Cervical spondylosis

                                          Dr. KS Dhillon

Introduction

Cervical spondylosis is a natural age-related degenerative disease of the cervical spine. The term cervical spondylosis encompasses a wide range of progressive degenerative changes that affect all the components of the cervical spine including intervertebral discs, facet joints, joints of Luschka, ligamentum flavum, and laminae [1]. Degeneration of the cervical spine is a natural process of aging and presents in the majority of people after the fifth decade of life [1]. By the age of 65 years the prevalence of cervical spondylosis is 95%. 

Etiology

Age-related degeneration of the intervertebral disc and cervical spinal elements is the primary risk factor and contributor to the incidence of cervical spondylosis. Besides the disc, degenerative changes also occur in surrounding structures, including the uncovertebral joints, facets joints, posterior longitudinal ligament, and ligamentum flavum. These degenerative changes all combine to cause narrowing of the spinal canal and intervertebral foramina. The narrowing can cause compression of the spinal cord, spinal vasculature, and nerve roots. Patients with cervical spondylosis can present with axial neck pain, cervical myelopathy, and cervical radiculopathy.

Several factors can contribute to an accelerated disease process and early-onset cervical spondylosis. These include exposure to significant spinal trauma, a congenitally narrow vertebral canal, dystonic cerebral palsy affecting cervical musculature, and some athletic activities such as soccer, rugby, and horse riding [1].

Epidemiology

About 25% of individuals under the age of 40, 50% of individuals over the age of 40, and 85% of individuals over the age of 60 have some degree of cervical spondylosis. Most people with radiographic evidence of cervical spondylosis remain asymptomatic [1]. The most commonly affected segment is C6-C7, followed by C5-C6. 

Neck pain is the most common symptom of cervical spondylosis. The point prevalence of neck pain ranges from 0.4% to 41.5% in the general population, the 1-year incidence ranges from 4.8% to 79.5%, and lifetime prevalence may be as high as 86.8% [1]. Neck pain along with back pain remains the leading cause of years lived with disability. 

Pathophysiology

Cervical spondylosis pathogenesis involves a degenerative cascade that produces biomechanical changes in the cervical spine. There is an increase in the keratin-chondroitin ratio that prompts changes in the proteoglycan matrix resulting in loss of protein, water, and mucopolysaccharides within the disc. Disc desiccation results in loss of elasticity of the nucleus pulposus and it shrinks and becomes more fibrous. The nucleus pulposus loses its ability to maintain weight-bearing loads effectively. It begins to herniate through the fibers of the annulus fibrosus resulting in the loss of disc height. 

The annular and Sharpey fibers peel off from the vertebral body edges, resulting in reactive bone formation. This reactive bone formation leads to formation of spurs or osteophytes along the ventral or dorsal margins of the cervical spine. These osteophytes can project into the spinal canal and intervertebral foramina. The uncovertebral and facet joints also undergo degenerative changes which leads to hypertrophy or enlargement of the joints with bony spur formation into the surrounding neural foramen. These degenerative changes lead to reduction in the range of cervical movements and narrowing of the spinal canal [1].

Spondylotic changes in the cervical spine occur at a single disc space level in 15% to 40% of patients and at multiple levels in 60% to 85% of the patients. The discs between the third and seventh cervical vertebrae are most commonly affected.

Repeated occupational trauma can contribute to the development of cervical spondylosis. An increased incidence of cervical spondylosis has been found in individuals who carried heavy loads on their heads or shoulders, in dancers, gymnasts, and in individuals with spasmodic torticollis [2]. Everyone does not agree that trauma is an important causal factor in the production of cervical spondylosis. In about 10% of patients, cervical spondylosis is due to congenital bony anomalies such as blocked vertebrae, malformed laminae-that place undue stress on adjacent intervertebral discs [2].

Histopathology

Disc herniation precedes the development of cervical spondylosis. The spondylotic discs and herniated discs undergo similar degenerative changes with macrophage infiltration, upregulation of growth factors, and cytokines. Herniated discs usually demonstrate more profound inflammatory reactions involving CD68-positive macrophage infiltration into the outer layer of the annulus fibrosus. Spondylotic discs have thicker bony endplates with a more diffuse expression of TNF-alpha and MMP-3 in the inner layer of the annulus fibrosus [3,4].

History and Physical Examination

Typically symptomatic cervical spondylosis presents as one or more of the following three clinical syndromes:

1.Axial Neck Pain

Usually, patients complain of stiffness of the neck. The pain in the neck is most severe in the upright position and it is relieved with bed rest.

Hyperextension and side-bending of the neck increases the pain.

In upper cervical disease, the pain radiates to the occiput and the back of the ear. In lower cervical spine disease the pain radiates into the superior trapezius or periscapular musculature.

Sometimes patients can present with atypical symptoms of jaw pain or chest pain.

2.Cervical Radiculopathy

Radicular symptoms from cervical spondylosis usually follow a myotomal distribution depending on the nerve root(s) involved. There can be unilateral or bilateral neck pain, scapular pain, arm pain, paresthesias, and weakness of the arm or hand.

Pain is usually exacerbated on tilting the head towards the affected side, on hyperextension of the neck, and side-bending toward the affected side.

Pain radiating down the upper limb with neck extension and ipsilateral head rotation to the affected side is considered as a positive Spurling test for cervical radiculopathy. A 2011 study by Shabat et al found that the Spurling test is 95% sensitive and 94% specific for diagnosing nerve root pathology [5].  

3.Cervical Myelopathy

Cervical myelopathy usually has an insidious onset with or without neck pain. It can initially present with hand weakness and clumsiness which results in an inability to carry out tasks that require fine motor coordination such as buttoning a shirt, tying shoelaces, and picking up small objects.

There can be frequent episodes of gait instability and unexplained falls.

Urinary incontinence can occur although it is rare and it typically appears at the late stage of the disease.

An electric shock-like sensation radiating down the spine and into the extremities with neck flexion is a positive Lhermitte's sign for cervical spondylotic myelopathy (CSM). A more specific sign for CSM is Hoffman’s sign. A Hoffman’s is positive if the thumb and/or index finger flexes when the distal phalanx of the middle finger is flicked by the examiner. 

Physical examination

A meticulous examination of all extremities should be carried to identify nerve root/roots compromise and/or myelopathy. Muscle strength is assessed, sensory examination is carried out and deep tendon reflexes are examined. 

The patient’s gait and balance are evaluated with a toe-to-heel walk test and Romberg’s test. In the toe-to-heel test, the patient is asked to walk 4 steps on the toes and then 4 steps on the heels. In the Romberg’s test, the patient is asked to stand with eyes closed, and arms held forward. A loss of balance is interpreted as a positive Romberg’s test. It is indicative of dysfunction involving the dorsal columns of the spinal cord.

The presence of spasticity, hyperreflexia, sustained clonus, extensor Babinski response would indicate the presence of myelopathy. The grip and release test is another screening test for CSM. Normally a person can make a fist and release it 20 times in 10 seconds, with some decrease in cut-off values with increasing age and lower cut-off values in females [6]. 

Investigations

X-rays

In patients with neck and upper extremity symptoms, plain radiographs of the cervical spine will be the appropriate initial imaging study. The degenerative changes seen on X-rays often poorly correlate with the presence of neck pain [7]. In patients with cervical scoliosis, the common radiographic findings include osteophytes, disc space narrowing, sclerosis of endplates, degenerative changes of uncovertebral and facet joints, as well as calcified/ossified soft tissues. Commonly, AP, lateral, and oblique views of the spine are obtained. These views are adequate to access foraminal stenosis, sagittal alignment, and the size of the spinal canal. 

The Torg-Pavlov ratio is obtained by dividing the sagittal length of the spinal canal by the sagittal diameter of the vertebral body. The normal value is 1.0, with a ratio of <0.8 indicating cervical stenosis. Flexion and extension views are carried out when ligamentous instability is suspected.

Magnetic Resonance Imaging (MRI)

MRI imaging is the modality of choice to evaluate neural structures and soft tissues. MRI allows for proper visualization of the cervical spine without exposing the patient to radiation. 

Axial and sagittal cuts can show the extent of nerve and cord compression, as well as show offending pathological changes such as herniated discs, bony spurs, ligamenta flava hypertrophy, and facet joint arthropathy. Hyperintense spinal cord signal on T2-weighted images can represent edema, inflammation, ischemia, myelomalacia, or gliosis [8]. MRI should not be a routine part of the diagnostic workup for cervical spondylosis unless indicated, because there is a high prevalence of degenerative findings on MRI in asymptomatic individuals [9].

Computed Tomography (CT)

 CT is more useful then X rays for evaluation of bony structures. CT is useful for assessing intervertebral foraminal stenosis. It is less useful than MRI for the evaluation of soft tissues and nerve root compression.

CT Myelogram

In patients in whom an MRI is contraindicated as in those with pacemaker and hardware, a CT with contrast (myelography) can be used to evaluate the location and amount of neural compression.

Electromyogram (EMG)

An EMG can be useful in supplementing neuroimaging findings in the diagnosis of cervical radiculopathy. It can differentiate nerve root compression from other concomitant neurologic conditions such as peripheral neuropathies, entrapment neuropathies, brachial plexus neuropathies, myopathies, and motor neuron diseases.

Management of cervical spondylosis

The treatment of cervical spondylosis will depend on the severity of the patient’s symptoms and signs. If there are no “red flag” symptoms and no significant myelopathy, the goals of treatment will be to relieve pain, improve function, and prevent permanent injury to neural structures. The treatment starts with non-operative management.

Neck pain will usually respond to conservative treatment but the optimal treatment for uncomplicated neck pain has yet to be established. Only a few treatments have been assessed in high quality randomised studies.

Non-surgical

Pharmacologic agents such as nonsteroidal anti-inflammatory drugs (NSAIDs), oral steroids, muscle relaxants, anticonvulsants, and antidepressants have been used for pain relief. No evidence however exists for the efficacy of non-steroidal anti-inflammatory agents or analgesics in the treatment of cervical spondylosis. The evidence that muscle relaxants relieve pain more than placebo is weak, while the incidence of side effects like drowsiness is high [10].

Opioid analgesics for refractory axial neck pain can be used but is not recommended as first-line or for long-term use due to their potential adverse effects.

A four- to six-week course of physical therapy, including isometric and resistance exercises to strengthen the neck and upper back muscles is the mainstay of non-surgical treatment. There are, however, two systematic reviews of small poor quality studies which showed that there is limited evidence of benefit for manipulation or mobilisation therapy [11,12].

There is very little evidence that home exercise regimens [13] pulsed electromagnetic field therapy [14], and multimodal therapy [15], is of benefit in treating neck pain.

Soft cervical collar can be used for short periods to alleviate acute neck pain and spasm. Nighttime use of a cervical pillow can also relieve neck pain by helping to maintain the normal cervical lordosis which would promote better quality sleep. 

