The femoral head/neck offset and hip resurfacing.

Because the femoral head/neck junction is preserved in hip resurfacing, patients may be at greater risk of impingement, leading to abnormal wear patterns and pain. We assessed femoral head/neck offset in 63 hips undergoing metal-on-metal hip resurfacing and in 56 hips presenting with non-arthritic pain secondary to femoroacetabular impingement. Most hips undergoing resurfacing (57%; 36) had an offset ratio or= 50.5 degrees. Most hips undergoing resurfacing have an abnormal femoral head/neck offset, which is best assessed in the sagittal plane.

Polyethylene wear characteristics in vivo and in a knee stimulator.

Validation of a wear simulator requires that the device produce a similar type and amount of wear and particles of a comparable morphology as occurs clinically. Using techniques previously established to compare polyethylene particles from hip simulators to those from retrieved tissues, particles isolated from six revised posterior stabilized knee replacements were characterized and compared to particles generated from the same knee design worn in a knee simulator. The particles produced in the knee simulator were of comparable size but had less variability in their form factor compared to the particles produced in vivo. Comparable wear features were seen on the articulating surfaces in both groups. These results indicate that this knee joint simulator is able to reproduce a baseline type of wear that is similar to that in vivo and should encourage further use of this device to better understand knee component wear and function.

Quality of life assessment in elite collegiate athletes.

The objectives of this study were to establish baseline Medical Outcomes Study Short Form Health Survey (SF-36) data for Division I collegiate athletes and to determine the effects of injury severity and training time. All participating athletes (N = 562) at a major university were evaluated with the SF-36. Regression analysis was performed to identify predictive factors. When the men without injury were compared with a previously established norm group, there was a significant increase in the role emotional score. In the women without injury there were significant increases in mental component summary, physical function, role emotional, mental health, and vitality scores when compared with the norm group. Serious injury was a predictor of lower scores in all domains, whereas minimal injury was predictive of lower physical component summary, role physical, bodily pain, social function, and general health scores. Increased training time was predictive of higher mental component summary, role physical, vitality, and general health scores. Elite collegiate athletes scored differently from previously established age-matched norms, and injury was a strong predictor of lower scores.

Growth and development of the pediatric cervical spine documented radiographically.

BACKGROUND: The radiographic anatomy of the cervical spine in children is complex and can be difficult to interpret. The present study was undertaken to document radiographically the growth and development of the cervical spine in a prospective, longitudinal manner and to establish standard radiographic measurements on the basis of findings in patients who were followed serially from the age of three months until skeletal maturity. METHODS: The radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush Collection, Cleveland, Ohio) were reviewed. From this large database, we identified fifty boys and forty-six girls who had a sufficient number of radiographs of the cervical spine for inclusion in our study. With use of a computerized image analyzer, the growth and development of the atlantodens interval, the diameter of the spinal canal, the Torg ratio, the height and width of the second through fifth cervical vertebral bodies, the height of the dens, and the ossification of the first cervical vertebra were assessed on serial radiographs made from the age of three months until skeletal maturity. RESULTS: Serial measurements of the atlantodens interval, the anteroposterior diameter of the cervical canal, the height and anteroposterior width of the cervical vertebral bodies, and the height of the dens, made in normal, healthy children from the age of three months to fifteen years, are presented in tabular and graphic forms. The median Torg ratio was 1.47 for both males and females primarily, and it reached values of 1.06 for males and 1.10 for females by maturity. The anterior arch of the first cervical vertebra had ossified in 33% of the children by the age of three months and in 81% of the children by the age of one year. Closure of the synchondroses was completed in all children by the age of three years. CONCLUSIONS: The measurements presented in the current study are important because they are the first, as far as we know, to document the radiographic parameters of the cervical spine in children who were followed longitudinally from before the age of three years through the course of growth and development until skeletal maturity.

Efficacy of nonoperative treatment for lateral epicondylitis.

One hundred cases of lateral epicondylitis among 97 patients were reviewed, and 84 patients were contacted for long-term follow-up. Patients participated in a structured nonoperative treatment regimen. Mean age of contacted patients was 49 years; mean follow-up was 2.8 years. Surgery was averted in 65 (75%) of 87 cases. Patients who achieved pain control after only 1 cortisone injection successfully avoided surgery 88% of the time, whereas those requiring multiple injections avoided surgery only 44% of the time. Eventual outcomes were similar, regardless of treatment type. Patients requiring multiple cortisone injections to alleviate acute pain have a guarded prognosis for continued nonoperative management.

