How do the expectations of patients compare with their surgeons regarding outcomes of periacetabular osteotomy?

Can We Enhance Shared Decision-making for Periacetabular Osteotomy Surgery? A Qualitative Study of Patient Experiences

BACKGROUND

Periacetabular osteotomy (PAO) surgery presents an opportunity for shared decision-making (SDM) and may be facilitated by decision-making tools. Currently, no diagnosis or treatment-specific decision-making tools exist for this patient population. Understanding patient PAO surgery decision-making experiences and processes would enable development of a treatment-specific decision-making tool and would help hip preservation surgeons with SDM practices.

QUESTIONS/PURPOSES

Qualitative methodology was used to address the following questions: (1) What were the information support needs of adult patients with hip dysplasia who decided to have PAO? (2) What was important to adult patients with hip dysplasia who decided to have PAO? (3) How did adult patients with hip dysplasia who have undergone PAO experience the surgical decision-making process? (4) What elements of SDM did adult patients with hip dysplasia experience with their surgeons when deciding to have PAO?

METHODS

Fifteen volunteer, English-speaking patients in the United States who had been diagnosed with hip dysplasia and who had undergone PAO surgery 6 to 12 months prior to the study were recruited through five PAO surgery Facebook support groups. Individuals were excluded if they had an underlying neuromuscular condition or other diagnosis related to nondevelopmental dysplasia of the hip or if they had a previous PAO surgery > 12 months before data collection. We used purposive sampling strategies to promote sample heterogeneity based on age and preoperative activity level, as these are characteristics that may impact decision-making. Participants were categorized into three age groups: 20 to 29 years, 30 to 39 years, and ≥ 40 years. Participants were also categorized as having "low activity," "moderate activity," or "high activity" preoperatively based on self-reported University of California Los Angeles (UCLA) Activity Scale scores. Participants were enrolled consecutively if they met the inclusion criteria and fulfilled one of our sampling categories; we had plans to enroll more participants if thematic saturation was not achieved through the first 15 interviews. Participants included 14 women and one man ranging in age from 23 to 48 years, and all had undergone PAO surgery for hip dysplasia 6 to 12 months prior to the interview. One-on-one semistructured interviews were conducted with each participant by a single interviewer through Zoom video conferencing using video and audio recording. Participants answered semistructured interview questions and provided verbal responses to survey questions so researchers could gain demographic information and details about their symptoms, diagnosis, and PAO surgery between June 2021 and August 2021. Quantitative survey data were analyzed using descriptive statistics. Qualitative data were analyzed by three researchers using principles of reflexive thematic analysis. Candidate themes were iteratively defined and redefined until central themes were developed that were distinctly different, yet centrally relevant, and answered the research questions. All codes that informed category and theme development were generated within the first six transcripts that were analyzed. The team felt that thematic saturation was established with the 15 interviews.

RESULTS

The main information needs for adult patients with hip dysplasia included diagnosis and treatment-related information, as well as logistics related to surgery and recovery. Many patients described that their information needs were only partially met by their surgeon; most engaged in additional information-seeking from scientific research and online resources and relied on patient peers to meet information needs about the lived experience and logistics related to surgery and recovery. It was important to patients that PAO surgery could preserve their native hip or delay THA and that PAO surgery was likely to reduce their pain and improve function; decision-making was facilitated when patients were able to identify how the indications and goals of PAO surgery aligned with their own situation and goals for surgery. Patients' experiences with decision-making were more positive when information needs were met, when indications and goals for PAO surgery aligned with their personal values and goals, and when their preferred and actual decision-making roles aligned. Adult patients with hip dysplasia described high variability in the extent to which patients were invited to share personal preferences, values, and goals around PAO surgery and the extent to which preferred patient decision-making roles were assessed.

CONCLUSION

We found that elements of SDM are not consistently integrated into hip preservation practice. The knowledge gained through this work about patient PAO surgery information needs, what matters to patients when deciding to have surgery, and their experiences with PAO surgery decision-making can inform future PAO surgery decision-making tool development. Future studies are needed to validate the findings of this study and to determine whether they are generalizable to adult patients with hip dysplasia with different demographic characteristics or to patients who do not participate in social media support groups.

