Search

Background: Postoperative physical therapy (POPT) is a critical aspect of patient recovery following orthopedic shoulder surgery. Despite the importance of POPT, some patients do not complete their course of physical therapy, which can affect postoperative recovery and outcomes. This study aimed to identify risk factors that influence patient adherence and attendance of POPT., Methods: Patients >90 days postop from elective shoulder surgery were retrospectively recruited for this study from an urban, academic tertiary medical center. Patient charts were reviewed for demographic factors with eligible patients being contacted via telephone call to answer a questionnaire concerning their use of POPT. Inadequate levels of POPT were defined as stopping formal physical therapy earlier than the physical therapist recommended. Final analysis cohorts were compared using Fisher's Exact Test and Wilcoxon Rank Sum Test., Results: A total of 104 patients were included in the final analysis with 84 completing POPT and 20 reporting having stopped therapy early. Patient medical history including elevated BMI (mean significance difference 3.8, [0.018 to 7.6 95% CI]) p=0.026)), being a smoker (p=0.027), having diabetes (p<0.001), and having Medicaid as their primary insurance (p=0.008) were significantly associated with stopping physical therapy earlier than recommended by the physical therapist (Table I). Demographic factors such as requiring additional assistance to get to medical appointments (p=0.012) and living farther away from a physical therapy center (p=0.007) were also substantially associated with a greater risk of stopping physical therapy earlier than recommended by the physical therapist (Table II)., Conclusion: Elevated BMI, tobacco use, diabetes, Medicaid enrollment status, requiring additional assistance to get to PT appointments, and living farther away from their physical therapy center are risk factors associated with patients stopping PT after elective shoulder surgery earlier than recommended by a physical therapist. Knowledge of these patient-specific risk factors should be considered by orthopedic surgeons and physical therapists when tailoring a POPT protocol., (Copyright © 2024. Published by Elsevier Inc.)

Background: Lines of action of the superior, middle, and inferior infraspinatus muscle fibers work together to produce moment arms that change throughout abduction in an intact shoulder, after a supraspinatus tear, and after superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (rTSA)., Purpose: To use moment arm values to indicate the efficacy of SCR and rTSA to restore infraspinatus function during shoulder abduction., Study Design: Descriptive laboratory study., Methods: A total of 5 human cadaveric shoulders placed in a testing apparatus were each actively abducted (0°-90°) under the following 4 conditions: intact, complete supraspinatus tear, SCR, and rTSA. The 3-dimensional coordinates of points were tracked along the origin and insertion of the superior, middle, and inferior infraspinatus fibers during abduction. Moment arm values were calculated using the origin-insertion method to determine abduction contribution of infraspinatus fiber sections. Analysis of variance and post hoc Tukey testing were used to compare differences in moment arms between the 4 conditions and between fiber sections., Results: In the intact condition, the superior infraspinatus fibers had an abduction moment that decreased with elevation until shifting to adduction. Conversely, the middle and inferior fibers had an adduction moment that turned to abduction (mean moment arm values from 0° to 90°: inferior, from -5.9 to 19.4 mm; middle, from -4.7 to 15.9 mm; superior, from 5.6 to -5.1 mm; P < .05). After a supraspinatus tear, superior fibers lacked any torque, and inferior and middle fibers lost adduction potential (inferior, from 4.8 to 14.0 mm; middle, from -0.2 to 9.6 mm; superior, from 1.0 to 0.7 mm; P < .05). SCR restored the initial superior fiber abduction moment (5.6 mm at 0°; P < .05); middle and inferior fibers had some restoration but were weaker than intact fibers. Loss of abduction moment in all fibers was seen with rTSA (inferior, from -9.6 to -1.6 mm; middle, from -10.5 to -3.6 mm; superior, from -1.7 to -4.6 mm; P < .05)., Conclusion: Infraspinatus fiber groups had different and inverse moment arms during scapular plane elevation. SCR most closely resembled the intact shoulder, whereas rTSA transformed the infraspinatus into an adductor., Clinical Relevance: These results support the efficacy of SCR at restoring biomechanical muscle function and suggest that the changes in moment arms for each fiber group be considered when choosing treatment modalities and rehabilitation protocols after rotator cuff tear., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.L.K. has received education payments from Medwest and consulting fees from Flexion Therapeutics. B.A.G. has received education payments from Medwest, consulting fees from Acumed and Baxter Healthcare, speaking fees from Graymont Equipment, and hospitality payments from Exactech. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Purpose: The rotator cuff (RC) muscles contribute to dynamic stability and rotational actions of the glenohumeral joint. Moment arm can be used to demonstrate the potential work a muscle contributes to a musculoskeletal joint rotation. This study aimed to understand the moment arm contributions of the RC muscles and explore changes following a complete supraspinatus tear treated with either superior capsular reconstruction (SCR) or reverse total shoulder arthroplasty (rTSA)., Methods: Five fresh-frozen cadaveric specimens were prepared and mounted in an apparatus where each intact RC muscle was held in tension with a line of action toward its origin on the scapula. Mean moment arms for each muscle were determined experimentally based on Optotrak data collected during cadaveric shoulder arm abduction., Results: Using ANOVA testing, our analysis demonstrated significant differences (p < 0.001) in infraspinatus and teres minor moment arms after rTSA compared to the intact shoulder model. After SCR, significant differences (p < 0.001) were seen in teres minor, with these differences being statistically similar to the changes seen in teres minor after rTSA. Subscapularis showed no significant difference in moment arm values between the models (p = 0.148)., Conclusion: Our results illustrate that mean moment arms were preserved in the RC muscles after complete supraspinatus tear. This study also shows evidence that subscapularis function may be maintained after SCR or rTSA. After SCR, infraspinatus may maintain similar abduction ability compared to the anatomical shoulder, while teres minor ability may increase. Infraspinatus may have decreased abduction ability after rTSA while teres minor may have increased ability.

