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1.  Two or More Impingement and/or Instability Deformities Are Often Present in Patients With Hip Pain 
Damage to the hip can occur due to impingement or instability caused by anatomic factors such as femoral and acetabular version, neck-shaft angle, alpha angle, and lateral center-edge angle (CEA). The associations between these anatomic factors and how often they occur in a painful hip are unclear but if unaddressed might explain failed hip preservation surgery.
We determined (1) the influence of sex on the expression of impingement-related or instability-related factors, (2) the associations among these factors, and (3) how often both impingement and/or instability factors occur in the same hip.
We retrospectively reviewed a cohort of 170 hips (145 patients) undergoing MR arthrography of the hip for any reason. We excluded 58 hips with high-grade dysplasia, Perthes’ sequelae, previous surgery, or incomplete radiographic information, leaving 112 hips (96 patients). We measured femoral version and alpha angles on MR arthrograms. Acetabular anteversion, lateral CEA, and neck-shaft angle were measured on pelvic radiographs.
We observed a correlation between sex and alpha angle. Weak or no correlations were observed between the other five parameters. In 66% of hips, two or more (of five) impingement parameters, and in 51% of hips, two or more (of five) instability parameters were found.
Patients with hip pain frequently have several anatomic factors potentially contributing to chondrolabral damage. To address pathologic hip loading due to impingement and/or instability, all of the anatomic influences should be known. As we found no associations between anatomic factors, we recommend an individualized assessment of each painful hip.
Level of Evidence
Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3825892  PMID: 23512747
2.  Validity and reproducibility of the Physical Activity Scale for the Elderly (PASE) questionnaire for the measurement of the physical activity level in patients after total knee arthroplasty 
The need for valid and reproducible questionnaires to routinely assess the physical activity level of patients after total knee arthroplasty (TKA) is of particular concern in clinical settings. Aims of this study were to evaluate the validity and reproducibility of the physical activity scale for the elderly (PASE) questionnaire in TKA patients, with a particular view on gender differences.
A total of 50 elderly patients (25 women and 25 men aged 70 ± 6 years) following primary unilateral TKA were recruited. The reproducibility was evaluated by administering the PASE questionnaire during two occasions separated by 7 days. The construct (criterion) validity was investigated by comparing the physical activity level reported by patients in the PASE questionnaire to that measured by accelerometry. Reproducibility was evaluated using intraclass correlation coefficients (ICC3,1) for reliability and standard error of measurement (SEM) and smallest detectable change (SDC) for agreement, while validity was investigated with Pearson correlation coefficients.
Reliability of the PASE total score was acceptable for men (ICC = 0.77) but not for women (ICC = 0.58). Its agreement was low for both men and women, as witnessed by high SEM (32% and 35%, respectively) and SDC (89% and 97%, respectively). Construct validity of the PASE total score was low in both men (r = 0.45) and women (r = 0.06).
The PASE questionnaire has several validity and reproducibility shortcomings, therefore its use is not recommended for the assessment of physical activity level in patients after TKA, particularly in women.
PMCID: PMC3936904  PMID: 24555852
Physical Activity; Questionnaire; Arthroplasty; Knee
3.  Psychometric properties of the Fatigue Severity Scale in obese patients 
The aim of this study was to examine the psychometric properties of the Fatigue Severity Scale (FSS) to verify whether this instrument is a valid tool to measure fatigue in obese patients, and to examine the prevalence of fatigue in obese patients.
Before and after a three-week residential multidisciplinary integrated weight reduction program, 220 patients were asked to fill in the questionnaires: FSS, Profile of Mood States (Fatigue-Inertia subscale, POMS-Fatigue, and Vigor-Activity subscale, POMS-Vigor), and the Obesity-Related Well-Being (ORWELL-97). A subsample of 50 patients completed the questionnaire within two days.
The prevalence of fatigue using a cut-off value of 4 for the FSS score was 59%. Correlations were found between FSS and POMS-Fatigue and -Vigor scores (r = 0.58 and 0.53, respectively). A relation was also found between FSS and ORWELL97 (r = 0.52, 0.42 to 0.61). From the factorial analysis only 1 factor was extracted explaining 63% of variance, with factor loading values ranging from 0.71 (item 7) to 0.87 (item 6). Intraclass Correlation Coefficient was 0.89 (0.82 to 0.94), while the agreement as measured using the Standard Error of Measurement was 0.43 (0.36 to 0.54) corresponding to 13% (11 to 17%). Cronbach’s alpha values ranged from 0.94 to 0.93. The internal responsiveness of FSS was comparable to the ORWELL97 (Standardized Response Mean = 0.50 and 0.44, respectively).
Fatigue is an important and frequent symptom in obese patients and therefore should be routinely assessed in both research and clinical practice. This can be achieved using the FSS, which is a short, simple, valid and reliable tool for assessing and quantifying fatigue in obese patients.