CLINICAL RELEVANCE

Surgeons should recognize that patients are likely to leave their office without their information needs being met. SDM strategies can promote more effective information exchanges in the clinic so surgeons can help patients identify their information needs, provide education and direction to accurate and reputable resources to meet those needs, and help patients appraise information they gather and apply it to their personal situation. Hip preservation surgeons can use the sample SDM script and checklist offered here to support adult patients with hip dysplasia who are making PAO surgery decisions until a future diagnosis and treatment-specific decision-making tool is available.

Long-term patient-centred outcomes of periacetabular osteotomy in a large consecutive series

Aims

We assessed the long-term outcomes of a large cohort of patients who have undergone a periacetabular osteotomy (PAO), and sought to validate a patient satisfaction questionnaire for use in a PAO cohort.

Methods

All patients who had undergone a PAO from July 1998 to February 2013 were surveyed, with several patient-reported outcome measures (PROMs) and radiological measurements of preoperative acetabular dysplasia and postoperative correction also recorded. Patients were asked to rate their level of satisfaction with their operation in achieving pain relief, restoration of activities of daily living, ability to perform recreational activity, and their overall level of satisfaction with the procedure.

Results

A total of 143 PAOs were performed between 1998 and 2013. Of those, 90 postoperative surveys were returned. Only 65 patients (73 hips) had both pre- and postoperative radiographs available for measurement. The mean time to follow-up was 15 years (6.5 to 20). Most patients were female (91%), with a mean age of 26.4 years (14.9 to 48.3) at the time of their surgery. A statistically significant improvement in radiological correction was detected in all hips (p < 0.001). A total of 67 patients (92.3%) remained either very satisfied or satisfied with their PAO. The internal consistency of the patient satisfaction questionnaire, measured using Cronbach's α, ranged from 0.89 to 0.94 indicating 'good' to 'excellent' reliability.

Conclusion

Outcomes of importance to patients undergoing a PAO include several key domains: pain relief, improve activities of daily living, and improve recreational ability. Our study demonstrates high rates of long-term patient satisfaction in all domains, and found the patient satisfaction questionnaire to be a valid and reliable instrument for use in this cohort.

Preoperative Expectations Do Not Correlate With Postoperative iHOT-33 Scores and Patient Satisfaction Following Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome

PURPOSE

To examine the correlation between preoperative patient expectation and International Hip Outcome Tool (iHOT-33) score and postoperative satisfaction of patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement syndrome.

METHODS

Patients scheduled for surgery completed the Hip Preservation Surgery Expectations Survey (HPSES), as well as the preoperative and a minimum 2-year postoperative iHOT-33. Patient demographics that were collected included gender, age, occupation, and body mass index (BMI). At the latest follow-up, patients were evaluated for their subjective satisfaction and postoperative complications. An in-depth analysis was performed to assess the correlation between HPSES, iHOT-33, and patient satisfaction.

RESULTS

Sixty-nine patients (62.3% males; mean age: 33.7 ± 13.1 years; BMI: 23.9 ± 3.5 kg/m²) were included in this study. The mean HPSES score was 83.8 ± 16.5. The mean iHOT-33 improved from 31.6 ± 15.8 preoperatively to 73 ± 25.9 postoperatively (95% CI = 35.2,47.8; P < .01), and the mean patient satisfaction was 75.9 ± 26.9. There were no statistically significant differences in mean HPSES score between males and females (95% CI = 79.9,87.8; P = .35) nor between different occupational groups (95% CI = 79.4,87.6, P = .095). No correlation was found between age and HPSES score (r = .036; P =.76). There was a negligible correlation between HPSES score and postoperative iHOT-33 score (r = -.117; P = .34) and patient satisfaction (r = -.042; P = .73). Postoperative iHOT-33 score had a significant high correlation with patient satisfaction (r = .8; P < .001).

CONCLUSION

Preoperative expectations do not correlate with postoperative iHOT-33 scores and patient satisfaction with surgery at 2 years after surgery. Gender and occupation did not differ significantly with regard to preoperative expectations, and there was no correlation between age and HPSES score.

LEVEL OF EVIDENCE

IV, retrospective case series.

