Robert B. Greer

Assessment of the risk of vertebral fracture in menopausal women.

The decision to institute prophylaxis in women with menopausal osteopenia is hampered by the absence of quantitative criteria for appraising the risk of fracture in the individual. We have developed standards for assessing the risk of fracture by relating the prevalence of atraumatic vertebral compression fractures to bone density in sixty-five menopausal women, forty-nine to ninety-two years old. To define the upper limit of the spectrum of bone density, we also studied thirty-one young women, seventeen to twenty-two years old. The density of trabecular bone in a vertebral body was determined by quantitative computed tomography and expressed in terms of milligrams per milliliter of dipotassium hydrogen phosphate. Twenty-five of the menopausal women exhibited at least one fracture (range, one to six fractures), and forty had no fracture. The bone density ranged from -9 to sixty-nine milligrams per milliliter in those with fractures and from twelve to 122 milligrams per milliliter in those without a fracture. The densities in the young women averaged 173 milligrams per milliliter and ranged from ninety-five to 248 milligrams per milliliter. The percentage of subjects with fractures increased as the bone density decreased. It was zero per cent in women with a density of seventy milligrams per milliliter or more, 38 per cent in women with a density between fifty and less than seventy milligrams per milliliter, 71 per cent in those with a density between thirty and less than fifty milligrams per milliliter, and 82 per cent in women with a density of less than thirty milligrams per milliliter.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Procedures in Primary Eye Care

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Total knee arthroplasty using the kinematic rotating hinge prosthesis.

Patients receiving a Kinematic Rotating Hinge total knee prosthesis with a 25-month minimum follow up were reviewed. A total of 46 patients and 54 knees were included in the study. A detailed clinical assessment was available on 38 knees. Twenty of these knees had primary arthroplasties performed with the Kinematic Rotating Hinge prosthesis and 18 knees had revision arthroplasty. Ninety-five percent of primary knees and 83% of revision knees caused no or mild pain postoperatively. Using the Brigham and Womens Hospital and Harvard Medical School knee rating system, 80% of primary knees and 61% of revision knees were rated as good to excellent. Using the criteria defined in this article, 90% of primary knees and 83% of revision knees were labeled as having a satisfactory result. Forty-five percent of primary components and 52% of revision components demonstrated lucent lines on radiographic review. Seven percent of primary knees and 20% of revision knees showed evidence of aseptic lucency progression in one or more zones. No radiographic evidence of aseptic loosening was noted in this review. Documented sepsis occurred in one primary knee and two revision knees. Patellar instability occurred in 21% of primary knees and 36% of revision knees, representing the major complication. The Kinematic Rotating Hinge prosthesis is intended for use in arthroplasty cases where there is functional absence of collateral ligament stability. This review suggests that a high percentage of satisfactory clinical results can be achieved with this prosthesis with long-term radiographic stability.

A critical analysis of quadriceps function after femoral shaft fracture in adults.

The surgical goals for treating proximal tibial fractures are to restore articular congruity, the mechanical axis, and knee motion while avoiding soft-tissue complications. The fracture pattern should be correctly identified and understood. For fractures with minimal intra-articular extension, fracture fixation with an intramedullary nail can decrease the risk of infection because it uses a small incision that is not placed directly over the injured soft tissue, and it provides better axial load sharing than a plate. Using the semi-extended technique, choosing the correct starting portal, incorporating blocking screws or stability screws into the fixation construct, and using mini-open reduction and internal fixation of the fracture will help achieve the goals of fracture fixation with an intramedullary nail. All proximal tibial fractures can be treated successfully with a plate or multiple plates. When a plate is used, the surgical approach and technique should minimize soft-tissue damage and account for future surgical procedures that may be needed. Fractures with intra-articular involvement and/or comminution of the medial metaphyseal region are appropriately treated with dual plating. Extra-articular fractures without major medial comminution may be treated with a locked lateral plate. Final union rates for patients treated with either intramedullary nail or plate fixation are reported at 96% and 97%, respectively. A prospective, randomized, multicenter study is currently in progress to further clarify and advance the treatment of proximal tibial fractures.The surgical goals for treating proximal tibial fractures are to restore articular congruity, the mechanical axis, and knee motion while avoiding soft-tissue complications.The fracture pattern should be correctly identified and understood. For fractures with minimal intra-articular extension, fracture fixation with an intramedullary nail can decrease the risk of infection because it uses a small incision that is not placed directly over the injured soft tissue, and it provides better axial load sharing than a plate. Using the semiextended technique, choosing the correct starting portal, incorporating blocking screws or stability screws into the fixation construct, and using mini-open reduction and internal fixation of the fracture will help achieve the goals of fracture fixation with an intramedullary nail. All proximal tibial fractures can be treated successfully with a plate or multiple plates.When a plate is used, the surgical approach and technique should minimize soft-tissue damage and account for future surgical procedures that may be needed. Fractures with intra-articular involvement and/or comminution of the medial metaphyseal region are appropriately treated with dual plating. Extra-articular fractures without major medial comminution may be treated with a locked lateral plate. Final union rates for patients treated with either intramedullary nail or plate fixation are reported at 96% and 97%, respectively. A prospective, randomized, multicenter study is currently in progress to further clarify and advance the treatment of proximal tibial fractures.

