The Hospital for the Ruptured and Crippled moves east on 42nd Street 1912 to 1925.

In 1912, the Hospital for the Ruptured and Crippled (R & C) moved to its third location since its founding in 1863. It was a newly constructed six-story building on 42nd Street between Second Avenue and First Avenue. At the time Dr. Virgil Gibney, the second Surgeon-in-Chief, was 65 years of age and had already served 25 years in that position. The building housed a New York City public school since the length of stay of the children, many afflicted with tuberculosis and poliomyelitis, might be over 1-2 years. The large number of immigrants in the city led to very challenging social conditions that saw changes made in the first two decades of the twentieth century. When this country entered World War I in 1917, the physician staff was significantly affected as many volunteered for military service. Soldiers, sailors, and marines were treated at R & C, and military physicians were educated in orthopedics and hernia care on the wards and in the outpatient department. Because of declining health in 1924, Dr. Gibney retired and was replaced as Surgeon-in-Chief by his long-term friend and colleague, Dr. William B. Coley in January 1925.

Hospital for special surgery. A brief review of its development and current position.

On May 1, 1999, the Hospital for Special Surgery was 136 years old. To present a history that does adequate justice to the many people, who have been or still are involved in the making of it, is an impossible task. Nevertheless, this document is important because the hospital, first under the name of Ruptured and Crippled and then under that of Special Surgery has played such an important role in the development of orthopaedics and rheumatology in America during the past century. The reader must forgive an orthopaedic bias to this account and also realize the limitation of space that makes it at best fragmentary and incomplete. The account begins with a description of the hospital's current situation, physical layout and governance. A terse history of the hospital's origin and subsequent development follows, which includes a more specific description of the growth of its orthopaedic surgical services. Finally, separate records of the 112-year-old Postgraduate Orthopaedic Educational Program and 44-year-old Research Division are presented.

Optimizing hospital reimbursement through physician awareness: a step toward better patient care.

We instituted a training program to improve the overall accuracy of medical record coding through greater physician awareness to enhance hospital reimbursement and maintain quality patient care. A physician-targeted course reviewed the prospective payment system, diagnosis-related group guidelines, ambulatory surgery reimbursement, and the relationship between accurate physician documentation and medical record coding. Annual increases in charges from prospective surgical case assignment, proper conversion of outpatient to inpatient status, and more accurate coding of inpatient comorbidities and complications led to an estimated increase in hospital charges of $1.6 million.

Incidence and risk factors for mitral valve prolapse in severe adolescent idiopathic scoliosis.

Mitral valve prolapse (MVP) is known to be associated with thoracic skeletal anomalies. To determine the incidence and risk factors for mitral valve prolapse in the adolescent population with severe idiopathic scoliosis (IS), a prospective follow-up study on 139 adolescent patients with IS from the Pediatric Orthopedic Service was undertaken. Data collected included age, sex, medical and family history, physical exam, electrocardiogram and echocardiogram, spinal x-rays, and pulmonary function tests. MVP was detected by echocardiogram in 13.6% (19/139) of patients with IS as compared with 3.2% in 154 age- and weight-matched controls (p < 0.006). All patients with MVP were asymptomatic and a systolic click or murmur was detected on the single preoperative exam only in 37% (7/19) of them. Patients with MVP and IS weighed less (45.1 +/- 2.0 vs 51.8 +/- 0.1 kg, p < 0.002) as compared with those IS patients without MVP. The electrocardiogram was abnormal in 21% (4/19) of patients with MVP as compared with only 1.6% (2/120) of patients with IS but no MVP. The two groups did not differ with respect to age at diagnosis, severity of scoliosis, positive family history of scoliosis, or the presence of restrictive lung disease. Though IS was more prevalent in females (79%), the presence of MVP was not related to gender. MVP was persistent in 10 of the 19 patients reevaluated by echocardiogram 2-4 years after spinal surgery. We conclude that MVP is four times more common in patients with severe IS than in the normal adolescent population, and is associated with a lower body weight in IS patients with MVP than in IS patients without MVP. The persistent nature of MVP, even after corrective spinal surgery, may be related to factors other than geometric changes of the heart caused by abnormal thoracic curvature.

Routine preoperative MRI and SEP studies in adolescent idiopathic scoliosis.

