Inter- and intra-observer errors in identifying the transepicondylar axis and Whiteside's line

PURPOSE

To assess inter- and intra-observer errors in identifying the transepicondylar axis and Whiteside's line in a cadaveric model mimicking total knee arthroplasty.

METHODS

Four cadaveric knees with intact soft tissues were used. The knees were exposed anteriorly using the Insall approach, with the patella everted laterally. Three observers (2 surgeons and one trainee) took turns to identify the anatomic landmarks of the transepicondylar axis and Whiteside's line. Each observer repeated the process 20 times. Each identification was photographed and referenced with the true values obtained from the knees after they were stripped of all soft tissue. Inter- and intra-observer errors in the anatomic landmarks were compared.

RESULTS

Inter-observer error was significant with both the transepicondylar axis and Whiteside's line (p<0.001, one-way ANOVA). The intra-observer variation was greater for Whiteside's line than the transepicondylar axis (standard deviation, 4.2 vs 2.5 degrees). The maximum potential errors in the transepicondylar axis and Whiteside's line were 13 degrees and 24 degrees, respectively.

CONCLUSION

The accuracy of rotational alignment of the transepicondylar axis and Whiteside's line were operator-dependent, and their intra-operative reproducibility was low.

Hip pain many years after fusion: a report of two cases

Arthrodesis of the hip has been employed since the late 19th century. Late complications can arise decades after fusion in patients who were previously asymptomatic. We describe two patients who developed pain in the hip many years after a successful fusion. There was no infection or loosening of the implants. After careful investigation, including oblique radiographs and diagnostic injections of local anaesthetic, the pain was found to be caused by protrusion of the implant. Subsequent removal of the device resulted in complete resolution of the symptoms.

Differential item functioning of the Geriatric Depression Scale in an Asian population

BACKGROUND

The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore.

METHODS

The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF.

RESULTS

We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless.

LIMITATIONS

The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses.

CONCLUSIONS

In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study

BACKGROUND

Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour.

METHODS

A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed.

RESULTS

After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families.

LIMITATIONS

These included use of self-reported doctor visits, and relatively high educational levels of the participants.

CONCLUSIONS

Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.

Subthreshold depression and cognitive impairment but not demented in stroke patients during their rehabilitation

BACKGROUND

Subthreshold depression (sD) and cognitive impairment but not demented (CIND) in stroke patients are associated with poorer rehabilitative outcomes. Their diagnosis can easily be operationalized using validated scales.

AIM

The aim of the study was to ascertain the prevalence of depressive symptoms and cognitive impairment in stroke patients during three crucial stages of the rehabilitative process, viz. upon admission, upon planned discharges from rehabilitation hospitals and at 6 months post-stroke, using validated scales like the Geriatric Depression Scale and Abbreviated Mental Test (recommended by the British Geriatric Society). Their baseline risk factors were also ascertained.

RESULTS

On admission, the prevalence of depressive symptoms and cognitive impairment was 60% and 54% respectively. The prevalence upon planned discharges and 6 months post-stroke, respectively, of depressive symptoms was 38% and 34% and that of impaired cognition was 33% and 40%. Baseline independent correlates at 6 months post-stroke depressive symptoms were: recurrent stroke (OR 3.34); on admission cognitive impairment (OR 4.78) and ADL dependence (OR 5.28). And that of cognitive impairment were: increasing age (OR 8.07); post-stroke dysphagia (OR 4.58); on admission cognitive impairment (OR 23.95) and on admission depressive symptoms (OR 3.50).

CONCLUSIONS

Continuous screening and appropriate intervention, especially at baseline, would significantly decrease the burden posed by stroke patients with such psychological impairments in the community.

Emotional and behavioural problems in Singaporean children based on parent, teacher and child reports

INTRODUCTION

This study aims to determine the prevalence of emotional and behavioural problems in a community sample of Singaporean children aged 6-12 years, and its agreement according to parent, teacher and child reports.

METHODS

The Child Behaviour Checklist (CBCL), Teacher Rating Form (TRF) and child report questionnaires for depression and anxiety were administered to a community sample of primary school children. 60 percent of the children sampled (n = 2,139) agreed to participate. Parents of a sub-sample of 203 children underwent a structured clinical interview.