Introduction: The tibial tubercle-trochlear groove (TT-TG) distance is commonly used to evaluate and guide treatment for patellar instability. There is limited data available regarding TT-TG variability based on patient demographics and anthropometric factors., Materials and Methods: TT-TG was measured on magnetic resonance imaging (MRI) for 384 consecutive adult patients. Demographic information for the corresponding was then gathered from the medical record and analyzed. Demographic variables analyzed included age, sex, race, height, weight, and body mass index (BMI)., Results: Mean TT-TG among the 384 patients was 12.68mm (standard deviation [SD]: 4.13mm, 95% confidence interval [CI] 12.26-13.10mm, range, 3.2-27.0mm), and there was a significant correlation with height (p=0.009), weight (p=0.017), and race (p<0.001). However, there was no significant correlation seen with sex (p=0.854), BMI (p=0.253), or age (p=0.096). Height and African American race were identified as independent predictors of increased TT-TG (p=0.007 and p<0.001, respectively); and females were found to have an increased TT-TG relative to height (p=0.015)., Conclusion: Tibial tubercle-trochlear groove distance was significantly correlated with race and height in the 384 patients examined. These findings may help explain clinical differences in these patients and help establish "norms" for patients of various ethnic and anthropometric variability.

Background: Previous studies have aimed to biomechanically improve the transosseous tunnel technique of rotator cuff repair. However, no previous work has addressed tunnel inclination at the time of surgery as an influence on the strength of the repair construct., Hypothesis: We hypothesized that the tunnel angle and entry point would influence the biomechanical strength of the transosseous tunnel in rotator cuff repair. Additionally, we investigated how tunnel length and bone quality affect the strength of the repair construct., Study Design: Controlled laboratory study., Methods: Mechanical testing was performed on 10 cadaveric humeri. Variations in the bone tunnel angle were imposed in the supraspinatus footprint to create lateral tunnels with inclinations of 30°, 45°, and 90° relative to the longitudinal axis of the humeral shaft. A closed loop of suture was passed through the bone tunnel, and cyclic loading was applied until failure of the construct. Load to failure and distance between entry points were the dependent variables. Analysis of variance, post hoc paired t tests, and the Bonferroni correction were used to analyze the relationship between the tunnel angle and failure load. The Pearson correlation coefficient was then used to evaluate the correlation of the distance between entry points to the ultimate failure load, and t tests were used to compare failure loads between healthy and osteoporotic bone., Results: Tunnels drilled perpendicularly to the longitudinal axis (90°) achieved the highest mean failure load (167.51 ± 48.35 N). However, there were no significant differences in the failure load among the 3 tested inclinations. Tunnels drilled perpendicularly to the longitudinal axis (90°) measured 13.86 ± 1.35 mm between entry points and were significantly longer ( P = .03) than the tunnels drilled at 30° and 45°. We found no correlation of the distance between entry points and the ultimate failure load. Within the scope of this study, we could not identify a significant effect of bone quality on failure load., Conclusion: The tunnel angle does not influence the strength of the bone-suture interface in the transosseous rotator cuff repair construct., Clinical Relevance: The transosseous technique has gained popularity in recent years, given its arthroscopic use. These findings suggest that surgeons should not focus on the tunnel angle as they seek to maximize repair strength., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.B. is a consultant for Smith & Nephew, Exactech, Arthrex, Liberty Surgical, Encore Medical, and Linvatec. B.G. is a consultant for Acumed, Iroko Pharmaceuticals, and Exactech. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Acute distal biceps tendon ruptures are uncommon injuries that often affect young active males, typically resulting from an eccentric load on their dominant extremity. The purpose of this study was to compare pullout strength and tendon gapping in the tension slide technique (TST) versus a knotless fixation technique (KFT)., Methods: Two sets of experiments were performed using cadaveric elbow specimens. In the first experiment, eight elbows from different cadavers were tested to compare TST with a standard locking whipstitch with KFT, four elbows in each group, using a standard locking whipstitch. In the second experiment, 12 elbows were used to study the differences between TST with a standard locking whipstitch with KFT using suture tape reinforced whipstitch (RKFT), using the TST data from the first and second experiment. Each experiment evaluated gapping after cyclic loading and the second experiment also tested the construct to load to failure., Results: Gapping for KFT with a standard locking whipstitch was 10.64 mm versus 2.69 mm for the TST after 1000 cycles (P = 0.016). A reinforced whipstitch significantly improved the failure to gap on the KFT with no significant difference in gapping when compared to TST after 3000 cycles (P = 0.36). The resultant gapping for TST and KST was 2.08 mm and 2.99 mm (P = 0.91), respectively. Load to failure for TST and KFT were 282 Nm and 328 Nm (P = 0.20), respectively., Conclusion: Bone-tendon gap resistance of a KFT repair of a torn distal biceps tendon is limited by suture technique. Using a tape reinforced locking whipstitch, the repair is as strong as TST repair., Levels of Evidence: Basic Science.