In this prospective study, 72 patients with the clinical diagnosis of adolescent idiopathic scoliosis underwent routine preoperative magnetic resonance imaging (MRI) scans and neurologic consultations. Forty-eight patients also had preoperative somatosensory evoked potentials (SEPs). All patients had normal neurologic examinations. Abnormal findings included two patients with Chiari type I malformation and one with a finding of a fatty collection in a vertebral body. In four cases, interpretation of the MRI was suspicious or equivocal, necessitating a computed tomography myelogram or other additional studies for clarification. Abnormal preoperative SEP results were obtained in three patients, none of which proved significant. All surgical patients underwent instrumentation and fusion without incident. The results indicate that routine preoperative SEP is not necessary. Routine preoperative MRI is probably not indicated in adolescent idiopathic scoliosis if the patient has a normal neurologic examination.

Scoliosis in familial dysautonomia. Operative treatment.

The results of operative treatment of scoliosis were reviewed for twenty-two patients (ten boys and twelve girls) who had familial dysautonomia, an autosomal recessive disorder affecting primarily Ashkenazi Jews. The indication for operative intervention was progressive kyphoscoliosis to 45 degrees or more in a skeletally immature patient for whom bracing had failed. The mean age at the time of the operation was fifteen years and five months (range, eight years and two months to nineteen years). Seventeen patients had a thoracic curve with a mean preoperative Cobb angle of 69 degrees (range, 47 to 112 degrees), and five patients had a double major curve with a mean preoperative Cobb angle of 71 degrees (range, 42 to 87 degrees) for the cephalad curves and 60 degrees (range, 45 to 72 degrees) for the caudad curves. Twenty patients had a rigid kyphosis; in fourteen, the apex was at the seventh thoracic vertebra or more cephalad. Two patients had a lordoscoliosis. The mean preoperative kyphosis was 64 degrees (range, 12 to 110 degrees) in the thirteen patients who had a thoracic curve and for whom information regarding kyphosis was available, and it was 70 degrees (range, 54 to 84 degrees) in the five patients who had a double major curve. Postoperior spinal arthrodesis and instrumentation was performed in all patients. Two patients had an anterior arthrodesis as well because of the severity and rigidity of the curve. Allograft bone was used in eighteen patients. Postoperatively, all patients were managed with a body cast or with a custom-molded thoracolumbar brace.(ABSTRACT TRUNCATED AT 250 WORDS)

A feasibility study for removing tissue contamination from porous implants.

Porous implants that are unpackaged in the operating room but not implanted are discarded because they must be considered potentially contaminated with tissue. To reduce this waste, a method was developed to decontaminate these implants so that they can be resterilized and implanted. This method consists of ultrasonic scrubbing, sequentially, in aqueous solutions of dishwashing detergent, 7% nitric acid, and 5.25% sodium hypochlorite. The effectiveness of the method was tested by contaminating samples of porous implants with tissue, subjecting them to the decontamination method, and then using the following techniques to determine whether any tissue remained. The weights of samples after decontamination were compared with their weights before contamination. The rate of removal of labeled protein contamination from samples was measured. The capacity of decontaminated samples to activate immune system cells was assayed. Bioburden evaluations were performed on decontaminated samples. Within the measurement capabilities of each technique, no tissue was detected in any sample after decontamination.

Cost awareness and cost containment at the Hospital for Special Surgery. Strategies and total hip replacement cost centers.

To help balance the operating budget of The Hospital for Special Surgery, which was encountering an annual major deficit of $4 million in 1989, a program of cost awareness leading to cost containment was instituted in 1990. Costs of supplies, implants, and equipment were identified and reviewed by the hospital staff, including orthopaedic surgeons, orthopaedic residents, health care personnel, and administration, for cost effectiveness. Methods to accomplish the goals included structuring committees for information; workshops organized by different services to affect change; feedback to health care professionals through posters and newsletters; and statistical identification for continued education. Major cost savings resulted from recycling wasted implants, reduction of costly implants, and reduction of unnecessary supplies. As a result, vendors had been challenged, leading to more competitive prices. This program has opened new avenues of cost reduction without sacrificing quality of medical care and has contributed to a breakdown of barriers between medical staff, administration, and finance, leading to a strong hospital-team commitment. The price of health care in the United States in 1993 exceeded $900 billion. Health care expenditures now account for approximately 14% of the gross domestic product. Health care costs have been rising faster than the inflation rate for more than a decade. The result is the current national focus on containment of health care expenditures.

