Relationship between subjective and objective assessment of outcomes after anterior cruciate ligament reconstruction.
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Anterior Cruciate Ligament↗
Biomedical subjects
Mininder S Kocher
Publications and source records attributed to Mininder S Kocher.
Determinants of patient satisfaction with outcome after rotator cuff surgery.
BACKGROUND: The outcome after rotator cuff surgery has been reported frequently with use of condition-specific measures, but patient satisfaction has not been well studied. The purpose of this study was to identify the determinants of patient satisfaction with the outcome after rotator cuff surgery. METHODS: A cohort of 311 patients undergoing rotator cuff surgery was studied prospectively. Two hundred and fifty-four patients had subjective follow-up for a minimum of one year, and fifty-seven patients had subjective and objective follow-up for a minimum of one year. Diagnoses included tendinitis or impingement (eighty patients), a partial-thickness rotator cuff tear (fifty-five patients), and a full-thickness rotator cuff tear (176 patients). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Independent variables included demographic, surgical, objective follow-up, and subjective follow-up parameters. Univariate and multivariate analyses were performed to identify the determinants of satisfaction. RESULTS: Univariate analysis of demographic variables demonstrated no significant differences (p > 0.05) with respect to patient satisfaction. Analysis of the surgical variables showed significantly decreased satisfaction (p < 0.05) for patients who had debridement for a massive, irreparable cuff tear; those who had subscapularis tears; and those with larger supraspinatus and infraspinatus tears. Analysis of the objective variables at follow-up demonstrated significantly decreased satisfaction (p < 0.05) for patients with diminished and weakened forward elevation, impingement signs, and acromioclavicular joint pain and tenderness. Univariate analysis of subjective variables at follow-up showed significantly decreased satisfaction (p < 0.001) for patients with pain, functional difficulty, and work disability. Multivariate analysis demonstrated significantly decreased satisfaction associated with pain (p < 0.001) and dysfunction (p < 0.05). A significant relationship (p < 0.05) was detected between satisfaction and a willingness to recommend the surgery to another. A significant relationship (p < 0.05) was also found between satisfaction and the American Shoulder and Elbow Surgeons score. CONCLUSIONS: Subjective variables of symptoms and function have the most robust associations with patient satisfaction following rotator cuff surgery. Thus, in assessing the outcome of rotator cuff surgery from the perspective of patient satisfaction with outcome, we emphasize the importance of patient-derived subjective assessment of symptoms and function.
Arthralgia↗
What's new in pediatric orthopaedics.
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Child↗
Anterior cruciate ligament reconstruction in skeletally immature knees: an anatomical study.
The purpose of this study was to anatomically evaluate anterior cruciate ligament (AL) reconstruction ate anterior cruciate ligament (ACL) reconstruction techniques in skeletally immature knees. Four cadav-techniques in skeletally immature knees. Four cadaveric knees from 2 skeletally immature children were used. After preoperative magnetic resonance imaging (MRI), various ACL reconstruction techniques were performed. On the tibial side, 30 degrees, 45 degrees, and 60 degrees tunnels were made; on the femoral side, a transtibial femoral tunnel was made, and over-the-top placement was used. After reconstruction, specimens underwent MRI imaging and were sectioned for descriptive analysis. The 30 degrees epiphyseal tunnel is feasible in older children, the standard 45 degrees tibial tunnel threatens the anteromedial proximal tibial physis and the tibial tubercle apophysis, and the 60 degrees vertical tunnel violates centrally in the proximal tibial physis. Both the transtibial femoral tunnel and the over-the-top placement are near the posterior distal femoral physis and perichondrial ring. When an interference screw is used for fixation, the physis is difficult to avoid. We recommend giving careful attention to technical details during ACL reconstruction in skeletally immature knees.
Anterior Cruciate Ligament↗
Ergogenic aids: a review of basic science, performance, side effects, and status in sports.