RESULTS

Higher prevalence of emotional and behavioural problems was identified by CBCL (12.5 percent) than by TRF (2.5 percent). According to parent reports, higher rates of internalising problems (12.2 percent) compared to externalising problems (4.9 percent), were found. Parent-teacher agreement was higher for externalising problems than for internalising problems. Correlations between child-reported depression and anxiety, and parent and teacher reports were low to moderate, but were better for parent reports than for teacher reports.

CONCLUSION

The prevalence rates of emotional and behavioural problems in Singaporean children based on CBCL ratings are comparable to those in the West, but the low response rate and exclusion of children with special needs limit the generalisability of our findings. Singaporean children have higher rates of internalising problems compared to externalising problems, while Western children have higher rates of externalising problems compared to internalising problems.

Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method

We presented a simple and economic method of preparing articulating antibiotic-loaded cement spacers for treatment of infection after total knee arthroplasty. From 1996 to 2004, 28 infected total knee arthroplasties were treated with 2-stage reimplantation. Static spacers were used in 7 knees, and articulating spacers were used in 21 knees. A minimum of 2 years' follow-up after final treatment was evaluated. In the static group, 1 (14%) knee had recurrence of infection. In the articulating group, 2 (9%) knees had recurrence of infection with the original organism. Patients receiving articulating spacer had better range of motion, better knee score, and less bone loss than patients with static spacer.

Nutrition screening among community-dwelling older adults in Singapore

INTRODUCTION

This study aimed to describe responses to the DETERMINE checklist and the nutritional risk level of community-dwelling older Chinese in Singapore, aged 55 years and older.

METHODS

Data was collected from a community health screening project for elderly residents in Singapore. All residents aged 55 years and older in the survey area were identified in door-to-door census surveys and were invited to participate. Participants completed a questionnaire interview conducted by research nurses. The survey also included questions which were potential predictors of nutritional risk: sociodemographic factors (age, gender, education, housing type, marital status, and living arrangement) and health-related factors (self-rated health, number of medical comorbidities, hospitalisations in the past year, functional disabilities and physical health status).

RESULTS

Data for analysis was provided by 2,605 Chinese subjects aged between 55 and 98 years (mean/standard deviation 66.0/7.7). The overall prevalence of nutritional risk (according to a DETERMINE score of 3 or greater) was 30.1 percent. 1,822 (69.9 percent) subjects had no nutritional risk (scores of 2 or lower), 664 (25.5 percent) had moderate nutritional risk and 119 (4.6 percent) had high nutritional risk. The most common contributions to nutritional risks were: changing food intake due to illness (40.3 percent), taking three or more different medications daily (25.0 percent), eating alone (14.5 percent) and consuming insufficient amount of fruits, vegetables or milk products on a daily basis (9.0 percent). Respondents at nutritional risk were more likely to have three or more comorbid medical conditions, were hospitalised in the past year, were functionally dependent on one or more instrumental or basic activities of daily living, were reported to have poor or fair self-rated health, and were in the lowest tertile scores for SF-12 quality of life and depression.

CONCLUSION

Self-rated general health, lowered quality of life, functional disability and depression have meaningful non-circular associations with the checklist. These support the validity of the DETERMINE checklist in predicting the risk of adverse health conditions and events.

Effects of a self-management arthritis programme with an added exercise component for osteoarthritic knee: randomized controlled trial

AIM

This paper is a report of a study to assess the effect of an adapted arthritis self-management programme with an added focus on exercise practice among osteoarthritic knee sufferers.

BACKGROUND

Osteoarthritis of the knee is a major source of loss of function in older people. Previous studies have found self-management programmes to be effective in increasing arthritis self-efficacy and in mastery of self-management practice.

METHOD

A randomized control trial was carried out from December 2002 to May 2003 and 120 participants (65.9%, including 67 in intervention group and 53 in control group) completed the 16-week postintervention assessments. Outcome measures included arthritis self-efficacy, use of self-management techniques, pain intensity and daily activity.

