John D. King

Routine Use of Magnetic Resonance Imaging in Idiopathic Scoliosis Patients Less than Eleven Years of Age

The purpose of this study was to determine the incidence of intraspinal pathology presenting as idiopathic scoliosis in children less than 11 years of age and otherwise neurologically normal. Twenty-six consecutive patients (5 boys, 21 girls) with idiopathic scoliosis measuring at least 15° were studied with magnetic resonance imaging. Five children (19.2%) were diagnosed by magnetic resonance imaging to have Chiari-I malformations with hydromyelia (two patients), syringomelia (one patient), intramedullary tumor (one patient) and terminal lipoma (one patient). Only two of the five patients had left thoracic curves. Intramedullary spinal cord pathology can present as scoliosis without neurologic signs. Scoliosis can be the initial neurologic sign suggesting intraspinal pathology, and magnetic resonance imaging is indicated in routine evaluation of children less than 11 years of age.

Avoiding paraplegia during anterior spinal surgery : The role of somatosensory-evoked potential monitoring with temporary occlusion of segmental spinal arteries

Three patients paraplegic following anterior spinal fusion for congenital kyphoscoliosis were noted to have complete somatosensory evoked potential signal loss shortly after segmental arterial ligations at the apex of their respective kyphosis. This has prompted us to use temporary segmental arterial occlusion with somatosensory evoked potential monitoring prior to ligation during anterior spinal fusion. As a result, we have noted seven additional cases, out of a total of 44 cases monitored in this fashion, in which complete loss of somatosensory evoked potential signals, reversible by release of vascular clips, has occurred. For each of these additional cases the critical segmental arteries were identified and were not ligated, usually resulting in some modifications in the planned surgical procedure, and the patients remained neurologically intact. We recommend temporary segmental arterial occlusion with somatosensory evoked potential monitoring during thoracolumbar anterior spinal fusion to potentially avert ischemic neurologic injury. Based on published data and the experience described herein, this technique should be especially important in anterior spinal fusion for congenital kyphoscoliosis.

The transverse radioulnar branch from the dorsal sensory ulnar nerve: Its clinical and anatomical significance further defined

The anatomy of the dorsal sensory ulnar nerve has been well described, but a transverse branch that innervates the distal radioulnar joint and overlying skin, has not been well delineated. This study, from both an anatomic and clinical perspective, confirms its presence approximately 80% of the time and documents the size, course, and type specificity.

Results of 21 Wagner limb lengthenings in 20 patients.

Roentgenograms and charts were reviewed on 20 patients (average age: 13.2 years) who had 21 Wagner limb lengthenings since 1975. Lengthenings included 15 femora (six acquired, eight congenital, and one fibrous dysplasia), four tibiae, and two humeri (one acquired and one congenital). Average femoral lengthening was 6.6 cm; tibial, 5.9 cm; and humeral, 9.7 cm. Lengthening of femora with congenital shortening (6.5 cm) was nearly the same as femora with acquired shortening (6.8 cm), and 85% of all lengthenings were greater than 5 cm. Humeri were lengthened more than 50%. Seventy-two percent of patients were in the 50th percentile or less of stature; 61% were in the 15th percentile or less of stature. Seventy-five percent had complications, with 65% having more than one major complication: pin tract and superficial infections in 40%; deep infections in 20%. All infections were in femoral lengthenings. Nonunion occurred in two patients (10%), and fracture after plate removal in two patients (10%). Five patients (25%) had nerve palsies, and four of these resolved without treatment. Malunion rate was 20%. Five patients developed joint contractures. Complications did not correlate with amount of lengthening but congenital deformities had a higher incidence of complication. Eleven patients required 19 additional procedures necessitated by the lengthening procedure. Wagner leg lengthening is generally recommended when amputation is only other surgical alternative and a full, complete informed consent is given to the parents and patient.

The factors influencing the decision making of operative treatment for proximal humeral fractures

BACKGROUND The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. METHODS A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. RESULTS Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. CONCLUSION Patient information-older age in particular-is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.

A comparative analysis of Ender's-rod and compression screw and side plate fixation of intertrochanteric fractures of the hip.

