Wound closure expectations after fasciotomy for paediatric compartment syndrome.

PURPOSE: Acute compartment syndrome often requires additional surgery to achieve wound closure. Little information exists regarding the expected number of surgeries, techniques and complications after closure in paediatric patients. METHODS: A retrospective chart review identified patients treated for acute compartment syndrome at four hospitals over a ten-year period. The cause of injury, type of dressing, number of surgeries, type of closure and complications were recorded. RESULTS: In all, 32 patients (mean 10.9 years, 1 to 17) who underwent 18 lower and 14 upper extremity fasciotomies met inclusion criteria. Definitive wound closure technique was delayed primary in 72%, split thickness skin graft in 25%, and primary in 3% of patients. Closure required a mean 2.4 surgeries (0 to 4) over a mean 7.7 days (0 to 34). Days to closure and number of surgeries required were not significantly affected by mechanism of injury, fasciotomy location or type of dressing used. A total of 23.1% of patients with upper extremity and 0% with lower extremity fasciotomies had concerns about the scar appearance. Other complications included neurapraxia (6.7%), stiffness (6.7%), swelling (3.3%), scar pain (3.3%) and weakness (3.3%). CONCLUSIONS: The most common complication after paediatric compartment syndrome is an unpleasant scar. Wound closure after upper or lower extremity fasciotomies in paediatric patients requires a split thickness skin graft in approximately one in four patients. However, avoiding a skin graft does not guarantee the absence of cosmetic concerns, which are more likely following upper extremity fasciotomies. LEVEL OF EVIDENCE: IV.

The prevalence of significant left-right differences in hip bone mineral density.

INTRODUCTION: We determined the prevalence of left-right differences in hip bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) and the resultant consequence, namely: the frequency at which patients would be classified differently if lumbar spine and only one hip (rather than both hips) were measured. METHODS: This was a retrospective DXA scan reanalysis of 3012 white women >or=50 yrs who had scans of both hips using Hologic DXA systems. The difference between left and right hips was considered significant if it exceeded the least significant change (LSC) for any of three hip subregions (total hip, femoral neck, trochanter). The number of women with osteoporosis in both hips, the left hip only, or the right hip only was determined by lowest T-score from total hip, femoral neck, or trochanter. RESULTS: Despite high left-right correlations of subregion BMD, significant left-right differences in BMD were common: the difference exceeded the LSC for 47% of women at total hip, 31% at femoral neck, and 56% at trochanter. Left-right differences in BMD that exceeded the LSC affected the percent agreement of left-right hip classification: for all women irrespective of spine status, there was 77% classification (diagnostic) agreement in hip pairs in which the left-right hip BMD difference exceeded the LSC versus 87% agreement in which LSC was not exceeded (significant difference in proportions, P<0.0001). The greatest risk of different classification would occur in women with normal spines as the diagnosis might be determined by hip T-scores. Using L1-4 lumbar spine T-scores, 1229 women were normal at the spine. Twenty-four (2%) were osteoporotic at both hips. However, 12 women (1%) were osteoporotic only in the left hip (significantly different from zero, P<0.001) and 11 (1%) only in the right hip (P<0.001); of these 23 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 16 (70% of those with osteoporosis in only one hip). Using L1-4 lumbar spine T-scores, 1159 women were osteopenic at the spine. Of these, 126 (11%) were osteoporotic at both hips, 54 (5%) only in the left hip (P<0.001), and 42 (4%) only in the right hip (P<0.001); of these 96 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 56 (58% of those with osteoporosis in only one hip). CONCLUSIONS: A statistically significant number of women with osteoporosis are potentially classified differently when scanning only one hip as a result of the high prevalence of left-right differences in BMD. Although the percentages are low, the total number of women affected may be large. From a public health perspective, the practice of scanning both hips could potentially identify more women with osteoporosis and may help prevent future hip fractures.

Assessment of osteoporosis-website quality.

