The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery.

OBJECTIVE: Little is known about the relationships among pain, function, psychological variables like perceived helplessness and emotional health, and patient satisfaction in people with revision knee replacement surgery. We hypothesized that pain and function would have a direct association with satisfaction as well as an indirect association through patient perceptions of helplessness and emotional health. DESIGN: This longitudinal study included 145 participants undergoing revision knee replacement surgery. Demographic data and expectation of benefit from surgery were recorded prior to surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Arthritis Helplessness Scale (AHS) and the Mental Component Scale (MCS) of the SF-36 (emotional health) were collected prior to and 2 years post-surgery. Satisfaction was recorded 2 years post-surgery. Regression analyses were conducted to test for mediation effects of helplessness and MCS. RESULTS: Participants were on average 69 years old and 54% were women. Participants were satisfied with the results of the surgery (mean ± standard deviation (SD) = 70.42 ± 31.46). Less pain and functional disability were associated with increased patient satisfaction and, the effect of pain or function was also mediated through helplessness whereby more pain and disability were associated with perceptions of helplessness and helplessness was associated with lower satisfaction. MCS did not mediate the relationship of pain and function with satisfaction. CONCLUSION: Helplessness plays an important role in understanding patient satisfaction. Interventions aimed at improving patient outcome should target not only pain and function but also should address strategies to support people in managing following knee revision surgery to maximize satisfaction with outcome.

Competencies for a Canadian orthopaedic surgery core curriculum.

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and sds were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are 'driven' by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.

In vivo wireless ethanol vapor detection in the Wistar rat.

Traditional alcohol studies measure blood alcohol concentration to elucidate the biomedical factors that contribute to alcohol abuse and alcoholism. These measurements require large and expensive equipment, are labor intensive, and are disruptive to the subject. To alleviate these problems, we have developed an implantable, wireless biosensor that is capable of measuring alcohol levels for up to six weeks. Ethanol levels were measured in vivo in the interstitial fluid of a Wistar rat after administering 1 g/kg and 2 g/kg ethanol by intraperitoneal (IP) injection. The data were transmitted wirelessly using a biosensor selective for alcohol detection. A low-power piezoresistive microcantilever sensor array was used with a polymer coating suitable for measuring ethanol concentrations at 100% humidity over several hours. A hydrophobic, vapor permeable nanopore membrane was used to screen liquid and ions while allowing vapor to pass to the sensor from the subcutaneous interstitial fluid.

Preliminary validation of curve progression model for brace treatment.

Brace treatment is the most commonly used non-surgical treatment for adolescent idiopathic scoliosis (AIS). A brace compliance monitoring system consisting of a microcomputer and a force transducer was used to monitor how brace candidates used their braces during daily activates. A prediction model of the brace treatment outcome was developed based on 20 AIS subjects. Six subjects (1M, 5F) with AIS who had worn their braces for six weeks participated into this study. One month data was recorded during the study period. Knowing the risk progression at the beginning of brace treatment plus how brace subjects used their braces in terms of brace tightness and wear time during brace treatment yielded a predicted outcome which was compared to the final treatment outcomes with 2 years followed-up. This preliminary result demonstrated that the prediction model was able to predict the treatment outcome within +/-3.5 degrees.

Desorption characteristics of uncoated silicon microcantilever surfaces for explosive and common nonexplosive vapors.

We measured the desorption of explosive trinitrotoluene (TNT), pentaerythritol tetranitrate (PETN), and hexahydro-1,3,5-triazine (RDX) vapors from piezoresistive silicon microcantilevers under ambient air. Depending on the amount of vapor loaded on the cantilever, TNT desorption took a few minutes to tens of minutes (for nanogram quantities). On the other hand, no significant loss of PETN or RDX was observed after many hours. We also measured desorption of common "nonexplosive" compounds (water, acetone, and ethyl alcohol) and observed that desorption was too fast to be measured. There is a good correlation between the desorption time and the melting point (or the vapor pressure) of a particular substance. In principle, this method can be used to measure desorption rates of various substances from cantilever surfaces.

Observation of the surface stress induced in microcantilevers by electrochemical redox processes.

