Predicting clinical outcome and length of sick leave after surgery for lumbar spinal stenosis in Sweden: a multi-register evaluation.

PURPOSE: Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008-2012 in Sweden, aimed to determine predictive factors for the outcome of surgery. METHODS: Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70-90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed. RESULTS: Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2 years, having comorbidities, being a smoker, being on social welfare and being unemployed. CONCLUSIONS: The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors' impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS. These slides can be retrieved under Electronic Supplementary Material.

A simple visual analog scale for pain is as responsive as the WOMAC, the SF-36, and the EQ-5D in measuring outcomes of revision hip arthroplasty.

BACKGROUND AND PURPOSE: Little is known about the comparative performance of patient-reported outcome measures in revision hip arthroplasty. We compared the performance of the WOMAC, the SF-36, the EQ-5D, and a pain-related visual analog scale (VAS) in revision hip arthroplasty. METHODS: 45 patients with aseptic prosthetic loosening following primary hip arthroplasty completed the WOMAC, the SF-36, the EQ-5D, and a VAS for pain-at baseline and 2 years after revision. Responsiveness of the measures was compared with the effect size (with ≥ 0.8 being considered large). Agreement between scales measuring the same type of outcome (pain or physical function) was assessed with the Bland-Altman method. RESULTS: The mean preoperative scores for the pain and physical function scales of WOMAC and SF-36, EQ-5D index, and VAS for pain improved statistically significantly 2 years after revision. The effect size for the WOMAC pain was 1.7, that for SF-36 pain was 1.4, that for WOMAC physical function was 1.6, that for SF-36 physical function was 0.8, and that for EQ-5D index was 1.2. The VAS for pain had an effect size of 2.1, which was larger than that for SF-36 pain and for the EQ-5D index (p ≤ 0.03) but not for WOMAC pain (p = 0.2). The limits of agreement between WOMAC pain, SF-36 pain, and the VAS scale measuring pain-and between the WOMAC and SF-36 scales measuring physical function-were wide. Internal-consistency reliability was high for the WOMAC and SF-36 scales but low for the EQ-5D. INTERPRETATION: In patients with first-time revision hip arthroplasty done for aseptic loosening, the WOMAC, SF-36, and EQ-5D showed high responsiveness in measuring patient-reported outcomes and the simple VAS for pain performed equally well.

The six-item CTS symptoms scale and palmar pain scale in carpal tunnel syndrome.

PURPOSE: To evaluate measurement properties of 2 brief outcome measures for carpal tunnel syndrome: the 6-item carpal tunnel symptoms scale (CTS-6) and the 2-item palmar pain scale (measuring severity of pain in the scar/palm and pain-related activity limitation). Our hypothesis was that the CTS-6 is responsive to change in symptoms after surgical treatment and the pain scale is a valid measure of surgery-related pain. METHODS: This study followed 447 consecutive patients with carpal tunnel syndrome undergoing open release; 308 completed the CTS-6 and the Disabilities of the Arm, Shoulder, and Hand-short form (QuickDASH) before surgery and the CTS-6, QuickDASH, palmar pain scale, and 2 items regarding global rating of change and treatment satisfaction once after surgery (range, 2-13 mo). The mean scores for the CTS-6 (range, 1-5) and QuickDASH and palmar pain scales (range, 0-100) were calculated (lower score is better). Responsiveness was assessed with the effect size (ES). We estimated the CTS-6 score change indicating minimal clinically important difference based on scores for patients with moderate self-rated improvement. RESULTS: The mean baseline CTS-6 score was 3.16, mean change after surgery was -1.54 (95% confidence interval [CI], -1.65 to -1.44), and ES was 2.0. The ES was large (2.5) in patients with the largest self-rated improvement and decreased with lower self-rated improvement. A score change of 0.9 indicated a minimal clinically important difference. The mean change in QuickDASH score was -25.4 (95% CI, -27.8 to -23.0), and ES was 1.25. The mean palmar pain score for patients with time since surgery of less than 3 months was 38.5, at 3 to 6 months was 35.4, and greater than 6 months was 19.5; the mean score was significantly higher among patients with lower satisfaction. CONCLUSIONS: The CTS-6 is highly responsive to change in symptoms, and the palmar pain scale is a valid measure of surgery-related pain. These brief scales can be appropriate primary and secondary outcomes measures in clinical trials studying carpal tunnel syndrome.

Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial.

PURPOSE: The purpose of this investigation was to extend the previously reported short-term randomized trial of open and endoscopic carpal tunnel release in patients with carpal tunnel syndrome (CTS) to compare outcomes 5 years after surgery. METHODS: In a single-center randomized controlled trial, 128 patients (25 to 60 years) with clinically diagnosed and electrophysiologically confirmed idiopathic CTS were randomized immediately before surgery to open or 2-portal endoscopic release. The outcome measures included the validated CTS questionnaire's symptom severity and functional status scales (scored from 1 to 5) completed at baseline and 1 year postoperatively. At the extended follow-up of the trial 5 years after surgery, 2 patients had died and the other 126 participants (63 patients in each group) completed the CTS questionnaire. RESULTS: At the 5-year follow-up no difference between the groups was found in the CTS symptom severity score. The mean (SD) score in the open group was 1.42 (0.7) and in the endoscopic group was 1.45 (0.7), and the mean difference in score change from baseline was 0.03 (95% confidence interval, -0.21 to 0.27). Between 1 year and 5 years postoperatively, the CTS symptom severity score had deteriorated by at least 0.4 point in 9 patients in the open group and in 10 patients in the endoscopic group. The mean (SD) CTS functional status score was 1.29 (0.5) in the open group and 1.30 (0.5) in the endoscopic group. At 5 years, 11 patients in the open group and 10 patients in the endoscopic group reported persistent pain in the scar or proximal palm. Three patients in each group had repeat surgery on the operated hand because of persistent or recurrent symptoms. CONCLUSIONS: The improvements in symptoms of CTS and hand-related disability 5 years after open and 2-portal endoscopic carpal tunnel release were equivalent. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Long-term cost and effect on quality of life of osteoporosis-related fractures in Sweden.

BACKGROUND AND PURPOSE: Few economic or quality-of-life studies have investigated the long-term consequences of fragility fractures. This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral, and wrist fracture 13-18 months after the fracture, based on 684 patients surviving 18 months after fracture. PATIENTS AND METHODS: Data regarding resource use and quality of life related to fractures was collected using questionnaires at 7 research centers in Sweden. Information was collected using patient records, register sources, and by asking the patient. Quality of life was estimated using the EQ-5D questionnaire. Direct and indirect costs were estimated from a societal standpoint. RESULTS: The mean fracture-related cost 13-18 months after a hip, vertebral, or wrist fracture were estimated to be euro2,422, euro3,628, and euro316, respectively. Between 12 and 18 months after hip, vertebral, and wrist fracture, utility increased by 0.03, 0.05, and 0.02, respectively. Compared to prefracture levels, the mean loss in quality of life between 13 and 18 months after fracture was estimated to be 0.05, 0.11, and 0.005 for hip, vertebral, and wrist fracture. INTERPRETATION: The sample of vertebral fracture patients was fairly small and included a high proportion of fractures leading to hospitalization, but the results indicate higher long-term costs and greater loss in quality of life related to vertebral fracture than previously believed.

Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement.

BACKGROUND: The use of impacted morselized allograft bone and cement in hip revision arthroplasty has been popular, but studies that specifically address intraoperative and postoperative complications have been scarce. METHODS: All complications that occurred during, and within the first year after, 144 consecutive hip revision arthroplasties (108 stems and 130 sockets) performed with impacted morselized allograft bone and cement were recorded. Clinical and radiographic follow-up evaluation was performed at three months and at one year after surgery for all patients except eight (seven who had died of causes unrelated to the hip surgery and one who had sustained a stroke). Of these eight patients, seven had a six-week and/or three-month follow-up evaluation. RESULTS: Thirty-nine femoral fractures occurred in thirty-seven hips; twenty-nine of the fractures occurred during surgery and ten, within five months after surgery. Of the intraoperative femoral fractures, twelve were proximal, nine were diaphyseal, and eight involved the greater trochanter. Of the postoperative femoral fractures, one was proximal and nine were diaphyseal. Other intraoperative complications were the creation of a femoral cortical window in seven hips and incidental perforation of the femoral cortex in fourteen. Multivariate analysis showed the risk factors for femoral fracture during or after revision to be concomitant disease, greater deficiency of the femoral bone stock, and an intraoperative femoral window or perforation. Other complications included dislocation of the femoral head in nine hips, deep infection in one hip, persistence of preoperative deep infection in one hip, and superficial wound infection requiring wound débridement in two hips. CONCLUSIONS: We found the complication rate to be high after hip revision arthroplasty performed with impacted morselized allograft bone and cement. The most serious complication was postoperative diaphyseal femoral fracture.