INTRODUCTION: The Internet provides great opportunities for patient healthcare education, but poses risks that inaccurate, outdated, or harmful information will be disseminated. Osteoporosis is a topic of great interest to patients, many of whom use the Internet to obtain medical information. The aim of this study was to develop and evaluate measurement tools to determine the quality of osteoporosis websites for patients. METHODS: Quality indicators in the categories of content, credibility, navigability, currency, and readability were incorporated into separate evaluation tools for healthcare professionals and for patients. Websites were selected from an Internet search. Interobserver reliability and validity were assessed, and a sample of osteoporosis websites was evaluated by an osteoporosis nurse educator and compared to patient evaluations. RESULTS: For the quality indicators, there was 79% agreement between the osteoporosis nurse educators, 88% agreement between the physician osteoporosis experts, and 71% agreement comparing the osteoporosis nurse educators to the physician osteoporosis experts. Quality scores for evaluated websites ranged from 18-96 (maximum possible=100), with a mean of 66. Websites with Uniform Resource Locator (URL) suffix .com scored significantly lower compared to those with .gov (P<0.05), .edu (P<0.01), and .org (P<0.01). Healthcare professionals and patients were in agreement on the quality of the highest-rated websites, with less agreement for lower-rated websites. CONCLUSIONS: In summary, a tool for measuring the quality of medical websites was developed and evaluated. Significant variability in osteoporosis-website quality was observed. Higher-quality scores were associated with a higher level of search engine match and specific URL suffixes. A validated tool for evaluating medical websites may have value in assisting patients to select high-quality osteoporosis educational information on the Internet, and may encourage website developers to improve the quality of information that is provided.

Special report on the official positions of the International Society for Clinical Densitometry.

The International Society for Clinical Densitometry (ISCD) periodically holds Position Development Conferences (PDCs) for the purpose of establishing standards and guidelines for indications, acquisition, and interpretation of bone density tests. Topics are selected for consideration by the ISCD Scientific Advisory Committee, reviewed by scientific working groups, and presented to an international panel of experts. Topic categories addressed to date include indications for bone density testing, selection of reference databases for T-scores and Z-scores, clinical applications for central and peripheral bone densitometry, serial bone density testing, instrument precision assessment, phantom scanning and calibration testing, requirements for a bone density report, nomenclature, and diagnosis of osteoporosis in postmenopausal women, premenopausal women, men, and children. Following an open session for public comment and discussion, the panel convenes for consideration of each topic and makes recommendations for positions to the ISCD Board of Directors. Recommendations that are accepted become the Official Positions of the ISCD. This Special Report summarizes the methodology of the ISCD PDCs and presents selected Official Positions of general interest.

Age and ovariectomy impair both the normalization of mechanical properties and the accretion of mineral by the fracture callus in rats.

The impact of age and ovariectomy on the healing of femoral fractures was studied in three groups of female rats at 8, 32 and 50 weeks of age at fracture. In the two older groups, the rats had been subjected to ovariectomy or sham surgery at random at 26 weeks of age. At fracture, all rats received unilateral intramedullary pinning of one femur and a middiaphyseal fracture. Rigidity and breaking load of the femora were evaluated at varying times up to 24 weeks after fracture induction by three-point bending to failure. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. In the youngest group, 8-week-old female rats regained normal femoral rigidity and breaking load by 4 weeks after fracture. They exceeded normal contralateral values by 8 weeks after fracture. In the middle group, at 32 weeks of age, fractures were induced, and the femora were harvested at 6 and 12 weeks after fracture. At 6 weeks after fracture there was partial restoration of rigidity and breaking load. At 12 weeks after fracture, only the sham-operated rats had regained normal biomechanical values in their fractured femora, while the fractured femora of the ovariectomized rats remained significantly lower in both rigidity and breaking load. In contrast, for the oldest group of rats, 50 weeks old at fracture, neither sham-operated nor ovariectomized rats regained normal rigidity or breaking load in their fractured femora within the 24 weeks in which they were studied. In all fractured bones, there was a significant increase in BMD over the contralateral intact femora due to the increased bone tissue and bone mineral in the fracture callus. Ovariectomy significantly reduced the BMD of the intact femora and also reduced the gain in BMD by the fractured femora. In conclusion, age and ovariectomy significantly impair the process of fracture healing in female rats as judged by measurements of rigidity and breaking load in three-point bending and by accretion of mineral into the fracture callus.

The influence of patient strength, aerobic capacity and body composition upon outcomes after coronary artery bypass grafting.