The use of drugs and supplements to enhance performance has become a part of mainstream athletics. Many team physicians and sports medicine practitioners are unfamiliar with the benefits and risks of these products and thus are unable to educate young athletes on this topic. In spite of numerous reports on the health risks of anabolic steroid use, 1 to 3 million Americans have used them. Human growth hormone has been tried by up to 5% of 10th graders, although no scientific study has shown that it is an effective performance-enhancing drug. Amphetamines and similar compounds may be the most widely abused drug in baseball; recently, they have come under increased scrutiny in sport. Erythropoietin is a highly effective aerobic enhancer that has been linked to multiple deaths in cyclists and other endurance athletes. The neutraceutical industry, led by supplements such as creatine, ephedra, and androstenedione, remains unregulated by the Food and Drug Administration and has serious issues with quality and side effects. An understanding of these products is essential for the sports medicine practitioner to provide sound, safe advice to the athlete.
Amphetamines↗
Delay in diagnosis of slipped capital femoral epiphysis.
OBJECTIVE: Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE. METHODS: A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed. RESULTS: The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis. CONCLUSIONS: Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.
Child↗
Reliability, validity, and responsiveness of the Lysholm knee scale for various chondral disorders of the knee.
BACKGROUND: The Lysholm knee scale is a condition-specific outcome measure that was originally designed to assess ligament injuries of the knee. The purpose of this study was to determine the psychometric properties of the Lysholm knee scale for various chondral disorders of the knee. METHODS: Test-retest reliability, internal consistency, content validity, criterion validity, construct validity, and responsiveness to change were determined for the Lysholm knee scale within subsets of an overall study population of 1657 patients with chondral disorders of the knee. The study population was a heterogeneous group of patients with various types of traumatic and degenerative chondral lesions, including isolated lesions and those associated with meniscal and ligament injuries. RESULTS: The overall Lysholm knee scale and six of the eight domains had acceptable test-retest reliability (intraclass correlation coefficient = 0.91) and internal consistency (Cronbach alpha = 0.65). The overall Lysholm knee scale demonstrated acceptable floor (0%) and ceiling (0.7%) effects; however, the floor effects for the domain of squatting and the ceiling effects for the domains of limp, instability, support, and locking were unacceptable (>30%). There was acceptable criterion validity with significant (p < 0.05) correlations between the overall Lysholm knee scale and the physical functioning, role-physical, and bodily pain domains of the Short Form-12 scale; the pain, stiffness, and function domains of the Western Ontario and McMaster Universities Osteoarthritis Index; and the Tegner activity scale. The overall Lysholm knee scale had acceptable construct validity, with all nine hypotheses demonstrating significance (p < 0.05), and it had acceptable responsiveness to change (effect size, 1.16; standardized response mean, 1.10), with large effects (> or = 0.80) for the domains of pain, limping, swelling, and squatting and a small effect (> or = 0.20) for the domain of instability. CONCLUSIONS: The Lysholm knee scale demonstrated overall acceptable psychometric performance for outcomes assessment of various chondral disorders of the knee, although some domains demonstrated suboptimal performance. Psychometric testing of other condition-specific knee instruments in patients with chondral disorders of the knee would be helpful to allow for comparison of psychometric properties.
Adult↗
What's new in pediatric orthopaedics.
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Bone Diseases↗
Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children.
BACKGROUND: The differentiation between septic arthritis and transient synovitis of the hip in children can be difficult. The purpose of the present study was to validate a previously published clinical prediction rule for this differentiation in a new patient population. METHODS: We prospectively studied children who presented to a major children's hospital between 1997 and 2002 with an acutely irritable hip. As in the previous study, diagnoses of septic arthritis (fifty-one patients) and transient synovitis (103 patients) were operationally defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression were used to compare the two groups. The predicted probability of septic arthritis of the hip from the prediction rule was compared with actual distributions in the current patient population. The area under the receiver operating characteristic curve was determined. RESULTS: The same four independent predictors of septic arthritis of the hip (a history of fever, non-weight-bearing, an erythrocyte sedimentation rate of 40 mm/hr, and a serum white blood-cell count of >12,000 cells/mm(3) (>12.0 x 10(9)/L)) were identified in the current patient population. The predicted probability of septic arthritis of the hip from the prediction rule was similar to the actual distributions in the current patient population. The area under the receiver operating characteristic curve for the current patient population was 0.86, compared with 0.96 in the original population. CONCLUSIONS: Clinical prediction rules typically demonstrate diminished performance in a new patient population because they are optimally modeled to the original data set. The previously published clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children demonstrated diminished, but nevertheless very good, diagnostic performance in a new patient population.
