William H. Replogle

Allograft Anterior Cruciate Ligament Reconstruction in the Young, Active Patient: Tegner Activity Level and Failure Rate

PURPOSE The purpose was to analyze outcomes of nonirradiated, fresh-frozen bone-patellar tendon-bone (BPTB) allograft anterior cruciate ligament (ACL) reconstruction in patients aged under 40 years with regard to activity level (Tegner score). METHODS Between 1993 and 2005, 111 patients, aged under 40 years, underwent primary, nonirradiated, fresh-frozen BPTB allograft ACL reconstruction and were retrospectively reviewed. Follow-up was limited to a minimum of 24 months. Patients with concomitant ligament injuries and previous surgeries were excluded. Seventy-eight patients met the inclusion criterion and were available for follow-up. Four hundred eleven patients had BPTB autograft ACL reconstructions and comprised the control group. Failure of the graft was defined as repeat ACL reconstruction because of reinjury or graft failure, 2+ Lachman (no endpoint), any pivot shift, and/or 5-mm side-to-side KT-1000 difference (MEDmetric, San Diego, CA) or greater. Initial examinations, surgical findings, and follow-up examinations were prospectively entered into a computerized relational database. The results were assessed by both objective and subjective measures. RESULTS High-activity allograft patients had a 2.6- to 4.2-fold increase in the probability of graft failure compared with low-activity BPTB allograft patients and low- and high-activity BPTB autograft patients. Patients undergoing BPTB autograft reconstruction reported significantly fewer problems on a visual analog scale and scored significantly higher on the postoperative Tegner activity scale than patients undergoing allograft reconstruction. CONCLUSIONS The active allograft group is 2.6 to 4.2 times more likely to fail compared with low-activity allografts and low- and high-activity autografts. We conclude that fresh-frozen BPTB allografts should not be used in young patients who have a high Tegner activity score because of their higher risk of failure. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Anterior Cruciate Ligament Graft Failure A Comparison of Graft Type Based on Age and Tegner Activity Level

Background: When reviewing anterior cruciate ligament instability, age, gender, activity level, associated injury, and type of graft should all be considered. Hypothesis: The authors hypothesized that patients under 25 years of age will have higher failure rates with anterior cruciate ligament reconstruction than those older than 25 years, and that in the patients younger than 25 years, bone–patellar tendon–bone autograft will have the lowest failure rate. Study Design: Cohort study; Level of evidence, 3. Methods: With use of a computerized relational database, all patients having primary anterior cruciate ligament reconstruction at 1 institution between January 2000 and July 2007 with allograft, bone–patellar tendon–bone, and hamstring grafts were evaluated. Results: A significant association was found between age group and graft failure (P = .012). Patients 25 years and younger had a significantly higher failure rate (16.5%) than patients older than 25 years (8.3%). Pairwise comparisons indicated that both allograft (29.2%) and semitendinosus/gracilis (25.0%) grafts resulted in significantly higher failure rates than bone–patellar tendon–bone grafts (11.8%) in the age group of patients 25 years and younger. Conclusion: Autograft hamstrings and allografts had a significantly higher failure rate in the age group of patients 25 years and younger compared with the bone–patellar tendon–bone autograft. These data suggest that bone–patellar tendon–bone autografts may be a better graft source for young, active individuals.

Age, Graft Size, and Tegner Activity Level as Predictors of Failure in Anterior Cruciate Ligament Reconstruction With Hamstring Autograft