In patients experiencing severe radicular pain, cervical traction may be useful to alleviate the nerve root compression that occurs with foraminal stenosis.

Surgical Treatment

Surgical intervention is usually considered in patients with severe or progressive cervical myelopathy, and in those patients with persistent axial neck pain or cervical radiculopathy following failure of non-operative treatment.

Indication for surgery

Before a decision to operate is made the diagnosis must be confirmed and that cervical spondylosis was the cause of the patients symptoms. Other  diseases such as motor neuron disease and multiple sclerosis must be  ruled out. The clinical diagnosis should be supplemented by appropriate imaging. Patients who are moderately or severely disabled on the first examination are usually candidates for surgery.

Surgical decompression of the cervical spine is indicated in patients with progressive impairment of function without sustained remission [16,17,18]. Patients with advanced neurological changes, diabetes, and alcoholism, are less suitable candidates because of the associated neuropathies. Those who are too old to engage actively in a postoperative rehabilitation programme are also less suitable candidates for surgery.

The surgical candidates must have a pathological condition on neuroimaging studies that corresponds to the clinical features. 

Types of surgery and surgical approach

The type of operation and surgical approach depends on the clinical syndrome and the site(s) of pathology.

An anterior approach is preferable in patients who have radicular pain due to central or bilateral disc herniation. In patients who have a lateral disc lesion, either an anterior or posterior approach is an option. Anterior cervical discectomy and fusion (ACDF) can be used to treat patients with myelopathy and pathological compression of up to three levels or when the cervical lordosis is lost.

The anterior approach involves a cervical discectomy or corpectomy followed by fusion with an allograft, autograft, or artificial intervertebral disc. Anterior plates, metallic cages, and synthetic spacers can be used in addition to the bone grafts. The fusion rates are comparable with these techniques. The long-term outcome of these procedures remains unclear.

The operations performed through the posterior approach include partial discectomy, laminoplasty, laminotomy-foraminotomy, and laminectomy. A foraminotomy alone is adequate in patients with foraminal stenosis due to osteophytes and/or lateral disc herniation. Laminectomy or laminoplasty is used to treat patients who require decompression at four or more levels or whose anterior column is already fused. Preservation of cervical lordosis is critical for a posterior approach as it allows the spinal cord to shift dorsally following the decompression. In patients with flexible cervical kyphosis  additional cervical posterior instrumentation is needed to help restore normal lordosis and maximize the posterior shift of the spinal cord [19].

Complications

Postoperative respiratory compromise due to trauma to the anterior soft-tissue and prolonged prone position has been reported to vary from 0%–14% [20,21,22,23]. This is probably caused by trauma to the anterior soft-tissue and prolonged prone position; both can cause upper airway oedema and impaired respiration [20,22].

Controlled hypotension used to reduce blood loss and facilitate surgical exposure during cervical surgery can cause spinal cord ischaemia and neurological damage. At least 65% of the usual spinal blood flow is required to maintain physiological integrity and a 12% decrease in blood flow can produce paralysis [24,25].

Long-term harvest site pain (3 months to 2 years) has been reported to occur in 2.5% of iliac crest bone grafting cases [26]. Anterior iliac crest bone graft harvest can be associated with injury to the lateral femoral cutaneous or ilioinguinal nerves due to direct injury, retraction, fracture or subfascial haematoma. Posterior iliac bone harvesting can cause injury to the superior cluneal nerves resulting in sensory deficit to the superior two-thirds of the buttocks.

The incidence of postoperative wound infections following anterior cervical discectomy and fusion is between 0.1%–1.6% [27]. Epidural abscesses can form and cause neurological complications. 

The risk of durotomy with CSF leak during cervical laminectomy is between 0.3%–13% and can be up to 18% following revision surgery [28,29]. Durotomies present with postural headache, vomiting, nausea, photophobia, dizziness, tinnitus and vertigo, but are usually asymptomatic. 

Persistent CSF leakage can lead to the formation of CSF fistulas or pseudomeningoceles.

The overall rates of complications following anterior cervical surgery in systematic review of literature by Timothy J. Yee, et al [30], were as follows: “dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%”. Carotid artery, cervical sympathetic chain, thoracic duct and tracheal injuries have also been reported [31].

Injury to the spinal cord and nerve roots can occur with both anterior and posterior surgery. Quadriplegia can occur with spinal cord injury. Graft dislodgement leading to failure of fusion and misplacement of screws leading to neurological or vascular injury has also been reported [31].

The incidence of kyphotic deformity after multilevel laminectomy is 20% [32].

Prognosis

Cervical spondylosis is a slowly progressive, degenerative disease of the cervical spine that deteriorates with age. The severity of symptoms, however, do not correlate with the degree of spondylosis seen on neuroimaging. Patients who present with axial neck pain usually improve with time but they can have a recurrence of pain. 

Gore et al [33] followed up 205 patients with neck pain for a minimum of 10 after onset of symptoms. They found that 79% of patients with neck pain improved or became asymptomatic on follow up. They also found that the presence or severity of pain was not related to the presence of degenerative changes, the spinal canal diameter, the degree of cervical lordosis, or to any changes in these measurements over the evaluation period.

Between 50 to 75% of persons with current neck pain will report neck pain again 1 to 5 years later. Psychosocial factors, including psychological health, coping patterns, and the need to socialize, are the strongest prognostic factors of neck pain [34].

Individuals who present primarily with axial neck pain do not develop more severe spondylotic changes leading to radiculopathy or myelopathy. Symptoms of cervical radiculopathy eventually resolve in 1 to 2 years without surgical intervention [35]. The long-term prognosis of cervical spondylotic myelopathy, on the other hand, is less clear.

The natural course of cervical spondylotic myelopathy is highly variable In patients with mild-to-moderate symptoms with the disease usually remaining static, and the symptoms occasionally improving [36]. Patients who have a progressive decline in neurologic function, and moderate to severe signs and symptoms, surgery is likely to be beneficial. 

A more recent Cochrane review by Nikolaidis et al [36] found that there is no good evidence in literature that surgery is beneficial for patients with cervical radiculopathy and myelopathy.

Conclusion

Cervical spondylosis is a natural age-related degenerative disease of the cervical spine. Degeneration of the cervical spine is a natural process of aging and by the age of 65 years the prevalence of cervical spondylosis is 95%. 

Most people with radiographic evidence of cervical spondylosis remain asymptomatic. The most commonly affected segment is C6-C7, followed by C5-C6. Neck pain is the most common symptom of cervical spondylosis. 

Patients can develop radiculopathy and/or myelopathy. 

X-rays and MRI imaging is used to confirm the diagnosis. The mainstay of treatment is conservative with the use of medications, exercises, collar and sometimes traction. Occasional surgery is necessary. Surgery can be associated with serious complications and should be used judiciously.

References

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           Unnecessary Surgeries   

                                   DR KS Dhillon

What is meant by unnecessary surgery? Unnecessary surgery is defined as any surgical intervention that is not needed or indicated and is not in the best interest of the patient [1,2].

In the USA, the threat of unnecessary surgery had been publicized as far back as 1953, when the Director of the American College of Surgeons,

Dr. Paul Hawley, stated that “the public would be shocked if it knew the amount of unnecessary surgery performed by dishonest doctors [3].

In 1976, the American Medical Association (AMA) called for a congressional hearing on unnecessary surgery. The association claimed that there were “2.4 million unnecessary operations performed on Americans at a cost of $3.9 billion and that 11,900 patients had died

from unneeded operations” [4].

In the USA it has been estimated that at least 20% of the money spent on health care is wasted which amounts to more than $700 billion dollars a year. Unnecessary medical care is a major contributor to this waste [5].

Types of unnecessary surgeries

There are many types of unnecessary procedures that are carried out. Some of them include [6]:

• Cardiac angioplasty and stents. According to a 2011 study in the Journal of the American Medical Association about 12 percent of all angioplasty interventions weren’t medically necessary. 
• Cardiac pacemakers. According to a 2011 study in the Journal of the American Medical Association, there was no medical evidence to support 22.5 percent of implantable cardioverter-defribrillator surgeries.
• Back surgery and spinal fusion. According to a 2011 study in the journal Surgical Neurology, over 17 percent of patients received unnecessary spinal surgery.
• Hysterectomy. About 70 percent of hysterectomies are unnecessary, according to a 2000 study for the American College of Obstetricians and Gynecologists.
• Knee and hip replacement. According to a 2012 study in Health Affairs, after patients received information on alternatives to joint replacement surgeries, researchers noted that approximately 26 percent of patients had fewer hip replacements and 38 percent had fewer knee replacements. 
• Cesarean section. According to a 2013 study in Health Affairs, C-section rates vary across hospitals. Even with lower-risk pregnancies, cesarean rates varied from 2.4 percent to 36.5 percent. 

There are many other areas of medical practice where unnecessary procedures are carried out.

In 2021, the existence of unnecessary surgery remains a daunting reality that continues to expose patients to unjustified surgical risk. There are multiple clinical trials that show that spinal fusions for back pain do not lead to improved long-term patient outcomes when compared to non-operative treatment [7,8]. Despite these insights from high-quality trials, spinal fusion rates continue to dramatically increase in the United States [9] and elsewhere in the world. 

Another example is arthroscopic partial meniscectomy. It is one of the most commonly performed surgical procedures in the world [10]. In the United States surgeons perform about 700,000 arthroscopic partial meniscectomies every year. A Finnish prospective randomized controlled trial that assessed patient outcomes after arthroscopic partial meniscectomy compared to sham surgery showed no benefit for patients from the surgical procedure at 12 months follow-up [11]. Although it is well known that any surgical procedure can be associated with a risk of severe intra- or postoperative complication [12] yet to date, a change in practice has not occurred, and arthroscopic meniscectomies continue to be performed on hundreds of thousands of patients in the USA every year [13,14].

In 2002 Moseley et al [15] published an article in the New England Journal of Medicine to show the futility of arthroscopic joint debridement for osteoarthritis of the knee but to date, such procedures are still carried out [15]. Moseley et al [15] did a randomized, placebo-controlled trial to assess the efficacy of arthroscopic knee surgery to relieve knee pain and improve function in patients with OA of the knee. They had three groups of patients who either had joint lavage, joint debridement, or sham incisions at the arthroscopic portals. Their study showed strong evidence that arthroscopic lavage with or without debridement is no better than placebo in relieving pain and improving self-reported knee function. The authors concluded that the billions of dollars spent annually on such procedures could be put to better use.

Kirkley et al [16] in 2008 published the outcome of a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. They randomly assigned patients to arthroscopic joint debridement with surgical lavage and physical plus medical therapy or to treatment with physical and medical therapy alone. At 2 years follow-up, they found that arthroscopic surgery for osteoarthritis of the knee provided no additional benefit as compared to optimized physical and medical therapy.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing around the world and in Australia, it is among the highest in the world [17,18]. There is a general belief that all ACL injuries must be treated with reconstruction to minimize symptoms, improve quality of life and minimize the risk of future complications such as chondral and meniscal injury. Now, however, there is level 1 scientific evidence that the mid-term (5 years) patient-reported and radiographic outcomes between those patients treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction are the same in young active individuals [19]. Despite such good level I evidence the incidence of ACL reconstruction is increasing around the world.

