Sexual Decision-Making in HIV-Positive Men Who Have Sex with Men: How Moral Concerns and Sexual Motives Guide Intended Condom Use with Steady and Casual Sex Partners

Determinants of intended condom use with steady and casual sex partners were examined among Dutch HIV-positive men who have sex with men (MSM) (N = 296). Given the proposition that safer sex behavior among HIV-positive people is a form of prosocial behavior, the present study extended the general framework of the Theory of Planned Behavior with Schwartz’s norm-activation theory and tested the assumption that personal norms would mediate the effects of other psychosocial factors on intended condom use for anal sex. In addition, it was hypothesized that, depending on the context in which sex occurs, specific motives for unprotected anal sex may have a negative influence on intended condom use and, as such, undermine a prosocial tendency to practice safer sex. Therefore, we also investigated the influence of sexual motives for unprotected anal sex on intended condom use with steady and casual sex partners. Results indicated that the Theory of Planned Behavior adequately predicted condom use intentions (for casual sex partners and steady sex partners, the explained variance was 52% and 53%, respectively). However, our proposed model of sexual decision-making significantly improved the prediction of behavioral intentions. For steady and casual sex partners, the assumption of the mediating role of personal norms on condom use intention was confirmed empirically. Additionally, sexual motives for unprotected anal sex exerted, as expected, a direct, negative effect on condom use intention with casual sex partners. The implications of the findings for future research and the development of HIV-prevention programs for HIV-positive MSM are discussed.
Introduction
Studies on the effects of HIV counseling and testing show that most individuals who are tested HIV-positive respond by reducing their sexual risk behavior (Weinhardt, Carey, Johnson, & Bickman, 1999). Nevertheless, it has been found that approximately one third of HIV-positive men who have sex with men (MSM) engaged in unprotected anal sex in the last two to three months (for a review, see Kalichman, 2000). Moreover, increased prevalence rates of gonorrhea and syphilis have been reported among HIV-positive and HIV-negative MSM in several western regions (e.g., Anon, 2002; Macdonald et al., 2004; Van de Laar & Op de Coul, 2003). These findings suggest a rise in unprotected anal sex among HIV-negative and HIV-positive MSM. Given that at least a subgroup of HIV-positive MSM, for various reasons, engage in risky sexual behavior, an understanding of why this occurs remains a matter of significant public healthy concern.
Studies have been conducted that examined possible antecedents of (un)safe sexual behavior in HIV-positive MSM (Crepaz & Marks, 2002). One of the factors that has been identified as promoting sexual behavior change is perception of risk, i.e., awareness that unprotected sex increases the risk for HIV infection and STDs. Accordingly, studies have indicated that HIV-positive MSM who believe that HIV-superinfection and other STDs may have negative consequences for their own health are more likely to use condoms for anal sex (Colfax et al., 2004; McConnell, Grant, & Greenwood, 2002). However, other studies suggest that a person’s own risk of HIV-superinfection and STDs is not a key concern. Of great importance is the finding that safer sex in HIV-positive MSM is primarily motivated by concerns about the risks for the other and that concerns about one’s own risks are subordinate (Keogh, Weatherburn, & Stephens, 1999; Van Kesteren, Hospers, Kok, & Van Empelen, 2005).
The notion that HIV-positive MSM engage in safer sex because of concerns about the welfare of sex partners can be characterized as a form of prosocial behavior. Prosocial behavior “represents a broad category of acts…that are defined as generally beneficial to other people” (Penner, Dovidio, Piliavin, & Schoeder, 2005, p. 366). If HIV-positive MSM indeed engage in safer sex to benefit others, or more specifically, are motivated to prevent harm to others, it is of particular importance to understand why this is the case and to determine which factors promote such behavior. The literature offers several explanations to account for prosocial behavior. One explanation for a wide range of moral and prosocial behaviors, which has received considerable attention, is the so-called personal standards approach (e.g., Manstead, 2000). This approach emphasizes how internalized, self-reinforced standards, such as altruism, can promote prosocial behavior as people strive to maintain a positive self-image or achieve their ideals (Penner et al., 2005).
Indeed, some qualitative studies suggest that internalized values or personal standards play an important role in the practice of safer sexual behavior. For example, Nimmons and Folkman (1999) showed that HIV-positive MSM described moral and altruistic values in regard to the need to practice safer sex. A study by Wolitski, Bailey, O’Leary, Gómez, and Parsons (2003) found that many HIV-positive MSM perceived that they had a particular responsibility for protecting their partners and that this perception influenced safer sexual decision-making. Participants cited altruism and self-imposed standards as the motivations underlying their beliefs about personal responsibility. Similarly, Van Kesteren et al. (2005) found that a greater concern about potential HIV transmission to sex partners was related to enhanced feelings of personal responsibility for safer sex.
While these studies have contributed greatly to a preliminary understanding of the role of intrinsic motivation in safer sexual behavior, the factors that may motivate HIV-positive MSM to adopt safer sex practices for the protection of others warrants further examination. This study represents such an attempt, examining social-psychological factors of condom use in the context of steady and casual sex. For this reason, we combined the Theory of Planned Behavior (Ajzen, 1991), a well-established framework used to understand behavior in a broad range of contexts, with the norm-activation theory (Schwartz, 1977; Schwartz & Howard, 1981), a framework specifically developed to understand prosocial behavior. In spite of the supposed importance of prosocial motivation in safer sexual behavior, it is possible that other motivations (e.g., sexual motives) for unprotected anal sex may have a negative influence on intended condom use in certain circumstances (Cooper, Shapiro, & Powers, 1998). Therefore, for both steady and casual sex partners, we examined the extent to which sexual motives for unprotected anal sex negatively affect intended condom use.
Theory of Planned Behavior
The Theory of Planned Behavior (TPB) (Ajzen, 1991) is one of the most important social psychological theories for predicting and understanding behavior. The TPB posits that the most proximal determinant of whether or not a person performs a behavior is his intention to do so. According to the theory, behavioral intention is determined by attitude, subjective norm, and perceived behavioral control. Attitude is the person’s overall evaluation of the advantages and disadvantages of a particular behavior whereas subjective norms are determined by the perceived social pressure to perform the behavior. Perceived behavioral control is the person’s conviction about whether or not the required skills and resources to perform the behavior are at his disposal and is closely related to Bandura’s (1986) concept of self-efficacy. The TPB has received significant support from research on the adoption of many health-related behaviors (Godin & Kok, 1996), including safer sex behavior (Albarracín, Fishbein, Johnson, & Muellerleile, 2001; Rye, Fisher, & Fisher, 2001; Sheeran, Abraham, & Orbell, 1999).
Essentially, the TPB stresses the importance of cognitive, information processing mechanisms in explaining behavior. However, not every act of safer sex is necessarily the result of deliberate thought processes. Of particular interest are the growing number of studies that suggest that HIV-positive MSM are motivated by concerns about the effect that their sexual behavior may have on others; that is, that they feel personally responsible for protecting their partners from HIV. Although we agree that the TPB provides a valuable framework for predicting safer sex practices, we argue that this perspective is too narrow and may not fully account for feelings of personal responsibility that may promote safer sexual behavior. More specifically, we believe that safer sexual behavior in HIV-positive MSM is based on concerns that go beyond a purely rational weighing of personal advantages and disadvantages, i.e., that safer sex is simply the right thing to do. One theory that may help explain why HIV-positive MSM are motivated to adopt safer sexual practices for the protection of others is Schwartz’ (1977) norm-activation theory.
Norm-Activation Theory
The norm-activation theory (Schwartz, 1977; Schwartz & Howard, 1981) seeks to predict and understand prosocial or altruistic behavior. According to norm-activation theory, personal norms are the immediate determinant of behavior. Personal norms are considered as strong intrinsic motivators, as they trigger an individual’s internal value system and are tied to one’s self-concept. In the case of sexual behavior, these aspects reflect the feeling of moral obligation to practice safer sex because of concern about the welfare of sex partners. That personal norms may play an important role in safer sexual behavior in HIV-positive MSM was shown in a study by Godin, Savard, Kok, Fortin, and Boyer (1996). Their study showed that personal norms, in addition to perceived behavioral control, are important predictors of intended condom use for anal sex.
The important relationship between personal norms and condom use intention underscores the assumption that safer sexual behavior is influenced by feelings of moral obligation. However, Schwartz argued that there will be no moral motivation unless: (1) an individual is aware of the specific action that is needed and the consequences of action or inaction to oneself and others (awareness of need); (2) an individual ascribes responsibility to himself for the consequences of the action or inaction (ascription of responsibility); (3) a person identifies actions that might be effective in handling the specific situation (efficacy); and (4) a person believes that he is capable of performing the required actions or behavior (ability). As such, we expect that, in predicting safer sex, awareness of need and ascription of responsibility may be important determinants of behavioral intention to use condoms for anal sex with steady and casual sex partners. Note that in this context, efficacy and ability are not differentiated because both concepts seem to be covered by the theoretical paradigm of the TPB (i.e., attitude and self-efficacy, respectively).
