Tosan Okoro

Coracoid impingement syndrome: a literature review

Coracoid impingement syndrome is a less common cause of shoulder pain. Symptoms are presumed to occur when the subscapularis tendon impinges between the coracoid and lesser tuberosity of the humerus. Coracoid impingement should be included in the differential diagnosis when evaluating a patient with activity-related anterior shoulder pain. It is not thought to be as common as subacromial impingement, and the possibility of the coexistence of the two conditions must be taken into consideration before treatment of either as an isolated process. If nonoperative treatment fails to relieve symptoms, surgical decompression can be offered as an option.

Tumor necrosis alpha-blocking agent (etanercept): a triple blind randomized controlled trial of its use in treatment of sciatica.

Study Design Triple blind randomized controlled study. Objective To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation. Summary of Background Data Etanercept is a selective competitor of tumor necrosis factor-α which is a proinflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease. Methods Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on magnetic resonance imaging scan. Exclusions were previous back surgery, spinal stenosis and any contraindications to the use of etanercept such as immunosuppression. The patient, the injector, and assessor were blinded to the agent being used. Follow-up was at 6 weeks and 3 months posttreatment. Oswestry disability index and visual analog scores were among the assessment criteria. Results Fifteen patients were recruited in a 4 years period with a 3 months follow-up of 80%. The etanercept group had 8 patients whereas the placebo group had 7. The average Oswestry disability index for the etanercept group preintervention was higher than that in the placebo group (53.6 vs. 50.4) and this remained the same after 6 weeks (46.1 vs. 31.2) and 3 months of follow-up (37 vs. 35). Visual analog score was also higher in the etanercept group versus placebo; preinjection (8.6 vs. 7.4), 6 weeks (5.0 vs. 3.8), and 3 months (4.8 vs. 4.5). Conclusions Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of etanercept over placebo in the pharmacologic treatment of sciatica.

An appraisal of rehabilitation regimes used for improving functional outcome after total hip replacement surgery

This study aimed to systematically review the literature with regards to studies of rehabilitation programmes that have tried to improve function after total hip replacement (THR) surgery. 15 randomised controlled trials were identified of which 11 were centre-based, 2 were home based and 2 were trials comparing home and centre based interventions. The use of a progressive resistance training (PRT) programme led to significant improvement in muscle strength and function if the intervention was carried out early (< 1 month following surgery) in a centre (6/11 centre-based studies used PRT), or late (> 1 month following surgery) in a home based setting (2/2 home based studies used PRT). In direct comparison, there was no difference in functional measures between home and centre based programmes (2 studies), with PRT not included in the regimes prescribed. A limitation of the majority of these intervention studies was the short period of follow up. Centre based program delivery is expensive as high costs are associated with supervision, facility provision, and transport of patients. Early interventions are important to counteract the deficit in muscle strength in the affected limb, as well as persistent atrophy that exists around the affected hip at 2 years post-operatively. Studies of early home-based regimes featuring PRT with long term follow up are needed to address the problems currently associated with rehabilitation following THR.

The prediction of outcome in somatised patients undergoing elective lumbar surgery

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months. Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.

A short report comparing outcomes between L4/L5 and L5/S1 single-level discectomy surgery.

Study Design Prospective cohort study. Objective To assess whether there is a difference in outcome between single-level discectomy at L4/L5 and L5/S1. Summary of Background Data There is sound biomechanical reasoning to suspect a difference between spinal levels. The L4/L5 disc is more susceptible to axial torsion and is the most common site of lumbar instability. The L5/S1 motion segment is protected from torsional strain by extensive iliolumbar ligaments but is more exposed to axial compressive forces. The available literature does not include studies with preoperative standard outcome measures. Methods Prospectively gathered data from a single center. The outcome measures were the Oswestry disability index, subjective walking distance, modified somatic perception, modified Zung depression index, low back outcome score, and visual analog score. Comparisons between L4/L5 and L5/S1 levels were made with these outcome measures using the Student t test. Results Seventy-seven L5/S1 and 53 L4/L5 discectomies were performed. There were no clinically significant differences. Preoperative walking distance for L5/S1 patients was longer than at L4/L5 (455 m vs. 278 m; P=0.027). At 6 months a difference also exists with the low back outcome score [47.11 (L4/L5) vs. 39.47 (L5/S1); P=0.0229]. After 12 months at L5/S1, men had a better Oswestry disability index score than women (17% vs. 32%; P=0.038). Across all other parameters, no significant difference was found to exist between the 2 groups. There was no difference in the recurrence rate or reoperation rate. Conclusions This is the first study comparing a discectomy outcome at L4/L5 and L5/S1 with complete preoperative data. No significant difference exists between the 2 levels in terms of postoperative outcome. Surgical procedures such as fusion or arthroplasty should not be carried out synchronous with primary discectomy for radiculopathy. The lack of a difference between L4/L5 and L5/S1 reinforces the fact that the mechanical environment does not affect outcome and should not influence treatment.

Pigmented villonodular synovitis of the talonavicular joint: A case report and review of the literature

Pigmented villonodular synovitis (PVNS) is a locally aggressive synovial proliferative disorder of unknown aetiology affecting the linings of joints, tendon sheaths, and bursae. A 22-year-old female patient presented with a 3-year history of an increasingly painful swelling on the dorsum of her right foot. Examination revealed a 4 cm x 2 cm swelling that was fluctuant, tender on palpation, unattached to overlying skin and partially mobile. A firm, pedunculated intra-articular lesion from the talonavicular joint was removed at surgery. Histology revealed a nodular lesion of stromal cells and numerous giant cells with villous architecture as well as abundant haemosiderin deposition with foamy macrophages (in keeping with PVNS). The patient is currently under review by the orthopaedic oncology team. Talonavicular joint PVNS is rare. MRI scanning is the optimum investigation. Complete excision is necessary to minimise high risk of recurrence.