There is controversy regarding whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is the treatment preferred for displaced intracapsular femoral neck fractures (FNFs). Using the US National Hospital Discharge Survey, we found that, of 12,757 patients admitted for FNF between 2001 and 2010, 4.6% underwent THA and 52.5% underwent HA. More of both procedures were performed over time. Mean age was higher for HA patients. Hospitalization duration and blood transfusion rates were higher for THA. There were region-based differences in frequency of THA and significant hospital-size-based differences in frequency of HA, possibly because of differences in regional training and subspecialist availability. In addition, a larger proportion of THA patients was covered by private insurance., Competing Interests: Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Distal biceps tendon ruptures are uncommon and generally occur in men aged 30 to 50 years in their dominant arm as a result of a strong eccentric load. Numerous surgical exposures and methods of fixation exist for repair of a ruptured distal biceps tendon. The goal of surgical management is to restore the anatomic footprint of the biceps tendon on the radial tuberosity to maximize flexion strength, supination strength, and muscle endurance. When compared with 2-incision repair techniques, single-incision repairs historically may not have restored the anatomic footprint of the distal biceps. Single-incision repair with the ArthroTunneler is a safe and effective technique that provides the anatomic restoration of a 2-incision approach with the decreased complication profile of a single-incision approach and does not require suture anchors, buttons, screws, or other implants.

The rate of total knee arthroplasty (TKA) utilization in younger patients (< 65 years old) is increasing. Little is known regarding demographics and in-hospital outcomes in this population. The National Hospital Discharge Survey (NHDS) database was searched using International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for patients admitted to U.S. hospitals for unilateral primary TKA between 2001 and 2010. Patients were separated into young (< 65 years of age) and senior cohorts (≥ 65 years of age). ICD-9 diagnosis and procedure codes were used to identify demographics, hospital length of stay, in-hospital adverse events, mortality, and discharge disposition. Trends were evaluated by linear regression with Pearson correlation coefficient ( r ) and statistical comparisons were made using Student t -test and chi-square analysis. The young cohort accounted for 38.4% of TKAs performed from 2001 to 2005, increasing to 42.7% of TKAs from 2006 to 2010. They had a higher percentage of males (36.4 vs. 34.2%, p  < 0.001). Rates of obesity (11.1 vs. 6.0%, p  < 0.001) and morbid obesity (5.8 vs. 1.9%, p  < 0.001) were significantly higher, yet they had less comorbidities (4.7 vs. 5.2, p  < 0.001), and lower rates of transfusion (12.2 vs. 19.8%, p  < 0.001), pulmonary embolism (PE) (0.31 vs. 0.49%, p  < 0.020), and mortality (0.03 vs. 0.18%, p  < 0.001). Patients < 65 years old undergoing TKA have almost double the rate of obesity of patients ≥ 65 years old. This could explain the higher rates of periprosthetic infection and aseptic mechanical failure seen in younger patients. However, the young cohort had a more favorable discharge disposition and lower mortality and risk of PE than elderly patients., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures., Methods: Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences., Results: Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision., Conclusions: There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions., Level of Evidence: Level III - Case controlled study.

Gluteal compartment syndrome (GCS) is a rare condition. We present a case of gluteal muscle strain with hematoma formation, methicillin-resistant Staphylococcus aureus (MRSA) superinfection, leading to acute GCS, rhabdomyolysis and acute kidney injury. This combination of diagnoses has not been reported in the literature. A 36-year-old Caucasian male presented with buttock pain, swelling and fever after lifting weights. Gluteal compartment pressure was markedly elevated compared with the contralateral side. Investigations revealed elevated white blood cell, erythrocyte sedimentation rate, C-reactive protein, creatine kinase, creatinine and lactic acid. Urinalysis was consistent with myoglobinuria. Magnetic resonance imaging showed increased T2 signal in the gluteus maximus and a central hematoma. Cultures taken from the emergency debridement and fasciotomy revealed MRSA. He had repeat, debridement 2 d later, and delayed primary closure 3 d after. GCS is rare and must be suspected when patients present with pain and swelling after an inciting event. They are easily diagnosed with compartment pressure monitoring. The treatment of gluteal abscess and compartment syndrome is the same and involves rapid surgical debridement.

