Influences and Practices in Colorectal Cancer Screening Among Health Care Providers Serving Northern Plains American Indians, 2011-2012

Introduction

The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians.

Methods

Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge.

Results

The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, χ² = 4.29, P = .04).

Conclusion

Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed.

Perioperative pain management in hip arthroscopy; what options are there?

Hip arthroscopy is a fast growing orthopedic field of expertise. As in any field of surgery adequate postoperative pain management regimes are of utmost importance. The purpose of this review is to provide an overview of current knowledge on anesthetic options for perioperative pain management for hip arthroscopy. We searched the Pubmed/Medline and Embase database for literature and included 10 studies for our analysis. Because of the variety of pain scales and different ways of measured pain no meta-analysis could be performed and a descriptive review is performed. There are several types of pain regimens that can mostly be divided in two groups: local anesthetics and nerve blocks. Included studies show a rather large variation in reported visual analogue scale scores, post anesthesia care unit admission time and opioid usage. There are several anesthetic options available for hip arthroscopy. Different studies use different dosages, anesthetic regimens and different protocols; this partly explains the differences between studies with similar techniques. Peripheral nerve blocks seems promising but regarding current literature no clear recommendation can be made about what the best perioperative pain management option is, an overview of all reported techniques is given.

Facing the decision about the treatment of hip or knee osteoarthritis: What are patients' needs?

PURPOSE

There is an increasing interest in modern orthopaedic practice to empower patients to participate in shared decision-making. Decision aids are thought to be helpful in this process. Before creating decision aids for patients with osteoarthritis in the knee or hip, the goal was to identify the needs of patients and physicians when deciding about the treatment. Specifically, this study tested the null hypothesis that there is no significant difference in decisional conflict between patients with knee or hip osteoarthritis and orthopaedic surgeons.

METHODS

Thirty-three orthopaedic surgeons and 172 patients with either knee or hip osteoarthritis were surveyed. Patients entered their demographic information and completed the Knee Injury and Osteoarthritis Outcome Score/Hip Disability and Osteoarthritis Outcome Score, the Assessment of Needs survey based on the Ottawa Decision Support Framework, the Decisional Conflict Scale, the Pain Self-Efficacy Questionnaire, the Patient-Doctor Relationship Questionnaire-9, the Pain Anxiety Symptoms Scale and the Patient Health Questionnaire. Physicians entered their demographic and professional information and completed the Assessment of Needs survey based on the Ottawa Decision Support Framework and the Decisional Conflict Scale.

RESULTS

The results showed that there was a significant difference (P < 0.01) between patients [mean (SD), 33 (19)] and physicians [mean (SD), 24 (14)], regarding decisional conflict about the treatment of knee and hip osteoarthritis. It also showed that patients' decisional conflict was associated with the patient-doctor relationship, and there was a need for information and clearness of one's values for risks and benefits.

CONCLUSION

Patients had a higher magnitude of decisional conflict than physicians and that the level of decisional conflict was positively influenced by the patient-doctor relationship. Patients had high needs regarding information and clearness of one's values for risks and benefits.

LEVEL OF EVIDENCE

II.

Evaluation of the Dutch version of the Foot and Ankle Outcome Score (FAOS): Responsiveness and Minimally Important Change

PURPOSE

The aim of this study was to evaluate the responsiveness of the Foot and Ankle Outcome Score (FAOS) and provide data on the Minimally Important Change (MIC) in patients 1 year after hindfoot and ankle surgery.

METHODS

Prospective pre-operative and 1 year post-operative FAOS scores were collected from 145 patients. A patient's global assessment and a longitudinal derived Function Change Score were used as external anchors. To assess responsiveness, effect sizes (ES) and Standardized Response Means (SRM) were calculated and hypotheses on their magnitudes were formulated. Additional ROC curve analysis was performed, and the Area Under the Curve (AUC) was calculated as a measure of responsiveness. MIC values were estimated using two different methods: (1) the mean change method and (2) the optimal cut-off point of the ROC curve.

