Differences in Radiotherapy-Treated Members with Cancer during COVID-19 Pandemic Using Nationwide Claim Data

PURPOSE/OBJECTIVE(S)

This study aimed to identify the impact of the pandemic on radiotherapy activity among members with cancer.

MATERIALS/METHODS

This retrospective study included fully-insured commercial members of a large national payor with cancer aged ≥18 years undergoing radiotherapy from March 1, 2018 to February 28, 2022. Radiotherapy activity was defined as the mean weekly number of treatment courses and attendances (fractions) per month pre-COVID (March 2018 to February 2020); during COVID (March 2020 to February 2021); and post-COVID (March 2021 to February 2022). T-tests assessed differences between pre-COVID and post-COVID on radiotherapy activity by age, gender, and cancer type. Interrupted time series analysis (ITS) assessed change in activity overtime, controlling for pre-COVID trends and other potential confounders. A p-value of <0.05 was considered significant.

RESULTS

The study included 9,275 members, 10,121 courses, and 169,257 fractions; most members were female (57%), the mean age was 57 years (SD = 12). Overall, there was a decline in mean weekly number of courses from the pre-COVID to post-COVID (-18%, p<0.05) timeframe. Females < 70 years experienced the largest decline in mean weekly number of courses (-23%, p<0.05) followed by males aged 70+ (-16%, p<0.05) and males < 70 years (-16%, p<0.05). All cancer types saw a significant decline (p<0.05); breast cancer reported the largest decline (-21%, p<0.05). Fraction numbers significantly declined overall by 27% (p<0.05) from the pre-COVID to post-COVID timeframe. The largest decline in fraction numbers was observed in females < 70 (-28%, p<0.05) followed by males < 70 years (-24%, p<0.05) and males aged 70+ (-22%, p<0.05). No difference between COVID and pre-COVID weeks for courses was observed once pre-COVID trends were accounted for using ITS. Females aged 70+ received 25% (p<0.05) fewer fractions during COVID compared to pre-COVID; a decline which continued to grow even as the pandemic eased (March 2021 to February 2022). Males aged 70+ also experienced a decreased level of fractions during the pandemic (-30%, p<0.05), but increased in the recovery period (+24%, p<0.05). Males < 70 years had an increased level of fractions during the pandemic (+14%, p<0.05).

CONCLUSION

Radiation mean weekly number of courses and fractions between pre-COVID and post-COVID declined with the effect more pronounced in females < 70 years. A decrease in fraction number was observed in all cancer types; specifically, breast cancer had the largest decline. ITS analysis revealed no difference between COVID and pre-COVID weeks for courses as the downward trend was already present prior to the pandemic. These findings suggest while radiotherapy courses and fractions were significantly impacted, fractionation was decreased to a greater extent, indicating an increased adoption of hypofractionation during the pandemic.

Predicted Rate of Secondary Malignancies Following Adjuvant Proton Versus Photon Radiation Therapy for Thymoma

PURPOSE

Thymic malignancies are the most common tumors of the anterior mediastinum. The benefit of adjuvant radiation therapy for stage II disease remains controversial, and patients treated with adjuvant radiation therapy are at risk of late complications, including radiation-induced secondary malignant neoplasms (SMNs), that may reduce the overall benefit of treatment. We assess the risk of predicted SMNs following adjuvant proton radiation therapy compared with photon radiation therapy after resection of stage II thymic malignancies to determine whether proton therapy improves the risk-benefit ratio.

METHODS AND MATERIALS

Ten consecutive patients treated with double-scattered proton beam radiation therapy (DS-PBT) were prospectively enrolled in an institutional review board-approved proton registry study. All patients were treated with DS-PBT. Intensity modulated radiation therapy (IMRT) plans for comparison were generated. SMN risk was calculated based on organ equivalent dose.

RESULTS

Patients had a median age of 65 years (range, 25-77 years), and 60% were men. All patients had stage II disease, and many had close or positive margins (60%). The median dose was 50.4 Gy (range, 50.4-54.0 Gy) in 1.8-Gy relative biological effectiveness daily fractions. No differences in target coverage were seen with DS-PBT compared with IMRT plans. Significant reductions were seen in mean and volumetric lung, heart, and esophageal doses with DS-PBT compared with IMRT plans (all P≤.01). Significant reductions in SMNs in the lung, breast, esophagus, skin, and stomach were seen with DS-PBT compared with IMRT. For patients with thymoma diagnosed at the median national age, 5 excess secondary malignancies per 100 patients would be avoided by treating them with protons instead of photons.

