Pub Date : 2020-03-01DOI: 10.1097/CORR.0000000000000932
M. Scarborough
The US healthcare financial system is a complicated maze of government and insurance regulations. Put simply, most veterans and people older than 65 years of age are covered by government-provided insurance. The majority of Americans 64 years of age and younger obtain insurance through their employer either directly or as a family plan. The remainder of the population in the United States qualifies for Medicaid, the Children’s Health Insurance Program (CHIP), purchases insurance through the exchanges (via the Affordable Care Act [ACA]), or is uninsured. To qualify for Medicaid, a family and/or an individual must have a very low income. The income levels and disabilities for qualification vary by state. In the 36 states that have expanded Medicaid by accepting federal dollars for the program, the income level for qualification increases and the number of uninsured people decreases correspondingly. Those that do not qualify for Medicaid and do not have employer-based coverage, or another source of insurance represent the majority of millions of uninsured Americans (27.4 million, in 2017) [3]. In the current study, Smartt and colleagues [8] used data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate cancer-related outcomes of patients with bone or soft-tissue sarcomas stratified by insurance status. This study provides an interesting snapshot into the complicated US healthcare system by focusing on outcomes of these rare diseases [1]. The authors looked at three important clinical outcomes in patients with a bone or soft-tissue sarcoma: (1) Presence of metastasis at the time of diagnosis; (2) rates of limb salvage compared to amputation; and (3) death related to cancer. The authors then correlated those cancer-related outcomes to insurance status and found that a patient with Medicaid who is diagnosed with sarcoma is more likely to present with metastases, have an amputation, and/or die of their disease compared to patients with non-Medicaid insurance. Their findings support those of other cancer-related outcome studies [1, 2].
{"title":"CORR Insights®: Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-Tissue Sarcomas? A SEER Database Study.","authors":"M. Scarborough","doi":"10.1097/CORR.0000000000000932","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000932","url":null,"abstract":"The US healthcare financial system is a complicated maze of government and insurance regulations. Put simply, most veterans and people older than 65 years of age are covered by government-provided insurance. The majority of Americans 64 years of age and younger obtain insurance through their employer either directly or as a family plan. The remainder of the population in the United States qualifies for Medicaid, the Children’s Health Insurance Program (CHIP), purchases insurance through the exchanges (via the Affordable Care Act [ACA]), or is uninsured. To qualify for Medicaid, a family and/or an individual must have a very low income. The income levels and disabilities for qualification vary by state. In the 36 states that have expanded Medicaid by accepting federal dollars for the program, the income level for qualification increases and the number of uninsured people decreases correspondingly. Those that do not qualify for Medicaid and do not have employer-based coverage, or another source of insurance represent the majority of millions of uninsured Americans (27.4 million, in 2017) [3]. In the current study, Smartt and colleagues [8] used data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate cancer-related outcomes of patients with bone or soft-tissue sarcomas stratified by insurance status. This study provides an interesting snapshot into the complicated US healthcare system by focusing on outcomes of these rare diseases [1]. The authors looked at three important clinical outcomes in patients with a bone or soft-tissue sarcoma: (1) Presence of metastasis at the time of diagnosis; (2) rates of limb salvage compared to amputation; and (3) death related to cancer. The authors then correlated those cancer-related outcomes to insurance status and found that a patient with Medicaid who is diagnosed with sarcoma is more likely to present with metastases, have an amputation, and/or die of their disease compared to patients with non-Medicaid insurance. Their findings support those of other cancer-related outcome studies [1, 2].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88491522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-03-01DOI: 10.1097/CORR.0000000000000889
Anne A. Smartt, Eugene S. Jang, W. Tyler
BACKGROUND Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate. QUESTIONS/PURPOSES (1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation? METHODS The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site. RESULTS Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were un
