Evangelia Protopapa

Osteonecrosis complicating developmental dysplasia of the hip compromises subsequent acetabular remodeling.

BackgroundOsteonecrosis of the femoral head secondary to treatment of developmental dysplasia of the hip (DDH) affects acetabular remodeling but the magnitude of this effect is unclear.Questions/purposesUsing four measures of acetabular development, we (1) determined whether acetabular remodeling differed in hips with and without osteonecrosis; and (2) determined the impact of severity of osteonecrosis contributing to acetabular remodeling.MethodsWe retrospectively reviewed 95 patients (118 hips) treated for DDH by closed or open reduction with or without femoral osteotomy between 1992 and 2006. We evaluated serial radiographs from the time when a stable reduction had been achieved. In 902 radiographs taken over 19 years, we measured the acetabular index and three other indices of hip development. Patients were followed for a mean of 8 years (range, 1–19 years). At last followup, 86 of the 118 hips (73%) had osteonecrosis according to the criteria by Bucholz and Ogden.ResultsThe acetabular index improved with time in all hips but the magnitude of improvement was larger in hips without osteonecrosis. The adjusted mean acetabular index at 14 years was 17° for hips with osteonecrosis (95% CI, 15°–18°) and 10° for hips without osteonecrosis (95% CI, 7°–13°). The lateral centering ratio improved after reduction to a normal value less than 0.85 in both groups but the rate of change with 0.06 versus 0.05 was higher in hips with osteonecrosis. The superior centering ratio was worse at all times in hips with osteonecrosis with a mean difference of 0.04. If only radiographic changes of Grades II and greater were considered osteonecrosis, the mean adjusted acetabular index at 14 years was 17.7° (15.6°–19.7°) for hips with osteonecrosis and 12.4° (10.3°–14.4°) for hips without osteonecrosis.ConclusionsAlthough radiographic indices improved consistently with time in hips without osteonecrosis, hips with osteonecrosis had abnormal indices of acetabular remodeling throughout followup. Osteonecrosis of the femoral head inhibited acetabular remodeling.Level of EvidenceLevel III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Patient-reported outcome (PRO) questionnaires for men who have radical surgery for prostate cancer: a conceptual review of existing instruments

To critically review conceptual frameworks for available patient‐reported outcome (PRO) questionnaires in men having radical prostatectomy (RP), psychometrically evaluate each questionnaire, and identify whether each is appropriate for use at the level of the individual patient. We searched PubMed, the Reports and Publications database of the University of Oxford Patient‐Reported Outcomes Measurement Group and the website of the International Consortium for Health Outcomes Measurement (ICHOM) for psychometric reviews of prostate cancer‐specific PRO questionnaires. From these we identified relevant questionnaires and critically appraised the conceptual content, guided by the Wilson and Cleary framework and psychometric properties, using well established criteria. The searches found four reviews and one recommendation paper. We identified seven prostate cancer‐specific PROs: the Expanded Prostate Cancer Index Composite‐26 (EPIC‐26), Expanded Prostate Cancer Index Composite‐50 (EPIC‐50), University of California‐Los Angeles Prostate Cancer Index (UCLA‐PCI), Functional Assessment of Cancer Therapy ‐ Prostate Cancer Subscale (FACT‐P PCS), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire – prostate specific 25‐item (EORTC QLQ‐PR25), Prostate Cancer – Quality of Life (PC‐QoL), and Symptom Tracking and Reporting (STAR). Six out of seven measures purported to measure health‐related quality of life (HRQL), but items focused strongly on urinary and sexual symptoms/functioning. The remaining questionnaire (STAR) claimed to assess functional recovery after RP. The psychometric evidence for these questionnaires was incomplete and variable in quality; none had evidence that they were appropriate for use with individual patients. Several questionnaires provide the basis of measures of urinary and/or sexual symptoms/functioning. Further work should explore other aspects of HRQL that are important for men having RP. Further psychometric work is also needed to determine whether they can be used at the individual level.

