The development of indications for the preoperative use of recombinant erythropoietin.

OBJECTIVE: To develop indications for the preoperative use of recombinant erythropoietin (rHuEPO) alone and in conjunction with preoperative autologous donation (PAD). DESIGN: A 2-round modified Delphi-consensus process. PARTICIPANTS: Nine physicians representing multiple clinical specialties, practice environments and geographic locations. METHOD: From evidence tables and a literature summary (MEDLINE database from January 1985 to August 1996) provided and using the RAND-UCLA appropriateness method, the physicians developed 264 indications for the preoperative use of rHuEPO by permuting 7 clinical factors (age, history of transfusion or antibody incompatibility, hemoglobin level, anemia of chronic disease, expected blood loss, presence of cardiovascular or cardiopulmonary disease and patient anxiety). These indications were rated on a 9-point appropriateness scale. Median scores and measures of agreement were determined. OUTCOME MEASURES: The significance of cost constraints or cost and blood supply constraints and the impact of each clinical factor on the ratings as judged by statistical analysis. RESULTS: Of the 264 indications, 54% were rated appropriate, 18% uncertain and 28% inappropriate. Expected blood loss had the greatest impact on the ratings (high expected blood loss had a 5.9 point more appropriate rating on the 9-point scale than low expected blood loss [p < 0.0001]). Preoperative hemoglobin level also significantly influenced the ratings (p < 0.0001). Compared with the clinical context, the ratings under the cost constraint were 1.0 less appropriate (p < 0.0001) for rHuEPO alone and 1.2 less appropriate for rHuEPO and PAD (p < 0.0001). The ratings for patients with moderate expected blood loss were significantly influenced by the cost constraint (less appropriate). CONCLUSIONS: Expected blood loss and preoperative hemoglobin level were the best indicators of rHuEPO appropriateness. Different contexts modify the appropriateness ratings of an expensive drug like rHuEPO.

Patient characteristics that affect the outcome of total hip arthroplasty: a review.

OBJECTIVE: To review the literature regarding patient factors pertinent to the outcome of total hip arthroplasty (THA). DATA SOURCE: MEDLINE from 1966 onward (key words "hip prosthesis" and "treatment outcome") and literature previously known to the authors and cited in papers from all sources. STUDY SELECTION: All identified studies were included provided the methodology permitted assessment of the effect of patient factors and a clear outcome was defined (either prosthesis survival or specific functional outcomes). DATA EXTRACTION: The patient factors, methods and outcomes described in each paper were summarized on a data extraction form. DATA SYNTHESIS: All data were reviewed by one author. This process was repeated by a second author, and the findings were reviewed by the remaining 2 authors to verify the findings. The best functional outcomes and prosthesis survival rates were reported among patients who were between 45 and 75 years of age, weighed less than 70 kg, had strong social support, had a higher educational level, had better preoperative functional status and had no comorbid disease. CONCLUSION: Important research remains to be done to examine the magnitude and interaction of patient factors on the the outcome of THA.

Generic total hip arthroplasty.

To decrease implant costs for total hip arthroplasty, a number of different options are available, including the use of remaindered implants, older designs, discounted stock, or specifically designed implants manufactured and sold at low cost. To determine the prevalence of these practices, 80 questionnaires were mailed to members of the Hip Society; 55 (79%) were completed and returned. In addition, 32 questionnaires were mailed to a representative group of orthopaedic surgeons in Canada; 29 (90%) were completed and returned. Analysis of these returns revealed that 73% of the respondents used a low-cost prosthesis for certain indications in total hip arthroplasty. No uniform policy with regard to cost containment or to the definition of low cost was apparent. In a parallel study, the results of a clinical trial with a generic hip implant in 150 patients observed for 2 years or longer revealed the general improvement in hip scores and the rate of complication to be compatible with those of other, more-expensive hip prostheses. Control of prosthetic costs as a means of influencing the cost of arthroplasty appears to be a wide-spread practice.

Laminectomy for metastatic epidural spinal cord tumors. Posterior stabilization, radiotherapy, and preoperative assessment.

In a retrospective analysis of 149 patients with metastatic spinal tumors, the postoperative outcome was compared in patients who had posterior decompressive laminectomies alone (PL) and patients who had supplemental posterior stabilization at the time of laminectomy (PLS). The object of the analysis was to define the indications for stabilization. Posterior stabilization relieved pain, improved sphincter function, and encouraged ambulatory status. The use of adjunctive radiotherapy preceding laminectomy did not significantly improve the patient's postoperative course. Sex, age, initial symptom, length of time from onset of initial neurologic symptom to the time of laminectomy, the presence or duration of pain or sensory loss, the number of vertebrae involved with tumor, and the presence of widespread metastatic disease did not seem to influence the results of the surgical treatment. The presence of significant motor dysfunction, which was rapidly progressive before surgery, or profound sphincteric dysfunction prior to decompressive laminectomy was more frequent in patients who had unsatisfactory results. Decompressive laminectomy with stabilization should be considered in patients: with progressive neurologic symptoms, who are ambulatory, but whose pain increases despite radiotherapy, and who are ambulatory and were receiving radiotherapy for pain relief but who display neurologic dysfunction. For patients with established paraplegia and sphincter dysfunction, decompressive laminectomy and posterior stabilization are adjunctive measures of pain control.

Pelvic disruption: assessment and classification.

A precise radiologic technique for assessing the forces producing pelvic disruption has been helpful in arriving at a logical classification of pelvic injury. The radiologic examination should include anteroposterior, inlet and outlet views, as well as tomograms and occasionally computed-assisted tomographic evaluation (CT scanning). On the basis of this radiologic assessment with some biomechanical studies, a classification of three major forces producing injury is suggested. The anteroposterior and lateral compression types, while vastly different, may both have stable and unstable subtypes associated with them. The vertical shear fracture is always unstable. An accurate history and physical examination in conjunction with the above radiologic principles will lead the surgeon to a precise determination of the fracture pattern. A knowledge of the forces necessary to produce this pattern is helpful in the management of the patient with this particular traumatic lesion.