背景:最近发表的几项基于人群的研究强调了保险状况与乳腺癌、头颈癌、睾丸癌和淋巴瘤等各种癌症患者生存率之间的关系[22,24,38,41]。一般来说，这些研究表明，没有医疗保险的患者或那些有医疗补助保险的患者比那些没有医疗补助保险的患者生存率要低。然而，这种差异尚未在原发性骨和四肢软组织肉瘤患者中进行研究，这是一种独特的肿瘤人群，通常在病程晚期出现，通常需要转诊和在三级保健中心进行复杂的治疗-健康保险覆盖范围的差异可能会加剧问题。(2)保险状况与远处转移的发生率有何关系?(3)保肢手术与截肢比例与保险状况有何关系?方法采用监测、流行病学和最终结果数据库(SEER)，对2007年至2014年诊断和治疗的12,008例患者进行分析，其中4257例原发性骨肉瘤患者和7751例肢体软组织肉瘤患者。患者被分为三个保险组:非医疗补助保险、医疗补助保险和未保险。没有保险信息的患者被排除在外(原发性骨肉瘤2.7%[113例]，四肢软组织肉瘤3.1%[243例])。使用Cox比例风险回归分析对患者年龄、性别、种族、民族、疾病程度(淋巴结和转移性累及)、肿瘤分级、肿瘤大小、组织学和原发肿瘤部位进行校正，评估保险状况与生存率之间的关系。结果有医疗补助保险的原发性骨肉瘤患者的疾病特异性生存率比没有医疗补助保险的患者低(风险比为1.3[95%可信区间为1.1 ~ 1.6];P = 0.003)。与没有医疗补助保险的患者相比，有医疗补助保险的肢体软组织肉瘤患者的疾病特异性生存率也降低(HR 1.2 [95% CI 1.0 ~ 1.5];P = 0.019)。原发性骨肉瘤患者(相对危险度1.8 [95% CI 1.3 ~ 2.4];p < 0.001)和四肢软组织肉瘤(RR 2.4 [95% CI 1.9 ~ 3.1];p < 0.001)，在诊断时，有医疗补助保险的患者比没有医疗补助保险的患者更有可能发生远处转移。原发性骨肉瘤患者(RR 1.8 [95% CI 1.4 ~ 2.1];p < 0.001)和四肢软组织肉瘤(RR 2.4 [95% CI 1.9 ~ 3.0];p < 0.001)，有医疗补助保险的患者比没有医疗补助保险的患者更容易截肢。没有医疗保险的原发性骨和四肢软组织肉瘤患者在诊断时不太可能发生远处转移，与没有医疗保险的患者相比，截肢手术的比例也不高。然而，未投保的四肢软组织肉瘤患者仍表现出疾病特异性生存率降低(HR 1.6 [95% CI 1.2 - 2.1];P = 0.001)。结论:在原发性骨或四肢软组织肉瘤患者中，保险状况差异所表现出的差异与诊断时转移风险增加、肢体保留手术治疗可能性降低以及疾病特异性生存率降低相关。虽然控制了几个潜在的混杂变量，但未测量的混杂因素在这些结果中发挥了作用。未来的研究应该寻求确定是什么因素导致了不合格的保险状况与癌症诊断后较差的生存相关的发现。候选变量可能包括医疗合并症、治疗延误、首次就诊和诊断的时间、接受治疗的类型、前往治疗的距离和交通障碍、自付负担以及教育和识字状况。这些变量几乎肯定与弱势患者群体的社会经济剥夺有关，一旦确定，就可以有针对性地进行治疗，以解决这些系统性不平等问题。证据等级:III级，治疗性研究。
{"title":"Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-Tissue Sarcomas? A SEER Database Study.","authors":"Anne A. Smartt, Eugene S. Jang, W. Tyler","doi":"10.1097/CORR.0000000000000889","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000889","url":null,"abstract":"BACKGROUND\u0000Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation?\u0000\u0000\u0000METHODS\u0000The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site.\u0000\u0000\u0000RESULTS\u0000Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were un","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75252810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-03-01DOI: 10.1097/CORR.0000000000000918
E. Newman, Jonathan Lans, Jason Kim, M. Ferrone, J. Ready, J. Schwab, K. Raskin, S. Calderón
BACKGROUND Desmoid tumors of the extremities often present with pain and functional limitation, but treatment can lead to morbidity and recurrence is common. The impact of treatment with respect to traditional "oncologic" metrics (such as recurrence rate) has been studied extensively, with a shift in recent years away from local therapies as first-line management; however, little is known about the association between treatment modality and long-term functional outcomes for patients with this benign disease. QUESTIONS/PURPOSES In a retrospective review of consecutive patients treated at two institutions, we asked: (1) Is event-free survival (EFS) different between patients who undergo local treatment and those who do not for primary as well as for recurrent desmoid tumors? (2) What treatment-related factors are associated with worse Patient-reported Outcomes Measurement Information System (PROMIS) function scores at a minimum of 1 year after treatment? METHODS Between 1991 and 2017, 102 patients with desmoid tumors of the extremities (excluding those of the hands and feet) were treated at two institutions; of those, 85 patients with 90 tumors were followed clinically for at least 1 year (median [range] 59 months follow-up [12 to 293]) and were included in the present analysis. We attempted to contact all patients for administration of PROMIS function (Physical Function Short Form [SF] 10a and Upper Extremity SF v2.0 7a) and Pain Interference (SF 8a) questionnaires. Complete survey data (minimum 1 year follow-up) were available for 46% (39 of 102) of patients with 40 tumors at a median of 125 months follow-up; only these patients were included in PROMIS data analyses. Though there was no formal institutional treatment algorithm in place during the study period, surgical resection typically was the preferred modality for primary tumors; radiation therapy and systemic treatments (including cytotoxic or hormonal agents earlier in the study period, and tyrosine kinase inhibitors later) were often added for recurrent or very symptomatic disease. We coded treatment for each patient into discrete episodes, each defined by a particular treatment strategy: local treatment only (surgery and/or radiation), systemic treatment only, local plus systemic treatment, or observation; treatment episodes rendered at other institutions (that is, before referral) were not included in the analyses. Treatment failure was defined as recurrence after surgical resection, or clinically significant radiologic and/or symptomatic progression after systemic treatment, and EFS was defined as time from treatment initiation to treatment failure or final follow-up. Episodes of treatment for recurrent tumors were analyzed in a pooled fashion, wherein discrete treatment episodes for patients with multiple recurrences were included separately as independent events. We analyzed 56 primary tumors (54 patients), and 101 discrete treatment episodes for recurrent tumors (88 patients). K
