Evaluating a targeted person-centred pain management intervention programme in lumbar spine surgery - a controlled segment-specific before-and-after interventional design.

BACKGROUND: Postoperative pain management in lumbar spine surgery care remains a challenge. The aim of this study was to evaluate the impact of a person-centred postoperative pain management intervention programme on lumbar spine surgery patients on postoperative pain, shared decision-making, and satisfaction with postoperative pain management. METHODS: The study was performed with a controlled before-and-after interventional design in an orthopaedic unit at a university hospital. Person-centred pain management for patients undergoing spine surgery was developed in co-creation by a multi-professional team and implemented throughout the care pathway. The usual care group (pre-intervention) served as a comparison to the intervention group. Pain intensity, shared decision-making in pain management, and patient satisfaction with results of pain management, served as patient-reported measures, collected using the International Pain Outcomes questionnaire and analysed using descriptive statistics. RESULTS: The intervention showed no benefit for patients' pain and satisfaction, while shared decision-making in pain management was significant lower in the intervention group than in the conventional group. The per-protocol analysis showed no significant differences between groups. CONCLUSION: The initial assumption of the study, that the implementation of a co-created structured person-centred care pathway would improve patient-reported outcomes, was not confirmed. The periodically low fidelity to the intervention due to organizational constraints (due to sub-optimal organizational conditions and managerial support) may have affected the results.

Detailed MRI evaluation of the spine: a 2-year follow-up study of young individuals reporting different training doses.

OBJECTIVE: To characterize the discs and vertebrae in detail over time in a group of adolescent individuals with varying training doses using magnetic resonance imaging (MRI). METHOD: Thirty-five students were recruited from regular high schools (n=13) as well as schools with athlete competitive skiing programmes (n = 22). The thoraco-lumbar spine of all individuals was examined at baseline and at 2-year follow-up using the same 1.5T scanner and imaging protocol. The individuals were grouped based on their reported training dose: low-to-normal training dose (≤5 h/week, n = 11, mean age 16.5 ± 0.5 years) and high training dose (>5 h/week, n = 24, mean age 17.2 ± 0.6 years.) RESULTS: At baseline, the signal intensity in the discs and vertebrae were significantly lower in individuals reporting high compared to low-to-normal training dose. The vertebral signal changed significantly over the 2-year period in both groups. However, only individuals reporting low-to-normal training dose displayed an overall disc signal change. Interestingly, the regional analysis displayed at baseline high annular signals in the more training-active individuals followed by a reduction over the two-year period. CONCLUSION: This study suggests that disc degeneration is manifested earlier in individuals reporting a higher training dose. Over a 2-year period, however, the degeneration process did not accelerate further. Also, a significant difference in the vertebral signal, at baseline and follow-up as well as over time, could be seen between groups of individuals reporting high versus low-to-normal training dose.

The impact of implementing a person-centred pain management intervention on resistance to change and organizational culture.

BACKGROUND: Resistance to change and organizational culture are essential factors to consider in change management in health care settings. Implementation of structural change remains a challenge. There is a lack of studies providing information on the impact of implementation processes on the organization. The aim of this study was to describe the impact of implementing a systematic change process concerning postoperative person-centred pain management on resistance to change and organizational culture in an orthopaedic spine surgery unit. METHODS: The study was set in an orthopaedic spine surgery unit at a university hospital. Person-centred bundles of care for postoperative pain management of spine surgery patients were developed in co-creation by a multi-professional expert group and implemented throughout the care pathway. The intervention was underpinned by theories on organizational culture and inspired by principles of person-centred care. Quantitative data were collected using the Resistance to Change Scale and the Organizational Culture Assessment Instrument and analysed using descriptive statistics. RESULTS: The findings showed a low resistance to change decreasing during the study. The organizational culture shifted from a result-oriented to a formalized and structured culture after the implementation. The culture preferred by the staff was team-oriented and participation-focused throughout the study. The discrepancy between the current and preferred cultures remained extensive over time. CONCLUSION: It is challenging to describe the influence of the development and implementation of a postoperative pain management program on organizational culture as well as in terms of resistance to change, in a complex health care setting. In the current study the unit was under organizational strain during the implementation. Albeit, the important discrepancy between the current and preferred organizational culture could imply that structural changes aren't enough when implementing person-centred pain management structures and needs to be combined with relational aspects of change.

