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1.
Bone Joint J ; 102-B(1): 33-41, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888365

RESUMEN

AIMS: The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures. METHODS: A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. RESULTS: The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). CONCLUSION: Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33-41.


Asunto(s)
Fracturas del Hombro/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Fijación de Fractura/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Tiempo de Tratamiento
2.
Lancet Haematol ; 7(2): e100-e111, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31958417

RESUMEN

BACKGROUND: Previous trials testing prevention strategies for chronic graft versus host disease (GVHD) have measured its cumulative incidence. In this trial of anti-thymocyte globulin, we measured treatment-independence at a long-term timepoint as the primary endpoint. METHODS: This was a randomised, open-label, multicentre, phase 3 trial done at ten centres in Canada and one in Australia. Eligible patients had a haematological malignancy (leukaemia, myelodysplastic syndrome, or lymphoma), were between 16 and 70 years of age, eligible for transplantation with a Karnofsky score of at least 60, and received an unrelated donor (fully matched or one-locus mismatched at HLA-A, HLA-B, HLA-C, or DRB1 loci) graft following myeloablative or non-myeloablative-reduced intensity conditioning. Patients were randomly assigned to receive anti-thymocyte globulin 4·5 mg/kg plus standard GVHD prophylaxis (cyclosporine or tacrolimus plus methotrexate or mycophenolate) or standard GVHD prophylaxis alone. The primary endpoint, freedom from immunosuppressive therapy without resumption at 12 months, was previously reported. Here we report on the prespecified 24-month analysis. Analyses were per-protocol, excluding those patients who did not proceed to transplantation. This trial is registered as ISRCTN 29899028 and NCT01217723, status completed. FINDINGS: Between June 9, 2010, and July 8, 2013, we recruited and randomly assigned 203 eligible patients to receive anti-thymocyte globulin (n=101) or no additional treatment (n=102) along with standard GVHD prophylaxis. 7 (3%) patients did not receive a transplant and were excluded from the analysis. 38 (38%) of 99 evaluable patients in the anti-thymocyte globulin plus GVHD prophylaxis group were free from immunosuppressive therapy at 24 months compared with 18 (19%) of 97 patients in the standard GVHD prophylaxis group (adjusted odds ratio [OR] 3·49 [95% CI 1·60-7·60]; p=0·0016. At 24 months, the cumulative incidence of relapse was 16·3% (95% CI 8·9-23·7) in the anti-thymocyte globulin plus GVHD prophylaxis group compared with 17·5 (9·9-25·1) in the standard GVHD prophylaxis group (p=0·73) and non-relapse mortality was 21·2% (95% CI 13·2-29·2) versus 31·3% (21·9-40·7; p=0·15). The cumulative incidence of chronic GVHD at 24 months was 26·3% (95% CI 17·5-35·1) in the anti-thymocyte globulin group and 41·3% (31·3-51·3) in the standard GVHD prophylaxis group (p=0·032). Overall survival at 24 months was 53·3% (95% CI 42·8-62·7) in the anti-thymocyte globulin plus GVHD prophylaxis group compared with 70.6% (95% CI 60·6-78·6) in the standard GVHD prophylaxis group (adjusted hazard ratio [HR] 0·56, 95% CI [0·35-0·90]; p=0·017. Symptoms of chronic GVHD by the Lee Scale were more prevalent in the standard GVHD prophylaxis group, with scores of 13·27 (SD 10·94) in the anti-thymocyte globulin plus GVHD prophylaxis group and 20·38 (SD 14·68) in the standard GVHD prophylaxis group (p=0·040). Depressive symptoms were more prominent in the standard GVHD prophylaxis group, the mean Center for Epidemiological Studies Depression scale (CES-D) scores were 10·40 (SD 9·88) in the anti-thymocyte globulin group and 14·62 (SD 12·26) in the standard GVHD prophylaxis group (p=0·034). Serious adverse events (CTCAE grade 4 or 5) occurred in 38 (38%) patients in the anti-thymocyte globulin group and in 49 (51%) in the standard GVHD prophylaxis group, the most common being infection and GVHD. One patient died of Epstein-Barr virus hepatitis. INTERPRETATION: The results of this prespecified 24-month analysis suggest that pretreatment with anti-thymocyte globulin provides clinically meaningful benefits when added to standard GVHD prophylaxis in patients undergoing unrelated donor transplantation, including a decrease in use of immunosuppressive therapy, chronic GVHD and its symptoms, depressive symptoms, and improved overall survival. Anti-thymocyte globulin could be included in the preparative regimens of patients with haematological malignancies selected for unrelated donor transplantation. FUNDING: Canadian Institutes of Health Research and Sanofi.


