The relationship between diagnosis and outcome in arthroscopy of the hip.

PURPOSE: The purpose of this study was to compare the results of arthroscopy of the hip for osteonecrosis (ON) with those obtained for other diagnoses by presenting a cohort of patients with diagnosis and symptoms as dependant variables in a consecutive series of 86 cases of hip arthroscopy. TYPE OF STUDY: Retrospective review of outcomes. METHODS: There were 83 patients (86 hips) who underwent arthroscopy. Indications included ON (43%), labral injuries (20%), osteoarthritis (degenerative joint disease, DJD) (10%), Legg-Calvé-Perthes (LCP) disease (10%), and loose bodies (10%). All but 2 patients had had symptoms for at least 6 months. Symptoms were pain (100%), mechanical problems (78%), and loss of motion (56%). Arthroscopy was performed in the supine position, using a standard traction table, 30 degrees and/or 70 degrees arthroscopes, and the anterior and peritrochanteric portals. Data were collected longitudinally, retrospectively reviewed, and statistically analyzed. RESULTS: No complications were seen; 60% of the patients had significant improvement over an average follow-up of 30 months. Better results were with labral tears (91%, P <.003) or LCP disease (89%, P <.05). ON and DJD did worse with only 40% and 44% improvement, respectively. After free-vascularized fibular graft (FVFG), 34% of patients showed improvement at follow-up (P =.003). Eighteen patients (21%) underwent total hip arthroplasty at an average of 8.4 months after arthroscopy. Mechanical symptoms were a significant favorable prognostic factor (P =.0019), with 85% having a good result. Patients with ON and mechanical symptoms had a significantly lower conversion rate to total hip arthroplasty than those with only pain or pain and decreased range of motion (P =.0043). CONCLUSIONS: Arthroscopy of the hip is useful for diagnosis and therapy of loose bodies, labral injuries, focal chondral lesions, or the late sequellae of LCP disease. We conclude that the presence of mechanical symptoms is a favorable prognostic factor for any diagnosis except degenerative arthritis. Furthermore, the identification of mechanical symptoms is a specific indication for arthroscopy in ON before or after FVFG.

Subungual melanoma. A review of 93 cases with identification of prognostic variables.

From 1970 to 1996, 93 patients received diagnoses of subungual melanoma. Followup data were complete on all patients and reviewed with a median duration of followup of 5.2 years. This study identifies significant clinicopathologic variables that affect survival and provides the orthopaedic surgeon assistance in the early diagnosis and treatment of this lesion. Eight-three percent of patients presented with Stage I disease, whereas 17% had nodal or distant disease. Fifty-three percent had locally advanced disease at presentation. Twelve percent of the patients were African-American. Fifty-five percent of the lesions arose on the hands with thumb involvement predominating in more than half of these cases. Operative therapy consisted of amputation. Elective lymph node dissection was performed in 34 patients (37%) for Stage I tumors of intermediate thickness. Therapeutic node dissection was required in 16 patients (17%) for positive nodes. Five-year survival was 74% for patients with Stage I disease and 40% for patients with Stage II disease. Statistical analysis identified stage at diagnosis, Clark and Wihm's level, the patient's race, and the presence of ulceration as prognostic variables affecting survival. The diagnosis of subungual melanoma carries a grave prognosis and often is misdiagnosed in the early stages. The treatment of choice is amputation at the appropriate level.

Uterine artery ligation in the control of postcesarean hemorrhage.

The technique is described for devascularizing the post-cesarean section uterus with bilateral mass ligation of the ascending branches of the uterine arteries and veins. This 30-year clinical experience with 265 patients includes the results and complications. Ten patients required additional therapy. The effectiveness of this technique makes it a reasonable alternative to hypogastric artery ligation and reduces the need for hysterectomy.

Chorioamnionitis and appendiceal abscess. A case report.

A rare case occurred of chorioamnionitis complicating a smoldering periappendiceal abscess. Neonatal death and maternal morbidity occurred. Direct spread of infection from the abscess to the fetal membranes is hypothesized.

Cephalic replacement for shoulder dystocia: present status and future role of the Zavanelli maneuver.

OBJECTIVE: To describe the pertinent clinical data, outcomes, and maternal and fetal complications of cephalic replacement for the management of shoulder dystocia. METHODS: A registry for the reporting of cases of cephalic replacement was established 5 years ago. Features of the registry cases were reviewed. RESULTS: Fifty-nine women underwent replacement of the fetal head following unsuccessful attempts at vaginal delivery. All but six infants were successfully replaced and delivered by cesarean without excessive maternal or fetal morbidity. CONCLUSION: Cephalic replacement is a useful technique that need not be used as a last resort, but may be considered if any undue difficulty is encountered. It may have a place as an initial technique for those inexperienced with shoulder dystocia treatment.

Abdominal rescue after failed cephalic replacement.

BACKGROUND: Since the introduction of cephalic replacement for shoulder dystocia, the management of failures has not been addressed. The purpose of this report is to describe abdominal hysterotomy as an alternative approach to the resolution of shoulder dystocia. CASE: A 21-year-old woman, gravida 1, experienced severe shoulder dystocia following partial delivery of a 4320-g infant. Classical maneuvers as well as cephalic replacement were unsuccessful before and after general anesthesia. A low transverse hysterotomy permitted manual rotation of the anterior shoulder to the oblique diameter and further descent of the posterior shoulder. Delivery of the posterior arm was then completed without difficulty. CONCLUSION: Persistent failed cephalic replacement, especially after general anesthesia, can be successfully resolved with a hysterotomy using a low transverse uterine incision.

