53 research outputs found
Hybrid versus double bundle hamstring ACL reconstruction – a review of 626 cases
No full textObjectives: Since 2008, we have offered patients Hybrid ACL (hamstring plus LARS ligament) graft or double bundle hamstring graft. We allow the patients with Hybrid ACL to jog at 2 months and return to sports at 6 months. In comparison we allow the double bundle hamstring group to jog at 4 months and return to sports at 12 months. We considered the hybrid graft, due to its initial stiffness, would allow safe accelerated rehabilitation. Our primary aim was to establish whether Hybrid ACL graft has a higher failure rate compared to double bundle hamstring graft. Our secondary aim was to compare reoperation rates and clinic visit rates between the two groups. Methods: We performed a retrospective study of skeletally mature patients that underwent primary isolated ACL reconstruction by the senior author between 2008 and 2015 comparing double bundle hybrid ACL (DB Hyb), single bundle hybrid ACL (SB Hyb), and double bundle hamstring ACL (DB Ham) graft types. Charts were reviewed to assess reoperation rate, complication rate, re-rupture rate, and number of clinic visits. Graft tensioning positions, remnant sparing percentage, and concurrent meniscal procedures were reviewed as well. Results: 626 patients met the inclusion criteria. DB Hyb group had more males (77%) and a longer mean follow up (5.6 years) than the other two groups. Rerupture rates were 1.2% per year for DB hyb, 0.5% per year for SB Hyb, and 0.8% per year for DB Ham group. DB Hyb group trended towards a higher reoperation rate for arthrofibrosis compared to DB Ham (9.4% vs 4.7%, p-value 0.054). There was no difference in number of clinic visits between the 3 groups. Conclusion: Double bundle hybrid ACL group was associated with higher rates of arthrofibrosis surgery but equivalent rates of failure. </jats:sec
Arthroscopic assessment of patellofemoral tracking predicts patellar instability
No full textObjectives: Surgical management of patellar instability includes proximal realignment procedure such as MPFL reconstruction. The decision to add a distal realignment procedure of tibial tubercle transfer is based on severity of patellar instability judged on either TTTG distance or arthroscopic patellofemoral tracking. We set out to validate our use of arthroscopic patellofemoral tracking for patellar instability management algorithm by analyzing its reproducibility and whether it correlates with patellar instability. Methods: A prospective observational study was carried out at Perth Orthopaedic and Sports Medicine Centre. Patient clinical presentations were divided into three groups - patellofemoral instability, patellofemoral pain, and no patellofemoral symptoms. Standard technique included low flow arthroscopy with single anterolateral viewing portal. Height of the fluid bag and presence of a knee holder was recorded. Knee flexion angle where patella first centrally engages in the trochlear groove was defined as Patellofemoral Congruent Angle (PCA). PCA was estimated by the primary surgeon and the angle was confirmed using a sterile goniometer. A second surgeon, blinded to the initial assessment, then repeated the measurements. Surgeon estimation error, interobserver reliability, and correlation with clinical presentation was analysed. Results: 57 knees were assessed for interobserver reliability. Intra-class correlation was 0.994 between surgeon’s estimate and goniometer reading. Intra-class correlation was 0.992 between the two surgeon’s readings suggesting a very high correlation. 157 patients had their PCA recorded and compared with their diagnosis. Mean PCA was 40 degrees in normal patients, and 118 degrees in patellar instability (p-value <0.001). Conclusion: Arthroscopic assessment of patellofemoral tracking is reproducible and correlates with patellar instability. A cut-off value of 40 degrees is recommended to differentiate normal tracking from abnormal. </jats:sec
Healthy markets - healthy people/ : reforming health care in Cambodia
No full textThe Cambodian experience shows that, under conditions of extreme poverty, market-based reforms have limited positive impact on health care delivery. Comparing three models of health policy making, this study underlines the critical importance of equity in service provision, government investment in health, and understanding the cultural determinates of demand
The hybrid anterior cruciate ligament reconstruction surgical technique does permit an accelerated early functional recovery and return to sport.