CONCLUSIONS

Treatment with proton therapy can achieve comparable target coverage but significantly reduced doses to critical normal structures, which can lead to fewer predicted SMNs compared with IMRT. By decreasing expected late complications, proton therapy may improve the therapeutic ratio of adjuvant radiation therapy for patients with stage II thymic malignancies.

Compression arthrodesis of the ankle by triangular external fixation: biomechanical and clinical evaluation

This article describes a technique of ankle arthrodesis using a triangular external fixation frame and presents the results of biomechanical analysis and clinical experience with the frame. Clinical evaluation of 23 ankle arthrodeses performed using a triangular external fixation frame yielded a 91.3% fusion rate at an average of 11 weeks postfusion. The triangular frame was 79% stiffer than a compression-only external frame in torsion and 39% stiffer in anteroposterior bending. This high rate of fusion is attributed to the elimination of micromotion at the fusion site because of the increased rigidity of the triangular external compression frame.

The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use

Echogenic venous emboli accompany tourniquet deflation during total knee arthroplasty. Two types of echogenic emboli appear in the central circulation: small venous emboli (miliary emboli) and large venous emboli (masses of echogenic material superimposed on miliary emboli). Presumably, medullary cavity trespass releases small and large echogenic emboli. However, patients undergoing lower extremity procedures with a tourniquet have large echogenic emboli regardless of medullary cavity invasion. Avoiding tourniquet inflation may decrease the release of large venous emboli. Thirteen patients undergoing total knee arthroplasty without pneumatic tourniquet received intramedullary guides and 11 patients received tibial extramedullary guides. Recordings of hemodynamic variables, mixed venous oximetry, end-tidal CO2, and echocardiographic images were made after the induction of anesthesia and for 15 min after femoral prosthesis cementing. Mean arterial pressure did not change during the study, and mean pulmonary arterial pressure increased minimally. Large venous emboli appeared in eight patients, small venous emboli appeared in 12 patients, and no emboli appeared in four patients. Compared with previous investigations of large venous emboli during total knee arthroplasty with a pneumatic tourniquet, multiple logistic regression analysis discloses a 5.33-fold greater risk of large venous embolism accompanied the use of a tourniquet during total knee arthroplasty.

IMPLICATIONS

One third of knee replacements performed without a tourniquet demonstrated large emboli. Reducing marrow cavity invasion did not decrease the release of large emboli. Compared with knee replacement without tourniquet, tourniquet use places patients at a 5.33-fold greater risk of having a large emboli.

Emboli observed with use of transesophageal echocardiography immediately after tourniquet release during total knee arthroplasty with cement

The right atrium and the right ventricle of fifty-five patients were imaged with transesophageal echocardiography during fifty-nine total knee arthroplasties performed with cement and the use of general anesthesia. The patients ranged in age from thirty-two to eighty-three years (mean, 65.5 years). Cardiopulmonary parameters were measured with use of hemodynamic monitoring systems, such as pulse oximeters, pulmonary artery catheters, and radial artery catheters. In addition, a femoral vein catheter was inserted on the side of the operation in ten of the fifty-five patients. Showers of echogenic material traversing the right atrium, the right ventricle, and the pulmonary artery after the tourniquet was deflated were observed to various degrees in all patients and lasted three to fifteen minutes. The mean peak intensity occurred within thirty seconds (range, twenty-four to forty-five seconds) after the tourniquet was released. The mean mixed venous oxygen saturation (and standard error of the mean) decreased (from 83+/-0.9 to 72+/-1.5 per cent) and the mean pulmonary arterial pressure increased (from 20+/-1.0 to 27+/-1.0 millimeters of mercury [2.67+/-0.13 to 3.60+/-0.13 kilopascals]), compared with the values before the tourniquet was released, in all patients. The pulmonary vascular resistance index increased after release of the tourniquet (to a maximum of 328+/-29 dyne.s.cm(-5).m2; p = 0.00002) only in the patients who had echogenic material that was at least 0.5 centimeter in diameter. Clinical pulmonary embolism developed postoperatively in three patients; all three had had echogenic particles that were more than 0.5 centimeter in maximum diameter on imaging. Blood aspirated from one of the pulmonary artery catheters and from five of the ten femoral vein catheters demonstrated fresh venous thrombus. Histological evaluation of the aspirates failed to demonstrate fat, marrow, or particles of polymethylmethacrylate. Surgeons should consider acute pulmonary embolism as a diagnosis when evaluating a patient who has hemodynamic collapse during total knee arthroplasty performed with cement.