BACKGROUND: Physical activity, physical fitness and body habitus of patients may be important predictors of outcomes after cardiac surgery. This study sought to quantify physical fitness and determine whether components of fitness enhance the prediction of outcomes in a group of patients undergoing coronary artery bypass grafting. METHODS: A group of 200 patients were evaluated prior to coronary artery bypass surgery. A Veterans Specific Activity Questionnaire (VSAQ) measured aerobic capacity. A grip dynamometer assessed strength. Skin-fold thickness was used to calculate percent body fat and lean body mass index. Patients were divided into low risk (0-2.5%) and high risk (>2.5%) groups based on the STS National Cardiac Surgery Database prediction of operative mortality. RESULTS: Patients with both a high percent body fat and a low VSAQ were at higher risk for at least one serious complication (p<0.05) and a longer postoperative length of stay (p<0.05). CONCLUSION: This study suggests: 1) An index of physical fitness can be obtained preoperatively in cardiac surgical patients; 2) This information aids in the prediction of operative risk.

Effects of combined aerobic and resistance training versus aerobic training alone in cardiac rehabilitation.

PURPOSE: This study examined the effects of performing combined resistance and aerobic training, versus aerobic training alone, in patients with coronary artery disease. METHODS: Thirty-six patients with coronary artery disease were randomized to either an aerobic-only training group (AE) or a combined aerobic and resistance training group (AE + R). Both groups performed 30 minutes of aerobic exercise 3 days/week for 6 months. In addition, AE + R group performed two sets of resistance exercise on seven different Nautilus machines after completion of aerobic training each day. Twenty patients (AE: n = 10; AE + R: n = 10) completed the training protocol with > 70% attendance. RESULTS: Strength gains for AE + R group were greater than for AE group on six of seven resistance machines (P < 0.05). VO2peak increased after training for both AE and AE + R (P < 0.01) with no difference in improvement between the groups. Resting and submaximal exercise heart rates and rate-pressure product were lower after training in the AE + R group (P < 0.01), but not in the AE group. AE + R increased lean mass in arm, trunk, and total body regions (P < 0.01), while AE increased lean mass in trunk region only (P < 0.01). Percent body fat was reduced for AE + R after training (P < 0.05) with a between group trend toward reduced body fat (P = 0.09). Lean mass gain significantly correlated with strength increase in five of seven resistance exercises for AE + R. CONCLUSIONS: Resistance training adds to the effects of aerobic training in cardiac rehabilitation patients by improving muscular strength, increasing lean body mass, and reducing body fat.

Measurement precision of body composition variables using the lunar DPX-L densitometer.

The objective of the study was to determine the precision of total- and regional-body composition measurements from a total-body scan using dual-energy X-ray absorptiometry (DXA). This is critical information necessary to determine the smallest change from baseline that could be detected with statistical significance when conducting longitudinal measurements of body composition variables in an individual. Twenty volunteers were scanned once each day for 4 consecutive days using a Lunar DPX-L densitometer and manufacturer-supplied software (version 1.3z). Coefficients of variation (CV, %) derived from data using the (preferred) extended research mode of analysis were 0.62, 1.89, 0.63, 2.0, 1.11, 1.10, and 1.09% for total-body bone mineral density (BMD), total percentage fat, total body tissue mass, fat mass, lean mass, bone mineral content (BMC), and total bone calcium, respectively. Regional measurements (arm, leg, trunk, pelvis, and spine) were less precise than total body measurements, with CVs in the range of 1% to 3% (but fat mass for arms was 4.26%, trunk 3.08%, BMC 3.65%). Small but statistically significant differences in mean values for most body composition variables were found when data were compared between extended and standard modes of analysis. Inconsistent use of analysis mode in a cohort or when following a patient longitudinally may negatively affect precision. We conclude that the measurement precision of total and regional body composition variables was generally comparable to the precision limits typically associated with lumbar spine and proximal femur BMD data.

Decreased ulnar bending stiffness in osteoporotic Caucasian women.

Mechanical response tissue analysis (MRTA) is a noninvasive measure of ulnar bending stiffness in vivo. It is unique in that the mechanical response to the lower range of vibrational frequencies is used to determine the average cross-sectional bending stiffness. The objective of this study was to compare ulnar bending stiffness among normal, osteopenic, and osteoporotic Caucasian women. World Health Organization criteria were used to define cohorts. Ulnar bending stiffness was expressed as the product of Young's modulus of elasticity (E) and the cross-sectional moment of inertia (I) in units of square Newton meters using MRTA. There was no difference in the mean body weight between cohorts but mean age was significantly different (p < 0.0001, analysis of variance): normal women, 34 +/- 12 yr (n = 55); women with age-related/idiopathic osteopenia, 52 +/- l l yr (n = 36(; and women with osteoporosis, 65 +/- 10 yr (n = 24). The mean EI of osteoporotic Caucasian women (25 Nm(2)) was 25% lower than normal subjects (33.1 Nm(2)) (p < 0.0001). However, there was no significant difference between EI of normal women and osteopenic women (30.l Nm(2)). EI was significantly but weakly correlated (i.e., the greatest r(2) value was 37%) to all dual X-ray absorptiometry variables, ulnar width, age, and body weight. In summary, results with MRTA were consistent with previous studies using classical ex vivo biomechanical techniques and in vivo vibrational techniques, showing decreased strength (i.e., bending stiffness) in osteoporotic bone compared with normal bone and a generalized decrease in bending stiffness with increasing age.

Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability.

The modified Brostrom procedure has become the standard for anatomic repair of symptomatic chronic lateral instability. However, it was our perception that this local tissue repair may fail eventually, particularly in patients that are overweight, hyperflexible, or are involved in strenuous work or athletic activity. This is a retrospective review of 21 lateral ankle reconstructions (20 patients) in which the modified Brostrom technique was augmented with a portion of the peroneus brevis tendon. All patients were interviewed at an average of 29.5 months (range, 14-56 months postsurgery). Fourteen patients also agreed to be evaluated by a physical therapist. No surgical complications were identified. American Orthopaedic Foot and Ankle Society ankle-hindfoot scores averaged 98.2. There was no significant difference in passive or active range of motion of plantarflexion or dorsiflexion when compared to the contralateral ankle. However, a statistically significant loss of inversion (passive, P = 0.011; active, P = 0.018) and eversion (passive, P = 0.004; active, P = 0.007) was noted when compared to the contralateral ankle. Measurement of isometric eversion strength, using a Cybex 340 Isokinetic device, and functional testing, using a lateral lunge test, revealed no significant loss of peroneal strength. The authors conclude that chronic lateral ankle instability in the general population can be successfully managed with a modified Brostrom procedure augmented with a portion of the peroneus brevis. The procedure remains technically simple and provides a greater static restraint for inversion stress without evidence of dramatic overtightening or loss of peroneal strength.

Evaluation of Lunar small animal software for measuring bone mineral content in excised rat bones.

The purpose of this study was to evaluate software from Lunar Corporation (Madison, WI) designed for the measurement of bone mineral content ([BMC],g) in excised rat femurs using dual-energy X-ray absorptiometry (DXA). Femurs were harvested from intact 2- to 12-mo-old female Sprague-Dawley rats, stripped of soft tissues, wrapped in saline-soaked gauze, and frozen at -20 degrees F. Thawed bones were scanned in air on a 1.7-cm-thick Lucite plate that was laid on the manufacturer's supplied Delrin platform. Bones were in an anteroposterior position and scanned in a proximal-to-distal manner. Small animal software version 1.0d was used with a Lunar DPX-L densitometer. Regions of interest (ROIs) were the middle one-third of the diaphysis, a small central area of the distal metaphysis, and the total bone. Precision (n = 6 femurs) was calculated for each region of interest. After DXA scanning, one group of bones (n = 10 femurs) was dried and incinerated in a muffle furnace to obtain bone ash. The ash was then digested in acid and aliquots assayed for calcium using atomic absorption spectrophotometry. This group of bones was used to correlate BMC with ash weight and areal bone mineral density (BMD) with calcium concentration. A second group of bones (n = 14 femurs) was used to correlate BMC with maximal load to failure (N), a biomechanical variable that provides information about bone strength. Precision of repetitive measurements for the three ROIs was 1.2, 3.0, and 0.65%, respectively. Total femur BMC and total femur ash weights were significantly correlated (r = 0.974, p <0.0001). Total femur area BMD (g/cm2) was significantly correlated with calcium concentration (microM) of the bone hydrolysate (r = 0.686, p = 0.029). Total femur BMC and maximum load to midshaft fracture were also significantly correlated (r = 0.914, p<0.0001). The greatest problem with the software was with edge detection: operator intervention was necessary to place edges manually during scan analyses. We conclude that the small animal software from Lunar Corporation accurately and precisely measured BMC in excised rat femurs. However, poor edge detection resulted in tedious and time-consuming analyses.

Relationship between length of stay and manipulation rate after total knee arthroplasty.