Sexual motives for unprotected anal sex
Notwithstanding our argument that personal norms play a central role in sexual decision-making, we expect that, depending on the social context in which sex occurs, strong motives to engage in unprotected sex may conflict with one’s personal norm for safer sex. For instance, Cooper et al. (1998) have demonstrated that sexual behaviors, whether risky or safe, may serve a range of psychological functions that have little to do with health protection and disease avoidance. Indeed, the study by Van Kesteren et al. (2005) indicated that the extent to which HIV-positive MSM acted in accordance with their feelings of personal responsibility to practice safer sex depended, in part, on their sexual motives for engaging in unprotected anal sex. Typically, HIV-positive MSM reported having engaged in unprotected anal sex to express emotions related to love or because they were “sexually turned-on” by their sex partners. Thus, sexual motives appear to have a negative influence on intended condom use, which may undermine a prosocial motivation to practice safer sex. However, it can be argued that a conflict such as this may play a role more in casual sex encounters than in steady sexual relationships, as it is likely that the benefits of unprotected sex are more salient in the context of casual sex (i.e., when one does not necessarily know one’s sex partner and is less likely to be confronted with the potential adverse longer term social consequences of having engaged in unprotected sex) than with steady partners (i.e., when one is emotionally involved with a partner and committed to an ongoing relationship) (Flowers, Marriott, & Hart, 2000; Van Kesteren et al., 2005). It has been shown that when people perceive increased benefits of a specific behavior (unsafe sex), it leads to a more favorable affective impression, resulting in lower judgments of risk (so-called affect-heuristic; Finucane, Alhakami, Slovic, & Johnson, 2000). Therefore, we expect that sexual motives may have a negative impact on intended condom use, particularly in casual sex encounters.
Proposed model of sexual decision-making
Safer sex in HIV-positive MSM can be seen as a prosocial behavior, making it vital to integrate variables specific to the TPB with variables specific to the norm-activation theory. In accordance with the TPB, we propose a model (see Fig. 1) in which intention is the most proximal determinant of behavior. However, in line with the norm-activation theory, we assume that the decision to use condoms for anal sex largely depends on one’s intrinsic motivation to engage in safer sex. Accordingly, we expect personal norms to be the most direct determinant of intention, thereby mediating the effects of the other determinants specific to the TPB and the norm-activation theory. Following Cooper et al. (1998), we further assume that sexual motives for unprotected anal sex may have a direct and negative impact on intended condom use and, as such, may compete with a prosocial tendency to engage in safer sex. However, due to the social context in which sex occurs, we hypothesize that sexual motives will contribute to the explanation of intended condom use with casual sex partners, whereas this is unlikely to be the case in the context of steady sex partners.Fig. 1Proposed model of sexual decision-making
Method
Participants
Data were obtained by means of a self-administered questionnaire between July 2002 and April 2003. Participants were recruited through AIDS consultants working in 15 Dutch hospitals. Participants were asked to fill out the questionnaire at home and return the questionnaires directly to the research institution by means of a stamped, pre-addressed envelope. Consequently, no information was available about the response rate per hospital. Participation was on a voluntary and anonymous basis. A pilot study indicated that completion of the questionnaire took about 30 to 45 min. Participants received no compensation for filling out the questionnaires. Approval for the study was obtained from the Ethics Committee of Maastricht University Hospital.
Participants who met the following criteria were included in the study: (1) tested positive for HIV-antibodies; (2) identified themselves as homosexual or bisexual; (3) aged between 20 and 65 years; and (4) were sufficiently fluent in Dutch to complete the questionnaire. A total of 1,050 questionnaires were distributed, of which 296 were completed and returned (response rate = 28.2%).
Table 1 summarizes the demographic characteristics of the participants. Participants were predominantly Dutch nationals, were mainly from the Western part of the Netherlands, including Amsterdam, and ranged in age from 25 to 59 years, with a mean age of 42.1 years. Most participants had a medium or high level of education and were employed full-time or part-time. Most participants identified themselves as exclusively homosexual. More than half of the men had known themselves to be HIV-positive for 6 years or less. The majority of men was aware of their CD4 counts and viral load and indicated that they were currently on some form of HIV antiretroviral therapy.Table 1Sociodemographic characteristics of the sample (maximum N = 296)CharacteristicsN%Nationality Dutch25185.7 Surinam/Antillean 51.7 Other3712.6Geographic area of the Netherlands Amsterdam7325.3 West (excluding Amsterdam)11038.0 South6723.2 Northeast3913.5Age 25–355518.9 36–4513646.7 46–558228.2 >56186.2Education Higher vocational education or university12443.1 Secondary vocational training or high school12041.7 Primary school or basic vocational training3411.8 Other103.5Employment status Full-time11743.5 Part-time8029.7 Unemployed7226.8Self-identification Homosexual24482.4 More homosexual than heterosexual3812.8 Bisexual 82.7 More heterosexual than bisexual 41.4 Other 20.7Years knowing HIV-positive status <2 yrs5920.1 2–6 yrs11639.6 7–11 yrs7124.2 12–16 yrs3712.6 >16 yrs103.4Self-reported CD4+ <2003311.1 200–50012040.5 >5009231.1 Don’t know5117.2Self-reported viral load Detectable [median=10.000, range 50–2.080.0007225.9 Undetectable17663.3 Don’t know3010.8Antiviral treatment No5920.1 Yes23479.9
Measures
The questionnaire was based on earlier studies (Hogeweg & Hospers, 2000; van Kesteren et al., 2005) and consisted of several questions on determinants for explaining condom use behavior: attitudinal beliefs, subjective norms, self-efficacy, personal norms, awareness of consequences, ascription of responsibility, sexual motives, intention and demographic variables. Separate scales were used for condom use with steady and casual sex partners for all determinants. The questionnaire was pre-tested among a group of 12 HIV-positive MSM for comprehension and completeness.
Attitudinal beliefs were measured through 16 items drawn from interviews with HIV-positive MSM (van Kesteren et al., 2005) and from an earlier quantitative study among MSM (Hogeweg & Hospers, 2000). Four items were used to assess response efficacy (e.g., “By using condoms when having anal intercourse, I protect my steady partner/casual sex partners against the AIDS virus/HIV-superinfection”). In addition, seven possible pros (e.g., “By using condoms during anal sex with my steady partner/casual sex partners, I worry less about his/their well-being”), and five possible cons of condom use behavior (e.g., “Using condoms for anal sex with my steady partner/casual sex partners reminds me of HIV/AIDS”) were included in the questionnaire. Items were indexed on 5-point scales (1 = totally disagree, 5 = totally agree), and had an alpha of .81 for steady and .76 for casual sex partners.
Subjective norms were measured through the use of three items on 5-point scales. Two items assessed the perception of participants of the opinions of other important people on whether or not they should use condoms when having anal intercourse (1 = certainly not, 5 = certainly). Following Schwartz (1973), one item assessed perceived social sanctions regarding not using condoms during anal intercourse and was expressed as follows: “How do you think important others would react if you told them that you don’t use condoms when having anal intercourse with your steady partner/casual sex partners?” (1 = very approving, 5 = very disapproving). Alpha for steady and casual sex partners was. 76 and .63, respectively.
Self-efficacy was measured with seven items based on van Kesteren et al. (2005) and Hogeweg and Hospers (2000) (e.g., “Suppose you want to use condoms when having anal intercourse, will you be able to discuss condom use with your steady partner/casual sex partners?”). Items were measured on 5-point scales (1 = certainly not, 5 = certainly), and had an alpha of .89 for steady and .87 for casual sex partners.
Personal norms were measured by means of three items on 5-point scales (Godin et al., 1996; Parker, West, Stradling, & Manstead, 1995), such as: “As a matter of principle, I use condoms every time I have anal intercourse with my steady partner/casual partners.” Items were rated on 5-point scales (1 = totally disagree, 5 = totally agree) and had an alpha of .96 and .90 for steady and casual sex partners, respectively.
Both awareness of consequences for self and awareness of consequences for others were assessed separately for condom use with steady and casual sex partners by a single item on a 5-point (1 = totally agree, 5 = totally disagree) scale. Awareness of consequences for self measured the participant’s view about whether the consequences for his health were negligible when not using condoms during anal sex. Awareness of consequences for others measured the participant’s views about whether the consequences for the health of his partner were negligible when not using condoms during anal sex.
Ascription of responsibility to self was measured by means of four items on 5-point scales concerning responsibility for condom use behavior and one item concerning transmission of HIV. For example: “How responsible are you yourself for negotiating condom use?” (1 = not at all, 5 = completely). Alpha for steady and casual sex partners was .91 and .89, respectively.
Sexual motives for unprotected anal sex were measured using seven affective states on 7-point scales (1 = considerably less, 7 = considerably more), such as lust, love, excitement, and feeling good. Following Nelissen, Dijker, and De Vries (in press), participants were asked to indicate the extent to which they would feel a particular emotion when engaging in unprotected anal sex with steady (alpha = .89) and casual sex partners (alpha = .85).
Intention to use condoms when having anal intercourse was measure by the following three items on 5-point scales: “I intend to use a condom when having anal intercourse with my steady partner/casual partners”; “I will try to use a condom when …”; and “I plan to use a condom when …” (1 = certainly not, 5 = certainly). Alpha for both steady and casual sex partners was .93.
With respect to sexual risk behavior, participants were asked whether or not they had engaged in receptive and insertive oral sex with ejaculation and in receptive and insertive anal sex in the past six months (separate for steady and casual sex partners). For each sexual behavior they had engaged in, the frequency of condom use (1 = never, 5 = always) was assessed.
