development of a questionnaire based on the Constant-Murley-Score for self-evaluation of shoulder function by patients]. / Entwicklung eines Fragebogens basierend auf dem Constant-Murely-Score zur Selbstevaluation der Schulterfunktion durch den Patienten.

The aim was to develop a German questionnaire for self-assessment of shoulder function equivalent to the Constant-Score (CS). To evaluate the retest reliability, the CS questionnaire was completed twice within 1 week by 47 patients prior to shoulder surgery. For validation the CS was assessed by the physician after the second self-test. The medium selectivity of the CS questionnaire at hospital admission was 0.47, the medium item difficulty 0.40, the test-retest reliability 0.675 ( p=0.000), the internal consistency of the questionnaire 0.80, and of the physician's CS evaluation 0.85. Construct, content, and discriminative validity of the questionnaire could be demonstrated. A high correlation of the patient-based questionnaire with the physician-assessed CS was found ( p=0.82). The statistical analyses demonstrated that the CS questionnaire is a reliable and valid instrument to evaluate the CS and can therefore be used for follow-up studies.

[Design and evaluation of the Extra Short Musculoskeletal Function Assessment Questionnaire XSMFA-D]. / Entwicklung und Evaluierung der Kurzversion des Funktionsfragebogens Bewegungsapparat XSMFA-D.

AIM: The XSMFA-D (German Extra Short Musculoskeletal Function Assessment Questionnaire) was developed on the basis of the SMFA-D to provide a short questionnaire for assessment of the functional status from patient's perspective in routine use. METHODS: Based on psychometric and medical aspects 16 items were extracted from the SMFA-D during an iterative process. 633 SMFA-D questionnaires of 199 patients were used as basic data. The XSMFA-D was evaluated on 67/51 patients with primary osteoarthritis of the knee/hip undergoing total joint replacement. RESULTS: The tests for reliability and internal consistency produced favorable results. The Knee Score, Harris Hip Score, WOMAC and SMFA-D showed significant correlations to the XSMFA-D indicating construct validity. The criterion validity could be demonstrated successfully by relations with external parameters like walking distance, patients reported pain, mobility judgements by physicians and degree of osteoarthritis. The discriminant validity could also be demonstrated by significant differences between several different patient groups. Almost all effect sizes were generally large. CONCLUSIONS: The XSMFA-D could be demonstrated to be an appropriate short questionnaire for the evaluation of therapy results from patient's perspective. The use of the XSMFA-D can be recommended for routine use. Further investigations of the instrument will be undertaken.