Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes

Background

Long-term postdiscectomy degenerative disc disease and low back pain is a well-recognized disorder; however, its patient-centered characterization and quantification are lacking.

Questions/purposes

We performed a systematic literature review and prospective longitudinal study to determine the frequency of recurrent back pain after discectomy and quantify its effect on patient-reported outcomes (PROs).

Methods

A MEDLINE search was performed to identify studies reporting on the frequency of recurrent back pain, same-level recurrent disc herniation, and reoperation after primary lumbar discectomy. After excluding studies that did not report the percentage of patients with persistent back or leg pain more than 6 months after discectomy or did not report the rate of same level recurrent herniation, 90 studies, which in aggregate had evaluated 21,180 patients, were included in the systematic review portion of this study. For the longitudinal study, all patients undergoing primary lumbar discectomy between October 2010 and March 2013 were enrolled into our prospective spine registry. One hundred fifteen patients were more than 12 months out from surgery, 103 (90%) of whom were available for 1-year outcomes assessment. PROs were prospectively assessed at baseline, 3 months, 1 year, and 2 years. The threshold of deterioration used to classify recurrent back pain was the minimum clinically important difference in back pain (Numeric Rating Scale Back Pain [NRS-BP]) or Disability (Oswestry Disability Index [ODI]), which were 2.5 of 10 points and 20 of 100 points, respectively.

Results Systematic Review

The proportion of patients reporting short-term (6–24 months) and long-term (> 24 months) recurrent back pain ranged from 3% to 34% and 5% to 36%, respectively. The 2-year incidence of recurrent disc herniation ranged from 0% to 23% and the frequency of reoperation ranged from 0% to 13%.

Prospective Study

At 1-year and 2-year followup, 22% and 26% patients reported worsening of low back pain (NRS: 5.3 ± 2.5 versus 2.7 ± 2.8, p < 0.001) or disability (ODI%: 32 ± 18 versus 21 ± 18, p < 0.001) compared with 3 months.

Conclusions

In a systematic literature review and prospective outcomes study, the frequency of same-level disc herniation requiring reoperation was 6%. Two-year recurrent low back pain may occur in 15% to 25% of patients depending on the level of recurrent pain considered clinically important, and this leads to worse PROs at 1 and 2 years postoperatively.     

The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21?years: the role of spinal deformity surgery

Background

Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS).

Methods

The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8–9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses.

Results

The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3–176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2–32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8–70.7, p = 0.01).

Conclusions

Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS.

Level of Evidence

Retrospective comparative study, Level III.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0682-8) contains supplementary material, which is available to authorized users.     

Prospective clinical and radiographic results of CHARITé III artificial total disc arthroplasty at 2- to 7-year follow-up: a Canadian experience

Background

Early and intermediate results have shown that the SB CHARITÉ III total disc arthroplasty (TDA) favourably compares to spinal fusion, but is associated with fewer complications and higher levels of satisfaction. We sought to prospectively report the clinical and radiographic results of the CHARITÉ III TDA after an average of 55 months follow-up.

Methods

We conducted a prospective study of patients receiving the CHARITÉ TDA at either L4–5 or L5–S1 between April 2001 and November 2006. The primary indication for surgery was discogenic low-back pain confirmed by provocative discography. Assessment included pre- and postoperative (3, 6 and 12 mo and yearly thereafter) validated patient outcome measures and radiographic review.

Results

Fifty-seven of the potential 64 (89%) patients were available for complete follow-up. Their mean age was 39 (range 21–59) years. A statistically significant improvement was demonstrated between all the mean pre- and postoperative intervals for the Oswestry Disability Index, visual analogue scale for back and leg pain, and Short Form-36 health survey (p < 0.001). The mean sagittal rotation was 6.5° (range 0.5°–22.4°), and the mean intervertebral translation was 1.1 mm (range 0–2.4 mm). Subsidence of the implant was present in 44 of 53 (83%) patients with an L5–S1 disc arthroplasty. The mean subsidence was 1.7 mm (range 0–4.8 mm).

Conclusion

The 2- to 7-year follow-up of this cohort of patients demonstrated satisfactory clinical and radiographic results in a carefully selected patient population. The radiographic assessment confirmed preservation and maintenance of motion at the replaced disc during the period of follow-up.     