Results
Sexual behavior
Table 2 shows that about 60% of the participants reported a male steady partner in the preceding six months. Among these, about one third (30.3%) reported that they had not had oral or anal sex with their steady partner. Among those who had had oral sex with ejaculation with their steady partners (23.6%), only one person reported that he consistently had used a condom. Among those who had had anal sex with their steady sex partners (51.1%), about half (48.4%) reported that they had not used condoms consistently. Approximately 72% of the participants reported male casual sex partners in the preceding six months. When oral intercourse was considered, none of the men who had engaged in oral sex with ejaculation (31.8%) reported consistent condom use. When anal sex was considered, about half (45.6%) of the participants who had engaged in anal intercourse with casual sex partners (74.8%) had not consistently used condoms.Table 2Descriptives of sexual behavior and disclosure in casual sex encounters of the sample HIV-positive MSM (N = 296)N%Steady partner(s) in the preceding  6 months17860.1 Anal or oral sex with steady sex  partner124 (178)69.7 Oral intercourse with ejaculation  with steady sex partner42 (178)23.6 Unprotected oral intercourse  with steady sex partner41 (42)97.6 Anal intercourse with steady sex  partner91 (178)51.1 Unprotected anal intercourse with  steady sex partner44 (91)48.4Casual partner(s) in the preceding  6 months21472.3 Anal or oral sex with casual sex  partners167 (214)78.0 Oral intercourse with ejaculation  with casual sex partners68 (214)31.8 Unprotected oral intercourse  with casual sex partners68 (68)100.0 Anal intercourse with casual sex  partners160 (214)74.8 Unprotected anal intercourse with  casual sex partner73 (160)45.6Disclosure of HIV status in casual  sex encounters Has never/rarely informed  casual sex partners about  HIV-positive status177 (214)82.8 Was never/rarely informed about  HIV-status of casual sex partners189 (214)88.3
Among men who had anal sex with their steady sex partner, unprotected sex occurred more often within the context of HIV-seroconcordant relationships than within HIV-serodiscordant relationships: 23.3% (7 out of 30) of the men with an HIV-positive partner reported consistent condom use in the preceding six months compared to 61.0% (25 out of 41) of the men with an HIV-negative partner and 73.7% (14 out of 19) of the men with a partner whose HIV status was unknown, χ2(2) = 14.7, p < .01.
Although no data were available on the HIV-status of casual sex partners, participants were asked two questions regarding disclosure of HIV-status. The majority of the participants (82.8%) reported that they never or rarely had informed casual sex partners about their HIV-status in the preceding six months. Similarly, most participants (88.3%) reported that casual sex partners had never or rarely informed them of their HIV-status (see Table 2). Thus, accurate knowledge of each others HIV-status appears to be minimal, which makes the use of effective partner selection strategies (i.e., “serosorting”) as an explanation for the occurrence of unprotected sex within casual sex encounters less likely.
Descriptive statistics and correlations
Means, SDs, and correlations for the determinants of condom use for anal sex are provided in Table 3. A missing value analysis was conducted for independent variables relating to condom use with steady and casual sex partners. Participants with missing values exceeding 10% of all items were excluded from further data analyses. For participants with less than 10% missing values, the item score was replaced with the mean of the remaining participants for the respective item. As a result, analyses of intention to use condoms were conducted among 149 out of 178 participants who reported a steady sex partner and 188 out of 214 participants who reported casual sex partners in the preceding six months. Of the participants who were included in the analyses with steady and casual sex partners, there were 22 and 24, respectively, who had one or more missing items (range 1–4). In both samples, however, the majority was missing only one of the questionnaire items.Table 3Means and correlations for determinants of condom use with steady (N = 149; below diagonal) and casual sex partners (N = 188; above diagonal)ScaleRange(1)(2)(3)(4)(5)(6)(7)(8)(9)Intention (1)1–5–.56**.57**.67**.83**.36**.25**.64**−.56**Attitudinal beliefs (2)1–5.60**–.49**.48**.57**.28**.18*.53**−.55**Subjective norms (3)1–5.77**.57**–.45**.62**.17*.07.45**−.43**Self-efficacy (4)1–5.74**.62**.69**–.62**.36**.24**.56**−.49**Personal norms (5)1–5.88**.64**.80**.74**–.32**.22**.64**−.53**Awareness consequences self (6)1–5.23*.30**.21*.26**.22**–.72**.26**−.29**Awareness consequences others (7)1–5.39**.35**.38**.37**.41**.53**–.23**−.23**Ascription of responsibility (8)1–5.60**.60**.51**.71**.60**.18*.35**–−.49**Sexual motives (9)1–7−.57**−.62**−.57**−.59**−.59**−.16*−.31**−.47**–Steady
M4.13.54.34.24.13.34.04.23.5
SD1.30.71.00.91.41.61.40.71.6Casual
M4.33.84.34.24.33.84.24.33.4
SD1.10.60.60.81.11.21.20.81.4*p < .05.**p < .01.
The descriptive statistics indicates that, in general, participants’ intentions to use condoms during anal sex with steady and casual sex partners were high. In addition, the means of most of the other determinants were on the positive side of the scale. The exception was for sexual motives for unprotected anal sex, where participants scored negative with regard to both steady and casual sex partners. Consistent with our proposed model (see Fig. 1), attitudinal beliefs, subjective norms, self-efficacy, personal norms awareness of consequences for self and others, and ascription of responsibility to self were all positively correlated with behavioral intention, with the exception of sexual motives for unprotected anal sex. As expected, the correlation between sexual motives for unprotected anal sex and intended condom use was negative for both steady and casual sex partners.
Predictors of intended condom use
Because intention for both steady and casual sex partners was positively skewed (more than 50% of the sample scored 5 on a 5-point scale), intended condom use with steady and casual sex partners was dichotomized on its median into high versus low intention. To test our proposed model (see Fig. 1), two hierarchical logistic regression analyses were conducted with intended condom use with steady and casual sex partners as the outcome variables. Personal characteristics and partner variables were controlled in both analyses and were entered first. In order to examine the relative contribution of the TPB variables (i.e., attitudinal beliefs, subjective norms and self-efficacy), these variables were entered in the second step. Awareness of consequences for self and others and ascription of responsibility were entered in the third step, followed by sexual motives for unprotected anal sex in the fourth step. Personal norms were entered in the final step of the regression analyses. In addition, we examined the mediating role of personal norms following the standard procedure specified by Baron and Kenny (1986).
Prior to analyses, collinearity between all variables in the regression analyses was checked by computing the Variance Inflation Factor (VIF) of each variable. Values above 10 were regarded as an indication of near-collinearity (Kleinbaum, Kupper, Muller, & Nizam, 1998). With respect to steady and casual sex partner variables, all VIFs were <5 and <3, respectively. Additionally, initial regression analyses were conducted to minimize the number of potential personal characteristics and partner variables used in the logistic regression. Only those personal characteristics and partner variables making significant contributions to prediction of intended condom use with steady or casual sex partners were included in subsequent analyses.
Steady sex partners
First, a regression of intended condom use with steady sex partners on personal characteristics (age, education, antiviral treatment, and years knowing HIV-positive status) and partner variables (steady partner only versus casual partners as well and HIV-negative or unknown status partner versus HIV-positive status) showed education level and partner HIV status to be the only significant predictors. Therefore, these variables were entered in the first step of the subsequent regression analysis, yielding an explained variance of 13% (see Table 4). When the TPB variables were entered in the second step, a further 40% (p <.001) of variance was explained, with self-efficacy as a significant predictor. Subjective norms were borderline significant (p = .05). As shown in Table 4, there was no significant increase in variance explained with the addition of awareness of consequences for self and others and ascription of responsibility in Step 3, or with sexual motives for unprotected anal sex in Step 4. At this stage of the analysis, self-efficacy significantly contributed to the prediction of intention, whereas a marginally significant effect was found for subjective norms (p <.10). When personal norms were entered in the final step of the analysis, a further 9% (p <.001) of variance was explained. In this model, the effect of personal norms was significant; however, the effects of subjective norms and self-efficacy dropped below significance, which suggested that the effects of subjective norms and self-efficacy were mediated through personal norms.
Testing this suggestion required that three conditions be met (see Baron & Kenny, 1986). The first condition-that subjective norms and self-efficacy be related to intended condom use-was assessed in the above analysis (see Step 4, Table 4). The second condition requires that the mediator (i.e., personal norms) predict intended condom use and that subjective norms and self-efficacy have weaker effects when controlling for personal norms. This was also confirmed in the above analysis (see Step 5, Table 4). The third condition requires that subjective norms and self-efficacy significantly predict the mediator. To test this condition, personal norms were regressed on subjective norms and self-efficacy, while controlling for educational level and partner HIV status. Results revealed that subjective norms (OR = 4.6, p <.001) and self-efficacy (OR = 16.3, p <.001) were significantly related to personal norms. Thus, there was evidence that personal norms mediated the effects of self-efficacy on intended condom use. In addition, there was evidence that personal norms mediated the tentative influence of subjective norms.
Casual sex partners
Initially, a regression of condom use intention with casual sex partners on personal characteristics (age, education, antiviral treatment, and years knowing HIV-positive status) and partner variables (casual partners only versus steady partners as well) showed antiviral therapy to be the only statistically significant predictor. Therefore, only this variable was subsequently entered in Step 1 of the logistic regression analysis, yielding an explained variance of 6% (see Table 5). When the TPB variables were entered in the second step, a further 46% (p <.001) of the variance was explained. Attitudinal beliefs, subjective norms and self-efficacy significantly predicted intention, whereas a marginally significant effect was found for antiviral therapy. The entry of awareness of consequences for self and others and ascription of responsibility in Step 3 led to a further 8% (p <.001) of explained variance. Step 4 also accounted for a significant increase of variance explained with 3% (p <.01). In this step of the analysis, antiviral therapy, self-efficacy, ascription of responsibility and sexual motives significantly contributed to the prediction of intention, whereas a marginally significant effect was found for subjective norms (p <.10). When personal norms were entered in the final step, a further 5% (p <.001) of variance was explained. As shown in Table 5, antiviral therapy and personal norms positively and sexual motives negatively predicted behavioral intention. Furthermore, the effects of subjective norms, self-efficacy and ascription of responsibility became non-significant, which suggested that these variables were mediated through personal norms.