RESULTS

Responsiveness was supported by confirmation of 84% of the hypothesized ES and SRM and almost all AUCs exceeding 0.70. MIC values ranged from 7 (symptoms) to 38 (sport) points. They varied between calculation methods and were negatively associated with baseline values. A considerable amount of MIC values did not exceed the smallest detectable change limit, indicating that the FAOS is more suitable at group level than for longitudinally following individual patients.

CONCLUSIONS

The FAOS demonstrated good responsiveness in patients 1 year after hindfoot and ankle surgery. Due to their wide variation, MIC estimates derived in this study should be interpreted with caution. However, these estimates can be of value to facilitate sample size calculation in future studies.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Designing Colorectal Cancer Screening Decision Support: A Cognitive Engineering Enterprise

Adoption of clinical decision support has been limited. Important barriers include an emphasis on algorithmic approaches to decision support that do not align well with clinical work flow and human decision strategies, and the expense and challenge of developing, implementing, and refining decision support features in existing electronic health records (EHRs). We applied decision-centered design to create a modular software application to support physicians in managing and tracking colorectal cancer screening. Using decision-centered design facilitates a thorough understanding of cognitive support requirements from an end user perspective as a foundation for design. In this project, we used an iterative design process, including ethnographic observation and cognitive task analysis, to move from an initial design concept to a working modular software application called the Screening & Surveillance App. The beta version is tailored to work with the Veterans Health Administration's EHR Computerized Patient Record System (CPRS). Primary care providers using the beta version Screening & Surveillance App more accurately answered questions about patients and found relevant information more quickly compared to those using CPRS alone. Primary care providers also reported reduced mental effort and rated the Screening & Surveillance App positively for usability.

Hip arthroscopy in obese, a successful combination?

Discussion persists about the outcome and results of hip arthroscopy in obese patients. Hip arthroscopy gained popularity over time. A current discussion is if obese patients can reach similar results after surgery compared with non-obese. To our knowledge, this is the first systematic review of literature about hip arthroscopy and obesity. We searched the Pubmed/Medline databases for literature and included three studies that compared the outcome of hip arthroscopy between different BMI groups. We extracted and pooled the data. For continues data a weighted mean difference was calculated, for dichotomous variables a weighted odds ratio (OR) was calculated using Review Software Manager. Heterogeneity of the included studies was calculated using I² statistics. Data were extracted from two studies. In the Obese group, there was significant more conversion to total hip replacement or resurfacing hip replacement (OR = 2.21, 95% CI 1.07–4.56) and more re-arthroscopy (OR = 4.68, 95% CI 1.41–15.45). Any reoperation occurred more often in the obese group (OR = 2.87, 95% CI 1.53–5.38). In the Non Arthritic Hip Score obese scored lower than the non-Obese group [10.9 (−14,6 to 7.1)]. For the modified Harris Hip Score the score is − 6,6, according to the MCID this difference is clinically relevant. For both scores obese show lower outcomes but similar improvement after hip arthroscopy. Regarding a higher chance of needing a re-operation and lower subjective outcome scores obesity appears to have a negative influence on the outcome of hip arthroscopy.

Validation of the Dutch language version of the Foot and Ankle Outcome Score

PURPOSE

The aim of this study was to develop a Dutch language version of the Foot and Ankle Outcome Score (FAOS-DLV) and evaluate its measurement properties according to the definitions of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

METHODS

After a standard forward-backward translation procedure, the Dutch version of the FAOS was evaluated for reliability and validity in 110 patients with various hind foot and ankle complaints. Reliability was evaluated by calculation of intraclass correlation coefficients (ICC), Cronbach's alpha for internal consistency, and the smallest detectable change (SDC). Construct validity of the FAOS was assessed by calculation of Spearman's correlation coefficients with similar and dissimilar domains of the SF-36 health survey, American Orthopedic Foot and Ankle Society Ankle and Hindfoot Scale, and visual analogue scales for pain and disability. Dimensionality was tested with confirmatory factor analysis.