Asunto(s)
Suero Antilinfocítico/uso terapéutico , Trasplante de Médula Ósea/efectos adversos , Enfermedad Injerto contra Huésped/prevención & control , Neoplasias Hematológicas/terapia , Inmunosupresores/uso terapéutico , Trasplante de Células Madre de Sangre Periférica/efectos adversos , Adolescente , Adulto , Anciano , Ciclosporina/administración & dosificación , Ciclosporina/uso terapéutico , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Enfermedad Injerto contra Huésped/etiología , Humanos , Inmunosupresores/administración & dosificación , Estimación de Kaplan-Meier , Masculino , Metotrexato/administración & dosificación , Metotrexato/uso terapéutico , Persona de Mediana Edad , Ácido Micofenólico/administración & dosificación , Ácido Micofenólico/uso terapéutico , Medición de Resultados Informados por el Paciente , Linfocitos T/inmunología , Tacrolimus/administración & dosificación , Tacrolimus/uso terapéutico , Trasplante Homólogo/efectos adversos , Resultado del Tratamiento , Donante no Emparentado , Adulto Joven
3.
JAMA ; 323(2): 149-163, 2020 01 14.
Artículo en Inglés | MEDLINE | ID: mdl-31935027

RESUMEN

Importance: Understanding adverse effects of contemporary treatment approaches for men with favorable-risk and unfavorable-risk localized prostate cancer could inform treatment selection. Objective: To compare functional outcomes associated with prostate cancer treatments over 5 years after treatment. Design, Setting, and Participants: Prospective, population-based cohort study of 1386 men with favorable-risk (clinical stage cT1 to cT2bN0M0, prostate-specific antigen [PSA] ≤20 ng/mL, and Grade Group 1-2) prostate cancer and 619 men with unfavorable-risk (clinical stage cT2cN0M0, PSA of 20-50 ng/mL, or Grade Group 3-5) prostate cancer diagnosed in 2011 through 2012, accrued from 5 Surveillance, Epidemiology and End Results Program sites and a US prostate cancer registry, with surveys through September 2017. Exposures: Treatment with active surveillance (n = 363), nerve-sparing prostatectomy (n = 675), external beam radiation therapy (EBRT; n = 261), or low-dose-rate brachytherapy (n = 87) for men with favorable-risk disease and treatment with prostatectomy (n = 402) or EBRT with androgen deprivation therapy (n = 217) for men with unfavorable-risk disease. Main Outcomes and Measures: Patient-reported function, based on the 26-item Expanded Prostate Index Composite (range, 0-100), 5 years after treatment. Regression models were adjusted for baseline function and patient and tumor characteristics. Minimum clinically important difference was 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritative symptoms, and 4 to 6 for bowel and hormonal function. Results: A total of 2005 men met inclusion criteria and completed the baseline and at least 1 postbaseline survey (median [interquartile range] age, 64 [59-70] years; 1529 of 1993 participants [77%] were non-Hispanic white). For men with favorable-risk prostate cancer, nerve-sparing prostatectomy was associated with worse urinary incontinence at 5 years (adjusted mean difference, -10.9 [95% CI, -14.2 to -7.6]) and sexual function at 3 years (adjusted mean difference, -15.2 [95% CI, -18.8 to -11.5]) compared with active surveillance. Low-dose-rate brachytherapy was associated with worse urinary irritative (adjusted mean difference, -7.0 [95% CI, -10.1 to -3.9]), sexual (adjusted mean difference, -10.1 [95% CI, -14.6 to -5.7]), and bowel (adjusted mean difference, -5.0 [95% CI, -7.6 to -2.4]) function at 1 year compared with active surveillance. EBRT was associated with urinary, sexual, and bowel function changes not clinically different from active surveillance at any time point through 5 years. For men with unfavorable-risk disease, EBRT with ADT was associated with lower hormonal function at 6 months (adjusted mean difference, -5.3 [95% CI, -8.2 to -2.4]) and bowel function at 1 year (adjusted mean difference, -4.1 [95% CI, -6.3 to -1.9]), but better sexual function at 5 years (adjusted mean difference, 12.5 [95% CI, 6.2-18.7]) and incontinence at each time point through 5 years (adjusted mean difference, 23.2 [95% CI, 17.7-28.7]), than prostatectomy. Conclusions and Relevance: In this cohort of men with localized prostate cancer, most functional differences associated with contemporary management options attenuated by 5 years. However, men undergoing prostatectomy reported clinically meaningful worse incontinence through 5 years compared with all other options, and men undergoing prostatectomy for unfavorable-risk disease reported worse sexual function at 5 years compared with men who underwent EBRT with ADT.