To test this notion, we again assessed the three conditions specified by Baron and Kenny (1986). First, the analysis above revealed that self-efficacy and ascription of responsibility significantly predicted intended condom use, whereas a marginally significant effect was found for subjective norms (see Step 4, Table 5). Second, the above analysis showed that adding personal norms gave a significant regression coefficient for personal norms, and non-significant regression coefficients for subjective norms, self-efficacy, and ascription of responsibility (see Step 5, Table 5). Finally, in an analysis predicting personal norms while controlling for antiviral therapy, subjective norms (OR = 2.7, p <.05), self-efficacy (OR = 3.0, p <.01), and ascription of responsibility (OR = 10.5, p <.001) emerged as significant predictors. Taken together, these results provided evidence that personal norms were a mediator of the self-efficacy-intention and ascription of responsibility-intention relationships. In addition, evidence was found that personal norms mediated the tentative influence of subjective norms.Table 4Logistic regression analyses predicting high intention (0 = no, 1 = yes) to use condoms with steady sex partners (N = 149)Model 1Model 2Model 3Model 4Model 5BOR95% CIBOR95% CIBOR95% CIBOR95% CIBOR95% CIStep 1 Education level.251.3*1.1–1.6.111.1.86–1.5.071.1.81–1.4.071.1.81–1.4.01 1.0.74–1.4 Partner HIV statusa−1.2.30**.14–.64−.43−.65.24–1.8−.40.67.24–1.9−.40.67.23–1.9−.35.70.22–2.3Step 2 Attitudinal beliefs.491.6.67–4.0.351.4.55–3.7.371.5.53–4.01.1.37–3.1 Subjective norms.672.01.0–3.8.611.8.92–3.7.621.9.92–3.7.07.64.20–2.1 Self-efficacy1.75.4***2.1–13.71.64.9**1.7–13.61.64.9**1.7–14.3−.442.7.82–8.9Step 3 ACSb−.02.98.71–1.4−.02.98.70–1.4−.01.99.70–1.4 ACOc.241.3.88–1.8.241.3.88–1.8.221.3.85–1.8 ARd.291.3.50–3.5.281.3.50–3.5.211.2.43–3.5Step 4 Sexual motives.021.0.70–1.5−.041.0.65–1.4Step 5 Personal norms2.410.8**2.0–57.5 Nagelkerke R2.13.53.54.54.62 Model χ215.874.577.177.192.1Note. At each step, variables were included in the equation simultaneously.aVariable coding: 0 = HIV-negative or unknown, 1 = HIV-positive.bAwareness consequences self.cAwareness consequences others.dAscription of responsibility.*p <.05.**p <.01.***p <.001 (two-tailed).Table 5Logistic regression analyses predicting high intention (0 = no, 1 = yes) to use condoms with casual sex partners (N = 188)Model 1Model 2Model 3Model 4Model 5BOR95% CIBOR95% CIBOR95% CIBOR95% CIBOR95% CIStep 1 Antiviral treatmenta.992.7**1.4–5.2.742.1.88–5.01.12.9*1.1–7.31.13.1*1.2–8.41.23.3*1.2–9.2Step 2 Attitudinal beliefs1.23.2**1.4–7.5.842.3.92–5.8.321.4.50–3.8.251.3.45–3.6 Subjective norms1.12.9**1.3–6.5.902.51.0–6.1.862.4.91–6.1.391.5.50–4.4 Self-efficacy1.54.2***2.3–7.91.12.9**1.5–5.9.862.4*1.1–5.0.531.7.76–3.8Step 3 ACSb.241.3.85–1.9.251.3.85–2.0.131.1.72–1.8 ACOc.341.4.89–2.2.341.4.88–2.2.341.4.86–2.3 ARd1.13.0*1.2–7.51.13.0*1.1–7.9.641.9.65–5.5Step 4 Sexual motives−.61.54**.35–8.3−.57.57*.36–.89Step 5 Personal norms1.33.8**1.6–8.9 Nagelkerke R2.06.52.60.63.68 Model χ28.991.4111.8120.5132.3Note. At each step, variables were included in the equation simultaneously.aVariable coding: 0 = no, 1 = yes.bAwareness consequences self.cAwareness consequences others.dAscription of responsibility.*p <.05.**p <.01.***p <.001 (two-tailed).
Discussion
The present study showed that the majority of HIV-positive MSM reported engaging in safer sexual behavior either though abstinence or consistent condom use for anal sex. Nonetheless, a high number of men who had had anal sex reported that they had not used condoms consistently with steady and casual sex partners. Results further indicated that HIV-positive MSM were more likely to engage in unprotected anal intercourse in the context of casual sex encounters than in steady sexual relationships (overall 34.1% and 24.7%, respectively). This finding was consistent with patterns of sexual risk behavior observed in other populations of HIV-positive MSM (cf. Crepaz & Marks, 2002).
In this study, we tested a model of factors that influence intended condom use for anal sex with steady and casual sex partners. The results showed that, compared with the TPB (Ajzen, 1991), our proposed model of sexual decision-making led to a significant increase of explained variance from 53% to 62% for steady sex partners and from 52% to 68% for casual sex partners. Furthermore, evidence was obtained for the mediating role of personal norms on intended condom use with both steady and casual sex partners, suggesting that moral issues play an important role. However, the study also showed that sexual motives may undermine the influence of personal norms on intended condom use in the context of casual sex, with the likelihood of unprotected sexual intercourse. Taken together, the results revealed strong support for our model of sexual decision-making.
In this study, the finding that personal norms appeared to exert a strong direct effect on intention to use condoms with both steady and casual partners was consistent with results of earlier studies that suggest that safer sex in HIV-positive MSM is largely determined by moral concerns or feelings of personal responsibility (e.g., Godin et al., 1996). Moreover, this finding lends further indirect support to the proposition that condom use behavior among HIV-positive MSM is a form of prosocial behavior (e.g., Kok, 1999; Nimmons, 1998). For steady partners, personal norms were identified as the most proximal determinant of intended condom use, whereas an indirect effect was found for self-efficacy on intended condom use through personal norms. Furthermore, some evidence that personal norms mediate the tentative effect of subjective norms on intended condom use with steady sex partners was found. Similar results were found for intended condom use with casual sex partners. However, we also found an additional indirect effect of ascription of responsibility on intended condom use through personal norms. These findings are important because they underscore the need to take into account the role of social expectations, self-efficacy expectations, and attributions about responsibility for condom use in promoting feelings of moral obligation-a process that has not been identified in previous research on sexual risk behavior in HIV-positive MSM.
Furthermore, in the case of casual sex partners, condom use intention was not only directly related to personal norms, but was also negatively influenced by sexual motives for unprotected anal sex. Thus, the findings from this study suggest that the need to engage in unprotected anal sex for physical and emotional satisfaction may supercede the prosocial motivation for safer sex. The fact that sexual motives contributed toward explaining intended condom use in casual sex encounters but not in steady relationships does not imply that sexual motives are not important in the context of steady sex. More likely, there are some differences between steady and casual sex that encourage HIV-positive MSM to suppress sexual motives within the context of steady relationships but not within casual sex encounters. As discussed previously, a possible explanation may lie in the so-called affect-heuristic. In the context of casual sex, the benefits of unprotected sex may be more salient, thus resulting in a decreased assessment of risk. It is worth noting that the affect-heuristic is especially likely to color judgments under time pressure, which may play a more important role in the context of casual sex (Finucane et al., 2000). The “Coolidge effect” may also explain why sexual motives play a role in the casual sexual context, but not in steady sexual relationships. The Coolidge effect refers to enhanced sexual arousal that is felt when sexual stimuli and partners are novel (Gregoire, 1999).1 A final explanation may be the greater ambivalence that HIV-positive MSM experience in casual sex encounters as opposed to steady relationships. Greater ambivalence is likely to result in a reduction in both behavioral intention and actual behavior. In addition, people who experience ambivalence are more easily persuaded (Conner & Armitage, 2000). It may be that pointing out the potential for casual sex partners to become steady partners in the future could increase the perceived benefits of safer sex, thus facilitating prosocial motivation to engage in protected sex. Indeed, the study by van Kesteren et al. (2005) suggests that such a mechanism exists. Further, the results of this study demonstrated that the use of antiviral therapy was associated with a greater intention to use condoms with casual sex partners. To date, inconclusive evidence exists regarding the association between the use of antiviral therapy and unprotected sex (for a meta-analysis, see Crepaz, Hart, & Marks, 2004).
