James D. Capozzi

Gifts from patients.

T.D. is a sixty-three-year-old woman who fell and fractured her wrist. She underwent a closed reduction and application of a short arm cast. Following removal of the cast, she was enrolled in a physical therapy program. She progressed slowly but eventually did well. Upon completion of treatment, she sent two bottles of wine to her physician. Two weeks later, T.D. made several requests of her physician. Despite nearly normal functioning of the wrist, she asked her doctor to prescribe additional physical therapy and to complete forms that would justify additional time off from work. She also asked for letters supporting suspension of her gym membership and alteration of her vacation plans. Patients often demonstrate their gratitude for the medical care that they have received by bringing gifts to the treating physicians. Usually, these tokens are cards, baked goods, articles of clothing, or handcrafted items—modest items given to physicians as gestures from appreciative patients or their families. As the above scenario illustrates, however, gifts can raise ethical issues of which we need to be aware. The potential problems usually involve the nature of the gift and the expectations of the patient. Certain gifts can create problems in and of themselves. Gifts of an exceedingly personal nature are usually inappropriate. Gifts of intimate items may be inconsistent with the maintenance of the doctor-patient relationship. They can certainly make the treating physician feel uncomfortable and interfere with the requisite boundaries of professionalism. Furthermore, the acceptance of such a gift by the physician may signal a departure from professionalism as well as the professional relationship. Similarly, gifts of excessive monetary value or cash gifts are usually improper. These types of gifts can be interpreted as payoffs or “tips” …

The Prevalence of Diabetes Mellitus and Routine Hemoglobin A1c Screening in Elective Total Joint Arthroplasty Patients

BACKGROUND Diabetes mellitus has been associated with significant perioperative complications in joint arthroplasty. In addition, many patients are unaware of their dysglycemic status, and the prevalence of undiagnosed dysglycemia in joint arthroplasty patients is unknown. METHODS Several years ago, we began routine hemoglobin A1c (HbA1c) level screening in all our patients planning to undergo elective total hip and total knee arthroplasties. We retrospectively reviewed the HbA1c levels in our initial 663 patients. RESULTS Forty-eight percent of these patients were found to be nondiabetic; 19% percent had a previous history of some level of dysglycemia. Most significantly, over one third, 33.6% of these patients were previously undiagnosed dysglycemic patients; 31% were diagnosed as prediabetic and 2.6% as diabetic. CONCLUSION Owing to the high prevalence of prediabetic patients who go on to develop diabetes and to the high correlation of poor glucose control with perioperative complications, we feel that it is imperative to identify this large number of previously undiagnosed dysglycemic patients. We recommend the routine screening of all patients planning to undergo major orthopedic procedures. Likewise, we recommend that identified patients be referred for diabetic counseling. We also recommend that patients with markedly elevated HbA1c levels have their elective surgery postponed until better glycemic control can be achieved.

Examining the Ethical Implications of an Orthopaedic Joint Registry

R.P., a fifty-seven-year-old man, underwent a total hip replacement with a newly designed, cementless hip system. Within the first several months after surgery, he had persistent thigh pain. Radiographs made at one year indicated progressive radiolucent lines surrounding the femoral component. He required revision surgery for aseptic loosening of the femoral component. Several months following the revision, a single journal article indicating a similar problem at another institution with the same device was published. A year later, two additional articles appeared in the literature. One year later, the femoral device originally implanted in R.P. was removed from the market.

Coping with racism in a patient.

B.F. is a sixty-seven-year-old woman who was transferred late one evening from another hospital with an apparent infection at the site of a total knee replacement. The orthopaedic resident on call attempted to evaluate the patient. The residents plan was to perform a history and physical examin

Ethics in Practice. Terminating the Physician-Patient Relationship

A.G. is a thirty-six-year-old reading teacher who presented to an orthopaedic surgeon with patellofemoral pain. After an appropriate evaluation, the physician suggested a course of physical therapy and anti-inflammatory medication. The patient asked for and received time off from her work, stating that her job required her to climb stairs. At multiple follow-up visits, A.G. was found to be poorly compliant with physical therapy and home-exercise programs. Her only interest appeared to be in securing the doctors letter of support for an extended medical leave. At each visit, she demanded that the physician write a letter stating that she was unable to work as a reading teacher due to knee pain. At one point, she became belligerent with the medical office staff when the letter was not prepared. When her physician tried to elicit information about whether there were any unaddressed obstacles to rehabilitation treatment, A.G. did not answer the questions. Instead, she explained that her job required her to climb stairs and that she was unable to return to work because of the continued knee pain. The physician explained that, on the basis of his examination and assessment, he expected that her pain would improve if she complied with the treatment plan. After multiple visits, the orthopaedic surgeon counseled the patient that he did not see that his attempts to help her were providing any benefit and that perhaps it would be best for her to seek help from another physician. A.G. replied that she did not want to start going to another doctor. She stated emphatically that he was her doctor, that she was paying him, and that she wanted a letter saying that she should be granted an extended medical leave from work because of her inability to climb stairs. After this encounter, the surgeon thought it best to terminate the professional relationship.