FINDINGS

At 16 weeks, there was a 'statistically' significant improvement in the arthritis self-efficacy level (P <or= 0.001), in most of the self-management skills, i.e. use of cold and hot compresses, in two of three joint protective practices (P <or= 0.001; P = 0.01), an increase in the duration of light exercise practice (P <or= 0.001), reduction of current arthritis pain (P <or= 0.001) and in the ability to perform daily activities (P <or= 0.001) among the intervention group but not for the control group (P-range from 0.04 to 0.95). One joint protective practice showed a statistically significant increase in both groups (P <or= 0.001).

CONCLUSION

Our findings add to evidence showing short-term beneficial effects of self-efficacy theory in education programmes. Self-efficacy theory has great potential for empowering sufferers of chronic conditions to live with their illness.

Sagittal pelvic mal-rotation and positioning of the acetabular component in total hip arthroplasty: Three-dimensional computer model analysis

Mal-rotation of pelvis on the sagittal plane, which is common in patients with fixed spinal kyhposis, for example, ankylosing spondylitis, can cause error in cup positioning when hip arthroplasty is performed. The present study was performed to quantify the effects of sagittal pelvic mal-rotation on the final cup position and to evaluate different methods of cup positioning to compensate for the mal-rotation. Three-dimensional reconstruction of computer tomograms of 15 sets of full pelvi was performed. Two methods of cup insertion were simulated and compared: a method mimicking genuine surgery (anatomical positioning) and one that compensates for the sagittal pelvic mal-rotation (functional positioning). Sagittal pelvic mal-rotation of more than 20 degrees , if ignored, resulted in a cup with an anterversion of more than 30 degrees and an inclination of more than 55 degrees. Half of the cup surface was not in contact with host bone when the cup position was maintained at 20 degrees anteversion and 45 degrees inclination in a patient with 50 degrees sagittal pelvic mal-rotation. The usual method of cup positioning may need to be modified in patients with sagittal pelvic mal-rotation in order to maintain the desired cup position. For each 10 degrees of sagittal pelvic mal-rotation beyond 20 degrees of mal-rotation, the cup needs to be put in such that it is 5 degrees less inclined and anteverted.

Prevalence of childhood asthma and control in children assessed in a pilot school-based intervention programme in Singapore

AIM

Because of a high childhood asthma burden in Singapore, assessment of disease control status is essential for formulating school-based strategy of childhood asthma control. The aim of the present study is to assess childhood asthma prevalence and control in Singapore and the socio-demographic and help-seeking correlates.

METHODS

School-based survey using parental self-administered questionnaire, conducted from February to April 2004. Four mixed-gender primary schools selected from geographically distinct zones of Singapore. All primary one (modal age - 6.5 years) and six (modal age - 11.9 years) students from selected schools were invited to participate. Questionnaire respondents were the students' parents or guardians. The response rate was 75.2% (2123/2825).

RESULTS

Prevalence of current asthma was 8.9% (190/2123). Among them, 26.3% (46/175) were assessed to have inadequate control. Asthma was more prevalent, and less adequately controlled in children from lower socio-economic backgrounds (lower-end housing type). Children with poorly controlled asthma were more likely to be treated by emergency room physicians and hospital specialists, and to be on preventer medications.

CONCLUSIONS

In Singapore, poor asthma control is found in a sizeable proportion of school children with asthma, is identifiable for high-risk groups of children from lower socio-economic backgrounds and having asthma-related attendance at the emergency rooms.

Determinants of length of stay during post-stroke rehabilitation in community hospitals

INTRODUCTION

Length of stay (LOS) in hospitals is the largest contributor of direct stroke care cost. Rehabilitation accounts for 16 percent of healthcare cost in the six-month post-stroke period. It is important to determine factors extending LOS in rehabilitation hospitals to identify focus areas of cost-control strategies. The aim of the study was to ascertain the predictors of LOS of post-stroke patients admitted into two community hospitals offering rehabilitation.

METHODS

An observational cohort study was conducted on 200 stroke patients admitted from acute hospitals into two community hospitals. Data collected included baseline sociodemographical variables, and the National Institute of Health Stroke Scale, Abbreviated Mental Test, Geriatric Depression Scale and Barthel Index were used to assess neurological impairment, cognitive impairment, depressive symptoms and functional disability, respectively. Medical complications (defined as new or exacerbated medical problems that generated additional physician evaluation, a change in medication or additional medical intervention), after patients were admitted to the community hospitals until discharged, were recorded. The outcome variables measured were length and cost of stay.

