Geoffrey Johnston

Accuracy of Intraoperative Assessment of Acetabular Prosthesis Placement

Anteversion and vertical tilt of the acetabular prostheses in 50 consecutive total hip arthroplasties were prospectively evaluated during surgery (by the surgeon, using an alignment guide) and radiographically (calculated). From postoperative standardized radiographs vertical tilt was measured directly and anteversion was calculated. The mean error of vertical tilt was 5 degrees (range, 0 degrees - 20 degrees). The mean error of version was 9 degrees (range, 0 degrees - 24 degrees). The reliability of prosthesis placement in a predetermined zone was examined. Although the surgeons believed that all 50 cups were inside this zone, radiographic measurements revealed that 21 of the cups were actually outside. It is concluded that vertical tilt can be reasonably assessed during surgery. Anteversion, however, cannot be accurately assessed during surgery, despite use of the alignment guide.

Computerized tomographic evaluation of acute distal radial fractures

To learn whether computerized tomography offered additional useful information over conventional radiographic evaluation of acute distal radial fractures in the younger adult, we scanned 22 consecutive injured wrists. Of the distal radial fractures in 19 wrists, sixteen were defined on plain films as intra-articular. In contrast, computerized tomography demonstrated that all fractures of the distal radius had intra-articular extension. In 3 wrists interpreted as being normal on plain films, despite clinical suspicion of a fracture, fractures were confirmed by computerized tomography. As a result of computerized tomography, injuries were assigned a higher Frykman value in 5 cases, and consideration of alternative patient management became necessary in 5 of the 22 patients.

The importance of patient expectations as a determinant of satisfaction with waiting times for hip and knee replacement surgery

OBJECTIVES The disconfirmation model hypothesizes that satisfaction is a function of a perceived discrepancy from an initial expectation. Our objectives were: (1) to test the disconfirmation model as it applies to patient satisfaction with waiting time (WT) and (2) to build an explanatory model of the determinants of satisfaction with WT for hip and knee replacement. METHODS We mailed 1000 questionnaires to 2 random samples: patients waiting or those who had received a joint replacement within the preceding 3-12 months. We used ordinal logistic regression analysis to build an explanatory model of the determinants of satisfaction. RESULTS Of the 1330 returned surveys, 1240 contained patient satisfaction data. The sample was 57% female; mean age was 70 years (SD 11). Consistent with the disconfirmation model, when their WTs were longer than expected, both waiting (OR 5.77, 95% CI 3.57-9.32) and post-surgery patients (OR 6.57, 95% CI 4.21-10.26) had greater odds of dissatisfaction, adjusting for the other variables in the model. Compared to those who waited 3 months or less, post-surgery patients who waited 6 to 12 months (OR 2.59, 95% CI 1.27-5.27) and over 12 months (OR 3.30, 95% CI 1.65-6.58) had greater odds of being dissatisfied with their waiting time. Patients who felt they were treated unfairly had greater odds of being dissatisfied (OR 4.74, 95% CI 2.60-8.62). CONCLUSIONS In patients on waiting lists and post-surgery for hip and knee replacement, satisfaction with waiting times is related to fulfillment of expectations about waiting, as well as a perception of fairness. Measures to modify expectations and increase perceived fairness, such as informing patients of a realistic WT and communication during the waiting period, may increase satisfaction with WTs.

A bird can't fly on one wing: patient views on waiting for hip and knee replacement surgery.

Objectives  To obtain patients’ perspectives on acceptable waiting times for hip or knee replacement surgery.

Attritional flexor tendon ruptures by an old lunate dislocation

A 76-year-old man sustained attritional disruption of the extrinsic flexor tendons to the ulnar two fingers over 40 years after an untreated palmar lunate dislocation. Spontaneous flexor tendon rupture is rare without wrist joint pathology, even in the absence of chronic pain or median nerve compression.

'There are too many of us to fix.' Patients' views of acceptable waiting times for hip and knee replacement.

Objectives: To assess patients’ views of maximum acceptable waiting times (MAWT) for hip and knee replacement, associated factors and the accuracy of self-reported waiting times. Methods: We mailed 1000 questionnaires each to two random samples of patients either waiting for or who had received an arthroplasty within the preceding 3-12 months. We used linear regression to assess the determinants of patient MAWT, and content analysis to assess reasons for MAWT and ideal waiting time. Results: Of the 1330 responses, 1127 had MAWT data. The sample was 57% women; mean age was 70+11 years. Median self-reported and actual waiting time was eight months (Spearman correlation 5 0.70). Median MAWT was four months and ideal waiting time was two months. The most frequent reasons for MAWT were pain, quality of life and needing time to prepare for surgery. A longer MAWT was associated with younger age, group (waiting), a longer self-reported waiting time, better EQ-5D index, an acceptable waiting time, a perception of fairness and a view that others worse off on the list should go ahead. Conclusions: Patients’ views of acceptable waiting times are important for a fair process of establishing waiting time benchmarks for joint replacement.

Harvesting of the sural nerve with a tendon stripper

The nerve most commonly used for peripheral nerve reconstruction is the sural nerve. The nerve can be dissected free through one long calf incision, by utilizing multiple small incisions, or by using a tendon stripper. We studied 12 above‐knee amputation specimens harvesting the nerve in the ways described. We found that the length of nerve harvested averaged 32, 36, and 25 cm for the open, limited open, and stripper techniques, respectively. Epineurial damage occurred with the stripper, but no perineurial damage was documented histologically. We concluded that the closed method (stripper) of harvesting sural nerve would provide quality graft material, but of unpredictable length. When reliably long segments of nerve are required, at least a limited open or an open approach for harvest is recommended.