Human Levels of MMP-1 in Degenerated Disks Can Be Mitigated by Signaling Peptides from Mesenchymal Stem Cells.

Degradation of extracellular matrix (ECM) in intervertebral disks (IVDs) during IVD degeneration plays a vital role in low back pain (LBP). In healthy IVDs, synthesis and degradation of ECM are kept in balance by matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs. MMPs are enzymes responsible for ECM degradation, and their expression levels are known to increase in degenerated disks. However, the exact pathophysiological concentration of MMP-1 in the degenerated disks of patients with chronic LBP has not been reported previously. Factors secreted by human mesenchymal stem cells (hMSCs) have shown positive results in cell therapy of degenerated disks. The aim of this study was to investigate the pathophysiological MMP-1 concentration (in ng/mL) in degenerated disk tissue and to evaluate if conditioned media (CM) from hMSCs could mitigate the effects of MMP-1 at the detected levels in a 3D in vitro disk cell (DC) pellet model. Tissue levels of MMP-1 were quantified in disk tissue collected from 6 chronic LBP patients undergoing surgery. DC pellet cultures were performed to investigate the effects of MMP-1 alone and the effects of conditioned media (CM) in the presence of MMP-1. MMP-1 was introduced in the pellets on day 14 at concentrations of 5, 50, or 100 ng/mL. The pellets were harvested on day 28 and evaluated for cell viability, proliferation, and ECM production. The mean concentration of MMP-1 in disk tissue was 151 ng/mL. Results from pellet cultures demonstrated a higher number of viable cells, glycosaminoglycan production, and ECM accumulation in the CM group even in the presence of MMP-1 compared to the controls. However, the level decreased with increasing MMP-1 concentration. The results demonstrated that CM has the ability to mitigate matrix degradation property of MMP-1 up to 50 ng/mL suggesting that CM could potentially be used to treat early stages of disk degeneration.

Axial loading during MRI reveals insufficient effect of percutaneous interspinous implants (Aperius™ PerCLID™) on spinal canal area.

PURPOSE: To evaluate the effect on the spinal canal at the treated and adjacent level(s), in patients treated for lumbar spinal stenosis (LSS) with percutaneous interspinous process device (IPD) Aperius™ or open decompressive surgery (ODS), using axial loading of the spine during MRI (alMRI). MATERIALS: Nineteen LSS patients (mean age 67 years, range 49-78) treated with IPDs in 29 spine levels and 13 LSS patients (mean age 63 years, range 46-76) operated with ODS in 22 spine levels were examined with alMRI pre- and 3 months postoperatively. Radiological effects were evaluated by measuring the dural sac cross-sectional area (DSCSA) and by morphological grading of nerve root affection. RESULTS: For the IPD group, no DSCSA increase was observed at the operated level (p = 0.42); however, a decrease was observed in adjacent levels (p = 0.05). No effect was seen regarding morphological grading (operated level: p = 0.71/adjacent level: p = 0.94). For the ODS group, beneficial effects were seen for the operated level, both regarding DSCSA (p < 0.001) and for morphological grading (p < 0.0001). No changes were seen for adjacent levels (DSCSA; p = 0.47/morphological grading: p = 0.95). Postoperatively, a significant difference between the groups existed at the operated level regarding both evaluated parameters (p < 0.003). CONCLUSIONS: With the spine imaged in an axial loaded position, no significant radiological effects of an IPD could be detected postoperatively at the treated level, while increased DSCSA was displayed for the ODS group. In addition, reduced DSCSA in adjacent levels was detected for the IPD group. Thus, the beneficial effects of IPD implants on the spinal canal must be questioned. These slides can be retrieved under Electronic Supplementary Material.

Correction to: Axial loading during MRI reveals insufficient effect of percutaneous interspinous implants (Aperius™ PerCLID™) on spinal canal area.

Unfortunately, the ninth reference was incorrectly published in the original publication. The complete correct reference is given below.

Good 5-year outcomes after arthroscopic treatment for femoroacetabular impingement syndrome.