Reoperation after lumbar disc surgery in two hundred and seven patients

Purpose

The purpose of this study was to compare the causes and characteristics of reoperations after different primary operations for lumbar disc herniation (LDH).

Methods

Out of a series of 5,280 patients who underwent operations for LDH between 2001 and 2012, 207 patients (135 male and 72 female, mean age 47.7 years) underwent primary and revision operations, which were included in this study. The following clinical parameters were retrospectively assessed: the primary surgical methods, the intervals between primary and revision operations, and surgical findings in the revisions.

Results

In total, 232 lumbar discs underwent reoperations. One hundred and nineteen reoperations were performed after microendoscopic discectomy (MED group), 68 after percutaneous endoscopic lumbar discectomy (PELD group) and 45 after open disc surgery (open group). The locations of revision operations had priority over those of primary surgery, with a moderate correlation (kappa coefficient = 0.533). A total of 46.6 % of reoperations were performed within 0.5 years after primary surgery, and 35.3 % were performed between one and five years. Real recurrent herniation (homolateral herniations at the same level) was significantly more common than other reoperative surgical findings (70.6 % in PELD group, 47.1 % in MED group, 37.8 % in open group). The overall mean interval until revision surgery was 18.9 months (8.1 months in the PELD group vs. 19.7 months in the MED group vs. 33.1 months in the open group, p < 0.01).

Conclusions

For LDH, real recurrent herniation was the most common cause of reoperations, and more reoperations for real recurrent herniations and shorter intervals were found after minimally invasive endoscopic discectomy than after open disc surgery.     

Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review

Purpose

Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.

Methods

Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.

Results

Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.

Conclusion

This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived.     

Satisfaction with upper extremity surgery in individuals with tetraplegia

Objective

To supplement the scant information available regarding the satisfaction of patients with tetraplegia following upper extremity reconstructive surgery for such individuals with spinal cord injury (SCI).

Study design

Retrospective study with questionnaire follow-up.

Setting

The Danish Spinal Cord Injury Centers.

Material and methods

In the initial review period, 119 upper extremity surgeries were performed on patients with tetraplegia (n = 49). Seven died and the remaining 42 were invited to complete a follow-up questionnaire with a five-level scale ranging from strongly agree to strongly disagree regarding satisfaction. Forty patients completed the questionnaire.

Results

Median time from first surgery was 13 years (2–36). Sixty-five percent of the sample had a C5–C6 SCI, with 64% experiencing complete injury. Initially, 76% of the sample expressed general satisfaction with life, but only 28% of the sample reported that hand appearance improved after surgery. Interestingly, those having surgery from 1991 to 2008 reported significantly greater satisfaction (P < 0.001) and were significantly more satisfied with activities of daily living (ADL) (P < 0.001) than those having surgery between the years 1973 and 1990. In particular, gain of independence was obtained with pinch/specific hand surgery compared to triceps activation. Accordingly, the pinch/specific hand surgery group was significantly more satisfied than the triceps group on the ADL (P = 0.027), and the independence questions (P < 0.001).

Conclusion

Overall satisfaction with upper extremity surgery is high. It can have a positive impact on life in general, ability to perform ADL, as well as supplying an increased level of independence.     

Can the Surgical Apgar Score predict morbidity and mortality in general orthopaedic surgery?

Purpose

The Surgical Apgar Score (SAS) is a simple tally based on intra-operative heart rate, blood pressure and blood loss; it predicts 30-day major postoperative complications and mortality in different surgical fields, but no validation has been performed in general orthopaedic surgery.

Methods

A prospective assessment of the SAS in 723 consecutive patients undergoing major and intermediate orthopaedic procedures was performed in an 18-month period. The SAS was calculated immediately after surgery, and the occurrence of major complications or death was registered within a 30-day follow-up.