The purpose of this study is to compare the results of compression screw fixation and Enders rods in the treatment of intertrochanteric fractures of the hip. A retrospective analysis of 77 cases of both unstable and stable cases of intertrochanteric fractures showed a higher incidence of complications in the Enders group; these included backing out, distal femur fracture, need for a secondary procedure, external rotation deformity, and knee pain. Indications for the use of Enders rods may be found among patients with burns, soft-tissue injuries of the proximal thigh, and patients refusing blood transfusions. Wiring of the distal ends of Enders rods prevents backing out of the rods. Dacron tape has also been successfully used to prevent the distal ends of the rods from backing out in the last six of the 77 cases. The compression hip screw is a preferred treatment of choice in both stable and unstable intertrochanteric fractures.

Does Rewording MRI Reports Improve Patient Understanding and Emotional Response to a Clinical Report

BackgroundDiagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like “tear” can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse.Questions/purposesThe aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive.MethodsOne hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report.ResultsAccording to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports.ConclusionsEmotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.Level of EvidenceLevel II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgeon confidence in an outpatient setting

BackgroundWe have the impression that provider uncertainty arises from either nonspecific pathology or disproportionate symptoms and disability, both of which correlate with symptoms of depression, heightened illness concern, and low patient self-efficacy. This study tested the primary null hypothesis that there is no correlation between provider confidence and patient self-efficacy.MethodsEighty-five patients visiting an orthopedic hand and upper extremity surgeon completed the Pain Self-Efficacy Questionnaire (PSEQ). The surgeon’s confidence in the diagnosis, optimal treatment, expected outcome, and the anticipated satisfaction of the patient and the referring doctor were measured with five questions rated on 5-point Likert scales (Physician Confidence Scale).ResultsOverall physician confidence was high and there was no correlation between the PSEQ score and the Physician Confidence Scale. Provider confidence was significantly lower for nonspecific diagnoses, but there was no significant difference between the mean PSEQ for the 72 patients with a specific diagnosis and the 12 patients with nonspecific diagnoses.ConclusionsPhysician confidence did not relate with self-efficacy in this study.Level of Evidence: Prognostic, level II

Classifications in Brief: Thoracolumbar Injury Classification and Injury Severity Score System

The classification of thoracolumbar injuries remains controversial, and no clear consensus has been reached despite various classification systems being used during the past several decades [9]. Although Böhler [2] introduced his sentinel scheme in 1929, the first published thoracolumbar injury classification in the English literature was byWatsonJones in 1938 [23] . He identified three distinct fracture types: the simple wedge fracture, the comminuted fracture, and the fracture dislocation [16, 23]. In 1949, Nicoll [11] further classified these injuries as anterior wedge fractures, lateral wedge fractures, and isolated neural arch fractures and characterized two basic groups of injury: stable and unstable fractures. He asserted that the fracture gap caused by the comminution of the vertebral body and injury of the posterior ligamentous complex (PLC) could induce instability [11]. In 1970, Holdsworth [5] defined a burst fracture as any vertebral body compression fracture that disrupted the posterior vertebral wall and proposed the first classification based on mechanism of injury. He recognized the importance of the traumatic forces causing distinct fracture patterns, described as flexion, flexion and rotation, extension, and compression. Holdsworth also conceptualized the anterior column as resisting compressive loads and the PLC resisting tensile forces acting as a tension band [5]. Kelly andWhitesides [8] formally presented the two-column concept in 1968, whereby the entire vertebral body and intervertebral disc were considered as the anterior column, and the posterior column comprised the neural arch and PLC. With the development of CT spine imaging, Denis [4] proposed the three-column theory of spinal stability in 1983. He introduced the concept of themiddle column between the PLC and the anterior longitudinal ligament. This middle column comprised the posterior wall of the vertebral body, the posterior longitudinal ligament, and posterior annulus fibrosus [4]. Denis further classified major spinal injuries into four different categories: compression, burst, seatbelttype injuries, and fracture-dislocations. In 1994, Magerl et al. [10] divided fractures into three types based on major external forces placed on the vertebral body (compression, distraction, and rotation). They reported the AO classification using the 3-3-3 principle that divides thoracolumbar injury into a total of 53 fracture groups [10]. In the 3-3-3 classification system each type is further subdivided into three additional groups, and these groups are each separated yet again into three more subgroups with specifications, or even further as required. In 2005, Vaccaro et al. [21] introduced the Thoracolumbar Injury Severity Score (TLISS), a scoring system that focused on injury mechanism rather than Each author certifies that neither he, nor any member of his immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at the University of Kentucky, Lexington, KY, USA.