Table Of Content04098-prelims.qxd 07/02/2004 17:38 PM Page i
Outcome Measures in Orthopaedics and
Orthopaedic Trauma
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Outcome Measures in Orthopaedics and
Orthopaedic Trauma
2nd Edition
Edited by
Paul B.Pynsent
Research and Teaching Centre,Royal Orthopaedic Hospital,
Birmingham,UK
Jeremy C.T.Fairbank
Nuffield Orthopaedic Centre,Oxford,UK
Andrew J.Carr
University of Oxford,Nuffield Orthopaedic Centre,Oxford,UK
A member of the Hodder Headline Group
LONDON
CRC Press
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Contents
Contributors vii
Preface xi
Acknowledgements xv
1 Choosing an outcome measure 1
Paul B. Pynsent
2 A systematic approach to developing comparative health outcome indicators 8
Alastair Mason, Andrew Garratt, Edel Daly and Michael J. Goldacre
3 Economic evaluation 18
Nikos Maniadakis and Alastair Gray
4 Randomized controlled trials 31
Jeremy C. T. Fairbank
5 Register studies 41
Leif I. Havelin, Birgitte Espehaug, Ove Furnes, Lars B. Engesæter,
Stein A. Lie and Stein E. Vollset
6 Measures of health status, health-related quality of life and patient satisfaction 54
Raymond Fitzpatrick
7 The measures of pain 63
Henry J. McQuay
8 Trauma severity indices 70
Julian P. Cooper
9 Complications 81
Alasdair J. A. Santini and Simon P. Frostick
10 Outcome after blast, missile and gunshot wounds 95
Jonathan C. Clasper
11 Deformity and cosmesis 105
T. N. Theologis
12 Growth plate injuries 113
D. M. Eastwood
13 Peripheral nerve injuries 127
David Warwick and Peter P. Belward
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vi Contents
14 Spine and spinal cord 136
Jeremy C. T. Fairbank and Harry Brownlow
15 Shoulder and elbow 172
Paul Harvie and Andrew J. Carr
16 The wrist 196
Joseph J. Dias
17 The hand 209
T. R. C. Davis
18 Pelvic and acetabular fractures 237
Philip J. Chapman-Sheath and Keith M. Willett
19 Femoral head and neck and the hip joint 263
Martyn J. Parker and Andrew Pearson
20 Tibial and femoral shafts 276
Badri Narayan, Raman V. Kalyan and David R. Marsh
21 The knee 301
Amir W. Hanna
22 The ankle and hindfoot 339
Mark L. Herron and Michael M. Stephens
23 The foot 357
Roger M. Atkins
Index 369
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Contributors
Roger M. Atkins, MA, FRCS, DM Oxon T. R. C. Davis, BSc, FRCS
Consultant Orthopaedic Surgeon, Bristol Royal University Hospital, Queens Medical Centre,
Infirmary and Avon Orthopaedic Centre, Nottingham, UK
Bristol Royal Infirmary, Bristol, UK
Joseph J. Dias, MD, FRCS(Ed), FRCS
Peter P. Belward, MCSP, SRP
Consultant Orthopaedic and Hand Surgeon,
Clinical Specialist Hand Therapist,
Glenfield Hospital, Groby Road, Leicester, UK
Southampton General Hospital,
Southampton, UK
D. M. Eastwood, MB, FRCS
Harry Brownlow, BSc, MBChB, MD, FRCS (Ortho) Consultant Orthopaedic Surgeon, The Royal
Consultant Orthopaedic Surgeon, National Orthopaedic Hospital and the
Royal Berkshire Hospital, Royal Free Hospital, London, UK
Reading, UK
Lars B. Engesæter, MD, PhD
Andrew J. Carr, ChM, FRCS
Orthopaedic Surgeon, Department of Orthopaedic
Nuffield Professor of Orthopaedic Surgery,
Surgery, Haukeland University Hospital,
Nuffield Department of Orthopaedic Surgery,
Bergen, Norway
Nuffield Orthopaedic Centre, Oxford, UK
Philip J. Chapman-Sheath, BSc, FRCS (Tr & Orth) Birgitte Espehaug, MSc, PhD
Consultant Orthopaedic Surgeon, Statistician, The Norwegian Arthroplasty
Southampton General Hospital, Register, Department of Orthopaedic Surgery,
Southampton, UK Haukeland University Hospital, Bergen, Norway
Jonathan C. Clasper, DPhil, DM FIMC FRCSEd (Orth) Jeremy C. T. Fairbank, MD, FRCS
DMCC Consultant Orthopaedic Surgeon, Nuffield
Consultant Orthopaedic Surgeon,
Orthopaedic Centre, Oxford, UK
Frimley Park Hospital, Surrey, UK
Raymond Fitzpatrick, BA, MSc, PhD
Julian P. Cooper, BSc,FRCS (Tr & Orth)
Professor of Public Health and Primary Care,
Consultant Orthopaedic Trauma Surgeon,
Department of Public Health, University of
South Birmingham Trauma Unit,
