The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease.

So that patients with degenerative glenohumeral joint disease who wish to consider total shoulder arthroplasty will be better informed, we sought to document the magnitude and durability of the improvement in shoulder function after this procedure. The function of 124 shoulders with primary degenerative joint disease was documented by patient self-assessment with the Simple Shoulder Test before and sequentially after total shoulder arthroplasty performed with a standardized technique. Patients reported that they could perform 3.8 +/- 0.3 (SEM) of the 12 Simple Shoulder Test functions before surgery. The total number of performable functions was consistent at different follow-up intervals: 8.0 +/- 0.4 at 6 months, 9.5 +/- 0.4 at 1 year, 10.0 +/- 0.3 at 2 years, 9.2 +/- 0.4 at 3 years, 9.6 +/- 0.4 at 4 years, and 10.0 +/- 0.4 at 5 years. We conclude that total shoulder arthroplasty can provide substantial and durable improvement in shoulder function.

Improvement in comfort and function after cuff repair without acromioplasty.

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.

Hybrid advanced Ilizarov techniques: analgesia use and patient satisfaction.

Patients involved in the initial Western application of the Ilizarov technique experienced frequent pain and could not tolerate the device. With "hybrid advanced" Ilizarov techniques, half-pins and other components are added to minimize these adverse reactions. In this study of advanced techniques, we determined patient satisfaction (with end results), device tolerance, pain levels, and need for analgesia. These techniques used at least 1 half-pin on each ring--except for the distal tibial ring, which had 3 transfixing wires--perpendicular to either another half-pin or a transfixing wire. Eighty-one consecutive patients treated with advanced techniques were prospectively studied until the treatment was completed and the device removed. All patients received intravenous analgesia while hospitalized. Narcotic and non-narcotic analgesia was available to all patients, and analgesia use was measured. In addition, patient satisfaction and pain level were recorded. All patients were satisfied with end results and tolerated the device prescribed by their physician. Mean postoperative hospitalization was 5.1 days. Upon discharge from the hospital, 3 patients (3.7%) with moderate pain used postoperative narcotics for a mean of 6 days (range, 1-11 d), and 41 patients (50.6%) with mild pain used over-the-counter non-narcotic analgesia or prescription antiinflammatory medication for a mean of 4.4 days (range, 1-35 d). The other 37 patients (45.7%) were comfortable and did not require analgesia. In general, patients undergoing hybrid-advanced Ilizarov techniques infrequently needed postoperative analgesia.

Computed tomography assessment of sacroiliac screw placement relative to the first sacral neuroforamen.

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.

Outcome of nonoperative management of full-thickness rotator cuff tears.

The study documented the functional outcome in a consecutive series of 46 patients from an individual practice meeting the inclusion criteria of (1) a full-thickness rotator cuff tear seen by ultrasonography, arthrogram, or magnetic resonance imaging, (2) absence of a Workers' Compensation claim or previous surgery, (3) followup of at least 1 year, and (4) election of nonoperative management by the patient. Twenty-six of the tears involved only the supraspinatus, two involved the supraspinatus and infraspinatus, and two involved the supraspinatus, infraspinatus, and subscapularis (16 reports did not specify the size of the tear). Treatment consisted only of patient education and a home program of gentle stretching and strengthening. Patients completed the Simple Shoulder Test at the initial visit and sequentially at 6-month intervals thereafter. At an average followup of 2.5+/-1.6 years, 27 (59%) patients experienced improvement with nonoperative treatment, 14 (30%) patients experienced worsening, and five (11%) patients remained unchanged. The average number of Simple Shoulder Test functions the patients could perform initially was 5.6+/-3.2. At the latest followup, the average number of Simple Shoulder Test functions the patients could perform improved to 7.0 +/-3.8. The ability to sleep on the affected side and the ability to place the hand behind the head were significantly improved.

Challenges in evaluating patients lost to follow-up in clinical studies of rotator cuff tears.