RESULTS

Reliability of the FAOS-DLV was good. The ICC of the subscales ranged from 0.83 to 0.88. The minimal value of Cronbach's alpha was 0.76. The SDC at individual level ranged from 18 to 21 and at group level between 2.1 and 2.5. Construct validity was supported by confirmation of 85 % of the hypothesized correlations. Unidimensionality of the FAOS-DLV domains was moderate.

CONCLUSION

The Dutch version of the FAOS seems to have acceptable measurement properties. The questionnaire can be used for functional assessment of patients with varying hindfoot and ankle symptoms. It is, however, more suitable for clinical evaluation at group level than for monitoring a specific patient.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

A Process Evaluation of the Alaska Native Colorectal Cancer Family Outreach Program

This article presents the results of a process evaluation of the Alaska Native (AN) Colorectal Cancer (CRC) Family Outreach Program, which encourages CRC screening among AN first-degree relatives (i.e., parents, siblings, adult children; hereafter referred to as relatives) of CRC patients. Among AN people incidence and death rates from CRC are the highest of any ethnic/racial group in the United States. Relatives of CRC patients are at increased risk; however, CRC can be prevented and detected early through screening. The evaluation included key informant interviews (August to November 2012) with AN and non-AN stakeholders and program document review. Five key process evaluation components were identified: program formation, evolution, outreach responses, strengths, and barriers and challenges. Key themes included an incremental approach that led to a fully formed program and the need for dedicated, culturally competent patient navigation. Challenges included differing relatives' responses to screening outreach, health system data access and coordination, and the program impact of reliance on grant funding. This program evaluation indicated a need for more research into motivating patient screening behaviors, electronic medical records systems quality improvement projects, improved data-sharing protocols, and program sustainability planning to continue the dedicated efforts to promote screening in this increased risk population.

Use of Tracking and Reminder Systems for Colorectal Cancer Screening in Indian Health Service and Tribal Facilities

BACKGROUND

Colorectal cancer (CRC) is a significant cause of morbidity and mortality among American Indian/Alaska Native (AI/AN) people. Screening at recommended intervals can detect CRC in its early, most treatable stages, or prevent CRC through removal of precancerous polyps. However, CRC screening percentages remain low among AI/AN people. Reminder and tracking systems can be used to improve CRC screening percentages.

PURPOSE

In this study we assessed the prevalence of CRC screening reminder and tracking systems in Indian Health Service (IHS), Tribal, or Urban (I/T/U) health facilities.

METHODS

A telephone survey of randomly selected small, medium and large I/T/U health facilities nationwide was conducted. Three health facilities from each of the 12 IHS areas nationwide were selected from a list of I/T/U healthcare facilities that provide CRC screening or refer patients to another facility for screening, with the goal of having one small, one medium, and one large I/T/U health facility from each IHS area.

RESULTS

Thirty-four facilities (94%) participated in the telephone survey between April 1 and September 24, 2010. All facilities used the IHS Resource and Patient Management System to manage their patient care, and 82% used the Electronic Health Record (EHR) version. Over half of these facilities (55%) performed in-office fecal occult blood tests (FOBT) collected during a digital rectal exam, all of which reported that they also sent FOBT cards home with patients. Fifty-three percent of facilities used an opportunistic, visit-based approach to CRC screening. Nearly a third (32%) of facilities reported using a reminder system to notify patients that they were due for CRC screening. Almost two-thirds (65%) of facilities used a reminder system to notify health care providers that patients were due for CRC screening. While 73% of facilities used a system to track whether patients were due for CRC screening, only 61% used a system to track patient results for CRC screening, and 42% used a system to track patients with a personal history of polyps or CRC.

CONCLUSIONS

A majority of facilities performed in-office FOBT tests using a digital rectal exam, which is a practice that is contrary to national CRC screening recommendations. Additionally, the majority of facilities reported not using an organized system for CRC screening. Use of patient reminders was suboptimal. However, facilities did report use of provider reminders, tracking when patients were due for CRC screening, and tracking CRC screening results. As the EHR system becomes more widely used and established, I/T/U facilities could be encouraged to increase their use of the EHR tools available to aid in systematically increasing CRC screening percentages.