Pseudoaneurysm following femoral fracture

If the physician is aware of this diagnosis and maintains an appropriate level of suspicion and low threshold to commence duplex evaluation. The potential morbidity of a fracture-induced traumatic pseudoaneurysm can be minimized.

Functional results of percutaneous laser discectomy

The purpose of the study was to evaluate laser disc decompression with the KTP 532 laser, used in conjunction with a percutaneous technique, in contained, small to moderately sized lumbar disc herniation. Sixty-three patients who had a contained herniated nucleus pulposus (HNP) and underwent percutaneous laser disc decompression were prospectively studied. Sixty-one were available for follow-up. Access to the disc space was attained with an 18-gauge probe, followed by dilating cannulas guided with an image intensifier. Discography was not performed. The power was set at 10 W, and laser pulses were delivered for 0.2 seconds, with an interval of 0.5 seconds. A total of 1250 J was delivered to the disc space. The average follow-up was 31.75 months (range, 20 to 45 months). Overall, 44 patients (72%) achieved relief of radicular pain, and 33 patients (54%) achieved relief of low back pain. Thirty-six of 61 patients (59%) returned to work by postoperative week 4. Fourteen patients failed treatment, experiencing persistent symptoms (with scores on the Andrews and Lavyne rating scale of < or = 3). In this study group, optimal results were obtained when symptoms were treated within 1 year of presentation. Results from a historical control group are provided for comparison.

A six-degrees-of-freedom instrumented linkage for measuring the flexibility characteristics of the ankle joint complex

Diagnosis of ligament injuries to the ankle joint complex is a difficult clinical problem which relies primarily on manual physical examination and on radiographic evaluations. In an attempt to develop a reliable, quantitative diagnostic tool for such injuries we developed a six-degrees-of-freedom instrumented linkage (Ankle Flexibility Tester-AFT) capable of measuring the flexibility characteristics of the ankle joint complex in vivo. The unique non-serial structure of this linkage was such that these characteristics were recorded directly in an ]anatomical coordinate system which enhanced clinical interpretation. The goal of the present study was to develop this linkage and to test its accuracy and its test-retest reliability. The positional accuracy of the AFT was measured and was found to be better than 0.5 mm for translation and 1.2 degrees for rotations. The results obtained from a study conducted on two cadaveric specimens indicate negligible effect of loading rate on the flexibility characteristics within the range of possible manually applied loads. Finally, the reliability of the AFT was examined from test-retest studies conducted on a total of thirteen young healthy volunteers. The intraclass correlation coefficient (ICC), calculated from the test-retest data, indicated a reliability higher than 0.85. It was concluded that the high reliability and accuracy of the AFT, its simplicity of operation, the easy alignment procedure, the on-line load-displacement results, and the elimination of complex data processing render this device suitable for use in the clinic as well as in the research laboratory.

Postoperative autotransfusion after total knee arthroplasty

To evaluate the quality of shed blood postoperatively after total knee arthroplasty (TKA), the safety of autotransfusion, and to minimize homologous transfusion, the Autovac system was used for reinfusion of whole blood following cemented TKA. The system was used in 50 consecutive patients who were reinfused an average of 420 cc of whole blood. Twenty-five patients had a calcium binding resin anticoagulant within the collection canister. A second group of 25 patients had 40 cc of acid citrate dextrose anti-coagulate (ACD-A) in the collection canister as an anticoagulant. Fifteen hematologic parameters were measured during five time periods. Each study group was compared to a control group of 25 TKAs with a standard drain. The clinical safety of auto-transfusion with ACD-A was proven. Blood collected in the calcium binding resin had a statistically significant higher hemoglobin (P < .05), plasma-free hemoglobin (P < .05), fibrin split products (P < .05), and a different white blood cell differential.