Some study considerations and limitations and implications for practice should be mentioned. First, as Ajzen and Fishbein (1970) held, it may be argued that the important role of personal norms as a predictor of intention can be attributed to a certain amount of overlap between the measures of personal norms and intention. In this study, high correlations were found between personal norms and intention. On theoretical grounds, however, it seems imperative to distinguish personal norms from intentions. As Manstead (2000) argued, holding the belief that something is morally “right” or “wrong” is not the same as the perceived likelihood of performing certain behaviors. Consequently, an individual may feel a personal obligation to act in a certain way, but intend to behave in a way that is contradictory to his personal norm because the personal or social advantages of acting inconsistently with his personal norm outweigh the personal or social advantages of acting consistently with the norm. Second, it should be noted that the data were cross-sectional, which hampers conclusions about causality. Due to the cross-sectional design, we did not specifically address the relationship between the psychosocial factors and behavior. It should be noted, however, that tentative support for our model was found in an additional analysis when intention was examined as a mediator of the personal norms-behavior relationship, both for steady and casual sex partners. Yet, longitudinal studies are needed to determine causative relationships between the measured constructs. A third limitation of the present study concerns the use of a single-item approach to measure awareness of consequences, as single-item measures are known to be less reliable. This issue merits attention in future research. Finally, the sample used in this study warrants some concern. More than 70% of those who received questionnaires did not respond. This raises the question as to whether these participants were predominantly more aware of the need to practice safer sex and, as such, are not a representative sample of Dutch HIV-positive MSM. On the other hand, Swanborn (2002) found that 30% is a common response rate for this type of research in the Netherlands. It is possible that the sensitivity of the subject and the fact that the participants suffer from a chronic disease may create barriers to participation. Moreover, substantial efforts were made to recruit HIV-positive MSM from throughout the Netherlands. Although this approach did not ensure that the sample was representative, it did enhance its diversity and therefore strengthens the external validity of the study results.
The findings reported in this study carry several implications for HIV-prevention efforts to promote safer sexual behavior among HIV-positive MSM. When addressing condom use behavior with steady and casual sex partners, it seems particularly crucial to enhance feelings of moral obligation to use condoms for anal sex. Feelings of moral obligation could be addressed by inducing HIV-positive MSM to reflect on their own personal risk and personal standards for safer sex (Kalichman, 1998). The findings of this study further suggest that desirable changes in subjective norms and self-efficacy expectations might lead to corresponding changes in personal norms and intentions (e.g., Deci & Ryan, 2000; van Empelen, Kok, Jansen, & Hoebe, 2001; van Empelen, Schaalma, Kok, & Jansen, 2001). Therefore, preventive interventions should focus on helping HIV-positive MSM to cope with an unsupportive social environment and to encourage them to build the skills and confidence required for communicating and negotiating condom use. For the promotion of condom use with casual sex partners, personal norms may be further increased by urging HIV-positive MSM to accept responsibility for safer sexual behavior. Moreover, especially within casual sex encounters, it is imperative to help HIV-positive MSM to deal with feelings that may conflict with the goal of safer sex. Possible methods that can help HIV-positive MSM to identify and control high risk situations are, for example, action planning and coping planning (Sniehotta, Schwarzer, Scholz, & Schüz, 2005). Action plans and coping plans are detailed plans of what a person needs to do when a specific situation occurs. When such situation arise, it is likely to function as a cue for the execution of those precise plans of implementation. Additionally, stimulating HIV-positive MSM to imagine how they would feel if they were in their sex partners shoes (i.e., perspective taking) may evoke a mixture of egoistic and altruistic motivation and, as such, lead to more protected sex (Batson, Early, & Salvarani, 1997). That such an approach is feasible has been shown in a study by van Kesteren, Kok, Hospers, Schippers, and De Wildt (2006), in which the above-mentioned methods have been integrated in an intervention to promote sexual health in HIV-positive MSM.

hiv-positive
men who have sex with men
sexual motives
personal norms
sexual risk behavior


The prevalence of vertebral fracture amongst patients presenting with non-vertebral fractures

Introduction Despite vertebral fracture being a significant risk factor for further fracture, vertebral fractures are often unrecognised. A study was therefore conducted to determine the proportion of patients presenting with a non-vertebral fracture who also have an unrecognised vertebral fracture.
Introduction
Osteoporosis may be defined as a ‘skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture’ [1]. Overall, osteoporotic or low trauma fractures are common - it has been estimated that one in two women and one in five men aged over 50 years will sustain at least one low trauma fracture in their lifetime [2].
The fracture sites which most commonly come to clinical attention include the distal radius (Colles’), proximal femur (hip), humerus and ankle. In the Fracture Liaison Service covering Glasgow, 82% of presenting fractures were at these sites [3].
The spine is another key fracture site; however, it has been estimated that only 30% of vertebral fractures receive clinical attention - which means that the majority of patients with vertebral fractures remain undetected [4]. It appears that only those patients with the most severe vertebral fractures come to clinical attention—it is likely that this is due to higher levels of back pain and disability [4].
The European Prospective Osteoporosis Study (EPOS) assessed vertebral fracture incidence in 3,174 men (mean age 63.1 years) and 3,614 women (mean age 62.2 years) over a mean of 3.8 years. The age-standardised incidence of morphometric fracture was 10.7/1,000 person years in women and 5.7/1,000 person years in men [6]. Vertebral fracture incidence increased markedly with age in both men and women. Indeed, the incidence in women aged 50–54 was 3.6/1,000 person years, rising to 29.3/1,000 person years in women aged 75–79 [5].
Lateral dorsal and lumbar X-rays were used in the European Vertebral Osteoporosis Study (EVOS) population to identify vertebral fracture over an 8-year period. The investigators found an incidence rate of 9.85/1,000 person years compared with 3.06/1,000 person years for hip fracture, 4.28/1,000 person years for Colles’ fracture and 4.76/1,000 person years for other fractures [6].
Low trauma fractures have substantial consequences. Although hip fracture has the greatest mortality and morbidity, vertebral fracture is also associated with significant mortality and morbidity. In one study, patients with vertebral deformity had a substantially higher risk of death compared to patients without vertebral deformity, regardless of age, sex and BMD (mortality rate 30.3% versus 10.7% over a 14-year follow-up). The risk of death was highest in those patients with a vertebral deformity who had a subsequent symptomatic fracture [HR 9.0 (3.1–26.0)] [7]. In terms of morbidity, around 70% of patients with symptomatic vertebral fracture complain of difficulty in standing and 65% of difficulty in bending, and 41% complain of constant pain [8].
It is well-established that the presence of one low trauma fracture significantly increases the risk of a further fracture [9–11]. In a systematic review carried out by Klotzbuecher et al. [9], women with a single pre-existing vertebral fracture, identified in eight studies at baseline by vertebral morphometry and in another seven as clinical (symptomatic) fractures, were 4.4-times more likely to have another vertebral fracture than women without vertebral fracture. Prior vertebral fracture also predicted non-vertebral fracture: in women with vertebral fracture, the risk of hip fracture was increased by 2.3-times, of Colles’ by 1.4-times and of any non-vertebral fracture by 1.8-times. Fracture risk increased even further with each additional vertebral fracture; for example, the odds of a new vertebral fracture in women with five or more prior vertebral fractures were 35-times greater than for women without prior vertebral fracture.
Given that vertebral fracture is a significant risk factor for further fracture, and that vertebral fractures often go undiagnosed, this study set out to determine the proportion of patients attending a Fracture Liaison Service following a non-vertebral fracture who also have an unrecognised vertebral fracture.
The standard method to assess vertebral fracture is radiography of the thoraco-lumbar spine [12]. However, there is no gold standard for the definition of osteoporotic vertebral fracture. A number of methods have been developed for interpretation of spinal X-rays, including the Genant semi-quantitative method [13], which has been used as a surrogate ‘gold standard’ in a number of key osteoporosis studies. This approach is more objective and reproducible than other qualitative methods [12]. Vertebral morphometry using dual-energy X-ray absorptiometry (DXA) also known as morphometric X-ray absorptiometry (MXA) is a fast, low-radiation technique which produces images that are of sufficient quality to be used to diagnose the presence of vertebral deformity consistent with fracture [14].
Methods
The Fracture Liaison Service in South Glasgow has been previously described [3]. This service assumes responsibility for all patients who present with a clinical low trauma fracture and ensures that appropriate assessment, diagnosis and treatment recommendations are made to prevent further fracture. A low trauma fracture is defined as one sustained from a standing height or less, and not occurring as a result of a road traffic accident. Patients with skull or facial fractures are not routinely offered assessment for osteoporosis [3]. All patients aged 50 years or over identified by an Osteoporosis Specialist Nurse have a DXA scan carried out if they are likely to be candidates for bisphosphonate therapy. It should be noted that patients aged over 70 years presenting to this service after hip fracture do not have a DXA scan carried out, since most of these patients have osteoporosis and require therapy.
All patients who presented with a low trauma fracture and who underwent DXA evaluation with vertebral morphometry from DV5/6 to LV4/5 were included in this prospective study. All scans were carried out on a Lunar Prodigy densitometer using the Dual Energy Vertebral Assessment (DVA) morphometry imaging software (version 6.3). Vertebral fractures were identified by direct visualisation using the Genant semi-quantitative grading scale [17]. All scans were reviewed by and vertebral deformities reported by the same physician (SJG). Although Genant’s semi-quantitative grading is based on analysis of X-rays and is not validated for MXA, it was used in this study to assess vertebral status on MXA since it provides a practical and pragmatic option.
Statistical analysis
Baseline differences that potentially explained observed differences in morphometric vertebral fracture rates (sex, age, body mass index, T-score and prior fracture history) were clustered into pre-defined categories:
Sex: male/femaleAge: 50–64, 65–74, 75+Body mass index:  ≤18 kg/m2, 19–24, 25–29, ≥30 kg/m2; also compared by quartilesT-score: ≥−1, −2.4 to −1.1, ≤−2.5Prior fracture history: yes/no
Contingency tables for each set of categories were prepared and chi-squared values calculated to test for overall interaction. Yates continuity correction was used where 2×2 tables resulted. Where the overall result was significant, individual pairwise comparisons and t-testing were then carried out.
Results
Data was collected during the routine work of the FLS between September 2004 and March 2005. The data was analysed between July 2005 and July 2006.