Background: Patient age, Tegner activity level, and graft size could be factors that influence the outcome of anterior cruciate ligament reconstruction (ACLR) with hamstring autografts. Hypothesis: Decreased graft size, higher Tegner activity score, and younger age are associated with an increased failure rate of ACLR, represented by continued knee laxity and revision surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 98 patients who had undergone ACLR with hamstring tendon autografts between 2000 and 2007 were identified from a computerized relational database. Inclusion criteria consisted of a minimum of 2 years of follow-up, all age groups, and all activity levels. Exclusion criteria consisted of treatment with other grafts or previous ligament surgery, previous ACL repairs, bilateral ACL injuries, and associated ligament tears. Failure was defined as a 2+ Lachman result, positive pivot shift, and 5-mm difference or more on KT-1000 arthrometer measurement. Results: Fifteen of the 98 ACLRs (15.3%) were defined as failures. Of the failures, 12 of 48 (25%) occurred in patients aged 25 years and younger, whereas 3 of 50 (6%) occurred in patients older than 25 years. There was a statistically significant association when comparing failure rate and age groups (P = .009); however, a significant association was not found between graft size and failure rate in the entire study population (P = .135) or within the different age groups (age ≤25 years vs >25 years) based on failure rate (P = .390 and P = .165, respectively). No statistical significance was found when Tegner activity level and failure rate were compared in the overall study population (P = .463) or within age groups (≤25 years, P = .707; >25 years, P = .174). Conclusion: In this study population, younger patients (≤25 years) demonstrated a higher failure rate compared with the over-25 age group. A statistically significant difference was not found in terms of graft size and activity level correlating with failure rate in ACL reconstruction with hamstring autograft.

Endoscopic-assisted adenoidectomy.

Adenoidectomy is a commonly performed procedure. The advent of endoscopic sinus surgery has Popularized the use of endoscopes. Endoscopic-assisted adenoidectomy (EAA) is a natural progression of this technology to allow a more complete adenoidectomy. Two hundred thirty-six patients undergoing adenoidectomy were evaluated with an endoscopic technique. A routine transoral adenoidectomy was performed first. Then a 4-mm 0° telescope was used transnasally, and residual adenoid tissue was removed from the anterior superior nasopharynx. Invariably, residual adenoid tissue was found after transoral adenoidectomy. The EAA technique is minimally invasive, adds less than 5 minutes to the procedure, and is not associated with excessive bleeding. Readily available telescope and endoscopic equipment is used. The EAA technique is advocated for use as an adjunct to a more complete adenoidectomy.

A randomized trial of the effect of prayer on depression and anxiety.

Objective: To investigate the effect of direct contact person-to-person prayer on depression, anxiety, positive emotions, and salivary cortisol levels. Design, Setting, and Participants: Cross-over clinical trial with depression or anxiety conducted in an office setting. Following randomization to the prayer intervention or control groups, subjects (95% women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, Daily Spiritual Experiences Scale, and underwent measurement of cortisol levels. Individuals in the direct person-to-person prayer contact intervention group received six weekly 1–hour prayer sessions while those in the control group received none. Rating scales and cortisol levels were repeated for both groups after completion of the prayer sessions, and a month later. ANOVAs were used to compare pre- and post-prayer measures for each group. Results: At the completion of the trial, participants receiving the prayer intervention showed significant improvement of depression and anxiety, as well as increases of daily spiritual experiences and optimism compared to controls (p < 0.01 in all cases). Subjects in the prayer group maintained these significant improvements (p < 0.01 in all cases) for a duration of at least 1 month after the final prayer session. Participants in the control group did not show significant changes during the study. Cortisol levels did not differ significantly between intervention and control groups, or between pre- and post-prayer conditions. Conclusions: Direct contact person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

The Effect of Prayer on Depression and Anxiety: Maintenance of Positive Influence One Year after Prayer Intervention

Objective: To investigate whether the effect of direct contact person-to-person prayer on depression, anxiety, and positive emotions is maintained after 1 year. Design, Setting, and Participants: One-year follow-up of subjects with depression and anxiety who had undergone prayer intervention consisting of six weekly 1-hour prayer sessions conducted in an office setting. Subjects (44 women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, and Daily Spiritual Experiences Scale after finishing a series of six prayer sessions and then again a month later in an initial study. The current study reassessed those subjects with the same measures 1 year later. One-way repeated measures ANOVAs were used to compare findings pre-prayer, immediately following the six prayer sessions, and 1 month and again 1 year following prayer interventions. Results: Evaluations post-prayer at 1 month and 1 year showed significantly less depression and anxiety, more optimism, and greater levels of spiritual experience than did the baseline (pre-prayer) measures (p < 0.01 in all cases). Conclusions: Subjects maintained significant improvements for a duration of at least 1 year after the final prayer session. Direct person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

Facial Nerve in Parotidectomy: A Topographical Analysis

Objective: Establish normative data concerning parotidectomy and facial nerve dissection and determine the relationship between the length of the facial nerve dissected during parotidectomy and subsequent facial nerve paresis.

