Moderate to Severe Osteoarthritis: What is the Economic Burden for Patients and the Health Care System? Insights from the "PONOS" Study.

OBJECTIVE: To assess the economic burden of moderate to severe osteoarthritis (OA) management for patients and the health care system in Greece. DESIGN: A noninterventional, cross-sectional, prospective, epidemiological analysis of data from the medical records of patients with moderate to severe OA, recruited in a single visit from 9 sites in Greece. Outcomes included health care resource use (direct/indirect costs) associated with this patient population. RESULTS: A total of 164 patients were included in the analysis: mean age was 70.5 years, and the majority of participants were females (78.7%). The presence of comorbidities was reported by 87.2% of patients, with hypertension being the most frequently reported (53.7%). Paracetamol was the most commonly used analgesic treatment (96%), followed by systemic nonsteroidal anti-inflammatory drugs (NSAIDs) (75%) and opioids (50%). The mean overall annual direct costs per patient was estimated at 1,675.3€, with approximately half incurred by the National Health Insurance Fund, whereas the mean overall annual indirect cost (absenteeism of patients and informal caregivers) was estimated at 3,501.4€. Joint replacement (JR) procedures and paid care were the major drivers of annual direct costs in this patient population (4,326.3€ and 9,360.0€, respectively). CONCLUSIONS: This real-world analysis of direct and indirect costs confirmed the substantial economic burden imposed by moderate to severe OA to the health care system and the patients. Our findings emphasize the need for interventions to enhance disease management, to improve patients' health outcomes and reduce the global burden of OA on society.

The impact of moderate to severe osteoarthritis on the physical performance and quality of life: a cross-sectional study in Greek patients (PONOS study).

BACKGROUND: Osteoarthritis (OA) represents a leading cause of disability with limited data available for the Greek patients. OBJECTIVES: To evaluate the impact of moderate to severe symptomatic hip/knee OA under treatment on physical performance and quality of life. METHODS: A non-interventional, cross-sectional, epidemiological study of patients with moderate/severe OA, recruited in a single visit from 9 expert sites in Athens, Greece. Assessments were based on commonly used outcome scales: the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EuroQol-5-Dimensions 3-levels questionnaire (EQ-5D-3L). RESULTS: One hundred sixty-four patients were included in the analysis. Most of the patients were females (78.7%), with a mean age of 70.5 ± 10.2 years. Comorbidities were reported by 87.2% of patients with hypertension being the most frequently reported (53.7%), followed by dyslipidemia (31.1%), obesity (24.4%) and diabetes mellitus (23.2%). Paracetamol was the most common treatment (96%), followed by NSAIDs (75%), opioids (50%) and locally applied medications (42.7%). Both hip and knee OA patients showed substantial deterioration in health-related quality of life (QoL) and health status as reflected by the HOOS/KOOS (Function in sport and recreation was the most impaired subscale, followed by Hip- or Knee-related QoL). The mean EQ-5D-3L index score was 0.396 ± 0.319 and the mean EQ-VAS score was 52.1 ± 1.9. When compared indirectly to the local population norms our OA population had worse QoL indices. CONCLUSION: Our findings suggest the functional disability and impaired QoL of Greek patients with moderate/severe hip/knee OA under treatment emphasizing the need for novel treatments that will reduce the burden of the disease.

The effect of radial osteotomy on the position of the posterior interosseous nerve.

The purpose of this study was to determine whether a radial shaft fracture would decrease the protection provided to the posterior interosseous nerve by the pronation maneuver during posterolateral exploration. The position of the nerve in 14 cadaveric elbows, before and after a radial osteotomy, was determined using CT scans in full supination and full pronation after injection of the nerve with radio-opaque dye. The angle formed by the olecranon, radial head and posterior interosseous nerve, and the distance between the nerve and the most lateral aspect of the radial head were measured.Pronation increased the distance between the lateral radial head and the nerve by a mean of 6.5 mm (range 3.6-10.7). After radial osteotomy, the mean increase was 4.2 mm (range 1.0-8.3), difference 2.3 mm (p = 0.044, 95% CI 0.10 to 3.33). The posterolateral approach requires additional care in the presence of a radial shaft fracture, but pronation is still beneficial.

The long-term results of a two-stage protocol for revision of an infected total knee replacement.