No full textObjectives: A major reason for undergoing anterior cruciate ligament reconstruction (ACLR) for patients is to return to high demand activity and sport. Published literature supports a return to sport (RTS) at 6-12 months, though the recovery of lower limb strength and functional symmetry is critical and is linked with a patient’s ability to RTS, as well as reducing the incidence of secondary re-tear. This study aimed to compare clinical outcomes and RTS between patients undergoing ACLR utilizing a hamstring graft and those undergoing a hybrid technique which augments the hamstring graft with a synthetic LARS ligament. Methods: A non-randomized study design was used to compare clinical outcomes at 10-12 months post-surgery, in 82 patients undergoing conventional ACLR via a hamstring graft (HG) and 35 patients undergoing a hybrid hamstring/LARS graft (HLG). All patients were assessed using a range of patient-reported outcome (PRO) scores (IKDC, KOOS, Cinncinati, Lysholm, SF-36, Tegner, Noyes, Global Rating of Change – GRC). Limb symmetry indices (LSIs) presenting the operated limb as a percentage of the unaffected limb were calculated for several strength/functional assessments (peak isokinetic quadriceps and hamstring strength, the single, triple and triple crossover hop for distance, and the 6 m timed hop). Results: There were no group differences (p>0.05) in patient demographics and the majority of PROs. The HLG group perceived themselves to be significantly ‘more recovered’ (p=0.046) on the GRC scale (HLG = 3.2, HG = 2.2), and also reported a significantly greater (p=0.004) Tegner score (HLG = 7.2, HG = 5.9). For the HG group, 62% of patients had returned to Noyes Level 1 or 2 activities, versus 80% of the HLG group. For the Tegner score, 57% of patients reported a score >6, versus 77% of the HLG group. There were no significant differences (p>0.05) in LSIs between groups for the strength and functional hop tests. However, the HLG group demonstrated a mean LSI above 90% for all four hop tests, while all four were below 90% in the HG group. Both groups demonstrated mean hamstring strength LSIs above 90%, while the quadriceps strength LSI was 81.9% and 85.8% for the HG and HLG groups, respectively. Conclusion: Patients in the HLG group perceived themselves to be more recovered, and had returned to a higher level of activity/sport, compared with the HG group. While not significant, the HLG group did demonstrate more favorable functional hop and quadriceps strength LSIs, which has been linked with the ability to RTS and the incidence of ACL re-tear. A larger patient cohort and follow-up is required to observe long-term outcomes. </jats:sec
Arthroscopic assessment of patellofemoral tracking predicts patellar instability
No full textObjectives: Surgical management of patellar instability includes proximal realignment procedure such as MPFL reconstruction. The decision to add a distal realignment procedure of tibial tubercle transfer is based on severity of patellar instability judged on either TTTG distance or arthroscopic patellofemoral tracking. We set out to validate our use of arthroscopic patellofemoral tracking for patellar instability management algorithm by analyzing its reproducibility and whether it correlates with patellar instability. Methods: A prospective observational study was carried out at Perth Orthopaedic and Sports Medicine Centre. Patient clinical presentations were divided into three groups - patellofemoral instability, patellofemoral pain, and no patellofemoral symptoms. Standard technique included low flow arthroscopy with single anterolateral viewing portal. Height of the fluid bag and presence of a knee holder was recorded. Knee flexion angle where patella first centrally engages in the trochlear groove was defined as Patellofemoral Congruent Angle (PCA). PCA was estimated by the primary surgeon and the angle was confirmed using a sterile goniometer. A second surgeon, blinded to the initial assessment, then repeated the measurements. Surgeon estimation error, interobserver reliability, and correlation with clinical presentation was analysed. Results: 57 knees were assessed for interobserver reliability. Intra-class correlation was 0.994 between surgeon’s estimate and goniometer reading. Intra-class correlation was 0.992 between the two surgeon’s readings suggesting a very high correlation. 157 patients had their PCA recorded and compared with their diagnosis. Mean PCA was 40 degrees in normal patients, and 118 degrees in patellar instability (p-value <0.001). Conclusion: Arthroscopic assessment of patellofemoral tracking is reproducible and correlates with patellar instability. A cut-off value of 40 degrees is recommended to differentiate normal tracking from abnormal. </jats:sec
Dementia in a regional hospital setting: contextual challenges and barriers to effective care