Evaluating an Electronic Measure of Colorectal Cancer Screening at Indian Health Service Facilities, 2008-2010

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer mortality in American Indian and Alaska Native (AIAN) people, and incidence rates vary considerably among AIAN populations throughout the United States. Screening has the potential to prevent CRC deaths by detection and treatment of early disease or removal of precancerous polyps. Surveillance of CRC screening is critical to efforts to improve delivery of this preventive service, but existing CRC screening surveillance methods for AIAN are limited. The Government Performance and Results Act (GPRA) CRC screening clinical care measure provides data on CRC screening among AIAN populations.

PURPOSE

The aim of this study was to evaluate the accuracy of the GPRA measure for CRC screening (sensitivity, specificity, positive predictive value and negative predictive value), determine reasons for CRC screening misclassification (procedures noted as screening when they were actually diagnostic exams), and to suggest opportunities for improving surveillance for CRC screening nationwide for AIAN populations.

METHODS

Medical record reviews (paper and electronic) were compared to the GPRA-reported CRC screening status for 1,071 patients receiving care at tribal health facilities. A total of 8 tribal health facilities (2 small, 3 medium, and 3 large) participated in the study from the Pacific Coast, the Southwest, the Southern Plains, and Alaska IHS regions. Screening-eligible patients were identified using queries of the local electronic health record from January 2007 to December 2008, and medical chart reviews were completed at participating facilities from September 2008 to June 2010.

RESULTS

Among 545 patients classified as screened by the GPRA measure, 305 (56%, CI: 52%-60%) had a false positive for screening as compared with medical record review. The overall sensitivity of the GPRA measure for CRC screening was 93% (CI=89%-95%) while specificity was 62% (CI: 59%-66%). The most common reasons for misclassification were for diagnostic or surveillance tests to be recorded as screening (67%), as well as medical record miscoding (18%) due to miscoding, charting errors, screenings performed outside the IHS, testing for a non-screening purpose, and categorization of patients as screened when a test had been ordered but not actually completed.

CONCLUSIONS

This study found that the GPRA CRC screening clinical measure overestimates the true screening rate due to the inclusion of diagnostic and surveillance exams, especially colonoscopy, as well as misclassification errors. The results of this study suggest a need to more accurately use the ICD-9 diagnostic code V76.51, which was associated with frequent coding errors. In combination with other programmatic efforts that focus on screening average- risk, asymptomatic American Indian and Alaska Native persons, improving the coding used for CRC screening may help to more accurately detect decreases in AIAN CRC incidence and mortality.

Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009

OBJECTIVES

We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data.

METHODS

We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling.

RESULTS

The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites.

CONCLUSIONS

Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

Comparison of fecal occult blood tests for colorectal cancer screening in an Alaska Native population with high prevalence of Helicobacter pylori infection, 2008-2012

Introduction

Alaska Native colorectal cancer (CRC) incidence and mortality rates are the highest of any ethnic/racial group in the United States. CRC screening using guaiac-based fecal occult blood tests (gFOBT) are not recommended for Alaska Native people because of false-positive results associated with a high prevalence of Helicobacter pylori-associated hemorrhagic gastritis. This study evaluated whether the newer immunochemical FOBT (iFOBT) resulted in a lower false-positive rate and higher specificity for detecting advanced colorectal neoplasia than gFOBT in a population with elevated prevalence of H. pylori infection.

Methods

We used a population-based sample of 304 asymptomatic Alaska Native adults aged 40 years or older undergoing screening or surveillance colonoscopy (April 2008–January 2012).