There are many surgeons who recommend a repair of grade 3 injuries of the lateral ligament of the ankle but there is no evidence that such surgery gives better results than conservative treatment.

Pihlajamaki et al [20] did a prospective randomized controlled trial to compare surgical versus functional treatment for acute ruptures of the lateral ligament of the ankle in young men. They found that at a mean follow-up of 14 years, all patients in both groups had recovered the pre-injury activity level and they could walk and run normally. There was no significant difference in the ankle scores.

In the United States, more than 18.9 million adults report chronic shoulder pain each year and it accounts for over 4.5 million primary care visits every year [21]. Shoulder impingement can account for about 85% of all shoulder complaints. It is estimated that almost 300,000 surgical procedures for shoulder pathology including impingement are performed yearly in the USA, with the direct financial burden estimated to be over US$3 billion annually [22].

Impingement syndrome is treated by subacromial decompression often by arthroscopy. There has been a sevenfold increase in subacromial decompression surgery in the United Kingdom from 2000 to 2010 and a fourfold increase in the US from 1996 to 2006 [23,24,25].

These increases in the number of subacromial decompression rates exist despite the presence of high-quality evidence that shows that subacromial decompression does not provide clinically important benefits as compared to placebo as far as pain, function, and health-related quality of life is concerned [26,27].

In ENT there is one procedure that has been done unnecessarily on millions of patients and wasted tens of billions of dollars over the past several decades, with no evidence that it even works for most patients. This overused procedure is endoscopic sinus surgery (ESS) [5].

Another ENT operation that is frequently done when it is not necessary is tonsillectomies in children. About 88 percent of tonsillectomies carried out on children in the UK each year are unnecessary [28].

If surgery was a pharmaceutical drug, the procedure would be required

to undergo scrutiny of testing for its safety and feasibility in several trials. 

Subsequently, the efficacy would have to be proven in randomized controlled trials before the Food and Drug Administration (FDA) would approve it [19]. The FDA, however, does not regulate surgical procedures. Common sense would dictate that whenever new level 1 evidence disproves a benefit for a certain surgical procedure, the ineffective practice should be immediately abandoned. This, however, is obviously not the case as far as surgery is concerned.

Why do surgeons continue to perform unnecessary surgery?

The question which begs for an answer is why would a reasonable surgeon consider performing unneeded surgical procedures which carry the risk of morbidity and mortality. The only surgery without risk of complications is the surgery that is not performed. 

There are estimates that as many as 1.3 million Americans suffer disabling injuries in hospitals every year, and 198,000 of those may result in death,  seven out of ten of which were preventable (48% from faulty surgery), and a third from negligence [29].

Unnecessary surgical procedures can be associated with the following:

• Death
• Infection, paralysis, blood clots, and other surgical complications
• Unnecessary loss of organs or organ function
• The need for follow-up expensive procedures and surgeries
• Diminished health and quality of life
• Surgical scars and other cosmetic blemishes
• Days, weeks, or months of missed work
• Huge medical bills

Unnecessary surgeries also lead to a profound loss of trust in the surgeon.

Surgeons have stated 2 primary reasons why unneeded surgeries continue to be performed [30]:

1. “We perform surgery because we have been trained to do so and because “we have always done it this way” or we simply do not know any better. 

2. We are incentivized to perform surgical procedures, either for financial gain, renown, or both”.

The main incentive for performing unnecessary surgery is financial gain.

Financial conflicts of interest usually drive physicians to perform worthless surgeries, and the field of orthopedics "is one of the worst offenders,"[31].

In the USA there have been many headlines of lawsuit allegations, investigations, guilty pleas, and convictions concerning this problem [32].  

In the USA and probably in many other parts of the world there are a number of reasons that drive medical overtreatment. 

Fee-for-service model is part of the problem. A profit-driven surgeon agenda is a problem since over 70% of U.S. doctors themselves believe that doctors "are more likely to perform unnecessary procedures when they profit from them" [33]. Doctors acknowledge that conflict of interest occurs because surgeons "are paid approximately ten times more money to perform surgery than to manage your problem conservatively" [34]. Hence financial pressures can lead to unnecessary surgery. One doctor quotes his residency professor who said that "there is nothing more dangerous than a surgeon with an open operating room and a mortgage to pay" [35].

Some surgeons have speaking agreements with medical device manufacturers and pharmaceutical companies. These surgeons carry out large numbers of operations, many of which are unnecessary, using their devices and implants. Surgeons receive consultancy fees for talks at meetings and conferences where the surgeon encourages others to use these devices and implants. Payments are made by these companies for trips, travel, lodging, food, honoraria, gifts, etc [36].  A conflict of interest in this setting can lead the surgeon to use a particular type of surgical device, even when it is not the right one for the patient. Unfortunately, there are many surgeons who are “in bed with the device industry." [34].

This "symbiotic" relationship between medical device manufacturers and surgeons provides the surgeons with an important source of revenue [35].  

Many of the surgeons don't disclose these potential conflicts of interest in studies that they publish about these devices [36]. Surgeons often tend to perform a given surgery due to their relationship with the device manufacturer instead of what is in the best interests of the patient.  There are even cases where some device-makers have even paid millions of dollars to settle cases involving allegations of improper payments to surgeons [37]. 

There are teaching hospitals in the USA that have come under scrutiny for accepting revenue from medical device manufacturers as well [38]. There are also many surgeons who are owners or co-owners of ambulatory surgical centers. This ownership model can be associated with conflicts of interest that affect surgical decisions leading to a higher volume of surgeries [39].   

Hospitals are also sometimes involved in these conflicts of interest. They drive the surgeons to do unnecessary procedures. The hospital administrators put pressure on surgeons to generate more money by performing more procedures [34]. In some cases, hospitals have purchased very expensive surgical equipment or devices and they need to justify their use. Hospitals sometimes require surgeons to perform a minimum number of some procedures every year or two years. 

When is Unnecessary Surgery Medical Malpractice?

Unnecessary surgery can be medical malpractice. To file a malpractice lawsuit for unnecessary surgery, one has to prove negligence. There are several ways to prove negligence and these includes but are not limited to:

• Doctor failed to inform the patient of the risks or benefits of the surgery versus the risks of not having the surgery.
• Doctor recommends surgery without considering or offering reasonable alternative treatment.
• When there is a misdiagnosis and surgery is performed. 

A claim of medical negligence could be filed for a medical malpractice lawsuit if a medical mistake was made during the surgery. Compensation can be obtained for unnecessary surgery if medical negligence can be proved. 

In the USA a Virginia doctor was sentenced to 59 years in prison for performing irreversible hysterectomies, improper sterilizations, and other medically unnecessary surgeries on his patients. In November of 2019, Dr Javaid Perwaiz was charged with health care fraud and making false statements relating to health care matters. 

His conviction resulted from various patient complaints. One patient had her fallopian tubes removed without her consent, resulting in being unable to conceive naturally. In another patient, an unauthorized hysterectomy was carried out which resulted in a perforated bladder which resulted in a 6-day hospital stay. Besides performing irreversible hysterectomies he carried out improper sterilizations and other medically unnecessary surgeries on his patients. 

Perwaiz was an obstetrician-gynecologist in Chesapeake, Virginia, since the 1980s. From 2010 to 2019, he defrauded health insurance programs, resulting in about $20.8 million in losses to health care insurers. He would often trick his patients into having unnecessary surgeries by telling them they had cancer or needed the surgery to avoid cancer. 

In four years, from January 2014 to August 2018, he operated on 40% of his Medicaid beneficiaries, or a total of 510 patients. Out of those, 42% of the patients had at least two surgeries [40].

Unnecessary surgeries in Malaysia

Anecdotal evidence suggests that the number of unnecessary surgeries in Malaysia is also high. There are no studies published to show the high incidence of unnecessary surgeries in Malaysia. 

Apparently, every year about 2,000 to 4,000 deaths occur due to some form of medical negligence and a large number of these cases go unreported partly because of the out-of-court settlements and partly due to the fact that many patients accept the incidents as matters of fate. Many patients are not aware of their rights and others are too poor to afford litigation especially in Malaysia where there is no speedy and inexpensive system of administration of justice in medical negligence [41].

Some have estimated that medical errors could be the No 2 killer in Malaysia after heart diseases and cardiovascular disorders. Medical errors probably kill more Malaysians than either cancer, diabetes, or motor vehicle accidents. Apparently for every case of medical error reported, 10 cases go unreported. About 80 percent of medical procedures performed today have never been properly tested [42].

In Malaysia, there is a lack of proper machinery to deal with poorly performing doctors except through the court of law. Medical negligence cases and malpractice cases are excessively difficult to prove and they take a very long time to settle. 

The Malaysian Medical Council (MMC) is a “passive regulatory body”. It deals with complaints of ethics and professional behavior that are reported to it.  There is no inspectorate to detect offenses. The regulatory bodies as well as the regulatory processes in Malaysia do not show that they provide sufficient safeguards to protect the interests of the public [43]. 

There have been questions as to why aren't the interests and the safety of millions of patients in Malaysia protected against medical mishaps and errors? Patients are not only not assured of consistent quality medical care but they are also denied a speedy, effective, and fair avenue for justice when there is medical negligence and malpractice [44].

They are also victims of a lack of an effective system to protect their interests and safety. 

A careless, incompetent, or irresponsible medical professional has the power to kill, paralyze, disfigure or dismember his patients. The safety and well-being of all patients should be of paramount importance. Hence it is important that the medical profession is most stringently regulated. However, unfortunately, the medical profession and the way it deals with medical errors seems to be shrouded in mystery and secrecy. It lacks integrity, accountability, and transparency. 'Prevention is better than cure' should be practiced more by the medical profession in preventing medical negligence, malpractice and errors because there are no quick, cheap, or painless cures for botched-up medical procedures [44].