PURPOSE: The purpose of the present study was to evaluate the outcome of arthroscopic treatment for femoroacetabular impingement (FAI) syndrome 5 years post-surgery using patient-reported outcome scores (PROMs) validated for a young and active population with hip complaints. METHODS: Patients were prospectively included in the study. A total of 184 patients [males = 110 (59.8%), females = 74 (40.2%)], with mean age 38.0, underwent arthroscopic treatment for FAI syndrome and were analysed. Preoperatively and at the 5-year follow-up, patients completed a set of self-administered web-based PROMs consisting of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the Hip Sports Activity Scale (HSAS), the EuroQoL-5 Dimension Questionnaire (EQ-5D), the EQ-Visual Analogue Scale (VAS) and the VAS for overall hip function and overall satisfaction. The Wilcoxon signed rank test was used to compare preoperative PROM values with those obtained at the 5-year follow-up. RESULTS: A comparison of preoperative PROM scores and those obtained at the 5-year follow-up revealed statistically significant improvements for all outcome scores (p < 0.05), except for the HSAS score, which were unchanged; iHOT-12 (42.9 vs 67.2), HAGOS different subscales (50.2 vs 69.6, 55.7 vs 76.1, 59.2 vs 72.3, 41.1 vs 66.4, 30.8 vs 60.2, 31.6 vs 60.4), EQ-5D (0.570 vs 0.742), EQ-VAS (66.6 vs 74.4), HSAS (3.13 vs 3.17) and VAS for overall hip function (47.9 vs 69.2). At the 5-year follow-up, 154 patients reported that they were satisfied with surgery (84.6%). Survivorship at the 5-year follow-up was 86.4%. CONCLUSION: Arthroscopic treatment for FAI syndrome yields good patient-reported outcome at the 5-year follow-up. LEVEL OF EVIDENCE: II.

Young elite Alpine and Mogul skiers have a higher prevalence of cam morphology than non-athletes.

PURPOSE: To investigate the prevalence of cam morphology in (1) a group of young elite Mogul and Alpine skiers compared with non-athletes and (2) between the sexes. METHOD: The hip joints of 87 subjects [n = 61 young elite skiers (29 females and 32 males) and n = 26 non-athletes (17 females and 9 males)] were examined using MRI, for measurements of the presence of cam morphology (α-angle ≥ 55). RESULTS: The skiers had a significantly higher prevalence of cam morphology compared with the non-athletes (49% vs 19%, p = 0.009). A significant difference (p < 0.001) was also found between females and males, where 22% of the females and 61% of the males had cam morphology. Among the skiers, there was also a significant difference (p < 0.001) between the sexes, where 28% of the females and 68% of the males had cam morphology. This difference between the sexes was not found in the non-athletic group. No significant differences were found between Mogul and Alpine skiers. CONCLUSION: Young male elite skiers have a higher prevalence of cam morphology of the hips compared with non-athletes. LEVEL OF EVIDENCE: II.

Healthcare practitioners' experiences of postoperative pain management in lumbar spine surgery care-A qualitative study.

AIMS AND OBJECTIVE: To explore and describe healthcare practitioners' experiences of postoperative pain management to patients undergoing planned lumbar spine surgery by identifying the healthcare practitioners' behaviours, attitudes and strategies. BACKGROUND: Poorly managed postoperative pain continues to cause suffering and prolong hospital care and may affect individual and team practitioners' strategies and attitudes. The impact of these strategies and attitudes needs greater understanding. DESIGN: Descriptive qualitative study. METHODS: In-depth interviews were conducted at a university hospital in Sweden during January-March 2016 with 9 healthcare practitioners (ages: 29-61 years; gender: male 3 and female 6; professions: medical doctor 3, registered nurse 3 and physiotherapist 3; professional experience: 1.5 months to 25 years). The interviews were analysed using Braun and Clarke's thematic analysis. The study adhered to the Consolidated Criteria for Reporting Qualitative Research COREQ. RESULTS: The interviews revealed healthcare practitioners' attitudes and strategies. Three themes were identified: (a) Connecting with the person was recognised as the key component in postoperative pain management; (b) Professionalism: a balancing act, accentuated health care practitioners' duality in being both vulnerable and strong in delicate care situations; and (c) Collaboration: being constantly responsive, the necessity for healthcare practitioners to be constantly responsive to their environment. CONCLUSIONS: The findings pinpoint the need for healthcare organisations to build structures enabling practitioners to deliver adequate pain management in acknowledging the practitioners' delicate situation when facing patients in pain. RELEVANCE TO CLINICAL PRACTICE: Given the global need for postoperative pain management, our findings have international relevance. Preconceived expectations on specific pain need to be depicted and postoperative pain taken seriously to protect the patient as well as the healthcare practitioners.