McRoberts maneuver for shoulder dystocia: a survey.

A survey of 108 major teaching institutions in the United States regarding the utilization of the McRoberts maneuver for shoulder dystocia was conducted. Only 40% taught the procedure but 64% reported being familiar with its use. Among users, only 32% used it as the initial step. Surprisingly, only 40% thought it reduced fetal trauma.

Shoulder dystocia: prevention and treatment.

Although shoulder dystocia is an infrequent event it has assumed a position of great clinical importance because of our litigious environment. Many cases are preventable by the proper identification of risk factors, especially glucose intolerance, macrosomia, obesity, and postdate pregnancies. The severity of the problem can be rapidly graded or determined by the response to a systematic treatment plan; such a plan is outlined.

Comparison of ultrasonographic and digital cervical evaluation.

Findings on ultrasound scanning of the cervix and lower uterine segment were compared with those on digital examination in patients in preterm labor or those in whom induction was planned. An ultrasound scoring system gave results that corresponded closely to those of the Bishop score.

Prophylactic tocolysis of twins.

The prophylactic use of oral terbutaline was studied in 28 normal, healthy, low-risk women with twin gestations. The mean birth weights were significantly increased over those in a similar group of control patients.

Ampicillin vs. ampicillin-gentamicin prophylaxis in high-risk primary cesarean section.

A randomized, prospective comparison of ampicillin and ampicillin-gentamicin therapy was conducted in a group of 123 women undergoing primary cesarean section after the onset of labor. All pretreatment patient profiles indicated similar high-risk factors for infection. Febrile morbidity, complication rate and hospital stay were all more favorable in women receiving ampicillin-gentamicin.

Retinal hemorrhage and vacuum extraction delivery.

The purpose of this prospective study was to investigate whether there is an increased risk of retinal hemorrhage in those infants delivered with the assistance of the silastic vacuum extractor from mothers who were low-risk and who had normal labors. Ocular fundi of 38 term newborns (19 vacuum assisted deliveries, 19 spontaneous deliveries) were examined for retinal hemorrhage within 72 hours after delivery. The overall frequency of retinal hemorrhage was 21.1%, 31.6% with the vacuum extractor and 10.5% with a spontaneous delivery. The mode of delivery did influence the number of infants with hemorrhages in each category, however this was only statistically significant in primiparous patients. The prognostic significance of the degree of retinal hemorrhage was not assessed.

Liquid silicone for the prevention of pelvic adhesions.

The prevention of postoperative adhesions would be beneficial to certain patients undergoing pelvic surgery. To date, a single, safe, simple and dependable method has not been found. Liquid silicone was placed in the abdominal cavity of 123 adult female mongrel dogs after the pelvic organs were abraded. Adhesion formation was markedly reduced in the study group. In view of these encouraging preliminary results, further animal investigation seems warranted.

Fetomaternal bleeding following diagnostic amniocentesis.

The frequency of diagnostic amniocentesis is increasing. Fetal bleeding and trauma have long been recognized to be complications of amniocentesis. For detection of fetomaternal bleeding, efficacy of modified Kleihauer-Betke staining and alpha-fetoprotein elevation in maternal blood was assessed. Preamniocentesis ultrasound scanning was found useful in reducing the incidence of fetomaternal bleeding and bloody taps. Elevation of alpha-fetoprotein was found to be a more sensitive indicator of fetomaternal bleeding than was modified Kleihauer-Betke staining. The use of alpha-fetoprotein to detect fetomaternal bleeding associated with amniocentesis is suggested for the identification of Rh-negative patients requiring anti-D gamma-globulin to prevent sensitization.

Plasma estrogens in the assessment of fetoplacental function.

A retrospective study has been undertaken to assess the diagnostic value of plasma estriol (E3) determinations, as compared with determinations of other biochemical parameters, in predicting the outcome of pregnancy. The normal levels of plasma unconjugated and total E3 were determined on weekly samples obtained during the third trimester of 258 normal pregnancies. Weekly concurrent specimens of plasma and 24-hour urine collections were obtained from 17 high-risk pregnancies associated with hypertension, intrauterine growth retardation and diabetes. Determination of plasma unconjugated and total E3 were made along with human placental lactogen (HPL), urinary E3, and other biophysical parameters such as the oxytocin challenge test, non-stressed test, ultrasonography, etc. The results of plasma E3 were not reported nor used for the clinical management of the patient. The data suggests that weekly plasma determinations were of little value in the assessment of feto-placental status. Some observations on the extent of variability of plasma E3 are discussed.

Evaluation of cefoxitin prophylaxis for cesarean section.

Prophylactic cefoxitin was evaluated in 101 patients undergoing cesarean section. A three-dose regimen of either cefoxitin or placebo was administered randomly in a double-blind manner, 46 patients receiving cefoxitin and 55 placebo, with the first dose given after the cord was clamped. In the placebo group, 29% of the patients developed pelvic or wound infection, compared to 4% in the cefoxitin group (P less than 0.003). No patient required re-operation, re-admission, or had a life threatening infection. Ten risk factors for infection were analyzed to help ascertain which patients would benefit from prophylaxis. Cefoxitin, with a broad spectrum of aerobic and anaerobic coverage, was found to be an effective and safe prophylactic agent when given to all patients undergoing cesarean section.