Katheryne Downes

Effects of Acquired Glenoid Bone Defects on Surgical Technique and Clinical Outcomes in Reverse Shoulder Arthroplasty

BACKGROUND Reverse total shoulder arthroplasty is the accepted method of treatment for selected shoulder disorders. The purpose of this study was to compare primary reverse shoulder arthroplasty surgical techniques as well as clinical and radiographic outcomes in patients with acquired glenoid bone defects and in those with normal glenoid morphology. METHODS Preoperative three-dimensional computed tomography scans were performed on 216 shoulders in 211 patients undergoing primary reverse shoulder arthroplasty between 2004 and 2007. The glenoids were classified as normal or abnormal on the basis of preoperative radiographs and three-dimensional reconstructions of the scapula. One hundred and forty-three shoulders had been followed for two years. There were eighty-seven normal and fifty-six abnormal glenoids. The surgical techniques that were compared included bone-grafting and glenosphere selection. The clinical outcomes for the two groups were compared with respect to the American Shoulder and Elbow Surgeons score. RESULTS Surgical technique differed between the groups. All fifty-six glenoids with acquired bone defects had center screw placement along an alternative (scapular spine) centerline. A bone graft was used in twenty-two shoulders with acquired glenoid bone defects compared with none of those with normal glenoid morphology (p = 0.016). Shoulders with glenoid defects were treated with larger glenospheres (36 or 40 mm) more often than those with normal glenoids (p < 0.001). No significant difference was detected between the groups with regard to the preoperative or postoperative American Shoulder and Elbow Surgeons scores. Radiographs did not demonstrate failure or resorption of a glenoid bone graft when present. All outcomes improved significantly postoperatively. There were five complications, and one patient was unsatisfied with the result. CONCLUSIONS Glenoid bone defects, when managed with an alteration of surgical technique, including bone-grafting when indicated, are not a contraindication to reverse total shoulder arthroplasty.

Paradoxical Trends in the Management of Unruptured Cerebral Aneurysms in the United States: Analysis of Nationwide Database Over a 10-Year Period

Background and Purpose— The objective of this study was to characterize demographics, treatments, and outcomes in the management of unruptured cerebral aneurysms in the United States using a national healthcare database. Methods— Clinical data were derived from the Nationwide Inpatient Sample for the years 1997 through 2006. Patients with unruptured cerebral aneurysms were identified using the appropriate International Classification of Diseases, 9th Revision code (437.3). Hospitalizations, length of stay, hospital charges, discharge pattern, age and gender distribution, and nature of intervention were analyzed. A Bureau of Labor statistics tool was used to adjust hospital and national charges for inflation. Population-adjusted rates were calculated using population estimates generated by the US Census Bureau. Results— Over 100 000 records were retrieved for analysis. During the time period studied, there was a 75% increase in the number of hospitalizations associated with unruptured cerebral aneurysms. Inflation adjusted hospital charges increased by 60%, whereas the total national bill increased by 200%. Overall, length of stay decreased by 37% and in-hospital mortality rates decreased by 54%. The increasing number of hospitalizations and total national charges related to inpatient treatment of unruptured aneurysms were significantly associated with endovascular treatment rather than surgical clipping. Conclusions— Despite recent studies suggesting a low risk of rupture of incidentally diagnosed cerebral aneurysms, data from this study suggest an increasing trend of treatment for this entity in the United States. Furthermore, endovascular intervention is now the major driving force behind the increasing overall national charges. Given the current healthcare climate, the impact of these trends warrants discussion and debate.

Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units.

OBJECTIVE To describe neonatal tracheal intubation (TI) performance across five neonatal intensive care units. METHODS This prospective descriptive study was conducted at five level III neonatal intensive care units (NICU) between July 2010 and July 2011. TI performance data were collected using a standardized data collection instrument (provider, procedure, and patient characteristics) and analyzed using descriptive and inferential statistics. The primary outcome of interest was procedural success rate defined as a tube placed in the airway between the vocal cords that could be used to provide ventilation. RESULTS Forty-four percent of 455 TI attempts (203 patients) were successful. Attending physicians and 3rd year neonatal fellows had the highest success rates; 72.2% and 70%, respectively. Pediatric residents had the lowest success rate (20.3%). The median duration of attempts was 30s for residents, 25s for fellows, and 20s for neonatal attending physicians. The most common reasons cited for failure were inability to visualize the vocal cords (25%), patient decompensation (desaturation/bradycardia, 41%) and esophageal TI (19%). The duration of all TI attempts ranged from 5s to 180s and there was no difference between successful and failed attempts. Impending respiratory failure (46.5%) was the most common indication for TI. Patient factors (weight, gestational age, or number of previous TI attempts) were not associated with TI success. CONCLUSIONS Overall TI procedure success rates were poor. Providers with advanced training were more likely to be successful. Patient factors were not associated with TI success.