Salvage and reinfusion of postoperative sanguineous wound drainage. A preliminary report.

Thirty-five patients who were to have posterior spinal arthrodesis, total hip arthroplasty, or total knee arthroplasty were entered into one of two groups: Group A, to receive unwashed, filtered sanguineous drainage from the wound, or Group B, to receive washed, filtered drainage. The purpose of this prospective study was to evaluate the safety, efficacy, and difficulty of reinfusion of washed compared with unwashed drainage that had been salvaged from the wound after an orthopaedic operation. The sixteen patients in Group A received a mean of 475 milliliters of unwashed drainage for each total knee arthroplasty, 427 milliliters for each total hip arthroplasty, and ten milliliters for the one posterior spinal arthrodesis. The complications included immediate hypotension (two patients), hyperthermia (one patient), and hypotension five hours after reinfusion (one patient). The latter patient died, four days after the operation, of a massive myocardial infarction. The nineteen patients in Group B received a mean of 193 milliliters of washed, filtered drainage for each total knee arthroplasty, 203 milliliters for each total hip arthroplasty, and 179 milliliters for each posterior spinal arthrodesis. Salvage and reinfusion of washed drainage from the wound caused no problems in these patients.

Percutaneous computed-tomography-guided biopsy of the thoracic and lumbar spine.

Axial computed tomographic scans were used to guide percutaneous needle biopsies in 76 patients with thoracic and lumbar spinal lesions. Prebiopsy evaluation included spine radiographs, radionuclide bone scans, computed tomographic scans, magnetic resonance imaging scans in some cases, and coagulation studies. Forty-five patients were diagnosed as having metastatic lesions, 11 infection, and 12 primary bone tumors. Of all patients, 34 had lytic vertebral lesions with significant collapse and questionable spinal stability. Six of those had a concomitant paravertebral mass. A clinical and pathologic correlation was completed for each of the cases studied. Histologic diagnosis confirming the clinical suspicion was obtained on the first biopsy attempt in 65 (86%) of the 76 cases.

Osteoporosis in Scheuermann's disease.

A prospective study was undertaken to evaluate osteoporosis in Scheuermann's disease. Ten consecutive untreated patients with thoracic Scheuermann's were studied. The mean age was 16 years, 1 month, and the mean kyphosis was 64 degrees. Osteoporosis was quantitated by single and dual photon absorptiometry. Seven age-, sex-, height-, and weight-matched subjects were used as controls. The mean bone mineral density (BMD) of the lumbar spine was 0.975, compared with 1.130 for the control group, significant at P less than 0.025. For patients with a kyphosis greater than 45 degrees, the BMD was 0.913, significant at P less than 0.005. The mean BMD of the femoral neck was 1.00, compared with 1.22, significant at P less than 0.005. For patients with a kyphosis greater than 45 degrees, the femoral neck BMD is 0.983, significant at P less than 0.005. The BMD of the radius by single photon absorptiometry was 0.689, compared with 0.748 in the controls, which was not significant. In patients with a kyphosis greater than 45 degrees, the BMD was 0.655, which is significant at P less than 0.01. A highly significant association exists between osteoporosis and Scheuermann's disease. Further investigation is indicated to determine the role of medical management in the treatment of these patients.

Long-term psychological sequelae of surgically versus nonsurgically treated scoliosis.

Forty-six female scoliosis patients (21-34 years of age) were tested psychologically 4 or more years following treatment. Twenty-three had been treated by bracing (Group A) and 23 by posterior spinal fusion (Group B). Variables evaluated were: self-esteem, capacity for intimacy, sexual satisfaction, and mental representation of the patient's own body (body image). The prediction that normal controls would show better psychological adjustment than scoliotic women--surgically treated or not--was only partially borne out. Contrary to expectations, both groups of scoliotics showed higher levels of sexual satisfaction than controls. Group B showed a greater need for intimacy and better sexual adjustment, self-esteem, and body image than Group A.