The incidence of venous emboli during extramedullary guided total knee arthroplasty

During total knee arthroplasty (TKA), instrumentation of the marrow cavity with an intramedullary guide appears responsible for fatal intraoperative pulmonary embolism. Transesophageal echocardiography demonstrates venous emboli (VE) after tourniquet deflation during intramedullary guided TKA. Extramedullary guides avoid manipulating the marrow cavity. We determined the incidence of VE in 20 patients undergoing extramedullary guided TKA. Recordings of hemodynamic variables, mixed venous oximetry, end-tidal CO2 and N2 tensions, and echocardiograph images occurred after induction of anesthesia, after tourniquet inflation, during cementing, and for 15 min after tourniquet deflation. Large VE appeared in 14 patients and small VE in the other 6 patients. Large VE occurred only after deflation of the tourniquet. Beginning 3 min after tourniquet deflation, mean pulmonary arterial pressures increased from the baseline of 21 +/- 1.0 to 30 +/- 1.3 mm Hg and remained increased for the duration of the procedure. The incidence of large VE with extramedullary guided TKA did not differ compared to the previously reported incidence with intramedullary guided TKA. These data suggest that VE might arise from a thrombogenic effect of the tourniquet rather than from manipulation of the marrow cavity.

Results of lumbar disk surgery in a city compensation population

This is a retrospective analysis of 118 patients who underwent 132 operations in a city compensation setting for the treatment of lumbar disk disease from January 1976 to December 1987. Each of these patients had a work-related injury. There was a minimum 2-year follow up with an average follow up of 6.9 years. No patients were lost to follow up. The purpose was to determine what percentage of patients treated in a work-related setting could be expected to return to a sustained, pre-injury employment state following a carefully executed lumbar spine surgical procedure. Satisfactory surgical results were considered achieved only by those patients who returned to full-duty work status. Only 31 of the 118 patients (26%) returned to full duty and were considered satisfactory. Regarding the number of surgical procedures, 31 of 132 operations (23%) were successful. Sixteen reoperations in 13 patients all resulted in failure. Only 16 of the 64 patients (25%) treated with laminectomy and diskectomy alone had a satisfactory result. When a two-level, posterior lateral spinal fusion was added the success rate was increased to 44%, with 12 of 27 patients returning to work. Six patients with spinal stenosis underwent decompression laminectomy and entry level foraminotomies, and all had unsatisfactory results. Five patients with isthmic spondylisthesis underwent a Gill procedure and fusion. Only one of these patients (25%) returned to work. For a 2-year period chymopapain injection was given to 14 patients. Only two returned to work, with a 14% success rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Conversion of resection arthroplasty to total hip replacement

Conversion of Girdlestone arthroplasty is a demanding procedure dependent on adequate debridement at time of resection and appropriate long-term antibiotic therapy. Patients must be followed closely for persistent sepsis through ESR, aspiration, and physical examination. Pre-reconstruction, existing bone stock should be assessed and revision techniques utilized where appropriate. Our experience is that conversion of Girdlestone pseudoarthrosis to THR can yield good functional results and restore independence.

Echogenic emboli upon tourniquet release during total knee arthroplasty: pulmonary hemodynamic changes and embolic composition

Echogenic venous emboli accompany tourniquet deflation during total knee arthroplasty. The associated pulmonary hemodynamic alterations and determined embolic composition were measured in 34 patients, undergoing 35 procedures. Ten patients received a femoral venous catheter on the operative side. Hemodynamic variables, heart rate and mixed venous oximetry, end-tidal CO2 and nitrogen tensions, and transesophageal echocardiograms were recorded after induction of anesthesia (baseline), after tourniquet inflation, after cementing, and for 15 min after tourniquet deflation. Echocardiograms revealed either showers of miliary echogenic material (Group S, 9 patients), or large echogenic masses superimposed on the showers (Group MS, 26 patients). In Group MS only, pulmonary vascular resistance index increased above baseline (205 +/- 16 [SEM] dyne.s.cm-2) beginning 5 min after tourniquet deflation (maximum 328 +/- 29, P < 0.05). Mean pulmonary arterial pressure increased above baseline (20 +/- 1.0 mm Hg) for both Groups S and MS beginning 3 min after tourniquet deflation (27 +/- 1.0, P < 0.05). Cardiac index did not change. Five of 10 patients demonstrated fresh thrombus from the catheter in the operative limb. Echogenic emboli occurred in all patients upon tourniquet deflation during knee arthroplasty. Pulmonary vascular resistance index increased only in patients with large echogenic material. Our data suggest that these emboli represent fresh thrombus formation during tourniquet inflation. Heparin administration prior to tourniquet inflation may diminish embolic showers.

