Background

There is a 20% dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied postoperatively have been widespread. However, it is unclear what sort of information patients would want from such a tool, how it would affect their decision making process, and at what part of the pathway such a tool should be used.

Background

Knee replacement surgery is currently facing three dilemmas: a high dissatisfaction rate; increasing demand with financial constraints; and variation in utilisation. A patient centred approach, usually achieved through shared decision-making, has the potential to help address these dilemmas. However, such an approach requires an understanding of the factors involved in patient decision-making. This is the first study examining decision-making in knee replacements that includes patients at different stages of decision-making – this is critical when considering decision-making as a process. We base our findings in a theoretical model, proposed by Elwyn et al, that highlights the distinction between deliberation and decision-making, and propose modifications to this model specific to knee replacement decision-making.

Introduction and Aims: Use of non-steroidals (NSAIDs) and additional factors such as advanced age, anticoagulants and co-morbid diseases, commonly found in patients with arthritis, increases the risk of upper gastrointestinal (UGI) bleeding. Our aim was to assess the incidence of peri-operative UGI bleeding in patients having hip and knee replacements for arthritis.

Method: A single centre, retrospective study was conducted on 100 consecutive hip replacements and 100 consecutive knee replacements performed at Victoria Infirmary, Glasgow, between 1998 and 2000.

Results: The mean age was 74 (41–86). Sixty-three percent of our patients were female. Seventeen percent of the patients had a previous history of UGI problems, of which only 50% were on gastro-protective medication. Fifty-four percent of the patients were on NSAIDs and all patients received anticoagulants (78 aspirin, 122 clexane) peri-operatively. Nine patients (4.5%) had UGI bleeding in the post-operative period. Five patients had endoscopies, which revealed bleeding from gastric ulcers (three), duodenal ulcer (one) and barretts oesophagus (one). Four patients, who had one episode of UGI bleeding, did not have endoscopies. All the nine patients with UGI bleeding were patients who had been on NSAIDs and anticoagulants (six clexane, three aspirin). These nine patients were from the group of patients who were not on any gastro-protective medication. Five of these patients requiring a hospital stay of more than two weeks.

Conclusion: We believe that the incidence of UGI bleeding in patients undergoing hip and knee replacements is underestimated. We propose gastro protective agents in the peri-operative period for patients on NSAIDs.

Aim: To investigate the efficacy of the Insall tube realignment procedure when used to treat osteoarthrosis of the lateral facet of the patello-femoral joint. This procedure has not been reported before for this indication.

Methods: The operation is a quadricepsplasty that tilts the patella to enable it to articulate on its intact medial facet, decreasing the loading of the damaged lateral surface. An independent retrospective review was performed with clinical examinations and a score of pain and activity. The mean period of follow-up was 3.6 years with a minimum of one year.

Results: There were 43 operations in 30 patients (12 males), with a mean age of 54 years. The patients graded their overall pain relief and functional change as being good to excellent in 32 knees, unchanged in four knees and worse in seven knees. The overall pre- and postoperative pain scores for sitting, walking, running and stair climbing all showed improvements. Ten patients felt some quadriceps weakness on descending stairs, but only one was clinically weak. There was an increase in the number of patients with severe pain on kneeling. Three patients with unsuspected tibio-femoral degenerative change seen at surgery all had poor results.

Discussion: We recommend this relatively simple and effective operation for the surgical treatment of isolated lateral facet patello-femoral osteoarthritis.

A review of 77 neonates who presented with congenital talipes equinovarus over a seven-year period revealed an increase in the condition amongst babies born in the winter quarter. This finding was particularly apparent among the less severe cases of club-foot. Possible reasons for this seasonal variation are discussed.