Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics.

The clinical effectiveness and costs of videoconferencing in orthopaedics between primary and secondary care were examined in an eight-month prospective, comparative study. The general surgery outpatient clinics of two Finnish district hospitals were compared: Peijas Hospital, with telemedicine, and Hyvinkää Hospital, without it. The three study primary-care centres referred a total of 419 adult patients to the outpatient clinics. The population-based number of referrals to Peijas Hospital was similar to that to Hyvinkää Hospital after adjusting for the proportion of older people living in the Hyvinkää Hospital municipalities. Of the 225 patients referred to Peijas Hospital, 168 (75%) were given appointments at the outpatient clinic of surgery and the rest of the referred patients received a teleconsultation. All patients referred to Hyvinkää Hospital were given appointments at the outpatient clinic. The direct costs of an outpatient visit were 45% greater per patient than for a teleconsultation, with a marginal cost decrease of EU48 for every new teleconsultation. A cost-minimization analysis of the alternative interventions showed a net benefit of EU2500 in favour of teleconsultations. The use of videoconferencing between primary and secondary care was modest in orthopaedics, although the use of this telemedicine method was shown to reduce direct costs and be cost-effective.

Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. A retrospective study.

A total of 167 feet in 125 patients were treated with a proximal osteotomy of the first metatarsal for hallux valgus. In addition, in 115 feet a resection of the base of the proximal phalanx was conducted, and in 25 feet the head of some lesser metatarsal bone was resected. Eight years (range 5-10 years) postoperatively the patients were sent a questionnaire concerning the present state of their feet. In all, 105 patients (142 feet) replied, and 63% stated that they felt no pain in their feet at all. Indeed, 86% of the patients indicated that, everything considered, the operation was worthwhile. The most common complaint was the difficulty of finding shoes to fit; 22.5% of the patients stated that they had a hard time with this. The average preoperative metatarsophalangeal angle was 38 degrees, reduced by 22 degrees postoperatively. The average preoperative first intermetatarsal angle was 15 degrees, reduced by 5 degrees after the operation. In the statistical analysis, no correlation between the preoperative body mass index, the hallux angle, the first intermetatarsal angle, the reduction achieved in the above mentioned angles by the operation, and patient satisfaction was found.

Ruptures of the heart in seatbelt wearers.

We analyzed the records of 4,169 victims of traffic collisions fatally injured during the period 1972 to 1985. Chest injuries were recorded as the main cause of death in 1,121 victims; 207 of them had worn a seatbelt. Rupture of the heart was found at autopsy in 75 of these seatbelt wearers. Exact information on the location and the size of the heart rupture was available in 47 cases. For a control group, we analyzed 47 randomly chosen unbelted victims who had sustained a fatal heart rupture in comparable collisions. The site of cardiac injury was a ventricle in 75.5%. In frontal impact collisions the mechanism leading to heart rupture is usually crushing against the steering wheel, even in seatbelt wearers. Most of the victims had multiple injuries, and only serious collisions, often with a heavier vehicle, led to fatal heart rupture.

Aortic ruptures in seat belt wearers.

Several investigations have indicated that rupture of the thoracic aorta is one of the leading causes of immediate death in victims of road traffic accidents. In Finland in 1983, 92% of front-seat passengers were seat belt wearers on highways and 82% in build-up areas. The mechanisms of rupture of the aorta have been intensively investigated, but the relationship between seat belt wearing and injury mechanisms leading to aortic rupture is still largely unknown. This study comprises 4169 fatally injured victims investigated by the Boards of Traffic Accident Investigation of Insurance Companies during the period 1972 to 1985. Chest injuries were recorded as the main cause of death in 1121 (26.9%) victims, 207 (5.0%) of those victims having worn a seat belt. Aortic ruptures were found at autopsy in 98 victims and the exact information of the location of the aortic tears was available in 68. For a control group, we analyzed 72 randomly chosen unbelted victims who had a fatal aortic rupture in similar accidents. The location of the aortic rupture in unbelted victims was more often in the ascending aorta, especially in drivers, whereas in seat belt wearers the distal descending aorta was statistically more often ruptured, especially in right-front passengers (p less than 0.05). The steering wheel predominated statistically as the part of the car estimated to have caused the injury in unbelted victims (37/72), and some interior part of the car was the most common cause of fatal thoracic impacts in seat belt wearers (48/68) (p less than 0.001). The mechanism of rupture of the aorta in the classic site just distal to the subclavian artery seems to be rapid deceleration, although complex body movements are also responsible in side impact collisions. The main mechanism leading to rupture of the ascending aorta seems to be severe blow to the bony thorax. This also often causes associated thoracic injuries, such as heart rupture and sternal fracture. Injuries in the ascending aorta were mostly found in unbelted victims and were sustained in frontal impact collisions, the injury-causing part of the car being the steering wheel. Ruptures of the distal descending part of the aorta were frequently associated with fractures of the thoracic vertebra.

Chest injuries sustained in severe traffic accidents by seatbelt wearers.