In locking plate osteosynthesis, proper surgical technique is crucial in reducing potential pitfalls, and use of a torque limiter makes it possible to control insertion torque. We conducted a study of the ways in which different techniques can alter the accuracy of torque limiters. We tested 22 torque limiters (1.5 Nm) for accuracy using hand and power tools under different rotational scenarios: hand power at low and high velocity and drill power at low and high velocity. We recorded the maximum torque reached after each torque-limiting event. Use of torque limiters under hand power at low velocity and high velocity resulted in significantly (P < .0001) different mean (SD) measurements: 1.49 (0.15) Nm and 3.73 (0.79) Nm. Use under drill power at controlled low velocity and at high velocity also resulted in significantly (P < .0001) different mean (SD) measurements: 1.47 (0.14) Nm and 5.37 (0.90) Nm. Maximum single measurement obtained was 9.0 Nm using drill power at high velocity. Locking screw insertion with improper technique may result in higher than expected torque and subsequent complications. For torque limiters, the most reliable technique involves hand power at slow velocity or drill power with careful control of insertion speed until 1 torque-limiting event occurs.

Introduction: Total shoulder arthroplasty (TSA) is a highly successful procedure for management of glenohumeral arthritis, fractures and rotator cuff tears. The purpose of this study was to evaluate patient demographics, perioperative outcomes and assess recent national trends in both primary and revision TSA., Methods: The National Hospital Discharge Survey database was searched for patients admitted to US hospitals for primary and revision TSA from 2001 to 2010., Results: A total of 1,297 patients who underwent primary TSA and 184 patients who underwent revision TSA were identified. The rates of primary TSA (r = 0.88) and revision TSA (r = 0.85) both demonstrated a strong positive correlation with time. The mean patient age of the primary group was significantly higher than the revision group. Gender was not significantly different between the groups. There was no significant difference in the racial make-up between the revision and primary groups. African Americans accounted for 3.3 % of primaries versus 4.3 % of revisions (p = 0.615). Revision TSA patients had a significantly longer average LOS (3.06 days vs 2.46 days, p < 0.01), more medical comorbidities (6.0 vs 5.1 comorbidities, p < 0.01) and a higher rate of developing a myocardial infarction (2.2 % versus 0 %, p < 0.01) than the primary TSA group., Conclusions: This study demonstrates that the rate of TSA is rapidly increasing in the US, with over a four-fold increase in revisions and five-fold increase in primaries over the ten years studied.

Contrast-enhanced ultrasound imaging is a radiation-free diagnostic tool that uses biocompatible ultrasound contrast agents (UCAs) to improve image clarity. UCAs, which do not contain dye, often salvage "technically difficult" ultrasound scans, increasing the accuracy and reliability of a front-line ultrasound diagnosis, reducing unnecessary downstream testing, lowering overall health care costs, changing therapy, and improving patient care. Two UCAs currently are approved and regulated by the US Food and Drug Administration. They have favorable safety profiles and risk/benefit ratios in adult and pediatric populations, including compromised patients with severe cardiovascular diseases. Nevertheless, these UCAs are contraindicated in patients with known or suspected right-to-left, bidirectional, or transient right-to-left cardiac shunts. These patients, who constitute 10% to 35% of the general population, typically receive no UCAs when they undergo echocardiography. If their echocardiographic images are suboptimal, they may receive inappropriate diagnosis and treatment, or they may be referred for additional diagnostic testing, including radiation-based procedures that increase their lifetime risk for cancer or procedures that use contrast agents containing dye, which may increase the risk for kidney damage. An exhaustive review of current peer-reviewed research demonstrated no scientific basis for the UCA contraindication in patients with known or suspected cardiac shunts. Initial safety concerns were based on limited rodent data and speculation related to macroaggregated albumin microspheres, a radioactive nuclear imaging agent with different physical and chemical properties and no relation to UCAs. Radioactive macroaggregated albumin is not contraindicated in adult or pediatric patients with cardiac shunts and is routinely used in these populations. In conclusion, the International Contrast Ultrasound Society Board recommends removal of the contraindication to further the public interest in safe, reliable, radiation-free diagnostic imaging options for patients with known or suspected cardiac shunts and to reduce their need for unnecessary downstream testing., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to measure in vivo axial-plane translation of the glenohumeral joint by use of magnetic resonance imaging in patients with and without SLAP lesions between the conventional adducted neutral rotation (AD) view and an abducted externally rotated (ABER) view., Methods: Seven patients with an intraoperative SLAP lesion that was unstable and required repair were selected into the SLAP group. Although they did not have normal shoulders, 15 patients were selected into the control or comparison group, most of whom had rotator cuff pathology. The glenohumeral contact point (CP) and humeral head center (HHC) were calculated and compared with the glenoid surface as a relative anterior or posterior translation. The relative posterior translation between the ABER and AD views for each patient was calculated as Delta CP and Delta HHC. These values were compared between the SLAP and control groups., Results: There was a significant difference in Delta CP between the SLAP and control groups (3.62 v 0.79 mm of relative posterior translation, P = .005). There was not a similar significant difference found in Delta HHC between the SLAP and control groups (3.19 mm v 1.48 mm of relative posterior translation, P = .14). There was a significant difference between the mean translations of the SLAP-ABER group and the SLAP-AD group for both CP (-3.65 mm v -0.04 mm, P = .008) and HHC (-2.22 mm v +0.97 mm, P = .03). The difference between the control-ABER group and the control-AD group was not as pronounced., Conclusions: The magnetic resonance imaging ABER view in patients with unstable SLAP lesions requiring repair showed in vivo glenohumeral posterior translation relative to the adducted neutral rotation view of greater than 3 mm., Clinical Relevance: This finding furthers the understanding of the pathokinematics in SLAP lesions., ((c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Transfer of the latissimus dorsi to the greater tuberosity has been used successfully in the treatment of massive rotator-cuff deficiency. For safe release and transfer of the tendon, the variations in the tendinous insertions of the latissimus dorsi and teres major onto the humerus need to be understood. In anatomical dissection of 12 cadavers, mean width of the latissimus tendon was 3.3 cm at its insertion, and mean length was 7.3 cm. In all specimens, there were fascial connections between the latissimus and teres major and between the latissimus and the long head of the triceps. There were 3 insertion patterns of the latissimus dorsi tendon onto the humerus with respect to the tendon of the teres major: completely separate (8 cadavers), loosely bound (3 cadavers), and completely joined (1 cadaver). If the latissimus dorsi were being transferred in the last type, the teres major would need to be transferred with the latissimus dorsi as a common musculotendinous unit.

Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. Increased anterosuperior translation of the humeral head occurs with forward flexion and can mimic the pain reported with impingement syndrome; however, the patient with impingement syndrome presents with normal range of motion. Initial management of posterior capsular contracture should be nonsurgical, emphasizing range-of-motion stretching with the goal of restoring normal motion. For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. Management involves regaining internal rotation such that the loss of internal rotation is not greater than the increase in external rotation. In the athlete who fails nonsurgical management, a selective posteroinferior capsulotomy can improve motion, reduce pain, and prevent further shoulder injury.

In the study reported here, we determined the effects on bone healing of rofecoxib, one of the selective cyclooxygenase-2 (Cox-2) inhibitors that has been used for postsurgical analgesia, and compared these effects with those of nonselective ibuprofen and placebo. Each of 66 male rats received a closed, nondisplaced femoral fracture and was fed rofecoxib, ibuprofen, or placebo for 4 weeks. Results of postsacrifice evaluation showed gross nonunions in 64.7% of rofecoxib rats (P < .0001), 17.6% of ibuprofen rats (P = .007), and 0% of placebo rats. Compared with ibuprofen, rofecoxib was significantly more likely to produce nonunions (P = .007). Mean callus width was 8.9 mm (SD, 1.3 mm) for rofecoxib (P = .03), 8.9 mm (SD, 1.2 mm) for ibuprofen (P = .03), and 8.0 mm (SD, 1.3 mm) for placebo. Mean healing maturity (Goldberg classification) was 1.6 (SD, 0.7) for rofecoxib (P < .0001), 1.7 (SD, 0.8) for ibuprofen (P = .0001), and 2.7 (SD, 0.6) for placebo. Mean fracture angulation was 30.8 degrees (SD, 16.7 degrees) for rofecoxib (P = .003), 14.3 degrees (SD, 14.4 degrees) for ibuprofen (NS), and 13.4 degrees (SD, 10.3 degrees) for placebo. Mean histologic healing was 5.75 for rofecoxib (P = .02), 6.35 for ibuprofen (P = .05), and 8.25 for placebo. Cox-2 inhibitors should be used with caution when bone healing is necessary. Further study is warranted to determine whether the adverse effects occur in humans.

Antegrade intramedullary nailing using the piriformis fossa as an entry point for insertion has become the treatment of choice for most diaphyseal fractures of the femur. In obese or well-muscled patients, however, creating an entry point can be difficult. This difficulty has led some authors to switch to retrograde intramedullary nailing. Unfortunately, retrograde nailing is associated with higher nonunion rates and increased incidence of knee pain and stiffness. We describe an antegrade nailing technique that is useful and easy to perform even in obese patients.

So that patients with degenerative glenohumeral joint disease who wish to consider total shoulder arthroplasty will be better informed, we sought to document the magnitude and durability of the improvement in shoulder function after this procedure. The function of 124 shoulders with primary degenerative joint disease was documented by patient self-assessment with the Simple Shoulder Test before and sequentially after total shoulder arthroplasty performed with a standardized technique. Patients reported that they could perform 3.8 +/- 0.3 (SEM) of the 12 Simple Shoulder Test functions before surgery. The total number of performable functions was consistent at different follow-up intervals: 8.0 +/- 0.4 at 6 months, 9.5 +/- 0.4 at 1 year, 10.0 +/- 0.3 at 2 years, 9.2 +/- 0.4 at 3 years, 9.6 +/- 0.4 at 4 years, and 10.0 +/- 0.4 at 5 years. We conclude that total shoulder arthroplasty can provide substantial and durable improvement in shoulder function.

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.