Diagnostic properties of nerve conduction tests in population-based carpal tunnel syndrome.

BACKGROUND: Numerous nerve conduction tests are used for the electrodiagnosis of carpal tunnel syndrome (CTS), with a wide range of sensitivity and specificity reported for each test in clinical studies. The tests have not been assessed in population-based studies. Such information would be important when using electrodiagnosis in epidemiologic research. The purpose of this study was to compare the diagnostic accuracy of various nerve conduction tests in population-based CTS and determine the properties of the most accurate test. METHODS: In a population-based study a questionnaire was mailed to a random sample of 3,000 persons. Of 2,466 responders, 262 symptomatic (numbness/tingling in the radial fingers) and 125 randomly selected asymptomatic responders underwent clinical and electrophysiologic examinations. A standardized hand diagram was administered to the symptomatic persons. At the clinical examination, the examining surgeon identified 94 symptomatic persons as having clinically certain CTS. Nerve conduction tests were then performed on the symptomatic and the asymptomatic persons by blinded examiners. Analysis with receiver operating characteristic (ROC) curves was used to compare the diagnostic accuracy of the nerve conduction tests in distinguishing the persons with clinically certain CTS from the asymptomatic persons. RESULTS: No difference was shown in the diagnostic accuracy of median nerve distal motor latency, digit-wrist sensory latency, wrist-palm sensory conduction velocity, and wrist-palm/forearm sensory conduction velocity ratio (area under curve, 0.75-0.76). Median-ulnar digit-wrist sensory latency difference had a significantly higher diagnostic accuracy (area under curve, 0.80). Using the optimal cutoff value of 0.8 ms for abnormal sensory latency difference shown on the ROC curve the sensitivity was 70%, specificity 82%, positive predictive value 19% and negative predictive value 98%. Based on the clinical diagnosis among the symptomatic persons, the hand diagram (classified as classic/probable or possible/unlikely CTS) had high sensitivity but poor specificity. CONCLUSIONS: Using the clinical diagnosis of CTS as the criterion standard, nerve conduction tests had moderate sensitivity and specificity and a low positive predictive value in population-based CTS. Measurement of median-ulnar sensory latency difference had the highest diagnostic accuracy. The performance of nerve conduction tests in population-based CTS does not necessarily apply to their performance in clinical settings.

Carpal tunnel syndrome and keyboard use at work: a population-based study.

OBJECTIVE: To investigate the relationship between carpal tunnel syndrome (CTS) and keyboard use at work in a general population. METHODS: A health status questionnaire was mailed to 2,465 persons of working age (25-65 years) who were randomly selected from the general population of a representative region of Sweden. The questionnaire required the subjects to provide information about the presence and severity of pain, numbness and tingling in each body region, employment history, and work activities, including average time spent using a keyboard during a usual working day. Those reporting recurrent hand numbness or tingling in the median nerve distribution were asked to undergo a physical examination and nerve conduction testing. The prevalence of CTS, defined as symptoms plus abnormal results on nerve conduction tests, was compared between groups of subjects that differed in their intensity of keyboard use, adjusting for age, sex, body mass index, and smoking status. RESULTS: Eighty-two percent responded to the questionnaire, and 80% of all symptomatic persons attended the examinations. Persons who had reported intensive keyboard use on the questionnaire were significantly less likely to be diagnosed as having CTS than were those who had reported little keyboard use, with a prevalence that increased from 2.6% in the highest keyboard use group (> or = 4 hours/day), to 2.9% in the moderate use group (1 to <4 hours/day), 4.9% in the low use group (<1 hour/day), and 5.2% in the no keyboard use at work group (P for trend = 0.032). Using > or = 1 hour/day to designate high keyboard use and <1 hour/day to designate low keyboard use, the prevalence ratio of CTS in the groups with high to low keyboard use was 0.55 (95% confidence interval 0.32, 0.96). CONCLUSION: Intensive keyboard use appears to be associated with a lower risk of CTS.