The potential-induced surface stress of a solid electrode was investigated in an electrochemical cell. Gold-coated atomic force microscopy microcantilevers were used as working electrodes to measure the current-potential response (by cyclic voltammetry) and simultaneous bending characteristics in solutions of NaNO3 and K3Fe(CN)6/NaNO3. The observed changes of differential surface stress at a microcantilever electrode were attributed to electrochemical-potential-induced changes in surface charge density, ion adsorption/desorption, and electron transfer across the electrode surface. The potential dependent change in stress shows promise for the study of microscopic properties at the solid-electrolyte interface.

Fatal ethibloc embolization of vertebrobasilar system following percutaneous injection into aneurysmal bone cyst of the second cervical vertebra.

A 4-year-old boy developed progressive neck pain and an expansile osteogenic lesion of C2; the diagnosis was an aneurysmal bone cyst. An image-guided biopsy with 3D CT planning was performed followed by Ethibloc injection into the aneurysmal bone cyst. Subsequent CT and MR images demonstrated embolization material in the vertebrobasilar system, and the patient died of brain stem and cerebellar infarction 23 hours after the intervention. The course of events and technical considerations are discussed.

Adsorption-desorption characteristics of explosive vapors investigated with microcantilevers.

Understanding the kinetics of adsorption and desorption of explosive vapors such as TNT from surfaces is important in the design of sensors. We report for the first time, the adsorption-desorption characteristics of TNT from a Si-microcantilever exposed to vapors of TNT. It was observed that TNT readily sticks to the exposed Si surface with the adsorption kinetics showing an initial exponential behavior followed by roughly linear kinetics. It was also observed that for cantilever temperatures close to room temperature, TNT desorbs spontaneously from the surface with decaying exponential kinetics. Based on the known equilibrium partial vapor pressures of TNT, the "effective" sticking coefficient for the silicon oxide surface at room temperature under the experimental conditions was calculated to be about 0.02. This information can be very useful in the design of sensors and that of vapor-delivery systems.

Health-related quality-of-life treatments for severe haemophilia: utility measurements using the Standard Gamble technique.

Prophylaxis for haemophilia improves outcomes, but at a substantial cost. Cost-utility analysis balances improvements seen in health-related quality of life (HRQoL) against costs, with the purpose of aiding healthcare decision-making. This analysis uses a measure of HRQoL known as utility. The objective of this study was to measure HRQoL (utility) values for states of health that result from on-demand therapy or prophylaxis. The HRQoL for different health states (including target joint bleeding, different intensities of prophylaxis, and indwelling intravenous catheters [ports]) was measured for healthy adults (n=30), parents of haemophilic children (n=30), and adults with haemophilia (n=28). Parents and patients rated health states similarly. Healthy adults gave the lowest ratings. The following rank, in order of HRQoL, was obtained: prophylaxis (low > medium > high) > on-demand therapy > prophylaxis with port> prophylaxis with infected port > on-demand therapy with development of a target joint. We conclude that: (1) haemophilia and its treatment reduce HRQoL; (2) prophylaxis is preferred to on-demand therapy; (3) intravenous ports substantially reduce HRQoL; (4) and an intravenous port to provide prophylaxis is preferable to on-demand therapy if a target joint develops.

Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children.

The authors assessed whether a period of 3 weeks, rather than the commonly used 6 weeks, of smooth Kirschner wire fixation and cast immobilization of the elbow was sufficient to achieve union of displaced fractures of the lateral humeral condyle treated by open reduction. The authors found only one nonunion in a case series of 104 children treated with 3 weeks of fixation. Infections occurred in two children (2%). Late review of 63 children (61%) showed abnormalities of elbow shape in 28 (44%) and wide surgical scars in 43 (68%). The abnormalities of elbow shape were mainly due to overgrowth of the lateral humeral condyle, to the formation of excessive amounts of bone over the outer surface of the condyle, or both. The authors' findings indicate that a period of 3 weeks of smooth Kirschner wire fixation and elbow immobilization is sufficient to achieve healing in most displaced fractures of the lateral humeral condyle treated by open reduction. The findings also indicate that new strategies are needed to reduce the occurrence of overgrowth of the lateral condyle, excessive formation of bone over the condyle, and wide scars.

The use of bone scan to investigate back pain in children and adolescents.

Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7-17.7) were reviewed on average 4.4 years after presentation (range, 1.1-7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermann's kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation.