We report the long-term results of the management of neglected chronically infected total knee replacements with a two-stage re-implantation protocol. In 18 of 34 patients (53%) a resistant organism was isolated. All cases were treated by the same surgical team in a specialist centre and had a mean follow-up of 12.1 years (10 to 14). They were evaluated clinically and radiologically using the Knee Society Score (KSS) and the American Knee Society Roentgenographic scoring system, respectively. One patient died after eight years from an unrelated cause and two were lost to follow-up. Three patients (8.8%) developed a recurrent infection for which further surgery was required. The infection was eradicated successfully in 31 patients (91.1%). There was one case of aseptic loosening after 13 years. We found a significant improvement in the KSS at final follow-up (p < 0.001).

The Trabecular Metal Monoblock acetabular component in patients with high congenital hip dislocation: a prospective study.

Between November 1997 and December 2000 we performed 27 total hip replacements in 22 patients with high congenital dislocation of the hip using porous tantalum monoblock acetabular components implanted in the true acetabular bed. Clinical and radiological evaluation was performed at regular intervals for a mean of 10.2 years (8.5 to 12). The mean Harris Hip Score improved from 48.3 (15 to 65) pre-operatively to 89.5 (56 to 100) at the final follow-up. The mean Oxford Hip Score was 49.5 (35 to 59) pre-operatively and decreased to 21.2 (12 to 48) at one year and 15.2 (10 to 28) at final follow-up. Migration of the acetabular component was assessed with the EBRA software system. There was a mean migration of 0.68 mm (0.49 to 0.8) in the first year and a mean 0.89 mm (0.6 to 0.98) in the second year, after excluding one initial excessive migration. No revision was necessary for any reason, no acetabular component became loose, and no radiolucent lines were observed at the final follow-up. The porous tantalum monoblock acetabular component is an implant offering adequate initial stability in conjunction with a modulus of elasticity and porosity close to that of cancellous bone. It favours bone ingrowth, leading to good mid-term results.

Neurological outcome following early versus delayed lower cervical spine surgery.

PURPOSE: To determine whether the timing of surgery affects neurological outcome in patients with lower cervical spine trauma. METHODS: 29 patients with a fracture and 38 with a fracture-dislocation of C3 to C7 cervical vertebrae were treated operatively during the inclusive period January 1987 to December 2000. Surgery was performed as soon as the patient's medical condition allowed, within 72 hours in 31 and more than 72 hours after the injury in 36. RESULTS: Only patients with incomplete spinal cord injury had neurological improvement after surgery. There was no statistically significant difference in final neurological outcomes in patients having early as opposed to delayed surgery. CONCLUSION: Surgical intervention for cervical injuries is safe, as no postoperative neurological deterioration was recorded. Timing of surgery does not affect neurological outcome.

The development of bone metastases as the first sign of metastatic spread in patients with primary solid tumours.

The purpose of this retrospective study was to investigate the incidence of bone metastases as the first sign of metastatic spread in patients with primary solid malignant tumours. Between January 1987 and December 1998, we treated 867 patients suffering from primary solid malignant tumours. Their average age was 67 (range: 30-96) years and all were thoroughly investigated with a complete physical examination and laboratory tests as well as imaging studies and bone scans. No bone metastases were found at the time of the initial diagnosis, and the patients were then re-assessed every 6 months for the first 5 years and then once a year. We found that, regardless of treatment, bone metastases appeared in a certain number of patients and that after excluding patients with prostate cancer a bone metastasis was the first sign of "recurrence" in 1.3% of the patients with a known primary solid malignant tumour.

Long-term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures.

We retrospectively reviewed 84 patients who underwent internal fixation of an intracapsular femoral neck fracture. The mean age was 58 years and the time from injury to operative treatment was 5.3 days. The mean follow-up was 4.7 years (range, 2-8 years). At the latest follow-up, in the 46 patients with undisplaced (Garden I, II) fractures, nonunion occurred in two patients and avascular necrosis of the femoral head in nine. Six of these nine patients had a good or excellent result, one had a fair result, and two had a poor result. Of 35 patients with no sign of avascular necrosis, 32 patients had a good or excellent result, two a fair and one had a poor result. In the group of 38 patients with displaced (Garden III, IV) fractures, nonunion occurred in six patients and avascular necrosis of the femoral head in 15. Of these 15 patients, 10 had a good or excellent result, two had a fair result, and three had a poor result. Of 17 patients with no sign of avascular necrosis, 14 had an excellent result and three patients a poor result. Overall only five of the 24 patients who developed avascular necrosis of the femoral head had undergone total hip arthroplasty. Internal fixation remains a simple and safe, method of treatment for both undisplaced and displaced femoral neck fractures in middle-age patients. Despite the relatively high rate of avascular necrosis after internal fixation of femoral neck fractures, only a few of these patients (20%) required further surgical treatment in the follow-up period of this study.