Tissue effects of saw palmetto and finasteride: use of biopsy cores for in situ quantification of prostatic androgens.

OBJECTIVES: To determine the effects of a saw palmetto herbal blend (SPHB) compared with finasteride on prostatic tissue androgen levels and to evaluate needle biopsies as a source of tissue for such determinations. METHODS: Prostate levels of testosterone and dihydrotestosterone (DHT) were measured on 5 to 10-mg biopsy specimens (18-gauge needle cores) in three groups of men with symptomatic benign prostatic hyperplasia: 15 men receiving chronic finasteride therapy versus 7 untreated controls; 4 men undergoing prostate adenomectomy to determine sampling variability (10 specimens each); and 40 men participating in a 6-month randomized trial of SPHB versus placebo, before and after treatment. RESULTS: Prostatic tissue DHT levels were found to be several times higher than the levels of testosterone (5.01 versus 1.51 ng/g), that ratio becoming reversed (1.05 versus 3.63 ng/g) with chronic finasteride therapy. The finasteride effect was statistically significant for both androgens (P <0.01), and little overlap of individual values between finasteride-treated and control patients was seen. In the randomized trial, tissue DHT levels were reduced by 32% from 6.49 to 4.40 ng/g in the SPHB group (P <0.005), with no significant change in the placebo group. CONCLUSIONS: For control versus finasteride-treated men, the tissue androgen values obtained with needle biopsy specimens were similar-both for absolute values and the percentage of change-to those previously reported using surgically excised volumes of prostatic tissue. The quantification of prostatic androgens by assay of needle biopsies is thus feasible and offers the possibility of serial studies in individual patients. The SPHB-induced suppression of prostatic DHT levels, modest but significant in a randomized trial, lends an element of support to the hypothesis that inhibition of the enzyme 5-alpha reductase is a mechanism of action of this substance.

The effect of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy.

BACKGROUND AND PURPOSE: The Bobath neurodevelopmental treatment approach advised against the use of resistive exercise, as proponents felt that increased effort would increase spasticity. The purpose of this study was to test the premise that the performance of exercises with maximum efforts will increase spasticity in people with cerebral palsy (CP). Spasticity, in the present study, was defined as a velocity-dependent hyperexcitability of the muscle stretch reflex. SUBJECTS: Twenty-four subjects with the spastic diplegic form of CP (mean age=11.4 years, SD=3.0, range=7-17) and 12 subjects without known neurological impairments (mean age=11.6 years, SD=3.5, range=7-17) were assessed. METHODS: Knee muscle spasticity was assessed bilaterally using the pendulum test to elicit a stretch reflex immediately before and after 3 different forms of right quadriceps femoris muscle exercise (isometric, isotonic, and isokinetic) during a single bout of exercise training. Pendulum test outcome measures were: (1) first swing excursion, (2) number of lower leg oscillations, and (3) duration of the oscillations. RESULTS: There were no changes in spasticity following exercise between the 2 groups of subjects. DISCUSSION AND CONCLUSION: These results do not support the premise that exercises with maximum efforts increase spasticity in people with CP.

Decompressive surgery for typical lumbar spinal stenosis.

Between 1991 and 1992, 103 consecutive patients (average age, 65 years) underwent decompressive surgery for treatment of typical lumbar spinal stenosis. Clinical results at 1-year followup revealed that four patients had revision surgery. At 2- to 5-years followup, there were no additional revision surgeries. Two patients underwent revision surgery for a deep infection, and two underwent revision surgery for a superficial infection. Outcome results showed that 77 patients completed the questionnaire, 15 were lost to followup and 11 died. Postoperative results showed that 64 of 77 patients had no or mild pain, 72 of 77 patients stated that they were satisfied or somewhat satisfied with their overall results of surgery, and 73 of 77 were satisfied with pain relief. Younger patients had greater improvement in function and a greater reduction in severity scores. However, satisfaction was similar in both groups. Survivorship results (failure was revision surgery) showed at the end of 4 years, a patient had a 95% chance of not having revision surgery. Statistically, there was no association between outcome and cofactors such as scoliosis, spondylolisthesis, number of levels decompressed, discectomy, or smoking. Satisfaction rates for older patients were similar to patients younger than 65 years although physical function scores and severity scores were less.

Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis.

Between 1990 and 1993, 54 consecutive patients were treated with decompression, fusion and instrumentation surgery for complex lumbar spinal stenosis. The mean age of the patients was 60 years. The average followup was 39 months. Clinically, there was one deep wound infection, and three mechanical failures. There were two staged operations. There were three revision surgeries performed for mechanical reasons. Of the 47 patients who completed the questionnaire, 96% of patients were very satisfied or somewhat satisfied with the operation, 98% were satisfied with relief of pain, 94% were satisfied with their ability to walk, 89% were satisfied with their strength, and 94% were satisfied with balance. Survivorship analysis (failure endpoint was revision surgery) revealed that at the end of 4 years, the patient had a 92% chance of not undergoing revision surgery for any reason (mechanical and infectious), and a 94% chance of not undergoing revision surgery for mechanical reasons. Lumbar decompression, fusion, and instrumentation surgery seems to be efficacious in patients with complex lumbar spinal stenosis (associated previous lumbar spine operations with evidence of radiographic instability, radiographic evidence of junctional stenosis after surgery, radiographic evidence of instability, degenerative spondylolisthesis greater than Grade I with instability, if present, and degenerative scoliosis with a curve greater than 20 degrees).

The John Charnley Award. Wear is a function of use, not time.

Polyethylene wear (linear penetration) in 37 hip replacements was assessed from digital images using a validated two-dimensional, edge detection-based computer algorithm. Patient activity was assessed with a pedometer, a step activity monitor and a simple visual analog scale. Joint use was related to wear at the 90% confidence level. Without three recognized outliers, wear was highly correlated to use. The visual analog scale activity rating was significantly related to wear for the 24 hip replacements with standard polyethylene. Univariate regression analysis indicated that male gender, height, weight (which were both highly correlated to male gender) and hip center of rotation were significantly correlated to wear. Multivariate regression analysis indicated that male gender, femoral off-set, and Hylamer were significantly correlated to wear. Based on the wear and activity data from the 24 hip replacements with standard polyethylene, the average volumetric wear rate per million cycles with a 70 kg patient weight was 30 mm3. This unique in vivo result can be considered a target wear rate for standard polyethylene in hip simulator studies.

Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome results and a 3-year survivorship analysis.

STUDY DESIGN: A cohort study of nonoperatively treated patients with lumbar spinal stenosis. OBJECTIVE: To assess the effectiveness of aggressive nonsurgical treatment for lumbar spinal stenosis. BACKGROUND DATA: While surgical treatment of lumbar spinal stenosis has been widely accepted, the natural history of this condition is poorly documented. Moreover, the effect of other available therapies is unclear. METHODS: Forty-nine patients meeting radiographic and clinical criteria for spinal stenosis underwent nonsurgical intervention consisting of therapeutic exercises, analgesics, and epidural steroid injections. Patients were followed for an average of 33 months. Outcome was assessed using a recently developed patient questionnaire for assessment of patients with lumbar spinal stenosis. Survival analysis was used to assess the probability of surgical intervention over the follow-up period. RESULTS: At 3 years following treatment, 9 of the 49 patients had undergone surgical intervention. Of the remaining 40 unoperated patients, it is reported that two suffered significant motor deterioration, one of whom still reported overall symptoms as mild improvement, and the other as definite worsening. Five of the 40 unoperated patients reported feeling overall symptoms as probably or definitely worse, 12 reported no change, 11 reported only mild improvement, and 12 reported sustained improvement. Twelve of the 40 unoperated patients also had none or only mild pain. CONCLUSIONS: The authors conclude that aggressive nonoperative treatment for spinal stenosis remains a reasonable option.

Effects of a saw palmetto herbal blend in men with symptomatic benign prostatic hyperplasia.