Asunto(s)
Antagonistas de Andrógenos/efectos adversos , Braquiterapia/efectos adversos , Medición de Resultados Informados por el Paciente , Prostatectomía/efectos adversos , Neoplasias de la Próstata/terapia , Radioterapia/efectos adversos , Anciano , Antagonistas de Andrógenos/uso terapéutico , Terapia Combinada , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Radioterapia/métodos , Disfunciones Sexuales Fisiológicas/etiología , Resultado del Tratamiento , Incontinencia Urinaria/etiología , Espera Vigilante
4.
N Engl J Med ; 382(1): 51-59, 2020 01 02.
Artículo en Inglés | MEDLINE | ID: mdl-31893515

RESUMEN

BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).


Asunto(s)
Instituciones Asociadas de Salud , Hospitales , Calidad de la Atención de Salud , Anciano , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Medicare , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Medición de Resultados Informados por el Paciente , Indicadores de Calidad de la Atención de Salud , Estados Unidos
5.
Bone Joint J ; 102-B(1): 82-89, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888355

RESUMEN

AIMS: The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). METHODS: In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. RESULTS: Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. CONCLUSION: These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82-89.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Actividades Cotidianas , Anciano , Estudios de Casos y Controles , Femenino , Fracturas de Cadera/cirugía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Fracturas Periprotésicas/cirugía , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios
6.
Bone Joint J ; 102-B(1): 108-116, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888356

RESUMEN

AIMS: Limited evidence is available on mid-term outcomes of robotic-arm assisted (RA) partial knee arthroplasty (PKA). Therefore, the purpose of this study was to evaluate mid-term survivorship, modes of failure, and patient-reported outcomes of RA PKA. METHODS: A retrospective review of patients who underwent RA PKA between June 2007 and August 2016 was performed. Patients received a fixed-bearing medial or lateral unicompartmental knee arthroplasty (UKA), patellofemoral arthroplasty (PFA), or bicompartmental knee arthroplasty (BiKA; PFA plus medial UKA). All patients completed a questionnaire regarding revision surgery, reoperations, and level of satisfaction. Knee Injury and Osteoarthritis Outcome Scores (KOOS) were assessed using the KOOS for Joint Replacement Junior survey. RESULTS: Mean follow-up was 4.7 years (2.0 to 10.8). Five-year survivorship of medial UKA (n = 802), lateral UKA (n = 171), and PFA/BiKA (n = 35/10) was 97.8%, 97.7%, and 93.3%, respectively. Component loosening and progression of osteoarthritis (OA) were the most common reasons for revision. Mean KOOS scores after medial UKA, lateral UKA, and PFA/BiKA were 84.3 (SD 15.9), 85.6 (SD 14.3), and 78.2 (SD 14.2), respectively. The vast majority of the patients reported high satisfaction levels after RA PKA. Subgroup analyses suggested tibial component design, body mass index (BMI), and age affects RA PKA outcomes. Five-year survivorship was 98.4% (95% confidence interval (CI) 97.2 to 99.5) for onlay medial UKA (n = 742) and 99.1% (95% CI 97.9 to 100) for onlay medial UKA in patients with a BMI < 30 kg/m2 (n = 479). CONCLUSION: This large single-surgeon study showed high mid-term survivorship, satisfaction levels, and functional outcomes in RA UKA using metal-backed tibial onlay components. In addition, favourable results were reported in RA PFA and BiKA. Cite this article: Bone Joint J 2020;102-B(1):108-116.