Demographics
Data were available for 337 patients presenting with low trauma fracture; 77.4% (n=261) were female. Of all patients, 10.4% were aged 50–64 years, 53.2% were aged 65–74 years and 36.2% were aged 75 years or over. Mean body mass index (BMI) was 24 kg/m2 (SD 32); 6% (n=20) had a BMI ≤18 kg/m2, 33% (n=112) between 19–24 kg/m2, 35% (n=118) between 25–29 kg/m2 and 26% (n=87) ≥30 kg/m2 According to WHO definitions, 35.0% of patients had normal lumbar spine BMD (T-score −1 or above), 37.4% were osteopenic (T-score −1.1 to −2.4) and 27.6% were osteoporotic (T-score −2.5 or lower).
Humerus (n=103, 31%), radius–ulna (n=90, 27%) and hand/foot (n=53,16%) were the most common presenting fractures (see Fig. 1). Other fracture sites included hip (n=16, 5%), clavicle (n=11, 3%), rib (n=7, 2%), tibia-fibula (n=8, 2%), pelvis–pubic rami (n=7, 2%) and olecranon, patella, scapula, sternum and shaft of femur (n=7, 2%).
Fig. 1Presenting fracture and prevalence of vertebral deformity for each type of fracture. *Other includes olecranon, patella, scapula, sternum and shaft of femur
The presenting fracture was the first non-vertebral, low trauma fracture to come to clinical attention in 72% of patients (n=241), the second in 25% (n=85), the third in 1% (n=5) and the fourth in 2% (n=6).
Information regarding risk factors for fracture—including prior history of fracture, early menopause, BMI, history of smoking or excess alcohol, thyrotoxicosis, history of maternal hip fracture, family history of osteoporosis, steroid use, rheumatoid disease, history of recurrent falls and partial gastrectomy—was also collected. Of all patients, 63% had one fracture risk factor, 23% had two risk factors, 11% had three risk factors and 3% had more than three risk factors. Risk fractures for fracture were assessed after patients had presented to the FLS with a non-vertebral fracture; therefore, every patient had a prior history of fracture.
Vertebral deformity consistent with fracture
The overall prevalence of vertebral deformity established by MXA was 25%. The prevalence of vertebral deformity by type of presenting fracture is shown in Fig. 1. Patients with a hip fracture were significantly more likely to have a vertebral deformity identified on MXA than were patients who presented with a non-hip fracture (p=0.009).
Overall, 55.4% of patients with vertebral deformities had deformities in the thoracic spine and 26.4% had lumbar spine deformities, whilst 18.2% had deformities in both regions. Of the patients with vertebral deformities identified by MXA, 45% had deformities of more than one vertebra. Multiple vertebral deformity prevalence varied considerably according to the site of the presenting fracture (see Fig. 2).
Fig. 2Presenting fracture and prevalence of multiple (two or more) vertebral deformities
Of the patients with vertebral deformities, 3 (3.6%) had unreadable scans for grading. Of the 80 remaining patients, 58 (72.5%) had Grade 2 or Grade 3 deformities. Thirty-two (55.2%) of the patients with vertebral deformity of Grade 2 and Grade 3 had multiple vertebral fractures. Of the sub-group of patients with vertebral deformity of Grade 2 and 3, 56.9% had deformities in the thoracic spine, 22.4% in the lumbar spine and 20.7% in both regions. There was no significant difference between the vertebral deformity population and the sub-population of patients with Grade 2 or 3 deformities, in terms of the proportion of patients with multiple vertebral deformities or in the site of deformity.
Table 1 shows the prevalence of vertebral deformity and multiple vertebral deformities by lumbar spine T-scores. Patients whose lumbar spine T-scores were consistent within the osteoporosis range (T-score ≤2.5) were significantly (p<0.05) more likely to have vertebral deformities (42%) than patients whose T-scores were in the osteopenic or normal ranges (20% and 16% respectively). They were also significantly more likely to have multiple vertebral deformities than those with a normal T-score (54% versus 14%, p<0.001).
Table 1Impact of lumbar spine T-score on prevalence of vertebral deformityLumbar spine T-scoreTotalVertebral deformityMultiple vertebral deformitiesFracture Grade 2 or 3n%n%%an%%bn%%aOsteoporotic (T-score ≤−2.5).93283947.041.9205451.33255.234.4Osteopenic (T-score −2.4 − −1.1).126372530.119.8123248.01627.612.7Normal118351922.916.151426.31017.28.5Totals337100831003710058100Vertebral deformity: Chi-squared=13.471, p=0.0012Multiple vertebral deformities: Chi-squared=16.304, p=0.0003a% within each T-score group with vertebral deformityb% of vertebral deformity group with multiple deformities within each T-score group
Patients with lower BMI (≤18 kg/m2) were significantly more likely to have vertebral deformity than patients with the highest BMI (≥30 kg/m2), (40% versus 17%, p<0.0001) (Table 2). A very similar picture was seen when BMI was divided into quartiles: 45% of patients in the lowest quartile had a vertebral deformity, compared with 18% of those in the highest quartile (p<0.0001). The mean BMI for patients with and without vertebral deformity did not differ significantly (24.35±4.78 kg/m2 vs 25.22±3.90 kg/m2), nor did the mean BMI of patients with multiple vertebral deformities (23.70±4.78 kg/m2).
Table 2Impact of BMI on prevalence of vertebral deformity, n=336BMITotalVertebral deformityMultiple vertebral deformitiesFracture Grade 2 or 3n%n%%n%%n%%Underweight <18206.089.640.0513.562.5813.840.0Normal 19–2411133.03947.035.12054.151.32441.421.625–2911835.12226.518.6616.227.31729.314.430+8725.91416.916.1616.242.9915.510.3Totals336100831003710058100Vertebral deformity: Chi-squared=16.572, p=0.0009Multiple vertebral deformities: Chi-squared=15.288, p=0.0016
Patients with a history of one or more non-vertebral fractures prior to the fracture they presented with were significantly more likely to also have vertebral deformity(ies) (Table 3), (43% versus 20%, p=0.008).
Table 3Impact of prior fracture history on prevalence of vertebral deformity TotalVertebral deformityMultiple vertebral deformitiesFracture Grade 2 or 3n%n%%n%%n%%024171.54959.020.32464.949.03560.314.51 or more9628.53441.042.71335.138.22339.724.0Totals337100831003710058100Vertebral deformity: Chi-squared=7.131, p=0.0078Multiple vertebral deformities: Chi-squared=0.237, p=0.63 (ns)
Table 1 also includes analysis of the sub-group of patients with vertebral deformities of Grade 2 and Grade 3
Patients with an osteoporotic T-score were significantly more likely to have vertebral deformities than those with a normal or osteopenic T-score (34% vs 12.7% [osteopenic] and 8.5% [normal] p<0.0001)Patients with BMI<18 kg/m2 were significantly more likely to have vertebral deformities than those with BMI of over ≥30 kg/m2 (40% vs 10.3%, p<0.0001)Patients with a history of one or more prior non-vertebral fractures were more likely to have vertebral deformity although this did not reach significance (24% vs 15%, p=0.055)
Older patients were slightly (although not statistically significantly) more likely to have a vertebral deformity: 30% of patients aged over 75 had a vertebral deformity, compared with 23% and 22% of patients aged 50–64 years and 65–74 years respectively. Gender did not appear to affect the likelihood of identifying a vertebral deformity (25% of women and 24% of men), although women were somewhat more likely to have multiple vertebral deformities (45% vs 40%, p=ns).
Discussion
One-quarter of patients presenting to our Fracture Liaison Service with a non-vertebral fracture had a previously undiagnosed vertebral deformity, of which almost one-half (45%) were multiple vertebral deformities. This is similar to the prevalence seen in previous studies using radiographic or MXA detection in women with and without non-vertebral fracture. Sub-analysis of patients by grade of deformity revealed that almost three-quarters of the patients had vertebral deformities of Grade 2 and Grade 3. These are more likely to be vertebral fractures, rather than vertebral deformities of non-osteoporosis aetiology, which might be more likely where Grade 1 deformities are present.
In the Study of Osteoporotic Fractures (SOF), a prospective study of almost 10,000 women, the prevalence of vertebral fracture was 20% (42% of which were multiple) in women aged over 65 years who did not have a non-vertebral fracture [11]. In another study of 482 women aged over 65 years without a non-vertebral fracture, the prevalence of vertebral fracture was 18.3% [15]. In a smaller study of 58 women with Colles’ fracture, vertebral fractures were identified by MXA in 19% of patients [16].
In this present study, patients presenting with hip fracture, spine T-score ≤−2.5, low BMI (either in the lowest quartile or ≤18 kg/m2) or with more than one prior non-vertebral fracture were all significantly more likely to have evidence of a prevalent vertebral deformity. However, we found that 16% of patients with normal BMD at the lumbar spine had a prevalent vertebral deformity (26% of which were multiple). This is comparable to that seen in an earlier study conducted in women aged over 65 years without a non-vertebral fracture and with normal BMD at the spine, which revealed a prevalence of vertebral fracture of 18.7% [15].
In the UK, current treatment decisions for patients with low trauma fracture are based on fracture status and BMD as determined by DXA [17, 18]. In England, patients aged under 75 receive treatment if they have a fracture and osteoporosis is confirmed by DXA scanning [17]. In Scotland, patients with vertebral fracture and BMD outside the osteoporotic range, as defined by the WHO classification, do not routinely receive treatment unless they have two or more vertebral fractures, irrespective of BMD, or one vertebral fracture and an osteopenic BMD score [18]. Identification of those patients who already have an (often unrecognised) prior vertebral fracture is particularly important, as they are at high risk of further fracture by virtue of their prior vertebral fracture. Although these patients might not fulfil the criteria for therapy on the basis of their (non-vertebral) fracture history and BMD, they might be candidates for therapy if their underlying positive vertebral fracture status was known.