BACKGROUND: Long-term follow-up studies are necessary to critically evaluate the outcome of a treatment intervention for a specific disorder. However, patients may cease participating in a long-term study and become lost to follow-up; thus, their current condition is unknown. The underlying characteristics that predispose a patient to become lost to follow-up are difficult to identify and control. Patients who are lost to follow-up may be contacted by telephone; however, the effect of administering a functional assessment questionnaire by telephone compared with that of mailing a questionnaire is unknown. The purpose of this study was to compare patients who continued to respond to requests for follow-up with those who did not. A second purpose was to compare responses obtained by mail with those obtained by telephone interview. METHODS: Two hundred and twenty-four patients with a rotator cuff tear were enrolled in an ongoing study of shoulder function and general health. Self-assessment questionnaires were mailed to every patient at six-month intervals. Sixty-seven patients (30 percent) regularly responded to mailings (identified as responders in this study), fifty-five patients (25 percent) responded occasionally (these patients were not included in the analysis), and 102 patients (46 percent) ceased to respond and became lost to follow-up (identified as nonresponders in this study). This investigation was performed to determine: (1) the characteristics of nonresponders compared with those of responders, (2) the functional status of nonresponders as assessed with a questionnaire over the telephone, and (3) the effect of administering a self-assessment functional questionnaire by telephone compared with that of sending the same questionnaire by mail. RESULTS: Nonresponders tended to have lower initial scores for the mental health summary (p = 0.03) and for social function (p = 0.01), were less likely to have had surgery (p = 0.009), and were less likely to consume alcohol (p = 0.03). At the last known time when they completed the mailed questionnaire, nonresponders reported significantly worse shoulder function than responders (p = 0.0001). However, on telephone questioning the mean number of shoulder functions that the nonresponders indicated that they could perform was greater than the mean number documented on their last mailed questionnaire (p < 0.0001). In a random subgroup of responders, the mean number of functions that the patients indicated that they could perform when interviewed by telephone was significantly greater than the number indicated on their most recent mailed questionnaire (p < 0.01). The results obtained by telephone from this random subgroup of responders were similar to those obtained by telephone from the nonresponders. CONCLUSIONS: There are differences between patients who continue to participate in a study and those who become lost to follow-up. Functional assessment questionnaires administered by telephone yield different results than the same questionnaires sent by mail. These considerations are relevant to the design, implementation, and interpretation of clinical studies in which functional questionnaires are used.

Intervention assessment in an Indian health service pharmacy.

OBJECTIVE: To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information. DESIGN: Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994. SETTING: Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon. MAIN OUTCOME MEASURES: Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem. RESULTS: Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%). CONCLUSION: This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.

The lateral impaction of the shoulder.

17 patients had radiographic demonstration of injury to the clavicle, scapula and ribs from an impact delivered to the lateral shoulder. The study included 13 males and 4 females whose ages ranged from 18 to 83 years (average 45 years). Most injuries were sustained in falls or motor vehicle accidents. Analysis of these cases suggests a biomechanical hypothesis concerning the transmission of the impact forces within the shoulder girdle. According to this hypothesis, the impaction force applied to the lateral shoulder is transmitted from outside inward following two paths. The anterior and superior path passes through the acromio-clavicular joint, the clavicle, the costo-clavicular joint and the sterno-clavicular joint. The posterior and inferior path is transmitted within the gleno-humeral joint, the scapula and the scapulo-thoracic joint. Major impacting force is required to disrupt the anterior and posterior arches of the shoulder girdle. When both of these supporting structures are damaged, the patient is at risk for more serious injuries, including disruption of the thorax, shoulder joint, brachial plexus and neck.

Management of the stiff shoulder.

Shoulder stiffness occurs as a result of (1) contractures of the intraarticular capsule or muscle-tendon units or (2) adhesions within the extraarticular humeroscapular or scapulothoracic motion interface. These contractures or adhesions may occur independently or in combination. A thorough history and physical examination usually reveal the diagnosis (idiopathic frozen shoulder or posttraumatic stiff shoulder) and the anatomical locations of fibrosis that is causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes). A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be indicated. If manipulation is not effective, capsular contractures are best released arthroscopically as this allows circumferential release without damaging the rotator cuff and thus allows rehabilitation without the need to protect the rotator cuff. The humeroscapular motion interface adhesions can be released either open or arthroscopically, but we believe that an open release combined with an arthroscopic capsular release is quicker and does not interfere with rehabilitation. When necessary, operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90% of patients can expect a good result with this treatment algorithm.

Proximal and distal femoral centralizers in modern cemented hip arthroplasty.

Third generation cementing techniques using intramedullary restrictors, low porosity cement with pressurization, lavage, and cement-stem bond enhancement do not prevent implant malalignment and inadequate cement mantle thickness. This has led to the development of modular proximal and distal centralizers to control the alignment of the femoral component and maintain an adequate thickness of the cement, thereby theoretically decreasing the rate of aseptic loosening. A retrospective analysis was performed of 100 primary cemented centralized femoral components. At an average followup of 5.7 years (range, 4-8 years), the average Harris Hip Score was 90. There were no cases of aseptic loosening, osteolysis, or impending failure. Ninety-one percent of femoral stems were implanted with satisfactory alignment with an optimal cement thickness. However, six distal centralizers and one proximal centralizer fractured at the time of insertion and voids frequently were seen in and around the distal centralizer. Although centralizers improve prosthesis alignment and cement mantle thickness, the long term effects of centralizer fracture and distal cement voids need to be observed to determine if centralizers improve previous implant survival.