Personal breast-feeding behaviors of female physicians in Mississippi.

Background In this study, we examined the personal breast-feeding behaviors of female physicians in Mississippi. Method Two hundred fifteen of 350 female physicians responded to a survey inquiring of their personal breast-feeding behaviors. Results One hundred fifty-five mothers (74%) reported having biologic children, and 146 (94.2%) breast-fed at least 1 child. Approximately 21% of the responding mothers breast-fed their first-born children for at least 6 months. There was a positive relationship between the duration of breast-feeding of older children and the breast-feeding duration for younger children. The major reasons for weaning were return to work, diminishing milk supply, and lack of time to pump breast milk. Conclusion The breast-feeding initiation rates among female physicians surpassed those of women in the general population, yet duration rates were comparable. Their own breast-feeding success might enhance the potential of female physicians as advocates and sources of credible information regarding breast-feeding; however, physicians need to be better educated regarding the management of breast-feeding.

Improving Influenza Vaccination Rates by Targeting Individuals not Seeking Early Seasonal Vaccination

BACKGROUND Influenza morbidity and mortality remain high in the United States although vaccination clearly improves health outcomes and reduces health expenditures. This study was designed to assess the effectiveness of mail and telephone reminder strategies on improving existing clinic influenza vaccination rates among those not seeking early seasonal vaccination. METHODS In mid-November, we randomized 1371 patients at a hypertension clinic into 1 of 2 intervention groups, a mail reminder group (letter plus the Centers for Disease Control [CDC] Influenza Vaccine Information Statement) or a phone reminder group (same information via a personal phone call), or a control group. The following spring, records were reviewed for vaccination documentation. Patients without documentation were contacted by phone to identify whether vaccination for the current season had been obtained. RESULTS The final analysis included 884 patients (62% women, mean age 57.2 years old): 325 in the mail reminder group, 246 in the phone reminder group, and 313 represented the control group. Overall, 388 of these patients (44%) were vaccinated. Vaccination rates were significantly higher in the intervention groups, 46% for the mail reminder group (age and sex adjusted odds ratio [OR], 1.8, 95% confidence interval [CI], 1.3-2.5; P=.001) and 56% for the phone reminder group (OR, 2.8; 95% CI, 1.9-4.0; P<.0001), compared to 33% in the control group. Both interventions increased vaccination rates in all age/sex groups. CONCLUSION In contrast to earlier studies, this intervention occurred later in the influenza vaccination period excluding those who seek early vaccination and allowing interventions to target those less likely to receive vaccination. Compared to previous studies demonstrating only trivial or modest benefits, both mail and phone reminders effectively increased clinic vaccination rates in our group of patients.

Fine-Needle Aspiration: Survey of Clinical Utility:

OBJECTIVES: The goal was to determine the features of clinical usage of fine-needle aspiration (FNA) in this country in terms of utilization, indications, and practice and demographic characteristics of those who use FNA. STUDY DESIGN: A survey was mailed to otolaryngologist-head and neck surgeons (OTO-HNSs) in the United States. The results were totaled and analyzed for indications for FNA performance, practice setting, age, and geographic location of practitioners. RESULTS: The most common indications for use of FNA were in the diagnoses of neck, thyroid, salivary, and other masses in the head and neck. In the survey group the average number of FNAs performed per month was 4.7 per respondent practitioner. FNA was statistically related to age (older physicians performed it less) and region of the country. FNAs are performed at a lower rate in the West. CONCLUSIONS: FNA is a commonly performed procedure. Certain groups of OTO-HNSs (older, located in western states) do not perform FNA as commonly as other OTO-HNSs. Further education regarding the merits of FNA is needed.