In this study, five of the 118 patients with normal BMD (4.2%) had two or more previously undiagnosed vertebral deformities plus a new non-vertebral fracture, and 25 of the 126 patients with osteopenic BMD (19.8%) had one or more previously undiagnosed vertebral deformities plus a non-vertebral fracture. These patients would not have been candidates for anti-resorptive treatment if MXA had not been performed and their vertebral deformities identified. Therefore, one in 20 patients with a normal T-score and almost one in five patients with an osteopenic T-score would experience a change in management by virtue of their underlying vertebral deformity or deformities.
Overall, 30 (8.9%) of the patients in this study would be eligible for treatment by virtue of their newly identified vertebral deformity., which means that 11 patients who present with a non-vertebral fracture would need to undergo vertebral morphometry in order to identify one patient who ought to be managed differently. This ‘Number Needed to Screen’ gives an indication of the number of patients for whom treatment recommendations would change after the identification of vertebral fracture.
These data also provide the first attempt to quantify the overlap between patient populations with non-vertebral and vertebral fracture. Estimates suggest that 1.28 million post-menopausal women in the UK have experienced a prior non-vertebral fracture [19] and 1.3 million have at least one prior vertebral fracture [20]. In this study, 72% of patients presented with their first non-vertebral fracture, and vertebral morphometry subsequently identified vertebral deformities in one in five (21%) of these patients. Nearly one-half of vertebral deformities were multiple (48%). It is highly likely that these vertebral fractures had occurred prior to the first non-vertebral fracture, suggesting that a substantial number of patients will have experienced a vertebral fracture prior to any non-vertebral fracture event.
Our results support the recommendation to perform vertebral morphometry in any patient who is referred for DXA testing after experiencing a non-vertebral fracture. Treatment decisions will then better reflect any given patient’s future absolute fracture risk. The 'Number Needed to Screen' if MXA is used in this way would be seven to identify one patient with vertebral deformity, and 14 to identify one patient with two or more vertebral deformities.
Routinely performing lateral vertebral morphometry does raise a number of issues. Firstly, there is an increase in radiation exposure for the patient. A standard AP spine and hip DXA scan is associated with a radiation exposure [entrance surface dose (ESD)] of around 0.037 mGy, and results in an effective dose of less than 2 μSv (microsieverts). The ESD associated with lateral vertebral morphometry is 0.083 mGy [21],corresponding to an estimated effective dose of about 2.5 μSv. These are relatively small doses compared to the UK natural background radiation level of approximately 2.5 mSv. The small carcinogenic potential associated with these scans has to be balanced against both the prognostic importance (in terms of future fracture risk) that is associated with the identification of unrecognised vertebral deformities and also the much higher radiation exposure risk associated with plain spine radiology (effective dose ∼0.6 mSv).
Lateral vertebral morphometry does have limitations; for example, it is less reliable than conventional lateral spine X-rays at the upper thoracic spine and in Grade 1 deformities.
A recent study [22] comparing MXA with lateral spine X-rays found that vertebral morphometry using MXA allowed diagnosis of vertebral fracture in the lumbar and mid thoracic spine, where vertebral fractures are most common. MXA was less reliable at the upper thoracic spine, which is also an established limitation of X-rays.
An earlier study [23] compared identification of vertebral fracture on MXA using the Genant semi-quantitative method using MXA with conventional X-rays in 80 post-menopausal women. Of the 1,027 potentially evaluable vertebrae, 81% were adequately visualised on MXA to allow grading. Prevalent vertebral fracture was identified in 40 vertebral bodies using X-ray; of these, 28 (70%) were correctly identified on MXA, 17/18 (95%) Grade 2 or 3 and 11/22 (50%) of Grade 1 fractures. Of the non-fractured vertebrae, 96.2% were correctly classified as normal by MXA.
Although the Genant semi-quantative method is not validated for MXA, it has been used in other studies [22, 23], and was used in this study as a pragmatic option. To carry out quantitative analysis on each scan would have been time-consuming and impractical.
Given that the sample population had already had at least one non-vertebral fracture (28% had more than one prior fracture), were drawn from the FLS population, and that almost three-quarters had Grade 2 or 3 vertebral deformity, it seems reasonable to expect the vertebral deformity to be due to osteoporosis, rather than other diagnoses such as degenerative change or Scheurmann’s disease.
The sensitivity of detection of a vertebral fracture is lower both where there is significant spine scoliosis and also where there is marked disc-space osteoarthritic change. In these settings, proceeding to plain spine radiology would be recommended [24]. Plain spine X-rays were not carried out in this study. Furthermore, in keeping with our local protocol, bone densitometry was not carried out in older patients (over the age of 70) after hip fracture. Both of these features may mean that the overall prevalence of vertebral deformity in this population has been underestimated.
In conclusion, undiagnosed vertebral deformity is highly prevalent in patients aged over 50 years who present with a new non-vertebral fracture. Given that prior vertebral fracture significantly increases the risk of further fracture and because newer diagnostic techniques make identification of vertebral deformity consistent with fracture relatively straightforward with minimal radiation exposure, we recommend that all patients undergoing DXA should also undergo vertebral morphometry to identify prior vertebral deformities consistent with fractures.

vertebral fracture
osteoporosis
low trauma fracture
vertebral morphometry
number needed to screen


Fibrin glue and transanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage?

Backgrounds and aim In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin.
Introduction
Perianal fistulas of cryptoglandular origin cause considerable discomfort and arise from infections in anal glands lying in the intersphincteric space [1]. To delineate the fistula tract, magnetic resonance imaging (MRI) and anal endosonography are nowadays readily available and are increasingly used for fistula imaging [2]. The essence of surgical treatment of perianal fistulas is to eradicate the fistula tract and at the same time preserve continence. Low fistulas, where the fistula tract is submucosal, intersphincteric or located in the lower third of the external anal sphincter can be treated by fistulotomy with low recurrence rates and relatively little impact on continence [3]. In patients with high perianal fistulas, the fistula tract is located in the upper two-thirds of the external sphincter. Fistulotomy performed on high fistulas results in loss of sphincter function in a considerable number of patients due to the interference of the external sphincter complex [4, 5]. There are various alternative surgical options for high fistulas, namely, rectal advancement, fibrin glue, and seton drainage.
In 2006, Johnson et al. [6] reported a new biologic anal fistula plug to treat high transsphincteric perianal fistulas. The anal fistula plug is biologic absorbable and consists of lyophilized porcine intestinal submucosa. In their series of 46 patients treated with the anal fistula plug, a success rate of 83% was achieved at a median follow-up of 12 months [7]. After this publication, several authors have reported their experience with the anal fistula plug, resulting in success rates ranging from 41–88% [8–10].
Currently, the transanal rectal advancement flap (AF) remains the “gold standard” in the treatment of high transsphincteric perianal fistulas of cryptoglandular origin. The rationale behind the AF is that the open internal opening is the cause of the persisting fistula tract. By advancing the tissue over the internal opening, it would be impossible for fecal material to be forced into the fistula tract during defecation. However, recurrence rates of the advancement flap found in literature vary considerably and extend up to 63% [11–15]. Roughly, one out of every four patients requires multiple surgical interventions to close the fistula tract successfully.
In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. As a result of the obliteration of the fistula tract and the closure of the internal opening, the fistula might heal. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results [16–20]. Recently, Zmora et al. [21] conducted a retrospective study including 37 patients with high perianal fistulas. In a subset of 13 patients with fistulas of various etiologies, the advancement flap was used in addition to the fibrin glue installation. The results showed a recurrence rate of 46%.
The aim of this study was to assess the additional value of fibrin glue to the transanal rectal advancement flap in a well-defined group of patients with high transsphincteric fistulas of cryptoglandular origin. Patients with previous fistula surgery are a surgically more challenging group as the result of scar tissue and sometimes anal stenosis. Therefore, patients were matched for the presence of a history of fistula surgery.
Materials and methods
Patient characteristics Between January 1995 and January 2006, a consecutive series of patients were treated by AF. Only patients with high transsphincteric perianal fistulas of cryptoglandular origin were analyzed. High perianal fistulas were defined as patients with fistulas running through the upper two thirds of the external sphincter complex, which is confined by the puborectal sling and the end of the anal canal. Patients in whom the internal fistula opening was not detectable and patients with perianal fistulas as a result of Crohn’s disease, HIV, and other causes were excluded. Patients over 18years of age were included. A consecutive series of patients were operated on with fibrin glue (Tissucol Duo®, Baxter International) in addition to the AF in an attempt to decrease the recurrence rate of the AF. This series of patients were treated on between February 2003 and January 2006. Patients were matched for previous surgery and divided into two groups; one group with previous fistula surgery and the other without. Preoperatively, no routine imaging was performed. Only in selected case when the fistula was complex and/or recurrent, MRI or anal endosonography was used to outline the fistula tract. In The Netherlands and Belgium, non-experimental clinical case series of patients treated with a CE-approved device do not require approval of the local Medical Ethics Commission. A subset of patients from this series were also included in a study where the aim was to assess the long-term functional outcome and identify risk factors for the development of recurrence in patients surgically treated for cryptoglandular fistulas [22].