The effect of endogenous estrogen fluctuation on metabolism of 25-hydroxyvitamin D

SummaryTo test the hypothesis that estrogen modulates the metabolism of 25-hydroxyvitamin D (25(OH)D) to 1,25-dihydroxyvitamin D (1,25(OH)2D) and 24, 25-dihydroxyvitamin D (24, 25(OH)2D), we studied 20 normal premenopausal women at four consecutive weekly intervals during one menstrual cycle. Estrogen stimulation was semiquantitatively defined into baseline, lowgrade, or medium-grade categories, based on endogenous estrone and estradiol concentrations. 1,25(OH)2D increased incrementally from baseline levels of 34±3(SE) pg/ml to 39±3 pg/ml (P=0.2) with low-grade estrogen stimulation and to 43±3 pg/ml (P<0.05) with medium-grade estrogen stimulation, while 25(OH)D, 24,25(OH)2D, vitamin D binding protein, parathyroid hormone, calcium, and phosphate did not change. 24,25(OH)2D was correlated to 25(OH)D at baseline (r=0.65,P<0.01) and with low-grade estrogen stimulation (r=0.062,P<0.01), but not with medium-grade stimulation (r=0.13); these relationships are consistent with the concepts that 25(OH)D is metabolized predominantly to 24,25(OH)2D at low estrogen levels, but not at higher estrogen levels. We conclude that endogenous estrogen elevation promotes formation of 1,25(OH)2D from 25(OH)D, and that it may reciprocally inhibit synthesis of 24,25(OH)2D.

Threaded acetabular components for primary and revision total hip arthroplasty

A clinical and radiographic review of 48 total hip arthroplasty patients with threaded acetabular components was undertaken at 24-44 months of follow-up study. Twenty-five patients had primary hip arthroplasties and 23 had revision procedures. Clinical scores revealed good to excellent results in 60% of primary and 30% of revision procedures. Radiographic analysis revealed stable acetabular components in 88% of primary and 61% of revision procedures. Potentially loose acetabular components were noted in 8% of primary and 4.3% of revision procedures and loose acetabular components in 4% of primary and 34.7% of revision procedures. The rate of acetabular component loosening was considered unacceptably high in revision cases and an area of concern in primary cases. Discretionary use of these components is advised.

Open and arthroscopic synovectomy in hemophilic arthropathy of the knee.

Open and arthroscopic synovectomies of the knee in patients with classic hemophilia were evaluated with regard to effectiveness in reducing bleeding episodes, the effect on range of motion (ROM), and roentgenographic progression of hemophilic arthropathy. Eleven patients underwent 13 synovectomies (eight open, five arthroscopic). The average follow-up periods were 7.9 years and 2.2 years for the open and arthroscopic groups, respectively. Both procedures significantly reduced recurrent hemarthroses. Knee ROM in the open synovectomy group was decreased or unchanged in 75% and minimally increased in 25%, whereas there was an increased in 80% and a decrease in 20% of the knees in the arthroscopic group. Furthermore, 62.5% of the knees required manipulation to improve ROM in the open synovectomy group, versus 0% in the arthroscopic group. Hemophilic arthropathy progressed in most knees in both groups. The arthroscopic group had a longer operative procedure (122 versus 59 minutes), but required less hospitalization (9.4 versus 23.1 days) and 25.6% less Factor VIII replacement. Both techniques reduce hemarthroses. There is usually a net loss of ROM with the open versus a net gain with the arthroscopic procedure, and roentgenographic progression hemophilic arthropathy is slowed but not halted after synovectomy.