Halo pin intracranial penetration and epidural abscess in a patient with a previous cranioplasty: case report and review of the literature.

STUDY DESIGN: Report of a patient with an epidural abscess after halo pin intracranial penetration at the site of a previous cranioplasty. OBJECTIVES: To report a rare case of intracranial penetration at the site of a previous cranioplasty associated with epidural abscess, and to discuss the diagnostic and therapeutic approach to its management. SUMMARY OF BACKGROUND DATA: The most serious complications associated with use of halo device occur when pins penetrate the inner table of the skull, resulting in cerebrospinal fluid leak and rarely in an intracranial abscess. However, no mention of intracranial halo pin penetration at the site of a previous cranioplasty was found in the literature. METHODS: A 64-year-old man with ankylosing spondylitis had a halo vest placed for management of a fracture dislocation through the C5-C6 intervertebral disc space associated with left C6 radiculopathy. One week later, the patient experienced fever and headache associated with pain, redness, and drainage at the site of the insertion of the left posterior pin. Computed tomography of the brain showed a 1.5-cm intracranial penetration of the halo pin through a previous cranioplasty of the temporal bone, associated with epidural abscess and cerebral edema in the left temporoparietal lobe. The pins and the halo vest were removed, the pin site was cleaned, and a Philadelphia cervical collar was applied. Staphylococcus epidermidis grew on the culture of drainage from the pin site. The patient started immediate intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 2 additional weeks. RESULTS: The patient had gradual improvement of his symptoms within the first 48 hours. At the latest follow-up visit, he had fully recovered and his fracture had healed. CONCLUSIONS: The halo device should not be used for patients with a previous cranioplasty, especially if the pins cannot be inserted at other safe areas of the skull. A thorough medical history and physical examination of the skull are important before the application of a halo device. Computed tomography of the skull may be necessary before elective halo application for patients with concomitant head trauma, confusion, or intoxication and for patients with a previous cranioplasty to ascertain the safest pin sites.

Evaluation of lumbar spine bone mineral density in the anteroposterior and lateral projections by dual-energy X-ray absorptiometry.

Dual-energy x-ray absorptiometry (DXA) is an established method for estimating bone mineral density (BMD) of the lumbar spine. In a prospective study, the sensitivity of BMD measurements between anteroposterior and lateral projections were evaluated in 204 postmenopausal women based on their DXA analysis. Patients were divided into two groups according to the absence or presence of lumbar scoliosis. Lateral projection DXA measurements were more sensitive than AP projection measurements for early detection of bone loss in postmenopausal women. Lateral projection DXA analysis is not recommended in spines with lumbar scoliosis.

Evaluation of pedicle screw position in thoracic and lumbar spine fixation using plain radiographs and computed tomography. A prospective study of 35 patients.

STUDY DESIGN: This was a prospective study of 35 consecutive patients in whom pedicle screw position was assessed after surgery, using lateral radiographs and computed tomography. OBJECTIVE: To evaluate the accuracy of plain radiographs and computed tomography in assessment of pedicle screw position. SUMMARY OF BACKGROUND DATA: Imaging techniques, such as postoperative anteroposterior and lateral plain radiographs and computed tomography, are currently the primary means of assessing pedicle screw placement. METHODS: Postoperative radiographs and computed tomographic scans were used to evaluate the position of 220 pedicle screws inserted in the spines of 35 consecutive patients who underwent thoracic and lumbar spine fusion and instrumentation. No recognized neurologic complication resulted from pedicle screw placement. Screw position was graded as in, out, or questionable. All observations were performed independently by three observers. The authors also analyzed the position of the screws according to the underlying spinal disease. RESULTS: More misplaced screws were clearly seen on computed tomographic scans than on plain radiographs; however, this difference was not statistically significant. Interobserver differences were not statistically significant. Intraobserver differences approached statistical significance when the results of the two test were compared. CONCLUSIONS: Although the accuracy of computed tomographic imaging is better than that of plain radiographs, the difference does not reach statistical significance. Postoperative use of plain radiographs remains a reliable method for evaluation of pedicle screw insertion in the absence of neurologic deficit.