{"title":"PROMIS Function Scores Are Lower in Patients Who Underwent More Aggressive Local Treatment for Desmoid Tumors.","authors":"E. Newman, Jonathan Lans, Jason Kim, M. Ferrone, J. Ready, J. Schwab, K. Raskin, S. Calderón","doi":"10.1097/CORR.0000000000000918","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000918","url":null,"abstract":"BACKGROUND\u0000Desmoid tumors of the extremities often present with pain and functional limitation, but treatment can lead to morbidity and recurrence is common. The impact of treatment with respect to traditional \"oncologic\" metrics (such as recurrence rate) has been studied extensively, with a shift in recent years away from local therapies as first-line management; however, little is known about the association between treatment modality and long-term functional outcomes for patients with this benign disease.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000In a retrospective review of consecutive patients treated at two institutions, we asked: (1) Is event-free survival (EFS) different between patients who undergo local treatment and those who do not for primary as well as for recurrent desmoid tumors? (2) What treatment-related factors are associated with worse Patient-reported Outcomes Measurement Information System (PROMIS) function scores at a minimum of 1 year after treatment?\u0000\u0000\u0000METHODS\u0000Between 1991 and 2017, 102 patients with desmoid tumors of the extremities (excluding those of the hands and feet) were treated at two institutions; of those, 85 patients with 90 tumors were followed clinically for at least 1 year (median [range] 59 months follow-up [12 to 293]) and were included in the present analysis. We attempted to contact all patients for administration of PROMIS function (Physical Function Short Form [SF] 10a and Upper Extremity SF v2.0 7a) and Pain Interference (SF 8a) questionnaires. Complete survey data (minimum 1 year follow-up) were available for 46% (39 of 102) of patients with 40 tumors at a median of 125 months follow-up; only these patients were included in PROMIS data analyses. Though there was no formal institutional treatment algorithm in place during the study period, surgical resection typically was the preferred modality for primary tumors; radiation therapy and systemic treatments (including cytotoxic or hormonal agents earlier in the study period, and tyrosine kinase inhibitors later) were often added for recurrent or very symptomatic disease. We coded treatment for each patient into discrete episodes, each defined by a particular treatment strategy: local treatment only (surgery and/or radiation), systemic treatment only, local plus systemic treatment, or observation; treatment episodes rendered at other institutions (that is, before referral) were not included in the analyses. Treatment failure was defined as recurrence after surgical resection, or clinically significant radiologic and/or symptomatic progression after systemic treatment, and EFS was defined as time from treatment initiation to treatment failure or final follow-up. Episodes of treatment for recurrent tumors were analyzed in a pooled fashion, wherein discrete treatment episodes for patients with multiple recurrences were included separately as independent events. We analyzed 56 primary tumors (54 patients), and 101 discrete treatment episodes for recurrent tumors (88 patients). K","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"338 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80711615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-03-01DOI: 10.1097/CORR.0000000000000883
S. Furtado, A. Godfrey, S. Del Din, L. Rochester, C. Gerrand
BACKGROUND Aspects of physical functioning, including balance and gait, are affected after surgery for lower limb musculoskeletal tumors. These are not routinely measured but likely are related to how well patients function after resection or amputation for a bone or soft tissue sarcoma. Small, inexpensive portable accelerometers are available that might be clinically useful to assess balance and gait in these patients, but they have not been well studied. QUESTIONS/PURPOSES In patients treated for lower extremity musculoskeletal tumors, we asked: (1) Are accelerometer-based body-worn monitor assessments of balance, gait, and timed up-and-go tests (TUG) feasible and acceptable? (2) Do these accelerometer-based body-worn monitor assessments produce clinically useful data (face validity), distinguish between patients and controls (discriminant validity), reflect findings obtained using existing clinical measures (convergent validity) and standard manual techniques in clinic (concurrent validity)? METHODS This was a prospective cross-sectional study. Out of 97 patients approached, 34 adult patients treated for tumors in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) were included in this study. Twenty-seven had limb-sparing surgery and seven underwent amputation. Patients performed standard activities while wearing a body-worn monitor on the lower back, including standing, walking, and TUG tests. Summary measures of balance (area [ellipsis], magnitude [root mean square {RMS}], jerkiness [jerk], frequency of postural sway below which 95% of power of acceleration power spectrum is observed [f95 of postural sway]), gait [temporal outcomes, step length and velocity], and TUG time were derived. Body-worn monitor assessments were evaluated for feasibility by investigating data loss and patient-reported acceptability and comfort. In addition, outcomes