Results

Thirty-seven patients had ≥1 complication (5.12 %). The complication rate did not augment as the score decreased (SAS 9–10 = 6.56 %; SAS 7–8 = 2.62 %; SAS 5–6 = 7.21 %; SAS ≤4 = 10.2 %), the relative risk did not augment as the score decreased and the likelihood ratio did not increase with decreasing SAS values, except in the subgroup of patients undergoing spine surgery. The C-statistic was 0.59 (95 % confidence interval 0.48–0.69), a weak discriminatory value. Using a threshold of 7 to define high-risk and low-risk patients, the SAS allowed risk stratification only for spine surgery.

Conclusions

The SAS does not predict 30-day major complications and death in patients undergoing general orthopaedic surgery, but it is useful in the subgroup of patients undergoing spine surgery.     

Surgical treatment of chronic groin pain in athletes

Purpose

Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities.

Methods

We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure.

Results

Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three–16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten–15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12–16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity.

Conclusion

Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.     

Massive lumbar disc herniation with complete dural sac stenosis

Background:

Large lumbar disc herniation (LDH) has been reported to have a greater tendency to resolve in clinical and pathomorphological evolutions. However, various definitions of large LDH have been used without validation, and the clinical symptoms of large LDH have not been fully elucidated. We conducted a retrospective analysis to determine the clinical characteristics and treatment outcome of massive LDH with complete dural sac stenosis

Materials and Methods:

We retrospectively reviewed 33 cases of LDH with complete dural sac stenosis on magnetic resonance imaging. Complete dural sac stenosis was defined as no recognizable rootlet and cerebrospinal fluid signal on T2-weighed axial MR images. The clinical outcome parameters included back pain, leg pain, Oswestry disability index (ODI), and neurological dysfunction. The paired t-test and Wilcoxon''s signed rank test were used to compare serial changes in back pain, leg pain and neurological dysfunction.

Results:

Mean duration of followup was 66 months (range 24 - 108 months). There were 24 male and 9 female. The mean age was 37 years (range 20 - 53 years). At presentation, mean visual analogue scales for back pain and leg pain were 75.3 ± 19.1 (range 12 - 100) and 80.2 ± 14.6 (range 0 -100), respectively. Mean ODI was 67.1 ± 18.8 (range 26 - 88). Neurological dysfunction was found in 9 patients (27.3%), and the bowel/bladder dysfunction was found in 2 patients (3.1%). Conservative treatment was performed in 21 patients (63.6%) with satisfactory results. Seven patients underwent decompressive surgery, and 5 underwent posterolateral fusion.

Conclusions:

A massive LDH with complete dural sac stenosis was found to be associated with severe back and leg pain at presentation, however surgical treatment can be deferred unless significant neurological symptoms occur.     

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation

Purpose

Proximal femoral excision is a salvage procedure for painful chronic hip dislocation in cerebral palsy (CP) patients. The primary objective of this article is to describe our experience of an amplified interposition myoplasty, with appropriate peri-operative pain and tone management strategies, in a cohort of non-ambulatory CP patients with painful chronic hip dislocation. Our secondary objective is to present the clinical outcomes of these patients.

Methods

We describe our experience in 20 CP patients (25 procedures) at mean 54-month (range 27–169) follow-up with a surgical technique that includes an augmented interposition myoplasty and tone management. The indications for surgery were pain (21 hips), poor sitting tolerance (11) and difficulty with perineal care (8).

Results

The mean age was 22 years (range 10–40) with 11 patients Gross Motor Function Classification Scale (GMFCS) IV and 9 patients GMFCS V. Mean length of stay was 13 days (3–35). One procedure required revision at 12 months. Mean pain score improved from 7.8 (5–10) pre-operatively to 2.8 (1–5) post-operatively (p < 0.001). Sitting tolerance improved in all patients and in 75 % (15) perineal care was easier.

Conclusions

Our interposition myoplasty technique with individualised pain/tone management has good outcomes in this cohort of patients with multiple co-morbidities.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0662-z) contains supplementary material, which is available to authorized users.     

Bicruciate-retaining Total Knee Replacement Provides Satisfactory Function and Implant Survivorship at 23?Years

Background

One of the goals of a TKA is to approximate the function of a normal knee. Preserving the natural ligaments might provide a method of restoring close to normal function. Sacrifice of the ACL is common and practical during a TKA. However, this ligament is functional in more than 60% of patients undergoing a TKA and kinematic studies support the concept of bicruciate-retaining (that is, ACL-preserving) TKA; however, relatively few studies have evaluated patients treated with bicruciate-retaining TKA implants.