Reference

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4. A.M.A. scores ‘unneeded surgery’ report. The New York Times, May 12, 1976.
5. Arthur W. Curtis. Endoscopic sinus surgery: A tale of overuse at https://rightcarealliance.org/article/endoscopic-sinus-surgery-tale-overuse/
6. Did You Undergo Unnecessary Surgery? You May Be a Victim of Medical Malpractice at https://www.mallardlawfirm.com/library/be-aware-of-the-common-types-of-unnecessary-surgeries.cfm.
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8. Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain. Arch Intern Med. 2012;172:1016–20.
9. Why ‘useless surgery’ is still popular. The New York Times, August 3, 2016. 
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11. Sihvonen R, Paavola M, Malmivaara A, Itala A, Joukainen A, Nurmi H, Kalske J, Jarvinen TL. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369:2515–24.
12. Grelsamer RP. A patient guide to unnecessary knee surgery. AuthorHouse, 2015, pp.150.
13. Lyu SR. Why arthroscopic partial meniscectomy? Ann Transl Med. 2015;3:217.
14. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med. 2015;49:1229–35.
15. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88
16. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D'Ascanio LM, Pope JE, Fowler PJ. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359((11)):1097–107.
17. Janssen K, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2011; 22: 495-501.
18. Moses B, Orchard J, Orchard J. Annual incidence of ACL injury and surgery in various populations. Res Sports Med 2012; 20: 157-179.
19. Frobell R, Roos H, Roos E, Roemar F, Ranstam J, Lohmander L. Treatment for anterior cruciate ligament tear: five year outcome of randomized trial. BMJ 2013; 346: f232.
20. Pihlajamäki, Harri MD, PhD1; Hietaniemi, Kalevi MD, PhD2; Paavola, Mika MD, PhD3; Visuri, Tuomo MD, PhD1; Mattila, Ville M. MD, PhD4 Surgical Versus Functional Treatment for Acute Ruptures of the Lateral Ligament Complex of the Ankle in Young Men, The Journal of Bone & Joint Surgery: October 20, 2010 - Volume 92 - Issue 14 - p 2367-2374 doi: 10.2106/JBJS.I.01176
21. Khan et al. Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ Open 2019, Jan -Mar; 7(1): E149-E158.
22. Colvin AC, Egorova N, Harrison AK, et al. National trends in rotator cuff repair. J Bone Joint Surg Am 2012;94:227-33.
23. Judge A, Murphy RJ, Maxwell R, et al. Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J 2014;96-B:70-4.
24. Vitale MA, Arons RR, Hurwitz S, et al. The rising incidence of acromioplasty. J Bone Joint Surg Am 2010;92:1842-50.
25. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ; CSAW Study Group. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018 Jan 27;391(10118):329-338.
26. Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019 Jan 17;1:CD005619. doi: 10.1002/14651858.CD005619.
27. Why ‘useless surgery’ is still popular. The New York Times, August 3, 2016.
28. Dana Šumilo, Linda Nichols, Ronan Ryan and Tom Marshall. Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic records. : Br J Gen Pract 2018; DOI: https://doi.org/10.3399/bjgp18X699833.
29. Unnecessary surgeries at https://sweeneylawfirm.com/content/unnecessary-surgeries.
30. Stahel et al.Why do surgeons continue to perform unnecessary surgery?  Patient Safety in Surgery (2017) 11:1 DOI 10.1186/s13037-016-0117-6.
31. Cheryl Clark. Orthopedists' Financial Conflicts Can Hurt Patients, Surgeon Says at https://www.medpagetoday.com/surgery/orthopedics/50601.
32. Mark Clore. Unnecessary Surgery: When the Doctor Gambles, Who Puts Up the Stakes? at https://www.clorelaw.com/insights/unnecessary-surgery-when-the-doctor-gambles-who-puts-up-the-stakes.
33. Lyu Xu T, et al, Overtreatment in the United States, PLOS One (Sep. 6, 2017), pp. 4-5, at: https://doi.org/10.1371/journal.pone.0181970.
34. Crouch M, 45 Secrets Surgeons Won’t Tell You, The Healthy, Nov. 25, 2019, Updated Nov. 14, 2020.
35. Cox, CE, Physician Conflict of Interest Disclosures to Journals for Device Industry Ties Falls Short, tct/md the heart beat, Aug. 24, 2018, p. 2.
36. Wolters Kluwer Health, Financial conflicts of interest are often not disclosed in spinal surgery journals, at: https://medicalxpress.com/news/2020-07-financial-conflicts-disclosed-spinal-surgery.html
37. U.S. Attorney's Office, Dist. of NJ Release, Medical Device Maker to Pay $18 Million to Settle Allegations of Improper Payments to Physicians, Oct. 14, 2020, at: https://www.justice.gov/usao-nj/pr/medical-device-maker-pay-18-million-settle-allegations-improper-payments-physicians, and U.S. Dep't of Justice (DOJ), Public Affairs, Medtronic to Pay Over $9.2 Million to Settle Allegations of Improper Payments to South Dakota Neurosurgeon, Oct. 29, 2020, at: https://www.justice.gov/opa/pr/medtronic-pay-over-92-million-settle-allegations-improper-payments-south-dakota-neurosurgeon.
38. Adams K. Drug, device companies' payments to teaching hospitals may spark conflict of interest, study suggests. Becker's Hospital Review, Sep. 9, 2020.
39. Hollingsworth JM, Ye Z, et al, Physician-Ownership of Ambulatory Surgery Centers Linked to Higher Volume of Surgeries, Vol. 29, No. 4, Health IT.
40. Virginia doctor sentenced to 59 years in prison for performing unnecessary surgeries on patients at https://www.usatoday.com/story/news/2021/05/19/doctor-who-performed-unnecessary-sterilizations-faces-59-years-jail/5170521001/
41. Prof Dr Ali Mohamad Matta. Issues in Medical Law and Ethics , Medical Law and Ethics Unit, Law Centre, Ahmad Ibrahim Kulliyyah of Laws, IIUM Malaysia, Dec 2003, p21.
42. SM Mohd Idris, Can Doctors Be Trusted? How to protect Yourself against Medical Errors (2004), Consumers' Association of Penang.
43. Dr Nik Rosnah Wan Abdullah (September 2003) The Malaysian Medical Professionals: Serving the Public Interests? , FEA Working Paper 2003-9, University of Malaya.
44. Kumaraguru. Justice for victims of medical negligence at https://www.malaysiakini.com/letters/29600.

         Breakthrough Covid-19 Infections

                            Dr. KS Dhillon

A vaccine breakthrough infection is defined as the detection of SARS-CoV-2 RNA or antigen in a respiratory specimen collected from a person 14 or more days after they have completed all recommended doses of a COVID-19 vaccine.

We are all aware that COVID-19 vaccines are a critical tool for controlling the ongoing global pandemic. In large, randomized-controlled trials, some vaccines have been found to be safe and efficacious in preventing symptomatic, laboratory-confirmed COVID-19. Despite the relatively high level of vaccine efficacy, a small percentage of fully vaccinated persons do develop symptomatic or asymptomatic infections with SARS-CoV-2, the virus that causes COVID-19.

In the USA as of 30th April 2021, a total of 10,262 SARS-CoV-2 vaccine breakthrough infections had been reported from 46 U.S. states and territories. Sixty-three percent of the cases occurred in females, and the median patient age was 58 years (range = 40–74 years). Twenty-seven percent of vaccine breakthrough infections were asymptomatic, 10% of the patients were hospitalized, and 2% of patients died. Among the 995 patients who were hospitalized 29% were asymptomatic and they were hospitalized for a reason unrelated to COVID-19. The median age of patients who died was 82 years (range = 71–89 years). 

The percent of patients who develop breakthrough infections is small in vaccinated individuals. The breakthrough infections in vaccinated individuals range from 0.2% to 5.9% of the total Covid-19 infections according to statistics from various states in the USA. Ninety-four to 99.8% of the infections occur in non-vaccinated individuals.

The number of breakthrough infection cases are probably underreported because the national surveillance system in the USA relies on passive and voluntary reporting, and data might not be complete or representative. Many individuals with vaccine breakthrough infections, especially those who are asymptomatic or who experience mild illness, might not go for testing. 

A review of Veterans Health Administration (VHA) medical records in the USA pertaining to COVID-19 breakthrough infections in Veterans with spinal cord injuries and disorders (SCI/D), showed that 17 out of 8,319 (0.20%) fully vaccinated Veterans with SCI/D had breakthrough infection as of April 20, 2021. Of those diagnosed with COVID-19 breakthrough infections, 6 (35.3%) were symptomatic and 11(64.7%) were asymptomatic. Of the six symptomatic cases, three were of mild severity, one was moderate, and two were severe. Three patients were hospitalized, and one patient died within 30 days of COVID-19 diagnosis.

A study was carried out at the largest medical center in Israel, to identify breakthrough infections among health care workers. Among 1,497 fully vaccinated health care workers, 39 SARS-CoV-2 (2.6%) breakthrough infections were detected. 

Most breakthrough cases were mild or asymptomatic, although 19% had persistent symptoms lasting more than 6 weeks. The alpha variant was found in 85% of the samples tested. 

A study was carried out in India to ascertain the number of breakthrough COVID19 infections after vaccinations in a chronic care, diabetes-centric healthcare facility. One hundred and seven (94.7%) out of 123 employees had completed their 2nd dose of vaccination. Symptomatic breakthrough infections after 14 days of the second dose occurred in 15 persons (13.3%). All 14 had mild COVID19 disease.  Symptoms lasted from 3 to 14 days. One patient required hospitalization for pneumonia. 

The Chicago Department of Public Health (CDPH) carried out a study to identify breakthrough infections among skilled nursing facility residents and staff members in Chicago, Illinois, between December 2020 and March 2021.

There were 627 persons with SARS-CoV-2 infection across 75 SNFs.  Breakthrough infections occurred in 12 residents and 10 staff members accounted for 16% (22 of 136) of the COVID-19 infections. Nearly two-thirds (14 of 22; 64%) of persons with breakthrough infections were asymptomatic; two residents were hospitalized because of COVID-19, and one died.

In the USA as of 2nd August 2021, more than 164 million people had been fully vaccinated against Covid-19. According to data from CDC, there have been 7,101 hospitalizations and 1,507 deaths due to breakthrough infections. Individuals who are fully vaccinated and develop breakthrough infections usually develop mild to moderate illness, if they develop symptoms at all.

Vaccines shorten the length of illness in individuals who develop breakthrough infections. Vaccination reduces disease severity and duration of illness in individuals who develop breakthrough infections. 

Previously, scientists believed that vaccinated individuals rarely transmitted the virus. However, the Delta variant has changed the game. Emerging evidence shows that vaccinated individuals can spread the Delta variant to some extent. Unvaccinated individuals transmit the virus at a higher rate than vaccinated individuals.

Individuals with weakened immune system are at higher risk of getting  breakthrough infection because the vaccines work less well for them. Immunocompromised individuals include organ transplant recipients, cancer patients, and those with advanced HIV or uncontrolled diabetes. Upto 46% of patients who had received solid organ transplants do not mount an antibody response after two doses of an mRNA vaccine. A booster shot may be required for immunocompromised individuals.

Older individuals are more at risk of developing severe complications from breakthrough infections. Around three-quarters of breakthrough infections that caused hospitalizations or deaths occur in those aged 65 and older.

Overall, the data in the USA, showed that approximately 1 in 900 vaccinated people had breakthrough infections. The vast majority of those infected have mild or no symptoms of Covid. About 1 in 17,000 need to be hospitalized. Approximately 1 in 83,000 vaccinated people die from Covid. 

In general, it's very, very rare to get Covid infection after being vaccinated.

Overall about 95% of breakthrough infections are mild and do not require hospitalization.