We hypothesized that a pattern of decreasing postoperative length of stay (LOS) in the hospital could lead to an increased rate of manipulation after total knee arthroplasty (TKA). The decision to manipulate is based on the patient's ability to perform normal physical activities, which may in large part be dependent on adequate knee flexion (ie, range of motion [ROM]). Decreased exposure to physical therapy (as a result of decreased LOS) may be a contributing factor leading to impaired functional ROM in the 6-week postoperative period. We examined records from 745 patients (2 surgeons) who had a primary TKA from 1993 to 1996. At our institution, development and implementation of clinical pathways resulted in a significant decrease in the average LOS beginning in 1993. The average LOS in 1993 was 6.4 +/- 1.8 days (mean +/- SD) and progressively decreased to 4.4 +/- 1.0 days in 1996 (P < .0001). The rate of manipulation (patients manipulated at 6 weeks/total number of patients receiving TKA) was 6.0% in 1993 and increased to 11.3% (P = .09) in 1994, 13.5% (P = .02) in 1995, and 12.0% (P = .05) in 1996. In the period 1993-1996, patients requiring manipulation consistently had a lower ROM at discharge from the hospital (69.0 +/- 10 degrees, n = 67, P < .0001) compared with patients not requiring manipulation (80.7 +/- 10.6 degrees, n = 542). The relatively low frequency and charge for manipulation may justify the decision to decrease patient exposure to physical therapy through reduction in LOS. As efforts to decrease LOS continue, however, we must aggressively manage patients and provide adequate exposure to inpatient and outpatient physical therapy to ensure optimal ROM results.

Radiolucent casting tape allows for accurate measurement of forearm bone mineral density using dual-energy X-ray absorptiometry.

The ability to perform dual-energy X-ray absorptiometry (DXA) while a patient is in a cast would give investigators the opportunity to follow early changes in bone mineral density (BMD, g/cm2) during fracture healing or to evaluate bone changes related to immobilization. The objective of this study was to determine if accurate and precise DXA scans could be obtained through polyester-based radiolucent casting tape (Delta-Cast Elite [DCE], Johnson & Johnson, Inc., Raynham, MA) and standard fiberglass casting tape (Delta Lite [DL], Johnson & Johnson, Inc.). DXA scans were performed using a Lunar DPXL densitometer. Standard forearm regions of interest were analyzed. Ten normal volunteers had three consecutive scans of their dominant arm with no cast, with a radiolucent (DCE) cast, and with a fiberglass (DL) cast. Precision was calculated using data from three volunteers (three scans each; no cast, DCE, DL). Results of DCE and DL were compared with results with no cast. In a second series, a spine phantom was placed inside rice-filled forearm casts and repetitively scanned; results with DCE and DL were compared with the mean BMD values for the phantom alone. Analyses of the scans through the DL casts were difficult because the radiodensity of the fiberglass interfered with edge detection. This problem was exacerbated by low BMD (i.e., scans for women). Edge detection was not a problem with the DCE scans. Although the group mean BMD values with in vivo no cast, DCE, or DL scans were similar for all regions of interest, the data obtained for ultradistal regions of interest with DL scans were less precise. BMD values for the fiberglass-encased phantom were significantly lower compared with no cast or DCE scans (p = 0.0002). This study demonstrates that it is possible to perform accurate and precise forearm DXA scans through polyester-based radiolucent DCE casting tape.

SF-36 general health status survey to determine patient satisfaction at short-term follow-up after total hip and knee arthroplasty.

The purpose of this study was to determine whether the SF-36 general health status survey was sensitive enough to document early improvements in patient health after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Early follow-up data were collected an average of 3 months after surgery. Results were striking, showing statistically significant improvements in all pain and function subcategories of the SF-36 for both THA and TKA. Further, the survey instrument successfully differentiated the course of healing after THA and TKA; at this early follow-up period, the patients who had had THA expressed greater improvement in pain, function, and overall health than did patients who had had TKA. These data suggest that the SF-36 is a simple, easy-to-administer, and effective instrument for monitoring improvements in patient health after THA and TKA.

Fixation with bioabsorbable pins in chevron bunionectomy.

