To The Editor:
I am writing in response to the recent Commentary entitled "The
Fallacy of Short-Term Outcomes Analysis in Pediatric Orthopaedics" (81-A:
1499-1500, Oct. 1999), by Winter. The purpose of assessment is to
determine the effect of treatment (or no treatment) on
patients. Orthopaedic treatments are intended to (1) prolong life,
as in patients with musculoskeletal oncology, (2) relieve concerns,
as in patients with hip osteoarthritis, (3) restore function, as
in patients with traumatic fractures, and (4) prevent future decline,
as in infants with hip dislocation1.
Patient-based assessments are most appropriate for the first three.
Dr. Winter points out very appropriately that, in the latter case,
in which the patient is young and asymptomatic, it would not be
appropriate to perform an outcomes assessment focusing solely on
the concerns of the child and the family immediately after
surgery. This, he suggests, is the "fallacy of short-term
outcomes analysis" in pediatric orthopaedics.
I have two comments in response to Dr. Winter’s Commentary.
First, patient evaluation should not be the only way of evaluating
surgical interventions. For an eighteen-month-old child with a dislocated hip,
the aim of treatment is to prevent premature osteoarthritis, which
may not develop until mid-adulthood. Because the child is usually
asymptomatic at the time of diagnosis, the clinical examination
and radiographic assessment are the best means of evaluation for
the first four to five years of life. Many, if not most, treatments
in pediatric orthopaedic surgery have lifelong effects; however, this
does not mean that the evaluation should be based solely on the
results near the end of life. For example, children as young as
five are able to self-report their physical disability2. Thus, even at that young age, child-reported
function may help us to choose among different surgical options
for congenital dislocation of the hip with different risks of stiffness
and avascular necrosis.
Second, many conditions in pediatric orthopaedics are symptomatic
at the time of presentation. Outcomes assessment has much to offer
in the case of a thirteen-year-old girl with a 50 scoliosis. Many teenagers
with scoliosis have pain3, and
cosmesis is one of their primary concerns4.
Furthermore, the literature suggests that the natural history is
rarely one of cor pulmonale but usually is one of a relatively healthy
and happy life5. Thus, outcomes
assessment plays an important role in evaluating treatments for
scoliosis. Randomized clinical trials may well show that patients
who have surgery have a reduction of pain, better appearance, and
improvement in their functional abilities. Given the magnitude of
the surgery and the potential risks, we need to accurately assess both
the short-term and the long-term benefits of scoliosis surgery.
The short-term outcomes analysis must include the concerns of children
and their families.
Orthopaedists have long been pioneers in recognizing the importance
of patients’ concerns and have been leaders in the outcomes
movement. Rather than going the way of "rebellion," I
hope the outcomes movement will achieve a healthy balance between
patient-based assessments and other types of measurement in determining
the benefits of orthopaedic procedures.
R.B. Winter replies:
In his comments on adolescent idiopathic scoliosis, Dr. Wright
states that "randomized clinical trials may well show that
patients who have surgery have a reduction of pain, better appearance,
and improvement in their functional abilities." This may
be true, but this argument continues to ignore the true benefit
of scoliosis surgery: the prevention of adult disability.
The author must incorporate the preventive half of the equation
in addition to the short-term cosmetic benefits of the operation.