Investigation of the Effect of Secreted Factors from Mesenchymal Stem Cells on Disc Cells from Degenerated Discs.

Low back pain is experienced by a large number of people in western countries and may be caused and influenced by many different pathologies and psychosocial factors including disc degeneration. Disc degeneration involves the increased expression of proinflammatory cytokines and matrix metalloproteinases (MMPs) in the disc environment, which leads to the loss of extracellular matrix (ECM) and the viability of the native disc cells (DCs). Treatment approaches using growth factors and cell therapy have been proposed due to the compelling results that growth factors and mesenchymal stem cells (MSCs) can influence the degenerated discs. The aim of this study was to investigate the effects of conditioned media (CM) from human MSCs (hMSCs) and connective tissue growth factor (CTGF) and TGF-ß on disc cells, and hMSCs isolated from patients with degenerative discs and severe low back pain. The aim was also to examine the constituents of CM in order to study the peptides that could bring about intervertebral disc (IVD) regeneration. DCs and hMSC pellets (approx.. 200,000 cells) were cultured and stimulated with hMSC-derived CM or CTGF and TGF-ß over 28 days. The effects of CM and CTGF on DCs and hMSCs were assessed via cell viability, proteoglycan production, the expression of ECM proteins, and chondrogenesis in 3D pellet culture. To identify the constituents of CM, CM was analyzed with tandem mass spectrometry. The findings indicate that CM enhanced the cellular viability and ECM production of DCs while CTGF and the control exhibited nonsignificant differences. The same was observed in the hMSC group. Mass spectrometry analysis of CM identified >700 peptides, 129 of which showed a relative abundance of ≥2 (CTGF among them). The results suggest that CM holds potential to counter the progression of disc degeneration, likely resulting from the combination of all the substances released by the hMSCs. The soluble factors released belong to different peptide families. The precise mechanism underlying the regenerative effect needs to be investigated further, prior to incorporating peptides in the development of new treatment strategies for low back pain that is potentially caused by IVD degeneration.

Pathological Effects of Cortisol on Intervertebral Disc Cells and Mesenchymal Stem Cells from Lower Back Pain Patients.

In western countries, lower back pain (LBP) is one of the most common disorders, experienced by more than 80% of the population. Chronic LBP due to disc degeneration has been linked to ongoing inflammatory processes in the disc and endplates. Pain effects the body in different ways, inducing a general stress response in which the body responds by releasing the stress hormone cortisol. Little is known about the impact of pain-induced stress on the progression of disc degeneration. Thus, the effects of cortisol on disc cells (DCs) and human mesenchymal stem cells (hMSCs) were explored in vitro with the objective of investigating the repercussions of cortisol on these cell types involved in de- and regenerative mechanisms of the disc. DC and hMSC pellet cultures were exposed to cortisol at two concentrations (150 and 300 ng/mL) for 28 days to simulate pain-induced stress. Cell viability, histological staining, and GAG DNA, along with apo-ptotic assays were conducted. Detection of OCT4, SOX9, IL-1R, and CXCR2 expressions was performed by immunohistochemistry. With cortisol treatment, restricted cell proliferation and less GAG production in both DCs and hMSCs were observed. Suppression of the differentiation and immunomodulatory efficacy of hMSCs was also detected. Moreover, elevated expressions of IL-1R and CXCR2 were detected in both cell types. To conclude, constant exposure to cortisol even at a physiological level enhanced pathological cellular processes in both DCs and hMSCs, which further jeopardized chondrogenesis. This suggests that cortisol resulting from pain-induced stress is a contributing component of intervertebral disc degeneration and may negatively affect regenerative attempts of the disc.

Adolescent elite skiers with and without cam morphology did change their hip joint range of motion with 2 years follow-up.