Fixation with bioabsorbable pins in distal chevron bunionectomy reduces the inconvenience and the risk of infection associated with fixation with stainless-steel Kirschner wires, which leaves a portion of the wires protruding from the skin. However, use of bioabsorbable implants has been reported to be associated with osteolysis and formation of a sinus with a sterile discharge. We studied the outcome and complications seen with use of poly-p-dioxanone pins and those seen with use of stainless-steel Kirschner wires after chevron bunionectomy in 114 patients (144 feet). We found no difference between the treatment groups with regard to the prevalence of complications or the stability of fixation. Notably, the prevalence of osteolysis was quite similar between the treatment groups; none of the feet that had had fixation with bioabsorbable pins had formation of a sinus with a sterile discharge. We believe that bioabsorbable pins can be used reliably to fix the site of the osteotomy for a distal chevron bunionectomy without undue risk of osteolysis or other complications.

Measurement of thumb abduction strength: normative data and a comparison with grip and pinch strength.

Abduction strength of the thumb was measured in normal men (n = 101; age range, 21-94 years) and women (n = 208; age range, 20-97 years). Abduction-strength measurements were conducted concurrently with grip and pinch strength measurements made by well-established clinical methods. Normal values were established and stratified by age and sex. Thumb abduction strength generally correlated with grip and pinch strength. All strength variables at all ages were greater in men than in women. The magnitude of all strength variables was maintained from 20 to 59 years of age, then decreased with increasing age in both men and women. Measurement of thumb abduction strength may prove to be a useful adjunct to the various tests currently used by hand surgeons to assess hand function.

The effects of low median nerve block on thumb abduction strength.

The relative contributions of the abductor pollicis longus (APL) and abductor pollicis brevis (APB) to thumb abduction strength (TAS) were determined after a selective nerve block in 21 normal volunteers. The median nerve was anesthetized (blocked) at the wrist. Needle electromyography verified paralysis of the APB and usually the opponens pollicis; in 6 study subjects, the superficial head of the flexor pollicis brevis (FPB) was also paralyzed. The APL, innervated by a branch of the posterior interosseous nerve, remained functionally intact. TAS was measured by a mechanical device before and after median nerve block. Median nerve block at the wrist resulted in a dramatic decrease in TAS in all volunteers. The mean loss of TAS was 70.3% in men and 74.3% in women. Postblock TAS tended to be greater in those subjects with retained function of the FPB. This study verifies that TAS is primarily a function of the APB.

Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty.

The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intra-articular administration of morphine or bupivacaine in patients undergoing TKA.

Health care information processing: how accurate are the data?

Managed health care providers, governmental agencies, lawmakers, and the general public are now relying on informational databases to influence health care decisions. This information is also used to derive efficiency profiles for both the individual physician and the institution. However, database reporting procedures are not standardized or monitored. Further, the ICD-9-CM coding system lacks specificity. Consequently, the accuracy of the information in a typical informational database is questionable. As a result, credentialing of physicians and institutions may be based on erroneous information from inaccurate databases. The objective of our study was to document the accuracy of a local informational database. We did a retrospective review of 40 randomly selected charts with surgical procedure codes (ICD-9-CM) for decompression or diskectomy. We compared the diagnosis, procedures, comorbid events, and complications as originally recorded by the surgeon with results of our chart review. We also compared the procedure codes as originally recorded by a hospital recorder with results of our chart review. Results indicated that the information actually reported to the hospital database was lacking or inaccurate in 70% of cases. Discrepancies were not the fault of hospital coders; the coding accuracy rate was 95%. Discrepancies were largely the result of two problems. First, the primary procedure code (ie, the first code on the list recorded by the hospital medical records personnel) did not always match the actual primary procedure (ie, the most complex procedure) done by the surgeon. Second, the ICD-9-CM code was not specific enough to accurately describe the actual surgery done. We conclude that critical discrepancies were recorded into the informational database.

Outcome of nonsurgical treatment for plantar fasciitis.

Four hundred eleven patients with a clinical diagnosis of plantar fasciitis were assessed for predisposing factors. Each patient completed an outcomes assessment survey instrument that ranked effectiveness of various nonsurgical treatment modalities. Listed in descending order of effectiveness, the treatment modalities assessed were short leg walking cast, steroid injection, rest, ice, runner's shoe, crepe-soled shoe, aspirin or nonsteroidal anti-inflammatory drug, heel cushion, low-profile plastic heel cup, heat, and Tuli's heel cup. Treatment with a cast ranked the best. The Tuli's heel cup ranked the poorest. Most of the treatments were found to be unpredictable or minimally effective. The ineffectiveness of nonsurgical treatments noted in this outcomes study is at variance with most published clinical studies in which generally favorable results are reported after nonsurgical treatment for plantar fasciitis.