Questions/purposes

I asked: (1) what is the long-term (minimum 20-year) survivorship, (2) what are the functional results, and (3) what are the reasons for revision of bicruciate-retaining knee arthroplasty prostheses?

Methods

From January 1989 to September 1992, I performed 639 total knee replacements in 537 patients. Of these, 489 were performed in 390 patients using a bicruciate-retaining, minimally constrained device. During the period in question, this knee prosthesis was used for all patients observed intraoperatively to have an intact, functional ACL with between 15° varus and 15° valgus joint deformity. There were 234 women and 156 men with a mean age at surgery of 65 years (range, 42–84 years) and a primary diagnosis of osteoarthritis in 89%. The patella was resurfaced in all knees. The mean followup was 23 years (range, 20–24 years). At the time of this review, 199 (51%) patients had died and 31 (8%) patients were lost to followup, leaving 160 (41%) patients (214 knees) available for review. Component survivorship was determined by competing-risks analysis and Kaplan Meier survivorship analysis with revision for any reason as the primary endpoint. Patients were evaluated every 2 years to assess ROM, joint laxity, knee stability, and to determine American Knee Society scores.

Results

The Kaplan-Meier survivorship was 89% (95% CI, 82%–93%) at 23 years with revision for any reason as the endpoint. Competing-risks survivorship was 94% (95% CI, 91%%–96 %) at 23 years. At followup, the mean age of the patients was 84 years (range, 63–101 years), the mean flexion was 117° (range, 90°–130°), the mean American Knee Society score improved from a preoperative mean of 42 (range, 26–49) to 91 (range, 61–100; p < .001). Twenty-two knees in 21 patients (5.6%) were revised, most commonly because of polyethylene wear.

Conclusions

ACL sacrifice may be an unnecessary concession during TKA. This study found satisfactory survivorship and function after more than 20 years of use for patients receiving a bicruciate-retaining TKA implant. A TKA that preserves cruciate ligaments provides a stable, well-functioning knee with a low likelihood of revision at long-term followup. Retaining both cruciate ligaments during knee arthroplasty is an attractive concept that is worth considering.

Level of Evidence

Level IV, therapeutic study.     

High Survivorship With Cementless Stems and Cortical Strut Allografts for Large Femoral Bone Defects in Revision THA

Background

Numerous studies have investigated the clinical and radiographic results of revision THAs with use of cementless stems and cortical strut allografts. However, to our knowledge, no long-term followup studies have evaluated patients undergoing revision THA with use of cortical strut allografts where the allografts provided the primary stability for extensively coated femoral stems in the presence of extensive femoral diaphyseal bone defects.

Question/purposes

We performed this study to determine (1) validated outcomes scores; (2) radiographic signs of fixation and allograft healing; (3) frequency of complications; and (4) survivorship of the components after use of cortical strut onlay allografts in Types IIIB and IV femoral diaphyseal bone defects.

Methods

Between 1994 and 2003, we performed 140 revision THAs in 130 patients with Paprosky Types IIIB and IV femoral diaphyseal defects. The patients were treated using extensively coated femoral stems and cortical strut allografts because primary axial or rotational stability could not be achieved without grafting. Ten of the patients (10 hips; 7.7%) were lost to followup or died before 10 years; the remaining 120 patients (130 hips) represent the study group in this retrospective study. There were 66 men and 54 women. Their mean age at the time of index surgery was 59 ± 18 years (range, 36–67 years). The primary diagnosis was predominantly osteonecrosis of the femoral head (53%). The most common reason for revision was aseptic loosening (97%), followed by periprosthetic fracture (3%). The mean time from primary to revision THA was 12 years (range, 8–27 years). The mean duration of followup was 16.1 years (range, 12–20 years).

