Patient function in serial assessments throughout the post-ACL reconstruction progression.

OBJECTIVE: To assess the changes in patient strength and function from 4- to 6-month assessments following ACLR, determine relationships between changes in strength to changes in subjective function, and identify factors that predict patients that fail to increase in strength. DESIGN: Prospective, Cohort Study. SETTING: Controlled Laboratory. PARTICIPANTS: Forty-seven patients(27 female, 24.3 ± 11.1 years) completed a battery of performance assessments at approximately 4- and 6-months following primary ACLR (4.03 ±0 .49 and 6.46 ±0 .68 months). MAIN OUTCOME MEASURES: Subjective scores and isokinetic knee flexor and extensor strength were compared across visits. Patients were categorized per their ability to increase in strength beyond a previously defined threshold(0.22 Nm/kg). Binary logistic regression models were used to determine predictors of patients that failed to meet strength changes. RESULTS: Patients demonstrated improvements in patient-reported outcomes and strength measures between visits(P's < 0.05). Higher age (B = -0.073, P = .039), lower pre-injury activity levels (B = 0.61, P = .022), and higher limb symmetry indexes (B = -0.044, P = .05) at 4-months were predictors of patients that did not achieve improvements in quadriceps strength between assessments. CONCLUSIONS: From 4- to 6-months post-ACLR, increases in subjective function, strength and symmetry were observed. High quadriceps symmetry at interim assessments without consideration of the magnitude of strength values could overestimate recovery of quadriceps function.

The Charnley stem: clinical, radiological and survival data after 11-14 years.

BACKGROUND: The Charnley stem provides good outcome for 10 years, but several studies find deteriorating results thereafter. However, study populations, techniques and data analysis vary widely. We have studied 240 Charnley stems in a homogeneous group of patients providing clinical, radiological and survival data after 11-14 years. HYPOTHESIS: The clinical and radiological outcome of the Charnley stem is not as good than previously thought. PATIENTS AND METHODS: Five surgeons implanted 240 femoral stems in a community hospital in Norway using antibiotic impregnated cement and third generation cementing techniques. The Charnley stems were implanted with a Charnley cup in 120 cases and an uncemented hemispherical cup (Duraloc) in 120 cases. The mean age of the patients was 65.5 years and the mean Body Mass Index (BMI) was 26.8. All patients received low molecular weight heparin and antibiotic prophylaxis. Patients were assessed after 10 years by means of Harris Hip Score (HHS)and radiographic evaluation. Implant survival studies were performed after 11-14 years. RESULTS: One hundred and fifty-eight patients were available for clinical and radiographic evaluation after 10 years. HHS improved from 48.4 (95% CI: 46.6-50,2) preoperatively to 87.9 (95%CI: 86.6-89.3) after 6 months and 87.6 (95% CI: 85.3-89.8) at 10 years. Thirty-one stems had been revised, the reasons for revision were loosening (21), infection (five), instability (four) and late perisprosthetic fracture (one). Forty-one stems had one or more signs of loosening.Stem survival was 83.6% using any revisions as end point, and mean estimated stem survival was 12.7 years (12.2-13.3 years). DISCUSSION: Other studies report survival at mid-term from 83-96%. Our results are in the low-end. Even though our rate of infection was high (2%), the main cause of the poor results is aseptic loosening. We do not know the reason for this high-rate of loosening. As we believe that our technique is adequate and patient population average, we suspect that this rate of loosening is a characteristic of the implant. Results from this prospective cohort study add to the evidence that the Charnley stem should not be used hip arthroplasty unless patient life expectancy is less than 10 years.

Initial development of a system-wide maternal-fetal outcomes assessment program.

OBJECTIVE: This study was undertaken to develop a comprehensive risk-assessment approach capable of evaluating maternal and fetal outcomes. STUDY DESIGN: Data from 10,984 women and 11,066 infants delivered at 79 military treatment facilities in the United States from 1995 to 1997 were used to develop two individual but complementary risk-adjustment models for maternal and, separately, fetal outcomes. A range of maternal and delivery-related risk variables and clinically important outcomes were identified by expert opinion and selected and weighted with ordinal logistic regression analysis. Receiver operating characteristic curves for the maternal and fetal models were determined. Variation across the facilities in risk-adjusted performance was also evaluated. RESULTS: Risk factors and poor outcomes were rare for both mothers and infants, with 96.9% of infants and 97.7% of mothers having good or excellent outcomes (0.7% mortality and 0.01% mortality, respectively). Despite the low frequency of poor outcomes both models performed well, with receiver operating characteristic curves of 0.75 for maternal outcomes and 0.78 for infant outcomes. When the models were applied to the military treatment facilities, there were significant differences among facilities in risk-adjusted outcomes. Twenty-four of the facilities in the study (30%) had outcomes odds ratios that were significantly >1 or significantly <1 (P <.05). There did not appear to be any relationship between the performance of a military treatment facility for maternal outcome and that for infant outcome. CONCLUSION: Complementary risk models for maternal and infant outcomes were developed that had satisfactory discriminatory power across a variety of facilities within a large health system. With further development and refinement this approach holds promise of being able to detect variations in risk-adjusted performance that could be used to identify best practices. The results might also be used to help coordinate and improve the quality of care for the entire conception-to-delivery process.