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis

Introduction and hypothesisThe objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires.MethodsA retrospective chart review was performed on 186 patients with a diagnosis of IC from April 2007 to December 2008. Demographics, history and physical examination, and validated pelvic floor dysfunction questionnaire scores were extracted. The data was evaluated with SPSS for Windows using Spearmans rho, Mann–Whitney, and Kruskal–Wallis statistical analyses.ResultsMyofascial pain was demonstrated in 78.3% of IC patients with at least one myofascial trigger point, and 67.9% of patients had numerous areas of trigger points. Mild correlations were seen with trigger points and scores from the PUF, PFDI-20, and PFIQ-7 questionnaires.ConclusionsMyofascial pain is prevalent among IC patients and positively correlated with pelvic floor dysfunction scores. These findings support evaluation of pelvic floor myofascial pain in IC patients and suggest a possible benefit from pelvic floor therapy.

Dietary consumption triggers in interstitial cystitis/bladder pain syndrome patients.

Objectives: The aim of this study was to survey interstitial cystitis/bladder pain syndrome (IC/BPS) patients with a Web-based questionnaire to determine which consumables (foods, drinks, supplements/spices, and general food categories) truly exacerbate IC/BPS symptoms. Methods: The Interstitial Cystitis Association posted a Web link on its Web site offering its members participation in the Web-based questionnaire from April 2009 to February 2010. Members were asked questions on the effect of 344 different foods, drinks, supplements, condiments/spices, and general food categories on urinary frequency, urgency, and/or pelvic pain symptoms. Members were asked to score symptoms related to consumables on a symptom Likert scale of 0 to 5. Questions on ethnicity, education, symptom duration, seasonal allergies, irritable bowel syndrome, and specific diets were included. Results: There were 598 complete responses to the questionnaire, and 95.8% of the participants answered that certain foods and beverages affected their IC/BPS symptoms. Most items had no effect on symptoms. Items that made symptoms worse were citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C. Only calcium glycerophosphate (Prelief; AK Pharma, Inc, Pleasantville, NJ) and sodium bicarbonate (baking soda) had a trend toward improvement in symptoms. Conclusions: Interstitial cystitis diets do not have to be overly restrictive. It is recommended that patients with IC/BPS avoid citrus fruits, tomatoes, coffee, tea, carbonated and alcoholic beverages, spicy foods, artificial sweeteners, and vitamin C. The use of calcium glycerophosphate and/or sodium bicarbonate before consumption of these trigger consumables may also help reduce sensitivity.

Correlation of subjective and objective measures before and after shoulder arthroplasty.

The degree to which subjective patient-reported measures reflects objective findings or how well subjective and objective measures reflect patient satisfaction is not well established. The purpose of this study was to determine the correlation between such measures before and after shoulder arthroplasty. A group of 174 patients (93 total shoulder arthroplasty and 81 reverse shoulder arthroplasty) were prospectively evaluated pre- and postoperatively (mean follow-up, 49 months) with the following subjective measures: American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 36 (SF-36) summary scores, and patient satisfaction. Objective measures included Biodex isometric strength and videotaped range of motion. The objective measures were combined to derive 1 number representative of the overall shoulder function. All measures improved from their preoperative statuses except the SF-36 physical component summary in patients undergoing revision and the SF-36 mental component summary in patients undergoing primary reverse shoulder arthroplasty. A patient satisfaction score of 5 or more was seen in 89% of patients. Preoperatively, a significant (P<.05) correlation existed between the American Shoulder and Elbow Surgeons and the Simple Shoulder Test (ρ=0.546), American Shoulder and Elbow Surgeons score and SF-36 physical component summary (ρ=0.407), and Simple Shoulder Test and SF-36 physical component summary (ρ=0.479). Objective measures had lower correlations (ρ<0.4) with subjective scores. Postoperatively, the correlation improved among all measures. Patient satisfaction correlated more with subjective than objective measures. Subjective measures had relatively low correlations with objective measures. Improvements in the current measures are necessary to provide evidence-based comparisons of the effectiveness of shoulder arthroplasty.

Paradoxical trends in the management of vestibular schwannoma in the United States

OBJECT Recent natural history studies of vestibular schwannomas (VSs) suggest that most of these tumors do not grow. The impact of these new data on management trends in the US is currently unknown. The aim in the present study was to evaluate current trends in the treatment of VS in the US by analyzing a national cancer database. METHODS The Surveillance, Epidemiology, and End Results Program is a national database maintained by the National Cancer Institute representing 26% of the US population. Data from the database were downloaded using provided software. Cases were isolated based on histology codes and the site code. Data from 2004 to 2007 were included in the analysis. The number of patients undergoing resection was compared with the number treated with beam radiation and observation, based on tumor size. RESULTS Three thousand six hundred fifty cases were identified in the database. Over the study period, management choices for VSs showed a significant change only for tumors with a diameter < 2 cm. In this tumor category, a decrease in resection and an increase in radiation were observed, with observation showing a modest increase but remaining low at an average of 25%. CONCLUSIONS Study data demonstrated a shift in the management of small VSs in the US between 2004 and 2007, with microsurgical removal giving way to radiation treatment and the overall rate for observation remaining low and stable. With recent literature suggesting that the majority of small tumors do not grow, the authors assert that VSs are being overtreated in the US.

