Total Hip and Knee Arthoplasty for Osteoarthritis : Factors Related to the Early Outcome of Surgery

Some perioperative clinical factors related to the primary cemented arthroplasty operation for osteoarthritis of the hip or knee joint are studied and discussed in this thesis. In a randomized, double-blind study, 39 patients were divided into two groups: one receiving tranexamic acid and the other not receiving it. Tranexamic acid was given in a dose of 10 mg/kg before the operation and twice thereafter, at 8-hour intervals. Total blood loss was smaller in the tranexamic acid group than in the control group. No thromboembolic complications were noticed. In a prospective, randomized study, 58 patients with hip arthroplasty and 39 patients with knee arthroplasty were divided into groups with postoperative closed-suction drainage and without drainage. There was no difference in healing of the wounds, postoperative blood transfusions, complications or range of motion. As a result of this study, the use of drains is no longer recommended. In a randomised study the effectiveness of a femoral nerve block (25 patients) was compared with other methods of pain control (24 patients) on the first postoperative day after total knee arthroplasty. The femoral block consisted of a single injection administered at patients´ bedside during the surgeon´s hospital rounds. Femoral block patients reported less pain and required half of the amount of oxycodone. Additional femoral block or continued epidural analgesia was required more frequently by the control group patients. Pain management with femoral blocks resulted in less work for nursing staff. In a retrospective study of 422 total hip and knee arthroplasty cases the C-reactive protein levels and clinical course were examined. After hip and knee arthroplasty the maximal C-reactive protein values are seen on the second and third postoperative days, after which the level decreases rapidly. There is no difference between patients with cemented or uncemented prostheses. Major postoperative complications may cause a further increase in C-reactive protein levels at one and two weeks. In-hospital and outpatient postoperative control radiographs of 200 hip and knee arthroplasties were reviewed retrospectively. If postoperative radiographs are of good quality, there seems to be no need for early repetitive radiographs. The quality and safety of follow-up is not compromised by limiting follow-up radiographs to those with clinical indications. Exposure of the patients and the staff to radiation is reduced. Reading of the radiographs by only the treating orthopaedic surgeon is enough. These factors may seem separate from each other, but linking them together may help the treating orthopaedic surgeon to adequate patient care strategy. Notable savings can be achieved.

Imaging of knee injuries with special focus on tibial plateau fractures

Acute knee injury is a common event throughout life, and it is usually the result of a traffic accident, simple fall, or twisting injury. Over 90% of patients with acute knee injury undergo radiography. An overlooked fracture or delayed diagnosis can lead to poor patient outcome. The major aim of this thesis was retrospectively to study imaging of knee injury with a special focus on tibial plateau fractures in patients referred to a level-one trauma center. Multi-detector computed tomography (MDCT) findings of acute knee trauma were studied and compared to radiography, as well as whether non-contrast MDCT can detect cruciate ligaments with reasonable accuracy. The prevalence, type, and location of meniscal injuries in magnetic resonance imaging (MRI) were evaluated, particularly in order to assess the prevalence of unstable meniscal tears in acute knee trauma with tibial plateau fractures. The possibility to analyze with conventional MRI the signal appearance of menisci repaired with bioabsorbable arrows was also studied. The postoperative use of MDCT was studied in surgically treated tibial plateau fractures: to establish the frequency and indications of MDCT and to assess the common findings and their clinical impact in a level-one trauma hospital. This thesis focused on MDCT and MRI of knee injuries, and radiographs were analyzed when applica-ble. Radiography constitutes the basis for imaging acute knee injury, but MDCT can yield information beyond the capabilities of radiography. Especially in severely injured patients , sufficient radiographs are often difficult to obtain, and in those patients, radiography is unreliable to rule out fractures. MDCT detected intact cruciate ligaments with good specificity, accuracy, and negative predictive value, but the assessment of torn ligaments was unreliable. A total of 36% (14/39) patients with tibial plateau fracture had an unstable meniscal tear in MRI. When a meniscal tear is properly detected preoperatively, treatment can be combined with primary fracture fixation, thus avoiding another operation. The number of meniscal contusions was high. Awareness of the imaging features of this meniscal abnormality can help radiologists increase specificity by avoiding false-positive findings in meniscal tears. Postoperative menisci treated with bioabsorbable arrows showed no difference, among different signal intensities in MRI, among menisci between patients with operated or intact ACL. The highest incidence of menisci with an increased signal intensity extending to the meniscal surface was in patients whose surgery was within the previous 18 months. The results may indicate that a rather long time is necessary for menisci to heal completely after arrow repair. Whether the menisci with an increased signal intensity extending to the meniscal surface represent improper healing or re-tear, or whether this is just the earlier healing feature in the natural process remains unclear, and further prospective studies are needed to clarify this. Postoperative use of MDCT in tibial plateau fractures was rather infrequent even in this large trauma center, but when performed, it revealed clinically significant information, thus benefitting patients in regard to treatment.

