David R. Steinberg

A quantitative system for staging avascular necrosis

Much of the current confusion and contradiction on the treatment of avascular necrosis of the femoral head is caused by the lack of an agreed efficient, quantitative system for evaluation and staging. We have used a new system to evaluate over 1000 hips with avascular necrosis during a period of 12 years; it has proved to be very valuable. The system is based on the sequence of pathological events known to take place. It allows accurate quantification in both early and later stages, does not use older, invasive diagnostic procedures, and incorporates the newer techniques of bone scanning and MRI. Clinical records of pain and reduced function are not a specific part of the system, although they help to determine treatment and outcome. Hips are first placed into one of seven stages from 0 to VI, based upon the type of radiological change. The extent of involvement is then measured. This allows more accurate evaluation of progression or resolution and better comparison of different methods of management. The system also helps to provide a prognosis and to decide on the best available method of treatment.

A new law for allocation of donor organs in Israel

Israel’s system for organ donation has been based, since its inception in 1968, on a model in which organs for transplantation are retrieved from brain-dead donors only after consent has been obtained from the appropriate fi rst-degree relatives. This consent is needed even if the potential donor has expressed a wish for posthumous organ donation by signing a donor card, which is a government form that allows people to voluntarily indicate their wish to donate specifi ed organs after their death. The consent rate for organ donation in Israel, defi ned as the proportion of actual donors of total number of medically eligible brain-dead donors, has consistently been 45% during the past decade, much lower than in most western countries. Similarly, the proportion of adults with donor cards in Israel is only 10%. In January, 2008, 864 candidates were listed for kidney, heart, lung, or liver transplantation, but only 221 patients were given transplants from deceased donors that year. In two formal surveys of public attitudes towards organ donation, which were done by the Israel National Transplant Centre in 1999 (n=758) and 2004 (n=417), 55% of individuals in each survey indicated their willingness to donate organs in exchange for prioritisation in organ allocation. In both surveys, the proportion of individuals who chose this option was much greater than the proportions choosing the second and third preferred options, which were direct (26%) or indirect fi nancial compensation (25%), respectively, for organ donation. The basis of this public reaction is mainly a perceived need to rectify the unfairness of free riders—people who are willing to accept an organ but refuse to donate one— as practised by a small yet prominent proportion of the Israeli public. These individuals are opposed to the idea of brain death and organ donation, yet they do not abstain from becoming candidates for transplantation when they need an organ for themselves. The results of the surveys of attitudes of Israeli people resemble those noted in similar surveys done in the USA in 1990 and 2004, in which 52% and 53% of responders, respectively, ranked a preferred status in organ allocation as their top-ranked option for compensation for organ donation. With the grim national statistics for organ donation, and the knowledge that relatives of potential donors who were holders of donor cards have consistently given their consent for organ donation, a national plan for prioritisation of organ allocation was devised to increase the number of individuals with donor cards in the hope that such an increase would lead to an increase in organ donation. The plan to increase the national number of individuals who have a donor card by giving priority in organ allocation to transplant candidates who had signed a donor card before their listing date was fi rst suggested to the Israel National Transplant Council (INTC) in March, 2006. This council established a special interdisciplinary committee—inclu ding leading ethicists, philosophers, legal advisers, representatives of the main religions, transplant physicians, surgeons, and coordinators—to review the various relevant ethical, legal, medical, and social issues. After long discussions, the committee recommended to the INTC that any candidate for a transplant who had a donor card for at least 3 years before being listed as a candidate will be given priority in organ allocation. Similar priority will be granted to transplant candidates with a fi rst-degree relative who was a deceased organ donor and to any live donor of a kidney, liver lobe, or lung lobe who subsequently needs an organ. Because the new plan includes, for the fi rst time, implementation of non-medical criteria in organ allocation, legal advisers said the policy could not be implemented by administrative rules and required legislation by the Israeli Parliament. After the approval of these recommendations by the INTC, the Ministry of Health has asked Israel’s Parliament to incorporate the prioritisation plan into the new bill for organ transplantation. After a long debate within the Israeli Parliament, clause 9(B)4 was added to the recently approved law for organ transplantation (panel). The Israeli law has increased the number of benefi ciaries for organ allocation from the signatory on the donor card to the fi rst-degree relatives (parents, children, sibling, or spouse) on the basis of past experience, whereby relatives who were holders of the card had always given their consent to organ donation even if the donor did not sign it, yet reduced the number of benefi ciaries by excluding living-directed donors. This restriction, which contradicts the INTC’s original recommendation, is being prepared by the Ministry of Health for an appeal for reconsideration by Parliament, because we strongly believe all living donors should be granted prioritisation in organ allocation. On the basis of a new law, the steering committee for Israel’s National Transplant Centre decided to set up three allocation priority categories with diff erent levels for each transplanted organ (table). On the one hand, a transplant candidate with a fi rst-degree relative who has signed a donor card would be given half the allocation priority that is given to a transplant candidate who has signed his or her own donor card. On the other hand, a transplant candidate with a fi rst-degree relative who donated organs after death or who was an eligible live non-directed organ donor would be given allocation priority 1·5 times greater than that given to candidates who have signed their own donor cards. Among candidates with an equal number of allocation points, organs will be allocated fi rst to prioritisation-eligible candidates. Lancet 2010; 375: 1131–33