PURPOSE: We tested the effects of a saw palmetto herbal blend in men with symptomatic benign prostatic hyperplasia (BPH) via a randomized, placebo controlled trial. MATERIALS AND METHODS: We randomized 44 men 45 to 80 years old with symptomatic BPH into a trial of a saw palmetto herbal blend versus placebo. End points included routine clinical measures (symptom score, uroflowmetry and post-void residual urine volume), blood chemistry studies (prostate specific antigen, sex hormones and multiphasic analysis), prostate volumetrics by magnetic resonance imaging, and prostate biopsy for zonal tissue morphometry and semiquantitative histology studies. RESULTS: Saw palmetto herbal blend and placebo groups had improved clinical parameters with a slight advantage in the saw palmetto group (not statistically significant). Neither prostate specific antigen nor prostate volume changed from baseline. Prostate epithelial contraction was noted, especially in the transition zone, where percent epithelium decreased from 17.8% at baseline to 10.7% after 6 months of saw palmetto herbal blend (p <0.01). Histological studies showed that the percent of atrophic glands increased from 25. 2% to 40.9% after treatment with saw palmetto herbal blend (p <0.01). The mechanism of action appeared to be nonhormonal but it was not identified by tissue studies of apoptosis, cellular proliferation, angiogenesis, growth factors or androgen receptor expression. We noted no adverse effects of saw palmetto herbal blend. When the study was no longer blinded, 41 men elected to continue therapy in an open label extension. CONCLUSIONS: Saw palmetto herbal blend appears to be a safe, highly desirable option for men with moderately symptomatic BPH. The secondary outcome measures of clinical effect in our study were only slightly better for saw palmetto herbal blend than placebo (not statistically significant). However, saw palmetto herbal blend therapy was associated with epithelial contraction, especially in the transition zone (p <0.01), indicating a possible mechanism of action underlying the clinical significance detected in other studies.

Surgical resection and intraperitoneal chemotherapy for recurrent abdominal sarcomas.

BACKGROUND: Recurrent abdominal sarcomas have an extremely high rate of recurrence and poor overall survival. A prospective study was initiated to assess the feasibility, toxicity, and benefit of surgical resection and intraperitoneal chemotherapy for improving local control of disease and overall survival. METHODS: Fifty-four patients underwent surgical excision of all gross disease and postoperative intraperitoneal chemotherapy with mitoxantrone. Thirty-five patients had peritoneal disease only (stage II), and 19 patients had peritoneal disease with hepatic metastases (stage III). RESULTS: Nine (17%) patients remain free of disease with a mean follow-up of 37 months. The remaining 45 patients (83%) have had recurrence, with a mean interval to recurrence of 11 months. Stage (P = .001) and grade (P = .005) were the only two variables found to significantly affect recurrence. There was an overall peritoneal recurrence rate of 48% and an overall hepatic failure rate of 69%. Nineteen (35%) of the patients are alive, with a mean follow-up of 46 months. The overall 5-year survival was 31%. The 5-year survival for stage II patients was 46%; for stage III patients, it was only 5%. Stage (P = .001) and grade (P = .056) were the only two variables found to significantly affect survival. There were no treatment-related deaths, and only 5 patients (9%) developed local complications. CONCLUSIONS: Aggressive surgical resection and intraperitoneal chemotherapy for recurrent abdominal sarcomas is a feasible treatment approach with minimal toxicity. Although this treatment had little effect on the hepatic spread of this disease and thus overall survival, it appears to have significantly lowered the rate of peritoneal recurrence and may provide a survival benefit for patients with disease limited to the peritoneum.

The outcome of lumbar discectomy in elite athletes.