Results

Specificity differed significantly (P < .001) between gFOBT (76%; 95% CI, 71%–81%) and iFOBT (92%; 95% CI, 89%–96%). Among H. pylori-positive participants (54%), specificity of iFOBT was even higher (93% vs 69%). Overall, sensitivity did not differ significantly (P = .73) between gFOBT (29%) and iFOBT (36%). Positive predictive value was 11% for gFOBT and 32% for iFOBT.

Conclusion

The iFOBT had a significantly higher specificity than gFOBT, especially in participants with current H. pylori infection. The iFOBT represents a potential strategy for expanding CRC screening among Alaska Native and other populations with elevated prevalence of H. pylori, especially where access to screening endoscopy is limited.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

BACKGROUND

The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer.

OBJECTIVE

We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska.

DESIGN

Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services.

SETTING

Alaska Tribal Health System.

PATIENTS

AN population.

INTERVENTIONS

Itinerant endoscopy, patient navigation.

MAIN OUTCOME MEASUREMENTS

AN patients screened for CRC, colonoscopy quality measures.

RESULTS

As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators.

LIMITATIONS

Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments.

CONCLUSIONS

The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

A survey of Indian Health Service and tribal health providers' colorectal cancer screening knowledge, perceptions, and practices

BACKGROUND

Provider recommendation is critical for colorectal cancer (CRC) screening participation, yet few data exist on practices of providers serving American Indians and Alaska Natives. We examined Indian Health Service (IHS) and tribal provider practices, beliefs about screening efficacy, and perceptions of barriers.

METHODS

We developed a Web-based questionnaire and recruited respondents via electronic distribution lists. We generated descriptive statistics by region, provider type, and workplace setting.

RESULTS

Most respondents (77%) recommend starting CRC screening of average-risk patients at age 50; however, 22% recommend flexible sigmoidoscopy and 43% colonoscopy at intervals inconsistent with national guidelines. Of those recommending fecal occult blood test (FOBT), 23% use a single, in-office FOBT card as their only FOBT method. Respondents reported barriers to screening to include underutilized reminder systems and inadequate resources.

CONCLUSIONS

Indian Health Service/tribal providers are knowledgeable about when to begin CRC screening; however, education about the appropriate use and frequency of CRC tests is needed.

[One-stage bilateral total hip arthroplasty: a systematic review and meta-analysis]

OBJECTIVE

To investigate whether bilateral total hip arthroplasty (THA) performed in one session is a safe procedure.

DESIGN

Systematic review.

METHOD

In a literature search, 1460 studies were found of which 5 prospective in nature and which met our inclusion criteria. The patient data from these studies were pooled for meta-analysis. Data from 579 patients could be pooled for the two-session bilateral THA group and data from 334 patients for the one-session THA group.

RESULTS

After this pooling of data, no difference in major complications was found (odds ratio: 0.72; 95%-CI: 0.45-1.15). Minor complications occurred more often in the one-session group (odds ratio: 0.50; 95%-CI: 0.32-0.78). Intra-operative blood loss was less in the one-session group (121.7 ml; 95%-CI: 51.6-191.9), whilst the number of transfusions was greater in this group than in the two-session group (-0.5 units; 95%-CI: -0.74--0.20). Duration of the surgical procedure was not influenced by the choice for one or two sessions (difference: 6.0 minutes; 95%-CI: -2.4-14.4). Length of hospital stay was significantly shorter in the one-session group (3.2 days; 95%-CI: 3.0-3.7).

CONCLUSION

We conclude that one-session bilateral THA appears to be a safe procedure in selected patients.

The validity of patient satisfaction as single question in outcome measurement of total hip arthroplasty

Patient satisfaction is an important goal in orthopaedic surgery; however, it may not always reflect the surgical result that is obtained. By means of a systematic review according to the QUOROM criteria, we investigated how often satisfaction measured by a single question was used in trials reporting on the clinical outcome of total hip arthroplasty. This review showed that in 2006, 24.4% of these trials reported on satisfaction obtained by a single question. To assess the validity of satisfaction as a single question, a randomly selected group of 106 patients were questioned at an average of 15.5 years after a total hip arthroplasty (THA; range 4.2 -29.8 years). Questioning consisted of a Likert 5 scale satisfaction question and the Harris Hip Score. Satisfaction as a single question showed to have a poor construct and content validity. Despite the fact that satisfaction may be an important outcome measure, it cannot be judged as a reflection of a good result of the surgical intervention alone when evaluated using a single question.

