Endoscopic versus open saphenous vein harvest: the effect on postoperative outcomes.

BACKGROUND: Endoscopic vein harvest (EVH) has been promoted as a possible solution to the wound complications, incisional pain, and prolonged convalesce associated with open vein harvesting (OVH). The purpose of this study was to objectively compare the two techniques. METHODS: One hundred patients were prospectively randomized to EVH or OVH. Primary outcomes were wound complications, pain (Medical Outcomes Study Pain Survey), and general health (SF-12). Secondary outcomes were operative times and patient preferences. Patients were assessed at hospital discharge, 3, and 6 weeks postdischarge. RESULTS: No significant differences were detected in the primary outcomes: leg infection (p = 0.75), incisional pain (p = 0.74), physical health (p = 0.84), mental health (p = 0.47), and postoperative length of stay (p = 0.74). However, patient preference for EVH was highly significant (p < 0.01). CONCLUSIONS: EVH does not demonstrate significant differences compared with OVH. This, coupled with higher operating room costs, should limit its use until clinical benefit is shown. However, strong patient preference and demand for EVH overshadow equivocal clinical outcomes.

Association between ratio of matrix metalloproteinase-1 to tissue inhibitor of metalloproteinase-1 and local recurrence, metastasis, and survival in human chondrosarcoma.

Chondrosarcoma, a malignant cartilage-forming mesenchymal tumor, displays a wide range of clinical behavior that can be difficult to predict with histological analysis. Matrix metalloproteinases contribute to the processes of local invasion and metastasis by controlling the ability of a tumor to transverse tissue boundaries. The specificity of matrix metalloproteinase-1 (interstitial collagenase) for fibrillar collagen may be central to those processes. Matrix metalloproteinase-2 facilitates invasion by degradation of such basement-membrane structures as type-IV collagen. The balance between the activity of tissue inhibitors of metalloproteinase and the activity of matrix metalloproteinase determines the proteolytic activity and may, in part, determine the overall invasiveness and potential for metastasis. The measurement of the ratio of matrix metalloproteinase to tissue inhibitor of metalloproteinase may have prognostic value for determining whether individual chondrosarcomas are locally invasive or will metastasize. Furthermore, there may be a specific pattern of expression of matrix metalloproteinase and tissue inhibitor of metalloproteinase in chondrosarcomas that is related to local invasion and probability of metastasis. Sixteen paraffin-embedded archival specimens of tumors were examined. Six twenty-micrometer-thick sections were cut from each tumor, and the amounts of cDNA formed from the mRNA were determined with reverse transcription-polymerase chain reaction with use of novel primers for matrix metalloproteinase-1, matrix metalloproteinase-2, tissue inhibitor of metalloproteinase-1, and tissue inhibitor of metalloproteinase-2. The amounts of cDNA for the matrix metalloproteinases and their inhibitors were determined by chemiluminescence and band densitometry. The ratio of the amount of cDNA for matrix metalloproteinase-1 to that for its tissue inhibitor and the ratio of the amount of cDNA for matrix metalloproteinase-2 to that for its tissue inhibitor were calculated, and the results were compared with use of the Student t test, enabling log-rank analysis of Kaplan-Meier survival curves. These ratios as well as the age and gender of the patient; the grade, size, and location of the tumor; the type of adjuvant therapy; and the operative margins were examined for significance with use of stepwise logistic-regression analysis. The patients who had recurrent disease had a significantly higher (p < 0.003) ratio of matrix metalloproteinase-1 to tissue inhibitor of metalloproteinase-1 (mean, 0.939; range, 0.647 to 1.101) than the patients who were free of disease (mean, 0.703; range, 0.629 to 0.772). Moreover, there was a striking difference between the Kaplan-Meier survival curve associated with a high ratio (more than 0.8) and that associated with a low ratio (p = 0.0015). The mean ratio of matrix metalloproteinase-2 to tissue inhibitor of metalloproteinase-2 was 1.814 (range, 1.206 to 3.77) in the patients who had recurrent disease compared with 1.473 (range, 1.073 to 2.390) in those who were free of disease; this difference was not found to be significant, with the numbers available. Analysis of the survival curves indicated that a worse prognosis was associated with a high ratio, but again this relationship was not found to be significant. Regression analysis revealed that a high ratio of matrix metalloproteinase-1 to its tissue inhibitor was a moderately significant independent predictor of a poor outcome (alpha = 0.07).