The changing face of acoustic neuroma management in the USA: Analysis of the 1998 and 2008 patient surveys from the acoustic neuroma association

Abstract Objective. A recent review of the national cancer center registry Surveillance Epidemiology and End Results (SEER) database revealed that in the United States, 25% of Acoustic Neuromas (AN) are managed with observation. Several articles have questioned the aggressive treatment of these slow growing tumors. Concern has been raised that data from the SEER database might be biased towards treatment as patients who chose observation are less likely to be seen at a cancer center. To try and adjust for this potential bias, we decided to investigate management trends of AN in the United States using patient surveys conducted by the Acoustic Neuroma Association (ANA). Study design. Database review. Methods. Data from the 1998 and 2008 ANA patients surveys were analyzed to detect trends between tumor size and treatment modality. Management trends including observation, microsurgical resection and radiation were examined as well based on tumor size criteria. Results. During this study period, tumor size at diagnosis decreased significantly (1966–1998: 23.8% ≤ 1.5 cm; 1999–2008: 45.3% ≤ 1.5 cm). The use of microsurgery decreased from 92.7% to 53.4%, while the use of radiosurgery/radiotherapy increased from 5% to 24.2% and observation increased to 22.4%. Conclusion. Review of data from the ANA confirmed that radiosurgery, and watch and wait are gaining popularity as treatment options. Regardless of this shift in tumor management, microsurgery continues to be the primary method of treatment across tumor sizes in the United States of America and observation remains the least common management modality.

Osteoporosis and shoulder osteoarthritis: incidence, risk factors, and surgical implications.

BACKGROUND Patients with osteoarthritis undergoing shoulder arthroplasty may suffer from osteoporosis. The purpose of this study was to determine whether computed tomography (CT)-derived Hounsfield unit (HU) measurements correlate with bone mineral density (BMD) and whether these data could predict implant size and fixation choice. MATERIALS AND METHODS The study analyzed preoperative dual energy x-ray absorptiometry and shoulder CT scans for 230 patients who underwent total shoulder arthroplasty. Hip BMD and T scores and HU attenuation in the humerus were correlated. HU cutoff values were developed to aid in differentiating patients whose BMD values were within normal reference ranges from patients with osteopenia or osteoporosis. Risk factors associated with low BMD were correlated, and the effect of BMD on humeral stem size, and fixation method was investigated. RESULTS Significant correlations between HU and hip BMD and T score were identified (P < .001). HU value ranges were identified that may alert the surgeon of metabolic bone disease. Significant correlation (P < 0.05) was found between low BMD and certain osteoporosis risk factors. Age at time of surgery was a predictor of cemented stem fixation (P = .024). Patients with a lower BMD were statistically more likely to receive a larger-diameter humeral stem (P = .016). CONCLUSIONS Orthopedic surgeons may be able to use data obtained from shoulder CT scans to predict the need for larger stem size or cement fixation during shoulder arthroplasty. In combination with the risk factor profile, these data may be useful in predicting the need for an osteoporosis workup and treatment. LEVEL OF EVIDENCE Level III, Study of Nonconsecutive Patients, Diagnostic Study.

Efficacy of temporal lobe surgery for epilepsy in patients with negative MRI for mesial temporal lobe sclerosis

Epilepsy surgery is a successful treatment for refractory temporal lobe epilepsy (TLE). Reports suggest fewer seizure-free outcomes for patients with TLE and who have a negative brain MRI (nMRI) for mesial temporal sclerosis. Data were collected prospectively from patients with nMRI who underwent temporal lobe surgery for TLE characterized by unilateral ictal temporal lobe seizure onset based on a scalp video electroencephalogram or invasive subdural electrode recordings. A total of 86 patients were followed for at least 24 months after surgery. Outcome was evaluated using the Engel classification. Seizure control was obtained by 55% (47/86) of patients (Class [CL]-I), 27% (23/86) showed significant improvement (CL-II) and 19% (16/86) were deemed surgical failures. Shorter duration of epilepsy, later onset of seizures, and ictal theta rhythm (5-7 Hz) were the most significant predictors of postoperative seizure control. Although hypometabolism on positron emission tomography scan and significant memory disparity (>2.5/8) were not significant prognosticators independently, cumulatively they were predictors for favorable outcome.