Surgical technique On the day of surgery, an enema was administered to the patient to clean the proctum. All procedures were performed under general or locoregional anesthesia in the lithotomy position, and broad spectrum antibiotics were administered perioperatively. Subsequently, the internal opening was located by probing the external opening. During surgery, the amount of sphincter involved was judged by palpation of the puborectal sling and the inferior edge of the external sphincter complex. In cases where the internal opening was not found by probing, hydrogen peroxide was injected to locate the internal opening. In case of active sepsis, a seton was placed for a period of at least 3 months insuring adequate drainage. In the group that was operated with the AF, the internal opening was excised followed by mobilization of the mucosa, submucosa, and a small amount of muscular fibers from the internal sphincter complex. The rectal flap was mobilized to sufficiently cover the internal opening with overlap. Hemostasis was performed to prevent a hematoma under the flap. The base of the advancement flap was kept wide enough to ensure adequate circulation in the flap. The internal opening was not closed before advancing the flap over the internal opening. This was followed by suturing the flap in the distal anal canal with Vicryl 2/0 after the fistula tract had been curetted. In the AF + G group, the identical procedure was carried out. In addition to the advancement procedure, fibrin glue was installed retrogradely in the fistula tract after the AF was completed and the fistula tract had been curetted. Installation of the fibrin glue was performed via the external opening, under direct vision of the advancement flap to prevent flap dislocation and subsequent failure. No specific postoperative instructions were given to the patients.
Data collection Chart review was performed on age, gender, tertiary referral, previous fistula surgery, smoking habits, complications, and fistula recurrence. All patients visited the outpatient’s clinics on a regular basis (every 2–4 weeks) until full closure of the fistula tract was achieved. The fistula was considered closed if the external opening was closed and no discharge or pain was experienced; otherwise, it was considered as a persistent or recurrent fistula. No routine postoperative imaging or proctoscopy was performed to confirm the closure of the fistula tract. The data was collected retrospectively and the outcome was compared between groups.
Statistical analysis Data are presented as median values with ranges, unless otherwise specified. Categorical data are presented as frequencies or percentages. Differences between groups were tested using Mann–Whitney U test for continuous data. Chi-square test or Fisher’s exact test were used when appropriate to compare groups in case of categorical or dichotomous variables. All reported p values are two-sided. A p value of 5% or less was considered as statistical significant. Statistical analysis was done using the SPSS v.12.0 package (SPSS, Chicago, IL, USA).
Results
In the study period, a total of 127 patients were operated for high perianal fistulas. Inflammatory bowel disease (n = 30), HIV (n = 12), or no internal opening found during surgery (n = 5) were the reason of exclusion in 47 patients. In total, 80 patients were analyzed in this comparative study. Of these, 54 patients were treated with the AF and 26 patients underwent AF combined with the installation of fibrin glue. Furthermore, patients were matched for a history of fistula surgery. Patient characteristics for both groups are shown in Tables 1 and 2. The groups were comparable for patients’ characteristics as sex, age, smoking, seton drainage, and number of tertiary referrals.
Table 1Characteristics of patients with high anorectal fistula without previous fistula surgeryVariableAF (n = 32)aAF + G (n = 9)bp valueM/F (n)18:146:30.711Age (median, in years)42 (21–67)41 (29–55)0.653Tertiary referral26 (81%)7 (78%)1.000Smoking43%71%0.232Seton drainage18 (56%)6 (67%)0.711aRectal advancement groupbRectal advancement group with fibrin glueTable 2Characteristics of patients with high anorectal fistulas with previous fistula surgeryVariableAF (n = 22)aAF + G (n = 17)bp valueM/F (n)18:411:60.282Age (median, in years)43 (22–62)47 (35–72)0.136Tertiary referral15 (68%)8 (47%)0.209Smoking53%50%1.000Seton drainage10 (46%)12 (71%)0.193aRectal advancement groupbRectal advancement group with fibrin glue
Clinical outcome All patients were operated in day case setting. There were no intraoperative complications. In two patients out of the AF group, a postoperative complication was encountered, consisting of a minor bleeding (n = 1) and a bradycardia for which the patient was observed overnight (n = 1, patient with cardial history). In the AF + G group, there were no postoperative complications recorded. The minimal follow-up after surgery was 13 months with a median of 67 months (range, 13–127). There were no patients lost to follow-up. The overall recurrence rate was 26% (n = 21; Table 3.). In 17% of the patients, the fistula persisted in the AF group compared to 46% in the AF + G group (p = 0.05). In the matched group without previous fistula surgery, the result was significantly worse for the AF + G group compare to the AF group (p = 0.014). The recurrence rates were 56% (n = 5) and 13% (n = 4), respectively. In the group with a history of fistula surgery, the recurrence rate was 23% (n = 5) compared to 41% (n = 7) in the AF and the AF + G group, respectively (p = 0.216).
Table 3Recurrence rates for the matched group analysisGroupAFaAF + Gbp valueOverall (n = 80)9/54 (17%)12/26 (46%)0.050No previous fistula surgery (n = 41)4/32 (13%)5/9 (56%)0.014Previous fistula surgery (n = 39)5/22 (23%)7/17 (41%)0.216aRectal advancement groupbRectal advancement group with fibrin glue
Discussion
High perianal fistulas remain a surgical challenge. There are various treatment options for treating high transsphincteric fistulas, e.g., the rectal and anodermal advancement flap, loose and cutting seton, fibrin glue, and potentially the newly developed anal fistula plug [3]. However, the results from these therapies vary. Transanal rectal advancement flap is nowadays the treatment of choice because of its sphincter-saving approach. Due to the low recurrence rate of only 30%, which leaves a lot of room for improvement [11, 14], fibrin glue has been widely studied. Fibrin glue was developed to obliterate the fistula tract by stimulating fibroblasts, which leads to permanent closure of the fistula tract. Unfortunately, the long-term results were not as good as expected [19, 20]. In the present series, an attempt was made to decrease the recurrence rate of the surgical treatment of high transsphincteric perianal fistulas of cryptoglandular origin by combining the two methods, i.e., fibrin glue and the rectal advancement flap in a consecutive series of patients. Overall, although not significant, a clear trend was found consisting of a worse outcome for patients from the AF + G group. The recurrence rate was 46% compared to 17% in the AF + G and AF group, respectively. In the group without a history of fistula surgery, patients in the AF + G group did significantly worse than the AF group. In the group with a history of fistula surgery, no significantly different recurrence rates were found.
In 2003, Zmora et al. [21] described a small retrospective series of 13 patients with perianal fistulas of different origins treated with fibrin glue in combination with the AF [14]. In their series, a recurrence rate of 46% was found after a mean follow-up of 12.1 months. The group contained patients with fistulas of cryptoglandular origin and fistulas associated with Crohn’s disease or surgical trauma. In addition, two patients with rectovaginal fistulas were included. More recently, Ellis and Clark [23] reported on a series of 58 patients randomized into advancement flap repair alone or advancement flap repair combined with fibrin glue. Selected were patients with perianal fistulas where the fistula tract comprised more than 30 to 50% of the sphincter complex. Furthermore, patients were included when the fistula was located anteriorly in women or when the patient had a history of incontinence. In two thirds of the patients, the mucosal advancement flap was used and the remaining patients were treated by anodermal advancement flap. The recurrence rate was significantly higher in the group where fibrin glue was combined with the advancement flap compared to the group treated only by advancement (46% vs 20%). Two techniques, i.e., mucosal advancement flap and anodermal advancement flap, were used. Furthermore, no information was provided on the distribution of causes of the fistulas in both groups making the results difficult to interpret.
The effectiveness of the AF is the result of the closure of the internal opening [24]. The reason why addition of fibrin glue fails to decrease the recurrence rate and even seems to worsen the result is still unclear. After AF, the fistula tract acts as a drainage canal for any remaining sepsis, with the external opening left open. With the installation of the fibrin glue, a temporary closure of the fistula tract is theoretically achieved. After a few weeks, when the clot resolves, the fibroblasts activated by the matrix should provide collagen syntheses for a definitive closure of the tract [25]. A possible explanation to why the AF + G group does worse is that the closure of the fistula tract with the fibrin glue leads to a situation where insufficient drainage from the primary and eventual secondary fistula tracts occurs.
Sentovich reported on a prospective series of 48 patients (75% of cryptoglandular origin) treated with fibrin glue [20]. In their technique of using the fibrin glue, the procedure was combined with closure of the internal opening with only a figure eight suture without an advancement flap. After a median follow-up of 22 months, a recurrence rate of 31% was found. Surprisingly, the patients with longer fistula tracts did significantly worse than those with short fistula tracts. Loungnarath et al. [26] reported on 39 patients with perianal fistulas treated with fibrin glue. The overall recurrence rate was 69%. In 6 of the 39 patients, the internal opening was closed using a figure eight suture to avoid clot extrusion because of high pressure from the anal canal during defecation. Four of these patients had a recurrence (33%).
This retrospective study, in contrast to earlier studies [21, 23], assessed the additional value of fibrin glue to the transanal rectal advancement flap of only patients with high transsphincteric fistulas of cryptoglandular origin with a long follow-up. The rectal advancement flap combined with fibrin glue installation was associated with a significantly higher recurrence rate, compared to the advancement flap treatment alone, in patients without previous fistula surgery. This observation must be interpreted carefully because of the small sample size of the AF + G group. As the costs of the fibrin glue are considerable and the therapeutic effect very doubtful, it cannot be recommended routinely in the adjunct of transanal rectal advancement flap treating high perianal fistulas. The rectal advancement flap remains the treatment of choice for high transsphincteric perianal fistulas of cryptoglandular origin until novel methods like the anal fistula plug are studied sufficiently in randomized trials.

fibrin glue
advancement
recurrence
surgery
rectal fistula