Morbid obesity in total hip arthroplasty: Redefining outcomes for operative time, length of stay, and readmission

Background The incidence of obesity amongst patients presenting for elective Total Hip Arthroplasty (THA) has increased in the last decade and the relationship between obesity and the need for joint replacement has been demonstrated. This study evaluates the effects of morbid obesity on outcomes following primary THA by comparing short-term outcomes in THA between a morbidly obese (BMI ≥40) and a normal weight (BMI 18.5 - <25) cohort at our institution between January 2003 and December 2010. Methods Thirty-nine patients included in the morbidly obese group were compared with 186 in the normal weight group. Operative time, length of stay, complications, readmission and length of readmission were compared. Results Operative time was increased in the morbidly obese group at 122 minutes compared with 100 minutes (p=0.002). Post-operatively there was an increased 30-day readmission rate related to surgery of 12.8% associated with BMI ≥40 compared with 2.7% (p= 0.005) as well as a 5.1 fold increase in surgery related readmitted bed days - 0.32 bed days per patient for normal weight compared with 1.64 per patient for the morbidly obese (p=0.026). Conclusion Morbidly obese patients present a technical challenge and likely this and the resultant complications are underestimated. More work needs to be performed in order to enable suitable allocation of resources.

Methodological perspectives for register-based health system performance assessment : Developing a hip fracture monitoring system in Finland

The resources of health systems are limited. There is a need for information concerning the performance of the health system for the purposes of decision-making. This study is about utilization of administrative registers in the context of health system performance evaluation. In order to address this issue, a multidisciplinary methodological framework for register-based data analysis is defined. Because the fixed structure of register-based data indirectly determines constraints on the theoretical constructs, it is essential to elaborate the whole analytic process with respect to the data. The fundamental methodological concepts and theories are synthesized into a data sensitive approach which helps to understand and overcome the problems that are likely to be encountered during a register-based data analyzing process. A pragmatically useful health system performance monitoring should produce valid information about the volume of the problems, about the use of services and about the effectiveness of provided services. A conceptual model for hip fracture performance assessment is constructed and the validity of Finnish registers as a data source for the purposes of performance assessment of hip fracture treatment is confirmed. Solutions to several pragmatic problems related to the development of a register-based hip fracture incidence surveillance system are proposed. The monitoring of effectiveness of treatment is shown to be possible in terms of care episodes. Finally, an example on the justification of a more detailed performance indicator to be used in the profiling of providers is given. In conclusion, it is possible to produce useful and valid information on health system performance by using Finnish register-based data. However, that seems to be far more complicated than is typically assumed. The perspectives given in this study introduce a necessary basis for further work and help in the routine implementation of a hip fracture monitoring system in Finland.

