Isam Atroshi

The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH.

BackgroundThe 30-item disabilities of the arm, shoulder and hand (DASH) questionnaire is increasingly used in clinical research involving upper extremity musculoskeletal disorders. From the original DASH a shorter version, the 11-item Quick DASH, has been developed. Little is known about the discriminant ability of score changes for the Quick DASH compared to the DASH. The aim of this study was to assess the performance of the Quick DASH and its cross-sectional and longitudinal validity and reliability.MethodsThe study was based on extracting Quick DASH item responses from the responses to the full-length DASH questionnaire completed by 105 patients with a variety of upper extremity disorders before surgery and at follow-up 6 to 21 months after surgery. The DASH and Quick DASH scores were compared for the whole population and for different diagnostic groups. For longitudinal construct validity the effect size and standardized response mean were calculated. Analyses with ROC curves were performed to compare the ability of the DASH and Quick DASH to discriminate among patients classified according to the magnitude of self-rated improvement. Cross-sectional and test-retest reliability was assessed.ResultsThe mean DASH score was 34 (SD 22) and the mean Quick DASH score was 39 (SD 24) at baseline. For the different diagnostic groups the mean and median Quick DASH scores were higher than the corresponding DASH scores. For the whole population, the mean difference between the Quick DASH and DASH baseline scores was 4.2 (95% CI 3.2–5.3), follow-up scores was 2.6 (1.7–3.4), and change scores was 1.7 (0.6–2.8).The overall effect size and standardized response mean measured with the DASH and the Quick DASH were similar. In the ROC analysis of change scores among patients who rated their arm status as somewhat or much better and those who rated it as unchanged the difference in the area under the ROC curve for the DASH and Quick DASH was 0.01 (95% CI -0.05–0.07) indicating similar discriminant ability.Cross-sectional and test-retest reliability of the DASH and Quick DASH were similar.ConclusionThe results indicate that the Quick DASH can be used instead of the DASH with similar precision in upper extremity disorders.

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire : reliability and validity of the Swedish version evaluated in 176 patients

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered regionspecific outcome instrument developed to measure upperextremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish versions reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.

Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial

Objective To evaluate the effectiveness of neuromuscular training in reducing the rate of acute knee injury in adolescent female football players. Design Stratified cluster randomised controlled trial with clubs as the unit of randomisation. Setting 230 Swedish football clubs (121 in the intervention group, 109 in the control group) were followed for one season (2009, seven months). Participants 4564 players aged 12-17 years (2479 in the intervention group, 2085 in the control group) completed the study. Intervention 15 minute neuromuscular warm-up programme (targeting core stability, balance, and proper knee alignment) to be carried out twice a week throughout the season. Main outcome measures The primary outcome was rate of anterior cruciate ligament injury; secondary outcomes were rates of severe knee injury (>4 weeks’ absence) and any acute knee injury. Results Seven players (0.28%) in the intervention group, and 14 (0.67%) in the control group had an anterior cruciate ligament injury. By Cox regression analysis according to intention to treat, a 64% reduction in the rate of anterior cruciate ligament injury was seen in the intervention group (rate ratio 0.36, 95% confidence interval 0.15 to 0.85). The absolute rate difference was −0.07 (95% confidence interval −0.13 to 0.001) per 1000 playing hours in favour of the intervention group. No significant rate reductions were seen for secondary outcomes. Conclusions A neuromuscular warm-up programme significantly reduced the rate of anterior cruciate ligament injury in adolescent female football players. However, the absolute rate difference did not reach statistical significance, possibly owing to the small number of events. Trial registration Clinical trials NCT00894595.

Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial

Abstract Objectives To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome. Design and setting Randomised controlled trial at a single orthopaedic department. Participants 128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome. Main outcome measures The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months. Results 63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially. Conclusions In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.

Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population: A 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations

OBJECTIVE—The purpose of this study was to compare the incidence of vascular lower-limb amputation (LLA) in the diabetic and nondiabetic general population. RESEARCH DESIGN AND METHODS—A population-based cohort study was conducted in a representative Swedish region. All vascular LLAs (at or proximal to the transmetatarsal level) performed from 1997 through 2006 were consecutively registered and classified into initial unilateral amputation, contralateral amputation, or reamputation. The incidence rates were estimated in the diabetic and nondiabetic general population aged ≥45 years. RESULTS—During the 10-year period, LLA was performed on 62 women and 71 men with diabetes and on 79 women and 78 men without diabetes. The incidence of initial unilateral amputation per 100,000 person-years was 192 (95% CI 145–241) for diabetic women, 197 (152–244) for diabetic men, 22 (17–26) for nondiabetic women, and 24 (19–29) for nondiabetic men. The incidence increased from the age of 75 years. Of all amputations, 74% were transtibial. The incidences of contralateral amputation and of reamputation per 100 amputee-years in diabetic women amputees were 15 (7–27) and 16 (8–28), respectively; in diabetic men amputees 18 (10–29) and 21 (12–32); in nondiabetic women amputees 14 (7–24) and 18 (10–28); and in nondiabetic men amputees 13 (6–22) and 24 (15–35). CONCLUSIONS—In the general population aged ≥45 years, the incidence of vascular LLA at or proximal to the transmetatarsal level is eight times higher in diabetic than in nondiabetic individuals. One in four amputees may require contralateral amputation and/or reamputation.

Incidence and characteristics of distal radius fractures in a southern Swedish region.

BackgroundThe incidence of distal radius fracture has increased substantially during the last 50 years according to several studies that estimated the overall incidence in various general populations. The incidence of fracture classified according to severity has not been well documented. The aim of this population-based study was to estimate the overall and type-specific incidence rates of distal radius fracture in a representative population in southern Sweden.MethodsDuring 2001, all persons older than 18 years with acute distal radius fracture in the southern Swedish region of Northeastern Scania were prospectively recorded. A radiologist classified the fractures according to the AO system and measured volar tilt and ulnar variance. A fracture with volar tilt outside a range of -5° to 20° and/or ulnar variance of 2 mm or greater was defined as displaced.Results335 persons with acute distal radius fracture were recorded during the 1-year period. The overall incidence rate was 26 (95% confidence interval 23–29) per 10,000 person-years. Among women the incidence rate increased rapidly from the age of 50 and reached a peak of 119 per 10,000 person-years in women 80 years and older. The incidence rate among women 50 to 79 years old (56 per 10,000 person-years) was lower than that reported in previous studies of similar populations. Among men the incidence rate was low until the age of 80 years and older when it increased to 28 per 10,000 person-years. Fractures classified as AO type A comprised about 80% of the fractures in women and 64% in men. Almost two-thirds of all fractures were displaced and among men and women 80 years and older more than 80% of the fractures were displaced.ConclusionThe incidence rate of distal radius fracture in women 50 to 79 years old was lower than previously reported, which may indicate declining incidence in this group. In both sexes, the incidence was highest in the age group of 80 years and older. With a growing number of elderly in the general population, the impact of distal radius fracture in the future may be considerable.

Self-administered outcome instrument in carpal tunnel syndrome. Reliability, validity and responsiveness evaluated in 102 patients

We evaluated a Swedish version of a self-administered disease-specific outcome questionnaire for carpal tunnel syndrome regarding reliability, validity and responsiveness to clinical change. It consists of multi-item scales assessing symptom severity, function, patient satisfaction and quality of life. It was given to 102 patients before and 3 months after carpal tunnel release. Test-retest reliability, studied in a subsample of 22 patients on two occasions with a 1-3-week interval, showed good agreement between the scores. Internal consistency of the scales was high (Cronbach alpha 0.80-0.95). Validity of the scales was evaluated using the SF-36 general health questionnaire in a subgroup of 48 patients as well as items concerning patient satisfaction, showing the expected relationships between these measures. Responsiveness of the scales to clinical change, estimated by the effect size and standardized response mean, was large (0.94-1.7). We conclude that this questionnaire can provide a standardized measure of symptom severity and functional status, as well as patient satisfaction and quality of life in the carpal tunnel syndrome.

Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement

Background: The use of impacted morselized allograft bone and cement in hip revision arthroplasty has been popular, but studies that specifically address intraoperative and postoperative complications have been scarce.Methods: All complications that occurred during, and within the first year after, 144 consecutive hip revision arthroplasties (108 stems and 130 sockets) performed with impacted morselized allograft bone and cement were recorded. Clinical and radiographic follow-up evaluation was performed at three months and at one year after surgery for all patients except eight (seven who had died of causes unrelated to the hip surgery and one who had sustained a stroke). Of these eight patients, seven had a six-week and/or three-month follow-up evaluation.Results: Thirty-nine femoral fractures occurred in thirty-seven hips; twenty-nine of the fractures occurred during surgery and ten, within five months after surgery. Of the intraoperative femoral fractures, twelve were proximal, nine were diaphyseal, and eight involved the greater trochanter. Of the postoperative femoral fractures, one was proximal and nine were diaphyseal. Other intraoperative complications were the creation of a femoral cortical window in seven hips and incidental perforation of the femoral cortex in fourteen. Multivariate analysis showed the risk factors for femoral fracture during or after revision to be concomitant disease, greater deficiency of the femoral bone stock, and an intraoperative femoral window or perforation. Other complications included dislocation of the femoral head in nine hips, deep infection in one hip, persistence of preoperative deep infection in one hip, and superficial wound infection requiring wound débridement in two hips.Conclusions: We found the complication rate to be high after hip revision arthroplasty performed with impacted morselized allograft bone and cement. The most serious complication was postoperative diaphyseal femoral fracture.

Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT

Background Little is known about the influence of compliance with neuromuscular training (NMT) on the knee injury rate in football. Aim To evaluate team and player compliance with an NMT programme in adolescent female football and to study the association between compliance and acute knee injury rates. Methods Prospective cohort study based on a cluster randomised controlled trial on players aged 12–17 years with 184 intervention teams (2471 players) and 157 control teams (2085 players). Exposure and acute time loss knee injuries were recorded. Team and player compliance was recorded by the coaches on a player attendance form. The intervention group was divided into tertiles of compliance. Injury rates were compared by calculating rate ratios (RRs) and 95% CIs using exact Poisson tests with the low-compliance tertile as reference. Seasonal compliance trends were analysed using linear regression. Results Players in the high-compliance tertile had an 88% reduction in the anterior cruciate ligament (ACL) injury rate (RR 0.12, 95% CI 0.01 to 0.85), whereas the rate in the control group players was not significantly different from those in the low-compliance tertile (RR 0.77, 95% CI 0.27 to 2.21). A significant deterioration occurred in team (b=−3.0% per month, 95% CI −5.2 to −0.8) and player (b=−5.0% per month, 95% CI −7.1 to −2.9) compliance over the season. Conclusions Players with high compliance with the NMT programme had significantly reduced ACL injury rate compared with players with low compliance. Significant deterioration in team and player compliance occurred over the season.

Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year

Background Non-bridging external fixation has been introduced to achieve better fracture fixation and functional outcomes in distal radius fractures, but has not been specifically evaluated in a randomized study in the elderly. The purpose of this trial was to compare wrist-bridging and non-bridging external fixation for displaced distal radius fractures. Method The inclusion criteria were women ≥ 50 or men ≥ 60 years, acute extraarticular or intraarticular fracture, and dorsal angulation of ≥20° or ulnar variance ≥ 5 mm. The patients completed the disabilities of the arm, shoulder and hand (DASH) questionnaire before and at 10, 26 and 52 weeks after surgery. Pain (visual analog scale), range of motion and grip strength were measured by a blinded assessor. Results 38 patients (mean age 71 years, 31 women) were randomized at surgery (19 to each group). Mean operating time was shorter for wrist-bridging fixation by 10 (95% CI 3–17) min. There was no significant difference in DASH scores between the groups. No statistically significant differences in pain score, range of motion, grip strength, or patient satisfaction were found. The non-bridging group had a significantly better radial length at 52 weeks; mean difference in change in ulnar variance from baseline was 1.4 (95% CI 0.1–2.7) mm (p = 0.04). Volar tilt and radial inclination were similar in both groups. Interpretation For moderately or severely displaced distal radius fractures in the elderly, non-bridging external fixation had no clinically relevant advantage over wrist-bridging fixation but was more effective in maintaining radial length.