Acetabular osteolysis in total hip arthroplasty: prevention and treatment

Osteolysis can occur around loose, as well as well fixed, cemented or cementless acetabular components in total hip arthroplasty. Histologic studies of tissues biopsied from osteolytic regions suggest an adverse foreign body response to polyethylene and other particulate debris from prosthetic materials. Phagocytosis of these particles by macrophages and giant cells stimulate the production of proteolytic enzymes and inflammatory mediators, all leading to tissue destruction. The importance of polyethylene wear debris is now fully appreciated, and it is clear that this is the major contributor to particulate debris. The authors strongly recommend the avoidance of 32 mm femoral heads, thin acetabular component liners, titanium heads, and acetabular screws when absolutely necessary. We strongly advise 26 mm to 28 mm femoral heads, polyethylene thickness of at least 8 mm, precise liner shell contact, rigid fixation of the acetabular metal shell, intimate bone-acetabular shell contact, and circumferential porous coating of femoral components to decrease the amount of and migration potential of polyethylene debris (Table). Based on our current knowledge, these measures will minimize the problem of acetabular osteolysis.

Technique for in vivo measurement of the three-dimensional kinematics and laxity characteristics of the ankle joint complex

We introduce here a technique to measure the three-dimensional kinematics and laxity characteristics of the ankle joint complex in vivo. The system consists of an optoelectric, kinematic data acquisition system that is used to measure the motion of the ankle joint complex in response to controlled moments applied through a system of pneumatic actuators. As a first step toward development of the method into a quantitative diagnostic tool for injuries of ankle ligaments, we addressed the following questions: (a) What is the reliability for measurement of range of motion and laxity of the ankle joint complex? (b) Are there significant differences in laxity between the left and right joints of a healthy individual? and (c) Are there significant differences in laxity of the ankle joint complex between men and women? To answer these questions, we performed repeated measures of range of motion and laxity of paired ankles in a population of 18 healthy young individuals. The high intraclass correlation coefficients obtained from the statistical analysis indicate that the new experimental system is highly reliable in measurement of total range of motion and total laxity of the ankle joint complex. We further concluded that, within the statistical power available in our experimental design, there are no significant differences in either range of motion or laxity between left and right ankles of healthy individuals or between men and women.

Thromboembolism coincident with tourniquet deflation during total knee arthroplasty

Despite prophylactic therapy, pulmonary embolism remains the leading cause of perioperative mortality in patients undergoing total knee arthroplasty (TKA). We used transoesophageal echocardiography to monitor 29 consecutive patients during TKA. Showers of substantial amounts of echogenic material, lasting for 3-15 min, were visible in the right atrium and ventricle within 10-15 s of tourniquet deflation in all patients. A 3 x 6 mm fresh thrombus was aspirated from the central circulation of one patient. Another patient, who had had a Greenfield filter placed for previous thromboembolism, showed very little echogenic material after tourniquet deflation. The composition and importance of these echogenic emboli remain uncertain.

Surgical results in anterior cervical discectomy and fusion using a countersunk interlocking autogenous iliac bone graft

The purpose of this study was to evaluate the surgical results of anterior cervical discectomy and fusion using a countersunk interlocking autogenous iliac bone graft. Two hundred thirty-two patients were followed for an average of 6.8 years. All patients suffered neck and arm pain. Two hundred twenty patients received conservative treatment for at least six months. Overall results were satisfactory in 202 patients (87%) and unsatisfactory in 30 patients (13%). The pseudoarthrosis rate was 6.5% which is significantly lower than previous reports. The premise of this technique is that the interlocking graft prevents migration, promotes fusion by providing immobilization, and restores the height of the interspace. Anterior cervical discectomy and fusion, using a countersunk interlocking autogenous iliac bone graft, is a satisfactory surgical procedure in which successful pain relief is to be expected.

Posttraumatic upper extremity wound coverage utilizing the extended deep inferior epigastric flap

The extended deep inferior epigastric artery (DIEA) flap was used in 4 patients with traumatic mid upper extremity wounds. Although there are numerous flaps available for resurfacing upper extremity defects, including the groin, thoracoepigastric, and a host of microvascular flaps, in each of these patients a preoperative consideration necessitated a novel approach. The DIEA flap is based on an axial vascular watershed resulting in a long, thin, well-vascularized, supple skin flap, which proved extremely effective in solving the reconstructive needs of these patients. The flap is technically simple to elevate and quite versatile. In all patients, the flaps survived and healing of the wounds was achieved. The DIEA flap should be considered a valuable reconstructive alternative when faced with elbow and forearm defects.