In Malaysia, the incidence of breakthrough infections is higher than in the USA. Between Aug 12 to Aug 29, 2021, there were 68,629 breakthrough infections comprising 17.8% of the total 385,542 Covid-19 cases. There has been a gradual increase in the percentage of breakthrough infections. On 12 August 2021 the percentage was 12.6% and on 29 August 2021, it was 23.9%. 

There were 8,159 patients in category 3 to 5 who were hospitalized. The percentage of fully vaccinated was 1.6% and 2.2% were not fully vaccinated. The number of ICU admissions of category 4 and 5 patients was 4,762. The percentage of fully vaccinated was 0.8% and not fully vaccinated was 1.3%.

In Malaysia, daily Covid-19 cases increased fourfold from 5,586 on June 27 to 22,070 on 27 August 2021, while daily deaths increased from 60 cases on June 27 to 339 on 27 August. 

As of 27 August 2021, 61.1 percent of the country's adult population had been fully vaccinated, while in the Klang Valley, 88.7 percent of the adult population had been fully immunized. New cases, however, continued to spike in Selangor (from 2,212 cases on June 27 to 5,920 on 27 August) and Kuala Lumpur (628 cases on June 27 to 1,809 on 27/8/21).

Death rates in Selangor also increased from 20 fatalities on June 27 to 103 on 27/8/21. In Kuala Lumpur, it spiked from 16 deaths on June 27 to 40 on 27/8/21.

An end to this pandemic does not appear to be in sight despite the large numbers of individuals having been vaccinated.

     Posterior cruciate ligament injuries

                                    Dr. KS Dhillon

Anatomy and Biomechanics

The posterior cruciate ligament (PCL) length averages between 32mm and 38mm from its origin to insertion, and its cross-sectional area narrows distally [1]. The PCL is mainly made up of two bundles, namely the anterolateral bundle (ALB) and posteromedial bundle (PMB). The femoral attachment of the ALB is nearly twice as big as the tibial insertion. The ALB is more lax in full extension and tight in full flexion. This bundle comprises about 65% of the total mass of the PCL. The PMB is taught in extension and lax in flexion. 

The PCL extends from the posterior tibial plateau to the roof of the femoral notch. It is intraarticular but extra synovial. The synovial membrane covers the entire ligament except for the posterior part. The PCL femoral insertion is half-moon shaped and the PCL tibial insertion is nonplanar and rectangular in shape.

The PCL is surrounded by the anterior meniscofemoral ligament known as the Humphrey ligament and the posterior meniscofemoral ligament which is known as the Wrisberg ligament, which emerges from the lateral aspect of the medial femoral condyle and inserts distally close to the posterior horn of the lateral meniscus. Both these ligaments are only present in 49% of the knees, providing up to 71% of the posterior stability in a PCL-deficient knee, particularly between 60° and 90° of flexion [2].

The PCL is the primary restraint to posterior tibial translation on the femur and the secondary restraint to external rotation [3]. These functional roles are most when the knee is flexed to 90 degrees. When the knee is in full extension there is a minimal posterior translation with an isolated PCL lesion [3]. 

Studies show that kinematic differences increased significantly with combined PCL/posterolateral corner (PLC) lesions when compared with isolated lesions [4,5,6]. 

Mechanism of Injury

Three mechanisms have been proposed for rupture of the PCL:

1. Hyperflexion

Hyperflexion knee injury is common in sports. The individual falls on hyperflexed knee and the traumatic forces are directed proximally up the tibia which leads to posterior subluxation of the tibia and rupture of the PCL.  Nearly always an anterior isolated intrasynovial intrasubstance tear occurs and often the posteromedial bundle remains intact. The laxity is rarely greater than grade II. These lesions can heal to some extent and with time the laxity may often decrease to grade I [7].

2. Pretibial Trauma

The most common traumatic mechanism for injury to the PCL is the dashboard injury. The knee is in a flexed position and a posteriorly directed force is applied to the anterior aspect of the proximal tibia. Such an injury results in an intrasubstance tear at the level of the tibial plateau or a tibial avulsion. Severe trauma will result in damage to the meniscofemoral ligaments as well.

An anteromedial and a rotational force can cause a tear of the posterolateral corner. When the PCL and posterolateral corner is torn, the posterior instability will be greater. 

3. Hyperextension

Hyperextension injury can result in tearing of the PCL and the posterior capsule. Hyperextension can lead to dislocation of the knee and neurovascular compromise. The PCL injury is frequently a proximal disruption at the femoral attachment. 

Epidemiology

The incidence of PCL injuries in the literature varies widely and this disparity results from differences in the population of individuals examined. Miyasaka and Daniel[8] reported an incidence of 3% in the general population, whereas Fanelli and Edson [9] reported an incidence of 38% in patients with acute knee hemarthrosis in an emergency room.

There is an association between athletic injuries and `isolated' PCL injuries. The most frequent mechanism of injury in athletes is hyperflexion injury. In an emergency room setting, 56.5% of injuries are trauma-related and 32.9% are athletic-related [7]. Fanelli and Edson [9] reported that 96.5% of the PCL injuries occurred in combination with other ligamentous injuries. 

The majority of PCL tears occurred in motor vehicle and motorcycle accidents. They concluded that the incidence of PCL injuries is higher in patients with trauma as compared to patients with athletic injuries.

Most grade III PCL injuries occur with other ligament injuries (79% of cases) [10]. Isolated PCL injuries are rare and occur in 3.5% of the patients, whereas 96.5% of PCL injuries occurred in combination with other ligament injuries [9]. 

Classification

The appropriate treatment of PCL injuries remains uncertain. This is partly due to inaccurate classification of patients in follow-up studies. PCL injuries can be classified according to the structures damaged (isolated vs combined), the degree of instability, and the mechanism of injury [7]. 

• Type I- Where the PCL is stretched, laxity is less than 5mm and the tibial plateau is 5mm to 10mm anterior to the femoral condyle.
• Type II- Where the PCL is torn, MF ligaments intact, laxity is 5mm to 9mm and the tibial plateau is 0 to 5mm anterior to the femoral condyle.
• Type III-Where the PCL and MF ligaments are torn, laxity is > 10mm and tibial plateau is flush with the femoral condyle.
• Type IVA- Where there is PCL, LCL, and posterolateral injury, laxity is >12 mm and the tibial plateau is > 2mm posterior to the femoral condyle.
• Type IVB-  Where there is PCL, MCL, and posteromedial injury, laxity is >12 mm and the tibial plateau is > 2mm posterior to the femoral condyle.
• Type IVC- Where there is PCL and ACL injury, laxity is >15mm and the tibial plateau is > 5mm posterior to femoral condyle.

Grades I to III are isolated injuries and grade IV is a combined injury.

Clinical Evaluation

History

A thorough history including the mechanism of injury is useful. The chief complaint and level of activity need to be determined. Patients with acute isolated PCL tear will complain of mild swelling, pain and inability to bear weight. Patients with chronic PCL laxity complain of pain. The pain is most prevalent with long distance walking and descending stairs. The pain is predominantly felt in the retropatellar area and medial compartment of the knee. Other complaints include difficulty walking with the knee extended in mid stance. They also can have apprehension while descending stairs because they get a sense of unsteadiness or sliding of the joint when going downstairs. Athletes often complain of a decreased ability to rapidly change direction [7]. However, significant giving way of the knee or buckling that is commonly seen with an ACL deficient knee is usually not seen with an isolated PCL tears. Instability is common in patients with combined injury.

Physical examination

A physical examination for a posterior cruciate deficient knee following an acute injury must include inspection over the anterior tibia for abrasions, ecchymosis or lacerations, range of motion, gait assessment, and a neurovascular examination. 

Testing for an acute posterior cruciate ligament injury is usually difficult because of a tense hemarthrosis and pain. The most accurate test for determining a posterior cruciate rupture is the posterior drawer test at 90° of knee flexion. Following an acute injury, it is often difficult to achieve 90 degrees of knee flexion because of pain. Staubli and Jakob [11]described significant posterior translation of the tibia at 10 to 15° of flexion. The posterior tibial sag and Lachman test and reverse pivot shift tests can be useful.

Injuries to other ligamentous structures must be excluded. Examination of the ACL, collateral ligaments, and posterolateral corner must be carried out.

Slightly increased posterior translation at 30° but not 90° indicates a posterolateral injury. An isolated PLC injury increases external rotation at all angles of flexion, but this is maximal at 30°. Neurovascular examination must be carried out to exclude peroneal nerve and vascular injury.

Ancillary Tests

Radiographs are taken to rule out an avulsion fracture of the PCL at its tibial insertion. Fibular head fractures are indicative of a PLC injury. Magnetic resonance imaging (MRI) has been shown to be highly accurate in the diagnosis of a complete PCL tear. Associated collateral ligament, meniscal and chondral injuries can also be diagnosed with an MRI. A good history and physical examination is very accurate in diagnosing a PCL injury, and hence an MRI is not routinely required. 

Treatment of isolated PCL injuries

There is no controversy about the treatment of PCL avulsion fractures, which are ideally treated by open reduction and internal fixation when the fragment is large enough to be fixed with a screw. Isolated injuries of the PCL usually produce a grade I to II posterior laxity of the knee while a grade III laxity is produced by a combined PCL and posterolateral corner injuries. What is the best method of treatment of isolated PCL injuries?

An acute midsubstance tear of the PCL may heal [12] unlike ACL mid-substance injuries which do not heal. Logically such injuries should be treated conservatively. The long-term natural history of isolated PCL injuries suggests that there is no indication for surgical treatment of such injuries because the outcome of conservative treatment is good. There are no studies to show that surgical treatment is better than conservative treatment for isolated tears of the PCL. Neither is there any evidence that surgical treatment reduces the incidence of osteoarthritis of the knee after PCL injuries [13]. 

Natural history of isolated PCL injuries

One of the earlier studies of the long-term outcome of non-operatively treated isolated PCL injuries was done by Parolie and Bergfeld in 1986 [14]. They studied 25 patients who were treated conservatively for isolated PCL injuries and followed up for a mean of 6.2 years (2.2 to 16 years). They found that 80% of the patients were satisfied with their knee and 84% had returned to their previous sport, with 68% at the same level of performance and 16% at a reduced level of performance. Patients who were satisfied with their knee and had returned to sports had quadriceps strength of more than 100% of the contralateral uninvolved knee and those who were dissatisfied with their knee and not returned to sports had less than 100% strength of the quadriceps as compared to the contralateral knee. 

Selbourne et al [15] prospectively studied the natural history of acute, isolated, nonoperatively treated PCL injuries in athletically active patients. The study included 133 patients all of whom completed a yearly questionnaire for an average of 5.4 years (2.3 to 11.4 years) and 51% of the patients (68 out of 133) returned for long-term clinical and radiological examination. The functional outcome was good with a mean modified Noyes knee score of 84.2 points, a mean Lysholm score of 83.4, and a mean Tegner activity score of 5.7. The grade of laxity had no correlation with subjective functional outcome. Fifty percent of the patients returned to the same sport at the same or higher level of performance, one-third (33.3%) returned to the same sport at a lower level and one-sixth (16.6%) did not return to the same sport.