in patients were compared with datasets of healthy participants collected in parallel studies using identical methods as in this study to assess discriminant validity. Body-worn monitor assessments were also investigated for their relationships with routine clinical scales (the Musculoskeletal Tumour Society Scoring system [MSTS], the Toronto Extremity Salvage Score [TESS], and the Quality of life-Cancer survivors [QoL-CS)] to assess convergent validity and their agreement with standard manual techniques (video and stopwatch) to assess concurrent validity. RESULTS Although this was a small patient group, there were initial indications that body-worn monitor assessments were well-tolerated, feasible to perform, acceptable to patients who responded (95% [19 of 20] of patients found the body-worn monitor acceptable and comfortable and 85% [17 of 20] found it user-friendly), and produced clinically useful data comparable with the evidence. Balance and gait measures distinguished patients and controls (discriminant validity), for instance balance outcome (ellipsis) in patients (0.0475
背景:下肢肌肉骨骼肿瘤手术后，身体功能的各个方面，包括平衡和步态都会受到影响。这些不是常规测量，但可能与骨或软组织肉瘤切除或截肢后患者的功能有关。小型、廉价的便携式加速度计可能在临床上用于评估这些患者的平衡和步态，但尚未得到很好的研究。问题/目的在接受下肢肌肉骨骼肿瘤治疗的患者中，我们的问题是:(1)基于加速度计的身体穿戴式监测评估平衡、步态和定时上下移动测试(TUG)是否可行和可接受?(2)这些基于加速计的穿戴式监测评估是否产生临床有用的数据(面部效度)，区分患者和对照组(区别效度)，反映使用现有临床测量(收敛效度)和临床标准手工技术(并发效度)获得的结果?方法前瞻性横断面研究。在97例患者中，34例因股骨/大腿(19例)、骨盆/髋关节(3例)、胫骨/腿(9例)或脚踝/足(3例)肿瘤接受治疗的成年患者被纳入本研究。27人接受了保肢手术，7人接受了截肢。患者在下背部佩戴体表监测器时进行标准活动，包括站立、行走和TUG测试。得出了平衡(面积[省略]、幅度[均方根{RMS}]、抖动[抽搐]、体位摆动频率(在此频率下观察到95%的加速度功率谱[体位摆动的f95])、步态[时间结果、步长和速度]和TUG时间的综合指标。通过调查数据丢失和患者报告的可接受性和舒适度来评估穿戴式监测仪评估的可行性。此外，采用与本研究相同的方法，将患者的结果与平行研究中收集的健康参与者的数据集进行比较，以评估区分效度。还研究了穿戴式监测评估与常规临床量表(肌肉骨骼肿瘤学会评分系统[MSTS]、多伦多肢体挽救评分[TESS]和生活质量-癌症幸存者[QoL-CS])的关系，以评估趋同效度，并与标准手工技术(视频和秒表)的一致性来评估并发效度。结果虽然这是一个小的患者群体，但初步迹象表明，穿戴式监护仪的评估耐受性良好，可行，对有反应的患者可接受(95%[19 / 20]的患者认为穿戴式监护仪可接受且舒适，85%[17 / 20]的患者认为其用户友好)，并产生了与证据相当的临床有用数据。平衡和步态测量区分了患者和对照组(判别效度)，例如，患者(0.0475 m/s[95%置信区间0.0251至0.0810])的平衡结果(省略)与对照组(0.0007 m/s [95% CI 0.0003至0.0502])相比受到影响;P = 0.001)。同样，与对照组(0.541秒[95% CI 0.496至0.573])相比，患者的步态结果(步数)也受到影响(0.483秒[95% CI 0.451至0.512]);P < 0.001)。此外，穿戴式监测仪评估与现有临床量表(收敛效度)存在相关性，例如与MSTS的省略(r = -0.393;P = 0.024)。同样，手工技术与体表监测的评估结果(并发效度)一致，例如秒表时间22.28 +/- 6.93秒与iTUG时间21.18 +/- 6.23秒(类内相关系数一致= 0.933;P < 0.001)。P < 0.05为差异有统计学意义。结论:虽然我们有一个小的、异质的患者群体，但这项初步研究表明，在临床上，穿戴式监测器可能对量化下肢肿瘤患者的身体功能有用。平衡和步态与残疾和生活质量有关。这些测量可以为临床医生提供关于平衡和步态的有用的新信息，从而可以指导康复策略。证据等级:诊断性研究III级。
{"title":"Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?","authors":"S. Furtado, A. Godfrey, S. Del Din, L. Rochester, C. Gerrand","doi":"10.1097/CORR.0000000000000883","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000883","url":null,"abstract":"BACKGROUND\u0000Aspects of physical functioning, including balance and gait, are affected after surgery for lower limb musculoskeletal tumors. These are not routinely measured but likely are related to how well patients function after resection or amputation for a bone or soft tissue sarcoma. Small, inexpensive portable accelerometers are available that might be clinically useful to assess balance and gait in these patients, but they have not been well studied.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000In patients treated for lower extremity musculoskeletal tumors, we asked: (1) Are accelerometer-based body-worn monitor assessments of balance, gait, and timed up-and-go tests (TUG) feasible and acceptable? (2) Do these accelerometer-based body-worn monitor assessments produce clinically useful data (face validity), distinguish between patients and controls (discriminant validity), reflect findings obtained using existing clinical measures (convergent validity) and standard manual techniques in clinic (concurrent validity)?\u0000\u0000\u0000METHODS\u0000This was a prospective cross-sectional study. Out of 97 patients approached, 34 adult patients treated for tumors in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) were included in this study. Twenty-seven had limb-sparing surgery and seven underwent amputation. Patients performed standard activities while wearing a body-worn monitor on the lower back, including standing, walking, and TUG tests. Summary measures of balance (area [ellipsis], magnitude [root mean square {RMS}], jerkiness [jerk], frequency of postural sway below which 95% of power of acceleration power spectrum is observed [f95 of postural sway]), gait [temporal outcomes, step length and velocity], and TUG time were derived. Body-worn monitor assessments were evaluated for feasibility by investigating data loss and patient-reported acceptability and comfort. In addition, outcomes in patients were compared with datasets of healthy participants collected in parallel studies using identical methods as in this study to assess discriminant validity. Body-worn monitor assessments were also investigated for their relationships with routine clinical scales (the Musculoskeletal Tumour Society Scoring system [MSTS], the Toronto Extremity Salvage Score [TESS], and the Quality of life-Cancer survivors [QoL-CS)] to assess convergent validity and their agreement with standard manual techniques (video and stopwatch) to assess concurrent validity.