Algorithms↗
Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis.
BACKGROUND: The management of the contralateral hip after unilateral slipped capital femoral epiphysis is controversial. The purpose of this study was to determine, with use of expected-value decision analysis, the optimal management strategy-prophylactic in situ pinning versus observation-for the contralateral hip. METHODS: Outcome probabilities were determined from a systematic review of the literature. Utility values were obtained from a questionnaire on patient preferences completed with use of a visual analog scale by twenty-five adolescent male patients without slipped capital femoral epiphysis. A decision tree was constructed, fold-back analysis was performed to determine the optimal treatment, and one and two-way sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. RESULTS: Observation was the optimal management strategy for the contralateral hip given the outcome probabilities and utilities that we studied (the expected value was 9.5 for observation and 9.2 for prophylactic in situ pinning, with a marginal value of 0.3). Increased rates of a late second slip favored prophylactic in situ pinning (the threshold probability was 27%). Risk-taking patients with a high utility for uncomplicated prophylactic in situ pinning favored prophylaxis (the threshold utility was 9.8). CONCLUSIONS: The iatrogenic risks of treating a healthy patient or an uninvolved body part rarely outweigh the potential benefits unless the probability of the adverse event is likely and the consequences of the adverse event are very severe. In this decision analysis, the optimal decision was observation. In cases where the probability of contralateral slipped capital femoral epiphysis exceeds 27% or in cases where reliable follow-up is not feasible, pinning of the contralateral hip is favored. For a given individual patient, the optimal strategy depends not only on probabilities of the various outcomes but also on personal preference. Thus, we advocate a model of doctor-patient shared decision-making in which both the outcome probabilities and the patient preferences are considered in order to optimize the decision-making process. LEVEL OF EVIDENCE: Economic and decision analysis, Level III-1 (limited alternatives and costs; poor estimates). See Instructions to Authors for a complete description of levels of evidence.
Bone Nails↗
Clinical epidemiology and biostatistics: a primer for orthopaedic surgeons.
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Achilles Tendon↗
Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children.
PURPOSE: The purpose of this study was to evaluate laxity and functional outcome of displaced tibial spine fractures in skeletally immature patients treated with arthroscopic reduction and internal fixation. TYPE OF STUDY: Retrospective case series. METHODS: Six patients (mean age, 12.0 years old) underwent subjective, objective, and instrumented knee laxity assessment at minimum 2 years (mean, 3.2 years) of follow-up time after arthroscopic reduction and 3.5-mm cannulated screw fixation of (Meyers and McKeever type III) tibial spine fractures. RESULTS: Physical examination showed persistent laxity, with an abnormal Lachman examination in 5 of 6 patients and an abnormal pivot-shift examination in 2 of 6 patients. Instrumented knee laxity (KT-1000) showed greater than 3-mm manual-maximum side-to-side difference in 4 of 6 patients. Functional assessment revealed excellent function, with a mean Lysholm score of 99.5 (range, 98-100), mean Marshall score of 49.0 (range, 47-50), and mean Tegner score of 8.7 (range, 7-9). CONCLUSIONS: Arthroscopic reduction and internal fixation of type III tibial spine fractures in skeletally immature patients results in persistent laxity but excellent functional outcome.
Adolescent↗
Meniscal disorders: normal, discoid, and cysts.
Meniscal injuries in children and adolescents are being seen with increased frequency. Meniscal tears are typically traumatic injuries in adolescents. Because of increased healing potential and the younger age of these patients, attempts at meniscal preservation should be emphasized for outer and middle third tears. Discoid meniscus typically presents as a snapping knee in younger children or as a meniscal tear in older children. Again, meniscal preservation by saucerization is emphasized. Careful attention should be given to the need for additional meniscal repair. Popliteal cysts typically present as a painless mass. Because they are usually not associated with an internal pathology and often resolve spontaneously, the preferred treatment is observation.