The authors concluded that ‘athletically active patients with acute isolated posterior cruciate ligament tears treated nonoperatively achieved a level of objective and subjective knee function that was independent of the grade of laxity’.

The longest follow-up study of patients with acute, isolated PCL injuries treated non-operatively was reported by Shelbourne et al in 2013 [16]. The study included 68 patients who had a subjective follow-up at a mean of 17.6 years and 44 of the patients had a subjective and objective follow-up at a mean of 14.3 years (10-21 years). The mean quadriceps strength was 97% of the contralateral side and the range of knee motion was normal in all patients. 

Fifty percent of the patients had no osteoarthritis (OA) of the knee, 30% had mild OA, 9% (4 patients) had moderate and 2% (1 patient) had severe OA of the knee at a mean follow-up of 14.3 years. The mean IKDC (International Knee Documentation Committee) and modified CKRS (modified Cincinnati Knee Rating System) subjective scores were 73.4 ± 21.7 and 81.3 ± 17.4, respectively at 17 years follow-up and the subjective scores did not correlate with the degree of PCL laxity.

The authors concluded that long-term follow-up of patients, with isolated PCL injuries treated non-operatively, shows that patients remain active, have good muscle strength, full range of knee motion and they report good subjective scores, and that the incidence of post-traumatic OA is low.

In 2007 Patel et al [17] published a study involving 57 patients with acute isolated PCL injuries who were treated non-operatively with a mean follow-up of 6.9 years (2 to 19.3 years). Seventeen patients (29.8%) had a grade I and 41 patients (71.9%) had a grade II laxity of the PCL. The functional outcome at 7 years was good with a mean Lysholm-II knee score of 85.2 points (range 51 to 100 points) and a mean Tegner activity level of 6.6 (range 3 to 10). The Lysholm-II knee scoring system showed excellent results in 40%, good in 52%, fair in 3%, and poor in 5% of the knees. The incidence of mild medial compartment OA was 12% and moderate medial compartment OA 5% and none of the patients had severe OA.

These medium and long-term studies of the natural history of isolated PCL injuries reveal that the subjective functional outcome is good, without surgical intervention, with the majority of the patients returning to their pre-injury activity level. Are the results of PCL reconstruction better than conservative treatment?

Surgical treatment of isolated PCL injuries

Most of the published studies reporting the outcome of PCL reconstruction for isolated PCL injuries are small case series with a short follow-up, and the heterogeneity of the patients studied and the technique used makes it difficult to judge outcomes in these patients [18].

However, there are two studies that have reported the long-term outcome of PCL reconstruction in patients with isolated PCL injuries. 

Herman et al [19] studied 25 patients (22 male, 3 female) with an average age of 30.8 years who underwent single-bundle PCL reconstruction for pain and functional instability of the knee. The mean follow-up was 9.1 years (6.5 to 12.6 years). Twenty-two patients were evaluated clinically and 3 patients were provided telephone interviews.

The final mean IKDC score was 65, Lysholm score was 75 and the VAS (visual analog score) was 8. The functional scores were fair to good and were significantly better than the pre-operatively scores. The final Tegner score was 5.7. The functional results were significantly better in patients with no cartilage damage at the time of surgery and in those who underwent surgery within 1-year post-injury.

Jackson et al [20] evaluated the long-term outcome of PCL reconstruction in 26 patients after failed conservative treatment. At 10 years follow-up, the IKDC score was 87 and the Lysholm score improved from 60 to 90 postoperatively. Twenty-two patients had a radiological examination and 18% of the patients had grade II OA changes and another 18% had grade III OA changes.

A careful analysis of the subjective outcome reported by Shelbourne [12] and Patel [17] for non-operative treatment and that by Herman [19] and Jackson [20] for surgical treatment of PCL injuries appears to be very similar. 

Complications of PCL surgery

PCL injuries are rare and the indications for surgery of the PCL are limited since conservative treatment has a good outcome, therefore the number of PCL surgeries carried out by surgeons per year are small. This limited experience with such complex surgery can lead to a higher incidence of complications especially when there are vital neurovascular structures at the back of the knee. Furthermore catastrophic complications usually never get reported which can give surgeons a false sense of relative risks involved when undertaking such procedures. 

Besides the standard complications, such as those associated with anesthesia and complication of surgery such as infections and thromboembolic complications which can occur with any orthopedic procedure, there are specific complications associated with PCL surgery, some of which includes neurovascular injury, osteonecrosis, fractures, stiffness, residual laxity and anterior knee pain. 

A survey of the frequency of complications associated with arthroscopic surgical procedures of the knee reported by Salzler et al [21], where the data was obtained from the ABOS (American Board of Orthopaedic Surgery) database, showed that the complication rate was the highest for PCL surgery as compared with other arthroscopic procedures. The complication rate for PCL surgery was 20.1%, ACL surgery 9.7%, meniscal repair 7.7%, meniscectomy 2.8%, and chondroplasty 3.5%. The overall pulmonary embolism rate was 0.11% and the infection rate 0.84%. These were self-reported complication rates and the authors believe that the actual rates may be higher.

Conclusion

Posterior cruciate injuries can be caused by a variety of different mechanisms. The usual cause is trauma and sports. It is important to differentiate isolated PCL injuries from combined ligament injuries. The diagnosis can be established by a good history and good clinical examination. If the diagnosis is uncertain an MRI will be useful. It is critical to rule out neurovascular injuries in patients who have combined injuries.

Most patients with isolated PCL injuries can be treated conservatively. The mainstay of treatment is quadriceps strengthening with avoidance of active hamstring exercises. 

Medium and long-term studies of the natural history of isolated PCL injuries reveal that the subjective functional outcome is good, without surgical intervention, with the majority of the patients returning to their pre-injury activity level.

The incidence of posttraumatic OA is low after PCL injuries. The incidence of mild medial compartment OA is 12% and moderate medial compartment OA 5% and none of the patients usually develop severe OA.

A careful analysis of the subjective outcome of non-operative treatment and  surgical treatment of PCL injuries appears to be very similar. 

The complication rate following  PCL surgery is the highest as compared with other arthroscopic procedures. The reported complication rate for PCL surgery is about 20% but in actual fact may be higher.

 

 References

1. Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res. 1975 Jan-Feb;(106):216-31. doi: 10.1097/00003086-197501000-00033. PMID: 1126079.
2. Gupte CM, Bull AMJ, Thomas RD, Amis AA. The meniscofemoral ligaments: secondary restraints to the posterior drawer. Analysis of anteroposterior and rotary laxity in the intact and posterior-cruciate-deficient knee. J Bone Joint Surg [Br] 2003;85-B:765-773.
3. Castle Jr TH, Noyes FR, Grood ES. Posterior tibial subluxation of the posterior cruciate-deficient knee. Clin Orthop 1992; 284: 193-202.
4. Veltri DM, Deng XH. Torzilli PA, et al. The role of the cruciate and posterolateral ligaments in stability of the knee: a biomechanical study. Am J Sports Med 1995; 23: 436-43.
5. Noyes FR, Stowers SF, Grood ES, et al. Posterior subluxations of the medial and lateral tibiofemoral compartments: an in vitro ligament sectioning study in cadaveric knees. Am J Sports Med 1993; 21: 407-14.
6. Harner CD, Vogrin TM, Höher J, Injury to the posterolateral structures has profound effects on the function of the human posterior cruciate ligament [abstract]. Trans Orthop Res Soc 1998; 44: 47.
7. Janousek et al. Posterior Cruciate Ligament Injuries of the Knee Joint. Sports Medicine 2000, 28(6):429-41.
8. Miyasaka KC, Daniel DM. The incidence of knee ligament injuries in the general population [abstract], Am J Knee Surg 1991; 4: 3-8.
9. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: II. Arthroscopy 1995; 11 (5): 526-9.
10. Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma 2013;27:226-231.
11. H-U. STAUBLI, R. P. JAKOB. Posterior instability of the knee near extension. A clinical and stress radiographic analysis of acute injuries of the posterior cruciate ligament. The Bone & Joint Journal. 1990, 72(2):225-30.
12. Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg 1999; 12:209-13.
13. Dowd GSE. Reconstruction of the posterior cruciate ligament: Indications and results. J Bone Joint Surg [Br] 2004; 86-B: 480-91.
14. Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986; 14:35-38.
15. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999 May-Jun; 27(3):276-83.
16. Shelbourne KD, Clark M, and Gray T. Minimum 10-Year Follow-up of Patients after an Acute, Isolated Posterior Cruciate Ligament Injury Treated Nonoperatively. Am J Sports Med July 2013 vol. 41 no. 7 1526-1533.
17. Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The Nonoperative Treatment of Acute, Isolated (Partial or Complete) Posterior Cruciate Ligament-Deficient Knees: An Intermediate-term Follow-up Study. HSS J. 2007 Sep; 3(2): 137–146.
18. Montgomery SR, Johnson JS, McAllister DR, Petrigliano FA. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med. 2013 Jun; 6(2): 115–123.
19. Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. Aug 2009; 37(8):1499-507.
20. Jackson WF, van der Tempel WM, Salmon LJ, Williams HA, Pinczewski LA. Endoscopically-assisted single-bundle posterior cruciate ligament reconstruction: results at minimum ten-year follow-up. J Bone Joint Surg Br. 2008 Oct; 90(10):1328-33. 
21. Salzler MJ, Miller CD, Lin A, Irrgang JJ, Harner CD. Complications Following Arthroscopic Knee Surgery. Orthopaedic Journal of Sports Medicine, September 2013 vol. 1 no. 4 suppl 2325967113S00044.

       Corruption Causes, Impact and Cures

                                            Dr. KS Dhillon

Introduction

The origin of the word corruption is from the Latin word “corruptus,” which means “corrupted”. Although the word has been widely deplored, there is no generally accepted definition of corruption. In legal terms, corruption is ‘the abuse of a trusted position in one of the branches of power (executive, legislative and judicial) or in political or other organizations with the intention of obtaining material benefit which is not legally justified for itself or for others’ [1].

Historical perspective

Corruption was labeled as a great sin in the Bible: “You shall not take a bribe, for a bribe blinds the clear-sighted and subverts the cause of the just” (Exodus 23:8).

The earliest records of corruption date back to the thirteenth century BC. Under Roman law, corruption was defined as receiving, giving, or claiming benefits in order to influence an official in connection with his work. Since corruption was so common a new law was introduced where the compensation for damage was double the value of the damage, and the perpetrator of the corrupt act lost his political rights. These laws did not help to alleviate corruption because corruption was mostly practiced by the members of the Senate and senior state officials in Rome and in the Roman provinces. 