Patients involved in the initial Western application of the Ilizarov technique experienced frequent pain and could not tolerate the device. With "hybrid advanced" Ilizarov techniques, half-pins and other components are added to minimize these adverse reactions. In this study of advanced techniques, we determined patient satisfaction (with end results), device tolerance, pain levels, and need for analgesia. These techniques used at least 1 half-pin on each ring--except for the distal tibial ring, which had 3 transfixing wires--perpendicular to either another half-pin or a transfixing wire. Eighty-one consecutive patients treated with advanced techniques were prospectively studied until the treatment was completed and the device removed. All patients received intravenous analgesia while hospitalized. Narcotic and non-narcotic analgesia was available to all patients, and analgesia use was measured. In addition, patient satisfaction and pain level were recorded. All patients were satisfied with end results and tolerated the device prescribed by their physician. Mean postoperative hospitalization was 5.1 days. Upon discharge from the hospital, 3 patients (3.7%) with moderate pain used postoperative narcotics for a mean of 6 days (range, 1-11 d), and 41 patients (50.6%) with mild pain used over-the-counter non-narcotic analgesia or prescription antiinflammatory medication for a mean of 4.4 days (range, 1-35 d). The other 37 patients (45.7%) were comfortable and did not require analgesia. In general, patients undergoing hybrid-advanced Ilizarov techniques infrequently needed postoperative analgesia.

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.

The study documented the functional outcome in a consecutive series of 46 patients from an individual practice meeting the inclusion criteria of (1) a full-thickness rotator cuff tear seen by ultrasonography, arthrogram, or magnetic resonance imaging, (2) absence of a Workers' Compensation claim or previous surgery, (3) followup of at least 1 year, and (4) election of nonoperative management by the patient. Twenty-six of the tears involved only the supraspinatus, two involved the supraspinatus and infraspinatus, and two involved the supraspinatus, infraspinatus, and subscapularis (16 reports did not specify the size of the tear). Treatment consisted only of patient education and a home program of gentle stretching and strengthening. Patients completed the Simple Shoulder Test at the initial visit and sequentially at 6-month intervals thereafter. At an average followup of 2.5+/-1.6 years, 27 (59%) patients experienced improvement with nonoperative treatment, 14 (30%) patients experienced worsening, and five (11%) patients remained unchanged. The average number of Simple Shoulder Test functions the patients could perform initially was 5.6+/-3.2. At the latest followup, the average number of Simple Shoulder Test functions the patients could perform improved to 7.0 +/-3.8. The ability to sleep on the affected side and the ability to place the hand behind the head were significantly improved.

Background: Long-term follow-up studies are necessary to critically evaluate the outcome of a treatment intervention for a specific disorder. However, patients may cease participating in a long-term study and become lost to follow-up; thus, their current condition is unknown. The underlying characteristics that predispose a patient to become lost to follow-up are difficult to identify and control. Patients who are lost to follow-up may be contacted by telephone; however, the effect of administering a functional assessment questionnaire by telephone compared with that of mailing a questionnaire is unknown. The purpose of this study was to compare patients who continued to respond to requests for follow-up with those who did not. A second purpose was to compare responses obtained by mail with those obtained by telephone interview., Methods: Two hundred and twenty-four patients with a rotator cuff tear were enrolled in an ongoing study of shoulder function and general health. Self-assessment questionnaires were mailed to every patient at six-month intervals. Sixty-seven patients (30 percent) regularly responded to mailings (identified as responders in this study), fifty-five patients (25 percent) responded occasionally (these patients were not included in the analysis), and 102 patients (46 percent) ceased to respond and became lost to follow-up (identified as nonresponders in this study). This investigation was performed to determine: (1) the characteristics of nonresponders compared with those of responders, (2) the functional status of nonresponders as assessed with a questionnaire over the telephone, and (3) the effect of administering a self-assessment functional questionnaire by telephone compared with that of sending the same questionnaire by mail., Results: Nonresponders tended to have lower initial scores for the mental health summary (p = 0.03) and for social function (p = 0.01), were less likely to have had surgery (p = 0.009), and were less likely to consume alcohol (p = 0.03). At the last known time when they completed the mailed questionnaire, nonresponders reported significantly worse shoulder function than responders (p = 0.0001). However, on telephone questioning the mean number of shoulder functions that the nonresponders indicated that they could perform was greater than the mean number documented on their last mailed questionnaire (p < 0.0001). In a random subgroup of responders, the mean number of functions that the patients indicated that they could perform when interviewed by telephone was significantly greater than the number indicated on their most recent mailed questionnaire (p < 0.01). The results obtained by telephone from this random subgroup of responders were similar to those obtained by telephone from the nonresponders., Conclusions: There are differences between patients who continue to participate in a study and those who become lost to follow-up. Functional assessment questionnaires administered by telephone yield different results than the same questionnaires sent by mail. These considerations are relevant to the design, implementation, and interpretation of clinical studies in which functional questionnaires are used.

Objective: To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information., Design: Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994., Setting: Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon., Main Outcome Measures: Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem., Results: Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%)., Conclusion: This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.