Fibroblast chemotaxis after tendon repair

Healing canine flexor tendons were treated with early controlled passive mobilization. The repair site and proximal and distal tendon stumps were stained for fibronectin and examined by light microscopy at three, seven, eleven, and seventeen days. Fibronectin increased dramatically in the epitenon adjacent to the repair site seven days after repair, a time when epitenon cellular activity was at its peak. By seventeen days, fibronectin staining had decreased substantially, both at the repair site and in the tendon stumps. A delayed increase in fibronectin activity was noted in the endotenon adjacent to the repair site. Fibronectin production appears to be an important component of the early tendon repair process. Fibroblast chemotaxis and adherence to the substratum in the days after injury and repair appears to be related directly to fibronectin secretion. This study is the first to provide documentation of fibronectin localization in a clinically relevant tendon repair model.

Osteonecrosis of the femoral head. Results of core decompression and grafting with and without electrical stimulation.

The effectiveness of core decompression and bone grafting with and without electrical stimulation was investigated in patients with avascular necrosis (AVN) of the femoral head. One hundred sixteen hips with AVN had decompression and grafting; 74 were also treated with direct current (DC). The DC stimulation was via a coil inserted directly into the femoral head. These were compared to 55 hips with AVN treated nonoperatively. Hips treated with electrical stimulation showed less roentgenographic progression and achieved a better clinical score than hips treated with decompression and grafting alone. Both groups had a significantly lower incidence of arthroplasty than the nonoperated controls. One patient developed a pulmonary embolus, but there were no fractures or other complications. Decompression and grafting are safe and reasonably effective in retarding the progression of AVN. Supplemental electrical stimulation seems to improve the results even further.

An “Opting In” Paradigm for Kidney Transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.

Treatment of castration-induced osteoporosis by a capacitively coupled electrical signal in rat vertebrae.

Castrated male Sprague Dawley rats were subjected to various capacitively coupled electrical fields for six and eight weeks at two and 4.5 months after castration, respectively, with pairs of electrodes that were located paraspinally on the surface of the skin dorsally at the eleventh thoracic and fourth lumbar levels. When the animals were killed, dry and ash weights per unit of volume (apparent density), elastic modulus, ultimate stress, work to failure, trabecular area fraction, and mean trabecular width were determined for selected vertebrae. The results indicated that a sixty-kilohertz, 100-microampere signal (a calculated current density of five microamperes root-mean-square per square centimeter and a field of twelve millivolts root-mean-square per centimeter) significantly reversed the castration-induced osteoporosis in the lumbar vertebrae and restored bone mass per unit of volume in rats that had been stimulated for eight weeks after castration.