Train accidents involving pedestrians, motor vehicles, and motorcycles.

In the United States, train-related accidents account for more than 18,000 injuries and 1,200 fatalities annually, yet there is a paucity of literature pertaining to this unique injury. We reviewed the medical records of 98 of 135 cases of train-related trauma treated at Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas, from 1990 to 1995. There were 50 train-pedestrian accidents, 47 train-automobile accidents, and 1 train-motorcycle accident, with a mean patient age of 30.1 years (range, 2 to 66 years). Eighteen patients (18%) were pronounced dead on arrival or died shortly after admission. Of the other 80 patients, 27 (34%) were discharged from the emergency department after minor medical treatment, while 53 (66%) were hospitalized, of whom 10 (13%) later expired. The mean Injury Severity Score (ISS) was 11.9 (discharged, 1.8; hospitalized, 14.3; expired, 29.2). Forty-five patients (56%) sustained 57 extremity fractures, and 30 patients (38%) required 40 amputations. Mean Mangled Extremity Severity Score (MESS) for all injured extremities was 5.2 (amputation, 7.7; no amputation, 2.8). On average, the hospitalization cost per patient was greater than $18,698, while the reimbursement from the patients was $2,261, leaving the hospital with a net deficit of approximately 2 million dollars. Surprisingly, train accidents do not always result in serious injury. However, when serious injury is sustained, it is often of high morbidity (amputation) and mortality, which appears to correlate well with the initial MESS and ISS. Extrapolating our cost data to include all train-related accident injuries and deaths indicates that the direct costs to society may exceed 300 million dollars annually. Greater public awareness and preventive measures may reduce the tremendous human and financial costs of train-related accidents.

Imaging assessment of sacroiliac screw placement relative to the neuroforamen.

STUDY DESIGN: Twenty-four cannulated sacroiliac screws were placed bilaterally into 12 cadaveric pelvi (12 titanium screws and 12 stainless-steel screws) and were imaged using conventional and multiplanar reconstructed computed tomography. OBJECTIVES: To determine whether sacroiliac screw position assessment relative to the neuroforamen is enhanced by: 1) computed tomography using multiplanar reconstructions and 2) the use of titanium screws rather than stainless-steel screws. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, there have been no prior studies demonstrating the accuracy of multiplanar computed tomography compared with that of conventional (axial) tomography in determining the position of sacroiliac screws relative to the neuroforamen. Although titanium screws have been shown to have less scatter than stainless-steel screws, the effect of alloy composition on the radiographic accuracy of interpreting the screw position relative to the sacral neuroforamen is unknown. METHODS: Screws were deliberately placed into: position A, in which the screw did not violate the neuroforamen; position B, in which the threads of the screw came within 3 mm of the neuroforamen; and position C, in which the screw clearly was nearly centered in the neuroforamen. The degrees of accuracy in assessing screw position relative to the neuroforamen using conventional (axial) images and using multiplanar reconstructed images were compared. RESULTS: The axial images were accurate in determining screw position relative to the neuroforamen in 50% of cases in which titanium screws were used and in 42% of cases in which stainless-steel screws were used. The corresponding values for multiplanar reconstructions were 92% for cases in which titanium screws were used and 67% for cases in which stainless-steel screws were used. The accuracy of multiplanar reconstructions was statistically better than that of axial images (P < 0.05). Metallic scatter was increased in stainless-steel screws. CONCLUSIONS: The results of this study suggest that the use of computed tomography with multiplanar reconstruction improves accuracy in determining sacroiliac screw position relative to the neuroforamen. The assessment of screw position may be facilitated using titanium screws.

Lumbar spine duplication presenting as adolescent scoliosis. A case report.

