Evaluation of patients' and physicians' expectations and attributes of osteoarthritis treatment using Kano methodology.

PURPOSE: To evaluate expectations regarding osteoarthritis (OA) treatment of patients (PT) and physicians (PH) (Orthopedic Surgeons) in Spain. METHODS: Multicenter, cross-sectional study in adult patients with OA with at least 1 year of disease progression and with at least one prescription of anti-inflammatory drugs within the last year. Sociodemographic, clinical, and treatment characteristics as well as patient-reported outcomes were obtained by phone interview. Using a treatment expectations questionnaire and applying Kano methodology, treatment attributes were classified as: must-be; one-directional; attractive; indifferent; reverse or questionable. RESULTS: A total of 965 adult patients with OA [mean age: 64 years (SD: 11); 75% women] and 383 PH [mean age: 47 years (SD: 10); 14% women] were surveyed. None of the treatment attributes showed a dominant "must-be" characteristic. The attributes that led to a greater dissatisfaction when absent were non-occurrence of long-term adverse effects, no discomfort upon administration, and achievement of symptoms relief. The two attributes that were considered most important by PT were as follows: achievement of both total disappearance of the symptoms and lasting symptom relief. Conversely, for PH, the two most important attributes were related to short- and long-term safety. CONCLUSIONS: A clear different perspective regarding treatment expectation was noted among PT (effectiveness) and PH (safety). Therefore, when selecting the most appropriate treatment for OA, PH should invite PT to participate in the decision making.

Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band.

Thirty-five patients with four-part displaced proximal humeral fractures and fracture-dislocations were retrospectively reviewed from the years 1977-1990. Thirty-three patients were available for study. All fractures were treated by open reduction and internal fixation allowing early motion. Surgical technique was as atraumatic as possible with the goal of restoring normal anatomy of the proximal humerus with a minimal fixation system. The fixation device consisted of two modified Kirschner wires introduced through the tuberosities and reinforced by a tension band wiring. Neer's criteria were used to evaluate results. With a mean follow-up of 7 years, results were excellent and satisfactory in 21 cases, nonsatisfactory in 10, and poor in two. The most common complication was avascular necrosis (nine patients). All cases of fracture-dislocations corresponded with the nonsatisfactory and poor results. Because of our results, we conclude that in four-part displaced fractures, open reduction and internal fixation with our system of osteosynthesis should be indicated initially. Prosthetic replacement should be considered as primary treatment in cases with marked comminution of the humeral head, in fracture-dislocations, and in patients > 75 years of age.

[Association between arthritis, functional disability and quality of life using a structural equation]. / Vinculación de la afectación artrósica, la discapacidad funcional y la calidad de vida mediante un modelo de ecuación estructural.

OBJECTIVES: To establish a conceptual model that links arthritis, functional disability in activities of daily living, and quality of life (QoL). METHODS: A multicentre, cross-sectional, observation study was performed. The location of the arthritis (presence/absence) was recorded. Disability was measured using the Health Assessment Questionnaire Disability Index and the QoL determined using the EQ-5D-3 Level questionnaire. The relationship between the arthritis, disability, and the QoL was evaluated using the structural equation model (SEM). PATIENTS: 965 patients with arthritis (mean age=64 years, with 75% females). Arthritis: mean areas affected: 2.8. Areas most frequently affected: knees (67%); lumbar spine (60%) and cervical spine (45%). QoL: The majority of patients did not mention serious problems in the five domains assessed. Disability: «other activities¼ (mean=1.2); «reach¼ (mean=1.1) and «walking¼ (mean=1.0) were the categories that demonstrated greater disability. The SEM showed arthritis, disability and QoL as associated latent variables. Although 92% of the QoL explained the disability, only 5% of the disability was due to the presence/absence of arthritis. The global model that describes arthritis as a cause of disability, and disability was affecting the QoL, had a reasonable goodness of fit (CMIN/DF=5.42; RMR=0.026; RMSEA=0.069). CONCLUSIONS: Functional disability can explain the decrease in QoL. In theory, arthritis is closely related with disability and QoL, but the model did not mange to fully explain this link. As statistical techniques required good measurement models to correctly determine relationships, conventional medical records seem to be insufficient for this purpose. Other valid measurements of arthritis are needed to provide tests of its direct effect on disability and QoL.

A series of tibial fractures treated conservatively.

Two hundred and two fractures of the tibia have been reviewed. They were treated by a standard, conservative method; with a Phemister graft when union was delayed and a pseudarthrosis threatened. The classifications of Charnley (1968) and Nicoll (1964) have proved to be useful in assessing results and these complement each other. The factors that influence bony union include damage to the interosseous membrane, the degree of the displacement and comminution of the fracture, and injury to soft tissues. Infection has a very unfavourable influence on bone union and leads to the majority of bad sequelae. The fundamental object in reduction is to obtain as perfect apposition and alignment of the fragments as possible. Imperfect apposition, however, with normal alignment does not affect bone union severely. The problem arising from the use of an above-knee walking plaster that affects the patient physically, psychologically and socially, may be solved by the early use of a below-knee plaster. The functional sequelae are the result of soft-tissue damage rather than of immobilization. The Chutro-Phemister type of graft has proved to be a safe method in preventing pseudarthrosis. The analysis of the results obtained with this conservative method is sufficient reason against choosing surgical treatment for these fractures.