Functional capacity evaluation: does it change the determination of the degree of work disability?

BACKGROUND: Determining the degree of work disability following traffic accidents is very challenging. Functional capacity evaluations (FCEs) are becoming more commonly used in the process of disability assessment. OBJECTIVES: This study aimed to assess the agreement of the physicians' decision regarding the degree of work disability in two conditions: 1) based solely on a medical examination 2) based on a combined medical and FCE. METHODS: This is a cross-sectional study, with 123 individuals who experienced car accidents; 76 with whiplash-associated disorders and 47 with a hip fracture. All subjects underwent an FCE, filled-in questionnaires and underwent a medical examination. The medical charts of each subject were rated twice and the degree of work disability was determined by orthopedic surgeons and occupational medicine specialists; once based solely on medical files and once based on medical files that included data from the FCE. The agreement was assessed by Intra-Class Coefficients (ICC) and the dependency between the two ratings by McNemar's test. RESULTS: An excellent ICC and significant dependency were found for the percent disability in the hip injury group whereas a fair ICC and a non significant dependency for the percent disability in the whiplash group. CONCLUSIONS: The use of FCEs highlights the worker's capacity to perform duties that are part of the physical demands at work. The integration of FCEs into the disability assessment procedure seems to be important especially for whiplash injuries or in cases of discrepancies between the rate of disability determined by the physician to the patient's complaints and participation.

Catastrophic failure due to massive osteolysis of both acetabular and femoral components in a metal-on-metal hip arthroplasty: a demonstrative case report.

Metal-on-metal (MOM) bearing surfaces in total hip arthroplasty have been recently shown to have acceptable survivorship properties, and they have certain advantages and disadvantages when compared to conventional metal-on-polyethylene bearing surfaces. Like traditional metal-on-polyethylene bearings, these metal-on-metal implants may also suffer from catastrophic failure. Patients can develop a local reaction to the metal ions produced by the articulation and present with pain or early loosening due to the local inflammatory reaction. The possible effects of MOM wear debris and its corrosion products are still the subject of debate. This case report represents an unusual situation in a 63-year-old woman in which extensive lysis derived in massive femoral osteolysis and hip arthroplasty catastrophic failure.

Functional capacity evaluation of work performance among individuals with pelvic injuries following motor vehicle accidents.

OBJECTIVE: Pelvic injuries following motor vehicle accidents (MVA) cause disability and affect work capabilities. This study evaluated functional, self-report, and medical-based factors that could predict work capacity as was reflected in a functional capacity evaluation (FCE) among persons who sustained a pelvic injury. It was hypothesized that self-reported functional status and bio-demographic variables would predict work capacity. PARTICIPANTS: Sixty-one community-dwelling adults previously hospitalized following a MVA induced pelvic injury. METHODS: FCE for work performance was conducted using the Physical Work Performance Evaluation (PWPE). Additional data was collected through a demographics questionnaire and the Functional Status Questionnaire. All participants underwent an orthopedic medical examination of the hip and lower extremities. RESULTS: Most participants self-reported that their work capacity post-injury were lower than their job required. PWPE scores indicated below-range functional performance. Regression models predicted 23% to 51% of PWPE subtests. Participants' self-report of functioning (instrumental activities of daily living and work) and bio-demographic variables (gender and age) were better predictors of PWPE scores than factors originating from the medical examination. CONCLUSIONS: Results support the inclusion of FCE, in addition to self-report of functioning and medical examination, to evaluate work capacity among individuals' post-pelvic injury and interventions and discharge planning.

[Chronic exertional compartment syndrome].

Chronic exertional compartment syndrome is an uncommon phenomenon first reported in the mid 50's. This condition is characterized by sharp pain during physical activity, causing reduction in activity frequency or intensity and even abstention. This syndrome is caused by elevation of the intra-compartmental pressure which leads to decreased tissue perfusion, thus ischemic damage to the tissue ensues. Chronic exertional syndrome is usually related to repetitive physical activity, usually in young people and athletes. The physical activity performed by the patient causes a rise in intra-compartmental pressure and thereby causes pain. The patient discontinues the activity and the pain subsides within minutes of rest. Chronic exertional syndrome is reported to occur in the thigh, shoulder, arm, hand, foot and gluteal region, but most commonly in the leg, especially the anterior compartment. The diagnosis of chronic exertional syndrome is primarily based on patients' medical history, supported by intramuscular pressure measurement of the specific compartment involved. Treatment of chronic exertional syndrome, especially the anterior and lateral compartment of the leg is mainly by surgery i.e. fasciotomy. If the patient is reluctant to undergo a surgical procedure, the conservative treatment is based on abstention from the offending activity, changing footwear or using arch support. However, the conservative approach is not as successful as surgical treatment.

Total hip arthroplasty after avascular necrosis of the femoral head: does etiology affect the results?

INTRODUCTION: The aim of the study was to evaluate the results of total hip arthroplasty (THA) due to avascular necrosis (AVN) of the femoral head and to establish whether the cause of AVN affects the results. MATERIAL AND METHODS: A group of 68 patients, 17-82 years of age (mean: 49.9 years) underwent 84 total hip arthroplasties due to AVN. The patients were divided into subgroups according to the etiology of AVN of the hip joint. The results of each group were evaluated by the Harris Hip score (HHS) at 3-18 years (mean: 6.2 years). The complication rate was also assessed. RESULTS: The mean preoperative HHS was 28.5+/-4.5 as opposed to a postoperative HHS of 86+/-10. The revision rate was 16.7%. Etiology does not affect the final outcome, but less favorable long-term results were found in the steroid-induced AVN patients. CONCLUSIONS: Despite the previously reported, less favorable results, THA is a good option for the younger population, even with AVN, especially in bilateral disease. Etiology did not affect the final outcome. However, patients with steroid-induced AVN should be informed that although their final functional results will equal those of other groups, the longevity of the implants is limited.

Total hip arthroplasty in patients younger than 30 years of age.

BACKGROUND: Previously reported results of total hip arthroplasty in patients under the age of 30 indicate a high complication rate and questionable durability. OBJECTIVES: To estimate the results of THA in extremely young patients. METHODS: We report the results of 69 THA procedures in 56 patients who were under the age of 30 at the time of surgery (mean age 23.23 +/- 4.31 years) and were followed postoperatively for 2-23 years (mean 7.4 +/- 3.79 years). RESULTS: Loosening of the cup (11/69) and early traumatic dislocation (5/69) accounted for the majority of complications. CONCLUSION: The final average Harris hip scores of 90.59 +/- 9.36 in these patients indicated that THA is a successful and durable treatment modality for young patients with disabling diseases affecting the hip joint. However, due to the likelihood of complications it should be used with caution in this patient group. Efforts should be made to diminish the complication rate.

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.

Versatile Utilization of Massive Bone Allografts in Orthopedic Surgery.

The clinical use of massive bone allografts in orthopaedic surgery has become common practice in tumour operations and primary and revision total joint replacement. In certain special clinical situations associated with large bone loss, such as trauma, limb-length discrepancy repair or even infection, massive bone allografts can be successfully used. We present our treatment results of 47 patients who suffered from major bone loss due either to trauma, limb-length discrepancy repair, or infection. Our results (> 2 years minimum follow-up to allow full-bone allograft incorporation) indicate that the use of massive bone allografts in these special and delicate medical conditions is feasible, and have good functional results.