Association between the ossific nucleus and osteonecrosis in treating developmental dysplasia of the Hip: updated meta-analysis

BackgroundA meta-analysis concluded that there was no effect of the femoral head ossification and the incidence of osteonecrosis in the treatment of developmental dysplasia of the hip (DDH), unless only osteonecrosis grades II-IV were considered. The meta-analysis, limited due to the small number of studies available at that time, identified a need for an update as further research emerges. We observed a trend in recent years towards delaying treatment of DDH in the absence of an ossified nucleus. Numerous new publications on this topic encouraged us to update the 2009 meta-analysis.MethodsWe performed a systematic review of the literature from 1967 to 2016 and included studies that reported on the treatment of DDH, the ossific nucleus and osteonecrosis. Two independent reviewers evaluated all articles. We performed a meta-analysis with the main outcome defined as the development of osteonecrosis of the femoral head at least two years after closed or open reduction.ResultsOf four prospective and ten retrospective studies included in the systematic review, 11 studies (1,021 hips) met the inclusion criteria for the meta-analysis. There was no significant effect of the ossific nucleus on the development of all grades of osteonecrosis (relative risk, 0.88; 95% confidence interval, 0.56–1.41) or osteonecrosis grades II–IV (0.67; 0.41–1.08). In closed reductions, the ossific nucleus halved the risk for developing osteonecrosis grades II–IV (0.50; 0.26–0.94).ConclusionsBased on current evidence there does not appear to be a protective effect of the ossific nucleus on the development of osteonecrosis. In contrast to the previous meta-analysis, this update demonstrates that this remains the case irrespective of the grade of osteonecrosis considered relevant. This updated meta-analysis is based on twice as many studies with a higher quality of evidence.

Weighted Diagnostic Criteria for Developmental Dysplasia of the Hip

OBJECTIVE To establish clinical diagnostic criteria for developmental dysplasia of the hip (DDH) that model the practices of expert clinicians. STUDY DESIGN Of 23 clinical criteria for the diagnosis of DDH, ranked in order of diagnostic importance by international consensus, the 7 most highly ranked were placed in all possible combinations to create unique case vignettes. Twenty-six experts rated 52 vignettes for the presence of DDH. We modeled the data to determine which of the 7 criteria were associated with a clinicians opinion that the vignette represented DDH. From the resulting regression coefficients, for each vignette we calculated a probability of DDH. An independent panel rated the same vignettes using a visual analog scale response. We correlated the visual analog scale ratings with probabilities derived from the model. RESULTS Our model identified 4 of 7 criteria as predictive of DDH (P < .001): Ortolani/Barlow test (β = 3.26), limited abduction (β = 1.48), leg length discrepancy (β = 0.74), and first-degree family history of DDH (β = 1.39). There was substantial correlation between the probability of DDH predicted by the model and that derived from an independent expert panel (r = 0.73; P < .001). CONCLUSION Weighted clinical criteria for inferring the likelihood of DDH produced consistent results in the judgment of 2 separate groups of experts. Using these weights, nonexperts could establish the probability of DDH in a manner approaching the practice of clinical experts.

Does pain acceptance predict physical and psychological outcomes in cancer outpatients with pain

Pain acceptance has been associated with improved physical and psychosocial well-being in chronic non-malignant pain patients. However, its effects are unclear in cancer outpatients with pain. Our aim was to determine whether pain acceptance predicts reduced pain, pain interference with function, anxiety, and depression in cancer outpatients. We recruited 116 outpatients from a tertiary oncology center, with various types of cancer and pain levels. Patients completed the Brief Pain Inventory, the Hospital Anxiety and Depression Scale and the Chronic Pain Acceptance Questionnaire, the latter of which comprises activity engagement and pain willingness. We carried out multiple regression analyses, adjusting for patient characteristics and outcomes. Activity engagement and pain willingness significantly predicted pain interference with function (P=0.033 and P=0.041 respectively). However, only activity engagement predicted anxiety (P=0.001) and depression (P<0.001). These findings support the beneficial role of pain acceptance in patients’ functional adaptation to cancer-related pain. Activity engagement in particular, shows promise in fostering psychological well-being. Further studies could confirm its role in reducing anxiety and depression in cancer patients with pain and whether it should be included in cancer pain management interventions. Further studies could confirm its role in reducing anxiety and depression in cancer patients with pain, and whether it should be included in cancer pain management interventions.

Dip and drip, swipe or squeeze? The best method of draining water for optimal strength in a plaster of Paris backslab.

Plaster of Paris backslabs are used post-operatively to provide stability and protect repaired structures. We hypothesized that forceful expulsion of excess water during backslab construction could weaken the backslab by reducing the final gypsum content. Our aim was to compare the final dry mass and strength of backslabs prepared by three different techniques: ‘dip and drip’, ‘swipe’ and ‘squeeze’. We applied an increasing force until the point of failure of the 30 backslabs prepared by the three methods. Backslabs prepared by swiping or squeezing away excess water were 9% lighter and 26% weaker and 13% lighter and 33% weaker, respectively, in comparison with simple drip drainage, and all results were statistically significant. We conclude that forceful drainage of excess water produces significantly weaker backslabs.