17 patients had radiographic demonstration of injury to the clavicle, scapula and ribs from an impact delivered to the lateral shoulder. The study included 13 males and 4 females whose ages ranged from 18 to 83 years (average 45 years). Most injuries were sustained in falls or motor vehicle accidents. Analysis of these cases suggests a biomechanical hypothesis concerning the transmission of the impact forces within the shoulder girdle. According to this hypothesis, the impaction force applied to the lateral shoulder is transmitted from outside inward following two paths. The anterior and superior path passes through the acromio-clavicular joint, the clavicle, the costo-clavicular joint and the sterno-clavicular joint. The posterior and inferior path is transmitted within the gleno-humeral joint, the scapula and the scapulo-thoracic joint. Major impacting force is required to disrupt the anterior and posterior arches of the shoulder girdle. When both of these supporting structures are damaged, the patient is at risk for more serious injuries, including disruption of the thorax, shoulder joint, brachial plexus and neck.

Shoulder stiffness occurs as a result of (1) contractures of the intraarticular capsule or muscle-tendon units or (2) adhesions within the extraarticular humeroscapular or scapulothoracic motion interface. These contractures or adhesions may occur independently or in combination. A thorough history and physical examination usually reveal the diagnosis (idiopathic frozen shoulder or posttraumatic stiff shoulder) and the anatomical locations of fibrosis that is causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes). A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be indicated. If manipulation is not effective, capsular contractures are best released arthroscopically as this allows circumferential release without damaging the rotator cuff and thus allows rehabilitation without the need to protect the rotator cuff. The humeroscapular motion interface adhesions can be released either open or arthroscopically, but we believe that an open release combined with an arthroscopic capsular release is quicker and does not interfere with rehabilitation. When necessary, operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90% of patients can expect a good result with this treatment algorithm.

In the United States, train-related accidents account for more than 18,000 injuries and 1,200 fatalities annually, yet there is a paucity of literature pertaining to this unique injury. We reviewed the medical records of 98 of 135 cases of train-related trauma treated at Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas, from 1990 to 1995. There were 50 train-pedestrian accidents, 47 train-automobile accidents, and 1 train-motorcycle accident, with a mean patient age of 30.1 years (range, 2 to 66 years). Eighteen patients (18%) were pronounced dead on arrival or died shortly after admission. Of the other 80 patients, 27 (34%) were discharged from the emergency department after minor medical treatment, while 53 (66%) were hospitalized, of whom 10 (13%) later expired. The mean Injury Severity Score (ISS) was 11.9 (discharged, 1.8; hospitalized, 14.3; expired, 29.2). Forty-five patients (56%) sustained 57 extremity fractures, and 30 patients (38%) required 40 amputations. Mean Mangled Extremity Severity Score (MESS) for all injured extremities was 5.2 (amputation, 7.7; no amputation, 2.8). On average, the hospitalization cost per patient was greater than $18,698, while the reimbursement from the patients was $2,261, leaving the hospital with a net deficit of approximately 2 million dollars. Surprisingly, train accidents do not always result in serious injury. However, when serious injury is sustained, it is often of high morbidity (amputation) and mortality, which appears to correlate well with the initial MESS and ISS. Extrapolating our cost data to include all train-related accident injuries and deaths indicates that the direct costs to society may exceed 300 million dollars annually. Greater public awareness and preventive measures may reduce the tremendous human and financial costs of train-related accidents.

Third generation cementing techniques using intramedullary restrictors, low porosity cement with pressurization, lavage, and cement-stem bond enhancement do not prevent implant malalignment and inadequate cement mantle thickness. This has led to the development of modular proximal and distal centralizers to control the alignment of the femoral component and maintain an adequate thickness of the cement, thereby theoretically decreasing the rate of aseptic loosening. A retrospective analysis was performed of 100 primary cemented centralized femoral components. At an average followup of 5.7 years (range, 4-8 years), the average Harris Hip Score was 90. There were no cases of aseptic loosening, osteolysis, or impending failure. Ninety-one percent of femoral stems were implanted with satisfactory alignment with an optimal cement thickness. However, six distal centralizers and one proximal centralizer fractured at the time of insertion and voids frequently were seen in and around the distal centralizer. Although centralizers improve prosthesis alignment and cement mantle thickness, the long term effects of centralizer fracture and distal cement voids need to be observed to determine if centralizers improve previous implant survival.

Study Design: Twenty-four cannulated sacroiliac screws were placed bilaterally into 12 cadaveric pelvi (12 titanium screws and 12 stainless-steel screws) and were imaged using conventional and multiplanar reconstructed computed tomography., Objectives: To determine whether sacroiliac screw position assessment relative to the neuroforamen is enhanced by: 1) computed tomography using multiplanar reconstructions and 2) the use of titanium screws rather than stainless-steel screws., Summary of Background Data: To the authors' knowledge, there have been no prior studies demonstrating the accuracy of multiplanar computed tomography compared with that of conventional (axial) tomography in determining the position of sacroiliac screws relative to the neuroforamen. Although titanium screws have been shown to have less scatter than stainless-steel screws, the effect of alloy composition on the radiographic accuracy of interpreting the screw position relative to the sacral neuroforamen is unknown., Methods: Screws were deliberately placed into: position A, in which the screw did not violate the neuroforamen; position B, in which the threads of the screw came within 3 mm of the neuroforamen; and position C, in which the screw clearly was nearly centered in the neuroforamen. The degrees of accuracy in assessing screw position relative to the neuroforamen using conventional (axial) images and using multiplanar reconstructed images were compared., Results: The axial images were accurate in determining screw position relative to the neuroforamen in 50% of cases in which titanium screws were used and in 42% of cases in which stainless-steel screws were used. The corresponding values for multiplanar reconstructions were 92% for cases in which titanium screws were used and 67% for cases in which stainless-steel screws were used. The accuracy of multiplanar reconstructions was statistically better than that of axial images (P < 0.05). Metallic scatter was increased in stainless-steel screws., Conclusions: The results of this study suggest that the use of computed tomography with multiplanar reconstruction improves accuracy in determining sacroiliac screw position relative to the neuroforamen. The assessment of screw position may be facilitated using titanium screws.