Long-term follow-up of spinal fusion in spinal muscular atrophy.

From 1966 to 1983, 11 females and eight males with spinal muscular atrophy were treated by arthrodesis. Seventeen of 19 patients were evaluated by follow-up physical examination, roentgenograms, and questionnaires. In order to compare long-term versus short-term results, changes in management, and factors contributing to morbidity and mortality, three groups were identified for study. Group I consisted of 11 patients operated between 1966 and 1983 and alive at follow-up evaluation. Group II consisted of five patients operated between 1980 and 1983. Group III consisted of three patients, all deceased at follow-up evaluation and operated before 1980. In Group I, the preoperative curve averaged 119 degrees and at final follow-up examination, 99 degrees. The average preoperative curve in Group II was 80 degrees and at follow-up examination, 49 degrees. Long-term follow-up vital capacities were obtained in nine patients. The average preoperative vital capacity was 1033 cm3, and the average vital capacity seven years postoperation was 860 cm3. Most patients reported improvement in sitting, balance, and comfort. All patients are wheelchair-bound, as they were before surgery. Few long-term respiratory problems were reported.

Creatine kinase MB in skeletal muscle and serum of spine-fusion patients.

The low specificity of creatine kinase (CK) MB elevations for myocardial infarction was confirmed by a prospective analysis of paraspinal muscle and postoperative serum levels of CK-MB. Eleven of 30 patients had serum elevations of CK-MB without myocardial infarction. Elevated CK-MB was not specific for myocardial infarction after spine surgery. CK-MB was found in paraspinal muscle of 93% of patients. CK-MB may be a pathologic marker in patients with spinal disease.

The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage.

Custom-made distraction instrumentation was placed in the lumbar spine of eight large dogs with care taken to preserve the integrity of two intervening apophyseal joints. Histologic staining of immobilized joint cartilage showed varying degrees of chondrolysis, cloning, invasion of the tide mark, and loss of proteoglycans as early as 2 months postoperatively. Every specimen had significant degenerative changes characteristic of osteoarthritis. The joints one segment caudal to the lower hooks also were examined and were found to have similar histologic evidence of degeneration. Three dogs had the instrumentation removed and were then sacrificed 1.5-3 months later. The degenerative changes were not reversible following instrumentation removal.

Evoked potentials recorded from scalp and spinous processes during spinal column surgery.

Peroneal nerve evoked potentials were simultaneously recorded from scalp and from wire electrodes inserted into lumbar and thoracic spinous processes at multiple levels during surgery for correction of spinal column curvature in 43 patients. Spinal potentials progressively increased in latency rostrally. Over cauda equina and rostral spinal cord initially positive triphasic potentials were recorded. Over caudal spinal cord the response consisted of initial positive-negative diphasic potentials that merged with broad large negative and positive potentials. At rapid rates of stimulation, the initial diphasic component was stable but the subsequent potentials significantly diminished in amplitude. This suggests that the diphasic component reflects presynaptic activity arising in the intramedullary continuations of dorsal root fibers and that the subsequent components reflect largely postsynaptic activity. Scalp recordings at restricted bandpass (30-3000 c/sec) revealed well defined positive and negative potentials with mean peak latencies of 25.9 and 29.9 msec (PV-N1). The amplitudes and latencies of PV-N1 remained relatively stable throughout general anesthesia with halogenated agents which suggests that this component may be a reliable monitor of conduction within spinal cord afferent pathways during spinal surgery. Data are presented which suggest that selective filtering may help to distinguish faster frequency, synchronous axonal events from slower frequency, asynchronous axonal or synaptic events.

Physical therapy management of familial dysautonomia.

This paper describes physical therapy programs to assist physical therapists in the rehabilitation of patients with familial dysautonomia. There have been no reports in the literature about a physical therapy program for patients with this disease. A retrospective analysis of the clinical manifestations in 80 patients in a dysautonomia clinic was performed. Scoliosis and kyphosis were found in 92 percent of the patients, 93 percent had ataxia, 74 percent had feeding difficulties, 69 percent had frequent pneumonias, and 63 percent exhibited delayed developmental milestones. Cardiovascular, gastrointestinal, pulmonary, musculoskeletal, and neurological symptoms and treatments are discussed.