Asunto(s)
Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Prótesis de la Rodilla/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Rodilla/métodos , Índice de Masa Corporal , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/cirugía , Medición de Resultados Informados por el Paciente , Falla de Prótesis , Reoperación/estadística & datos numéricos , Estudios Retrospectivos
7.
Bone Joint J ; 102-B(1): 42-47, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888361

RESUMEN

AIMS: Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture. METHODS: A total of 744 adults with an isolated fracture of the proximal humerus, elbow, or distal radius completed PROMs. Due to multicollinearity of patient engagement and psychosocial variables, we generated a single variable combining measures of engagement and psychosocial factors using factor analysis. We then performed multivariable analysis with p < 0.10 on bivariate analysis. RESULTS: Patient engagement and psychosocial factors combined to form a single factor (factor 1) accounting for 20% (QuickDASH, semi-partial R2 = 0.20) and 14% (PROMIS UE PF, semi-partial R2 = 0.14) of the variation in limitations six to nine months after fracture. Factor 1 also accounted for 17% (NRS-C, semi-partial R2 = 0.17) of variation in satisfaction with care, and 21% (NRS-S, semi-partial R2 = 0.21) of variation in satisfaction with services. Demographic factors (age, sex, work status) and measures of greater pathophysiology (type of fracture, high-energy injury, post-surgical complications), accounted for much less variation. CONCLUSION: Patients who actively manage their health and demonstrate effective emotional and social functioning share a common underlying trait. They have fewer limitations and greater satisfaction with care during recovery from upper limb fractures. Future efforts should focus on evaluating initiatives that optimize patient engagement, such as patient education, coaching, and a communication strategy for healthcare professionals. Cite this article: Bone Joint J 2020;102-B(1):42-47.


Asunto(s)
Articulación del Codo/lesiones , Conductas Relacionadas con la Salud , Fracturas del Húmero/cirugía , Fracturas Intraarticulares/cirugía , Participación del Paciente , Fracturas del Radio/cirugía , Actividades Cotidianas , Adaptación Psicológica , Adulto , Anciano , Anciano de 80 o más Años , Articulación del Codo/cirugía , Femenino , Fracturas Óseas , Promoción de la Salud , Humanos , Fracturas del Húmero/psicología , Fracturas Intraarticulares/psicología , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Estudios Prospectivos , Fracturas del Radio/psicología , Autoeficacia , Factores Socioeconómicos , Encuestas y Cuestionarios , Adulto Joven
8.
Bone Joint J ; 102-B(1): 125-131, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888366

RESUMEN

AIMS: The primary aim of this study was to assess whether pain in the contralateral knee had a clinically significant influence on the outcome of total knee arthroplasty (TKA) according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary aims were to: describe the prevalence of contralateral knee pain; identify if it clinically improves after TKA; and assess whether contralateral knee pain independently influences patient satisfaction with their TKA. METHODS: A retrospective cohort of 3,178 primary TKA patients were identified from an arthroplasty database. Patient characteristics, comorbidities, and WOMAC scores were collected preoperatively and one year postoperatively for the index knee. In addition, WOMAC pain scores were also collected for the contralateral knee. Overall patient satisfaction was assessed at one year. Preoperative contralateral knee pain was defined according to the WOMAC score: minimal (> 78 points), mild (59 to 78), moderate (44 to 58), and severe (< 44). Multivariate regression analysis was used to adjust for confounding. RESULTS: According to severity there were 1,425 patients (44.8%) with minimal, 710 (22.3%) with mild, 518 (16.3%) with moderate, and 525 (16.5%) with severe pain in the contralateral knee. Patients in the severe group had a greater clinically significant improvement in their functional WOMAC score (9.8 points; p < 0.001). Only patients in the moderate (22.9 points) and severe (37.8 points) groups had a clinically significant improvement in their contralateral knee pain (p < 0.001), but they were significantly less likely to be satisfied with their TKA (moderate: odds ratio (OR) 0.64, 95% confidence interval (CI) 0.4 to 0.92, p = 0.022; severe: OR 0.57, 95% CI 0.39 to 0.82, p = 0.002). CONCLUSION: Contralateral knee pain did not impair improvement in the WOMAC score after TKA, and patients with the most severe contralateral knee pain had a clinically significantly greater improvement in their functional outcome. More than half the patients presenting for TKA had mild-to-severe contralateral knee pain, most of whom had a clinically meaningful improvement but were significantly less likely to be satisfied with their TKA. Cite this article: Bone Joint J. 2020;102-B(1):125-131.


