Gregory J. Golladay

Evaluation of cancer information on the Internet

The Internet is a massively expanding body of information, with an estimated 320 million Web pages available. In 1997 an estimated 24 million North Americans used the Internet, and Internet use has been estimated to double each year. Even prior to the advent of the Internet as a source of medical information, patients have become more informed regarding their care, seeking increased amounts of information regarding their diagnoses and primarily wanting more information regarding their treatment options. In the past, these patients would rely heavily on health professionals for this information, through conversations or from pamphlets, videos, or books available to physicians for office distribution. Some resourceful patients may have ventured into medical libraries and some may have navigated through Index Medicus. Even the accessibility of MEDLINE searches in libraries and public institutions provided patients chiefly with peer-reviewed medical articles. We are living in a time of exponential expansion in accessibility to medical information. Data that previously would have required hours of research in a medical library now can be found easily by anyone with access to the Internet. This has enhanced the medical professional’s ability to gain extensive knowledge of research findings from many different medical specialties. However, medical professionals are not the only ones searching the Internet for such information. Our patients have the same capability that we have to research a medical topic thoroughly via the Internet. However, of concern is the quality of this newly gained knowledge. The free flow of information on the Internet permits anyone with good computer skills and a modem to establish a Web site with whatever information they wish to share. In this respect, the Internet becomes the great equalizer: experts, specialists, authorities, professionals, alternative therapy promoters, interested lay people, charlatans, and hucksters all may set up sites containing information regarding specific topics of interest. As physicians, we are concerned whether medical information 381

Cementless acetabular revision with the Harris-Galante porous prosthesis. Results after a minimum of ten years of follow-up.

BACKGROUND Revisions of the acetabular component of a total hip arthroplasty have a higher rate of complications, particularly loosening and dislocation, than do primary procedures. The purpose of this study, in which the results of a consecutive series of revisions performed with the Harris-Galante Porous acetabular component by a single surgeon were evaluated at an average of twelve years, was to quantify the complications and outcomes of acetabular revision. METHODS Clinical and radiographic results were evaluated to assess loosening, lysis, radiolucencies, and trochanteric union in 188 hips (170 patients) treated between 1984 and 1990. One hundred and twenty-two hips in 110 patients were followed for at least ten years, which was required for inclusion in the study. Thirty-one patients (thirty-six hips) died less than ten years postoperatively, and twenty-nine patients (thirty hips) were lost to or refused to return for follow-up. RESULTS The average Harris hip score was 78 points at an average of 12.5 years after revision, which was a 29-point improvement compared with the preoperative score. The rate of repeat revision because of aseptic loosening of the acetabular shell was 4% (five of 122). The rate of repeat revision of the shell for any reason was 15% (eighteen of 122). Eight unrevised sockets were loose radiographically, for a total rate of aseptic loosening of 11% (thirteen of 122). CONCLUSIONS This study demonstrated that most acetabular revisions with this cementless hemispherical socket were successful. Few structural grafts and no cages were used. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Chest wall deformities.

Children present with chest wall deformities to their pediatrician because of physiologic and psychologic causes. We have a 22-year experience in the operative management of more than 300 of these children. Initial evaluation should accurately categorize the deformity, determine the severity, assess for associated problems and refer the child at an appropriate time for further management. Pectus carinatum is the most common deformity that can cause physical pain from an intercostal neuropathy and psychologic pain from the unsightly protuberance. Poland syndrome is managed by early correction of the hand deformity and later correction of the chest wall deformity if necessary for psychologic or functional reasons. Jeune syndrome and failure of sternal fusion may have severe associated cardiopulmonary compromise. Each should be corrected in infancy for the best results.

Autodigestion of a hamstring anterior cruciate ligament autograft following thermal shrinkage. A case report and sentinel of concern.

Thermal and laser heat shrinkage of collagen recently has been proposed as a means of treating selected cases of shoulder instability12. While such treatment is controversial, clinical reports of capsular shrinkage procedures involving the shoulder have shown limited but promising results1,2,9,10. Thermal technology also has been applied to the treatment of anterior cruciate ligament laxity in the knee11. Basic-science investigators have elucidated the macroscopic and molecular changes that occur in the collagen fibrils following thermal shrinkage3-7. However, long-term clinical follow-up to determine the integrity of these structures following thermal shrinkage is still lacking. We present the case of a patient in whom an endoscopic reconstruction of the anterior cruciate ligament was performed with a hamstring autograft, which, following reinjury, underwent thermal shrinkage. The findings at arthroscopy, both during the initial thermal shrinkage and at fifteen weeks postoperatively, are discussed. A sixteen-year-old female athlete sustained an anterior cruciate ligament tear while twisting her left knee during a basketball game. She subsequently underwent an arthroscopically assisted reconstruction of the anterior cruciate ligament with a semitendinosus-gracilis graft and a partial lateral meniscectomy. The graft, a four-bundle construct, was secured to the femur with endobutton fixation (Smith and Nephew, Memphis, Tennessee), and it was secured to the tibia with a soft-tissue interference screw and suture fixation. Following the reconstruction, the intraoperative Lachman test was negative. Postoperatively, the patient followed a regimented, physical-therapist-monitored protocol that included progressive range-of-motion and strengthening exercises. Four months postoperatively, physical examination revealed a negative pivot-shift test and a grade of 1+ (less than five millimeters of side-to-side difference), with a firm end point, on the Lachman test. Evaluation of laxity with a KT-2000 arthrometer (MEDmetric, San Diego, California) revealed that the value on the …