PURPOSE: To investigate how range of motion of the hips and the lumbar spine are affected by continued elite, alpine skiing in young subjects, with and without a magnetic resonance imaging verified cam morphology, in a 2-year follow-up study. The hypothesis is that skiers with cam morphology will show a decrease in hip joint range of motion as compared with skiers without cam, after a 2-year follow-up. METHOD: Thirty adolescent elite alpine skiers were examined at the baseline (mean age 17.3 ± 0.7 years) and after 2 years. All skiers were examined for the presence of cam morphology (α-angle > 55°) using magnetic resonance imaging at the baseline. Clinical examinations of range of motion in standing lumbar flexion and extension, supine hip flexion, internal rotation, FABER test and sitting internal rotation and external rotation were performed both at the baseline and after 2 years. RESULTS: Skiers with and without cam morphology showed a significant decrease from baseline to follow-up in both hips for supine internal rotation (right: mean - 13.3° and - 10.9° [P < 0.001]; left: mean - 7.6° [P = 0.004] and - 7.9° [P = 0.02]), sitting internal rotation (right: mean - 9.6° and - 6.3° [P < 0.001]; left: mean - 7.6° [P = 0.02] and - 3.3° [P = 0.008]) and sitting external rotation (right: mean - 16.9° and - 11.4° and left: mean - 17.9° and - 14.5° [P < 0.001]) and were shown to have an increased left hip flexion (mean + 8.4° and + 4.6° [P = 0.004]). Skiers with cam were also shown to have an increased right hip flexion (mean + 6.4° [P = 0.037]). Differences were found between cam and no-cam skiers from baseline to follow-up in the sitting internal rotation in both hips (right: mean 3.25°, left: mean 4.27° [P < 0.001]), the right hip flexion (mean 6.02° [P = 0.045]) and lumbar flexion (mean - 1.21°, [P = 0.009]). CONCLUSION: Young, elite alpine skiers with cam morphology decreased their internal rotation in sitting position as compared with skiers without the cam morphology after 2 years of continued elite skiing. LEVEL OF EVIDENCE: II.

Patients' Experiences of Pain Have an Impact on Their Pain Management Attitudes and Strategies.

OBJECTIVES: Postoperative pain remains undermanaged in orthopedic surgery. To identify areas of improvement for future structural changes in pain management, patients' experiences of pain and pain management when undergoing elective lumbar spine surgery were explored, using a qualitative method with focus group interviews. SETTING: The study setting was an orthopedic spine surgery department at a University Hospital in Sweden. METHODS: This study consisted of two focus group interviews with patients (n = 6/group, a total of 12 patients) who had undergone lumbar spine surgery 4 days to 5 weeks prior to the focus group interviews. The interviews were semi-structured, and the analysis was performed using qualitative content analysis. RESULTS: The main result of this study revealed that patients' experiences of pain influenced their attitudes and strategies for pain management. Three main categories emerged from the focus group interviews: I. Coping with pain while waiting for surgery; II. Using different pain-relieving strategies after surgery; and III. How organizational structures influence the pain experiences. CONCLUSIONS: In conclusion the results from this study acknowledge that postoperative pain experiences and coping strategies after spine surgery are highly diverse and individual. This calls for staff having a more personalized approach to pain management in order to optimize pain relief, which was stressed as highly valued by the patients.

No difference in prevalence of spine and hip pain in young Elite skiers.

PURPOSE: To investigate the prevalence between back and hip pain in young Elite skiers. METHODS: Sample group (n = 102), consisted of young Elite skiers (n = 75) and age-matched non-athletes (n = 27), all completed a three-part back and hip pain questionnaire, Oswestry Disability Index and EuroQoL to evaluate general health, activity level, back and hip pain prevalence. RESULTS: No significant differences were shown for lifetime prevalence of back pain in the skiers (50%) compared with controls (44%) (n.s.). Duration of back pain for the skiers showed (30%) > 1 year, whilst (46%) > 5 years. A significant difference was shown with increased Visual Analogue Scale back pain levels for skiers 5.3 (SD 3.1) compared with controls 2.4 (SD 1.9, p = 0.025). No significant differences were shown for lifetime prevalence of hip pain in skiers (21%) compared with controls (8%) (n.s.). CONCLUSION: Young Elite skiers are shown not to have increased lifetime prevalence for back and hip pain compared with a non-athletic control group. LEVEL OF EVIDENCE: II.