Asunto(s)
Artralgia/psicología , Artroplastia de Reemplazo de Rodilla/psicología , Satisfacción del Paciente , Anciano , Femenino , Humanos , Masculino , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
9.
Bone Joint J ; 102-B(1): 17-25, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888370

RESUMEN

AIMS: The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture. METHODS: An initial pool of 109 items was generated from previous qualitative data relating to recovery following an open tibial fracture. These items were field tested in a cohort of patients recovering from an open tibial fracture. They were asked to comment on the content of the items and structure of the scale. Reduction in the number of items led to a refined scale tested in a larger cohort of patients. Principal components analysis permitted further reduction and the development of a definitive scale. Internal consistency, test-retest reliability, and responsiveness were assessed for the retained items. RESULTS: The initial scale was completed by 35 patients who were recovering from an open tibial fracture. Subjective and objective analysis permitted removal of poorly performing items and the addition of items suggested by patients. The refined scale consisted of 50 Likert scaled items and eight additional items. It was completed on 228 occasions by a different cohort of 204 patients with an open tibial fracture recruited from several UK orthoplastic tertiary referral centres. There were eight underlying components with tangible real-life meaning, which were retained as sub-scales represented by ten Likert scaled and eight non-Likert items. Internal consistency and test-retest reliability were good to excellent. CONCLUSION: The Wales Lower Limb Trauma Recovery (WaLLTR) Scale is the first tool to be developed from patient data with the potential to assess recovery following an open tibial fracture. Cite this article: Bone Joint J 2020;102-B(1):17-25.


Asunto(s)
Fracturas Abiertas/cirugía , Fracturas de la Tibia/cirugía , Actividades Cotidianas , Adaptación Psicológica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Miedo/psicología , Fracturas Abiertas/psicología , Fracturas Abiertas/rehabilitación , Humanos , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , Recuperación de la Función , Autoeficacia , Índice de Severidad de la Enfermedad , Fracturas de la Tibia/psicología , Fracturas de la Tibia/rehabilitación , Adulto Joven
10.
Bone Joint J ; 102-B(1): 48-54, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888371

RESUMEN

AIMS: Distal radial fractures are the most common fracture sustained by the adult population. Most can be treated using cast immobilization without the need for surgery. The aim of this study was to assess the feasibility of a definitive trial comparing the commonly used fibreglass cast immobilization with an alternative product called Woodcast. Woodcast is a biodegradable casting material with theoretical benefits in terms of patient comfort as well as benefits to the environment. METHODS: This was a multicentre, two-arm, open-label, parallel-group randomized controlled feasibility trial. Patients with a fracture of the distal radius aged 16 years and over were recruited from four centres in the UK and randomized (1:1) to receive a Woodcast or fibreglass cast. Data were collected on participant recruitment and retention, clinical efficacy, safety, and patient acceptability. RESULTS: Over an eight-month period, 883 patients were screened, 271 were found to be eligible, and 120 were randomized. Patient-reported outcome measures were available for 116 (97%) of participants at five weeks and 99 (83%) at three months. Clinical outcomes and patient acceptability were similar between the two interventions and no serious adverse events were reported in either intervention arm. CONCLUSION: Both interventions were deemed efficacious and safe in the cohort studied. This study showed that a definitive study comparing Woodcast and fibreglass was feasible in terms of patient recruitment and retention. Cite this article: Bone Joint J 2020;102-B(1):48-54.


Asunto(s)
Moldes Quirúrgicos , Inmovilización/instrumentación , Fracturas del Radio/terapia , Adolescente , Adulto , Anciano , Estudios de Factibilidad , Femenino , Humanos , Inmovilización/métodos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Seguridad del Paciente , Resultado del Tratamiento , Madera , Adulto Joven
11.
Bone Joint J ; 102-B(1): 55-63, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888375

RESUMEN

AIMS: The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis. METHODS: In this cohort study, all patients with a unilateral TFA treated with the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) implant system in Sahlgrenska University Hospital, Gothenburg, Sweden, between January 1999 and December 2017 were included. The cohort comprised 111 patients (78 male (70%)), with a mean age 45 years (17 to 70). The main reason for amputation was trauma in 75 (68%) and tumours in 23 (21%). Patients answered the Questionnaire for Persons with Transfemoral Amputation (Q-TFA) before treatment and at two, five, seven, ten, and 15 years' follow-up. A prosthetic activity grade was assigned to each patient at each timepoint. All mechanical complications, defined as fracture, bending, or wear to any part of the implant system resulting in removal or change, were recorded. RESULTS: The Q-TFA scores at two, five, seven, and ten years showed significantly more prosthetic use, better mobility, fewer problems, and an improved global situation, compared with baseline. The survival rate of the osseointegrated implant part (the fixture) was 89% and 72% after seven and 15 years, respectively. A total of 61 patients (55%) had mechanical complications (mean 3.3 (SD 5.76)), resulting in exchange of the percutaneous implant parts. There was a positive relationship between a higher activity grade and the number of mechanical complications. CONCLUSION: Compared with before treatment, the patient-reported outcome was significantly better and remained so over time. Although osseointegration and the ability to transfer loads over a 15-year period have been demonstrated, a large number of mechanical failures in the external implant parts were found. Since these were related to higher activity, restrictions in activity and improvements to the mechanical properties of the implant system are required. Cite this article: Bone Joint J 2020;102-B(1):55-63.