Results

The mean Harris hip score was 39 ± 10 points before revision and improved to 86 ± 14 points at 16 years followup (p = 0.02). The mean preoperative WOMAC score was 62 ± 29 (41–91) points and improved to 22 ± 19 (11–51) points at 16 years followup (p = 0.003). Of the 130 stems, 113 (87%) had bone ingrowth, five (4%) had stable fibrous ingrowth, and 12 (9%) were unstable. All allografts were incorporated. Four hips (3%) had a displaced femoral shaft fracture at the stem tip; four (3%) had a postoperative dislocation; and six (5%) had early postoperative infection. Kaplan-Meier survivorship analysis, with revision or radiographic failure as the endpoint, revealed that the 16-year rate of survival of the components was 91% (95% CI, 0.88%–0.96%).

Conclusion

Supportive cortical strut onlay allografts provided high survivorship beyond 12 years of followup in revision THAs. Future studies might compare this approach with allograft-prosthesis composites, proximal femoral replacement, or modular fluted, tapered stems.

Level of Evidence

Level IV, therapeutic study.     

Functional Impairment Is a Risk Factor for Knee Replacement in the Multicenter Osteoarthritis Study

Background

Debilitating pain associated with knee osteoarthritis (OA) often leads patients to seek and complete total knee arthroplasty (TKA). To date, few studies have evaluated the relation of functional impairment to the risk of TKA, despite the fact that OA is associated with functional impairment.

Questions/purposes

The purpose of our study was to (1) evaluate whether function as measured by WOMAC physical function subscale was associated with undergoing TKA; and (2) whether any such association varied by sex.

Methods

The National Institutes of Health-funded Multicenter Osteoarthritis Study (MOST) is an observational cohort study of persons aged 50 to 79 years with or at high risk of symptomatic knee OA who were recruited from the community. All eligible subjects with complete data were included in this analysis. Our study population sample consisted of 2946 patients with 5796 knees; 1776 (60%) of patients were women. We performed a repeated-measures analysis using baseline WOMAC physical function score to predict the risk of TKA from baseline to 30 months and WOMAC score at 30 months to predict risk of incident TKA from 30 months to 60 months. We used generalized estimating equations to account for the correlation between two knees within an individual and across the two periods. We calculated relative risk (RR) of TKA over 30 months by WOMAC function using a score of 0 to 5 as the referent in multiple binomial regressions with log link.

Results

Those with the greatest functional impairment (WOMAC scores 40–68; 62 TKAs in 462 knee periods) had 15.5 times (95% confidence interval [CI], 7.6–31.8; p < 0.001) the risk of undergoing TKA over 30 months compared with the referent group (12 TKAs in 3604 knee periods), adjusting for basic covariates, and 5.9 times (95% CI, 2.8–12.5; p < 0.001) the risk after further adjusting for knee pain severity. At every level of functional limitation, the RR for TKA for women was higher than for men, but interaction with sex did not reach significance after adjustment for covariates including ipsilateral pain (p = 0.138).

Conclusions

Baseline physical function appears to be an important element in patients considering TKA. Future studies should examine whether interventions to improve function can reduce the need for TKA.

Level of Evidence

Level III, observational cohort study.     

What Risk Factors Predict Recurrence of Heterotopic Ossification After Excision in Combat-related Amputations?

Background

Heterotopic ossification (HO) is common after combat-related amputations and surgical excision remains the only definitive treatment for persistently symptomatic HO. There is no consensus in the literature regarding the timing of surgery, and recurrence frequency, reexcision, and complications have not been reported in large numbers of patients.

Questions/purposes

(1) What are the rates of symptomatic recurrence resulting in reexcision and other complications resulting in reoperation in patients with HO? (2) Is either radiographic or symptomatic recurrence dependent on timing and type of initial surgery, the experience of the surgeon in performing the procedure, the severity of preexcision HO, the presence of concomitant neurologic injury, or the use of postoperative HO prophylaxis?

Methods

Between March 2005 and March 2013 our institution treated 994 patients with 1377 combat-related major extremity amputations; of those, 172 amputations underwent subsequent excision of symptomatic HO. The mechanism of injury resulting in nearly all amputations (n = 168) was blast-related trauma. We reviewed medical records and radiographs to collect initial grade of HO, radiographic recurrence, complete compared with partial excision, concomitant neurologic injury, timing to initial surgery, surgeon experience, and use of postexcision prophylaxis with our primary study outcome being a return to the operating room (OR) for repeat excision of symptomatic HO. All 172 combat-related amputations were considered for this study irrespective of followup, which was noted to be robust, with 157 (91%) amputations having at least 6 months clinical followup by an orthopaedic surgeon or physiatrist (median, 20 months; range, 0–88 months).