RESULTS

The mean LOS in our study was 34.4 (standard deviation [SD] 18.4) days, and the mean cost of hospital stay was S$2,410.83 (SD S$2,167.26). Length and cost of hospital stay were significantly correlated (r equals 0.52; p-value is less than 0.01). On multiple linear regression analysis, the significant variables positively associated with LOS were medical complications and functional dependence on admission. Significant variables negatively associated with LOS were unplanned discharge and recurrent strokes.

CONCLUSION

Medical complication is a key reversible determinant of increased LOS of post-stroke patients receiving rehabilitation in community hospitals. Strategies for prevention, early detection and treatment of medical complications during stroke rehabilitation are discussed.

Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning

PURPOSES

To study the incidence of femoral or tibial bowing in the coronal plane in a Chinese population, and how it affects the accuracy of bone cuts for total knee replacement when an intramedullary alignment system is used.

METHODS

Standing radiographs of the entire lower limb of each patient with end-stage primary osteoarthritis of the knee were analysed. All radiographs were digitised and the extent of bowing in the coronal plane measured. A bowing was marked if an angulation was more than 2 degrees. The projected error of cutting was then calculated.

RESULTS

Of 93 lower limbs, 58 (62%) of the femurs had marked bowing in the coronal plane; 41 (44%) had a mean lateral bowing of 5.3 (standard deviation [SD], 3.2) degrees; 17 (18%) had a mean medial bowing of 4.4 (SD, 1.9) degrees. Marked tibial bowing in the coronal plane was less common (30 tibias, 32%). If a cutting error of more than 2 degrees was considered unacceptable, significantly more unacceptable cuts would ensue in the groups with marked bowing (p=0.003 for femurs and p<0.001 for tibia, respectively).

CONCLUSION

The incidence of femoral or tibial bowing in the coronal plane was high in a Chinese population with end-stage osteoarthritis of the knee. This phenomenon may increase bone cut errors in total knee replacement if an intramedullary alignment system is used and the extent of bowing is not recognised.

The accuracy of extramedullary guides for tibial component placement in total knee arthroplasty

Anteroposterior radiographs that included the whole tibia were taken before and after 75 total knee arthroplasties in 48 patients. The same tibial extra-medullary alignment guide system was used in every knee. The average tibial component alignment was 0.4 (SD 2.5, range -4.9 to 6.4) degrees of valgus post-operatively. 59 tibial components (78.7%) had a tibial cut within 3 degrees from being perpendicular to the mechanical axis, ten were too valgus (13.3%) and six were too varus (8%). The chance of the tibial components becoming too varus was higher if there was lateral tibial bowing, compared with no tibial bowing (p=0.048). A smaller lateral width of the leg increased the chance of the tibial components becoming too valgus (p=0.047).

Impact of an Arthritis Self-Management Programme with an added exercise component for osteoarthritic knee sufferers on improving pain, functional outcomes, and use of health care services: An experimental study

OBJECTIVE

The aim of this study was to assess the effect of an adopted Arthritis Self-Management Programme (ASMP) with an added exercise component among osteoarthritic knee sufferers in Hong Kong.

METHODS

An experimental study with 88 participants assigned to an intervention group and 94 participants to a control group. One hundred and forty-nine participants (81.9%) completed the 1 week and 120 participants (65.6%) the 16 week post-intervention assessments. Participants in the intervention group received a 6-week ASMP with an added exercise component. Outcome measures included arthritic pain and fatigue rating, practice of light exercise routines, functional status, and number of unplanned arthritis-related medical consultations. To assess the programme's effect on outcome measures, the between-groups and within-group mean changes were compared using Mann-Whitney U-test and Friedman test.

RESULTS

At 16 weeks, there were significant mean changes between groups in four outcome measures: reduction in arthritis pain (p=0.0001) and fatigue (p=0.008), and increased duration of weekly light exercise practice (p=0.0001) and knee flexion (p=0.004). The ability to perform daily activities and the number of unplanned arthritis-related medical consultations show statistically significant improvements between three time-points within the intervention group only (p=0.0001 and p=0.005, respectively), but not between-groups (p=0.14 and p=0.86, respectively). Both groups apparently had no changes in muscle strength.