Adolescent↗
It is money that matters: decision analysis and cost-effectiveness analysis.
Clinical decisions must be made, often under circumstances of uncertainty and limited resources. Decision analysis and cost-effectiveness analysis are methodologic tools that allow for quantitative analysis and the optimization of decision-making. These methods can be useful for decisions regarding individual patient evaluation and treatment options or in formulating healthcare policy. We overview the methodology of expected value decision analysis and of cost-effectiveness analysis, including cost-identification, cost-effectiveness, cost-benefit, and cost-utility analyses. Examples are provided of these methods and a user's guide to cost-effectiveness analysis is outlined.
Achilles Tendon↗
Family violence: tools for the orthopaedic surgeon.
Family violence, in the form of child abuse, adult domestic violence, and elder abuse, is a major public health problem in the United States. It leads to physical and psychological disability, loss of productivity, and even death. It can perpetuate itself through successive generations and contributes to the escalating costs of health care in this country. Family violence affects a significant proportion of the US population either as direct victims or as witnesses of abuse. As a result, orthopaedic surgeons are undoubtedly treating family violence victims, knowingly or unknowingly in their practices. Therefore, it is important that orthopaedic surgeons understand that victims of family violence often present for orthopaedic care in both emergency department and office or clinic settings. It is equally important that orthopaedic surgeons acquire the skills that are needed for the appropriate evaluation, diagnosis, treatment, and referral of such victims.
Adult↗
Effect of functional bracing on subsequent knee injury in ACL-deficient professional skiers.
The effect of functional bracing on subsequent knee injury in anterior cruciate ligament (ACL) deficient professional skiers was evaluated. A cohort of 180 ACL-deficient skiers was identified from a knee screening of 9410 professional skiers from 1991-1997. An ACL-deficient knee was defined by an abnormal examination (Lachman or pivot-shift) and a > or = 5-mm KT-1000 manual maximum difference. The dependent variable was subsequent knee injury, which occurred in 12 knees. A significantly higher proportion of injuries occurred in nonbraced skiers compared with braced skiers (P = .005). The risk ratio for subsequent knee injury comparing nonbraced with braced skiers was 6.4 (13% and 2%, respectively). Univariate analysis revealed no significant effects of the other covariates. Logistic regression identified bracing status (P < .01; odds ratio = 8) and KT-1000 manual maximum difference (P = .02; odds ratio = 1.3) as significant multivariate risk factors for subsequent knee injury, controlling for covariates.
Adult↗
Osteopetrosis.
Osteopetrosis is a rare skeletal condition characterized by skeletal sclerosis caused by aberrant osteoclast-mediated bone resorption. Three clinically distinct forms of osteopetrosis are recognized--the infantile malignant autosomal recessive form, the intermediate autosomal recessive form, and the adult benign autosomal dominant form. The disease represents a spectrum of clinical variants because of the heterogeneity of genetic defects resulting in osteoclast dysfunction. The pathogenic defects may be intrinsic to either the osteoclast-monocyte lineage or the mesenchymal cells that constitute the microenvironment that supports osteoclast ontogeny and activation. Implicated factors include specific proto-oncogenes, growth factors, and immune regulators. A subset of patients with the intermediate autosomal recessive form has been characterized with carbonic anhydrase II isoenzyme deficiency. Management of patients with osteopetrosis requires a comprehensive approach to characteristic clinical problems including hematologic and metabolic abnormalities, fractures, deformity, back pain, bone pain, osteomyelitis, and neurologic sequelae. Medical treatment of osteopetrosis is based on efforts to stimulate host osteoclasts or provide an alternative source of osteoclasts. Stimulation of host osteoclasts has been attempted with calcium restriction, calcitrol, steroids, parathyroid hormone, and interferon. Bone marrow transplant has been used with cure for infantile malignant osteopetrosis. As osteopetrosis likely represents a spectrum of underlying etiologies resulting in osteoclast dysfunction, effective therapies most likely need to be individualized.
Humans↗
A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.
BACKGROUND: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children. METHODS: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups. RESULTS: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion. CONCLUSIONS: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.
Anti-Bacterial Agents↗