Outcome of gastroplasty and gastric bypass in a single centre in the UK

BackgroundMorbid obesity is defined as BMI>40 kg/m2. It affects 124,000 men and 412,000 women in England and Wales (NICE, July 2002). According to NICE guidelines, Bariatric surgery is indicated if the treatments for obesity such as exercise, diet and drugs fail. Procedures include laparoscopic gastric banding (LGB), vertical banded gastroplasty (VBG), and Gastric Bypass (GB).AimsThe aim of this audit was to determine if NICE guidelines on the use of Bariatric surgery in the Manor Hospital, Walsall was being adhered to. Secondary aims were also to establish if Bariatric surgery is achieving its goal in the long-term and if weight reduction is being maintained in this group of patients.MethodsA retrospective cohort study was carried out on patients who underwent Bariatric surgery between 1990 and 2004. Retrieved records were scrutinised and the following parameters were collated: pre-operative morbidities, intra and post-operative complication rates and weight reduction on follow-up.Results129 patients were operated on in the 14 year period. For VBG, 40 out of 105 patients had weight gain by the 5th follow-up visit. This compared with 5 out of 18 patients after the same timescale for the GB group and 1 out of 6 in the LGB group. The most common post-operative complication was stenosis (28% of VBG group).ConclusionBariatric surgery is relatively safe as an intervention for morbid obesity. Weight loss however is not maintained in the long term. VBG and LGB are short term interventions. Further research is required to look into the merits of gastric bypass surgery.

An assessment of the impact of behavioural cognitions on function in patients partaking in a trial of early home-based progressive resistance training after total hip replacement surgery

Abstract Background: Control cognitions have been directly related to positive engagement with rehabilitation regimes. The impact of such cognitions on recovery following surgery is not well understood. Purpose: To assess whether perceived control cognitions predict function 9–12 months following total hip replacement (THR). Methods: Prospective cohort study performed as part of a randomised controlled trial. Behavioural cognitions (BC) (recovery locus of control (RLOC); perceived external behavioural control (PEBC))) and subjective functional outcome measures (Oxford hip score (OHS) and a reduced version of the Western Ontario and McMasters University Osteoarthritis Function scale (rWOMAC PF)) were administered pre-operatively and up to 12 months post-operatively to 50 patients randomised to home-based progressive resistance training (N = 26) or standard rehabilitation (N = 24), post-THR. Regression analysis investigated variance in functional scores. Results: Group randomisation had no effect on BC. RLOC and OHS (6 months) correlated significantly with 12-month OHS, with 6-month OHS predicting 62.3% of the variance in 12-month OHS. 12-month rWOMAC PF was determined by each of its three previous assessments (pre-operative 8.8%, 6 weeks 17.8% and 6 months 67.3%). Variance in functional gain at 12 months (OHS and rWOMAC PF) was explained by pre-operative OHS and rWOMAC PF (63.7% and 63.8%, respectively). Conclusions: BC had no impact on functional outcome in this population. Subjectively assessed function at 12 months, as well as the levels of functional gain over time, was best explained by the patients’ earlier functional status. Implications for Rehabilitation It is important to assess psychological factors such as poor pre-operative mental health and pain catastrophising in patients undergoing joint replacement surgery as these factors have an adverse effect on subjective patient outcomes. Pre-operative behavioural cognitions appear to have no impact on subjective functional outcome at 12 months post-THR. The pre-existing functional status of the patient appears to be most predictive of subjective function at 12 months post-THR, implying that perhaps earlier surgery may be optimal before the onset of a decline in function.

The effects of sex, parity and maternal age on birth weights in a specialist hospital setting in Nigeria

This study looked at the combined effects of maternal age, fetal sex and parity in a specialist hospital setting and compared it with already published figures obtained from public health-care data in Nigeria. The results show a relationship exists with bivariate analysis between these variables and birth weight, but with multivariate analysis the relationship proves to be spurious. Socio-economic status and maternal health were felt to be the most important considerations within the specialist hospital setting, as patients who attend are more likely to be of high socio-economic status and therefore on a higher income and better educated. This has a beneficial impact on maternal health and a positive outcome on birth weight.

The efficacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: A review

Introduction Standard physiotherapy rehabilitation fails to restore normal levels of muscle mass, strength and physical function in patients following elective total hip arthroplasty for osteoarthritis. Consequently, more intense forms of exercise rehabilitation have been advocated for these patients. The aim of this article was to review the controlled trials that have evaluated post-total-hip-arthroplasty exercise interventions aimed at improving function. Materials and methods The electronic databases MEDLINE and CINAHL were searched using the following terms: �total hip arthroplasty/replacement�, �exercise�, �rehabilitation� and �function�. This search was expanded by hand-checking the reference lists of the studies and reviews identified by electronic scanning. Results Thirteen appropriate studies (18 papers) were identified, comprising 8 �early� intervention studies (<5 weeks from surgery) and 5 �delayed� intervention studies. Conclusion The studies reviewed suggest that centre-based, but not home-based, exercise rehabilitation are effective in restoring muscle mass, strength and function in total hip arthroplasty patients during the immediate post-surgery phase, and that the efficacy of the centre-based interventions is most likely due to higher training intensity that is facilitated by supervision and access to specialised equipment and facilities. When commencement of training is delayed, however, both home- and centre-based training programs provide significant improvements in patient strength and function.