Results

Eleven of 172 patients (6.5%) underwent reexcision of HO, and 67 complications resulting in return to the OR occurred in 53 patients (31%) of patients. Multivariate analysis of our primary outcome measure showed more frequent symptomatic recurrences requiring reexcision when initial excision was performed as a partial excision (p = 0.03; odds ratio [OR], 5.0; 95% confidence interval [CI], 1.2–29.6) or when the initial excision was performed within 180 days of injury (p = 0.047; OR, 4.1; 95% CI, 1.02–16.6). There was no association between symptomatic recurrence and HO grade, central nervous system injury, experience of the attending surgeon, or postoperative prophylaxis. Radiographic recurrence was observed when partial excisions (eight of 30 [27%]) were done compared with complete excisions (five of 77 [7%]; p = 0.008).

Conclusions

HO is common after combat-related amputations, and patients undergoing surgical excision of HO for this indication often have complications that result in repeat surgical procedures. Partial excisions of immature lesions more often resulted in both symptomatic and radiographic recurrence. The likelihood of a patient undergoing reexcision can be minimized by performing a complete excision at least 180 days from injury to surgery with no evidence of a reduced risk of reexcision by waiting longer than 270 days.

Level of Evidence

Level III, therapeutic study.     

Time Seeing a Hand Surgeon Is Not Associated With Patient Satisfaction

Background

Previous studies, predominantly in the primary care setting, identified time spent with the physician as an important predictor of satisfaction. It is unknown if the same holds true in hand surgery.

Questions/purposes

Is patient satisfaction measured immediately after an office visit associated with the duration of time spent with the hand surgeon? What other factors are associated with satisfaction directly after the visits and 2 weeks after the appointment?

Methods

We prospectively enrolled 81 patients visiting our hand and upper extremity surgery outpatient clinic. We recorded their demographics and measured physical function, pain behavior, symptoms of depression, time spent in the waiting room, time spent with the physician, and patient satisfaction. Office times were measured using our patient ambulatory tracking system and by a research assistant outside the clinic room. To assess satisfaction we used items from the Consumer Assessment of Healthcare Providers and Systems survey (a federally developed standardized survey instrument) relevant to our study. Two weeks later, 51 (64%) patients were available for telephone followup and the same measures were completed. Mean time spent with the hand surgeon was 8 ± 5 minutes and mean in-office wait time to see the hand surgeon was 32 ± 18 minutes. A priori power analyses indicated that 77 patients would provide 80% power to detect an effect size f² = 0.18 for a regression with five predictors. This means that we would detect time spent with the physician as a significant factor if it accounted for 7% or more of the variability in satisfaction.

Results

Time spent with the hand surgeon was not associated with patient satisfaction measured directly after the visit (r = –0.023; p = 0.84). Longer time waiting to see the physician correlated with decreased patient satisfaction (r = –0.30; p = 0.0057). The final multivariable model for increased satisfaction directly after the office visit included shorter waiting time (regression coefficient [β] –0.0014; partial R² 0.094; 95% confidence interval [CI], –0.0024 to –0.00042; p = 0.006) and being married/living with a partner (β 0.057; partial R² 0.11; 95% CI, 0.021–0.093; p = 0.002 [adjusted R² 0.18; p < 0.001]). Similarly, multivariable analysis found higher patient satisfaction 2 weeks after the visit to be independently associated with shorter waiting time (β –0.0037; partial R² 0.10; 95% CI, –0.0070 to –0.00054; p = 0.023) and being married/living with a partner (β 0.15; partial R² 0.12; 95% CI, 0.033–0.26; p = 0.012 [adjusted R² 0.16; p = 0.0052]).

Conclusions

Patient satisfaction among patients undergoing hand surgery may relate more to shorter time in the waiting room and to the quality more than the quantity of time spent with the patient.

Level of Evidence

Level II, prognostic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-4090-z) contains supplementary material, which is available to authorized users.