End Stage Hip Osteoarthritis in Klippel-Trenaunay Syndrome - A Case Report.

Introduction: Klippel-Trenaunay syndrome (KTS) affects the development of blood vessels, soft tissues (such as skin and muscles), and bone. It is a rare cause of severe degenerative joint disease at an early age. Orthopedic interventions in these patients bring numerous difficulties for various reasons. Up to this point, only six cases of attempted total hip arthroplasty (THA) in patients with KTS have been reported in the literature. The two most recent cases were prematurely aborted due to excessive bleeding and imminent risk of exsanguination. One of the most recent published case reports suggested that hip joint replacement should be avoided in this patient population. Case Report: A middle-aged female presented with end stage coxarthrosis secondary to KTS. A thorough workup was performed and magnetic resonance imaging revealed that the direct anterior interval was relatively free of vascular malformations. After intensive work-up, uneventful THA was performed, resulting in dramatic improvement of quality of life. Conclusion: Effort should be put into identifying those patients with a relatively easy accessible joint so they are not unnecessarily being denied successful joint replacement.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons.

OBJECTIVE: To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care. METHODS: Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA. RESULTS: 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036). CONCLUSION: Our multifaceted intervention did not improve SDM and ptDA uptake was low. PRACTICE IMPLICATIONS: In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Experienced barriers in shared decision-making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons.

INTRODUCTION: In shared decision-making (SDM), physicians encourage the patient to participate in the care process. The theory of planned behaviour describes that behaviour is dependent on intention. In its turn, intention is explained by attitude, subjective norm and perceived behavioural control. In orthopaedics, little is known about current SDM behaviour and how to promote it.The aim of the present study was to gain insight into the SDM behaviour of orthopaedic residents and supervisors by measuring levels of intention, attitudes, subjective norms and perceived behavioural control. Furthermore, we aimed to determine the predictors of intention for SDM. METHODS: A questionnaire survey study was conducted among orthopaedic surgeons and residents working in the care of hip and knee osteoarthritis, to determine their intentions, attitudes, subjective norms and perceived behavioural control regarding SDM. RESULTS: Of the 385 physicians approached, 71 residents and 64 orthopaedic surgeons participated. Residents and the supervisors alike had positive intentions regarding SDM. Intention for SDM behaviour was explained by attitude, subjective norm and perceived behavioural control, with perceived behavioural control having the strongest association. In residents, the intention to engage in SDM was more hampered by a lower level of perceived behavioural control than in surgeons. CONCLUSIONS: Physicians are willing to perform SDM and consider SDM as favourable in the orthopaedic clinic. The implementation of SDM is mainly hampered by experienced barriers that they cannot control. These findings underline the importance of incorporating SDM in the curriculum of postgraduates. Possibilities for efficient SDM implementation should be explored, to overcome perceived barriers.

Internet self-diagnosis in hand surgery.

BACKGROUND: Some Internet sites have programs that attempt to help patients find their diagnosis based on symptoms. This study tested the null hypothesis that there are no factors associated with correspondence between online diagnosis and the hand surgeon's diagnosis in an outpatient hand and upper extremity surgeons' office. METHODS: Eighty-six outpatients were prospectively enrolled and used WebMD® symptom checker to guess their diagnosis. We collected demographic information, hours spent on the Internet per week, and the following questionnaires: Pain Catastrophizing Scale (PCS) and Center of Epidemiologic Studies Depression scale (C-ESD). RESULTS: Thirty-three percent of online diagnoses matched the final diagnosis of the hand surgeon. Factors associated with an online diagnosis corresponding to the hand surgeon's diagnosis included sex (women) and patients who studied their symptoms online prior to the visit. The best multivariable model included sex, more years of education, and prior use of the Internet to research their medical condition and explained 15 % of the variation in correspondence of diagnosis. CONCLUSIONS: The majority of online diagnoses for hand and upper extremity conditions do not correspond with the diagnosis of the treating hand surgeon. Psychological factors do not influence the correspondence of online diagnosis with the hand surgeon's diagnosis. LEVEL OF EVIDENCE: Prognostic, level II.

Excisional biopsy of suspected benign soft tissue tumors of the upper extremity: correlation between preoperative diagnosis and actual pathology.