Five-year follow-up of socket movements and loosening after revision with impacted morselized allograft bone and cement: a radiostereometric and radiographic analysis.

In 1999, we reported on the 2-year results of a series of 21 first-time socket revisions using impacted morselized allograft bone. Seven still migrated between 1.5 and 2 years. Seventeen remained for the current 5-year follow-up. No socket had been rerevised. Five sockets showed signs of radiographic loosening. These 5 cases also exhibited radiographic signs of allograft resorption as well as high rates of socket migration and rotation as measured by radiostereometric analysis. Of the 6 remaining sockets that had migrated between 1.5 and 2 years, 3 stabilized and 3 were among those with signs of radiographic loosening. Fifteen patients (15 hips) revealed pain reduction at the 5-year follow-up. Three had slight pain on walking that disappeared immediately at rest (pain score 4). All the others revealed either no pain (pain score 6) or slight pain that disappeared with activity (pain score 5). No pattern of early socket migration according to radiostereometric analysis could be identified, predicting later socket migration or loosening. The rate of cases with signs of radiographic loosening (29%, 5/17) was comparable to that reported by the Nijmegen group but the follow-up was shorter in the current study. The rate of cases with signs of radiographic loosening was comparable to both conventionally cemented socket revisions and cementless revisions. The future will show if further sockets loosen and if the loose sockets up to date will end up in rerevisions.

Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.

OBJECTIVES: To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome. DESIGN AND SETTING: Randomised controlled trial at a single orthopaedic department. PARTICIPANTS: 128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome. MAIN OUTCOME MEASURES: The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months. RESULTS: 63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially. CONCLUSIONS: In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.

Costs and quality of life associated with osteoporosis-related fractures in Sweden.

This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral and wrist fracture 1 year after the fracture, based on a patient sample consisting of 635 male and female patients surviving a year after fracture. Data regarding resource use and quality of life related to fractures was collected by questionnaires at baseline, 4 months and 12 months. Information was collected by the use of patients' records, register sources and by asking the patient. Quality of life was estimated with the EQ-5D questionnaire. Costs were estimated from a societal perspective, including direct and indirect costs. The mean fracture-related cost the year after a hip, vertebral and wrist fracture were estimated, in euros (), at 14,221, 12,544 and 2,147, respectively [converted from Swedish krona (SEK) at an exchange rate of 9.1268 SEK/]. The mean reduction in quality of life was estimated at 0.17, 0.26 and 0.06 for hip, vertebral and wrist fracture, respectively. Based on the results, the yearly burden of osteoporosis in Sweden could be estimated at 0.5 billion (SEK 4.6 billion). The patient sample for vertebral fracture was fairly small and included a high proportion of fractures leading to hospitalization, but they indicate a higher cost and loss of quality of life related to vertebral fracture than previously perceived.

Activities of daily living decrease similarly in hospital-treated patients with a hip fracture or a vertebral fracture: a one-year prospective study in 151 patients.

AIMS: A hip fracture is commonly regarded as the most devastating fragility fracture, as regards both morbidity and mortality, while a vertebral fracture is usually regarded as having lower general morbidity. The purpose of this study was to investigate whether hospitalized patients with a hip or a vertebral fracture experience similar functional deterioration following the fracture as regards activity of daily living (ADL) and experienced quality of life (QOL). METHODS: Eighty-seven women and 22 men, mean age 81 (range 66-96), with a hip fracture and 34 women and 8 men, mean age 81 (range 68-92), with a vertebral fracture were followed up for 12 months. ADL before fracture and at 4 and 12 months after the fracture were evaluated as well as QOL at 4 and 12 months after the fracture, by questionnaires. RESULTS: A hip and a vertebral fracture in community dwellers within the same age range confers a similar decrease in ADL during the four months following the fracture. No restoration was seen in ADL or total QOL during the year following the fracture. Patients with a vertebral fracture had a lower QOL than patients with a hip fracture 4 and 12 months after the fracture. CONCLUSION: The need for external community assistance for patients with a vertebral fracture that forces them to have hospital treatment may be similar to the need following a hip fracture.

Primary care patients with musculoskeletal pain. Value of health-status and sense-of-coherence measures in predicting long-term work disability.