Using the Internet to Enhance Physician-Patient Communication

&NA; The rise in Internet use by patients with musculoskeletal problems has put orthopaedic surgeons under increased pressure to provide Web‐based resources. Patients are researching musculoskeletal conditions online, and many want to communicate electronically with their physicians. Online medical information may be a useful adjunct to traditional physician‐patient interaction because it is readily available, is wide in scope, and can provide the patient with basic knowledge on a given topic. A clinical encounter may then be efficiently spent refining information and answering specific questions. Orthopaedic surgeons should be aware of the advantages of using Internet resources as part of their practice as well as the potential legal and confidentiality pitfalls in electronic communication. Some patient concerns may be easily satisfied and communication enhanced through the use of e‐mail. Physicians planning to incorporate electronic communication with their patients must be prepared to manage unsolicited e‐mail, maintain patient confidentiality, and adopt practices that maximize the use of online resources to enhance patient education.

Current concepts review. Internet resources for orthopaedic surgeons.

The origin of the Internet is credited to the United States Department of Defense7,26, which developed ARPANET (Advanced Research Projects Agency Network) in the 1960s to allow researchers across the country to collaborate reliably with use of linked supercomputers in the event of a nuclear war or another emergency. Stanford University, the University of California at Santa Barbara, the University of Utah, and the University of California at Los Angeles were the first four universities to be connected to ARPANET, by means of telephone lines, in 1969. By 1971, twenty-three institutions were participating. In 1973, the first international connections were made. The first Usenet was founded in 1979, by students at the University of North Carolina and Duke University, as an electronic forum for discussing various topics. The term Internet was coined in 1981. In response to the growing body of relatively unorganized electronic information, the University of Minnesota released Gopher, the first software program for using the Internet, in 1991. Many educational institutions used Gopher to send and retrieve electronic data and communications. Information that was shared with use of Gopher was restricted to text and was presented to the user in a menu format. There were no images or multimedia capabilities. That same year, Tim Berners-Lee, working at the European Council for Nuclear Research (CERN) in Switzerland, developed the World Wide Web, which allowed computers to work together to transfer information more readily. He was able to improve communication between computers by standardizing the program language (hypertext markup language [HTML]) that they used and the way that files were created and stored (with use of hypertext transport protocol [HTTP]). The Web allows the use of software, termed Web browsers, to communicate with Web servers, which are the computers that house the information. The important …

Patient Optimization—Strategies That Work: Malnutrition

BACKGROUND Patient optimization is receiving increasing attention as outcomes monitoring and bundled payments have been introduced in joint arthroplasty. Optimization of nutrition is an important aspect of perioperative management. METHODS This manuscript is a review of previously published material related to nutrition and the impact of malnutrition on surgical outcomes, with guidance for surgeons preparing patients for elective joint arthroplasty. RESULTS Patients with optimized nutritional parameters have fewer complications, especially related to wound healing and infection. CONCLUSION Nutritional assessment and optimization should be a part of the perioperative management of patients undergoing lower extremity arthroplasty.

Orthopaedic information: How to find it fast on the Internet

The Internet is a rapidly expanding source of information that has gained a valued place in the knowledge armamentarium of the orthopaedic surgeon. Access to current knowledge, published literature, and a vast array of academic, federal, and commercial information has changed the information landscape for both orthopaedic surgeons and their patients. It is valuable to highlight readily available information for orthopaedic surgeons to use for continuing medical education, literature updates, patient education materials, and presentations. There are multiple techniques for accessing and organizing orthopaedic information as well as for identifying and using specific, high-quality, frequently updated Internet sources of information.

Depression Moderates the Relationship Between Pain and the Nonmedical Use of Opioid Medication Among Adult Outpatients.

Background:The nonmedical use of prescription medication among US adults is a growing public health problem. Healthcare providers should proactively address this problem in outpatient encounters. Objective:We sought to understand the interactive effects among prescription drugs, pain, and psychiatric symptoms among adult outpatients to build an empirical foundation for comprehensive screening. Methods:We screened 625 adult neurosurgery and orthopedic patients at a suburban satellite clinic of an urban academic medical center. A convenience sample was screened for psychiatric and substance use disorder symptoms using the American Psychiatric Associations recommended screening protocol. We tested whether psychiatric symptoms moderated the relationship between pain level and nonmedical use of prescription medicine. Results:Patients reported average levels of depression, anxiety, and pain symptoms, within 1 standard deviation of the screeners’ normative data. However, patients reported highly elevated levels of nonmedical use of opioids and benzodiazapines compared with national data. Controlling for age, sex, and race, pain level predicted nonprescription use of opioid and benzodiazapine medications. Patients with high levels of depression and pain were more likely to engage in the unprescribed use of opioids. Likewise, patients with reduced levels of depression and pain were protected against the unprescribed use of opioids. Conclusions:These findings highlight the importance of examining unprescribed medication use even with patients at moderate levels of psychiatric symptoms and pain.

Inflammatory demyelinating polyneuropathy after total hip arthroplasty

Inflammatory demyelinating polyneuropathy is a rare but devastating condition. Guillain-Barré syndrome is the most common cause with acute inflammatory demyelinating polyneuropathy being the most common subtype that follows a monophasic course and does not recur. Chronic inflammatory demyelinating polyneuropathy occurs when symptoms persist for greater than 8 weeks. With many proposed etiologies, few reports have described acute inflammatory demyelinating polyneuropathy after total joint arthroplasty. To our knowledge, this is the first case report of chronic inflammatory demyelinating polyneuropathy developing after total hip arthroplasty that was further complicated by dislocation.