Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE: The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally. METHODS: A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated. RESULTS: There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%). CONCLUSIONS: Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.

Spontaneous correction of a traumatic kyphosis after posterior spinal fusion in an infant.

Posterior spinal fusion of presumed traumatic kyphosis at T11-T12 in a 23-month-old child resulted in spontaneous correction of a major angular deformity. Considerable resorption of the T12 body occurred. The remodeling process was largely completed by 8 years and 8 months of age.

Traction-induced rupture of an extracranial vertebral artery aneurysm associated with neurofibromatosis. A case report.

STUDY DESIGN: This report describes presumed traction-induced rupture of a vertebral artery aneurysm in a patient with neurofibromatosis Type I. OBJECTIVE: To draw attention to the need for preoperative arteriography in the surgical management of severe cervical kyphosis in neurofibromatosis. SUMMARY OF BACKGROUND DATA: Aneurysmal dilatation is a rare but well-documented manifestation of neurofibromatosis. The complication of rupture of a vertebral artery lesion has not been described previously. METHODS: The clinical features of the reported complication in a 56-year-old woman are detailed. RESULTS: A successful outcome was achieved by embolization and later anterior and posterior spinal fusions. CONCLUSIONS: Vertebral arteriography should be part of the preoperative assessment of neurofibromatotic cervical kyphosis. Skull traction may produce aneurysmal rupture.

De Quervain's disease: surgical or nonsurgical treatment.

Ninety-one wrists in 82 consecutive patients with Quervain's disease were treated by the one surgeon between 1978 and 1987. The treatment of 79 wrists in 71 patients who had received their entire treatment from this surgeon is analyzed. Uniformity of injection technique is thus ensured. Initial treatment in 63 wrists was an injection of steroids and local anesthetic into the tendon sheath, which gave complete relief in 45 cases. Seven wrists received two injections before the pain abated. Only 11 of the 63 injected wrists had an operation. In 10 of these the extensor pollicis brevis tendon was in a separate compartment. It is concluded that injection of steroids is the preferred initial treatment in de Quervain's disease, giving complete and lasting relief in 80% of cases. If injection fails, it appears likely that the extensor pollicis brevis tendon lies in a separate compartment.

Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction.

103 patients with acute airflow obstruction (56 asthma, 47 chronic obstructive pulmonary disease [COPD]) completed a double-blind trial of nebulised bronchodilator treatment in a hospital accident and emergency department. Each patient was randomised to receive either 10 mg of salbutamol nebuliser solution in 2 ml of saline or 10 mg of salbutamol in 2 ml (0.5 mg) of preservative-free ipratropium bromide. Peak flow rate (PFR) was recorded before treatment and 1 hour after beginning nebulised treatment. In 23 asthmatic patients given salbutamol alone PFR rose by a mean 31% 1 hour after treatment whereas in 33 such patients given combined treatment it rose by a mean 77% (95% confidence interval for the difference 8-84%). Patients whose PFR was below 140 l/min at entry gained maximum benefit from the combined treatment. For COPD patients the PFR rise was almost identical for both treatments. In acute asthma the immediate PFR response to a mixture of salbutamol and ipratropium bromide was better than the response to nebulised salbutamol alone. For COPD patients, the two treatments were of equal benefit.

Effectiveness of theophylline monitoring by the use of serum assays.

Ten men and 10 women out-patients who were attending a chest diseases clinic and who received an oral theophylline preparation were studied to determine the effectiveness of the use of serum theophylline assays on the monitoring of their treatment. Criteria were laid down with regard to the indications for drawing blood samples, interpretation of the results and documentation. There were definite indications for drawing samples in nine patients, no indications in three patients, and relative contraindications in eight patients. There were inadequate records for 14 patients. Adequate records permitting full interpretation of the results were kept for six patients. The therapeutic range was not stated in the assay report from the laboratory. The daily theophylline dose was stated incorrectly for seven patients. The reports did not determine whether doses were stated as theophylline or aminophylline. Interpretation of the assay results was appropriate for nine patients and poor for five. Reports of the results were sent to 10 of the patients' general practitioners. Four of these letters stated the result in numbers. The letters were sent 1-2 weeks after the blood sample was taken. A number of recommendations are made as a result of this study. The use of serum theophylline assays could be improved.

Risk factors for inadequate use of pressurized aerosol inhalers.

We studied 86 patients to determine the sources of error in patient use of pressurized aerosol inhalers (PAIs), the risk factors for poor technique, and the effect of instruction of patients on PAI technique. Patients were assessed before and after instruction using a standard procedure. Critical initial assessment showed that 31% of patients had an adequate technique. Seventy-five patients were reassessed after instruction, and 72% of these were determined to be adequate users. The most common errors were failure to breath-hold after-inhalation, failure to exhale prior to inhalation, and poor coordination of aerosol administration with the start of inhalation. Elderly patients were consistently poor users. Technique improved with more PAIs being used, but duration of PAI use was not a significant factor.