Patient and physician views of shared decision making in cancer Tamirisa, Nina P.; Goodwin, James S.; Kandalam, Arti ...
Health expectations : an international journal of public participation in health care and health policy,
December 2017, Volume:
20, Issue:
6
Journal Article
Peer reviewed
Open access
Context
Engaging patients in shared decision making involves patient knowledge of treatment options and physician elicitation of patient preferences.
Objective
Our aim was to explore patient and ...physician perceptions of shared decision making in clinical encounters for cancer care.
Design
Patients and physicians were asked open‐ended questions regarding their perceptions of shared decision making throughout their cancer care. Transcripts of interviews were coded and analysed for shared decision‐making themes.
Setting and participants
At an academic medical centre, 20 cancer patients with a range of cancer diagnoses, stages of cancer and time from diagnosis, and eight physicians involved in cancer care were individually interviewed.
Discussion and conclusions
Most physicians reported providing patients with written information. However, most patients reported that written information was too detailed and felt that the physicians did not assess the level of information they wished to receive. Most patients wanted to play an active role in the treatment decision, but also wanted the physician's recommendation, such as what their physician would choose for him/herself or a family member in a similar situation. While physicians stated that they incorporated patient autonomy in decision making, most provided data without making treatment recommendations in the format preferred by most patients. We identified several communication gaps in cancer care. While patients want to be involved in the decision‐making process, they also want physicians to provide evidence‐based recommendations in the context of their individual preferences. However, physicians often are reluctant to provide a recommendation that will bias the patient.
Objectives:
The purpose is to report minimum 10-year follow-up survivorship, defined as non- conversion to total hip arthroplasty (THA), and patient-reported outcome scores (PROS) following primary ...hip arthroscopy with acetabular microfracture in the setting of femoroacetabular impingement syndrome (FAIS) and acetabular chondral lesions, respectively.
Methods:
Data was prospectively collected and retrospectively analyzed on all patients who underwent a primary hip arthroscopy and received an acetabular microfracture between June 2009 and January 2011 and included in this study. Patients with a minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain were included. If available, the minimum 10-year follow-up for the Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) was reported. The demographics, intraoperative findings, surgical procedures, PROS, rate of achieving the minimal clinical important difference (MCID), and secondary surgeries were analyzed and reported.
Results:
Twenty-two hips (20 patients) were included in the study, and the mean follow-up time was 124.5 ± 2.2 months. There were 17 hips (77.3%) from males and 5 hips (22.7%) from females. The average patient age at the time of surgery was 42.3 years ± 9.6. All patients on average experienced statistically significant improvement (P < 0.05) between preoperative and minimum 10-year follow-up scores for all PROs. In total, 77.3% of the patients did not require conversion to THA. Additionally, 83.3% of the patients achieved the MCID for the mHHS, NAHS, and VAS for pain.
Conclusions:
At a minimum 10-year follow-up, survivorship of 77.3% was reported for patients that underwent primary hip arthroscopy with acetabular microfracture for the treatment of FAIS and focal/full-thickness acetabular cartilage lesions. Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated.
Objectives:
To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral (ASPBT) and open subpectoral (OSPBT) techniques via interference screw (IS) or all-suture ...anchor with a single suture (SSSA) fixation with radiostereometric analysis (RSA).
Methods:
Distal migration of the biceps tendon following OSPBT with a Polyetheretherketone (PEEK) IS, OSPBT with one SSSA, ASPBT with PEEK IS, and ASPBT with two SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative Patient-Reported Outcome Measures (PROMs) including CMS, SANE, or PROMIS-UE scores were included. A tantalum bead was sutured on the proximal end of the long head biceps tendon before fixation. AP radiographs were performed immediately postoperatively, 1 week, and 3 months. Bead migration was measured, and PROMs were compared.
Results:
Of 115 patients, 94 were available for final follow-up (82%). Average age was 52.1±10.5 years, and BMI was 30.8±5.4 kg/m2. There was no difference in tendon migration between OSPBT and ASPBT performed with an IS (P=0.70). OSPBT performed with one SSSA (21.70 mm) demonstrated significantly greater migration than ASPBT with IS (4.31mm, P<0.001) and OSPBT with IS (5.04 mm, P<0.001). Three patients (9.4%) who had OSPBT with one SSSA and one who had ASPBT with two SSSAs (3.8%), developed a Popeye deformity; none occurred in the IS groups. Mean 12-week bead migration in patients with versus without Popeye deformity was 60.8 mm and 11.2 mm, respectively (P<0.0001). PROMs did not differ at final follow-up.
Conclusions:
ASPBT and OSPBT with IS fixation demonstrated the least tendon migration, while OSPBT with one SSSA yielded the most. Compared to IS, fixation with one, but not two, SSSAs resulted in significantly greater migration. Average bead migration following a Popeye deformity was 6.1cm. To minimize migration when using SSSAs, at least 2 sutures should be used with an interlocking pattern within the tendon.