Factors influencing long-term results in high tibial osteotomy

Recorded here is a comprehensive review of the current literature on high tibial osteotomy with emphasis on postponing an inevitable total knee arthroplasty (TKA). Accompanying this review is a confirmatory, retrospective study of 35 patients with 39 high tibial osteotomies with an average follow-up study of 8.5 years (range, 3.8-15.1 years). Twenty-two of the patients (57%) had good results, seven (18%) fair, and ten (25%) poor at final follow-up examination. Nine of the 35 patients required TKA at an average of 4.7 years post-osteotomy. The percentage of good results diminished with time of follow-up study, starting at two years with 87% good results and ending at 15 years with only 57% of the patients remaining in that category. Patients lost an average of 8 degrees of flexion post-osteotomy, regardless of good, fair, or poor result. Patients with favorable results were usually younger than 60 years of age, and had less than 12 degrees of angular deformity, pure unicompartmental disease, ligamentous stability, and a preoperative range of motion are of at least 90 degrees.

Evaluation of total knee arthroplasty using isokinetic testing

Although total knee arthroplasty (TKA) has been studied extensively, objective muscle testing has not been reported. Isokinetic testing of 68 patients with degenerative joint disease scheduled for unilateral TKA revealed that marked muscular deficits in flexion and extension were present preoperatively in the involved knee. Postoperatively, hamstring peak-torque values were able to attain strength levels of the uninvolved knee within the period of seven to 12 months after surgery, whereas the quadriceps mechanism still showed a residual deficit at two years follow-up evaluation. In addition, the ratio of flexion to extension peak torques in the operated knee returned to normal values as the quadriceps mechanism was rehabilitated. A comprehensive evaluation system consisting of Cybex II isokinetic testing, gait mat analysis, and the Hospital for Special Surgery knee rating scale is also presented. Isokinetic testing correlated well with gait analysis. Patients with a nearly balanced quadriceps-to-hamstring ratio walked with a more symmetrical gait pattern. The knee rating scale was less reliable in assessing functional outcome. Functional testing and evaluation at the authors' institution has provided an important source of objective information that allows better planning and evaluation of TKAs. These isokinetic studies enable more critical planning of the rehabilitation program. Hamstring or quadricep exercises may be emphasized as required. The authors conclude that a balanced hamstring to quadriceps mechanism is needed for resumption of normal gait.

A comparison of the mechanical properties of fiberglass cast materials and their clinical relevance

The mechanical properties of five synthetic fiberglass casting materials were evaluated and compared with the properties of plaster of Paris. Two of the tests were designed to bear clinical relevance and the third to determine intrinsic material properties. The effect of water on strength degradation was also evaluated. It was found that the synthetics as a group are far superior to plaster of Paris in all methods of testing and that, among the synthetics, KCast Tack Free, Deltalite "S", and KCast Improved were the stronger materials. Clinically, the most important results are that the synthetics attain their relatively high strength in a much shorter time frame than does plaster of Paris, and retain 70-90% of their strength after being immersed in water and allowed to dry.

Comparison between intermittent (spring-loaded) and continuous closed suction drainage of orthopedic wounds: a controlled clinical trial

A randomized prospective trial of a continuous vacuum system (VariDyne) and an intermittent spring type system (Hemovac) was conducted in 126 consecutive orthopedic surgical wounds between February 1988 and October 1988 in which postoperative suction drainage was required. Comparison between the two groups showed a statistically significant difference among total drainage removed by the vacuum units and wound drainage into the dressing following drain removal. Hip and knee arthroplasty patients receiving continuous vacuum suction experienced a greater average drainage volume and better wound healing than those receiving the spring-loaded device. Overall, all wounds which utilized continuous vacuum drained less serosanguinous or serous fluid than those wounds utilizing the intermittent system following drain removal. A clear advantage to using a continuous vacuum suction device over an intermittent spring-loaded device is seen with respect to hematoma evacuation, wound drainage, wound healing, and possible complications.

Compression arthrodesis of the ankle by triangular external fixation: an improved technique

In this preliminary report, the authors present a new application of an external tubular fixation system for compression arthrodesis of the ankle. A triangular ankle fusion frame was designed that provides rigid immobilization of the tibiotalar joint, with midfoot control provided by a metatarsal pin. Over the past 3 years, the authors have used this device to achieve solid tibiotalar arthrodesis in 12 of 14 patients. The surgical method, including step-by-step construction and application of the triangular ankle fusion frame, is presented. Early results suggest a nearly 90% union rate, including reoperative cases for failed primary fusion.

