Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study.

BACKGROUND: Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes. METHODS: A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery. RESULTS: Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery. CONCLUSION: Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.

Pathophysiology of long-standing overt ventriculomegaly in adults.

OBJECT: Long-standing overt ventriculomegaly in adults (LOVA) is a unique form of hydrocephalus that develops during childhood and manifests symptoms during adulthood. The aim of the present study was to analyze the specific pathophysiological characteristics of LOVA. METHODS: The specific diagnostic criteria for LOVA include severe ventriculomegaly in adults that is associated with macrocephalus measuring more than two standard deviations in head circumference and/or neuroradiological evidence of a significantly expanded or destroyed sella turcica. Twenty patients who fulfilled these criteria, 14 males and six females, were retrospectively studied. These patients' ages at diagnosis ranged from 15 to 61 years (mean 39.4 years). All had symptoms and/or signs indicating that hydrocephalus first occurred at birth or during infancy in the absence of any known underlying disease. The authors performed a pathophysiological study that included specific variations of magnetic resonance (MR) imaging, such as fluid-attenuated inversion recovery and cardiac-gated cine-mode imaging; intracranial pressure (ICP) monitoring; three-dimensional computerized tomography (CT) scanning; and other techniques. Hydrocephalus was caused by aqueductal stenosis in all patients. Severe ventriculomegaly involving the lateral and third ventricles was associated with a marked expansion or destruction of the sella turcica in 17 cases. Cardiac-gated cine-MR imaging did not reveal any significant movements of cerebrospinal fluid in the aqueduct. Three-dimensional CT ventriculography confirmed that the expanded third ventricle protruded into the sella and, sometimes, extended a diverticulum. Fourteen patients revealed symptoms and signs that indicated increased ICP with prominent pressure waves. Dementia or mental retardation was seen in 11 patients, gait disturbance in 12, and urinary incontinence in eight; all three of these symptoms were observed in seven patients. Thirteen patients experienced visual disturbance. Nine patients underwent ventriculoperitoneal shunt implantation as the initial treatment, leading to postoperative subdural hematoma in all seven cases in which a differential pressure valve was used. Nine patients, three of whom were initially treated by shunt placement, underwent a neuroendoscopic procedure, mainly for third ventriculostomy. Postoperatively, ICP returned to normal, and marked to-and-fro pulsatile movements at the site of ventriculostomy were recognized on cine-MR imaging in patients treated endoscopically. However, the ventriculomegaly was little improved. Consequently, all patients eventually demonstrated improvement in response to either a shunt equipped with a pressure-programmable valve or an endoscopic procedure; however, depression appeared in six patients, who required psychiatric consultation or medication. CONCLUSIONS: Such remarkably decreased intracranial compliance but relatively high ICP dynamics are the pathophysiological characteristics of LOVA. The therapeutic regimen should be determined based on the individual's specific pathophysiological makeup.

Neuroendoscopic surgery for specific forms of hydrocephalus.

Neuroendoscopic surgery was used to treat patients with various forms of hydrocephalus with specific pathophysiology, including long-standing overt ventriculomegaly in adulthood (LOVA), isolated unilateral hydrocephalus (IUH), isolated IV ventricle (IFV), disproportionately large IV ventricle (DLFV), isolated rhombencephalic ventricle (IRV), isolated quarto-ventriculomegaly (IQV), dorsal sac in holoprosencephaly (DS), and loculated ventricle (LV). A total of 26 operative procedures were performed, with neuroendoscopic surgery in 22 patients, 12 with unique forms of noncommunicating hydrocephalus and 10 with various types of postshunt isolated compartment. These procedures included III ventriculostomy, aqueductal plasty by both rostral and caudal approaches, foraminal plasty in the foramen of Monro/foramen of Magendie, septostomy, IV ventriculostomy, fenestration of septation in the loculated ventricle, fenestration of arachnoid cyst or cystic tumor obstructing a ventricle with or without tumor removal, and dorsal sac ventriculostomy. The characteristics of the cerebrospinal fluid (CSF) dynamics in the individual specific pathophysiologies were delineated by cardiac-gated cine-mode magnetic resonance imaging (MRI) before and after the endoscopic procedure. The consequent success rate (success = restoration of communication of the CSF pathway in the individual patients) was 19/22 (86.4%). The progression of ventricular dilatation was stopped in 17 of 19 patients (89.5%) in whom the endoscopic procedure was successful (radiologically arrested hydrocephalus). Improvement in the clinical symptoms and signs (clinically arrested hydrocephalus) was obtained in 15 of the patients (68.2% of all patients: 5 with LOVA, 3 with IQV, 5 with IUH and 2 with LV). Seven patients (2 LOVA, 2 IFV, 1 DS, 1 DFLV and 1 IRV) underwent a shunt procedure after the neuroendoscopic procedure(s). The postoperative changes of ventriculomegaly were complicated, reflecting the differences in the brain parenchymal compliance and postoperatively corrected CSF flow dynamics in the major CSF pathway.

Virtual endoscopic environments in modern neurosurgical practice.

Modern radiographic techniques have allowed the creation of high-definition planar images that can provide important anatomical as well as physiological data. Planar imaging sets can be reformatted into three-dimensional (3-D) data sets that can then be manipulated to demonstrate important anatomical or gross pathological features. Three-dimensional data sets have been used with success in modern image-guided or frameless stereotactic surgery. Another potential application is so-called "virtual endoscopy" or "scopeless endoscopy," in which a 3-D anatomical data set is reformatted into a volume-rendered image that can then be viewed. By reformatting images in this way, a "surgeon's-eye" view can be obtained, which can aid in presurgical planning and diagnosis. The use of virtual endoscopy has the potential to increase our understanding of the appropriate anatomy and the anatomical relationships most apparent during neurosurgical approaches. In so doing, virtual endoscopy may serve as an important means of planning for therapeutic interventions. On the other hand, one must always be cognizant of the technical limitations of these studies regardless of the quality of the reconstructed images. Prospective, correlative, clinical studies in which the anatomical advantages of virtual-based endoscopy are evaluated in large cadaver or patient series must be performed. Until then, the only potential ways to compensate for errors that exist in the algorithms and reconstructions of 3-D endoscopic images are based on the surgeon's understanding of the clinical state of the patient and prior experience with the anatomy in the region of question.