Objectives:
It has previously been established that screw fixation results in better outcomes than button fixation for arthroscopic anatomic glenoid reconstruction (AAGR) with frozen allograft. There ...has been considerable debate on the causes for the higher dislocation rates with non-rigid fixation. The purpose of this study was to evaluate which factors may affect failure rates for AAGR with non-rigid fixation.
Methods:
This was a retrospective review of patients who had AAGR using non-rigid fixation that were age-, gender-, and followup-matched with screw fixation patients. Arthroscopic videos were used to evaluate surgical factors including graft placement, fixation quality, tensioning, graft contact, soft tissue quality, quality of soft tissue repair, presence of Hill-Sachs, and addition of Remplissage. Patient demographic factors (age, gender, medical history etc) were also assessed. XRays and CTs were used to evaluate graft union, screw and button angle, graft remodeling, and button pull through.
Results:
A total of 36 patients were included in our study who had AAGR between 2014 and 2019 (18 non-rigid fixation matched to 18 screw fixation). Seven patients who had non-rigid fixation had a dislocation requiring reoperation. Of these, 4/7 had poor anterior soft tissue. All but one patient had excellent soft tissue repair and balance at end of surgery. All seven patients had complete graft resorption compared with those did not fail who had a normal post-operative glenoid A-P dimension.
Conclusions:
In our case series, AAGR with non-rigid fixation had high rate of recurrent dislocation. These failed patients had appropriate surgical factors that were equivalent between dislocated patients and successful patients. The failure rate was not correlated with surgical technique, patient or radiographic factors but rather only fixation type. Further study is needed to evaluate fixation methods and to assess whether type of graft impacts these clinical outcomes.
Objectives:
Femoroacetabular impingement (FAI) has become an increasingly recognized diagnosis contributing to morbidity in the adolescent and young adult population over the past decade. Our ability ...to treat such pathology with hip arthroscopy has grown in parallel. As the number of hip arthroscopy cases performed annually continues to rise, so will the number of patients requiring revision surgery. Trending outcomes and indications for revision hip arthroscopy is essential to improve surgical techniques, facilitate accurate diagnoses and address pathology appropriately. The purpose of this study was to report outcomes for revision hip arthroscopy and assess if outcomes vary by indication.
Methods:
A single-center hip preservation registry was reviewed to identify patients who underwent revision hip arthroscopy for the treatment of FAI between 2012 and 2019. Patient demographics and primary indications for revision hip arthroscopy were determined, patient reported outcomes were collected preoperatively and at an average follow-up of 5.2 years post-operatively.
Results:
A total of 239 patients met inclusion criteria for this study. The top 4 primary indications for revision were: Residual FAI 67.8%, instability 14.6%, heterotopic ossification (HO) 4.6% and adhesions 4.2%, trends in indication did not vary over time. On average patients improved significantly from pre- to post-operatively in mHHS 20.4(95% CI: 16.6 - 24.1), HOS ADL 15.0 (95%CI: 11.9 -18.2), HOS SS 23.8 (95% CI: 18.8 – 28.9), iHOT-33 30.2 (95% CI: 26.0 – 34.3), p<0.001. Rates of achieving MCID varied from 62.9%-78.3%, SCB 44.9-56.6% and SCB by absolute value at final follow-up of 32.1-65.9%. In a subgroup analysis, significantly lower pre-operative function was noted in the instability cohort compared to the impingement cohort as measured by HOS SS only, p=0.004. Post-operatively this instability cohort demonstrated significantly worse outcomes as measured by mHHS, HOS ADL and iHOT33. Rate of re- revision arthroscopy was 6.4% and 8.7% of patients required THA or were planning soon.
Conclusions:
The most common indication for revision hip arthroscopy in the treatment of femoroacetabular impingement remains residual impingement. Capsular complications have significant consequence for function and may represent a subset of patients who demonstrate more dysfunction both before and after revision arthroscopy. Lastly, heterotopic ossification is third most common reason for revision hip arthroscopy underlining the importance of postoperative prophylaxis.
Objectives:
The purpose of our study was to determine if patients 65 years and over meet the minimally clinical important difference (MCID) for Patient-Reported Outcomes Measurement Information ...System Upper Extremity (PROMIS-UE), Depression (PROMIS-D), and Pain Interference (PROMIS-PI) at similar rates compared to a cohort of younger patients.
Methods:
A retrospective review of a prospectively collected database of patients undergoing RCR was performed. Patients with completed preoperative and 6-month follow up postoperative PROMIS scores were included. A cohort of 65 years and older (65<) was compared to a cohort of 64 years and younger (64>=) in terms of their clinical outcomes and PROMIS scores. A propensity matched analysis was then performed, which matched patients 65+ years old 1:1 to a cohort of 50 years or younger via tear size and body mass index (BMI).