STUDY DESIGN: A report of a case of lumbar spine duplication with the clinical appearance of adolescent scoliosis. OBJECTIVE: To increase knowledge about the pathogenesis and treatment of lumbar spinal duplication. SUMMARY OF BACKGROUND DATA: Although there have been other reports of lumbar spine duplication of this magnitude, these malformations typically are associated with severe neurologic abnormalities (dicephalus, myelomeningocele) or gastrointestinal abnormalities (omphalocele, neurenteric fistulas). Several investigators have recommended early surgical intervention for this abnormality because of the perceived risk of progressive neurologic abnormality from tethering of the cord. METHODS: In a 13-year-old girl who had truncal asymmetry, lumbar spine duplication was noted on plain radiographs. A magnetic resonance study was obtained, and the patient was observed with conservative treatment for 3 years. RESULTS: Although extensive abnormalities were noted on the magnetic resonance images, which were related to duplication of spinal cord and vertebral bodies, the patient was neurologically intact and remained so until skeletal maturity. CONCLUSIONS: This rare malformation typically has severe neurologic sequelae. Conservative management in the reported patient did not result in a progressive neurologic lesion at the time of skeletal maturity.

Nonunion of a distal femoral epiphyseal fracture-separation.

Distal femoral physeal fractures account for approximately 1% of all epiphyseal injuries. Complications include growth arrest and leg length discrepancy, malunion and deformity, and stiffness and knee instability. However, nonunion of such a fracture is exceedingly rare and has only been reported in patients with spinal dysraphism. We report a case of distal femoral physeal nonunion in a neurologically intact adolescent athlete. Initially, there was a delay in the diagnosis of this nondisplaced fracture, as the patient had normal roentgenograms. Additional imaging modalities (magnetic resonance imaging, stress radiographs) should be performed if there is a high index of suspicion of physeal injury when roentgenograms are normal.

AIDS and patient confidentiality. More dilemmas for physicians--and lawyers.

If patients who have AIDS or ARC, or who are seropositive for HIV antibody, refuse to engage in "safe sex" to protect their sexual partners, may physicians warn those partners? Must they warn them? Does the law apply equally to symptomatic and asymptomatic patients? The law is not only confusing but in a state of flux. Both physicians and lawyers are cautioned against answering these questions categorically on general principles derived from the famous (or infamous) Tarasoff case. If the questions can be answered at all, they must be preceded by minute examination of the laws of each jurisdiction. The difficulty lies in knowing whether and how the law should be changed. A physician may be required to warn certain contacts of certain patients, and forbidden to warn other contact equally at risk from other patients equally infectious. Issues of morality and politics are posed: Is AIDS to be treated as a sickness or a sin? Of the measures physicians recommend to protect public health, which will be politically acceptable to various pressure groups? And if the laws are enacted, will they survive widespread resistance and evasion?

Third-party payor decisions. Doctor, don't dare be intimidated by them!

The case of Wickline v. State forebodes a new tort: malpractice by a physician who unprotestingly complies with a third-party payor's hospitalization restrictions. Medi-Cal granted this patient only half the hospital stay extension requested by her physicians. Following discharge on the appointed date her condition deteriorated, and ensuing complications resulted in the need for leg amputation. The patient subsequently sued the State for injuries, and won. The State appealed and obtained a reversal of the judgment on the verdict. Despite the fact that the premature discharge led to the need for amputation, the decision to discharge the patient had been made by the physicians, not by Medi-Cal. Therefore, Medi-Cal was not liable.

Io's Sodium Cloud.

The first two-dimensional images of the source region of Io's neutral sodium cloud have been acquired by ground-based observation. Observed asymmetries in its spatial brightness distribution provide new evidence that the cloud is supplied by sodium that is ejected nonisotropically from Io or its atmosphere. Complementary, high-time-resolution, calibrated image sequences that give the first comprehensive picture of the variations of the fainter regions of the cloud extending more than 10(5) kilometers from Io were also obtained. These data demonstrate that the cloud exhibits a persistent systematic behavior coupled with Io's orbital position, a distinct "east-west orbital asymmetry," a variety of spatial morphologies, and true temporal changes. The geometric stability of the sodium source is also indicated. Isolation of the cloud's temporal changes constitutes an important milestone toward its utilization as a long-term probe of Io and the inner Jovian magnetosphere.

The peer review privilege: a law in search of a valid policy.

The peer review privilege prevents patient-plaintiffs from obtaining the hospital records prepared in connection with quality review proceedings. The privilege, created by statute in most states, is rationalized by the need for confidentiality in promoting complete and candid peer review. In this Article, the Author argues that the privilege cannot effectively promote confidentiality since a common exception allows physicians to obtain the records when seeking judicial review of proceedings leading to their exclusion or dismissal from hospital medical staffs. More significantly, the Author notes that while the privilege began as a device to protect physicians from testifying against their will in malpractice suits--a condonation of the "conspiracy of silence"--it has evolved into a vehicle which enables hospitals to conceal the evidence of their own neglect.