OBJECTIVE: To investigate long-term sick leave among primary care patients with musculoskeletal disorders and the predictive value of health-status and sense-of-coherence measures. METHODS: Patients aged 17 to 64 years who, during seven weeks, attended one of six primary care centers because of non-traumatic musculoskeletal pain and who completed the SF-36 health questionnaire and the sense of coherence (SOC) scale at baseline and after one year. RESULTS: Of 189 patients, 36 (19%) were sicklisted for at least three months before and/or after their visit; the most common diagnoses were non-specific soft-tissue or multiple joint, low back, and shoulder pain. The long-term sicklisted patients had significantly worse baseline SF-36 and SOC scores than the non-sicklisted patients; moderate improvement in the SF-36 bodily pain but no improvement in the physical functioning scores occurred. The duration of sick leave at baseline and the SF-36 bodily pain score were significant predictors of continuos one-year work disability. CONCLUSION: Long-term sick leave was common among primary care patients with musculoskeletal pain. The physical functioning and return-to-work outcomes after one year were poor. The SF-36 bodily pain scale might be helpful in identifying at risk patients.

Hip revision using the Exeter stem, impacted morselized allograft bone and cement: a consecutive 5-year radiostereometric and radiographic study in 15 hips.

BACKGROUND: Impaction grafting in hip revision surgery is widely used but studies with mid- and long-term follow-up are scarce. PATIENTS, METHODS AND RESULTS: A 5-year radiostereometric (RSA) follow-up of 15 hip revisions with the Exeter stem, morselized impacted allograft bone and cement revealed that 3 stems had not migrated between 2 and 5 years after revision, 11 stems had migrated to a minor degree in at least 1 direction, and 1 stem was loose according to RSA but without any radiographic signs of loosening or pain. The pain score was comparable to primary arthroplasties. INTERPRETATION: From a 5-year perspective, first-time hip revisions for aseptic loosening with impacted morselized allograft bone and cement appear to yield good clinical results, although stem migration continues to a minor degree 2 years after revision.

Hip revision with impacted morselized allografts: unrestricted weight-bearing and restricted weight-bearing have similar effect on migration. A radiostereometry analysis.

BACKGROUND: No consensus exists as to whether to let patients bear weight or not after revision of a loosened hip prosthesis using morselized and impacted allograft bone and cement. In the original description of the method, the patients were advised not to bear weight for 3 months postoperatively. Theoretically, bone graft remodeling is enhanced by mechanical load, but an increased migration of the prosthesis within the graft can also be anticipated. In addition, practicing restricted weight-bearing is cumbersome for the patients. METHODS: The present study was initiated to evaluate the migration, as measured by radiostereometry analysis (RSA), in patients mobilized with unrestricted weight-bearing after a hip revision using the X-change Revision Instruments System. This group was compared with a previous series with restricted weight-bearing for the initial 3 months postoperatively. Seven stems and 12 sockets were evaluated by RSA over 2 years. Only patients without intraoperative complications were mobilized with unrestricted weight-bearing. RESULTS: All 7 stems migrated in the distal direction (median 2.6 mm; range 0.8-16.5 mm) and in the posterior direction (median 2.3 mm; range 0.7-22.1 mm). Eleven of the 12 sockets migrated in the proximal direction (median 2.5 mm; range 0.2-8.1 mm). The migration rate decreased gradually in all directions, but 3 stems and 5 sockets still migrated between the 1.5- and 2-year follow-ups. There were no significant differences in migration in any direction for either the stems or the sockets compared to the group with restricted weight-bearing. CONCLUSION: No increased migration occurred in the group free to bear weight as compared to restricted weight-bearing. We shall continue to allow unrestricted weight-bearing in cases where the femoral bone feels competent to withstand the initial load. It simplifies the postoperative mobilization, and we speculate that it might increase the remodeling of the graft.

Chronic upper extremity pain and co-occurring symptoms in a general population.

OBJECTIVE: To estimate the prevalence of self reported chronic upper extremity pain associated with physical impairment in a general population, and its co-occurrence with chronic upper extremity numbness or tingling and chronic pain at other locations. METHODS: A general health questionnaire was mailed to 3,000 persons (age 25-74 years) who were randomly selected from a general population register. RESULTS: The response rate was 83%. The prevalence of chronic upper extremity pain associated with physical impairment was 20.8% (95% confidence interval [95% CI] 19.2-22.5), and that of co-occurring numbness or tingling was 6.7% (95% CI 5.7-7.7). Among the responders with chronic upper extremity pain associated with physical impairment, 84% reported more than 1 painful area. CONCLUSION: Chronic upper extremity pain associated with physical impairment and co-occurring chronic upper extremity numbness or tingling were common in the general population. The presence of more than 1 location for pain in the upper extremity as well as in other parts of the body was frequent.