PMCID: PMC3599447  PMID: 23496886
Obesity; Symptoms; Questionnaires; Psychometrics
The use of an evidence‐based approach to practice requires “the integration of best research evidence with clinical expertise and patient values”, where the best evidence can be gathered from randomized controlled trials (RCTs), systematic reviews and meta‐analyses. Furthermore, informed decisions in healthcare and the prompt incorporation of new research findings in routine practice necessitate regular reading, evaluation, and integration of the current knowledge from the primary literature on a given topic. However, given the dramatic increase in published studies, such an approach may become too time consuming and therefore impractical, if not impossible. Therefore, systematic reviews and meta‐analyses can provide the “best evidence” and an unbiased overview of the body of knowledge on a specific topic. In the present article the authors aim to provide a gentle introduction to readers not familiar with systematic reviews and meta‐analyses in order to understand the basic principles and methods behind this type of literature. This article will help practitioners to critically read and interpret systematic reviews and meta‐analyses to appropriately apply the available evidence to their clinical practice.
PMCID: PMC3474302  PMID: 23091781
evidence‐based practice; meta‐analysis; systematic review
5.  How Active are Patients Undergoing Total Joint Arthroplasty?: A Systematic Review 
Qualitative research studies regarding physical activity in patients undergoing total joint arthroplasty (TJA) unfortunately are sparse in the current literature.
To provide a foundation for future investigations, we performed a systematic review to identify the different instruments used to quantify physical activity in patients undergoing TJA and to determine how active these patients really are.
We systematically reviewed the literature on the bibliographic databases Medline, Cochrane Library, and EMBASE published until September 2008, focusing on studies assessing total physical activity in patients after or undergoing TJA. Results of those studies quantifying physical activity using accelerometers and pedometers were combined using meta-analytic methods.
In the 26 studies included (n = 2460 patients), motion sensors and recall questionnaires were most commonly used. The research aims and goals varied widely among the studies and the results mainly were descriptive. Studies quantifying physical activity using pedometers and accelerometers suggested a weighted mean of 6721 steps/day (95% confidence interval [CI], 5744–7698). Steps per day determined by accelerometers were 2.2 times the steps measured by pedometers. Metaregression showed that walking activity decreased by 90 steps/day (95% CI, −156 to −23) every year of patient age.
These results suggest patients undergoing TJA are less active than recommended to achieve health-enhancing activity levels (greater than 10,000 steps/day), but they appear more active than normally assumed in typical wear simulations. Future investigations have to evolve more standardization in the assessment and reporting of physical activity in TJA patients.
PMCID: PMC2881985  PMID: 19862586
6.  Which Are the Most Frequently Used Outcome Instruments in Studies on Total Ankle Arthroplasty? 
The number of studies reporting on outcomes after total ankle arthroplasty is continuously increasing. As the use of valid outcome measures represents the cornerstone for successful clinical research, we aimed to identify the most frequently used outcome instruments in ankle arthroplasty studies and to analyze the evidence to support their use in terms of different quality criteria. A systematic review of the literature identified 15 outcome instruments reported in 79 original studies. The most commonly used measures were the American Orthopaedic Foot and Ankle Society hindfoot score (n = 41), the Kofoed ankle score (n = 21), a visual analog scale assessing pain (n = 15), and the generic SF-36 (n = 6). Eight additional instruments were used only once or twice. The American Orthopaedic Foot and Ankle Society and Kofoed instruments include a clinical examination and score up to 100 points. Evidence to support their use in terms of validity, reliability, responsiveness, and interpretability is limited, raising the question whether their use is justified. Self-reported questionnaires related to ankle osteoarthritis or arthroplasty are rather disregarded in the current literature, and only the Foot Function Index is associated with evidence in terms of the above-mentioned quality criteria. Future research is warranted to improve the outcome assessment after total ankle arthroplasty.
PMCID: PMC2816756  PMID: 19672670
7.  Money matters: exploiting the data from outcomes research for quality improvement initiatives 
European Spine Journal  2009;18(Suppl 3):348-359.
In recent years, there has been an increase in studies that have sought to identify predictors of treatment outcome and to examine the efficacy of surgical and non-surgical treatments. In addition to the scientific advancement associated with these studies per se, the hospitals and clinics where the studies are conducted may gain indirect financial benefit from participating in such projects as a result of the prestige derived from corporate social responsibility, a reputational lever used to reward such institutions. It is known that there is a positive association between corporate social performance and corporate financial performance. However, in addition to this, the research findings and the research staff can constitute resources from which the provider can reap a more direct benefit, by means of their contribution to quality control and improvement. Poor quality is costly. Patient satisfaction increases the chances that the patient will be a promoter of the provider to friends and colleagues. As such, involvement of the research staff in the improvement of the quality of care can ultimately result in economic revenue for the provider. The most advanced methodologies for continuous quality improvement (e.g., six-sigma) are data-driven and use statistical tools similar to those utilized in the traditional research setting. Given that these methods rely on the application of the scientific process to quality improvement, researchers have the adequate skills and mind-set to embrace them and thereby contribute effectively to the quality team. The aim of this article is to demonstrate by means of real-life examples how to utilize the findings of outcome studies for quality management in a manner similar to that used in the business community. It also aims to stimulate research groups to better understand that, by adopting a different perspective, their studies can be an additional resource for the healthcare provider. The change in perspective should stimulate researchers to go beyond the traditional studies examining predictors of treatment outcome and to see things instead in terms of the “bigger picture”, i.e., the improvement of the process outcome, the quality of the service.