Gene linkage in neurofibromatosis

Neurofibromatosis (NF) is a disease of protean manifestations involving tissues of ectodermal and mesodermal origin. Modern terminology divides NF into NF-1 (classically peripheral NF) and NF-2 (classically central NF). Gene linkage will provide many answers to understanding the varied and unpredictable course of NF. Gene linkage may explain phenotypic variations among NF patients, malignant transformation potential of neurofibromas, increased likelihood of malignant sarcomas in NF patients, and possible insight into learning disability in NF patients. Chromosome location has been narrowed to the pericentric region of chromosome 17 for NF-1 and to the center of the long arm of chromosome 22 for NF-2.

Blood loss with total knee arthroplasty

A substantial drop in blood volume occurs in patients being treated by total knee arthroplasty (TKA). Of 140 TKAs (108 patients) studied to analyze this blood loss, 70 required transfusion and 70 did not. The average transfusion was 2.6 units per arthroplasty. Blood loss in the nontransfused group was 1.8 units per arthroplasty. The overall mean blood loss was 2.2 units per TKA. Insertion of a constrained TKA resulted in a statistically significant increase in blood loss. Preoperative diagnosis, anesthetic technique, revision arthroplasty, patellofemoral arthroplasty, and tourniquet technique did not statistically affect the blood loss. The bulk of the blood loss is collected postoperatively in the suction drainage system.

The orthopedic manifestation of neurofibromatosis. A clinical experience and review of the literature

A retrospective review of 47 patients with neurofibromatosis was performed to evaluate the effects of that disease on patient function and disability. Clinical manifestations were distributed as follows: cafe-au-lait markings were the most prevalent manifestation (87%), followed by a positive family history (49%), scoliosis (53%), neurofibromata (19%), and pseudarthrosis of the tibia (19%). The classic scoliosis was resistant to brace treatment; bracing failed in 70% of patients, necessitating spinal fusion. Pseudarthrosis of the tibia can be subdivided into normal, narrow sclerotic, and cystic medullary canal groups. This study supported the theory that tibias with narrow sclerotic medullary canals should be prophylactically braced until skeletal maturity to prevent fracture. Once fractured, the incidence of non-union is high regardless of treatment mode. Eighty percent of patients with pseudarthrosis of the tibia did not heal with multiple bone grafts and were amputated below the knee. Many patients in this study were educable or only mildly mentally retarded, and performed quite well in activities of daily living.

Quantitative gait analysis after unilateral or bilateral total knee replacement

Using a gait mat, we characterized the functional results for thirty-five patients before and after a total knee replacement for the treatment of degenerative arthritis. Preoperatively, we studied three distinct populations of patients. Group I consisted of sixteen patients who were scheduled to have a unilateral total knee replacement and who had no signs or symptoms of arthritis in the contralateral knee. Group II consisted of twelve patients who were scheduled to have a unilateral total knee replacement but who had asymptomatic degenerative arthritis in the contralateral knee. Group III consisted of seven patients who had bilateral arthritis that was to be managed by total knee replacement. The gait mat allowed us to measure stance time, step length, double-support time, swing time, swing-to-stance ratio, and velocity. A knee-rating scale was used to measure pain. The data were compared with those obtained from an age-matched control group of ninety-one subjects. Postoperatively, the gait evaluation revealed marked improvement in all of the patients. However, the patients in Group II did not improve as much as those in Groups I and III did. We concluded that even asymptomatic arthritis can impair gait, that bilateral total knee replacement can yield excellent results, and that patients tend to use the lower limbs in as symmetrical a way as possible. Gait analysis can be an important source of objective information, and it is easily performed by using a gait mat.

The use of preoperative computed tomography scanning in total hip arthroplasty

Computed tomography (CT) scanning is a useful tool in many areas of orthopedics. This prospective study reviews the authors' experience with CT scans in 73 patients studied prior to total hip arthroplasty. The CT scan is valuable in the primary total hip arthroplasty if the radiograph suggests medial, posterior, or superior acetabular wall defects. In some instances, bone grafting or other special procedures are required for the reconstruction of these defects. In the present study, preoperative CT identified an abnormality in 18 cases with deficient acetabular walls, while plain radiographs identified only six of these difficulties. Although important information for planning revision total hip arthroplasties was noted in this series, CT scans are indicated primarily in instances of suspected acetabular wall defects.

