Prescriber profiles.

Within a two-week period, two sales representatives from competing pharmaceutical companies visited the office of an orthopaedic group practice. One representative was elated that the group had been steadily prescribing his company's new arthritis medication. The physicians assumed that the representative was speaking about the number of sample packs used by their office. Several days later, a competing drug representative visited the office and complained that several physicians in the group were "not thinking of my company's medication first." The physicians were perplexed and asked him how he had come by that information. After multiple attempts at evading the question, the representative explained that pharmaceutical companies pay the drugstores for such data. Although unwilling to disclose the details of the arrangement, he did inform the physicians that the pharmaceutical companies know exactly which physicians are writing which prescriptions. He assured the physicians that patients' names are not disclosed. The physicians spoke to several pharmacists and other pharmaceutical representatives, who confirmed the practice.

Residency training.

R. C. is an orthopaedic resident in a teaching program. At the orthopaedic clinic, he examines an elderly, otherwise healthy patient who requires a total hip replacement. He presents the patient to his covering attending physician, who agrees to supervise the joint replacement surgery. The resident discusses the surgery with the patient. The procedure, risks, goals, benefits, and alternatives are presented. The patient agrees to proceed with the surgery. The resident performs the surgical procedure with the attending physician's assistance. The surgery lasts forty minutes longer than the attending physician's usual surgical time, and the blood loss is 300 milliliters greater. Postoperative radiographs demonstrate a well positioned press-fit acetabular component and a cemented femoral component in 6 degrees of varus.

Paternalism.

J. S. is a sixty-five-year-old man who was treated at another hospital with arthroscopic debridement of an infection at the site of a right total knee replacement and was placed on long-term intravenous antibiotics. He signed out of that hospital against medical advice. One month later, he presented at our hospital with recurrent sepsis of his knee. Knee aspiration yielded frank pus with a white blood-cell count of 80,000 cells per cubic millimeter. Gram-staining demonstrated gram-positive cocci. The patient was placed on intravenous antibiotics. The patient appeared cachectic, reporting a sixty-pound (27.2-kilogram) weight loss over the past year. A metastatic workup, including a chest radiograph, an abdominal sonogram, prostate-specific antigen, a complete blood-cell count, erythrocyte sedimentation rate, and a purified-protein-derivative skin test, was negative; however, an occult neoplasm could not be excluded. The patient displayed episodes of confusion, disorientation, and argumentative behavior. Medical and psychiatric consults did not determine whether this behavior was due to previous substance abuse or a primary psychiatric disorder. Nevertheless, psychiatrists at our institution determined that the patient lacked decisional capacity. Attempts were made to salvage the knee replacement, and the patient underwent an extensive surgical debridement of the knee with insertion of drains. He was placed on intravenous antibiotics. The plan was for the patient to be managed with long-term oral suppressive antibiotics. After treatment, the patient was transferred to a skilled-nursing facility. Psychiatrists at the nursing facility deemed the patient to have decisional capacity, and the patient was permitted to leave the facility. He was discharged without antibiotics. Several weeks later, he presented at our hospital with a grossly purulent knee. The orthopaedic options were reviewed with the patient and his brother. Removal of the components was recommended. The patient did not want to "lose" his knee replacement, and he refused surgical intervention. We did not believe that the infection could be either controlled or eradicated with the components in place.

Ethical considerations in orthopaedic surgery.

Because our actions as physicians have far-reaching consequences, and because society allows us to do things to others that no one else is free to do, physicians' professional activities fall under the domain of ethical evaluation. We are charged with the obligation to use specialized scientific knowledge, to work in concert with others, and to act for the good of our patients. In fact, acting for the good of our patients is the central tenet of ethical medical behavior. What constitutes the good of the patient, however, is not always clear. In general, we act to limit disease, restore function, alleviate suffering, and prolong life. We understand fully, however, that these goals may conflict with one another. Judgment about what is right for a particular patient leads us to another crucial consideration of ethical behavior, namely, respect for patient autonomy. We recognize that individuals have the right to control their own destiny. Patients have a right, therefore, to make choices about their medical care. As physicians, we must respect those rights. As such, certain ethical behavior is expected of us. We must be honest with our patients. We must provide them with accurate information on which to base their decisions. We must convey to them information about their diagnosis, prognosis, and treatment, even when it is unpleasant to do so. We must be open about our expertise and level of training for a particular procedure. We must respect their privacy and their right to withhold information even from family and friends. In short, we must respect their choices, even if we may disagree with those choices. To truly respect patient autonomy is to understand that, ultimately, the final decision lies with the patient.

Ethics in practice.

H. K. is a ninety-two-year-old woman with Alzheimer's disease and mild hypertension. She resides at a nursing home, where she transfers from bed to chair with maximal assistance. She presents to our emergency department with a painful right hip. Physical examination demonstrates a confused, elderly patient with significant right hip pain and shortening and external rotation of the lower extremity. Radiographs demonstrate a displaced intertrochanteric hip fracture. The patient lacks the capacity for informed consent. Her family is contacted to obtain consent for insertion of a compression screw. The family refuses to give consent, stating that the patient is too old and the surgery is too dangerous.

Primary non-Hodgkin lymphoma of bone: unusual manifestation of lymphoproliferative disease following liver transplantation.

We present the case of a 66-year-old man with primary non-Hodgkin lymphoma of the right femur that developed following orthotopic liver transplant, while on immunosuppressive therapy. The diagnosis was suggested on the basis of the MRI findings and confirmed by open biopsy. He was treated successfully with local radiotherapy and has remained disease free for 14 months after the onset of the disease.