CONCLUSION

Our findings suggest that the intervention had a positive effect in reducing pain, fatigue, knee range of motion, the practice of exercise routines, the number of medical consultations and in improving functional status and over a 16-week period.

PRACTICE IMPLICATIONS

The self-management programme we applied took into account the local context and the ethnicity of the group. This process is worth further exploration and testing in different groups.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients

BACKGROUND

Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care.

AIM

The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings.

METHODOLOGY

Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants.

RESULTS

The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98).

CONCLUSION

Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.

Assessment of the proximal femoral morphology using plain radiograph-can it predict the bone quality?

We evaluated the relationship between the radiological indices that assessed the proximal femoral morphology and the degree of osteoporosis in 45 Chinese cadaveric femora. Canal-calcar ratio, canal flare index, morphological cortical index, and canal bone ratio were determined in the plain anteroposterior radiographs. Canal bone ratio is the ratio between the endosteal and outer diameters of the proximal femur at 10 cm below the lesser trochanter. Bone mineral density of the proximal femora was measured with dual-energy x-ray absorptiometry, and T score that depicted the degree of osteoporosis was determined. Canal bone ratio showed a strong correlation with the T score (r = -0.71, P < .001) and the best overall performance in diagnosing osteoporosis with receiver operating characteristic curve analysis. The proximal femur was likely to be osteoporotic if the canal bone ratio was 0.49 or higher.

Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore

BACKGROUND

To investigate the prevalence, socio-cultural and psychosocial risk factors for perinatal depression in Singaporean women.

METHOD

A prospective cohort of 559 women was interviewed antenatally and at six weeks' postpartum at a tertiary hospital. Women were interviewed for diagnosis of depression using a two-stage design, with a screening questionnaire and diagnostic interview.

RESULTS

Postnatally, a negative confinement experience was associated with depression. Other independent factors included poor emotional support, a past history of depression, unplanned pregnancy and perceived potential conflicts with relatives over childcare antenatally and dissatisfaction, poor instrumental support postnatally. The prevalence of depression antenatally and postnatally was 12.2% and 6.8%, respectively.

LIMITATIONS

Measures of satisfaction with social support were based on self-report; there were high dropout rates at six weeks' postpartum; and other modulating social factors such as pre-existing interpersonal conflicts were not studied.

CONCLUSIONS

Perinatal depression in Singaporean women is common. Contrary to expectations, a negative 'confinement' experience is a significant risk factor for postnatal depression, and is not universally welcomed by women. Depression is modulated by dissimilar sets of psychosocial factors antenatally and postnatally.

Residual posterior femoral condyle osteophyte affects the flexion range after total knee replacement

We followed up 92 patients with total knee replacement and a pre-operative knee flexion of at least 90 degrees . The patients were followed up regularly at 3 months, 6 months and 1 year. The outcome measured was the amount of maximum passive knee flexion at the end of 1 year after replacement. The potential factors affecting the final flexion range were investigated. After regression analysis, apart from pre-operative knee flexion (p<0.001), the most significant independent surgical factors that predict the amount of post-operative flexion were presence of residual posterior femoral condyle osteophyte (p=0.046) and overstuffing the patella by more than 2 mm during resurfacing of the patella (p<0.001).

Intraobserver errors in obtaining visually selected anatomic landmarks during registration process in nonimage-based navigation-assisted total knee arthroplasty: a cadaveric experiment

This study investigated the intraobserver errors in obtaining visually selected anatomic landmarks that were used in registration process in a nonimage-based computer-assisted total knee replacement (TKR) system. The landmarks studied were center of distal femur, medial and lateral femoral epicondyle, center of proximal tibia, medial malleolus, and lateral malleolus. Repeated registration in the above sequence was done for 100 times by a single surgeon. The maximum combined errors in the mechanical axis of the lower limb were only 1.32 degrees (varus/valgus) in the coronal plane and 4.17 degrees (flexion/extension) in the sagittal plane. The maximum error in transepicondylar axis was 8.2 degrees. The errors using the visual selection of anatomic landmarks for the registration technique of bony landmarks in nonimage-based navigated TKR did not introduce significant error in the mechanical axis of the lower limb in the coronal plane. However, the error in the transepicondylar axis was significant in the "worst-case scenario."

Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty

PURPOSES

The importance of the femoral sagittal bowing on total knee arthroplasty is under-recognized. The bowing could lead to potential errors in positioning of the femoral component if it is ignored. We aimed to document the femoral sagittal bowing at different segments of the Chinese femur and to discuss the implications of this sagittal bowing on total knee arthroplasty.

METHODS

One hundred lateral radiographs of the entire lower limbs of 85 Chinese patients admitted for total knee arthroplasty were digitized. The radii of curvature of the intramedullary canal of the proximal, middle and distal one-third of the femora were measured.

RESULTS

The average age of the patients was 67.3 years. The radii of curvature of the proximal, middle and distal one-third of the femora were 1081.6, 926.2 and 715.1 mm, respectively. The distal one-third of the femora was significantly more bowed than the other parts of the femora (p<0.001). The distal femoral bowing was more profound in rheumatoid patients and in those with a short femur.

CONCLUSIONS

The lateral contour of the Chinese femur is like a hockey stick. This exaggerated sagittal bowing in the Chinese femur can affect the final sagittal position of the femoral component and has implications for the choice of implant design. In revision setting, a long and straight press-fit stem might either endanger the anterior cortex or deflect the femoral component to an abnormally extended position.

Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs

OBJECTIVES

The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs.

METHODS

A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs.

RESULTS

The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15-2.82] and waiting time (OR = 1.96, 95% CI 1.20-3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29-0.83). Satisfaction with doctor-patient interaction was not associated with CAM use. Being 'very satisfied' on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14-0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the 'chronic disease triad' (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45-6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14-0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07-3.31).

CONCLUSION

CAM use in Asian patients is prevalent and associated with the 'chronic disease triad' (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor-patient interaction.

Extensively coated femoral components in revision hip arthroplasty: follow-up study of 23 patients

PURPOSE

To review the outcome of revision hip arthroplasty using extensively coated femoral components.

METHODS

We reviewed the results of revision involving 24 extensively porous-coated cementless femoral components in 23 patients, whose mean age was 52.4 years (range, 28.0-79.0 years). Most revisions were performed for aseptic loosening of the previously cemented femoral component. All patients were followed up for a minimum period of 24.0 months (mean, 61.1 months).

RESULTS

Of the 24 femoral stems, 20 showed bone ingrowth, 3 showed stable fibrous ingrowth, and one was unstable because of deep infection. Intra-operative anterior femoral diaphyseal perforation occurred in 2 hips during the insertion of straight femoral components of 200 mm. Postoperative radiographs displayed marked cortical erosion in 3 other hips and cortical perforation in one.

CONCLUSION

The results from the use of extensively coated femoral components were promising. Nevertheless, anterior cortical perforations were also common, which may be related to more bowing of the femora among the Chinese patients. Caution must be exercised when inserting a long, straight, extensively coated femoral component.

Factors leading to blood transfusion among Chinese patients undergoing total knee replacements: a retrospective study

PURPOSE

To investigate the risk factors leading to blood transfusion among Chinese patients undergoing total knee replacement.

METHODS

From July 2001 to June 2002, a total of 128 primary total knee replacements were performed in 83 Chinese patients (38 unilateral and 45 one-stage sequential bilateral). No pharmaceutical prophylaxis against deep vein thrombosis was used. The risk factors leading to allogenic blood transfusion were analysed.

RESULTS

The important predictive factors for postoperative blood transfusion were preoperative haemoglobin level (p=0.005), intra-operative blood loss (p<0.001), and bilateral total knee replacements (p<0.001).

CONCLUSION

To reduce the need of allogenic blood transfusion, we suggest administering erythropoietin or iron supplements to increase the haemoglobin level for patients undergoing total knee replacement. Routine use of intra-operative blood salvage can be considered for patients undergoing one-stage bilateral total knee replacement. Use of a postoperative blood salvage system is recommended for surgeries that may result in major intra-operative blood loss.