The Christian faith in the early days condemned corruption. Despite the condemnation, corruption later reached its peak with the selling of indulgences in the Middle Ages. The selling of indulgences as well other immoral acts of the clergy were condemned by Martin Luther. 

The early feudalism in medieval Europe between the 9th and 15th centuries was familiar with various laws that punished the bribing of courts sometimes with death. In the later days of Feudalism, countries became helpless in the fight against corruption. France in 1716 established a special court that handled cases of abuse of royal finances. These abuses including embezzlement, extortion, bribery, scams, etc. were so extensive that the court was abolished and a general amnesty was introduced in 1717. From then some forms of corruption became a tradition. 

Corruption was also widespread during the time of the Spanish Inquisition. During that period the victim of the accusation could make amends with money. 

Throughout history, several intellectuals dealt with corruption or theorized about it. Machiavelli, the Renaissance political theorist, had a low opinion of republics. He considered them even more corrupt than other regimes. According to him, corruption leads to moral degradation, bad education, and bad faith.

The great philosopher, diplomat, and lawyer Sir Francis Bacon was known both for receiving and taking bribes. He reached the highest judicial position in England and during that time he was caught accepting bribes  28 times. He defended himself in parliament by saying that he accepted a bribe from both parties involved and hence the dirty money did not affect his decisions. The parliament refused to accept his arguments and sent him to jail. He, however, only spent a few days in jail since he was able to bribe the judge.

Historically although corruption has been present in society ever since, it has only garnered more attention in the recent past. Research on corruption and its negative impacts has become more common after 1995 when international institutions and countries began to be aware of this problem. Before that, the attitude of the public toward corruption was rather neutral. 

In 1998, Kaufmann and Gray from the World Bank [2] noted that:

• Bribery is widespread, especially in developing and transition countries. There are significant differences between and within regions. For example, survey responses suggest that Botswana and Chile have less bribery than many fully industrialized countries.
• Bribery has been found to increase transaction costs and it creates insecurity in the economy.
• Bribery usually leads to ineffective economic outcomes and in the long term impedes foreign and domestic investments. It misallocates talents to rent-seeking activities and distorts sectorial priorities and technology choices (for example, it creates incentives for contracting major defense projects or unnecessary infrastructure projects, but does not encourage investments in rural specialist health clinics or in preventive health care). This pushes companies “underground” (outside the formal sector), weakens the state’s ability to increase revenue, and leads to ever-increasing tax rates which are levied on fewer and fewer taxpayers, consequently diminishing the state’s ability to provide enough public goods, including the rule of law. A vicious circle of increasing corruption and underground economic activity can result.
• Bribery is unfair, as it imposes a regressive tax, which heavily burdens, in particular, commercial and service activities performed by small businesses.
• Corruption also destroys the legitimacy of the state.

Many ‘researchers and institutions including the World Bank Institute, the European Commission, the United Nations, and the EBRD have investigated corruption and its impact on macroeconomic and microeconomic indicators through various forms of corruption, as well as its connection with local customs and habits, and how it affects the everyday lives of people’ [1]. Most of the studies are mainly the analyses of the effects of corruption on various economic indicators, such as GDP growth, employment, investments, tax revenues, and foreign investments [1] or the study of various forms of corruption in relation to politics and the economic environment [1]. 

Causes of corruption

The level and extent of corruption differs from country to country. There are key common driving forces that generate it. Svensson [3] has identified what is common to all countries that are the most corrupt. They are developing countries or countries in transition and with rare exceptions low-income countries. Most of the corrupt countries have a closed economy, the influence of religion is visible (Protestant countries have far the lowest level of corruption), they have low media freedom and a relatively low level of education.

Corruption usually arises from an array of several interrelated factors, such as political factors, economic environment, professional ethics, legislation, customs, habits as well as traditions.

1. Political and economic environment

The political and economic environment has a great role to play in the phenomenon of corruption. When the economic activity in the country is heavily regulated and limited, the greater is the authority and the power of officials in decision making and this increases the possibility of corruption. In such situations, individuals are willing to pay or offer payment in order to avoid restrictions. When regulations are such that officials are given the opportunity to decide on the basis of discretion, a great potential for corruption exists.

The level of corruption is also affected by the monetary policy. A strong link between monetary policy and corruptive activity has been found. Countries with a well-regulated financial sector that do not have a lot of informal economies or black markets are less corrupt than those where the opposite is true. There is also less corruption in countries with higher economic and political freedom.

The level of efficiency of public administration determines the extent to which corruption can sprout. Such efficiency is determined by the type of regulations and permits. Ineffective and unclear regulations help to increase the level of corruption in two different ways:

• Artificially created monopoly of power enables civil servants to obtain bribes based on their superior position.
• Ineffective and unclear regulations cause inhibition and encourage people to pay bribes in order to speed up the bureaucratic procedure.

Corruption is also strongly influenced by the low salaries of public employees, who try to improve their financial position by receiving bribes. The socio-economic status of government officials also affects the phenomenon of corruption. 

Corruption arises because agencies, institutions, and governments cannot control corruption effectively due to underpaid officials, and this is especially so in developing countries, where they do not have sufficient tax revenue to properly reward the officials.

Low wages are not the only cause of corruption. The poor state of the public administration, that results from political “overcrowding” of officials is another cause of corruption. Political “overcrowding” of officials leads to loyalty prevailing over professional standards leading to corruption. 

Satisfaction with work done by officials is also an important factor that influences corruption. There is some evidence that the more officials are dissatisfied with their work or place of work, the higher the degree of corruption. The private sector has higher ethical values with higher-level satisfaction with work, than the public sector and hence is less unethical especially with regard to thefts and corruption. In principle, the salary level of civil servants affects the receipt of a bribe. The higher it is, the smaller the chance that the person will accept a bribe. On the other hand, a higher salary also strengthens the negotiating power of the official, which leads to higher bribes. Hence, it is very difficult to determine whether a higher salary will lead to less corruption. It means that the level of salary is not a decisive factor, but merely one of many causes of corruption.

The economy is largely dependent on politics and the rule of law. Individuals exploit various options for eliminating competition, and bribery is just one of the possible weapons in the struggle to obtain a job. 

The cost of a bribe is a substantial business cost, and it is an integral part of the business contract. Some believe that even if they stop giving bribery, their rivals will not, and therefore they have to bribe in order to remain competitive. They believe that bribery and misleading behavior are not crimes, they are just part of the business practice. It is also known that lubricating the bureaucratic wheel by the private sector helps to get certain things moving faster or easier.

There is no doubt that the political influence of corruption is rampant in many countries. When people at the top in politics i.e government, parties, and leading politicians are corrupt, then corruption infiltrates to all levels, and at the same time spreads among the ordinary population. In such situations, nobody trusts the institutions or the rule of law. 

Corruption is low in situations where openness and independence of the institutions are in balance and the officials are accessible. They should not be excessively exposed to private influences and should be able to make authoritative decisions, without using their power to arbitrate.

The possibility of corruption is high where the official power is poorly institutionalized and is too exposed to private influence. In such instances, the officials’ independence is reflected in excessive exploitation of their power and they can do as they please.

2. Professional ethics and legislation

Corruption emerges and spreads when there is a lack of professional ethics and there are deficient laws regulating corruption as a criminal offense. Ineffective sanctioning of corruption encourages those involved in corrupt practices to continue with such practices. It also encourages others to get involved in such practices. 

In transition countries, the lack of professional ethics is a particular issue. In some countries, ethics and professional standards change rapidly and approach that in developed countries. In some countries, the standards remain the same. In transition countries, the “softer” acts of corruption are often considered to be justifiable and acceptable. In some countries with professional ethics which manage illegal corruption well, there is nevertheless a widespread form of legal corruption.

Lack of transparency and a lack of control by supervisory institutions provides fertile grounds for corruption to flourish. Non-transparent functioning of both politics and the economy creates an atmosphere for corruption to flourish. Corruption is also affected by extensive, non-transparent, and incomplete legislations which allows for laws to be interpreted in different ways for the benefit of those who are willing to pay.

3. Customs, habits, tradition, and demography

Different countries have different views about corruption. In Europe for example, we can find two extremes; in the North where corruption is not tolerated, and in the South, corruption is an almost normal, socially acceptable phenomenon. 

Countries with a democratic past traditionally prosecute corruption, while in former socialist countries, corruption in the state apparatus was a part of their tradition. 

There are also different customs; for example in some cases, a “thank you” in the form of a gift for a service is an expression of courtesy, while elsewhere it is considered corruption. Everything is a matter of ethics and morality, and it can be very different in different areas and different countries.

Corruption apparently prospers better in countries where Islam and Orthodoxy are the main religion. 

Protestantism has been tested several times and has been found to be associated with low levels of corruption in a country. 

The least corrupt countries are those countries where the rule of law is the strongest. They were predominantly Protestant in 1900 and the most corrupt were predominantly Orthodox in the same year. There is a link between religion and corruption on one hand and respect for the rule of law on the other. The question that arises is: Why do some religions respect the rule of law more than others and control corruption?. 

A study by Melgar et al [5] titled Perception of corruption tried to find out which groups of people are more likely to pay for corruption. They found that people who think that there is a lot of corruption also perceive it so and are more willing to pay for it. It has been shown that social status and personal characteristics also play an important role in the shaping of corruption perception.

 Divorced women, unemployed individuals, people working in the private sector, and those who are self-employed are considered to be in positive correlation with the perception of corruption. The opposite applies to married individuals, full-time employees, people who frequently attend religious ceremonies, and people with at least secondary education. They perceive less corruption and are also not willing to pay. 

In all African and Asian countries, the former socialist countries, and most of the East Asian countries, people perceive more corruption than people living in other countries. Most European countries and some of the former English colonies show lower perceptions of corruption. They also found that better economic results reduce the perception of corruption, while macroeconomic instability and income inequalities have precisely the opposite effect [5]. 

High unemployment and low purchasing power increases the perception of corruption. 

Demographics is also a very important factor that affects corruption. There is evidence that a patriarchal society is more prone to corruption. There are several studies that have found that women are less corrupt than men. An influential study by the World Bank [6] of 150 countries in Europe, Africa, and Asia showed that women are more reliable and less prone to corruption.

A study by Rivas [7] also showed that women are less corrupt than men and he believed that an increase in the number of women in the labor market and in politics could help fight corruption.

 Lee and Guven [8] in a study: Engaging in corruption—the influence of cultural values and the contagion effects at the micro-level, also raised the question of whether men are more corrupt than women. Their findings support the thesis that women are less susceptible to corruption than men, and this is especially true in cultures that require men to be ambitious, competitive, and materially successful. 

In 2009, the Peruvian government decided to involve more women in the police units because women were supposed to be less corrupt than men. When 2,500 female police officers joined as traffic police officers, bribery was drastically reduced, and the people in Peru welcomed the female police officers on the streets [9].