A logical coronal pattern classification of 2,000 consecutive idiopathic scoliosis cases based on the scoliosis research society-defined apical vertebra.

STUDY DESIGN: Two thousand consecutive idiopathic scoliosis records and radiographs were reviewed for coronal pattern typing and categorization, based on Scoliosis Research Society definitions of the apical vertebra. Apical frequency was determined for each of the patterns identified, and represents a database from a large series of cases for the already accepted Scoliosis Research Society definitions. OBJECTIVES: To identify and numerically pattern-type a large series of idiopathic coronal curves, for the basic purpose of written and oral communication. Some pattern types were not described previously. SUMMARY OF BACKGROUND DATA: Although spinal deformity must be considered three dimensional for treatment in 1998, no comprehensive, databased, and user friendly coronal or sagittal classification of idiopathic scoliosis has been reported. METHODS: Two thousand idiopathic curve patterns from charts and radiographs were reviewed and the coronal patterns categorized by the apical vertebra. The resulting classification was tested for inter- and intraobserver reliability by 12 spine surgeons and 6 orthopedic residents. Apical frequencies were determined for each pattern type. RESULTS: Twenty-one pattern categories were identified, and all were right or left mirror image patterns (except for a quadruple pattern) that permitted separation into 11 types. Incorporating the widely recognized five numbered King types mad pattern recognition simple. Interobserver reliability testing was 98.2%. The left single thoracic curve pattern was included in this classification because only 9 (20.4%) of 44 patients with left thoracic curves had intraspinal pathology. CONCLUSION: Two thousand consecutive idiopathic coronal curve patterns separated into eleven readily identifiable types, and incorporating the widely referenced five King types, makes recognition simple for purposes of identification and communication. Sagittal and 3D factors excluded from this classification are equally important in the process of treatment decisions. Apical frequency data determined in this study lends credence to Scoliosis Research Society definitions for idiopathic curve patterns.

Perioperative nutrition and postoperative complications in patients undergoing spinal surgery.

STUDY DESIGN: The authors undertook a three-part study to better understand the impact of perioperative nutritional status on postoperative complications in patients undergoing spinal surgery. In preliminary Parts I and II, the authors targeted two groups of patients who are particularly nutritionally challenged. In Part III, they studied a large group of consecutive patients undergoing routine lumbar spinal fusion. OBJECTIVES: To determine whether preoperative nutritional status was a significant predictor of postoperative complications in patients undergoing elective lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: In Part I, 27 patients treated surgically for vertebral osteomyelitis were divided into two groups based on their preoperative nutritional status. Twenty-four of the 26 postoperative complications were in the malnourished group (P < 0.001). In Part II, 15 (75%) of 20 patients treated surgically for spinal cord injury were found to become malnourished in the postoperative period. Seventeen complications were noted, all in the malnourished group (P = 0.001). METHODS: One hundred fourteen consecutive patients undergoing selective lumbar decompression and fusion were identified and their records reviewed. In addition to preoperative nutritional status, data gathered included age, sex, height, weight, past medical history, steroid use, alcohol use, tobacco use, type of bone graft (allograft vs. autograft), history of previous lumbar surgery, number of levels fused, and use of spinal instrumentation. RESULTS: Eleven of 13 postoperative infectious complications (10 deep wound infections) were noted in the malnourished group (P < 0.001). By stepwise logistic regression analysis, preoperative nutritional status was an extremely significant independent predictor of postoperative complications in patients undergoing elective lumbar spinal fusion (P = 0.0018). CONCLUSIONS: The prevalence data in our study population suggest that a large number (25%) of patients undergoing elective lumbar spine surgery are nourished inadequately at surgery. This number is higher (42%) in older patients. The authors recommend that close attention be paid to the perioperative nutritional status of patients undergoing lumbar spinal surgery. Patients with suboptimal nutritional parameters should be supplemented and replenished before elective surgery.

Is the orthopedic generalist moving toward extinction?

Medical students are influenced in their career choice by many factors. By government mandate, 50% of medical students from each graduating class should select primary care as their career choice. Peers and mentors contribute additional influences. The student's personality, preference for living in a rural or urban community, and the possible educational and cultural opportunities for self and/or family in a particular community are also influential factors. The medical student choosing orthopedic surgery as a professional career faces competition; there are four applicants for each residency opening, and the number of orthopedic residents allowed for each program is being reduced. The current belief of policy-makers both outside and within orthopedics is that there are "too many specialists of all kinds." The present article examines the factors that influence the medical student's choice in career selection and shows the present trend of clinical practices.