Asunto(s)
Amputación/métodos , Prótesis Anclada al Hueso , Fémur/cirugía , Adolescente , Adulto , Anciano , Amputación/instrumentación , Amputados/psicología , Miembros Artificiales , Femenino , Neoplasias Femorales/cirugía , Fémur/lesiones , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Oseointegración/fisiología , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , Falla de Prótesis , Adulto Joven
13.
World Neurosurg ; 133: e745-e750, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31605853

RESUMEN

BACKGROUND: Minimally invasive fusion of the sacroiliac (SI) joint has gained popularity for the treatment of refractory dysfunction. The purpose of this study was to compare the clinical outcomes of minimally invasive SI joint fusion between cylindrical threaded implants (CTIs) and triangular dowel implants (TDIs). METHODS: We retrospectively reviewed consecutive patients who underwent SI joint fusions with either CTIs or TDIs. Data collected included patient demographics, perioperative data, and all patient-reported outcomes (PROs) including postoperative visual analog scale (VAS), Oswestry Disability Index, and Short Form-12 at 6 months and 1 year. The change from baseline PROs between the cohorts was analyzed as the primary outcome. Secondary outcomes included revision rates and time to revision between the two cohorts. A P value <0.05 was considered significant. RESULTS: One hundred fifty-six consecutive patients underwent SI joint fusion, 74 patients with CTIs and 82 with TDIs. There was a significant difference in procedure length with CTI averaging 60.0 minutes (confidence interval: 55.7-64.3) and TDI averaging 41.2 minutes (confidence interval: 38.4-43.9, P < 0.0005). In both cohorts, there was a significant improvement in all PROs at 6 months when compared with preoperative values. However, when compared, there was no significant difference between the cohorts at 6-month follow-up or 1-year follow-up for either VAS-back, VAS-leg, Oswestry Disability Index, or Short Form-12. A 6.1% revision rate in the CTI cohort was observed compared with a 2.4% revision rate in the TDI cohort (P = 0.11). CONCLUSIONS: SI joint fusions with TDI or CTI offer a significant improvement in pain, disability, and quality of life. However, no difference was observed between devices to suggest superior clinical outcomes. Increased revision rates in the Rialto group warrants further investigation.


Asunto(s)
Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Articulación Sacroiliaca/cirugía , Fusión Vertebral/instrumentación , Fusión Vertebral/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Prótesis e Implantes , Estudios Retrospectivos , Titanio , Resultado del Tratamiento
14.
J Oral Rehabil ; 47(2): 229-234, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31452211

RESUMEN

OBJECTIVES: To compare the patient-reported effect of treatment with implant-supported fixed prosthesis (ISFP) and fixed dental prosthesis (FDP) in patients with a small number of tooth losses to replace. METHODS: From a population of 155 patients receiving either ISFP or FDP, 68 patients were matched in pairs based on gender, number of teeth replaced, zone of replacement, age and number of remaining teeth. The patient-reported effect was prospectively obtained by measuring change in the short-form oral health impact (OHIP-14) from before to one month after treatment. Effect size (ES), standardised response mean (SRM) and a minimal important difference of two units were applied to estimate the magnitude of the change. RESULTS: Both the ISFP and FDP groups decreased significantly in OHIP-14 after treatment (P < .01). The change was not significantly different between the ISFP and FDP groups. The magnitude of the change was for both treatments moderate and slightly higher in the ISFP group (ES = 0.52 and SRM = 0.58) than in the FDP group (ES = 0.48 and SRM = 0.47). Applying the minimal important difference showed that 23 participants in the ISFP group and 21 in the FDP group had good effect. CONCLUSIONS: The patient-reported effect of treatment with ISFP or FDP was similar, clinically meaningful and of moderate magnitude in patients with a small number tooth losses to replace.