Oxford, Institute of Health Sciences,
Selly Oak Hospital, University Hospital
Oxford, UK
Birmingham NHS Trust, Birmingham, UK
Edel Daly,DPhil Simon P. Frostick, MA, DM, FRCS
Research Officer, Unit of Health Care Department of Musculoskeletal Science,
Epidemiology, Department of Public Health, Royal Liverpool University Hospital,
Oxford University, Oxford, UK Liverpool, UK
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viii Contributors
Ove Furnes, MD, PhD and Primary Health Care, University of Bergen,
Orthopaedic Surgeon and Head of the Bergen, Norway
Norwegian Arthroplasty Register, Department of
Nikos Maniadakis, PhD, MSc
Orthopaedic Surgery, Haukeland University
General Manager, General University Hospital of
Hospital, Bergen, Norway
Patras, Rion Patras, Greece
Andrew Garratt, BA, MSc, PhD
David R. Marsh, MD, FRCS
Research Lecturer, Unit of Health Care
Professor of Trauma and Orthopaedics,
Epidemiology, Department of Public Health,
Queens University, Belfast
Oxford University, Oxford, UK
Musculoskeletal Education and Research Unit,
Michael J. Goldacre, BM, BCh, FFPHM Musgrave Park Hospital, Belfast, UK
Professor of Public Health, Unit of Health Care
Alastair Mason, FRCP, FFPHM
Epidemiology, Department of Public Health, Oxford
Epidemiologist, Cobblers Close, Gotherington, UK
University, Oxford, UK
Henry J. McQuay
Alastair Gray, PhD
Pain Research, Nuffield Department of
Director, Health Economics Research Centre,
Anaesthetics, University of Oxford,
Department of Public Health, University of
The Churchill Oxford Radcliffe Hospital,
Oxford, Institute of Health Sciences, Oxford, UK
Oxford, UK
Amir W. Hanna, MS, PhD, FRCS
Clinical Lecturer Orthopaedics and Trauma, Badri Narayan, MS, MCh (Orth),
Dundee University, Tayside University Hospitals, FRCS (Tr & Orth)
Consultant Orthopaedic Surgeon, Royal Liverpool
Dundee, UK
and Broadgreen University Hospitals NHS Trust,
Paul Harvie, BSc, MBChB, MRCS Liverpool, UK
Girdlestone Scholar in Orthopaedic Surgery,
Nuffield Department of Orthopaedic Surgery, Martyn J. Parker, MD, FRCS
Orthopaedic Research Fellow, Peterborough
University of Oxford, Oxford, UK
District Hospital, Peterborough, UK
Leif I. Havelin, MD, PhD
Orthopaedic Surgeon, Head of the Department of Andrew Pearson, FRCS (Trt & Orth)
Specialist Registrar, The Royal Orthopaedic
Orthopaedic Surgery, Haukeland University
Hospital, Birmingham, UK
Hospital, Bergen, Norway
Mark L. Herron, FRCS (Tr & Orth) Paul B. Pynsent, PhD
The Royal Orthopaedic Hospital, Director, Research and Teaching Centre,
Birmingham, UK Royal Orthopaedic Hospital, Birmingham, UK
Raman V. Kalyan, D Ortho, Dip N B Ortho Surg Alasdair J. A. Santini, FRCS (Orth)
Spine Fellow, Department of Trauma and Royal Liverpool Hospital, Liverpool, UK
Orthopaedics Surgery, Queen’s University of
Michael M. Stephens, MSc (Bioeng), FRCSI
Belfast, Musgrave Park Hospital, Belfast, UK
Consultant Orthopaedic Surgeon, Cappagh
Stein A. Lie, PhD, MSc National Orthopaedic, Mater Misericordae and
Research Fellow, Section for Epidemiology and University Children’s Hospitals,
Medical Statistics, Department of Public Health Dublin, Ireland
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Contributors ix
T. N. Theologis, FRCS David Warwick, MD, BM, DIME, FRCS, FRCS (Orth)
Consultant Orthopaedic Surgeon, Nuffield Consultant Hand Surgeon, Southampton
Orthopaedic Centre, Oxford, UK University Hospitals, Southampton, UK
Stein E. Vollset, MD, DrPH Keith M. Willett, FRCS
Section for Epidemiology and Medical Statistics, Consultant Orthopaedic Trauma Surgeon, Trauma
Department of Public Health and Primary Health Service, John Radcliffe Hospital, Oxford, UK
Care, University of Bergen, Bergen, Norway
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Preface
‘Outcome’ is defined by The Oxford English Dic- relationship to any intervention, social or
tionary as ‘a visible or practical result’. Outcome environmental circumstance is understood.
measures play an important rôle in medical practice. An example is infant mortality rate.
