Montserrat Núñez

Total knee replacement and health-related quality of life: Factors influencing long-term outcomes

OBJECTIVE To evaluate health-related quality of life (HRQOL) in patients with osteoarthritis undergoing total knee replacement (TKR); identify the influence of sociodemographic, clinical, intraoperative, and postoperative variables on HRQOL; and determine patient perceptions at 7 years. METHODS We conducted a prospective study with 7 years of followup. HRQOL measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and Short Form 36 [SF-36]); sociodemographic, clinical, intraoperative, inpatient, and postoperative data; patient perceptions of TKR outcomes; and physical activity at 7 years were determined. Associations were analyzed using linear regression models. RESULTS Of 146 eligible patients, 112 (86 women, mean age 67.3 years) completed followup data. There were significant differences between pre- and postoperative WOMAC pain, stiffness, and function scores (P < 0.001). Variables retained in each of the models explained 14-32% (adjusted R(2)) of variability of the WOMAC dimensions. Obesity and postdischarge complications were associated with worse scores in all WOMAC dimensions (P < 0.05). Eighty-six percent of patients were satisfied with TKR, 80% would undergo the operation again, and 56% did regular physical activity and had better WOMAC scores (P < 0.05, except for stiffness [not significant]). Mean +/- SD SF-36 scores for men and women at 7 years were 55.1 +/- 27.1 and 39.5 +/- 22.9 for physical function, 71.2 +/- 36.5 and 51.5 +/- 42.7 for physical role, 66.2 +/- 26 and 55.6 +/- 28.9 for bodily pain, and 60.7 +/- 17.1 and 50.7 +/- 21.2 for general health, respectively. CONCLUSION WOMAC dimension scores, especially pain, significantly improved at 7 years and were negatively influenced by obesity and postdischarge complications. HRQOL measures may help identify an increased risk of negative outcomes after TKR.

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: A cross-sectional analysis in a tertiary hospital

BACKGROUND Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care. AIM To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality. DESIGN Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital. METHODS Adoption of an operational definition of chronic disorder based on the WHO. MAIN OUTCOME co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality. RESULTS Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 +/- 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 +/- 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity (P < 0.001) and mortality (P < 0.001). CONCLUSION The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

Lipoprotein Lipase Activity in Developing Rat Brain Areas

Lipoprotein lipase (LPL) is a key extracellular enzyme that enables tissue to import fatty acids from triacylglyceride-rich lipoproteins. LPL is present in most tissues of the body, but in the brain its functional significance remains unclear. Lipids constitute the main components of myelin and undergo significant changes during maturation. However, nothing is known of the postnatal evolution of LPL activity in the brain areas during postnatal development. Here we found that LPL activity is relatively high in the newborn brain and peaks between the 5th and the 10th days after birth, reaching activities 5 times higher than in the adult brain. In all the areas studied (olfactory bulbs, cortex, thalamus, cerebellum, hippocampus, striatum, brain-stem and spinal cord) LPL also increases sharply during postnatal development. Hippocampus shows the highest LPL activity levels, which are between 5 and 11 times higher than in the other regions. The significance of these high LPL activity levels is discussed.

Histologic Grade and CD44 Are Independent Predictors of Axillary Lymph Node Invasion in Early (T1) Breast Cancer

Background: The detection rate of small, often subclinical breast cancers is increasing in affluent societies. Concomitantly, the demand for more conservative surgical approaches is also increasing among the women affected. Predictors of the absence of nodal invasion would spare many patients with early breast cancer the risks, costs and side effects of lymphadenectomy, and thus treatment with curative intent would be applied using really minimal surgery. Patients and Methods: We reviewed the records of 135 patients with unifocal invasive breast cancers, 2 cm or less in diameter, operated upon at ‘Fundación Tejerina-Centro de Patología de la Mama’, Madrid, Spain, between January 1993 and December 1997. Full clinical and pathological data were available for all of them, together with estrogen and progesterone receptor determinations, which had been routinely performed in 134 and 133 cases, respectively. Additionally, Ki67, c-erb-B2, p53, nm23, HSP27, HSP60 and CD44std expression was studied on archival, paraffin-embedded tumor material from these same patients by means of immunohistochemistry. Results: In the univariate analysis, only histologic grade 3 (p < 0.001), Ki67 expression in more than 10% of tumor cells (p = 0.005) and CD44std negativity (p = 0.004) were significantly associated with axillary node involvement. In multivariate analysis, histologic grade 3 and CD44std negativity retained statistical significance, and thus emerged as independent predictors of nodal invasion. The combination of both, furthermore, identified a subgroup in which the axillary nodes were invariably affected. Conclusion: Some pathological and molecular features of small breast cancers were able to predict nodal metastasis significantly. However, none, either alone nor combined, was able to exclude axillary node invasion completely.