\u0000\u0000\u0000RESULTS\u0000Although this was a small patient group, there were initial indications that body-worn monitor assessments were well-tolerated, feasible to perform, acceptable to patients who responded (95% [19 of 20] of patients found the body-worn monitor acceptable and comfortable and 85% [17 of 20] found it user-friendly), and produced clinically useful data comparable with the evidence. Balance and gait measures distinguished patients and controls (discriminant validity), for instance balance outcome (ellipsis) in patients (0.0475","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"111 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79181411","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-03-01DOI: 10.1097/CORR.0000000000000933
J. Mayerson
Physicians often use performancebased clinical assessments like physical therapist evaluations or standardized scoring systems to assess function in our patients. Modern technology is impacting health care in many ways, but little is known about how we might use wearable technology to devise new clinical assessments of function for patients with sarcoma. Traditional functional outcome measures in sarcoma care include the Musculoskeletal Tumor Society Functional Assessment Score [3] and the Toronto Extremity Salvage Score [2]. Generally, gait has been studied in a laboratory using force plates that include costly equipment not easily used by the general public [1]. But recently, we have seen tremendous growth in personal wearable technology, including a number of devices that give users a somewhat-accurate assessment of the distance, time, places, and types of activities that we participate in. Other wearable devices canmeasure heart rate, the number of steps we take, and the number of stairs we climb. It seems reasonable, therefore, for clinicianscientists to explore the breadth of disease processes that can be analyzed with wearable technology [5, 7]. In the current study, Furtado and colleagues [4] bring wearable technology into the clinical realm of sarcoma care. To my knowledge, they are the first to report accelerometerbased body-worn monitor assessments of balance, gait, and timed upand-go tests to produce clinically useful data. Furtado and colleagues [4] demonstrate in a small subset of patients that wearable devices can be used to discriminate balance and gait differences between controls and limb salvage patients.
{"title":"CORR Insights®: Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?","authors":"J. Mayerson","doi":"10.1097/CORR.0000000000000933","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000933","url":null,"abstract":"Physicians often use performancebased clinical assessments like physical therapist evaluations or standardized scoring systems to assess function in our patients. Modern technology is impacting health care in many ways, but little is known about how we might use wearable technology to devise new clinical assessments of function for patients with sarcoma. Traditional functional outcome measures in sarcoma care include the Musculoskeletal Tumor Society Functional Assessment Score [3] and the Toronto Extremity Salvage Score [2]. Generally, gait has been studied in a laboratory using force plates that include costly equipment not easily used by the general public [1]. But recently, we have seen tremendous growth in personal wearable technology, including a number of devices that give users a somewhat-accurate assessment of the distance, time, places, and types of activities that we participate in. Other wearable devices canmeasure heart rate, the number of steps we take, and the number of stairs we climb. It seems reasonable, therefore, for clinicianscientists to explore the breadth of disease processes that can be analyzed with wearable technology [5, 7]. In the current study, Furtado and colleagues [4] bring wearable technology into the clinical realm of sarcoma care. To my knowledge, they are the first to report accelerometerbased body-worn monitor assessments of balance, gait, and timed upand-go tests to produce clinically useful data. Furtado and colleagues [4] demonstrate in a small subset of patients that wearable devices can be used to discriminate balance and gait differences between controls and limb salvage patients.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77744936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-02-01DOI: 10.1097/CORR.0000000000001040
J. Falvey, M. Bade, C. Hogan, Jeri E. Forster, J. Stevens-Lapsley
BACKGROUND With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown. QUESTIONS/PURPOSES (1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA? METHODS This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence. RESULTS Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008). CONCLUSIONS Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoin
背景:随着最近医疗保险支付方式的改变，老年人在全关节置换术(TJA)后越来越可能出院回家，而不是去延长护理设施，因此再入院的风险可能增加。确定再入院的风险因素可以帮助重新调整易感患者的护理路径;最近的研究表明，术前日常生活活动依赖(ADL)可能会增加围手术期和术后手术并发症。然而，老年手术患者术前ADL依赖的比例，以及ADL依赖对再入院频率和时间的影响尚不清楚。(1)TJA后出院的老年人术前ADL依赖的比例是多少?(2)术前ADL依赖是否与TJA后出院的老年人在30天或90天再次住院的风险增加有关?方法回顾性队列分析2012年以来6270份医疗保险按服务收费索赔，这些索赔来自5%的全国医疗保险样本，这些老年人(65岁以上)在选择性TJA后出院后接受家庭医疗保健。使用医疗保险家庭健康声明有两个原因:(1)主要关注人群是老年人;(2)随附的患者水平评估数据包括先前对四项ADL任务的依赖性评估。日常生活依赖活动被分为严重(需要人类帮助完成所有四项评估任务)或部分/无(需要三个或更少的adl帮助);在先前的研究中，这个临界值被用于评估再入院风险。多变量logistic回归模型，在医院水平聚类，并根据已知的再入院风险因素(如合并症状态或年龄)进行调整，用于模拟严重ADL依赖患者30天、90天和再入院的几率。结果总共有411名患者在研究期间住院。在所有再入院患者中，64%(411例中的262例)发生在前30天内，再入院的中位数(四分位数间距[IQR])时间为17天(5至46天)。术前严重的ADL依赖在从TJA恢复的老年家庭健康接受者中很常见，影响了我们样本人口的17%(6270人中的1066人)。在调整临床协变量后，严重的ADL依赖与90天再入院无关(调整优势比= 1.20 [95% CI 0.93至1.55];P = 0.15)。然而，术前严重的ADL依赖与30天再入院的几率较高相关(调整后OR = 1.45 [95% CI 1.11至1.99];P = 0.008)。结论术前重度ADL依赖与TJA术后早期再入院相关，但与晚期不相关。这项工作表明，术前对ADL依赖进行简单的筛查可能很重要，这样外科医生就可以指导老年人接受TJA的护理计划的变化，其中可能包括参与术前康复(预康复)或术后30天内更积极的随访。严重的ADL依赖是否可以在手术前改变，以及这些依赖的改变是否可以降低TJA后再入院的风险，还需要进一步的研究。证据等级:III级，治疗性研究。
{"title":"Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty.","authors":"J. Falvey, M. Bade, C. Hogan, Jeri E. Forster, J. Stevens-Lapsley","doi":"10.1097/CORR.0000000000001040","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001040","url":null,"abstract":"BACKGROUND\u0000With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA?\u0000\u0000\u0000METHODS\u0000This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence.\u0000\u0000\u0000RESULTS\u0000Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008).\u0000\u0000\u0000CONCLUSIONS\u0000Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoin","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"142 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77459970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-02-01DOI: 10.1097/CORR.0000000000000997
Q. Thio, A. Karhade, Paul T. Ogink, J. Bramer, M. Ferrone, S. Calderón, K. Raskin, J. Schwab
BACKGROUND A preoperative estimation of survival is critical for deciding on the operative management of metastatic bone disease of the extremities. Several tools have been developed for this purpose, but there is room for improvement. Machine learning is an increasingly popular and flexible method of prediction model building based on a data set. It raises some skepticism, however, because of the complex structure of these models. QUESTIONS/PURPOSES The purposes of this study were (1) to develop machine learning algorithms for 90-day and 1-year survival in patients who received surgical treatment for a bone metastasis of the extremity, and (2) to use these algorithms to identify those clinical factors (demographic, treatment related, or surgical) that are most closely associated with survival after surgery in these patients. METHODS All 1090 patients who underwent surgical treatment for a long-bone metastasis at two institutions between 1999 and 2017 were included in this retrospective study. The median age of the patients in the cohort was 63 years (interquartile range [IQR] 54 to 72 years), 56% of patients (610 of 1090) were female, and the median BMI was 27 kg/m (IQR 23 to 30 kg/m). The most affected location was the femur (70%), followed by the humerus (22%). The most common primary tumors were breast (24%) and lung (23%). Intramedullary nailing was the most commonly performed type of surgery (58%), followed by endoprosthetic reconstruction (22%), and plate screw fixation (14%). Missing data were imputed using the missForest methods. Features were selected by random forest algorithms, and five different models were developed on the training set (80% of the data): stochastic gradient boosting, random forest, support vector machine, neural network, and penalized logistic regression. These models were chosen as a result of their classification capability in binary datasets. Model performance was assessed on both the training set and the validation set (20% of the data) by discrimination, calibration, and overall performance. RESULTS We found no differences among the five models for discrimination, with an area under the curve ranging from 0.86 to 0.87. All models were well calibrated, with intercepts ranging from -0.03 to 0.08 and slopes ranging from 1.03 to 1.12. Brier scores ranged from 0.13 to 0.14. The stochastic gradient boosting model was chosen to be deployed as freely available web-based application and explanations on both a global and an individual level were provided. For 90-day survival, the three most important factors associated with poorer survivorship were lower albumin level, higher neutrophil-to-lymphocyte ratio, and rapid growth primary tumor. For 1-year survival, the three most important factors associated with poorer survivorship were lower albumin level, rapid growth primary tumor, and lower hemoglobin level. CONCLUSIONS Although the final models must be externally validated, the algorithms showed good performance
