Mary Lou V. H. Greenfield

Autogenous iliac crest bone graft: Complications and functional assessment

Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decrease with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.

Association Between the Menstrual Cycle and Anterior Cruciate Ligament Injuries in Female Athletes

Anterior cruciate ligament injury rates are four to eight times higher in women than in men. Because of estrogens direct effect on collagen metabolism and behavior and because neuromuscular performance varies during the menstrual cycle, it is logical to question the menstrual cycles effect on knee injury rates. Of 40 consecutive female athletes with acute anterior cruciate ligament injuries (less than 3 months), 28 (average age, 23 11 years) met the study criteria of regular menstrual periods and noncontact injury. Details concerning mechanism of injury, menstrual cycle, contraceptive use, and previous injury history were collected. A chi-square test was used to compute observed and expected frequencies of anterior cruciate ligament injury based on three different phases of the menstrual cycle: follicular (days 1 to 9), ovulatory (days 10 to 14), and luteal (day 15 to end of cycle). A significant statistical association was found between the stage of the menstrual cycle and the likelihood for an anterior cruciate ligament injury (P 0.03). In particular, there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. These hormones may be a factor in the knee ligament injury dilemma in women.

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

Anterior cruciate ligament injuries in the female athlete. Potential risk factors

In the general population, an estimated one in 3000 individuals sustains an anterior cruciate ligament injury per year in the United States, corresponding to an overall injury rate of approximately 100,000 injuries annually. This national estimate is low for women because anterior cruciate ligament injury rates are reported to be two to eight times higher in women than in men participating in the same sports, presenting a sizable health problem. With the growing participation of women in athletics and the debilitating nature of anterior cruciate ligament injuries, a better understanding of mechanisms of injury in women sustaining anterior cruciate ligament injuries is essential. Published studies strongly support noncontact mechanisms for anterior cruciate ligament tears in women, which make these injuries even more perplexing. Speculation on the possible etiology of anterior cruciate ligament injuries in women has centered on anatomic differences, joint laxity, hormones, and training techniques. Investigators have not agreed on causal factors for this injury, but they have started to profile the type of athlete who is at risk. In the current study the most recent scientific studies of intrinsic and extrinsic risk factors thought to be contributing to the high rate of female anterior cruciate ligament injuries will be reviewed, important differences will be highlighted, and recommendations proposed to alleviate or minimize these risk factors among female athletes will be reported where appropriate.

The epidemiology of bilateral slipped capital femoral epiphysis. A study of children in Michigan

The records of 224 children who had a slipped capital femoral epiphysis and who had no underlying metabolic or endocrine disorder were studied retrospectively to investigate the epidemiology of bilateral slipped capital femoral epiphysis. Eighty-two (37 per cent) of the 224 children (fifty-one boys and thirty-one girls) had a bilateral slip. Sixty-four of these children were black and eighteen were white. The age at the time of the diagnosis of the first slip was 13 +/- 1.7 years (mean and standard deviation), the duration of the symptoms was 5 +/- 5.0 months, and the angle of the slip was 26 +/- 16 degrees. Obese children were younger at the time of the diagnosis of the first slip (12 +/- 1.6 compared with 13 +/- 1.6 years for the children who were not obese, p = 0.001). The diagnosis of a slipped capital femoral epiphysis was made simultaneously in both hips in forty-one children and sequentially in forty-one children. Compared with the children in whom both hips were diagnosed simultaneously, the children in whom the hips were diagnosed sequentially had had a shorter duration of the symptoms before the diagnosis of the first slip (3 +/- 2.4 compared with 7 +/- 5.9 months, p = 0.0003), were younger at the time of the diagnosis of the first slip (12 +/- 1.9 compared with 13 +/- 1.2 years, p = 0.001), and tended to be more obese (p = 0.025). In 88 per cent of the patients who had sequential slips, the second slip was diagnosed within eighteen months after the diagnosis of the first slip.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic versus open carpal tunnel release: a cost-effectiveness analysis.

&NA; Endoscopic carpal tunnel release is a controversial procedure used in the treatment of carpal tunnel syndrome. Although endoscopic carpal tunnel release is associated with less incisional pain and faster recovery time than the open carpal tunnel release, opponents of endoscopic carpal tunnel release suggest that its benefits are outweighed by its higher complication rates from median nerve transection and transient numbness of the fingers. Because of the huge economic and social impact of carpal tunnel syndrome in this country, we performed a cost‐effectiveness analysis comparing endoscopic carpal tunnel release and open carpal tunnel release using guidelines established by the Panel on Cost‐Effectiveness in Health and Medicine of the U.S. Public Health Service. A decision analytic model was used to measure differences in cost and effectiveness—expressed as quality‐adjusted life‐years (QALYs)—between endoscopic carpal tunnel release and open carpal tunnel release. The societal perspective was chosen, and probabilities for various outcomes for the two procedures were obtained from published randomized‐controlled trials. Cost data were derived from the Medicare Resource‐Based Relative Value Units published in the Federal Register. QALYs were obtained from two groups of health care providers using a utility‐assessment questionnaire. Using probabilities for various outcomes from the two published randomized‐controlled trials comparing endoscopic carpal tunnel release and open carpal tunnel release, we constructed a decision tree to derive both the cost and the QALYs for the two procedures. The incremental cost difference between endoscopic carpal tunnel release and open carpal tunnel release was

The role of melatonin in the pathogenesis of adolescent idiopathic scoliosis

46, using Medicare cost and probabilities of various outcomes derived from a study by Brown et al. in 1993. We calculated QALYs for five age groups—25, 35, 45, 55, 65—assuming a life expectancy of 75 years. The marginal effectiveness (QALY of endoscopic carpal tunnel release minus QALY of open carpal tunnel release) ranged from 0.235 QALY for the 25‐year‐old age group to 0.066 QALY for the 65‐year‐old age group, giving a cost‐effectiveness ratio of

Prospective analysis of ice hockey injuries at the Junior A level over the course of one season

195/QALY and

A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement

693/QALY, respectively. When compared with other accepted medical interventions such as breast cancer screening (

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials.

4836/QALY) and exercise to prevent coronary heart disease (