Health-Related Quality of Life and Direct Costs in Patients With Anterior Cruciate Ligament Injury: Single-Bundle Versus Double-Bundle Reconstruction in a Low-Demand Cohort—A Randomized Trial With 2 Years of Follow-up

PURPOSE To evaluate health-related quality of life (HRQL) in patients undergoing anterior cruciate ligament (ACL) reconstructive surgery by use of 2 procedures and to estimate the direct costs of surgery. METHODS We performed a 2-year randomized, prospective intervention study of 2 surgical ACL reconstruction techniques (anatomic single bundle [SB] v double bundle [DB]). Fifty-five consecutive outpatients, with a mean age of 30.88 years, were randomized to SB or DB ACL reconstruction. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to measure HRQL (primary outcome). ACL injuries were assessed by the International Knee Documentation Committee (IKDC) score (secondary outcome). The use of medical resources and their costs were evaluated. RESULTS We included 52 patients in the final analyses (23 in the SB group and 29 in the DB group). At baseline, there were no significant differences in study variables. At 2 years of follow-up, there were no significant differences in SF-36 and IKDC scores between groups. However, compared with baseline, the SF-36 physical function, physical role, bodily pain, social function, and emotional role scores were significantly better in the SB group (P < .05), whereas only the physical function dimension score was better in the DB group (P = .047). IKDC scores at 2 years improved significantly in the SB group (P < .001) and DB group (P = .004) compared with baseline. There was a significant correlation between the SF-36 physical function, physical role, and bodily pain dimensions and the IKDC score at 2 years (P < .05). The costs were € 3,251 for the SB group and € 4,172 for the DB group. CONCLUSIONS HRQL and medical outcomes were similar between SB and DB ACL reconstruction techniques, 2 years after surgery. However, the SB technique was more cost-effective.

Knee osteoarthritis: interpretation variability of radiological signs

Abstract<The aim of this study was (1) to determine the variability in detecting radiological signs of knee osteoarthritis (OA) between an orthopaedics specialist, a fourth-year resident in the speciality and a recently qualified doctor and (2) to determine which of the existing criteria show the greatest variability when used by the three participants to detect the degree of evolution of the pathology. This observational study included radiographs of 95 patients with knee pain. Osteophytes, narrowing of joint space (excluding inter-osteophyte bridges) subchondral sclerosis, subchondral cysts, collapse of the central joint cortical bone and lateral deformity, according to the criteria of Kellgren and Lawrence, modified by Kallman et al. were evaluated. Anteroposterior radiographs were used. Knees that had undergone previous surgery were excluded. Cohen’s kappa index was used to calculate the degree of agreement between observers. The concordance analysis showed a low level of agreement among the three observers of the radiological variables with a maximum of 50% in some parameters. The authors discuss the possible causes of this low level of agreement. The low degree of agreement of 50% among the three observers is in line with previous reports and suggests that better training of observers is necessary and that the use of any classification is problematic.

Meniscal repair using the FasT-Fix device in patients with chronic meniscal lesions

The aim of this prospective study was to evaluate meniscal suturing using the FasT-Fix device for chronic meniscal tears. This procedure was carried out on 25 patients between 2006 and 2007. Nineteen patients were male and the median age was 31 (14–47) years. The median waiting time to surgery was 27 (6–80) months and the median follow-up was 20 (14–29) months. Eleven patients (44%) required reconstruction of an associated anterior cruciate ligament (ACL) injury. 20 patients (80%) showed medial meniscus tears. All tears were located in the red zone or red–white zone. According to Barett’s criteria, meniscal tear healing was achieved in 21 patients (84%). Lysholm and Tegner scale scores improved from 60 (47–77) preoperatively to 95 (58–100) postoperatively and from 3 (2–6) preoperatively to 6 (3–9) postoperatively, respectively. There were no neurovascular complications. Revision surgery was necessary in one patient, in whom a partial meniscectomy was performed. The results obtained suggest that chronic meniscal tears in the zones described can be healed.

Prevalence of knee osteoarthritis and analysis of pain, rigidity, and functional incapacity.