Professionalism in the Face of Adversity

R.D. is a thirty-four-year-old man who presented to the emergency department after sustaining several deep lacerations to his hand. He underwent an irrigation, debridement, and wound closure procedure and was discharged with pain medication and antibiotics. The patient returned to the emergency department three days postoperatively. He explained that his prescriptions had been stolen at the shelter where he lives. On examination, the bandage on his wounds was soiled and the skin of his injured hand was macerated. After his dressing was changed, R.D. was again discharged with prescriptions for his medications. He returned the following day, again with complaints of pain and wound breakdown. In the emergency department, he was seen picking at his wounds. This time he was admitted to the hospital for observation and the administration of intravenous antibiotics. The following morning, R.D. was found unresponsive and lying on his hospital bathroom floor. It was determined that he had overdosed on narcotics. After the administration of an appropriate dose of naloxone, he was revived. In response to questions, he confided that he had injected himself with heroin. Hospital protocol was initiated: his room was searched, his drug paraphernalia was confiscated, and one-to-one security observation was initiated. Later that day, he signed out of the hospital against medical advice and has since been lost to follow-up. The doctor-patient relationship has been described as a partnership with obligations ascribed to both the physician and the patient1,2. While we may wish for professional relationships that are true partnerships with both parties agreeing on the goals for their interaction and each attending judiciously to an assigned portion of the work, that often is not the case. Despite the best-laid plans of health-care providers, a patient may not only fail to actively participate in the partnership but may, …

Assessing a patient's capacity to refuse treatment

A ninety-four-year-old woman who lived alone fell in her home. She presented to our emergency room with a displaced fracture of the femoral neck. Surgical treatment with hemiarthroplasty was recommended. The patient adamantly refused surgery. The risks and benefits of a hemiarthroplasty were explained, as were the severe limitations and impairments of an untreated hip fracture. She persisted in her refusal. Specific questions answered by the patient indicated that she clearly understood the diagnosis and the proposed treatment plan. However, she believed that she could return to her home with the untreated hip fracture and continue to function independently. Multiple attempts to explain to her that she would be unable to walk, let alone care for herself, were unsuccessful. At this point, her medical attending physician requested a consultation from liaison psychiatry. The psychiatrist decided that the patient had the capacity to refuse hip surgery. Nevertheless, the patient agreed to remain in the hospital. She was admitted to the orthopaedic service and was placed in skin traction pending intervention from social services. Within twenty-four hours, the pain worsened and the patient requested surgical intervention. Patients who have decisional capacity may refuse any treatment, even life-preserving treatment. Physicians are obliged by law and by ethics to respect the treatment refusals of competent patients even if the physician disagrees with those choices or does not share the patients values. Even when the consequences will be dire, a patients choices must be respected, as in the case of the Jehovahs Witness who refused blood transfusions in the face of exsanguination. Society, however, recognizes that from time to time people who are in the grip of fear, depression, or psychosis or who are overwhelmed by difficult circumstances may express preferences that do not reflect the values, commitments, or goals that they usually endorse. Society …

Catastrophic Polyethylene Failure Diagnosed With Magnetic Resonance Imaging in a Painful Total Knee Arthroplasty

Determining the etiology of a painful knee after arthroplasty can be extremely challenging. Traditionally, orthopedists relied mainly on physical examination, laboratory results, serial radiographs, and 3-phase bone or indium-labeled white blood cell scans; however, recent advances in magnetic resonance imaging (MRI) software have given orthopedists another powerful tool in their diagnostic armamentarium. We provide the MRI software modification technique for metallic artifact reduction as well as present a novel case in which MRI was used to diagnose catastrophic polyethylene postfailure in a posterior cruciate ligament substituting knee. Although the role for MRI in the postarthroplasty knee has yet to be clearly defined, its utility in working up a painful arthroplasty when history, physical examination, and other diagnostic utilities fail to provide answers is clearly demonstrated in this case.

Discussing treatment options.

A sixty-year-old man presented to an orthopaedic surgeon with a periprosthetic infection after total knee arthroplasty performed by another surgeon. He underwent removal of the components, placement of an antibiotic spacer, and antibiotic suppression therapy. Eight weeks later, a revision total knee arthroplasty was performed. The patient did well initially but returned four months after the revision with periprosthetic reinfection. The revision components were removed, another antibiotic spacer was placed, and antibiotic suppression therapy was again administered. During the operation, the entire extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, was found to be necrotic and required radical débridement. Five months later, another operation was performed to remove the spacer, and a plastic surgeon was consulted to assist in the wound closure because of the presence of extensive scar tissue. Intraoperative cultures were negative during these two most recent procedures. The orthopaedic surgeon presented the patient with four treatment options: arthrodesis, resection arthroplasty, amputation, or revision total knee arthroplasty with extensor mechanism allograft and a possible flap closure (rotational or free flap). The patient refused a knee arthrodesis and voiced a strong preference for amputation over arthrodesis. The patients first choice, however, was to save the knee and to have a second radical revision performed. The surgeon then discussed in detail the risks that would be involved with reconstruction, including the high risk of reinfection and other wound complications. An infection, he explained, could lead to amputation, sepsis, and death. The surgeon also informed the patient that the procedure was not commonly performed, had no proven success rate, and could be fraught with complications. The patient remained steadfast in his choice and elected to undergo radical reconstruction of the knee.

Primary non-Hodgkin lymphoma of bone: unusual manifestation of lymphoproliferative disease following liver transplantation

Abstract We present the case of a 66-year-old man with primary non-Hodgkin lymphoma of the right femur that developed following orthotopic liver transplant, while on immunosuppressive therapy. The diagnosis was suggested on the basis of the MRI findings and confirmed by open biopsy. He was treated successfully with local radiotherapy and has remained disease free for 14 months after the onset of the disease.