{"title":"Development and Internal Validation of Machine Learning Algorithms for Preoperative Survival Prediction of Extremity Metastatic Disease.","authors":"Q. Thio, A. Karhade, Paul T. Ogink, J. Bramer, M. Ferrone, S. Calderón, K. Raskin, J. Schwab","doi":"10.1097/CORR.0000000000000997","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000997","url":null,"abstract":"BACKGROUND\u0000A preoperative estimation of survival is critical for deciding on the operative management of metastatic bone disease of the extremities. Several tools have been developed for this purpose, but there is room for improvement. Machine learning is an increasingly popular and flexible method of prediction model building based on a data set. It raises some skepticism, however, because of the complex structure of these models.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000The purposes of this study were (1) to develop machine learning algorithms for 90-day and 1-year survival in patients who received surgical treatment for a bone metastasis of the extremity, and (2) to use these algorithms to identify those clinical factors (demographic, treatment related, or surgical) that are most closely associated with survival after surgery in these patients.\u0000\u0000\u0000METHODS\u0000All 1090 patients who underwent surgical treatment for a long-bone metastasis at two institutions between 1999 and 2017 were included in this retrospective study. The median age of the patients in the cohort was 63 years (interquartile range [IQR] 54 to 72 years), 56% of patients (610 of 1090) were female, and the median BMI was 27 kg/m (IQR 23 to 30 kg/m). The most affected location was the femur (70%), followed by the humerus (22%). The most common primary tumors were breast (24%) and lung (23%). Intramedullary nailing was the most commonly performed type of surgery (58%), followed by endoprosthetic reconstruction (22%), and plate screw fixation (14%). Missing data were imputed using the missForest methods. Features were selected by random forest algorithms, and five different models were developed on the training set (80% of the data): stochastic gradient boosting, random forest, support vector machine, neural network, and penalized logistic regression. These models were chosen as a result of their classification capability in binary datasets. Model performance was assessed on both the training set and the validation set (20% of the data) by discrimination, calibration, and overall performance.\u0000\u0000\u0000RESULTS\u0000We found no differences among the five models for discrimination, with an area under the curve ranging from 0.86 to 0.87. All models were well calibrated, with intercepts ranging from -0.03 to 0.08 and slopes ranging from 1.03 to 1.12. Brier scores ranged from 0.13 to 0.14. The stochastic gradient boosting model was chosen to be deployed as freely available web-based application and explanations on both a global and an individual level were provided. For 90-day survival, the three most important factors associated with poorer survivorship were lower albumin level, higher neutrophil-to-lymphocyte ratio, and rapid growth primary tumor. For 1-year survival, the three most important factors associated with poorer survivorship were lower albumin level, rapid growth primary tumor, and lower hemoglobin level.\u0000\u0000\u0000CONCLUSIONS\u0000Although the final models must be externally validated, the algorithms showed good performance ","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90215117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-02-01DOI: 10.1097/CORR.0000000000000969
L. Dorr
Inmy experience, a successful total knee replacement is determined by implant positioning, leg alignment, and soft-tissue balance, which includes medial-lateral and AP stability. My definition of a well-done TKA has not changed since the early 1980s, when our specialty—and patients’ lives— were improved by the development of precision mechanical alignment guides, and by the tireless work of David S. Hungerford MD who taught surgeons how to use them. The principles of successful rotational alignment of the implants, and soft-tissue treatment and balance were taught by Chitranjan S. Ranawat MD, and John N. Insall MD for posterior cruciate ligament sacrificing knees, andRichard D. ScottMD and Tom S. Thornhill MD for posteriorcruciate ligament retaining knees. These principles of total knee replacement have not appreciably changed through four decades, nor has implant design resulted in anything other than evolutionary change. The authors of the current study do not change the principles of the operation, but describe more-precise instrumentation, specifically for the bone cuts in the coronal plane [4]. Since the success of total knee replacement is dependent on rotational mating of the femoral and tibial implants, and the soft-tissue balance of the knee, both of which remain dependent on surgeon decisions no matter the instrumentation, it is unreasonable to expect a difference in clinical scores or revisions between a surgeon who performed 340 total knee replacements per year (as did the surgeon in this study) and the use of high-tech instruments. Indeed, no difference was found. But that does not mean that robotic instrumentation offers no value to low volume or inexperienced surgeons.
根据我的经验，成功的全膝关节置换术取决于植入物的定位、腿部对齐和软组织平衡，包括内侧外侧和前后关节的稳定性。自20世纪80年代初以来，我对一个做得好的TKA的定义就没有改变过，当时我们的专业和患者的生活都得到了改善，这是由于精密机械校准指南的发展，以及大卫·s·亨格福德博士(David S. Hungerford MD)不知疲倦的工作，他教外科医生如何使用它们。Chitranjan S. Ranawat医学博士和John N. Insall医学博士教授了成功旋转假体对准、软组织处理和平衡的原则，后者用于后交叉韧带保留膝，richard D. ScottMD和Tom S. Thornhill医学博士用于后交叉韧带保留膝。四十年来，全膝关节置换术的这些原则并没有明显的改变，植入物的设计也没有导致任何其他的进化变化。本研究的作者没有改变手术原理，但描述了更精确的仪器，特别是冠状面骨切口[4]。由于全膝关节置换术的成功取决于股骨和胫骨植入物的旋转配合，以及膝关节的软组织平衡，而这两者都取决于外科医生的决定，无论使用何种器械，期望每年进行340次全膝关节置换术的外科医生(本研究中的外科医生也是如此)与使用高科技器械之间的临床评分或修正存在差异是不合理的。事实上，没有发现任何差异。但这并不意味着机器人仪器对低容量或缺乏经验的外科医生没有价值。