No full textDementia is a growing public health problem, which may be under-recognised and poorly managed in regional hospitals. With projections of increasing dementia among older adults in regional and rural areas, knowledge about dementia and capacity of professionals to provide best-evidence care is paramount. This research investigates the challenges of dementia care in a publicly funded regional hospital in Australia. The study elucidates prevalence of dementia-related admissions, costs of treatment, length of stay and capacity for dementia care. A mixed methodology was employed in this study, including analysis of hospital records (N = 2405), dementia knowledge surveys (n = 50) and semi-structured interviews with clinical staff (n = 13). Hospital records showed that dementia-related admissions were lower than population prevalence reported in regional Australia. Dementia patients, however, attracted significantly higher treatment costs and greater length of stay than age-matched admissions who did not have a diagnosis of dementia. Clinicians reported several obstacles to effective dementia care, including staff knowledge deficits, environmental challenges, resource constraints and organisational factors
Overcoming access barriers to health services through membership-based microfinance organizations: a review of evidence from South Asia
No full textAbstrAct It is a challenge for the poor to overcome the barriers to accessing health services. Membership-based microfinance with associated health programmes can improve health outcomes for the poor. This study reviewed the evidence published between 1993 and 2013 on the role of membership-based microfinance with associated health programmes in improving health outcomes for the poor in South Asia. A total of 661 papers were identified and 26 selected for inclusion, based on the relevance and rigour of the research methods. Of these 26, five were evidence reviews. Of the remaining 21 papers, 12 were from India, seven from Bangladesh, and one each from Sri Lanka and Indonesia. Three papers addressed more than one theme. Five key themes emerged from the review: (i) the impact of microfinance programmes on the social and economic situation of the poor; (ii) the impact of microfinance programmes on community health; (iii) the impact of integrated microfinance health programmes on raising client awareness; (iv) the impact of integrated microfinance health programmes on financing health care; and (v) the impact of integrated microfinance health programmes on affordable health-care products and services. The review provides new evidence on the pathways through which microfinance helps to improve population health and value for money for such programmes. Among countries with large populations in the informal sector, there is a strong case for policy-makers to support these groups in providing access to life-saving health care among the poor
Barriers to access and the purchasing function of health equity funds: lessons from Cambodia
No full textPROBLEM: High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined. APPROACH: Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers. LOCAL SETTING: Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes. RELEVANT CHANGES: HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care. LESSONS LEARNED: HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully
Strengthening district health service management and delivery through internal contracting: Lessons from pilot projects in Cambodia
No full textAbstractFollowing a decade of piloting different models of contracting, in mid-2009 the Cambodian Ministry of Health began to test a form of ‘internal contracting’ for health care delivery in selected health districts (including hospitals and health centers) contracted by the provincial health department as Special Operating Agencies (SOAs) and provided with greater management autonomy. This study assesses the internal contracting approach as a means for improving the management of district health services and strengthening service delivery. While the study may contribute to the emerging field now known as performance-based financing, the lessons deal more broadly with the impact of management reform and increased autonomy in contrast to traditional public sector line-management and budgeting. Carried out during 2011, the study was based on: (i) a review of the literature and of operational documents; (ii) primary data from semi-structured key informant interviews with 20 health officials in two provinces involved in four SOA pilot districts; and (iii) routine data from the 2011 SOA performance monitoring report. Five prerequisites were identified for effective contract management and improved service delivery: a clear understanding of roles and responsibilities by the contracting parties; implementation of clear rules and procedures; effective management of performance; effective monitoring of the contract; and adequate and timely provision of resources. Both the level and allocation of incentives and management bottlenecks at various levels continue to impede implementation. We conclude that, in contracted arrangements like these, the clear separation of contracting functions (purchasing, commissioning, monitoring and regulating), management autonomy where responsibilities are genuinely devolved and accepted, and the provision of resources adequate to meet contract demands are necessary conditions for success
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