The long-term outcome of the cemented Weber acetabular component in total hip replacement using a second-generation cementing technique

We report the long-term outcome of a modified second-generation cementing technique for fixation of the acetabular component of total hip replacement. An earlier report has shown the superiority of this technique assessed by improved survival compared with first-generation cementing. The acetabular preparation involved reaming only to the subchondral plate, followed by impaction of the bone in the anchorage holes. Between 1978 and 1993, 287 total hip replacements were undertaken in 244 patients with a mean age of 65.3 years (21 to 90) using a hemispherical Weber acetabular component with this modified technique for cementing and a cemented femoral component. The survival with acetabular revision for aseptic loosening as the endpoint was 99.1% (95% confidence interval 97.9 to 100 after ten years and 85.5% (95% confidence interval 74.7 to 96.2) at 20 years. Apart from contributing to a long-lasting fixation of the component, this technique also preserved bone, facilitating revision surgery when necessary.

Supracondylar correction osteotomy to prevent repetitive posterior dislocation of a hip prosthesis

Recurrent dislocation of a total hip prosthesis can be a challenging and often disappointing problem. This case report describes a 78-year-old woman who had recurrent posterior dislocations of a revision total hip replacement (THR) that occurred on flexion and internal rotation of the hip. The initial THR for posttraumatic osteonecrosis and extensive revision THA were performed through an anterolateral approach. Conservative treatment was not successful in preventing posterior re-dislocation, neither was open surgery in which offset was improved. Investigation under anesthesia by means of an image-intensifier showed that the prosthesis was easily dislocated posteriorly on flexion and internal rotation. On external rotation the hip was completely stable. Flexion-internal rotation is a rare motion which, if the patient is clearly instructed should be avoidable. The mechanism of an anterior dislocation caused by external rotation, extension and adduction is more common, especially since an anterolateral approach was used in all procedures. We describe the surgical technique of performing an supracondylar external rotating osteotomy of the femur to avoid further dislocation. Fixation was performed with a condylar plate fixation of which the proximal part is fixated above the distal point of the femur component to avoid a stress riser. Since the foot and knee of the patient are now internally rotated, the patient is forced to produce an external rotation in the hip to have a normal leg alignment, therefore preventing the internal rotation on which the dislocation occurred. In the prevention of a re-dislocation, solutions other than performing a revision of the THA can successfully solve the problem and should therefore be considered.

Outcome of Kienböck's disease 22 years after distal radius shortening osteotomy

Loading of the lunate in patients with Kienböck's disease and a negative ulnar variance provide the rationale for a radial shortening osteotomy. This osteotomy decreases forces transmitted from the radius to the lunate. We retrospectively reviewed 12 patients with Kienböck's disease who had 13 radial shortening osteotomies to ascertain whether the reported short- and medium-term results endured in the long-term. We evaluated nine osteotomies in nine of the 12 patients with a minimum of 16 years followup (average, 22 years; range, 16-31 years). Three patients died and one was lost to followup. For the nine patients, the range of motion was impaired compared with the normal side. Grip strength was on average 90% of the unaffected side. The average visual analog scale score for pain was 2.4 and the average Disabilities of the Arm, Shoulder, and Hand score was 14 at latest followup. In eight patients, the Lichtman classification of Kienböck's disease did not change at followup, but in three patients there was radiographic progression of the disease, which occurred during the first 10 years postoperatively. The medium- and long-term results therefore were comparable. We recommend radial shortening in stable wrists (Stage 3A or less) with a negative ulnar variance. The radius should be shortened to the level of the ulna, normally 4 to 6 mm, after which stable (plate) fixation should be performed under compression.

Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey

Current literature shows that intertrochanteric osteotomies can produce excellent results in selected hip disorders in specific groups of patients. However, it appears that this surgical option is considered an historical one that has no role to play in modern practice. In order to examine current awareness of and views on intertrochanteric osteotomies among international hip surgeons, an online survey was carried out. The survey consisted of a set of questions regarding current clinical practice and awareness of osteotomies. The second part of the survey consisted of five clinical cases and sought to elicit views on preoperative radiological investigations and preferred (surgical) treatments. The results of our survey showed that most of these experts believe that intertrochanteric osteotomies should still be performed in selected cases. Only 56% perform intertrochanteric osteotomies themselves and of those, only 11% perform more than five per year. The responses to the cases show that about 30–40% recommend intertrochanteric osteotomies in young symptomatic patients. This survey shows that the role of intertrochanteric osteotomies is declining in clinical practice.

Total hip replacement using hemi-circumferential interposition acetabuloplasty for acetabular deficiency in post-Perthes deformities: technique and long-term results

We describe a technique of hemi-circumferential interposition grafting that allows placement of the cup in the anatomical position of the original acetabulum in the rare cases of post-Perthes or Perthes-like deformities of the femoral head combined with a steep and shallow acetabulum. This technique was performed on 10 hips (9 patients, with an average age of 56 years). One revision was performed for septic loosening after 2.1 years; however, the graft was well integrated and provided sufficient support for the revision cup. All the others had a good clinical and radiological result after an average of 11.4 years with an average Harris Hip Score of 97. The authors have found this an easy-to-use method, which can give an excellent, long-lasting result. It also provides important bone stock for possible subsequent revisions.;

Bilateral varus osteotomies in hip deformities: are early interventions superior? A long-term follow-up

Coxa valga (with or withour excessive femoral anteversion) combined with acetabular dysplasia is a well-known cause of early osteoarthritis. Many authors have stated that the best result of an osteotomy can be achieved at an early stage of these osteoarthritic changes. In this study, we present 26 patients with a symmetrical hip deformity for which we performed a therapeutic osteotomy on the symptomatic hip. The contralateral hip had the same anatomical predisposition to develop an OA, but there were only minor to no complaints. We advised and performed an early osteotomy on these hips. On radiological evaluation, an average Sharp angle of 42.2 degrees and an average CCD of 142 degrees was present. During an average follow-up period of 19.9 years (range 15.0-25.9), 14 hips were converted to THR after the primary osteotomy, whereas there were only 6 after the early osteotomy (chi-square P<0.05). Using a Pearson correlation analysis, the age, preoperative grade of OA, preoperative Merle d'Aubigne score and excessive femoral anteversion were significantly correlated with the outcome. Our results show that the effect of an early, more prophylactic varus osteotomy in patients with a coxa valga with excessive femoral anteversion and acetabular dysplasia can be superior to the results achieved when surgery is postponed until the complaints and arthrosis have become more severe.

Intertrochanteric osteotomies do not impair long-term outcome of subsequent cemented total hip arthroplasties

The literature contains contradictory evidence as to whether previous proximal femoral osteotomy impairs the long-term outcomes of total hip arthroplasty. We therefore examined whether our patients with cemented total hip arthroplasties after previous osteotomies had inferior outcomes. We also investigated whether the intraoperative complication rate and the clinical and radiologic outcomes were altered by a previous osteotomy. We compared a group of 121 consecutive patients who had total hip arthroplasties (1974-1993) after osteotomies with a group of 290 consecutive patients who had total hip arthroplasties (1974-1987) without previous surgery. There was no difference in survival rate. There was a 10-year survival rate of 90% compared with 92% for the control group. The 15-year survival rates were 83% and 81%, respectively. There were no differences in radiologic and clinical followups. Intraoperative perforation of the femur occurred more often in patients with a total hip arthroplasty after an osteotomy. Our data suggest the long-term outcome of a cemented total hip arthroplasty is not impaired by a previous well-performed osteotomy.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.