BACKGROUND: Tumors of the upper extremity are common and mostly benign. However, the prevalence of discordant diagnosis of a solid hand tumor is less studied. The objectives of this retrospective study were (1) to determine the proportion of patients with a different (discrepant or discordant) pathological diagnosis compared to the preoperative diagnosis, (2) to determine the prevalence of the types of pathologies encountered at excisional biopsy for suspected benign tumors, and (3) to determine the types of tumors diagnosed when the surgeon does not make a preoperative diagnosis. METHODS: One hundred and eighty-two suspected benign soft tissue tumors of the upper extremity with a preoperative diagnosis other than ganglion cyst were excised by one of three surgeons over a 10-year period. A preoperative diagnosis was applied for 125 tumors. No preoperative imaging was used. RESULTS: Only 26 of the 125 tumors (21 %) with a preoperative diagnosis were discrepant. The tumors that were most likely to have a discrepant diagnosis were vascular tumors (32 %) and other less common benign tumors (33 %). Among the entire cohort of 182 tumors, lipomas (19 %), giant cell tumors of tendon sheath (GCTTS; 19 %), and vascular tumors (16 %) were the most frequent pathological diagnoses. Among the 57 tumors that did not have a preoperative diagnosis, most were vascular tumors (23 %), fibromas (14 %), and GCTTS (11 %). One tumor without a preoperative diagnosis was a malignant tumor, but we consider this unusual and possibly spurious. CONCLUSIONS: A hand surgeon's preoperative diagnosis without imaging is usually correct prior to excision of a mass in the hand. Discrepant diagnoses are usually benign and do not alter treatment. LEVEL OF EVIDENCE: Prognostic II.

Relationships between pain misconceptions, disability, patients' goals and interpretation of information from hand therapists.

INTRODUCTION: Patient interpretation of advice from hand therapists may be related to nonadaptive pain thoughts (automatic, overprotective, unduly pessimistic statements triggered by nociception and exacerbated by psychological distress). PURPOSE OF THE STUDY: This study aimed to determine whether there were correlations between participants' hand therapy goals, interpretation of advice from hand therapists, nonadaptive pain thoughts, and upper extremity-specific disability. METHODS: One hundred and five participants completed questionnaires assessing nonadaptive pain thoughts, upper extremity-specific disability, lessons from hand therapists, and hand therapy goals. RESULTS: Nonadaptive pain thoughts correlated with disability and were bi-directionally related to participant goals and interpretation of advice from hand therapists. DISCUSSION: Patients' nonadapative pain thoughts and the words/concepts used by hand therapists are both important in recovery from upper extremity illness. CONCLUSIONS: Hand therapists should be mindful that nonadaptive pain thoughts are an important determinant of disability and that such thoughts can affect and be affected by their recommendations. LEVEL OF EVIDENCE: n/a.

Informed shared decision-making and patient satisfaction.

BACKGROUND: Evidence suggests that when patients have a role in medical decisions they are more satisfied with their health care. OBJECTIVE: To assess predictors of patient satisfaction, ratings of the provider's informed shared decision-making (ISDM), and disability among patients with orthopedic pain complaints. RESEARCH DESIGN: A total of 130 patients with nontraumatic painful conditions of the upper extremity were enrolled. Medical encounters were audio recorded and coded by 2 independent coders. Eight ISDM elements and a total ISDM score were evaluated. Bivariate and multivariable analyses were used to answer the study questions. MEASURES: Participants completed the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire to measure satisfaction; the Disabilities of Arm, Shoulder and Hand questionnaire; the Patient Health Questionnaire-9 to measure depression; the Whiteley Index to assess heightened illness concerns; and the pain catastrophizing scale to assess coping strategies in response to pain. RESULTS: Less health anxiety, female gender, the ISDM element Identify choice, and any specific diagnosis determined 22% of the variation in satisfaction. Less health anxiety and unemployed unable to work compared with full-time working status were associated with a better rating of shared decision-making on the ISDM. Catastrophic thinking, female gender, symptoms of depression, and any specific diagnosis were associated with greater disability. Catastrophic thinking and symptoms of depression were the greatest contributors to the variation in disability. CONCLUSIONS: Psychologic factors are the strongest determinants of patient satisfaction, ratings of shared decision-making on the ISDM, and upper-extremity disability. Health anxiety is the most important factor in ratings of patient satisfaction and ISDM, whereas depression and catastrophizing are salient predictors of disability. LEVEL OF EVIDENCE: Prognostic level I.

Predictors of readmission in orthopaedic trauma surgery.

OBJECTIVES: This study of patients who had operative treatment of skeletal trauma addresses (1) the association between readmission within 30 days of discharge and comorbidities and (2) differences in factors associated with all-cause readmissions and those because of a surgical adverse event. DESIGN: Retrospective study. SETTING: Tertiary care referral center. PATIENTS: Three thousand four hundred fifty-two operations for skeletal trauma between 2008 and 2012 with comorbidities quantified using the updated Charlson comorbidity index (CCI). OUTCOME MEASUREMENT: Readmission to the hospital within 30 days of surgery and the subset of readmissions because of adverse events related directly to surgery. RESULTS: There was a significant association between readmission within 30 days of surgery and higher CCI (P < 0.001), older age (P < 0.001), and marital status (widowed) (P < 0.001). The factors associated with readmission related to an adverse event were identical. The best multivariable logistic regression models for all-cause 30-day readmission and 30-day readmission related to a surgical adverse event included CCI and older age in both models (odds ratio 1.1, P < 0.01, pseudo R = 0.03). CONCLUSIONS: Older patients and patients with greater comorbidity are more likely to be readmitted within 30 days of surgery for musculoskeletal trauma, whether for a surgical adverse event or another reason. The best multivariable models predicted very little of the variability in readmission, which reflects the complexity of readmission and the difficulty reducing the risk to a few specific factors. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Determinants of disability after fingertip injuries.