North Carolina stroke prevention and treatment facilities survey. Statewide availability of programs and services.

BACKGROUND/PURPOSE: The aim of this study was to determine the statewide availability of facilities and programs for stroke prevention and treatment to identify underserved regions and target educational efforts. METHODS: A single-page survey was mailed to the directors of each inpatient medical facility in North Carolina. Data collected included the availability of selected diagnostic tests, programs, and services. Facilities were categorized as providing basic (emergency department, brain CT, treatment with rtPA, transthoracic echocardiography, carotid ultrasonography, cerebral angiography, carotid endarterectomy) or advanced (basic services plus brain MRI, MR angiography, transesophageal echocardiography, transcranial Doppler ultrasonography, interventional radiology) services. The availability of other programs and services, including having a neurologist on staff, organized anticoagulation clinics, inpatient rehabilitative services, diffusion-weighted MRI, community awareness and rapid stroke identification programs, stroke teams, stroke acute care units or an equivalent, and the use of stroke-care maps, were also determined. RESULTS: Complete responses were obtained from all of the state's 125 inpatient medical facilities. Overall, 97% of the state's population resided in counties with a hospital providing at least some stroke prevention or treatment procedures or services. Full basic services were provided by 23 facilities located in 19 of the state's 100 counties and were available to 52% of the state's population based on county of residence; advanced services were provided by 8 facilities located in 7 counties and were available to 26% of the state's population based on county of residence. Stroke-care maps were used in 83% of basic or advanced centers versus 23% of other hospitals (P<0.001), stroke teams were organized in 48% versus 12% (P=0.001), stroke units or equivalents were available in 61% versus 9% (P<0.001), rapid patient identification programs were in place in 57% versus 9% (P<0.001), and community awareness programs were in place in 57% versus 21% (P=0.005). CONCLUSIONS: Only 52% of the state's population reside in counties with hospitals providing full basic services; by expanding these services to only 6 additional facilities and thereby encompassing the state's 50 most populous counties, this proportion would be increased to 84%. Services that may improve outcomes and reduce costs (eg, stroke teams, stroke units, care maps) are not widely used, even in centers with full basic capabilities. Targeting educational efforts to these centers could improve the overall level of stroke care for the majority of the state's population. The study serves as a model that can be applied to other states and regions.

North Carolina stroke prevention and treatment facilities survey: rtPA therapy for acute stroke.

BACKGROUND AND PURPOSE: North Carolina is situated in the "stroke belt" region of the United States, an area of the country with a particularly high incidence of cerebrovascular disease. The North Carolina Stroke Prevention and Treatment Facilities Survey was carried out to determine the availabilities of a variety of stroke prevention and treatment services throughout the state. The purpose of the present study was to determine how widely recombinant tissue-type plasminogen activator (rtPA) has been adopted for the treatment of patients with acute ischemic stroke and to determine the characteristics of the medical facilities in the state offering this therapy. METHODS: A single-page survey was mailed to the medical center directors of each inpatient medical facility in North Carolina. Data collected included questions related to the availability of selected basic and advanced diagnostic tests and procedures, stroke prevention and treatment programs and services (community stroke awareness program, acute stroke identification program, acute stroke team, stroke rtPA protocol, stroke care map, neurologist), and facilities (Stroke Acute Care Unit or equivalent). RESULTS: Responses were obtained from all 125 inpatient medical facilities in North Carolina. rtPA stroke protocols were adopted in 54 facilities located in 46 of the state's 100 counties. Seventy-four percent of the state's population resides in counties with hospitals providing rtPA treatment. Compared with facilities not offering rtPA, those with rtPA protocols more commonly sponsored stroke community awareness programs (41% versus 17%, P=0.003) and more frequently had an organized stroke team (31% versus 8%, P=0. 001), used stroke care maps (56% versus 17%, P<0.001), had rapid stroke identification programs (33% versus 6%, P<0.001), or had a Stroke Acute Care Unit or its equivalent (33% versus 7%, P<0.001). Neurologists were available in 78% of the facilities offering rtPA compared with 38% in facilities without rtPA protocols (P<0.001). CONCLUSIONS: These data show that this new therapy for ischemic stroke is potentially available to a high proportion of the state's citizens based on their county of residence. However, other services that may improve outcomes and reduce stroke-related costs (eg, stroke teams, stroke units, care maps) are not being widely used, even in centers providing treatment with rtPA. The simple methodology used in this study is potentially applicable in other states and permits targeting of selected centers for development of stroke treatment capabilities.