Disc degeneration on MRI is more prevalent in young elite skiers compared to controls.

PURPOSE: Evidence-based facts regarding spine abnormalities and back pain are needed in order to develop rehabilitation programs and prevent spine injuries in young skiers. The aim therefore is to identify MRI changes in the thoraco-lumbar spine and the lifetime prevalence of back pain, as well as the association between them, in young skiers compared to non-athletes. METHODS: Seventy-five young elite alpine and mogul skiers, age range 16-20 years, were compared with 27 non-athletic controls. All subjects underwent spinal MRI and answered back pain questionnaires. RESULTS: Fifty-six percent of skiers had at least one disc Pfirrmann grade ≥3 compared to 30% of controls (p = 0.027). Schmorl's nodes (46%) and disc height reduction (37%) were significantly more prevalent in skiers compared to controls (0%) (p < 0.001). When all parameters were combined together, skiers had significantly higher rate of radiological changes than controls, 82% compared to 54% (p = 0.007). The mean number of discs with Pfirrmann grade ≥3 was 1.1 per individual in skiers (median 1, range 0-6) versus 0.6 in controls (median 0, range 0-3). There was no significant difference in lifetime prevalence of back pain between skiers (50%) and controls (44%) (n.s.). MRI abnormalities in skiers did not correlate with lifetime prevalence of back pain. Skiers had a better health perception than controls (p = 0.026). CONCLUSION: Alpine skiers have more degenerative disc changes compared to non-athletes, but these changes do not correlate with the lifetime prevalence of back pain. Lifetime prevalence of back pain is not significantly different between the groups; however, skiers report more severe pain on VAS score. LEVEL OF EVIDENCE: II.

A standardised outcome measure of pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement: cross-cultural adaptation and validation of the international Hip Outcome Tool (iHOT12) in Swedish.

PURPOSE: There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the English version of the international Hip Outcome Tool (iHOT12) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the consensus-based standards for the selection of health status measurement instruments checklist. METHODS: Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pre-testing. The final version was evaluated for reliability, validity and responsiveness in a clinical study of patients [median age 37 (range 15-75)], undergoing surgery for femoro-acetabular impingement. RESULTS: Cronbach's alpha was 0.89, and significant correlations were obtained with the Copenhagen Hip and Groin Outcome Score (Spearman's r 0.10-0.70; p < 0.05) and the EuroQol, EQ-5D average score (Spearman's r 0.27-0.56; p < 0.01). Test-retest reliability (intraclass correlation coefficient) ranged from 0.59 to 0.93 for the individual items. The smallest detectable change ranged from 17.1 to 44.9 at individual level and 3.6 to 9.4 at group level. Factor analysis revealed one factor of pain and symptoms and another factor of physical function. Effect sizes were generally medium or large. CONCLUSION: The Swedish version of the iHOT12 is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting.

Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement.

PURPOSE: There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the Danish version of the Copenhagen Hip and Groin Outcome Score (HAGOS) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist. METHODS: Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pretesting. The final version was evaluated for reliability, validity and responsiveness. Five hundred and two patients (337 men and 167 women, mean age 37, range 15-75) were included in the study. RESULTS: Cronbach's alpha for the six HAGOS-S subscales ranged from 0.77 to 0.89. Significant correlations were obtained with the international Hip Outcome Tool average score (r s = 0.37-0.68; p < 0.01) and a standardised instrument, the EuroQol, EQ-5D total score (r s = 0.40-0.60, p = 0.01), for use as a measurement of health outcome. Test-retest reliability (intraclass correlation coefficient) ranged from 0.81 to 0.87 for the six HAGOS-S subscales. The smallest detectable change ranged from 7.8 to 16.1 at individual level and 1.6-3.2 at group level. Factor analysis revealed that the six HAGOS-S subscales had one strong factor per subscale. Effect sizes were generally medium or large. CONCLUSION: The Swedish version of the HAGOS is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting at individual and group level.

A Swedish hip arthroscopy registry: demographics and development.