Movement pattern of the Exeter femoral stem; a radiostereometric analysis of 22 primary hip arthroplasties followed for 5 years..

BACKGROUND: The design of the Exeter stem may facilitate distal migration, but radiostereometric analysis (RSA) studies have been limited to 2 years of follow-up. PATIENTS AND METHODS: We followed migration of the Exeter femoral stems in 22 primary hip arthroplasties for 5 years with RSA. RESULTS: All stems migrated distally and the median migration at 2 years was 1.34 mm, while at 5 years it was 1.77 mm. 7 stems migrated above accuracy between 3 and 5 years. (RSA) evaluation of the cement mantle could be performed in 14 cases, and in 5 slight migration was found. Most of the stems rotated towards retroversion and the median rotation at 2 years was 1.2 degrees, while at 5 years it was 1.6 degrees. We found 1 patient with impending clinical failure but no deviation in the RSA migration pattern, and 1 patient with unstable migration pattern but no clinical symptoms. INTERPRETATION: We found a greater distal migration of the Exeter stem for longer periods of time than seen with other types of cemented implants.

Quality of life after hip revision with impaction bone grafting on a par with that 4 years after primary cemented arthroplasty.

BACKGROUND: There have been few studies evaluating patient-reported quality of life outcomes after hip revision with impaction bone grafting. PATIENTS AND METHODS: The inclusion criteria were aseptic loosening after primary arthroplasty performed for osteoarthrosis, and first-time revision with impacted morselized allograft bone and cemented Exeter stem. During a 4-year period, 35 patients were eligible and all were included. The Nottingham Health Profile (NHP) was completed by the patients and the Charnley hip scores recorded by the examining surgeon preoperatively, after 6 months and yearly up to 4 years (28 patients) postoperatively. For comparison, 35 osteoarthrotic patients completed the NHP 4 years after cemented Exeter primary arthroplasty. RESULTS: At 4 years, the NHP scores for the revision patients did not differ significantly from those recorded in the primary arthroplasty group. Among the revision patients, mixed model analysis showed improvement in NHP pain (p < 0.001) and physical mobility scores (p = 0.002). The effect size at 4 years was large for pain (1.2) and moderate for physical mobility (0.6). The major improvement was recorded at 6 months, with no further substantial change observed. The correlations between the NHP and Charnley scores were weak or moderate (r, -0.15 to -0.67). INTERPRETATION: Hip revision with impaction bone grafting leads to substantially improved quality of life, similar to that 4 years after primary arthroplasty.

Severe carpal tunnel syndrome potentially needing surgical treatment in a general population.

PURPOSE: To estimate the prevalence of severe carpal tunnel syndrome (CTS) that potentially needs surgical treatment in a general population. METHODS: A health-status questionnaire was mailed to a random general population sample of 3,000 subjects (ages, 25-74 y). The responders who reported numbness and/or tingling in the median nerve distribution in the hands were asked to attend a clinical evaluation at which they completed the validated CTS questionnaire and underwent physical examination and nerve conduction tests. The CTS questionnaire measures the severity of symptoms and disability on a scale from 1 (none) to 5 (most severe). The potential need for surgery was defined as CTS symptom severity score of 3.2 or greater or functional status score of 2.5 or greater (corresponding to median preoperative scores for surgical patients in previous reports). RESULTS: The response rate for the survey was 83%. Of the responders who reported numbness and/or tingling in the median nerve distribution in the hands 81% attended the clinical evaluation. Of the 94 subjects diagnosed with clinically certain CTS, 19 (20%; 12 with electrophysiologically proven median neuropathy) had previously undiagnosed CTS that potentially needed surgical treatment, yielding a population prevalence of 7 per 1,000 (95% confidence interval, 4-11 per 1,000). CONCLUSIONS: In a general population there was a 0.7% prevalence of undiagnosed CTS with a severity similar to that of patients undergoing surgery. The degree to which variable numbers of this group are drawn into a medical system could account for variations in the rate of surgery performed.