PMCID: PMC2899321  PMID: 19294433
Research [H01.770.644]; Practice guidelines [N04.761.700.350.650]; Patient [M01.643]; Hospital costs [N05.300.375.500]; Six-sigma (not in IndexMedicus)
8.  Reliability and Validity of the Cross-Culturally Adapted German Oxford Hip Score 
There is currently no German version of the Oxford hip score. Therefore we sought to cross-culturally adapt and validate the Oxford hip score for use with German-speaking patients (OHS-D) with osteoarthritis of the hip using a forward-backward translation procedure. We then assessed the new score in 105 consecutive patients (mean age, 63.4 years; 48 women) undergoing THA. We specifically determined: the number of fully completed questionnaires, reliability, concurrent validity by correlation with the WOMAC, Harris hip score, and SF-12, and distribution of floor and ceiling effects. We received 96.6% fully completed questionnaires. An intraclass correlation coefficient of 0.90 and Cronbach’s alpha of 0.87 suggested the OHS-D was reliable. Correlation coefficients between the OHS-D and the WOMAC total score, pain subscale, stiffness subscale, and physical function subscale were 0.82, 0.70, 0.68, and 0.82, respectively. OHS-D correlated with the Harris hip score (r = 0.63) and the physical component scale of the SF-12 (r = 0.58). We observed no ceiling or floor effects. The OHS-D appeared a reliable and valid measurement tool for assessing pain and disability with German-speaking patients with hip osteoarthritis.
Level of Evidence: Level I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2650060  PMID: 18726655
9.  Which is the Best Activity Rating Scale for Patients Undergoing Total Joint Arthroplasty? 
We compared the metric properties of the University of California, Los Angeles (UCLA) activity scale, the Tegner score, and the Activity Rating Scale for assessment of activity levels in 105 patients undergoing THA (48 women; mean age, 63.4 years) and 100 patients undergoing TKA (61 women; mean age, 66.5 years). We assessed construct validity by correlating these scales with the International Physical Activity Questionnaire and different traditional patient self-reporting outcome measures. Test-retest reliability, feasibility, and floor and ceiling effects also were determined. The UCLA scale showed the strongest correlations with the other measures (r = −0.35 to 0.56 for THA; r = −0.55 to 0.23 for TKA) and was the only scale that discriminated between insufficiently and sufficiently active patients undergoing THA and TKA. The UCLA scale had the best reliability, provided the highest completion rate, and showed no floor effects. It seems to be the most appropriate scale for assessment of physical activity levels in patients undergoing total joint arthroplasty.
Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2650053  PMID: 18587624
10.  Acetabular Morphology: Implications for Joint-preserving Surgery 
Appropriate anatomic concepts for surgery to treat femoroacetabular impingement require a precise appreciation of the native acetabular anatomy. We therefore determined (1) the spatial acetabular rim profile, (2) the topography of the articular lunate surface, and (3) the 3-D relationships of the acetabular opening plane comparing 66 bony acetabula from 33 pelves in female and male pelves. The acetabular rim profile had a constant and regular wave-like outline without gender differences. Three prominences anterosuperiorly, anteroinferiorly and posteroinferiorly extended just above hemispheric level. Two depressions were below hemispheric level, of 9° at the anterior wall and of 21° along the posterosuperior wall. In 94% of all acetabula, the deepest extent of the articular surface was within 30° of the anterosuperior acetabular sector. In 99% of men and in 91% of women, the depth of the articular surface was at least 55° along almost half of the upper acetabular cup. The articular surface was smaller in women than in men. The acetabular opening plane was orientated in 21° ± 5° for version, 48° ± 4° for inclination and 19° ± 6° for acetabular tilt with no gender differences. We defined tilt as forward rotation of the entire acetabular cup around its central axis; because of interindividual variability of acetabular tilt, descriptions of acetabular lesions during surgery, CT scanning and MRI should be defined and recorded in relation to the acetabular notch. Acetabular tilt and pelvic tilt should be separately identified. We believe this information important for surgeons performing rim trimming in FAI surgery or performing acetabular osteotomies.
PMCID: PMC2635447  PMID: 19130159

Results 1-10 (10)