Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review

BACKGROUND

High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure.

PURPOSE

To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded.

RESULTS

A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%).

CONCLUSION

Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis

Background

This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis.

Methods

We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery.

Results

Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/μL [standard deviation, 52 576.3/μL] vs 92 162.7/μL [59 330.6/μL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/μL [95% confidence interval, -65 355/μL to -20 213.90/μL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/μL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02).

Conclusions

The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report

CASE

A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required.

CONCLUSION

HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws

Background

Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal.

Methods

Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal.

Results

Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80).

Conclusion

Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal.

Level of Evidence

Level III, retrospective cohort study.

How to place a cephalomedullary screw when visualization is obscured by the jig in peritrochanteric hip fractures using "peek radiographs."

Lag screw positioning can be difficult to discern intraoperatively on lateral fluoroscopic imaging during intramedullary fixation of proximal femur fractures in some nailing systems due to the drill guide handle obstructing the view. We have described a method of obtaining non-obstructed lateral-oblique "peek" views that reliably assist in obtaining adequate tip-apex distance (TAD) measurements when using intramedullary fixation for these fractures. The purpose of this study was (1) to describe an intraoperative radiographic technique to obtain non-obscured views for appropriate center-center placement of the lag screw(s) within the femoral head during jig-aided cephalomedullary nailing of peritrochanteric hip fractures and (2) to present a case series detailing the radiographic results using this technique. This clinical series of sixty-five patients with intertrochanteric or subtrochanteric proximal femur fractures stabilized with a cephalomedullary nail had an average TAD of 15.1 ± 3.3mm (range: 9.4mm-26.2mm). This suggests that our technical trick of obtaining "peek" radiographs intraoperatively may aid in a precise lag-screw placement.

Impingement and perforation of the anterior femoral cortex in cephalomedullary nailing: Systematic review and surgical techniques

BACKGROUND

Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence?

HYPOTHESIS

Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement.

PATIENTS AND METHODS

In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed.

RESULTS

The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93).

DISCUSSION

Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Is Patellar Instability a Contraindication to Semiextended Tibial Nailing?: A Case Report

CASE

We report a 40-year-old woman with undiagnosed patellofemoral instability that worsened 8 months after intramedullary nailing of a distal left tibia fracture in the semiextended position through a partial medial parapatellar approach. Patella stability and asymptomatic knee function were restored after IM nail removal, medial patellofemoral ligament repair, and left tibial tubercle transposition.

CONCLUSION

The optimal surgical approach for tibial IM nailing in patients with chronic patellar instability has not been described. Clinicians should be cognizant of the potential for worsening patellofemoral instability in these patients when using the medial parapatellar approach in the semiextended position.

Efficacy of detergent-based cleaning and wiping against SARS-CoV-2 on high-touch surfaces

Efficacy of cleaning methods against SARS-CoV-2 suspended in either 5% soil load (SARS-soil) or simulated saliva (SARS-SS) was evaluated immediately (hydrated virus, T0) or 2 hours post-contamination (dried virus, T2). Hard water dampened wiping (DW) of surfaces, resulted in 1.77-3.91 log reduction (T0) or 0.93-2.41 log reduction (T2). Incorporating surface pre-wetting by spraying with a detergent solution (D + DW) or hard water (W + DW) just prior to dampened wiping did not unilaterally increase efficacy against infectious SARS-CoV-2, however, the effect was nuanced with respect to surface, viral matrix, and time. Cleaning efficacy on porous surfaces (seat fabric, SF) was low. W + DW on stainless steel (SS) was as effective as D + DW for all conditions except SARS-soil at T2 on SS. DW was the only method that consistently resulted in > 3-log reduction of hydrated (T0) SARS-CoV-2 on SS and ABS plastic. These results suggest that wiping with a hard water dampened wipe can reduce infectious virus on hard non-porous surfaces. Pre-wetting surfaces with surfactants did not significantly increase efficacy for the conditions tested. Surface material, presence or absence of pre-wetting, and time post-contamination affect efficacy of cleaning methods.