Prearthritic Hip Disease: Important Issues

Prearthritic hip disease is challenging to define, diagnose, and treat. The mechanically abnormal hip, which has not yet suffered irreversible damage but will do so if its abnormal mechanics are not corrected, can be considered to be in a prearthritic stage. A conundrum regarding the treatment of many patients with a variety of hip diseases involving a hip at mechanical risk is that the best opportunity for preventing progressive osteoarthritis lies in the period before symptoms are severe enough to demand treatment solely on that basis. It is difficult to institute treatment for a minimally symptomatic but at-risk hip because of the multitude of variables that affect symptoms and hip longevity. Input from an established team of multiple hip experts with varying areas of expertise is ideal. Shared decision-making is highly effective in this prearthritic situation of high patient sensitivity. The cornerstone of treatment of the prearthritic hip is the correction of the problematic mechanical abnormality. As methods of analysis and treatment methods evolve and as long-term outcomes of treatments become understood, the role of intervention during the prearthritic stage of hip disease is likely to increase.

Patient comprehension of hip arthroscopy: an investigation of health literacy

Several studies have demonstrated that patients have significant impairments in understanding their injury and appropriate course of management in orthopedic surgery. The purpose of this investigation is to determine if patients are able to obtain a fundamental understanding of the requisite care associated with hip arthroscopy. Any patient who elected to have hip arthroscopy was prospectively recruited to participate in the study. All patients were told they would be asked to complete a questionnaire about their surgery and post-operative instructions. The answers to each question of the questionnaire they would receive at the first post-operative visit were verbally given to each patient during the pre-operative visit. They were also given a post-operative instruction sheet on the day of surgery that contained answers to the questionnaire. At the first post-operative visit, all patients were then asked to complete a multiple-choice questionnaire prior to seeing the surgeon. A total of 56 patients (14 males, 42 females) were enrolled. All patients reported they had read the post-operative instruction sheet. The average number of correct answers was 6.5 ± 0.6 (95% CI 6 - 7) out of 11 questions (59% correct response rate ±18% [95% CI 52 - 66%]). Although we made significant pre-operative oral and written efforts to help patients achieve an elementary level of health literacy regarding their forthcoming hip arthroscopy, many patients did not achieve satisfactory comprehension. Even with instruction and information given verbally and physically (via post-operative instruction sheet) patients did not obtain satisfactory comprehension of their surgical procedure. New ways (through video, simplified cartoons or verbal explanations) must be considered in educating patients concerning surgical procedures to increase comprehension and health literacy.

Is There an Association Between Preoperative Expectations and Patient-Reported Outcome After Hip Arthroscopy for Femoroacetabular Impingement Syndrome?

PURPOSE

To determine the relationship between preoperative patient expectation and postoperative satisfaction and overall patient-reported outcome (PRO) of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

METHODS

Patients who underwent hip arthroscopy for femoroacetabular impingement syndrome completed the validated Hip Preservation Surgery Expectations Survey (21 questions; 0-100 range), as well as multiple PROs before surgery. High expectation was defined as an expectation score greater than 1 standard deviation above the mean. Patients with osteoarthritis, dysplasia, and those having undergone previous hip surgery were excluded. At 1 year postoperatively, patient visual analog scale (VAS) satisfaction, VAS pain, and PROs were assessed. Univariable and multivariate analyses were performed.

RESULTS

One-hundred fifty-three subjects (mean age 34.4 ± 12.6 years, female: 114 [71.3%], body mass index: 25.9 ± 5.3 kg/m²) participated. The mean expectation score was 84.5 ± 12.3. Significant correlations between high expectation scores (>96.7) and achieving the minimal clinical important difference (MCID) for modified Harris Hip Score (mHHS; r = 0.339; P = .043) and patient acceptable symptomatic state (PASS) for Hip Outcome Score-Activities of Daily Living Subscale (HOS-ADL; r = 0.207; P = .032) were observed. There were no significant correlations between high expectation scores and preoperative or postoperative PROs or patient satisfaction scores. χ² analysis demonstrated patients with greater expectations had increased rates of reaching MCID mHHS (92.3% vs 74.7%; P = .08), PASS mHHS (85.7% vs 69.7%; P = .046), and PASS HOS-ADL (93.8% vs 67.4%; P = .031).

CONCLUSIONS

High preoperative expectation is associated with increased rates of MCID/PASS achievement on mHHS and increased rate of PASS achievement on HOS-ADL. Preoperative expectations did not have an impact on Hip Outcome Score-Sports Subscale; however, patients with high preoperative expectations also have a high baseline Hip Outcome Score-Sports Subscale. In addition, preoperative expectations are not associated with postoperative VAS satisfaction scores.

LEVEL OF EVIDENCE

III; non-randomized cohort, therapeutic.