Study Design: A report of a case of lumbar spine duplication with the clinical appearance of adolescent scoliosis., Objective: To increase knowledge about the pathogenesis and treatment of lumbar spinal duplication., Summary of Background Data: Although there have been other reports of lumbar spine duplication of this magnitude, these malformations typically are associated with severe neurologic abnormalities (dicephalus, myelomeningocele) or gastrointestinal abnormalities (omphalocele, neurenteric fistulas). Several investigators have recommended early surgical intervention for this abnormality because of the perceived risk of progressive neurologic abnormality from tethering of the cord., Methods: In a 13-year-old girl who had truncal asymmetry, lumbar spine duplication was noted on plain radiographs. A magnetic resonance study was obtained, and the patient was observed with conservative treatment for 3 years., Results: Although extensive abnormalities were noted on the magnetic resonance images, which were related to duplication of spinal cord and vertebral bodies, the patient was neurologically intact and remained so until skeletal maturity., Conclusions: This rare malformation typically has severe neurologic sequelae. Conservative management in the reported patient did not result in a progressive neurologic lesion at the time of skeletal maturity.

Distal femoral physeal fractures account for approximately 1% of all epiphyseal injuries. Complications include growth arrest and leg length discrepancy, malunion and deformity, and stiffness and knee instability. However, nonunion of such a fracture is exceedingly rare and has only been reported in patients with spinal dysraphism. We report a case of distal femoral physeal nonunion in a neurologically intact adolescent athlete. Initially, there was a delay in the diagnosis of this nondisplaced fracture, as the patient had normal roentgenograms. Additional imaging modalities (magnetic resonance imaging, stress radiographs) should be performed if there is a high index of suspicion of physeal injury when roentgenograms are normal.

The first two-dimensional images of the source region of Io's neutral sodium cloud have been acquired by ground-based observation. Observed asymmetries in its spatial brightness distribution provide new evidence that the cloud is supplied by sodium that is ejected nonisotropically from Io or its atmosphere. Complementary, high-time-resolution, calibrated image sequences that give the first comprehensive picture of the variations of the fainter regions of the cloud extending more than 10(5) kilometers from Io were also obtained. These data demonstrate that the cloud exhibits a persistent systematic behavior coupled with Io's orbital position, a distinct "east-west orbital asymmetry," a variety of spatial morphologies, and true temporal changes. The geometric stability of the sodium source is also indicated. Isolation of the cloud's temporal changes constitutes an important milestone toward its utilization as a long-term probe of Io and the inner Jovian magnetosphere.

If patients who have AIDS or ARC, or who are seropositive for HIV antibody, refuse to engage in "safe sex" to protect their sexual partners, may physicians warn those partners? Must they warn them? Does the law apply equally to symptomatic and asymptomatic patients? The law is not only confusing but in a state of flux. Both physicians and lawyers are cautioned against answering these questions categorically on general principles derived from the famous (or infamous) Tarasoff case. If the questions can be answered at all, they must be preceded by minute examination of the laws of each jurisdiction. The difficulty lies in knowing whether and how the law should be changed. A physician may be required to warn certain contacts of certain patients, and forbidden to warn other contact equally at risk from other patients equally infectious. Issues of morality and politics are posed: Is AIDS to be treated as a sickness or a sin? Of the measures physicians recommend to protect public health, which will be politically acceptable to various pressure groups? And if the laws are enacted, will they survive widespread resistance and evasion?

The first direct images of Io's sodium cloud are reported and analyzed. The observed cloud extends for more than 10(5) kilometers along Io's orbit and is a somewhat "banana-shaped" partial toroid. More sodium atoms precede Io than follow it. A model based on the escape of sodium from a specific localized area on Io provides a reasonable fit to the observed intensity distribution whereas isotropic escape does not.

The case of Wickline v. State forebodes a new tort: malpractice by a physician who unprotestingly complies with a third-party payor's hospitalization restrictions. Medi-Cal granted this patient only half the hospital stay extension requested by her physicians. Following discharge on the appointed date her condition deteriorated, and ensuing complications resulted in the need for leg amputation. The patient subsequently sued the State for injuries, and won. The State appealed and obtained a reversal of the judgment on the verdict. Despite the fact that the premature discharge led to the need for amputation, the decision to discharge the patient had been made by the physicians, not by Medi-Cal. Therefore, Medi-Cal was not liable.