STUDY DESIGN: An outcomes assessment of 14 elite college athletes who had undergone lumbar disc surgery was performed using the SF-36, a validated questionnaire that assesses quality of life. OBJECTIVES: To determine the outcomes and results of lumbar disc surgery in an elite group of athletes and compare the results with those in the general population and in age-matched control subjects. SUMMARY OF BACKGROUND DATA: Lumbar disc surgery is reported to be a highly successful procedure with excellent results. The outcome in elite athletes has not been assessed and compared with population norms and age-matched control subjects. METHODS: Fourteen athletes from schools in the National Collegiate Athletic Association with a mean age of 20.7, underwent lumbar discectomy for radiculopathy refractory to conservative treatment. Ten had a single-level microdiscectomy, three a two-level microdiscectomy, and one a percutaneous discectomy. Patients were evaluated at a mean follow-up of 3.1 years, underwent a detailed clinical evaluation, and filled out the SF-36 questionnaire. RESULTS: All 14 patients had improvement of pain with elimination of the radicular component, took less medication than before surgery, and returned to recreational sports. Nine patients, all with a single level microdiscectomy, returned to varsity sports. Five athletes prematurely retired from competitive sports because of continued symptoms. Three of the athletes who retired underwent two-level procedures, and one had a percutaneous discectomy. SF-36 scores for bodily pain, physical role, and social and mental health roles were significantly lower in those athletes who retired. Patient scores were also compared with those in a group of noninjured age-and sport-matched college athletes. There were no differences between injured and noninjured athletes, but both groups had scores significantly lower than normal values in an age-matched group for bodily pain, physical role, general health, and social function. CONCLUSIONS: All patients were satisfied with their surgeries, were greatly improved, and were pain free in activities of daily living. For a single-level microdiscectomy, the success rate in elite athletes is excellent, with 90% of athletes able to return to a high level of competition. Two-level disease may be associated with a less favorable outcome.

Endoprosthetic reconstruction for malignant upper extremity tumors.

Between December 1980 and December 1992, 59 patients underwent 60 reconstructions with endoprostheses after resection of malignant tumors in the upper extremity. There were 32 male patients and 27 female patients, with a mean age of 33 years (range, 3-83 years). The type of reconstruction was based on the location of the primary tumor site. The histologic diagnoses included osteosarcoma, chondrosarcoma, Ewing's sarcoma, malignant fibrous histiocytoma, soft tissue sarcoma, and fibrosarcoma of bone. Most of the patients had Stage IIB disease (N = 38), as established by the Musculoskeletal Tumor Society classification. An additional six patients had metastatic tumors to the upper extremity. Twenty-seven of 59 patients died of disease progression. Two patients died of other causes (chronic leukemia, human immunodeficiency virus infection). The 30 survivors had a mean followup of 90 months (range, 60-170 months). The Musculoskeletal Tumor Society functional analysis for the patients with a minimum 2-year followup (N = 41) averaged 74%. Sixteen of the 59 (27%) patients had local complications. Problems related to mechanical failure and infection were managed successfully with second operation. Amputation was rare, occurring in three of 60 (5%) patients and was related only to local recurrence. Endoprosthetic reconstructions of the upper extremity after tumor resections have proven to be successful.

Long-term effects of finasteride on prostate tissue composition.

OBJECTIVES: To determine the long-term effects of finasteride treatment on prostate tissue composition; to relate these effects to clinical outcomes; and to test the hypothesis that finasteride exerts a selective or preferential action on the transition zone. METHODS: Nineteen men with symptomatic benign prostatic hyperplasia (BPH) who completed a 6-month double-blind trial of finasteride were enrolled in a 24-month open-label extension study of drug responders. Magnetic resonance imaging and prostate biopsy for morphometric analysis were performed together 70 times: at baseline (n = 19), after treatment periods of intermediate duration (6 to 18 months, n = 32), and after long-term drug treatment (24 to 30 months, n = 19). At baseline, prostate volume averaged 51 cc, of which 57% was transition zone. RESULTS: Decreases in symptom score, dihydrotestosterone and prostate-specific antigen levels, and prostate volume occurred at 6 months (P <0.01), stabilized, and were maintained without further long-term decreases. Prostate epithelium contracted progressively from baseline (19.2% tissue composition; 6.0-cc volume; 3.2 stroma/epithelial ratio) to intermediate (12.5%, 3.3 cc, and 5.6, respectively) to long-term treatment (6.4%, 2.0 cc, and 17.4, respectively, P <0.01 for all). Percent epithelial contraction was similar in the peripheral and transition zones (P = NS). The transition zone remained a relatively constant proportion (53% to 58%) of whole-prostate volume from baseline to long-term observation. CONCLUSIONS: Long-term finasteride treatment (24 to 30 months) results in a marked involution of the prostate epithelium, which continues to progress for many months after clinical effects stabilize. The effect on the epithelium is similar in the peripheral and transition zones for both morphometric and volumetric changes. Progressive contraction of the prostate epithelium appears to constitute the underlying mechanism for sustained action of finasteride.