Making Music, Making Muslims : A Case Study of Islamic Hip Hop and the Discursive Construction of Muslim Identities on the Internet

Hip-hopin juuret juontavat 1970-luvulle Yhdysvaltoihin, mutta hip-hop-kulttuuri ja musiikkityyli ovat sen jälkeen levinneet ympäri maailmaa osana globalisaatiokehitystä. Myös monet nuoret muslimit tekevät nykyään hip-hop-musiikkia, ja yhä useampi tuo myös sanoituksiinsa vaikutteita Islamista ja elämästään muslimina. Musiikin asema on islamissa varsin kiistelty, eikä sitä ole selvästi sallittu (halal) tai kielletty (haram) muslimeilta. Muslimien tekemää hip-hoppia on toistaiseksi tutkittu hyvin vähän. Tutkielmassa tarkastellaan diskurssianalyysin keinoin, miten tapaustutkimuksena toimivalla muslimhiphop.com-internetsivustolla argumentoidaan ja konstruoidaan käsityksiä muslimi-identiteetistä. Teoreettisena ja analyyttisenä viitekehyksenä toimii sosiaalikonstruktivistinen näkemys identiteetistä kontekstisidonnaisena sekä puheessa ja teksteissä diskursiivisesti rakentuvana. Tutkielma kyseenalaistaa aiempien tutkimusten oletuksen hip-hopista vaikutuksiltaan yksinomaan positiivisena muslimi-identiteetille sekä muslimeja yhdentävänä tekijänä. Aineisto on kerätty edellä mainitulta sivustolta syksyn 2010 ja kevään 2011 aikana, josta analyysiin on rajattu vain itse sivusto ja sen hip-hoppia käsittelevät osiot. Sivusto ja sen perustaja ovat yhdysvaltalaisia, mutta sivustolla esiteltävien artistien tausta on hyvin monikulttuurinen. Moni on myös maahanmuuttajana nykyisessä kotimaassaan. Aineistossa esiintyviä teemoja ja diskursseja eritellään ja analysoidaan tutkielmassa lainauksien avulla. Sivuston periaatteissa ja artistien esillepääsyn kriteereissä määritellään tarkasti asennoituminen Islamin ja musiikin yhdistämiseen: mikäli sanoitukset ja artistit noudattavat Islamin oppeja, on muslimin sallittua tehdä ja kuunnella tällaista musiikkia. Islam-aiheisen hip-hopin perustellaan olevan ennen kaikkea vaihtoehto valtavirran hip-hopille, jota konstruoidaan aineistossa moraalisesti arveluttavaksi. Hip-hopille sekä muslimeille sallittuja ja kiellettyjä elementtejä erottelevan halal-haram-diskurssin ohella aineistosta nousee esiin opetusdiskurssi. Muslimien tekemän hip-hopin perustellaan edistävän Islamin opettamista erityisesti nuorille muslimeille ja siten vahvistavan positiivista muslimi-identiteettiä. Myös positiivisen muutoksen diskurssia käytetään aineistossa runsaasti liittyen mm. muslimiyhteisöihin sekä muslimeihin kohdistuviin taloudellisiin ja sosiaalipoliittisiin epäkohtiin ja stereotypioihin; musiikin sisältöä ja sen tekemistä perustellaan sen voimalla muuttaa asioita parempaan suuntaan. Monet muslimiartistit kamppailevat yhdistääkseen toisaalta Islamin ja taiteellisen luovuuden ja ilmaisuvapauden, toisaalta menestyäkseen kaupallisesti unohtamatta uskonnollista vakaumustaan. Monilla heistä hip-hop on ollut vahvasti läsnä kasvuympäristössä, mutta sen yhdistäminen Islamin periaatteisiin aiheuttaa kysymyksiä ja kyseenalaistuksia oman musiikillisen ja uskonnollisen identiteetin muodosta ja sisällöstä. Aineiston perusteella monet muslimiartistit ja Islam-aiheista hip-hoppia kuuntelevat muslimit joutuvat jatkuvasti puolustamaan musiikkia siihen kielteisesti suhtautuville muslimeille sekä ei-muslimeille, jotka vierastavat sen uskonnollisuutta. Muslimi-identiteettiä neuvotellaan jatkuvasti, ja se näyttäytyy aineistossa moniulotteisena ja tilanteisesti rakentuvana. Avainsanat: Muslimit, Islam, hip-hop, identiteetti, Internet, diskurssi, diskurssianalyysi