{"title":"CORR Insights®: Does Robotic-assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial.","authors":"L. Dorr","doi":"10.1097/CORR.0000000000000969","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000969","url":null,"abstract":"Inmy experience, a successful total knee replacement is determined by implant positioning, leg alignment, and soft-tissue balance, which includes medial-lateral and AP stability. My definition of a well-done TKA has not changed since the early 1980s, when our specialty—and patients’ lives— were improved by the development of precision mechanical alignment guides, and by the tireless work of David S. Hungerford MD who taught surgeons how to use them. The principles of successful rotational alignment of the implants, and soft-tissue treatment and balance were taught by Chitranjan S. Ranawat MD, and John N. Insall MD for posterior cruciate ligament sacrificing knees, andRichard D. ScottMD and Tom S. Thornhill MD for posteriorcruciate ligament retaining knees. These principles of total knee replacement have not appreciably changed through four decades, nor has implant design resulted in anything other than evolutionary change. The authors of the current study do not change the principles of the operation, but describe more-precise instrumentation, specifically for the bone cuts in the coronal plane [4]. Since the success of total knee replacement is dependent on rotational mating of the femoral and tibial implants, and the soft-tissue balance of the knee, both of which remain dependent on surgeon decisions no matter the instrumentation, it is unreasonable to expect a difference in clinical scores or revisions between a surgeon who performed 340 total knee replacements per year (as did the surgeon in this study) and the use of high-tech instruments. Indeed, no difference was found. But that does not mean that robotic instrumentation offers no value to low volume or inexperienced surgeons.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"128 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73879716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-02-01DOI: 10.1097/CORR.0000000000000986
D. Axelrod, Seper Ekhtiari, A. Bozzo, M. Bhandari, H. Johal
BACKGROUND Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. RESULTS Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and C
背景:移位的三分之一锁骨骨折很常见，其治疗方法尚不清楚。虽然一些荟萃分析比较了特定的手术技术与非手术治疗，但不可能使用标准的荟萃分析来比较不同的手术结构。相反，网络荟萃分析允许在两个以上的治疗组之间进行比较，在许多试验中使用直接和间接比较干预措施。据我们所知，尚无网络荟萃分析对移位性锁骨骨折的多种治疗方案进行比较。问题/目的我们对随机对照试验(RCTs)进行了网络荟萃分析，以确定用于治疗移位的锁骨中轴骨折的方法:(1)1年愈合机会最高的干预措施，(2)翻修手术风险最低的干预措施，(3)功能结局评分最高的干预措施。其次，我们也(4)比较了在上述相同终点的现有随机对照试验中的手术亚型。方法回顾medline、Embase和Cochrane Central Register of Controlled Trials，检索截至2018年7月25日发表的相关随机对照试验。回顾了284篇论文，其中22篇符合随机对照试验的纳入标准，采用适当的随机化技术，成年人群，至少1年随访，至少包括一个手术治疗组。总共有1002例患者接受了钢板治疗，378例患者接受了髓内装置治疗，585例患者接受了非手术治疗。治疗亚型包括锁定髓内装置(56例)、未锁定髓内装置(322例)、前路电镀(89例)、前上路电镀(150例)、上路电镀(449例)或未另行指定的电镀(314例)。我们进行了一项网络荟萃分析，对移位性锁骨骨折的治疗方法进行比较和排序。我们考虑了以下结果:愈合情况、翻修手术风险和功能结果(DASH和Constant Scores)。Constant和DASH评分的最小临床重要差异(MCID)被认为是8分，分别代表证据中DASH和Constant报告的MCID评分的平均值。结果非手术组愈合率较低(88.9%)，手术组愈合率较高(96.7%)，相对危险度[RR] 1.128 [95% CI 1.1 ~ 1.17];p < 0.001)，需要治疗的人数(NNT) = 10)。骨连成就随钢板结构的不同而增加(97.8%，RR 1.13 [95% CI 1.1 ~ 1.7];p < 0.0001, NNT = 9)和前或前上钢板(99.3%，RR 1.14 [95% CI 1.1 ~ 1.8];p < 0.0001, NNT = 8)。再手术的风险在所有治疗组中都是相似的。最后，手术治疗优于非手术治疗，DASH和Constant评分略有改善，但未接近MCID。在亚型水平上，前上镀在DASH和Constant功能评分中排名最高，Constant评分的平均差异达到10分(95% CI 4.4至2.5)，DASH评分的平均差异达到7.6分(95% CI 5.2至20)。结论:我们发现手术治疗在1年随访中使移位的成人中三分之一锁骨骨折患者愈合的可能性更大。总的来说，手术治疗并没有使功能评分增加到患者可能认为具有临床重要性的程度。使用特定亚型的钢板(前、前上)导致Constant评分的改善，略高于MCID，但未达到DASH评分的MCID，这表明任何有利于手术的结果评分益处可能是难以察觉的或很小的。根据这些发现，我们认为患者可以被告知，手术治疗这种损伤可以逐渐增加愈合的可能性(大约10名患者需要接受手术以避免一例骨不连)，但他们不应该期望比不手术更好的功能;大多数患者完全可以避免手术，绝对不愈合的风险很小。选择手术的患者必须被告知，这个决定应该与并发症和接受第二次手术摘除硬件的可能性进行权衡。选择不手术治疗急性锁骨中轴骨折的患者可以被告知，不愈合发生在略多于10%的患者中，并且这些患者可能比急性骨折更难治疗。证据水平:I级，治疗性研究。
{"title":"What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials.","authors":"D. Axelrod, Seper Ekhtiari, A. Bozzo, M. Bhandari, H. Johal","doi":"10.1097/CORR.0000000000000986","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000986","url":null,"abstract":"BACKGROUND\u0000Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints.\u0000\u0000\u0000METHODS\u0000MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively.\u0000\u0000\u0000RESULTS\u0000Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and C","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84017238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-01-01DOI: 10.1097/CORR.0000000000000937
Charles N Cornell
{"title":"CORR Insights®: Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database.","authors":"Charles N Cornell","doi":"10.1097/CORR.0000000000000937","DOIUrl":"10.1097/CORR.0000000000000937","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":"88-89"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000046/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81917819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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