A comparative study of TLSO, Charleston, and Milwaukee braces for idiopathic scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine which of TLSO, Charleston, or Milwaukee bracing best prevents curve progression and surgery in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Bracing has been shown to prevent curve progression in idiopathic scoliosis, when compared with no treatment. However, there is little literature available comparing the effectiveness of different brace designs. METHODS: One hundred seventy patients who completed brace treatment for adolescent idiopathic scoliosis between 1988 and 1995 were studied. Forty-five thoracolumbosacral orthoses, 95 Charleston braces, and 35 Milwaukee braces were used. Thoracolumbosacral orthoses and Charleston braces were used on comparable curves, whereas Milwaukee braces were used in a subgroup in which the other brace designs were considered inappropriate. Evaluated were the absolute increase in curve severity, the percentage of curves that progressed beyond 6 degrees and 10 degrees thresholds, and the percentage of patients who underwent surgery. RESULTS: Age, Risser stage, curve size, and time braced and observed did not differ among groups. Mean progression of the curve during bracing was 1.1 degrees with thoracolumbosacral orthosis, 6.5 degrees with the Charleston brace, and 6.3 degrees with the Milwaukee brace (P = 0.012; analysis of variance). Proportion of patients with more than 10 degrees of curve progression was 14% with thoracolumbosacral orthosis, 28% with the Charleston brace, and 43% with the Milwaukee brace (P = 0.017; chi-square). The proportion of patients who underwent surgery was 18% with thoracolumbosacral orthosis, 31% with the Charleston brace, and 23% with the Milwaukee brace (P = 0.26; chi-square). CONCLUSIONS: The thoracolumbosacral orthosis was superior at preventing curve progression in adolescent idiopathic scoliosis.

Proprioception in anterior cruciate ligament-deficient and reconstructed knees.

Proprioceptive function of the knee was quantified and compared in three groups of patients: those with anterior cruciate ligament deficiency, with hamstring tendons-ligament augmentation device anterior cruciate ligament reconstructions, and with bone-patellar tendon-bone anterior cruciate ligament reconstructions. A total of 32 subjects, including 6 uninjured control subjects, were tested for threshold to perception of passive motion of the knee. All other sensory input was neutralized and testing occurred in the 30 degrees to 40 degrees range of knee flexion. The noninvolved contralateral knee served as a control for each subject. Each leg was moved at 0.5 deg/sec into flexion or extension in a random sequence. The variables of age, KT-1000 arthrometer scores, injury-to-surgery interval, injury-to-followup interval, and patient satisfaction were statistically analyzed for correlation with threshold to perception of passive motion of the knee. Control subjects showed no statistically significant differences in threshold between their two knees. The three test groups all showed significantly higher values in the involved knee compared with the noninvolved knee (P < 0.01). However, no statistically significant differences were found between the groups, including controls, with respect to mean threshold to perception of passive motion. According to these results, anterior cruciate ligament reconstruction did not improve proprioception in the patients in this study.

Is there a difference between the epidemiologic characteristics of hip dislocation diagnosed early and late?

OBJECTIVE: To determine if there are epidemiologic differences between patients with early and late developmental dislocation of the hip (DDH). DESIGN: A chart review. SETTING: A university-affiliated children's hospital. PATIENTS: Two hundred and forty-three children, 191 with early DDH and 52 with late DDH. MAIN OUTCOME MEASURES: Sex, side involved and prevalence of bilaterality. RESULTS: There were significant differences between the two groups with respect to side involved (p < 0.0002) and bilaterality (p = 0.006) but not in relation to sex. Left-sided dislocations were predominant in the early group and right-sided dislocations in the late group. Bilaterality was more common in the late group. CONCLUSION: There is circumstantial epidemiologic evidence that late DDH may be a different entity from early DDH.

Effects of an accelerated rehabilitation program after anterior cruciate ligament reconstruction with combined semitendinosus-gracilis autograft and a ligament augmentation device.