Anterior Compartment Neurovascular Bundle Entrapment in a Minimally Displaced Distal Tibial Fracture: A Case Report

CASE

A 29-year-old woman presented with a low-energy, minimally displaced pilon fracture with progressive pain and paresthesias in the affected foot, ultimately requiring open reduction and internal fixation. Intraoperatively, the deep peroneal nerve and anterior tibial artery and vein were entrapped within the fracture. After freeing the bundle and fixing the fracture, the paresthesias improved and ultimately resolved.

CONCLUSION

Injury to the anterior leg compartment neurovascular structures should be considered in low-energy, minimally displaced pilon fractures. In this instance, progressive neurologic symptoms not consistent with the radiographic findings indicated the patient for surgical exploration and fixation.

Residual Antimicrobial Coating Efficacy Against SARS-CoV-2

AIMS

This study evaluated the residual efficacy of commercially available antimicrobial coatings or films against SARS-CoV-2 on nonporous surfaces.

METHOD AND RESULTS

Products were applied to stainless steel or ABS plastic coupons and dried overnight. Coupons were inoculated with SARS-CoV-2 in the presence of 5% soil load. Recovered infectious SARS-CoV-2 was quantified by TCID50 assay. Tested product efficacies ranged from <1.0 to >3.0 log₁₀ reduction at a 2-hour contact time. The log₁₀ reduction in recovered infectious SARS-CoV-2 ranged from 0.44 to 3 log₁₀ reduction on stainless steel and 0.25 to >1.67 log₁₀ on ABS plastic. The most effective products tested contained varying concentrations (0.5 to 1.3%) of the same active ingredient: 3- (trihydroxysilyl) propyldimethyloctadecyl ammonium chloride. Products formulated with other quaternary ammonium compounds were less effective against SARS-CoV-2 in this test.

CONCLUSIONS

The residual antimicrobial products tested showed varied effectiveness against SARS-CoV-2 as a function of product tested. Several products were identified as efficacious against SARS-CoV-2 on both stainless steel and ABS plastic surfaces under the conditions evaluated. Differences in observed efficacy may be due to variation in active ingredient formulation; efficacy is, therefore, difficult to predict based upon listed active ingredient and its concentration.

SIGNIFICANCE AND IMPACT

This study highlights formulation-specific efficacy of several products against SARS-CoV-2 and may inform future development of residual antiviral products for use on nonporous surfaces. The identification of antimicrobial coatings or films showing promise to inactivate SARS-CoV-2 suggests that these products may be worth future testing and consideration.

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, P=.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [Orthopedics. 2021;44(5):e668-e674.].

Inflammatory and Coagulative Considerations for the Management of Orthopaedic Trauma Patients With COVID-19: A Review of the Current Evidence and Our Surgical Experience

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature. LEVEL OF EVIDENCE:: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Controversies in Initial Management of Open Fractures

BACKGROUND

Treatment of open fractures continues to be a challenge for orthopedic and trauma surgeons, and early treatment recommendations, which persist in the literature for decades, often do not have supporting data.

METHODS

This is a critical review of the literature surrounding controversies in the initial management of open fractures. It also focuses on the utility of negative pressure dressings in the care of associated complex wounds. Studies were selected based on their relevance to the treatment of open fractures.

RESULTS

A total of 40 studies were included. The following topics were critically discussed: timing of initial debridement, antibiotic coverage, utility of obtaining cultures, and timing of wound closure.

CONCLUSION

The majority of open fractures require urgent, not emergent, irrigation and debridement. Antibiotics are essential in preventing infection in open fractures. Timely wound closure after all necrotic tissue has been debrided decreases complications in open fractures. Finally, negative pressure wound therapy has dramatically changed the care of associated complex wounds.

Intraperitoneal cisplatin-based chemotherapy for primary treatment of epithelial ovarian cancer

INTRODUCTION

This study looks at the feasibility of intraperitoneal cisplatin-based treatment in patients newly diagnosed with ovarian cancer in a community hospital setting and provides long-term follow-up of a cohort of patients.

METHODS

Sixteen patients with epithelial ovarian cancer were studied. All patients underwent definitive surgical debulking. Patients were scheduled to be treated with six cycles of intraperitoneal cisplatin and either intravenous cyclophosphamide or intravenous doxorubicin at four week intervals.

RESULTS

Fifteen patients were evaluable for response. All patients received at least three cycles of intraperitoneal therapy. All patients had an initial clinical response. Nine of 15 patients underwent second-look laparotomy; five of the nine patients had positive second-looks, none had residual macroscopic disease. Of the remaining six patients, five had clinical complete remissions and four are alive without recurrence.