The impact of corruption on the economy

In 1997, Tanzi and Davoodi [10] published an IMF working paper on the impact of corruption on public finances. In the working paper several important findings came to light:

• Corruption leads to an increase in public investments at the expense of private investments. There are many ways in which public expenditure can be manipulated and this is carried out by high-level officials so they can get bribes. In simple terms, it means that more government expenditures and a large budget offer more opportunities for corruption.
• Corruption redirects the public expenditure from that necessary for basic functioning and maintenance to expenditure on new pieces of equipment.
• Corruption tends to take away allotments for public expenditure from essential areas such as health and education since there is less chance of getting commissions in these areas as compared to areas where there are unnecessary projects.
• Corruption reduces the effectiveness of public investments as well as effectiveness of the infrastructure of a country.
• Corruption can also reduce tax revenues by compromising the ability of the state administration to collect taxes and fees.

The influence of corruption on the economy was also studied by Tanzi and Davoodi [10]. The influence of corruption on the economy occurs through several means:

• Through the effect of corruption on businesses. The impact of corruption on a business to a large extent depends on the size of the company. Large companies are better protected in environments that are prone to corruption. They can avoid taxes more easily and their size protects them from petty corruption. They are also often politically protected. The survival of small and middle-sized companies, regardless of their economic importance, is much more difficult than the survival of large companies.
• Through the effect of corruption on investments. Corruption affects total investments, the size, and form of investments by foreign investors, and the size of public investments. It also affects the quality of investment decisions and investment projects.
• Through the effect of corruption on public spending. Corruption has a negative impact on public spending, especially on education and health. There is a strong correlation between corruption and military expenditure. When there is corruption the military expenditure is higher. Higher military expenditure reduces economic growth. 
• Through the effect of corruption on taxes: Because of corruption, fewer taxes are levied than would otherwise be, since some of the taxes go into the pockets of corrupt tax officials. In corrupt countries, there are also frequent tax relieves selective taxes and various types of progressive taxes. Hence, there will be much less money in the country. Therefore corruption, through the country’s fiscal deficit, will affect economic growth.

A study by Smarzynska and Wei [11] on the effects of corruption on the size and composition of investments showed that corrupt countries are less attractive for investors. If they do invest, they often enter the market with a joint venture with local partners who usually understand or control matters of the home country better. The local partner can also help foreigners with the acquisition of local licenses and permits as well as negotiate with the bureaucratic labyrinths at a lower cost. 

Corruption also affects employment for various reasons, because the job does not go to the most qualified or suitable person, but goes to the one who is ready to pay for it in some form or another. 

Corruption also affects the total investments, the size and composition of foreign investments, and the size of public investments. Corruption also affects the effectiveness of investment decisions and projects. When there is corruption, investments are smaller, because investors are aware that they will have to bribe the officials or even give them a profit share for a successful implementation of a business. Because of these increased costs, the investors are usually not keen to invest.

Wei [12] made a projection which predicted that if corruption in Bangladesh could be brought to the level of corruption in Singapore then the growth rate of GDP per capita in Bangladesh could increase by 1.8% per year between 1960 and 1985 and the average per capita income could have been more than 50% higher. The Philippines could have raised their investments in relation to GDP by as much as 6.6% (which means a significant increase in the investments) if the level of corruption could be brought down to that of Singapore. 

Wei [12] also notes that in order to reduce the corruption level to that of Singapore in countries such as India, Ghana, Kenya, Turkey, Sri Lanka, Colombia, and Mexico, the salaries of officials have to be increased by 400—900% which is unlikely to be possible. He goes on to say that if there was such a hike in salaries, a new form of corruption would arise when people would be prepared to pay a bribe to get these well-paid jobs.

The effectiveness of various financial assistance programs is reduced when there is corruption because the money is lost along the way and does not reach the intended target. Furthermore, the financial benefits deriving from corruption cannot be taxed because they are hidden. The state hence loses part of the income from the taxes due to corruption. 

The European Commission in its 2014 report noted that corruption alone cost the EU economy EUR 120 billion per year, which is just a little less than the annual budget of the European Union [13]. According to the European Commissioner for Home Affairs, Cecilia Malstotröm, corruption in Europe is mainly present in public procurement, financing of political parties, and health care [13].

According to the United Nations, Afghanistan’s cost of corruption in 2012 was estimated to be $ 3.9 billion. 

According to Transparency International, Suharto, the former leader of Indonesia, embezzled between $15 and $35 billion. Embezzlements by Mobutu in Zaire, Ferdinand Marcos in the Philippines, and Abacha in Nigeria have been estimated to amount to $5 billion [14]. 

According to a World Bank survey, $1 billion in bribes is paid annually in both the rich and developing countries [15]. This actually means that even the developed countries are not immune to corruption. Political corruption is present in large infrastructure projects. 

Bađun [29] studied the relationship between political corruption and public investment in Croatia. They found that countries with high public investment have bigger political corruption. According to Badun, Croatia's infrastructure is in a bad state despite a high share of public capital expenditure in their GDP. The existence of huge allocations for public investment in the presence of weak control mechanisms provides plenty of opportunities for political corruption. 

There is a strong relationship between the degree of corruption and the emergence of the shadow economy. When there is a high degree of corruption, the level of the shadow economy is also higher. There is a link between low quality of institutions, the holders of the rule of law, and the shadow economy. When the law is weak, higher is the degree of corruption and level of shadow economy. Higher the degree of corruption, lower is the economic development as measured by GDP per capita. Hence, corruption affects the economic development of countries.

A devastating combination of widespread state intervention and subsidies in the absence of a strong institutional framework and lack of control of public finances and lack of effective anti-trust legislation promotes corruption. There is no clear evidence that private monopolies are more effective and less corrupt than the public ones. Public procurement is the breeding ground of corruption. 

Failure to respect copyright and intellectual property has a damaging effect on the global economy. This is obvious in corrupt countries. The economic damage can amount to billions of dollars when there is a failure to respect copyright and intellectual property.

Year after year the perception of corruption is increasing. Despite all the anti-corruption initiatives and anti-corruption moves, people still do not hesitate to accept and offer a bribe. The individuals who give bribes are becoming more innovative. They adapt to the situation and their innovations in paying bribes and hiding them are becoming more visible. The negative effects of corruption are the same all over the world. It reduces both foreign direct and domestic investments and increases inequality and poverty. Corruption increases the number of renter seekers in the economy and it also distorts and exploits public investments as well as reduces public revenues.

Remedial Measures

Corruption exists in all countries but it is more widespread in low-income countries. This is not because people in poor countries are more corruptible than in rich countries. It is because conditions in poor countries are more conducive for corruption to flourish. Bribery and graft are crimes of calculation. When the benefits are large, chances of getting caught are small, and penalties are light, then many people will succumb to corruption.

Low-income countries usually have highly regulated economies with large monopoly rents. Accountability is usually weak, political competition and civil liberties are often restricted. Laws and principles of ethics are poorly developed and legal institutions charged with enforcing them are ill-prepared to address the task. Watchdog organizations are not well developed and are often suppressed. The discretionary powers of administrators are extensive, with poorly defined rules and regulations which makes the situation worse [17] Given these constraints, what can be done to redress the situation?

The pessimist says nothing can be done. There are, however, others with more optimistic views. The more optimistic people point out that there are developing countries in the world, such as Chile and Botswana that, at present, have less bribery than many industrialized countries. They also point out that developing economies like Singapore, Hong Kong, and China have been able to transform themselves from being very corrupt to relatively clean within a reasonably short period of time [17].

Some ideas and suggestions of the optimistic groups to fight corruption include [17]: 

(i) Leadership: There are many authors, including Professor Syed Hussein Alatas of Malaysia, a noted authority on corruption, who are of the view that the leadership in a country has a key role to play in fighting corruption [18].

Asians traditionally hold their leaders and those in authority in high regard and esteem. Top leaders are expected to set a good example with respect to honesty, integrity, and capacity for hard work. Fighting corruption involves taking difficult decisions, hence the leadership must display firmness, political will, and commitment to carry out reforms that are required. Honest and dedicated leaders are necessary to counter corruption. 

(ii) Credibility: For success in the drive against corruption, the offenders on the demand and supply side of a corrupt deal have to be convinced that the government is serious about fighting corruption. There have been suggestions that some well-known corrupt people in the country should be publicly tried and punished.

In several Asian countries, some highly publicized trials and convictions of important officials and businessmen on charges of corruption have taken place.

(iii) Involving people: People should be involved in campaigns to eradicate corruption. Publicity campaigns to create greater awareness of the adverse effects of corruption can be useful. There should be clear and unequivocal official pronouncements by the authorities on the desirability to bring corruption under control. 

Help and cooperation of ordinary citizens, who have a lot of first-hand experience with corruption, should be solicited for the successful launch of anti-corruption drives. People will extend their full cooperation once they are convinced that a sincere and genuine effort to combat corruption is underway. Providing opportunities for people to express their views on such matters will bring forth an outpouring of information, ideas, and suggestions.

 (iv) Responsible press: A responsible press can go a long way to help fight corruption. Secretiveness helps politicians and public officials to get away with corruption. A responsible press can gather, analyze, organize, present, and disseminate information which is vital to create greater public awareness as well as to provide the momentum for undertaking reforms necessary to overcome corruption. A responsible and investigative press can play an important role in exposing misconduct as well as in serving as a watchdog to reduce corruption. It can also prevent the spread of corruption. The power of the press to limit misconduct and improper behavior should not be underestimated.

(v) Oversight bodies: There are mixed views on the effectiveness of anti-corruption oversight or watchdog bodies. In some situations, the views have been useful. The Independent Commission Against Corruption in Hong Kong, China, and similar institutions in other countries such as

Botswana, Chile, Malaysia, and Singapore have apparently done a good job. According to surveys and interviews of public officials and members of civil society organizations, many respondents do not believe that these organizations have done a good job to reduce corruption. 

For such bodies to be effective, they have to be created in an environment where leaders are honest and civil servants are insulated from political interference. Better incentives have also to be provided to discourage corruption. Oversight bodies are often misused for political gain which renders these oversight bodies useless.

Conclusion

Corruption is a symptom of deep-seated economic, political, and institutional weaknesses and shortcomings in a country. To tackle corruption the underlying causes must be addressed. Root causes of corruption must be tackled by undertaking economic, political, and institutional reforms. 

Anti-corruption enforcement measures such as a strengthened police force oversight bodies and more efficient courts will not be sufficient to tackle corruption without making serious efforts to address the fundamental causes of corruption. 

Corruption is prevalent where there are other forms of institutional weaknesses, such as bureaucratic red tape, political instability, and weak legislative and judicial systems. Corruption and such institutional weaknesses are usually linked together and they feed upon each other. Getting rid of corruption helps a country to overcome institutional weaknesses, and reducing institutional weaknesses helps to curb corruption.

Undertaking reforms (both economic and political) by reducing institutional weaknesses offers the best hope of overcoming corruption. Reforms will not make corruption disappear but reforms will bring it under control so that adverse consequences can be minimized so that the country can progress to become a modern, developed nation [17]. 

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