Forty patients with anterior cruciate reconstructions using semitendinosus and gracilis autografts and a ligament augmentation device were reviewed at a minimum of 20 months postoperatively to determine if an accelerated rehabilitation program was detrimental to intermediate follow-up results. The rehabilitation program included immediate full weightbearing, using crutches as aids for 2 weeks only, and a Generation II rehabilitation brace set at full range of motion for 2 weeks followed at 2 weeks by bicycle riding and strengthening exercises. Return to sports was allowed at 4 months for nonpivoting sports and at 6 months for level 1 sports involving pivoting. Thirty-seven patients were available for followup. At followup, three grafts were determined to be nonfunctional (KT-1000 arthrometer testing indicating > 4 mm of side-to-side difference). The other 34 patients had good or excellent results, with all returning to their preinjury levels of sport with a brace. Early accelerated rehabilitation after anterior cruciate ligament reconstruction with semitendinosus and gracilis tendon autograft and a ligament augmentation device does not seem to affect the results adversely. Results in this series were as good as or better than other series using the same reconstructive technique.

Extra-articular triplane fracture of the distal tibial epiphysis.

We describe an extra-articular triplane fracture of the distal tibia in the skeletally immature patient. This variant of the triplane fracture has been largely ignored in the literature. The clinical significance of recognizing this fracture is that, although it constitutes an epiphyseal fracture, it remains extra-articular. Unlike the standard triplane fracture that exists through the tibiotalar joint, this variant can be treated acceptably with less than an anatomical reduction, therefore often avoiding the need for surgical management.

Unusual burst fracture in an adolescent involving the apophyseal plate.

A 12-year-old girl sustained an unusual burst-type fracture of her first lumbar vertebrae. The main fracture occurred through the anterior ring apophyses and the pedicle-body junction. The anterior ring apophyses were left close to their anatomic position. However, the whole vertebral body with minor internal fracturing was retropulsed into the spinal canal, resulting in incomplete paraplegia. Initial radiographs were complicated by a fracture-dislocation. However, a computed tomography scan elucidated the above-stated fracture pattern. This pattern has not been previously reported to our knowledge. Treatment consisted of intravenous steroids, anterior decompression, anterior fusion with instrumentation, and postoperative thoracolumbar-sacral orthosis. Neurologic improvement has occurred. The patient can now walk independently, but still has absent bladder/bowel function 3 months postoperatively.

Comparison of three noninvasive methods for measuring scoliosis.

The premise behind most noninvasive techniques for the measurement of scoliotic conditions of the spine is that the lateral distortion of the spine relates directly to transverse rib cage deformity within the transverse plane. The focus of this study was to examine this assumption by comparing different noninvasive methods for the assessment of scoliotic curves. The three techniques examined were (1) use of the Scoliometer (SCOL), (2) use of the back-contour device (BCD), and (3) use of moiré topographic imaging (MTI). Fourteen subjects (10 female, 4 male) with idiopathic adolescent scoliosis were measured. Posterior-anterior radiographs were obtained for the clinical assessment of all subjects and were subsequently used to determine Cobb angles. Significant correlations between axial trunk rotation and Cobb-angle measurements were observed in the thoracic region (MTI, r = .80, df = 10, P less than .005; BCD, r = .70, df = 10, P less than .025; SCOL, r = .59, df = 10, P less than .025) but were not found within the lumbar region (MTI, r = .42; BCD, r = .17; SCOL, r = .20). Factors other than trunk deformity, such as the posture assumed by the subject during measurement, may have influenced axial trunk rotation. Hence, the techniques appear to provide valid estimations of lateral curvature of the spine in the thoracic region of the trunk but not the lumbar region. The results suggest that the measurement techniques cannot be used interchangeably in clinical recording.

The inwardly pointing knee. An unrecognized problem of external rotational malalignment.

Twelve patients with inwardly pointing knees had chronic knee pain and disability suggestive of patellofemoral subluxation. None had responded well to conservative measures or surgical correction at the level of the soft tissues. Their pattern of limb alignment was studied roentgenographically and was found to differ significantly from the control group of 49 healthy young adults. The deformities primarily related to the tibia were external tibial torsion, excess varus angulation of the tibial plateau, and varus knees. Angulation of the femoral condyles was normal and femoral anteversion did not appear to contribute significantly to the deformity. Surgery in seven cases (nine knees) was by derotation valgus Maquet osteotomy of the tibia and lateral release realignment of the patellae. Outcome assessments after a three-year follow-up period (five knees) were excellent. Early results on the remaining cases were satisfactory.