CONCLUSION

High-dose intraperitoneal cisplatin-based with sodium thiosulfate protection is generally well-tolerated and possibly an appropriate alternative first-line therapy for selected patients with epithelial ovarian cancer.

Outpatient morning report: a new conference for internal medicine residency programs

To clarify the use of outpatient morning report in internal medicine residency programs, we conducted a national survey of internal medicine residency directors and a local survey of a cohort of residents at a large teaching hospital. The program directors reported a 24% prevalence of outpatient morning report. The cohort of residents reported that the conference contributed much to their education by meeting specific learning needs and covering topics not covered elsewhere in their residency training.

The formation of polychlorinated dibenzo-p-dioxins/dibenzofurans from carbon model mixtures containing ferrous chloride

The potential to form polychlorinated dibenzo-p-dioxins/furans (PCDD/F) was investigated in carbon model systems containing ferrous chloride tetrahydrate and a matrix representative of that found in particle emission from the catalytic extraction process (CEP) for wastes. Various types of carbons were used resulting in different PCDD/F yields but, with one exception, similar homologue distributions. Due to the similarity between the turbostratic structure of the carbon in the representative CEP dusts and the carbon blacks used in the model system, experiments were performed using two carbon blacks (termed CBA and CBB). On a mass basis, CBB was more reactive over the temperature range of 275-325 degrees C and reaction times of 20-60 min in the formation of PCDD/F; as well as more adsorptive in terms of the desorption of PCDD/F. On a volume basis, the reactivities and adsorptivities were similar. A maximum in PCDD/F formation occurred at an oxygen concentration of 2% in nitrogen.

Safety and costs of treating neutropenic fever in an outpatient setting

PURPOSE

The purpose of this study is to analyze the safety of outpatient treatment for cancer patients with chemotherapy-induced neutropenic fever in a community hospital setting and to compare the costs of outpatient treatment with those of inpatient treatment for such patients.

PATIENTS AND METHODS

We reviewed charts and charges for 32 consecutive patients initially treated for neutropenic fever with broad-spectrum antibiotics in the offices of Hematology/Oncology Associates (HOA) at the Bennett Cancer Center in the Stamford Hospital January 1997-June 1998. We also reviewed charts and charges for eight consecutive HOA patients with neutropenic fever who met the criteria for outpatient treatment but were initially hospitalized for other reasons during this period. We compared these two groups with respect to mean nadir absolute neutrophil count (ANC), mean number of days when ANC < 1,000 cells cu mm, and mean number of days of intravenous antibiotic treatment. We compared costs for ambulatory and hospital care of the two groups using Health Care Financing Administration (HCFA) payments in 1998 as a proxy for costs.

RESULTS

Of 32 patients with neutropenic fever initially treated in the outpatient setting, only four required hospitalization. No patients in either group died in connection with neutropenic fever. Although outpatients received an average of 3.6 days and inpatients only 2.5 days of antibiotic treatment, outpatient treatment was significantly less costly than inpatient treatment.

CONCLUSION

In a community hospital setting most cancer patients with neutropenic fever who meet certain criteria can be safely, effectively, and inexpensively treated as outpatients.

Low-dose vincristine-associated bilateral vocal cord paralysis

BACKGROUND

Vincristine-associated peripheral neuropathy is a well-described entity. We describe a case of vincristine-induced vocal cord paralysis, which is a rare complication of this drug. We report herein the second case of bilateral vocal cord paralysis in a patient receiving conventional doses of vincristine.

OBJECTIVE

To present a case report of vincristine-associated vocal cord paralysis and to review the relevant English language literature on this subject.

DESIGN

Report and review of the literature.

SETTING

Outpatient community cancer center.

PATIENT

A 58-year-old female with a diffuse large cell lymphoma stage IV receiving cyclophosphamide, doxorubicin, vincristine, and prednisone.

RESULTS

Bilateral vocal cord paralysis occurred in this patient receiving vincristine as part of her chemotherapy regimen. In addition to this case there have been a total of 25 prior reports, which are reviewed in the text.