Asunto(s)
Implantes Dentales , Pérdida de Diente , Prótesis Dental de Soporte Implantado , Fracaso de la Restauración Dental , Dentadura Parcial Fija , Humanos , Salud Bucal , Medición de Resultados Informados por el Paciente
15.
Urology ; 135: 111-116, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31454660

RESUMEN

OBJECTIVE: To explore relationships between dose to periprostatic anatomic structures and erectile dysfunction (ED) outcomes in an institutional cohort treated with prostate brachytherapy. METHODS: The Sexual Health Inventory for Men (SHIM) instrument was administered for stage cT1-T2 prostate cancer patients treated with Pd-103 brachytherapy over a 10-year interval. Dose volume histograms for regional organs at risk and periprostatic regions were calculated with and without expansions to account for contouring uncertainty. Regression tree analysis clustered patients into ED risk groups. RESULTS: We identified 115 men treated with definitive prostate brachytherapy who had 2 years of complete follow-up. On univariate analysis, the subapical region (SAR) caudal to prostate was the only defined region with dose volume histograms parameters significant for potency outcomes. Regression tree analysis separated patients into low ED risk (mean 2-year SHIM 20.03), medium ED risk (15.02), and high ED risk (5.54) groups. Among patients with good baseline function (SHIM ≥ 17), a dose ≥72.75 Gy to 20% of the SAR with 1 cm expansion was most predictive for 2-year potency outcome. On multivariate analysis, regression tree risk group remained significant for predicting potency outcomes even after adjustment for baseline SHIM and age. CONCLUSION: Dose to the SAR immediately caudal to prostate was predictive for potency outcomes in patients with good baseline function. Minimization of dose to this region may improve potency outcomes following prostate brachytherapy.


Asunto(s)
Braquiterapia/efectos adversos , Disfunción Eréctil/diagnóstico , Erección Peniana/efectos de la radiación , Neoplasias de la Próstata/radioterapia , Traumatismos por Radiación/diagnóstico , Anciano , Braquiterapia/métodos , Relación Dosis-Respuesta en la Radiación , Disfunción Eréctil/etiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Órganos en Riesgo/efectos de la radiación , Paladio/administración & dosificación , Paladio/efectos adversos , Medición de Resultados Informados por el Paciente , Pronóstico , Estudios Prospectivos , Próstata/patología , Próstata/efectos de la radiación , Neoplasias de la Próstata/patología , Traumatismos por Radiación/etiología , Radioisótopos/administración & dosificación , Radioisótopos/efectos adversos , Análisis Espacio-Temporal , Factores de Tiempo
16.
J Urol ; 203(1): 159-163, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31441673

RESUMEN

PURPOSE: Patients who undergo cystectomy due to bladder cancer can elect an ileal conduit or a neobladder for urinary diversion. Decision regret related to this choice is an important and undesirable patient reported outcome. Our objective was to compare the severity of decision regret experienced by patients with a neobladder vs an ileal conduit. MATERIALS AND METHODS: We analyzed data from a longitudinal cohort study of patients who underwent cystectomy from 2013 to 2015. We applied multivariable linear regression to examine associations of the urinary diversion method (neobladder vs ileal conduit) with decision regret measured with the DRS (Decision Regret Scale) 6 and 18 months after cystectomy. Covariates included demographic and clinical characteristics, health care utilization and complications after cystectomy, quality of life and factors related to the decision making process, including informed and shared decision making, and goal concordance. RESULTS: Of the 192 patients in our cohort 141 received an ileal conduit and 51 received a neobladder. We observed no significant difference in the DRS score in patients with a neobladder vs an ileal conduit at 6 or 18 months (b=-1.28, 95% CI -9.07-6.53, vs b=-1.55, 95% CI -12.48-9.38). However, informed decision making was negatively related to decision regret at 6 and 18 months (b=-13.08, 95% CI -17.05--9.11, and b=-8.54, 95% CI -4.26--2.63, respectively). Quality of life was negatively associated with decision regret at 18 months (b=-5.50, 95% CI -8.95--2.03). CONCLUSIONS: Patients treated with cystectomy who were more informed about bladder reconstruction options experienced less regret independent of the method selected. Efforts to inform and prepare patients for the bladder reconstruction decision may help prevent decision regret.


Asunto(s)
Cistectomía , Toma de Decisiones , Neoplasias de la Vejiga Urinaria/cirugía , Derivación Urinaria/métodos , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Calidad de Vida , Neoplasias de la Vejiga Urinaria/patología
18.
Orthop Clin North Am ; 51(1): 109-120, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31739874

RESUMEN

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.