Forty degree angled coronal CT scanning of scaphoid fractures through plaster and fiberglass casts

A method for obtaining coronal CT scans angled 40 degrees to the longitudinal axis of the wrist, parallel to the long axis of the scaphoid, is described. Its potential for evaluating scaphoid fractures is assessed in 10 patients with healing or clinically suspected fractures. Overlapping 3 mm thick angled coronal CT scans were obtained for each patient both in and out of cast. The CT images were compared to plain films and tomography. Comparisons were also made of CT images obtained through fiberglass and plaster casts. All fractures apparent by plain films and tomography were apparent by CT; one case suspected of fracture on initial plain films showed no evidence of fracture on CT and subsequent clinical course and plain films. Osseous union of healing fractures was more reliably assessed on CT than on plain films and plain film tomography. There was no degradation of CT images by either fiberglass or plaster casts; fiberglass casts allowed easy planning of tomographic slices from scout films. We conclude that direct 40 degree angled coronal CT examination of the scaphoid is a quick reliable method to detect scaphoid fractures and to assess their healing without the need of cast removal.

Changes in fall risk and functional status in women aged 50 years and older after distal radius fracture: A prospective 1-year follow-up study

Study Design: Prospective cohort study. Introduction: Few studies have evaluated the course of recovery after distal radius fracture (DRF) when functional decline and fracture risk may be affected. Purpose of the Study: The purpose of this study was to determine changes in overall functional status over the first year after a DRF in women aged 50 years and older. Methods: Seventy‐eight women were assessed for balance, balance confidence, lower extremity strength, gait speed, fall history, physical activity levels, and self‐reported wrist pain and function (Patient‐Rated Wrist Evaluation) at weeks 1, 3, 9, 12, 26, and 52 after DRF. Descriptive data were generated for all variables; a 3‐way mixed analysis of variance with repeated measures was used to compare differences between participants aged 50–65 years and 65 years and older. Results: There was a significant improvement in functional status measures for both age categories except single‐leg balance and fast gait speed, from 1 week after fracture extending up to 1 year after fracture (ranging from 6.1% improvement to 25% improvement, P < .05). There was no significant time × age interaction, as both age groups had the same pattern of recovery; however, there was significantly lower functional status in the older group across all time points. Conclusion: Regardless of age, monitoring and addressing functional status including upper limb function, overall strength, balance, confidence, usual gait speed, and physical activity right up to 1 year after fracture is an important consideration for clinicians treating women recovering from DRF. Given the high future fracture risk for these women, identifying functional recovery patterns can help to direct future research and determine preventative strategies. HIGHLIGHTSWomen older than 50 years demonstrate functional improvements over the first year after a distal radius fracture, regardless of whether the women were aged 50–64 or >65 years. A similar pattern of recovery occurs in those aged 50–65 years, compared to those > 65 years, suggesting that both younger and older women do not fully achieve their full potential of functional status until up to 1 year after fracture.Clinically, we know that wrist fractures are the first fracture to occur and are a signal for future fracture risk. The recovery pattern reported in this study prompts a need to address physical function beyond just recovery of wrist strength and range of motion in this early‐phase after fracture.Women older than 65 years demonstrated higher fall risk than women younger than 65 years; however, the similarity in recovery patterns for both groups suggests screening and the identification of declines in functional status is important for both age categories to decrease future risk for falls and fracture.

Falls and Wrist Fracture: Relationship to Women's Functional Status after Age 50

RÉSUMÉ: Après l’âge de cinquante ans, les femmes éprouvent une hausse rapide de l’incidence des fractures du poignet. En conséquence, cette étude vise (1) de déterminer les circonstances internes et environnementaux liés aux chutes entraînant des fractures du poignet, et (2) d’examiner la relation entre l’état fonctionnel et de telles circonstances. Les femmes âgées de 50 à 94 années sont rapportées sur la nature de la blessure (n = 99) et ont subi tests pour l’activité physique, l’équilibre, la force et la mobilité (n = 72). La majorité des chutes causant la fracture d’un poignet a eu lieu à l’extérieur, pendant les mois d’hiver, à la suite d’un glissement ou trébuchement tout en marchant. La moitié de ces chutes a entraîné d’autres blessures, y compris à la tête et au cou, et des traumatismes médullaires. Une vitesse plus rapide de la marche, une force inférieure d’adhérence, et une plus grande confiance en équilibre ont été toutes significativement associées aux chutes à l’extérieure, par comparaison aux chutes, glissades et trébuchements intérieures contre d’autres causes. Cette étude donne un aperçu des mesures de dépistage et de prévention potentielles pour les fractures du poignet liées aux chutes parmi les femmes. ABSTRACT: Women experience a rapid rise in the incidence of wrist fracture after age 50. Accordingly, this study aimed to (1) determine the internal and environmental fall-related circumstances resulting in a wrist fracture, and (2) examine the relationship of functional status to these circumstances. Women aged 50 to 94 years reported on the nature of the injury (n = 99) and underwent testing for physical activity status, balance, strength, and mobility (n = 72). The majority of falls causing wrist fracture occurred outdoors, during winter months, as a result of a slip or trip while walking. Half of these falls resulted in other injuries including head, neck, and spine injuries. Faster walking speed, lower grip strength, and higher balance confidence were significantly associated with outdoor versus indoor falls and slips and trips versus other causes. This study provides insights into potential screening and preventive measures for fall-related wrist fractures in women.