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)

"Idiopathic" scoliosis associated with congenital upper-limb deficiency

Sixty patients with congenital upper-limb deficiency were evaluated for scoliosis in 1972. Twenty-one patients had scoliosis of 5 degrees or more and 15 had scoliosis of 10 degrees or more. Fifteen of these patients had long-term follow-up periods. Thirteen patients had idiopathic scoliosis. Idiopathic scoliosis associated with congenital upper-limb deficiency could be divided into three groups, and the progression of scoliosis was predictable within each group. All but one of these patients had a relatively benign course and did not require treatment. Double curves with rotation progressed throughout the growth period. Double curves with Grade 0 rotation tended not to be progressive. Single curves did not have rotation deformity and resolved spontaneously or remained stable. Magnitude of limb deficiency did not correlate with the curve magnitude, progression, or pattern. Muscle imbalance did not appear implicated as a cause for the scoliosis in these patients. Young age at discovery of the curve did not correlate with progression of the curve.

Muscle biopsy: proper surgical technique

Muscle biopsy is often incorrectly performed despite the fact that it is a relatively simple procedure. A consistently reproducible surgical technique in 93 open vastus lateralis muscle biopsies implemented in conjunction with neuromuscular and malignant hyperthermia research demonstrated 14 cases of malignant hyperthermia and a variety of forms of neuromuscular pathology. No wound complications or disabilities have resulted from this procedure. The procedure includes careful selection of biopsy site, regional anesthesia, atraumatic dissection, and immediate processing of the biopsy sample. A new muscle biopsy clamp is described. The authors recommend the vastus lateralis for the biopsy site unless another area of involvement is specifically indicated. Careful attention to technical details is required for optimal results.

Low-velocity gunshot wounds in police officers

One hundred forty-five Philadelphia police officers were injured as a result of gunfire during the period from January 1971 to February 1983. Arrests and arrest attempts were the most common causes of these injuries; on- and off-duty accidents were the second most common causes. Twenty fatalities occurred among the 145 officers. Specific medical and surgical management of gunshot wounds depended largely on the location of the wound and the extent of the damage. Analyses of the location of the wounds in this study revealed that many could have been alleviated through the use of body armor, such as bullet-proof vests and lightweight helmets. Of the treatment records of 100 patients completed for evaluation, average hospitalization time was ten days, time without duty averaged 143 days, and limited duty averaged 70 days. Twenty-two persons received permanent and partial disabilities related either partially or wholly to their wounds. Fourteen individuals expressed anxiety about returning to work as police officers, and two received disability retirements for emotional instability. An officer who is aware of the probability of injury while performing a specific task can decide whether to wear an armored helmet or bullet-proof vest at the appropriate time. In the treatment of low-velocity gunfire injury, the physician could use the guidelines reviewed for specific treatment of the injury and thus anticipate the length of time or probability of the individual returning to work. Early recognition of these factors could help to avoid psychologic trauma.

A comparison of CT scanning and myelography in the diagnosis of lumbar disc herniation

Computerized tomographic (CT) scanning of the fourth and fifth lumbar disc spaces with the GE CT/T8800 scanner followed by metrizamide myelography was obtained for 134 consecutive patients with suspected lumbar disc disease. There was an overall concordance rate of 85% between CT scanning and myelography. In those 52 patients treated by surgery, concordance between the CT and the myelogram was similar at 86.5%. Myelography and surgical findings were in agreement in 94.2% of cases, while CT findings and surgical finding agreed in 92.3% of cases. The authors' data indicate that the CT scan is as accurate as myelography in the diagnosis of lumbar disc disease. When the CT scan interpretation is supported by clinical findings, the myelogram may be eliminated in the preoperative patient. Myelography may be reserved for equivocal cases.

The effects of epidural injection of local anesthetics and corticosteroids on patients with lumbosciatic pain

Although epidural cortisone injections are commonly used for treatment of lumbosciatic pain, insufficient critical analysis of the end result can be found in the literature. The present study is a retrospective critical analysis of 367 patients with leg pain who were engaged for a minimum of two weeks or an average of two months in multifaceted conservative management without relief of pain. Injections of 10 cm3 of 0.5% bupivacaine and 100 mg of methylprednisolone were given to inpatients treated by the same anesthesiologist. The average follow-up period was 21.4 months (range, 6-36 months). Results were analyzed according to duration of pain and history of prior lumbar spine surgery. The most favorable results (approaching 70% offd-excellent) were observed in patients with subacute radicular leg pain (of less than three months' duration) and chronic leg pain (of greater than three months' duration) with no prior surgery. Negative myelograms and electromyograms (EMGs), in the absence of reflex or motor deficits on physical examination, also pointed toward optimal results. Those patients with chronic pain who had had prior lumbar spine surgery had the least satisfactory results.