Postreduction computed tomography in developmental dislocation of the hip: part I: analysis of measurement reliability.

Twenty computed tomographic (CT) scans of infants in spica casts after closed or open reduction for developmental hip dislocation (DDH) were analyzed for intra- and interrater reliability. Ten measurements of infant hip anatomy were assessed by three raters by using standard statistical analysis. All six measurements of acetabular anteversion and lateral or posterior displacement of the femoral metaphysis from the acetabulum or from a modified Shenton's line drawn from the pubic rami demonstrated both intra- and interrater reliability. All four measurements of acetabular structure could not be reliably measured either within or between observers. We also introduced a new measurement based on the principle of Shenton's line to aid in the assessment of femoral-head location after reduction in patients with DDH; this was reliably determined both within and among observers.

Postreduction computed tomography in developmental dislocation of the hip: part II: predictive value for outcome.

Computed tomographic (CT) scans were performed after closed reduction of 68 dislocated hips in 53 infants in spica casts with developmental hip dislocation (DDH). Ten measurements were made on the CT scans including acetabular indices and anteversion, hip-abduction angle, lateral and posterior displacement of the femur from the acetabulum, and femoral displacement from a modified Shenton's line drawn from the pubic rami. By using analysis of variance, the correlation of each variable with outcome after reduction was determined, including the development of avascular necrosis or the need for further surgery because of residual dysplasia. None of the variables was predictive of the outcome of persistent hip dysplasia. The subsequent development of avascular necrosis was statistically associated with hip-abduction angles >55 degrees as measured on postreduction CT scans, with 20% of the involved hips developing avascular necrosis on subsequent follow-up.

Development and implementation of an extremity free-tissue-transfer database.

Rigorous clinical outcomes research requires accurate, complete, and standardized data. No such system is currently being used by reconstructive microsurgeons to evaluate free-tissue-transfer procedures. To facilitate collection of relevant and complete data, the authors propose a standardized format for data collection regarding these procedures. Data are collected via computer entry or scannable forms. The database includes sociodemographic, clinical, health/functional status, patient satisfaction, and resource utilization variables--the necessary components of a well-constructed clinical outcome study. Such studies will give rise to meaningful treatment algorithms for managing reconstructive problems. In addition, widespread use of a standardized databse will facilitate comparisons between practices and allow for meta-analyses. Resultant practice guidelines and microsurgery care maps will ultimately improve patient care and minimize unnecessary costs.

Treatment of severe spondylolisthesis in children by reduction and L4-S4 posterior segmental hyperextension fixation.

Twenty children with severe lumbosacral spondylolisthesis underwent reduction, posterolateral fusion, and posterior fixation with an L4 to S2, 3, and 4 sublaminar wired rectangular rod to lessen lumbosacral kyphosis, allow early ambulation, and maintain correction. All patients had a postural deformity, 10 had preoperative neurologic findings, and 8 had severe pain. The average percentage of slip improved from 76% preoperatively to 55% postoperatively, and the slip angle improved from 25 degrees to 5 degrees (p < 0.0001). All patients had solid fusion by 6 months and no progression at 43 month follow-up on the average. We conclude that this technique reliably provides partial reduction, solid fixation, and fusion for patients with severe spondylolisthesis while allowing early ambulation. As with any spondylolisthesis reduction technique, neurologic risk should limit this procedure to well-selected patients.

Transesophageal echocardiography in quantification of emboli during femoral nailing: reamed versus unreamed techniques.

We quantified the embolic load to the lungs created with two different techniques of femoral nailing. Eleven patients with 12 traumatic femur fractures were randomized to reamed (7 fractures) and unreamed (5 fractures) groups. Intramedullary nailing was with the AO/ASIF* universal reamed or unreamed nail. Transesophageal echocardiography (TEE) was used to evaluate the quantity and quality of emboli generated by nailing. Data were analyzed using software that digitized the TEE images and quantified the area of embolic particles in each frame. The duration of each level of embolic phenomena (zero, moderate, severe) was used to determine total embolic load with various steps (fracture manipulation, proximal portal opening, reaming, and nail passage). Manual grading of emboli correlated highly with software quantification. Our data confirm the presence and similarity of emboli generation with both methods of intramedullary nailing. Unreamed nails do not protect the patient from pulmonary embolization of marrow contents.