They should provide the basis for both clinical audit
• An Outcome Measurementis a sub-type of
and research. The principal object of this book is
health status measurement where changes in
to provide references to sources of instruments
the measure are known (or at least believed) to
and techniques used for outcome measurement in
be largely attributable to a health service
orthopaedics and trauma and to advise on the opti-
intervention. An example, in the field of
mum choice of instrument. It will become clear to
paediatrics is life expectancy for people with
any student of this topic that it is not an easy subject
cystic fibrosis.
and there remain many areas without adequate out-
comemeasures. • An Implied Outcome Measurementis an
The text is aimed at medical staff in orthopaedic indirect indicator of health that can be used as
units, trauma centres and accident and emergency a valid proxy for an outcome measurement.
departments. The book may also be of value to Examples are immunization coverage, and
physiotherapists, metrologists, research nurses and coverage of a screening programme of proven
others involved in clinical research into orthopaedics effectiveness. In our view, the health status
and trauma. There is a medico-legal dimension to measurement may also be described as
this topic. Outcome measures are vital to the setting ‘functional status measurement’ and a ‘quality
of standards of care and their measurement, as well of life measure’. These measurements can be
as in the assessment of disease or injury severity. made without necessarily seeking improvement.
This is of relevance to both lawyers and clinicians
The Editors of this book have all had a longstand-
in this area, who will find in this book a reference
ing interest in outcome measures. Each has con-
to the most appropriate outcome measures for their
tributed both to the original development of outcome
purpose. The setting of standards of care and the
instruments and to studies to establish their validity,
assessment of the quality of care is also of concern
reliability and responsiveness. We have collaborated
to doctors in public health medicine, purchasers
to produce collections of outcome measures for
and government. It is important for the clinician to
orthopaedics (Pynsent et al. 1993) and for trauma
maintain an interest in this field, not least to ensure
(Pynsent et al.1994) in separate texts, and also in a
that managers are receiving accurate and relevant
text on methodology (Pynsent et al.1997). We have
clinical information about his or her activities.
also collected classification systems in trauma
The British Paediatric Association Outcome
(Pynsent et al.1999).
Measures Working Group (British Paediatric Asso-
In this book, we have combined orthopaedic and
ciation 1992) has presented a number of definitions:
trauma outcome measures in a single volume. In our
• A Health Status Measurementis a direct original texts we used a conference based on the
measure of some aspect of health in which Dahlem model to review draft chapters (Dixon
improvement is sought, whether or not its 1987) but on this occasion we have asked authors
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xii Preface
to collect, classify and – where possible – to tabu- been included in the summary table, but with an
late outcome measures. We also asked them to rank asterisk beside it and comments in the chapter text.
outcome measures according to a formula laid out These papers have not been added into the score.
below. This has not always been achieved but we In the event of a score tie, then if one is self-reporting
believe that the results will be of value to both clin- (i.e. completed by the patient) then it wins. If they
ical research and audit. There may be some circum- are both self-reporting then the one with the fewest
stances where instruments can be used to evaluate questions wins – otherwise it is a tie.
individual patients as an aid to clinical assessment In general, many of the outcome measures in clin-
and decision making. ical practice are based on scoring systems, though
most of these systems are poorly validated. New-
comers to the field will experience difficulties not
OUTCOME INSTRUMENTS only in finding the available instruments but also in
making an informed choice as to the most appro-
Where possible, instruments (questionnaires or priate for their purpose. This book is designed to
other outcome systems) have been either actually help in making such a choice. We have tried to be
included as an appendix or carefully referenced. descriptive as well as proscriptive. Often, there are
A summary of instruments (questionnaires or other differences between the requirements of outcome
outcome systems) has been tabulated in Table 1. measures for audit as opposed to clinical research.
In most cases there is a pay-off between the demands
of speed, efficiency and acceptability to both doctor
SCORING OUTCOME and patient and the demands of precision and
INSTRUMENTS specificity. In our opinion, some instruments are so
complex that they have become impossible to
Instruments have been scored according to Table 2. use. Where possible, it should be indicated where
Where a paper has been published showing poor apparently clear-cut measures of outcome (for
validity, reliability or responsiveness results, it has example, the union of a fractured tibia) may be
Table 1
Instrument name What it
(reference) measures Validation Reliability Responsiveness Usage Score
Table 2
No Yes (by author) Independent (by another author)
Validated 0 1 2
Reliability tested 0 1 2
Responsiveness tested 0 1 2
Usage published† 0 Scores from 1 for each publication,to a maximum of 4
†This should exclude any publications that have scored in the three previous categories.