CONCLUSION

The incidence of bilateral vocal cord paralysis in patients receiving vincristine on the usual low-dose schedule is low. Prompt withdrawal of the offending agent results in prompt recovery without untoward long-lasting sequela.

Adrenal calcification: an incidental finding or not?

When the adrenal gland is calcified but no mass is found, the calcification is usually assumed to be due to prior adrenal hemorrhage. We report a case of adrenal calcification without a noncalcified mass in a child who subsequently presented with neuroblastoma elsewhere. This case has implications for the investigation of children with adrenal calcification.

Competence and the elderly patient with cognitive impairments

OBJECTIVE

The purpose of this paper is to discuss the assessment of competence in the elderly, focusing particularly on individuals with cognitive impairments.

METHOD

An analysis of autonomy forms the basis of an ethical discussion which attempts to modify the existing concept of competence.

RESULTS AND CONCLUSION

A discussion of the factors which influence competence is presented including variations in situation, task and degree of risk. A critical analysis of four standards of competence is presented, leading to a discussion of the standards which can most successfully promote self-determination in elderly patients. Finally, three classes of competence are suggested which extend the criteria of competence to patients to cognitive deficits.

MR imaging of bone marrow in children with osteosarcoma: effect of granulocyte colony-stimulating factor

OBJECTIVE

Granulocyte colony-stimulating factor (GCSF) is used to stimulate myeloid cell production and function in children undergoing chemotherapy for osteosarcoma. We hypothesize that GCSF can cause reconversion of marrow from fatty to hematopoietic and that this change can be detected by MR imaging at sites away from the primary tumor. This benign effect of treatment should not be confused with tumor spread.

MATERIALS AND METHODS

MR images of marrow of the affected and contralateral limbs were retrospectively reviewed for 16 patients with osteosarcoma of the femur or tibia; nine of these patients had received GCSF. A grade was assigned to marrow signal intensity at sites away from the tumor, and findings before and after treatment were compared. The validity of MR image interpretation was assessed by comparing the signal intensity of marrow with the histologic appearance of marrow at 19 resection margins.

RESULTS

Changes consistent with reconversion were seen on MR images in seven of nine patients who had received GCSF in addition to chemotherapy and in none of seven patients who had received chemotherapy alone. The difference in proportions was statistically significant (p = .006; Fisher's exact test, two tailed). The histologic appearance of marrow at the resection margins agreed with the interpretation of the short-Tl inversion recovery sequence in all cases (100%).

CONCLUSION

The findings suggest that GCSF causes changes in the MR imaging appearance of marrow. Histologic correlation supports the hypothesis that these changes are attributable to reconversion from fatty to hematopoietic marrow. Awareness of this finding is important to avoid false-positive diagnosis of marrow metastases.

Suppurative inflammation of vas deferens: an unusual groin mass

We report a case of suppurative vasitis that presented as an inguinal mass in a young man. Inflammation of the vas deferens may occur as a manifestation of genital tuberculosis or other genitourinary tract infection. A granulomatous vasitis, vasitis nodosa, is usually associated with previous trauma or surgery. Suppuration is rare. We report a case that represents a rare cause of an inguinal mass.

Location of the vibratory segment in tracheoesophageal speakers

The Singer-Blom tracheoesophageal puncture procedure for surgical-prosthetic voice restoration has proved to be a viable option for alaryngeal speech rehabilitation. Following tracheoesophageal puncture, occlusion of the tracheostoma shunts pulmonary air through the Blom-Singer prosthesis into the cervical esophagus. The pulmonary air passing through the cervical esophagus and into the hypopharynx causes a portion of the upper alimentary tract to vibrate in a manner similar to that of the pharyngoesophageal segment during the production of esophageal speech. To study the location and shape of the vibratory segment in tracheoesophageal speakers, videofluoroscopy and simultaneous voice recording were performed with 16 patients. To analyze the vibratory segment(s), photographs were made of the videotaped image while it was stopped during the patients' production of the /a/ sound. The most frequent location of the vibratory segment was in the lower third of the neck, which corresponds to cervical vertebrae C5 through C7. Five of the subjects had two separate vibratory segments and two other subjects had long vibratory segments. The vibratory segment(s) in tracheoesophageal speakers was found to be similar to the vibratory segment(s) in esophageal speakers.