BACKGROUND: Psychological factors, such as depression, catastrophic thinking, and self-efficacy, account for more of the variation in upper extremity disability than motion and other impairments, but their influence in the setting of hand trauma is less well studied. OBJECTIVE: The aim of this study was to determine which factors account for variation in disability 1 month after fingertip injuries. METHODS: We enrolled 82 patients with finger injuries distal to the proximal interphalangeal joint, and 70 patients completed the study. Questionnaires and measurements were taken at the initial visit and approximately 1 month later. Patients completed the short version of the Disabilities of the Arm Shoulder and Hand questionnaire, the pain self-efficacy questionnaire, and the Patient Health Questionnaire to assess depressive symptoms. Bivariate and multivariable analyses determined factors associated with QuickDASH scores. RESULTS: The mean disabilities of the arm shoulder and hand questionnaire score was 35 at the initial visit (the U.S. norm is 10) and 17 approximately 1 month later. The best model explained 54% of the variation in disabilities of the arm shoulder and hand questionnaire 1 month after injury and included symptoms of depression (Patient Health Questionnaire; partial R2 0.43) and injury mechanism (saw injury compared with sport injury; partial R2 0.14). The criterion symptoms of depression was also the factor most strongly associated with both pain intensity and time off work. CONCLUSIONS: In patients with fingertip injury, symptoms of depression account for most of the variability in hand and arm-specific disability, pain intensity, and days to return to work. Identification and treatment of symptoms of depression might facilitate recovery from fingertip injuries.

Does rewording MRI reports improve patient understanding and emotional response to a clinical report?

BACKGROUND: Diagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like "tear" can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse. QUESTIONS/PURPOSES: The aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive. METHODS: One hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report. RESULTS: According to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports. CONCLUSIONS: Emotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.

What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture?

BACKGROUND: Fracture of the proximal humerus is common in older patients during the decline of their physical health. QUESTIONS/PURPOSES: Our purpose was to evaluate the association between specific risk factors in patients with fractures of the proximal humerus and any inpatient adverse events, mortality, and discharge to a short-term or long-term care facility. METHODS: The National Hospital Discharge Survey (NHDS) provided estimates of all adult patients who were admitted to hospitals after fractures of the proximal humerus in the United States between 1990 and 2007. The influences of sex, age, days of care, diagnosis and procedures (based on ICD-9 codes) on inpatient adverse events and death, and discharge to a short-term or long-term care facility, were studied in bivariate and multivariable analyses. RESULTS: Among an estimated 867,282 patients admitted for proximal humerus fractures, 20% experienced adverse events, and 2.3% died in the hospital. Older age, concomitant femur and femoral neck fractures or head trauma, operative fracture care, congestive heart failure, and chronic alcoholism were associated with inpatient adverse events. Intubation, acute myocardial infarctions, malignancies, and skull fractures were associated with inpatient deaths. Older age, lower limb fractures, specific comorbidities (obesity, congestive heart failure, dementia), and inpatient adverse events (pneumonia, anemia treated with transfusion) were associated with discharges to short-term or long-term care facilities. CONCLUSIONS: Knowledge of risk factors for inpatient adverse events, mortality, and discharge to facilities can help make treatment decisions, improve overall care, discharge planning, and resource utilization for patients with proximal humeral fractures.

Surgeon confidence in an outpatient setting.

BACKGROUND: We have the impression that provider uncertainty arises from either nonspecific pathology or disproportionate symptoms and disability, both of which correlate with symptoms of depression, heightened illness concern, and low patient self-efficacy. This study tested the primary null hypothesis that there is no correlation between provider confidence and patient self-efficacy. METHODS: Eighty-five patients visiting an orthopedic hand and upper extremity surgeon completed the Pain Self-Efficacy Questionnaire (PSEQ). The surgeon's confidence in the diagnosis, optimal treatment, expected outcome, and the anticipated satisfaction of the patient and the referring doctor were measured with five questions rated on 5-point Likert scales (Physician Confidence Scale). RESULTS: Overall physician confidence was high and there was no correlation between the PSEQ score and the Physician Confidence Scale. Provider confidence was significantly lower for nonspecific diagnoses, but there was no significant difference between the mean PSEQ for the 72 patients with a specific diagnosis and the 12 patients with nonspecific diagnoses. CONCLUSIONS: Physician confidence did not relate with self-efficacy in this study. LEVEL OF EVIDENCE: Prognostic, level II.