Spectrum of injury and treatment options for isolated dislocation of the scaphoid. A report of three cases.

A characteristic radiographic feature that distinguishes dislocation of the scaphoid from perilunate dislocation is the palmar and radial displacement of the proximal pole of the scaphoid out of the scaphoid scaphoid embodies a variety of injuries. An isolated dislocation of the scaphoid can occur with a variable amount of ligamentous damage, with some indication of the severity of the injury detectable on radiographic

The early history of arthroplasty in the United States.

Arthroplasty is defined in the broadest sense as a reconstructive procedure that alters the structure or function of a joint. The first recorded procedures done in the United States in the early nineteenth century and the introduction of modern total joint replacement in the 1970s will be discussed. Although major surgical procedures occasionally were performed in the early 1800s, it was not until the introduction of general anesthesia and antiseptic techniques during the latter half of the nineteenth century that the field of surgery could be developed. Procedures involving the major joints of the upper and lower extremities are described. These procedures include resection and interposition arthroplasties, joint debridement, procedures done to correct complications of hip fractures and developmental dysplasia of the hip, cup arthroplasties, endoprosthetic replacement, hinge arthroplasties, resurfacing procedures, and early total joint replacement.

The Detrimental Effects of Systemic Ibuprofen Delivery on Tendon Healing Are Time-Dependent

BackgroundCurrent clinical treatment after tendon repairs often includes prescribing NSAIDs to limit pain and inflammation. The negative influence of NSAIDs on bone repair is well documented, but their effects on tendon healing are less clear. While NSAIDs may be detrimental to early tendon healing, some evidence suggests that they may improve healing if administered later in the repair process.Questions/purposesWe asked whether the biomechanical and histologic effects of systemic ibuprofen administration on tendon healing are influenced by either immediate or delayed drug administration.MethodsAfter bilateral supraspinatus detachment and repair surgeries, rats were divided into groups and given ibuprofen orally for either Days 0 to 7 (early) or Days 8 to 14 (delayed) after surgery; a control group did not receive ibuprofen. Healing was evaluated at 1, 2, and 4 weeks postsurgery through biomechanical testing and histologic assessment.ResultsBiomechanical evaluation resulted in decreased stiffness and modulus at 4 weeks postsurgery for early ibuprofen delivery (mean ± SD [95% CI]: 10.8 ± 6.4 N/mm [6.7–14.8] and 8.9 ± 5.9 MPa [5.4–12.3]) when compared to control repair (20.4 ± 8.6 N/mm [16.3–24.5] and 15.7 ± 7.5 MPa [12.3–19.2]) (p = 0.003 and 0.013); however, there were no differences between the delayed ibuprofen group (18.1 ± 7.4 N/mm [14.2–22.1] and 11.5 ± 5.6 MPa [8.2–14.9]) and the control group. Histology confirmed mechanical results with reduced fiber reorganization over time in the early ibuprofen group.ConclusionsEarly administration of ibuprofen in the postoperative period was detrimental to tendon healing, while delayed administration did not affect tendon healing.Clinical RelevanceHistorically, clinicians have often prescribed ibuprofen after tendon repair, but this study suggests that the timing of ibuprofen administration is critical to adequate tendon healing. This research necessitates future clinical studies investigating the use of ibuprofen for pain control after rotator cuff repair and other tendon injuries.

Surgical release of the carpal tunnel

A thorough understanding of the normal anatomy and possible anomalies that may exist is important for the surgeon managing median nerve compression at the wrist. Given the high incidence of anatomic variability occurring in and around the carpal canal, open decompression of the median nerve is the preferred surgical technique for treating carpal tunnel syndrome. This approach provides complete visualization of the region, enabling the surgeon to decompress the nerve thoroughly, identify and treat anatomic abnormalities, and protect important neurovascular structures. Open carpal tunnel release is a safe and reliable operation with a high rate of functional improvement and patient satisfaction.