In Finland during the period 1972-1985, there occurred 3,468 severe traffic accidents in which one or more of the drivers or passengers sustained an injury leading to a fatal outcome within 30 days. Of the victims who had been wearing seatbelts, 207 had fatal and 73 had severe chest injuries. The four leading causes of fatalities resulting from chest injuries were ruptures of the aorta (37%), ruptures of the heart (28.4%), and bilateral lung contusions (31.1%) or lacerations (15.5%). Seatbelt wearers with heart ruptures more often had concomitant rib fractures, lung injuries, and sternum fractures than those who had sustained ruptures of the aorta. The side of rib fractures was associated with the victim's location in the car, drivers seated on the left having more right-sided and right front passengers more left-sided rib fractures. In addition to chest injuries, 87% of the victims had other concomitant injuries, the most common abdominal injuries being liver injuries (40.2%) and spleen ruptures (26.5%). In seatbelt wearers chest injuries with a fatal outcome appear to be caused by impacts of exceptional severity, since in more moderate accidents seatbelt wearing has proved to save lives.

A retrospective analysis of chest injuries in 280 seat belt wearers.

The usefulness of seat belts is today well documented. The purpose of the present study was to analyse the factors which caused the fatal outcome of 207 seat belt wearers, a chest injury being recorded as the main cause of death. The control material consisted of 73 seat belt wearers who sustained severe chest injury in the same kind of traffic accidents. The basic material consisted of 3,468 traffic accidents investigated by the Boards of Traffic Accidents Investigation of Insurance Companies in Finland. Since 1972, the Boards have investigated accidents involving one or more victims dying within 30 days of the accident. In the group of fatally injured victims drivers outnumbered passengers statistically (p less than 0.01), this being the case especially in frontal impact collisions. In those frontal crashes the part of the car causing injury was the steering wheel in 28.6% of the cases, but in lateral collisions the injury was in 4.8% due to impact by steering wheel (p less than 0.001). In lateral impact collisions there were more fatalities compared with other directions of impact (p less than 0.001) and only 3.3% survived in the front seat on the side impact. The injury mechanism on the body was grouped as follows: deceleration, contusion, and crushing force. Crushing force was the most common mechanism leading to the fatal outcome and was statistically more common in lateral impact collisions than in other types of crashes (p less than 0.001). Improving the constructions of steering assembly and strengthening side panels of the cars can be considered one of the main priorities in the prevention of fatal chest injuries.

Abdominal injuries sustained in severe traffic accidents by seatbelt wearers.

In Finland during the period 1972-1983, there were 3,564 severe traffic accidents involving one or more victims dying within 30 days of the accident. Forty-two of the victims had been wearing a seatbelt and had an abdominal trauma as the main cause of death or as first diagnosis of injury. Small intestine and colon injuries were more common in the severely injured victims than was the case with the fatally injured ones and in these accidents the injury mechanism was always deceleration or contusion, which was in most cases caused by the seatbelt. Liver injuries seem to be the major abdominal cause of fatality, and in the fatally injured group, half of the victims sustained the fatal abdominal injury through gross crushing impact. When the direction of the impact was analyzed, all the victims seated on the receiving side of the vehicle in lateral impact collisions sustained an abdominal injury with fatal outcome. It seems that the seatbelt is less effective in protecting wearers from severe or fatal abdominal injuries in lateral impact collisions.

Revision arthroplasty of the hip joint. A retrospective analysis.

During the period 1974-1983, 768 total hip arthroplasties were performed at the Surgical Hospital, University Central Hospital in Helsinki. Brunswik prostheses were used until 1980, and after this the operations were routinely performed with Lubinus prostheses. Additionally, from 1977 to 1981 Wagner and Freeman resurfacing prostheses were used in 107 cases. Of all these patients, 44 (5.7%) needed revision arthroplasty. The average interval between the primary operation and revision arthroplasty was 3.7 years and the follow-up period after the second operation averaged 2.9 years. The patients who underwent revision arthroplasty were compared with a matched control group. In the revision group, radiographs revealed that the medial cement packing was complete in 28% of the hips, this being the case in 78% of the controls (P less than 0.001). Also, the cement tip packing was more often incomplete in the revision hips than in the controls (P less than 0.01). Regarding the lateral cement packing there was no statistical difference between the two groups. The revision rate of the resurfacing prostheses was 14.9%, compared with 7.8% of the Brunswik prostheses which were inserted at the same time. At the follow-up, the patients with revised hips had less pain than before the primary operation (P less than 0.001) and their mobility was similarly improved. We conclude that adequate medial and tip cement packing must be emphasized in the primary arthroplasty. Resurfacing prostheses have a relatively high loosening tendency. Revision arthroplasty is the treatment of aseptic loosening after total hip replacement and it gives good clinical results. Aseptic loosening is the most common long-term complication after total hip replacement surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Maxillofacial trauma in fatally injured victims of motor vehicle accidents.

A survey of 84 victims of maxillofacial injuries sustained in road traffic accidents is presented. The material was based on the files of the Finnish National Board of Traffic Accident Investigation of the Insurance Companies, comprised the years 1972-1983 and covered the whole country. 86% of the victims were occupants of motor cars; only 24% had worn seat belts. Similarly only two of the eight motor-cyclists had worn a helmet. The majority of all victims also had other head injuries but only 24% had brain injuries; over 50% had a chest injury. In 20 cases the facial injury was thought to be the definitive fatal trauma. In the remaining cases the other injuries could have been responsible for the fatal outcome. However, aspiration of blood from the facial wounds, unconciousness and an injured thorax probably all contributed to death which in 87% was immediate. Thirty-six of the 64 victims who had not used a seat-belt or helmet could certainly, or probably, have been saved by either the belt or the helmet. The possibilities of preventing fatal maxillofacial injuries in road traffic are discussed.