Results:
A total of 318 patients were included with 79 patients ≥ 65 years (69.2 ± 3.4 years, mean ± SD) and 239 patients <65 years (55.1 ± 3.4 years). No significant differences were found in terms of gender, tear thickness, tear size, reoperation rate, retear rate, preoperative PROMIS-UE, PROMIS-PI, and PROMIS D scores, or change in postoperative PROMIS-UE, PROMIS-PI, and PROMIS D after 6 months. In the sub-analysis, 44 patients over 65 years of age were propensity matched to 44 under 50 years of age. No differences were found in PROMIS-UE change, PROMIS-D change, proportion meeting MCID PROMIS UE, and proportion meeting MCID of PROMIS PI after 6 months. Patients in the 65+ years group experienced larger changes in PROMIS PI scores (12.5 ± 9.6 vs 7.2 ± 7.5, p=0.005) while fewer patients experienced significant declines in PROMIS D scores (26% vs 47%, p=0.03).
Conclusions:
Patients ≥ 65 years experience no differences in reoperation or retear rate when compared to younger patients. Older patients undergoing RCR were more likely to have a larger improvement in pain scores but were less likely to have significant clinical change in their depression scores. With proper patient selection, patients ≥ 65 years can achieve clinically significant improvements 6 months after RCR that is similar to their younger counterparts.
Category:
Hindfoot; Other
Introduction/Purpose:
Minimally invasive (MIS) percutaneous calcaneal osteotomy has been increasingly investigated as a potentially safe alternative to open calcaneal ...osteotomy due to reduced postoperative complication and decreased pain compared to an open procedure. This retrospective chart review aims to evaluate the postoperative outcomes and complication rates of patients undergoing MIS vs. open calcaneal osteotomy.
Methods:
IRB approval was obtained. The study was performed by 2 fellowship-trained orthopaedic foot and ankle surgeons. 20 patients underwent MIS percutaneous calcaneal osteotomy, and 33 patients underwent open calcaneal osteotomy. All cases were completed between March 2021 and February 2023. Patient charts were reviewed for outcome data including complication rate, union rate, revision rate, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores.
Results:
Average follow up for the MIS group was 130.4 days and 258.2 days for the open group. The MIS group was found to have a lower rate of revision, infection, and sural neuritis (0%, 5%, and 10%) compared to the open group (3%, 13.3%, and 16.7%). All participants achieved union. Average preoperative PROMIS scores in the domains of physical function, pain interference, and mobility for the MIS group were 36.8 (28.6-46), 67.1 (54.3-78), and 34.6 (25-40). Average postoperative PROMIS scores for the MIS group were 35.7 (21-76), 62.3 (39-76), and 33.4 (16-75). In the open group, preoperative PROMIS scores in these same domains were 37.0 (22.4-49.8), 65.2 (54.3-77.8), and 35.0 (19-56), whereas they were 39.6 (19-56), 60.0 (39-72), and 37.4 (16-53) postoperatively.
Conclusion:
MIS percutaneous calcaneal osteotomy appears to be an efficacious and safe treatment with lower rates of revision, infection, and nerve injury compared to an open procedure. Early outcome measures show comparable PROMIS scores in all three domains of physical function, pain interference, and mobility following MIS percutaneous calcaneal osteotomy when compared to standard open calcaneal osteotomy. Surgeons may consider MIS percutaneous calcaneal osteotomy as an alternative to open calcaneal osteotomy when treating hindfoot deformities.
Category:
Midfoot/Forefoot; Trauma
Introduction/Purpose:
The purpose of this study was to compare the time to radiographic and clinical healing between patients with metadiaphyseal metatarsal ...fractures (True Jones) treated operatively and those treated nonoperatively.
Methods:
This was a retrospective cohort study of patients presenting to a single large, urban, academic hospital center with Jones fractures between December 2012 and April 2022. Jones fractures were defined as 5th metatarsal base fractures occurring in the proximal metadiaphyseal region, just distal to the articulation of the 4th and 5th metatarsals on the oblique radiographic view (Zone 3). Information regarding patient demographics, injury mechanism, clinical presentation, management, and time to healing was collected. A fracture was defined as clinically healed when the patient had returned to their baseline ambulatory status without pain and there was an absence of tenderness to palpation on physical examination. Radiographic healing was defined as the presence of complete osseous consolidation. A total of 2,466 patients presented with 5th metatarsal fractures during the study period.
Results:
Among all 5th metatarsal fractures, 170 patients (6.9%) were classified as “true Jones” fractures. The mean age of patients presenting with Jones fractures was 46.1 +/- 18.6 years, and 65.8% were female. 19.9% were treated operatively (92.9% with screw fixation and 7.1% with ORIF), and 80.1% were treated nonoperatively. 95.9% of patients with Jones fractures went on to heal with no difference in time to radiographic healing (p = 0.296) or clinical healing between both groups (p = 0.228). Furthermore, there was no difference between groups with respect to the proportion of patients who developed delayed radiographic union with incomplete osseous healing at 6 months post-injury (9.3% in the nonoperative group versus 10.7% in the operative group, p = 0.098).
Conclusion:
Contrary to popular opinion, operative treatment of true Jones fractures was not associated with faster or more reliable radiographic union or time to clinical healing compared to patients treated nonoperatively. The overall rate of nonunion in true Jones fractures was found to be lower than previously described, and there was no evidence of any difference in nonunion rate with operative treatment compared to nonoperative management.
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