Unipolar or bipolar prosthesis for the displaced intracapsular hip fracture? An unanswered question.

Modular bipolar prostheses were developed to address the problems of loosening, cartilage wear, and protrusio which were seen with single unit endoprostheses. Modular unipolar prostheses address many of these problems and are significantly less expensive than the bipolar prosthesis. Recent data suggest that use of the modular unipolar prosthesis is indicated in elderly patients with low demands.

Total-hip arthroplasty: periprosthetic indium-111-labeled leukocyte activity and complementary technetium-99m-sulfur colloid imaging in suspected infection.

Indium-111-labeled leukocyte images of 92 cemented total-hip arthroplasties were correlated with final diagnoses. Prostheses were divided into four zones: head (including acetabulum), trochanter, shaft, and tip. The presence (or absence) and intensity of activity in each zone was noted, and compared to the corresponding contralateral zone. Though present in all 23 infected arthroplasties, periprosthetic activity was also present in 77% of uninfected arthroplasties, and was greater than the contralateral zone 51% of the time. When analyzed by zone, head zone activity was the best criterion for infection (87% sensitivity, 94% specificity, 92% accuracy). Fifty of the arthroplasties were studied with combined labeled leukocyte/sulfur colloid imaging. Using incongruence of images as the criterion for infection, the sensitivity, specificity, and accuracy of the study were 100%, 97%, and 98%, respectively. While variable periprosthetic activity makes labeled leukocyte imaging alone unreliable for diagnosing hip arthroplasty infection, the addition of sulfur colloid imaging results in a highly accurate diagnostic procedure.

Blood conservation in major orthopedic surgery.

During an eight-year period, intraoperative autotransfusion was performed in 1922 operations. There were 476 primary hip arthroplasties, 1017 revision hip arthroplasties, 339 spinal procedures, and 90 vascular cases. There were no known complications related to autotransfusion in any of the cases. With proper technique, red cell salvage is approximately 58% effective, and intraoperative blood loss can be reduced by that amount. The first four years' experience with the preoperative autogeneic blood program is as follows. Using a combined program of predonation and primary hip arthroplasty, 72% of the revision hip arthroplasties and 81% of the spinal instrumentations required only autologous blood. A combined program of autologous donation and intraoperative autotransfusion is an excellent alternative to allogeneic blood replacement and a means of eliminating transfusion-related disease.

Acute myocardial dysfunction and recovery: a common occurrence after coronary bypass surgery.

To evaluate whether acute myocardial dysfunction was common in the early postoperative period, serial hemodynamic measurements and radionuclide evaluation of ventricular function were performed before and after operation in 24 patients undergoing elective coronary bypass surgery. All patients had uncomplicated surgery, and no patient sustained an intraoperative infarction. In 96% of patients, significant depression in right and left ventricular ejection fraction was seen postoperatively, reaching a nadir at 262 +/- 116 min after coronary bypass. Left ventricular ejection fraction was 58 +/- 12% preoperatively and 37 +/- 10% at trough. Right ventricular function displayed a similar pattern. These findings were also associated with depressed cardiac and left ventricular stroke work index despite maintenance of adequate ventricular filling pressures and mean arterial pressure. The depression in ventricular function was partially reversible within 8 to 10 h after surgery. Left ventricular ejection fraction had increased to 55 +/- 13% at 426 +/- 77 min after coronary bypass and showed complete recovery within 48 h. Left ventricular end-systolic and end-diastolic volume index increased significantly postoperatively, but recovery in left ventricular ejection fraction was mostly due to decreases in end-systolic volume index (50 +/- 22 ml at trough and 32 +/- 16 ml at recovery). Depressed myocardial function was independent of bypass time, number of grafts placed, preoperative medications or core temperatures postoperatively. Postoperative therapy with pressors or inotropic agents delayed but did not prevent the occurrence of postoperative ventricular dysfunction. Despite improvements in operative techniques and methods of myocardial protection, postoperative left ventricular dysfunction continues to be common in patients undergoing cardiopulmonary bypass surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of inguinal hernia in the adult with Prolene mesh.

Three surgeons in the private practice of general surgery began to use Prolene (polypropylene) mesh in the treatment of all adult inguinal hernias in 1978. The reason for using this technique was to perform a truly tension-free repair to reduce the recurrence rate and produce less pain and disability postoperatively. The rational for using Prolene as the mesh material is discussed in relation with the other materials available. The technique is outlined in detail along with precautions to decrease the already low recurrence rate documented in this series. From 1978 through 1985, 745 repairs were analysed. The complication and recurrence rates were minimal, and the follow-up rate was 87 per cent. A plea is made not to report recurrence rates without follow-up rates. This technique is simple and effective and should be seriously considered in the treatment of hernias occurring in adults.

Giant cell reaction of small bones.

A radiographically nonspecific lytic lesion in the middle phalanx of the index finger with microscopic evidence of a benign fibrous stroma with giant cells and osteoid was investigated in an 18-year-old man. Giant cell reaction is a rare, benign lesion of the small bones of the hands and feet. Trauma as the cause of a giant cell lesion poses an interesting question.

Acquired arteriovenous fistulas of the scalp in hemophiliacs.

The development of arteriovenous fistulas following multiple intravenous infusions in hemophiliacs has been previously reported. In this report, we discuss two patients in whom arteriovenous fistulas developed following the use of scalp veins as sites of infusion. Because of the rich vascularity of this area and the proximity of the arterial and venous systems we recommend that this site not be used for factor infusion.