Management strategy for prevention of avascular necrosis during treatment of congenital dislocation of the hip.

We retrospectively analyzed the cases of fifty children with unilateral congenital dislocation of the hip in an attempt to determine what factors in treatment were associated with the prevention of avascular necrosis of the femoral head. All children were less than thirty-six months old at the initiation of treatment, had no other anomalies, had their entire treatment rendered at the same institution, and were followed for at least one year after reduction. Avascular necrosis occurred in 36% of the patients; in all cases definite roentgenographic signs were apparent within twelve months of reduction. No patient whose hip had grown normally during the first twelve months after reduction later had avascular necrosis. The management strategy for congenital dislocation of the hip in the child who is less than thirty-six months old should include a minimum two-week period of traction until achievement of the +2 traction station and immobilization in the so-called human position following reduction. Skeletal traction, gradually increased over several weeks to an average of 39% of body weight, usually was required to attain the +2 station. Observation of these principles should decrease the incidence of avascular necrosis and increase the probability of obtaining a normal hip.

The Berkeley Rudimentary Vision Test.

Purpose. Very poor visual acuity often cannot be measured with letter charts even at close viewing distances. The Berkeley Rudimentary Vision Test (BRVT) was developed as a simple test to extend the range of visual acuity measurement beyond the limits of letter charts by systematically simplifying the visual task and using close viewing distances to achieve large angular sizes. The test has three pairs of hinged cards, 25 cm square. One card-pair has four Single Tumbling E (STE) optotypes at sizes 100 M, 63 M, 40 M, and 25 M. Another card-pair has four Grating Acuity (GA) targets at sizes 200 M, 125 M, 80 M, and 50 M. The third card-pair has a test of White Field Projection (WFP) and a test of Black White Discrimination (BWD). As a demonstration of feasibility, a population of subjects with severe visual impairment was tested with the BRVT. Methods. Adults with severe visual impairments from a wide variety of causes were recruited from three different rehabilitation programs. Vision measurements were made on 54 eyes from 37 subjects; test administration times were measured. Results. For this population, letter chart visual acuity could be measured on 24 eyes. Measurements of visual acuity for STE targets were made for 18 eyes and with GA targets, for two eyes. Five eyes had WFP, and one had BWD. Four had light perception only. The median testing time with the BRVT was 2.5 min. Discussion. The BRVT extends the range of visual acuity up to logMAR = 2.60 (20/8000) for STEs, to logMAR = 2.90 (20/16,000) for gratings and includes the WFP and BWD tests. Conclusions. The BRVT is a simple and efficient test of spatial vision that, with 13 increments, extends the range of measurement from the limits of the letter chart up to light perception.

Interaction between parathyroid hormone and endogenous estrogen in normal women

It has been hypothesized that estrogens conserve bone substance by blocking the resorbing effect of parathyroid hormone (PTH). We evaluated this hypothesis by examining the relation of circulating PTH to endogenous estrogen fluctuation during four quarters of a single menstrual cycle in 20 normal women. The hypothesis predicts that PTH should vary directly with estrogen, since PTH should increase following estrogen elevation to satisfy physiologic demands for calcium. Contrary to the predicted direct variation, PTH remained constant throughout the menstrual cycle despite sharply fluctuating estrogen levels. Furthermore, PTH was negatively associated with estrone during the early follicular (r = -.65, P less than 0.005) and late follicular (r = -.84, P less than 0.0001) phases. We attempted to determine whether this unexpected relationship between estrone and PTH signified a direct physiologic link, by excluding factors which could have spuriously engendered the inverse correlation. Stepwise multiple regression and partial correlation showed that estrone contributed significantly to circulating PTH independent of the effects of dietary calcium, 25-hydroxyvitamin D, serum calcium, 1,25-dihydroxyvitamin D, phosphate, estradiol, progesterone, and body weight. Therefore, it is possible that the inverse correlation between estrone and PTH signified a direct physiologic link, as an artifactual cause for the relationship could not be identified. These data imply that estrone interacts with PTH, but not by blocking PTH-mediated bone resorption. We conclude that estrone is associated with reduced circulating PTH through an as yet undetermined mechanism.