PURPOSE: Hip arthroscopy is a rapidly expanding field in orthopaedics. Indications and surgical procedures are increasing. Although several studies report favourable clinical outcomes, further scientific evidence is needed for every aspect of this area. Accordingly, a registry for hip arthroscopy was developed. The purpose of this study is to describe the development of the registry and present its baseline data. METHODS: A Scandinavian expert group agreed to use a set of functional outcome scores for the evaluation of hip arthroscopy patients. They were the international hip outcome tool-12, hip and groin outcome score, EQ-5D, hip-specific activity level scale and visual analogue scale for overall hip function. These scores were validated and culturally adapted to Swedish. A database was created for web-based, self-administered questionnaires. Perioperative data were also collected. RESULTS: The process leading to the registry is reported. Baseline data from the first 606 patients collected during a 14-month period are presented. The preferred surgical technique is presented. The mean operation time was 69 (SD 14) minutes. In 333 procedures, mixed cam and pincer pathology were addressed, compared with 223 procedures with the treatment of isolated cam pathology. Outpatient surgery was performed in all patients. CONCLUSION: The baseline data in this study can be used as reference values for future scientific work from this registry. Knowledge of the process leading to the development of the registry could be useful to other researchers planning similar work.

Full-Endoscopic Lumbar Discectomy vs Standard Discectomy: A Noninferiority Study on Clinically Relevant Changes.

BACKGROUND: Surgery for lumbar disc herniation (LDH) has had a remarkable technological development during the past 20 years. Microscopic discectomy has traditionally been the gold standard method to treat symptomatic LDH before the introduction of full-endoscopic lumbar discectomy (FELD). The FELD procedure allows unsurpassed magnification and visualization and is currently the most minimally invasive surgical technique. In this study, FELD was compared with standard surgery for LDH, with a focus on medically relevant changes in patient-reported outcome measures (PROMs). PURPOSE: The purpose of this study was to investigate whether FELD is noninferior to other surgical methods for LDH surgery in the most common PROMs, including postoperative leg pain and disability, while still reaching the necessary thresholds for relevant clinical and medical improvements. METHODS: Patients undergoing a FELD procedure at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2013 to 2018 were included. A total of 80 (41 men and 39 women) patients were enrolled. The FELD patients were matched 1:5 to controls from the Swedish spine register (Swespine) who had a standard microscopic or mini-open discectomy surgery. PROMs, including the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS), as well as the patient acceptable symptom states (PASS) and the minimal important change (MIC), were used to compare the efficacy of the 2 surgical approaches. RESULTS: The FELD group achieved medically relevant and significant improvements noninferior to standard surgery within the predefined thresholds of MIC and PASS. No differences could be found in disability measured by ODI FELD -28.4 (SD 19.2) vs standard surgery -28.7 (SD 18.9) or leg pain NRSLeg FELD -4.35 (SD 2.93) vs standard surgery -4.99 (SD 3.12). All intragroup score changes were significant. CONCLUSIONS: The FELD results are not inferior to standard surgery 1 year postoperatively after LDH surgery. There were no medically significant differences regarding MIC achieved or final PASS in any of the measured PROMs, including leg pain, back pain, or disability (ODI) between the surgical methods. CLINICAL RELEVANCE: The present study highlights that FELD is noninferior to standard surgery in clinically relevant PROMs.

Nighttime versus Fulltime Brace Treatment for Adolescent Idiopathic Scoliosis: Which Brace to Choose? A Retrospective Study on 358 Patients.

The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20-40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, age ≥ 10 years, curve 20-40°, Risser ≤ 3 or Sanders stage ≤ 6 and curve apex below T6 vertebra. Exclusion criteria: incomplete radiological or clinical follow-up and previous treatment. The primary outcome was failure according to the SRS outcome assessment: increase in main curve > 5° and/or increase in main curve beyond 45° and/or surgery. The subgroup analyses were secondary outcomes. In total, 249 patients in the PNB and 109 in the BB groups were included. The BB showed a higher success rate compared to the PNB (59% and 46%, respectively) in both crude and adjusted comparisons (p = 0.029 and p = 0.007, respectively). The subgroup analyses showed higher success rates in pre-menarchal females, thoracic curves and curves > 30° in the BB group compared to the PNB group. Based on the findings, fulltime braces should be the treatment of choice for more immature patients and patients with larger and thoracic curves while nighttime braces might be sufficient for post-menarchal females and patients with lumbar and smaller curves.