Knee osteoarthritis is one of the most prevalent health problems in our society. It accounts for 10% of all primary care visits in general medicine and 30% of outpatient appointments. The objectives of this cross-sectional descriptive study of 100 patients suffering from gonarthritis were to assess pain, functional capacity, and joint damage in patients diagnosed with knee osteoarthritis, as well as the possible repercussions for subsequent surgical treatment. Sociodemographic, clinical, and radiological data were collected, and pain and functional capacity were evaluated by using the Western Ontario and McMaster Universities Osteoarthritis Index. The majority (71) of patients were women, mean age 71 years (SD=7.84), of low educational (66%) and financial (89%) status, with mean disease duration of 11.8 years. Of the total, 87% presented with comorbidity. Radiographs revealed a varus malalignment in 31% of patients and a valgus malalignment in 17%, with bone collapse in 39% of these. The factors that most affect surgery and subsequent rehabilitation are closely linked to social status, the general state of the patient, and the radiological severity of gonarthritis. Most of the patients were obese and suffered from comorbid conditions, and some presented with psychopathology. These factors may influence surgery, and thus improvements in primary care should be made as a way of offering a simpler and more effective treatment for gonarthritis.

Total Knee Arthroplasty in the Context of Severe and Morbid Obesity in Adults

Medical treatment for knee osteoarthritis proves insufficient in a considerable number of patients, who thus require surgical intervention, with arthroplasty being one of the most common procedures. The rate of knee replacement is consequently higher in the obese population. Obese patients who undergo knee arthroplasty face a larger number of associated comorbidities than do non-obese individuals, and this greater comorbidity can lead to more postoperative complications and worse outcomes. Given that obesity defined according to BMI would cover a large proportion of the population (a quarter of adults have a BMI > 30 kg/m 2 in some western societies) attention has focused on which sub- groups might present the greatest problems. It appears that morbidly obese patients (BMI > 40 kg/m 2 ) are most at risk of complications. Some authors suggest the need to study more precise methods for component alignment in these patients. The use of an intramedullary guide made surgical intervention easier and was associated with a significantly shorter tourniquet time. Although the studies refer greater surgical difficulties on the basis of their BMI, the difficulty of surgery will ultimately depend on the morphology of the knee. The factors associated with a worse postoperative WOMAC score in severely and morbidly obese patients were the number of comorbidities, infrapatellar anthropometric index below percentile 75, greater intraoperative difficulty and the number of postoperative complications. When starting from a comparable preoperative status, severely and morbidly obese patients show a similar improvement than other patients.

A therapeutic education and functional readaptation program for Spanish patients with musculoskeletal chronic diseases

Chronic musculoskeletal diseases are one of the main reasons for health consultations. They cause pain and disability and reduce the quality of life, producing restrictions on activity and considerable economic and social costs [1, 2]. Musculoskeletal diseases are usually chronic, meaning that informing patients and their families of all factors that may lead to improvements, together with their participation in the control and evolution of the disease, is essential [3, 4]. Therapeutic patient education, provided by trained health professionals, may fulfil these objectives. The therapy should be based on a set of educational activities organized to provide the patient with information on their disease and the competence (knowledge, skills and attitudes) to manage living with a chronic disease. The educational contents should be adjusted to the patients’ needs [3–5] and be designed to reorient them towards healthy lifestyles. Active learning is a dynamic system based on the idea that adults can learn autonomously, using their own experience to solve problems, and that knowledge must be reinforced by practice to reach the competence necessary to apply that knowledge practically [6]. Patients, starting with the consequences of their disease process and their own needs, interests and expectations, learn in two ways: firstly, receiving knowledge from the therapist on the relationship between the aspects of their disease and the available therapeutic resources and, secondly, experiencing these relationships themselves, which permits the acquisition of practical knowledge applicable to the solution of diseasespecific problems. This enables patients to assume at least part of the responsibility for treating their own disease autonomously [7]. Within the framework of social cognitive theory and planned change strategies, in the Rheumatology Department of the Hospital Clinic of Barcelona (Spain), a tertiary care center, we began to implement a program of Therapeutic Education and Functional Readaptation (TEFR) using active learning [8, 9]. Although this type of program has been implemented in other countries [3], the project described in this article is, to our knowledge, the first specific therapeutic education program for patients with musculoskeletal diseases in Spain. The aims of this study were to assess whether a TEFR program could reduce disability and pain and increase competence in disease self-management in patients with musculoskeletal diseases and to determine the use of health resources and the costs derived.