Extending health insurance in Ghana: effects of the National Health Insurance Scheme on maternity care

Background There is considerable interest in exploring the potential of social health insurance in Africa where a number of countries are currently experimenting with different approaches. Since these schemes have been introduced recently and are continuously evolving, it is important to evaluate their effectiveness in the enhancement of health care utilization and reduction of out-of-pocket expenses for potential policy suggestions. Objective To investigate how the National Health Insurance Schemes (NHIS) in Ghana affects the utilization of maternal health care services and medical out-of-pocket expenses. Methods We used nationally-representative household data from the Ghana Demographic and Health Survey (GDHS). We analyzed the 2014 GDHS focusing on four outcome variables, i.e. antenatal check up, delivery in a health facility, delivery assisted by a trained person and out-of-pocket expenditure. We estimated probit and bivariate probit models to take into account the issue of self selection into the health insurance schemes. Results The results suggest that, also taking into account the issue of self selection into the health insurance schemes, the NHIS enrollment positively affects the probability of formal antenatal check-ups before delivery, the probability of delivery in an institution and the probability of being assisted during delivery by a trained person. On the contrary, we find that, once the issue of self-selection is taken into account, the NHIS enrollment does not have a significant effect on out-of-pocket expenditure at the extensive margin. Conclusion Since a greater utilization of health-care services has a strong positive effect on the current and future health status of women and their children, the health-care authorities in Ghana should make every effort to extend this coverage. In particular, since the results of the first step of the bivariate probit regressions suggest that the educational attainment of women is a strong determinant of enrollment, and those with low education and unable to read are less likely to enroll, information on the NHIS should be disseminated in ways that reach those with little or no education. Moreover, the availability of government health facilities in a region is associated with higher likelihood of enrollment in the NHIS. Accordingly, extending geographical access is an important strategy for expanding NHIS membership and improving access to health-care

Accuracy of acetabular cup positioning using imageless navigation

Background: Correct placement of the acetabular cup is a crucial step in total hip replacement to achieve a satisfactory result and remains a challenge with free-hand techniques. Imageless navigation may provide a viable alternative to free-hand technique and improve placement significantly. The purpose of this project was to assess and validate intra-operative placement values for both inclination and anteversion as displayed by an imageless navigation system to post-operative measurement of cup position using high resolution CT scans

Medial gastrocnemius flap for reconstruction of the extensor mechanism of the knee following high-energy trauma. A minimum 5 year follow-up

The purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage.This retrospective review consisted of a consecutive series of four patients (age 28-40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score.At the final follow up was 61.5 (57-66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training.For severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique

Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons

Purpose: To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences. Methods: Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%. Results: There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%). Conclusions: Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures. Level of evidence: Level V, expert opinion

U-type bilateral sacral fracture with spino-pelvic dissociation caused by epileptic seizure

Sacral fracture with spino-pelvic dissociation is a rare and unstable injury caused by high-energy trauma, often with serious haemodynamic and neurological implications. Diagnosis is easily delayed or missed as it is often masked by severe associated injuries. Here, we present an unusual case of spino-pelvic dissociation sustained during a seizure episode in a young epileptic patient on long-term anticonvulsant therapy with previous thoracolumbar spinal arthrodesis. This unique case brings to light the need for clinicians to consider sacral fractures in patients presenting with low back pain with no preceding trauma who otherwise may have risk factors for pathological fractures

Anabolic steroids after total knee arthroplasty. A double blinded prospective pilot study

Background: Total knee arthroplasty is reported to improve the patient’s quality of life and mobility. However loss of mobility and pain prior to surgery often results in disuse atrophy of muscle. As a consequence the baseline functional state prior to surgery may result in poorer outcome “post surgery” and extended rehabilitation may be required. The use of anabolic steroids for performance enhancement and to influence muscle mass is well established. The positive effects of such treatment on bone and muscle could therefore be beneficial in the rehabilitation of elderly patients. The purpose of this study was to investigate the effects of small doses of Nandrolone decanoate on recovery and muscle strength after total knee replacement and to establish the safety of this drug in multimorbid patients. Methods: This study was designed as a prospective double blind randomized investigation. Five patients (treatment group) with a mean age of 66.2 (58-72), average BMI of 30.76 (24.3-35.3) received 50 mg nandrolone decanoate intramuscular bi-weekly for 6 months. The control group (five patients; mean age 65.2, range 59-72; average BMI 31.7, range 21.2-35.2) was injected with saline solution. “Pre-operatively” and “post-operatively” (6 weeks, 3,6,9 and 12 months) all patients were assessed using the knee society score (KSS), isokinetic strength testing and functional tests (a sit-to-stand and timed walking tests). In addition, a bone density scan was used preoperatively and 6 month postoperatively to assess bone mineral density. Results: Whilst the steroid group generally performed better than the placebo group for all of the functional tests, ANOVA failed to reveal any significant differences. The steroid group demonstrated higher levels of quadriceps muscle strength across the postoperative period which reached significance at 3 (p = 0.02), 6 (p = 0.01), and 12 months (p = 0.02). There was a significant difference for the KSS at 6 weeks (p = 0.02), 6 (p = 0.02) and 12 month (p = 0.01). The steroid group demonstrated a reduction in the amount of bone mineral density at both the femur and lumbar spine from “pre-” to “post-surgery”, however, these results did not reach significance (p < 0.05) using one-way ANOVA. Conclusions: This project strongly suggests that the use of anabolic steroids result in an improved outcome as assessed by the KSS and significantly increases extensor strength. No side effects were seen in either the study or control group. Trial Registration Number: Regional Health District: Register No. 03.05 Human Research Ethics Committee University: Clearance Number: 04/03-1

Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction

The purpose of this study was to evaluate the functional and psychological outcomes of patients who underwent delayed lower limb amputation following failed limb salvage surgery.This retrospective, descriptive study evaluated functional outcomes using the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) in 12 patients. Inclusion criteria included patients who underwent limb reconstruction and delayed amputation between July 2006 and December 2014, with an age range between 18 and 80 years of age, the ability to ambulate independently, a time interval between the last salvage procedure and amputation greater than six months, and a minimum follow-up of 24 months. Patients were contacted via telephone by the principal investigator and both the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) were completed. Descriptive analysis (means and standard deviation) was used to determine outcomes for both SIP and SF-36 health profiles.Ten patients who had amputations following failed reconstruction (2006-2014) with a mean age of 53±10years were interviewed. Six patients had a SIP 10 points. The main deficit on the SF-36 was in the physical component. The SF-36 scores demonstrated a mean score of 40.8±11.5 for the physical component, and 57.4±7.9 for the mental component. Three patients returned to work after amputation and continued performing their pre-injury duties as farmers. Three other patients returned to work, but were allocated to administrative duties. Two patients were pensioners at the time of their injuries, and the only female patient was a housewife. One patient went into early retirement.The results of this study strongly suggest that delayed amputation following failed limb salvage surgery can still result in good and satisfactory outcomes in the majority of patients and achieves results similar to early amputation and limb reconstruction techniques

Does the relative density of periarticular bone influence the failure pattern of intra-articular fractures?

Introduction: The architecture of joints almost certainly influences the nature of intra-articular fractures, and the concavity is much more likely to fail than the associated convexity. However, local differences in periarticular bone density potentially also plays a critical role. The purpose of this study was to investigate if there was any difference in periarticular bone density in intra-articular fractures between the two opposing joint surfaces, comparing the convexity to the concavity. Materials and methods: We retrospectively identified a series of 1003 intra-articular fractures of the hip, knee, and ankle; 129 of these patients had previously undergone CT scanning during their routine clinical assessment. Periarticular bone density was assessed using Hounsfield Units (HU) as a measure of the composite density of the adjacent bone. Bone density was compared between the opposite sides of each joint, to determine if a relationship exists between local bone density and the risk of articular surface fracture. Results: There was a statistically significant difference in density between the two opposing surfaces, with the convexity 19% more dense than the concavity (p = 0.0001). The knee exhibited the largest difference (55%), followed by the hip (18%); in the ankle, an inverse relationship was observed, and the concave surface was paradoxically denser (5%). There was no significant difference between those cases where the concavity failed in isolation compared to those where the convexity also failed (p = 0.28). Conclusion: When the results were pooled for all three joints, there was a statistically significant higher local bone density demonstrated on the convex side of an intra-articular fracture. However, while this relationship was clearly exhibited in the knee, this was less evident in the other two joints; in the ankle the reverse was true, and the local bone adjacent to the concavity was found to have greater density. This suggests local bone density plays only a minor role in determining the nature of intra-articular fractures

Single-stage osseointegrated reconstruction and rehabilitation of lower limb amputees: the Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2) for a prospective cohort study

Introduction: Lower limb amputations have detrimental influences on the quality of life, function and body image of the affected patients. Following amputation, prolonged rehabilitation is required for patients to be fitted with traditional socket prostheses, and many patients experience symptomatic socket–residuum interface problems which lead to reduced prosthetic use and quality of life. Osseointegration has recently emerged as a novel approach for the reconstruction of amputated limbs, which overcomes many of the socket-related problems by directly attaching the prosthesis to the skeletal residuum. To date, the vast majority of osseointegration procedures worldwide have been performed in 2 stages, which require at least 4 months and up to 18 months for the completion of reconstruction and rehabilitation from the time of the initial surgery. The current prospective cohort study evaluates the safety and efficacy of a single-stage osseointegration procedure performed under the Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2), which dramatically reduces the time of recovery to ∼3–6 weeks. Methods and analysis: The inclusion criteria for osseointegrated reconstruction under the OGAAP-2 procedure are age over 18 years, unilateral transfemoral amputation and experiencing problems or difficulties in using socket prostheses. All patients receive osseointegrated implants which are press-fitted into the residual bone. Functional and quality-of-life outcome measures are recorded preoperatively and at defined postoperative follow-up intervals up to 2 years. Postoperative adverse events are also recorded. The preoperative and postoperative values are compared for each outcome measure, and the benefits and harms of the single-stage OGAAP-2 procedure will be compared with the results obtained using a previously employed 2-stage procedure. Ethics and dissemination: This study has received ethics approval from the University of Notre Dame, Sydney, Australia (014153S). The study outcomes will be disseminated by publications in peer-reviewed academic journals and presentations at relevant clinical and orthopaedic conferences