Asunto(s)
Pie Plano/cirugía , Pie/cirugía , Procedimientos Quirúrgicos Reconstructivos/métodos , Transferencia Tendinosa/métodos , Adulto , Artrodesis/métodos , Calcáneo/cirugía , Terapia Combinada/métodos , Toma de Decisiones/ética , Femenino , Pie Plano/diagnóstico por imagen , Pie Plano/patología , Pie/diagnóstico por imagen , Pie/patología , Humanos , Ligamentos Articulares/cirugía , Masculino , Osteotomía/métodos , Medición de Resultados Informados por el Paciente , Radiografía , Estudios Retrospectivos , Resultado del Tratamiento
19.
Orthop Clin North Am ; 51(1): 121-130, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31739875

RESUMEN

Peroneal tendon pathology is becoming an increasingly recognized source of lateral-sided ankle pain. High clinical suspicion, along with judicious physical examination coupled with confirmatory advanced imaging modalities, are necessary to make an accurate diagnosis and aid in guiding treatment. Peroneal pathology encompasses several distinct conditions. Peroneal tendon tears and injuries to the peroneal retinaculum must be identified to guide treatment. Patients with peroneal pathology report high levels of satisfaction after surgical management with most returning to their preinjury level of function. An early and accurate diagnosis, along with treatment tailored to the individual, is necessary to obtain optimal outcomes.


Asunto(s)
Traumatismos del Tobillo/cirugía , Traumatismos de los Tendones/cirugía , Transferencia Tendinosa/métodos , Tendones/cirugía , Tobillo/anatomía & histología , Tobillo/diagnóstico por imagen , Tobillo/patología , Traumatismos del Tobillo/diagnóstico por imagen , Traumatismos del Tobillo/patología , Fenómenos Biomecánicos , Cadáver , Humanos , Incidencia , Inestabilidad de la Articulación/epidemiología , Inestabilidad de la Articulación/etiología , Inestabilidad de la Articulación/cirugía , Imagen por Resonancia Magnética , Medición de Resultados Informados por el Paciente , Radiografía , Recuperación de la Función , Estudios Retrospectivos , Rotura , Traumatismos de los Tendones/diagnóstico por imagen , Traumatismos de los Tendones/patología , Tendones/anatomía & histología , Tendones/patología
20.
Br J Sports Med ; 54(1): 13-22, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31186258

RESUMEN

BACKGROUND: Despite absence of evidence of a clinical benefit of arthroscopic partial meniscectomy (APM), many surgeons claim that subgroups of patients benefit from APM. OBJECTIVE: We developed a prognostic model predicting change in patient-reported outcome 1 year following arthroscopic meniscal surgery to identify such subgroups. METHODS: We included 641 patients (age 48.7 years (SD 13), 56% men) undergoing arthroscopic meniscal surgery from the Knee Arthroscopy Cohort Southern Denmark. 18 preoperative factors identified from literature and/or orthopaedic surgeons (patient demographics, medical history, symptom onset and duration, knee-related symptoms, etc) were combined in a multivariable linear regression model. The outcome was change in Knee injury and Osteoarthritis Outcome Score (KOOS4) (average score of 4 of 5 KOOS subscales excluding the activities of daily living subscale) from presurgery to 52 weeks after surgery. A positive KOOS4 change score constitutes improvement. Prognostic performance was assessed using R2 statistics and calibration plots and was internally validated by adjusting for optimism using 1000 bootstrap samples. RESULTS: Patients improved on average 18.6 (SD 19.7, range -38.0 to 87.8) in KOOS4. The strongest prognostic factors for improvement were (1) no previous meniscal surgery on index knee and (2) more severe preoperative knee-related symptoms. The model's overall predictive performance was low (apparent R2=0.162, optimism adjusted R2=0.080) and it showed poor calibration (calibration-in-the-large=0.205, calibration slope=0.772). CONCLUSION: Despite combining a large number of preoperative factors presumed clinically relevant, change in patient-reported outcome 1 year following meniscal surgery was not predictable. This essentially quashes the existence of 'subgroups' with certain characteristics having a particularly favourable outcome after meniscal surgery. TRIAL REGISTRATION NUMBER: NCT01871272.


Asunto(s)
Meniscectomía , Medición de Resultados Informados por el Paciente , Lesiones de Menisco Tibial/cirugía , Adolescente , Adulto , Anciano , Dinamarca , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Meniscectomía/efectos adversos , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Adulto Joven
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