The Journal of Bone & Joint Surgery最新文献

{"title":"Arthroscopic Acromioplasty: A Comparison Between Workers' Compensation and Non-Workers' Compensation Populations","authors":"G. Nicholson","doi":"10.2106/00004623-200304000-00015","DOIUrl":"https://doi.org/10.2106/00004623-200304000-00015","url":null,"abstract":"Background: The purpose of the present prospective study was to analyze a consecutive series of patients with subacromial impingement syndrome who were managed with arthroscopic acromioplasty by a single surgeon.Methods: A consecutive series of 106 patients (106 shoulders) with a mean age of 44.7 years (range, twenty to seventy years) was analyzed after a mean duration of follow-up of thirty-two months. The Workers' Compensation group included forty patients (twenty-five men and fifteen women) with a mean age of 41.7 years. The non-Workers' Compensation group included sixty-six patients (thirty-two men and thirty-four women) with a mean age of 46.5 years. The work-demand level was categorized according to the Dictionary of Occupational Titles from the United States Department of Labor. Previously unrecognized intra-articular pathological changes were categorized with use of consistent criteria. Workers' Compensation status, the work-demand level, and the presence of associated intra-articular pathological changes were analyzed for their effect on outcome scores and time to return to full-duty work.Results: The mean outcome scores for the entire population showed significant improvement when the preoperative values were compared with the postoperative values; specifically, the American Shoulder and Elbow Surgeons (ASES) score improved from 41.8 to 86.9, the Simple Shoulder Test (SST) score improved from 5.1 to 10.0, and the visual analog scale (VAS) for pain improved from 6.0 to 1.1 (p < 0.05). Postoperatively, there was no significant difference in the mean outcome scores between the Workers' Compensation and non-Workers' Compensation groups or between different work-demand levels. There was, however, a significant difference in the average time to return to full-duty work (13.7 weeks in the Workers' Compensation group compared with 9.1 weeks in the non-Workers' Compensation group; p = 0.0001), with the Workers' Compensation group having relatively heavier work-demand levels. Intra-articular pathological findings did not affect the outcome scores, but pathological findings that changed treatment were associated with a longer time to return to work (p = 0.04).Conclusion: Arthroscopic acromioplasty consistently provided a good surgical outcome and the ability to return to work in both the Workers' Compensation and non-Workers' Compensation populations. The work-demand level had a direct effect on the time to return to full duty, regardless of Workers' Compensation status. Patients, physicians, therapists, and employers may benefit from the knowledge of these expected outcomes and realistic time-frames for return to work.Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"38 1","pages":"682–689"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78376307","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Prospective Multipractice Investigation of Patients with Full-Thickness Rotator Cuff Tears: The Importance of Comorbidities, Practice, and Other Covariables on Self-Assessed Shoulder Function and Health Status","authors":"D. T. Harryman, C. Hettrich, Kevin L. Smith, B. Campbell, J. Sidles, Frederick A Matsen","doi":"10.2106/00004623-200304000-00016","DOIUrl":"https://doi.org/10.2106/00004623-200304000-00016","url":null,"abstract":"Background: Rotator cuff tears are among the most common conditions of the shoulder. One of the major difficulties in studying patients with rotator cuff tears is that the clinical expression of these tears varies widely and different practices may have substantially different patient populations. The goals of the present prospective multipractice study were to use patient self-assessment questionnaires (1) to identify some of the characteristics of patients with rotator cuff tears, other than the size of the cuff tear, that are correlated with shoulder function, and (2) to determine whether there are significant differences in these characteristics among patients from the practices of different surgeons.Methods: Ten surgeons enrolled a total of 333 patients with a full-thickness tear of the supraspinatus tendon into this prospective study. Each patient completed self-assessment questionnaires that included items regarding demographic characteristics, prior treatment, medical and social comorbidities, general health status, and shoulder function.Results: As expected, patients who had an infraspinatus tendon tear as well as a supraspinatus tendon tear had significantly worse ability to use the arm overhead compared with those who had a supraspinatus tear alone (p < 0.005). However, shoulder function and health status were correlated with patient characteristics other than the size of the rotator cuff tear. The number of shoulder functions that were performable was correlated with the subscales of the Short Form-36 and was inversely associated with medical and social comorbidities. The patients from the ten different surgeon practices showed significant differences in almost every parameter, including age, gender, method of tear documentation, tear size, prior treatment, medical and social comorbidities, general health status, and shoulder function.Conclusions: Clinical studies on the natural history of rotator cuff tears and the effectiveness of treatment must control for a wide range of variables, many of which do not pertain directly to the shoulder. Patients from the practices of different surgeons cannot be assumed to be similar with respect to these variables. Patient self-assessment questionnaires appear to offer a practical method of uniform assessment across different practices.Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"19 1","pages":"690–696"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91144346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Tibial Osteotomy for the Treatment of Varus Gonarthrosis: Survival and Failure Analysis to Twenty-two Years","authors":"T. R. Sprenger, J. Doerzbacher","doi":"10.2106/00004623-200303000-00011","DOIUrl":"https://doi.org/10.2106/00004623-200303000-00011","url":null,"abstract":"Background: The purpose of this retrospective study was to assess the long-term results after the treatment of medial compartment gonarthrosis with a proximal tibial osteotomy to determine whether various clinical and radiographic factors relate to the outcome. Methods: From 1972 to 1990, seventy-six valgus-producing high tibial osteotomies were performed in sixty-six patients with medial compartment gonarthrosis. Stabilization was achieved with use of a plate on the lateral side of the proximal part of the tibia and a figure-of-eight wire on the medial side. The mean age of the patients at the time of surgery was sixty-nine years, and the mean duration of follow-up was 10.8 years. The factors that were analyzed included postoperative valgus alignment; the age, gender, and weight of the patient; preoperative Ahlbäck radiographic grade; adverse events; Workers' Compensation status; and public liability. Survivorship outcome end points were conversion to arthroplasty, a Hospital for Special Surgery knee score of <70 points, and patient dissatisfaction with the procedure. Results: Ten-year survival, according to the life-table method, was 74%, 70%, and 65% with conversion to arthroplasty, a Hospital for Special Surgery knee score of <70 points, and patient dissatisfaction, respectively, as the end points. Radiographic valgus alignment that ranged between 8° and 16° at one year after the osteotomy had the most significant positive effect on survivorship for all end points (p < 0.01) compared with the other parameters. Complications occurred in sixteen (21%) of the seventy-six procedures, and they had a significant effect on survival, with all three end points (p < 0.05). Conclusions: We found that survival at ten years was 90% (95% confidence interval, 80% to 99%) when the radiographic valgus angle at one year was between 8° and 16° with arthroplasty as the end point. We believe that there is a role for tibial osteotomy, as an alternative to total knee arthroplasty, in patients who are less than sixty years old. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"10 1","pages":"469–474"},"PeriodicalIF":0.0,"publicationDate":"2003-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89600582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes of Total Hip Arthroplasty and Contralateral Bipolar Hemiarthroplasty: A Case Series","authors":"M. Flören, D. Lester","doi":"10.2106/00004623-200311000-00039","DOIUrl":"https://doi.org/10.2106/00004623-200311000-00039","url":null,"abstract":"There is continuing controversy about whether total hip arthroplasty or bipolar hemiarthroplasty should be used for the management of displaced subcapital hip fractures or advanced avascular necrosis of the femoral head, especially in patients with normal-appearing acetabular cartilage. The decision regarding which procedure to perform may be influenced by several factors, including the underlying disease process, perioperative risks 1,2, likelihood of revision 3-5, and economic considerations 6-8. Published reports are difficult to interpret because the series differ with regard to the surgeons performing the operations, surgical approaches, methods of fixation, postoperative protocols, patient mix, and duration of follow-up 3,5,9-18. In our retrospective review, we compared the clinical and radiographic results and patient-reported outcomes of the two procedures in nine patients who had undergone a bipolar hemiarthroplasty on one side and a total hip arthroplasty on the other.\u0000\u0000We conducted a retrospective review of the records on 750 consecutive hip arthroplasties performed between 1988 and 1995, and we identified seventy-five patients (10%) who had undergone bilateral hip replacement. Of these, nine had undergone total hip arthroplasty on one side and bipolar hemiarthroplasty on the other. There were eight women and one man.\u0000\u0000The mean age (and standard deviation) at the time of the bipolar hemiarthroplasty was 74 ± 19 years (range, twenty-eight to eighty-seven years), and the mean age at the time of the total hip arthroplasty was 74 ± 18 years (range, twenty-seven to eighty-seven years). Eight bipolar hemiarthroplasties were performed because of a displaced subcapital hip fracture and one, because of avascular necrosis. Five total hip arthroplasties were performed because of a subcapital hip fracture; two, because of avascular necrosis; and two, because of osteoarthritis.\u0000\u0000All patients underwent staged bilateral hip replacement. A …","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"14 1","pages":"523–526"},"PeriodicalIF":0.0,"publicationDate":"2003-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87857787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Microcirculation Associated with Degenerative Rotator Cuff Lesions: In Vivo Assessment with Orthogonal Polarization Spectral Imaging During Arthroscopy of the Shoulder","authors":"P. Biberthaler, E. Wiedemann, A. Nerlich, M. Kettler, T. Mussack, S. Deckelmann, W. Mutschler","doi":"10.2106/00004623-200303000-00012","DOIUrl":"https://doi.org/10.2106/00004623-200303000-00012","url":null,"abstract":"Background: Diminished vascular supply is associated with degenerative rotator cuff lesions. Orthogonal polarization spectral imaging allows noninvasive assessment of microcirculation without application of fluorescent contrast medium. The aim of our study was to visualize and quantify in vivo the microcirculation of the rotator cuff during arthroscopic surgery and to compare the results with the number of microvessels identified in vitro by immunostaining of biopsy specimens taken from the scanned areas. Methods: Eleven patients with clinical signs of a degenerative rotator cuff lesion were studied. Prior to arthroscopic subacromial decompression, the superficial part of the supraspinatus tendon at the edge of the lesion as well as the unaffected tendon insertion was examined. Microvascular parameters established for the description of tissue perfusion with use of conventional intravital fluorescence microscopy (functional capillary density and capillary diameter) were assessed in vivo. Biopsy specimens were taken from the scanned areas, and the microvessels were localized by immunostaining for the endothelial surface marker CD31. Results: In the region of the unaffected tendon insertion, the mean baseline functional capillary density (and standard deviation) was 106 ± 13 cm/cm 2 and the mean capillary diameter was 10 ± 0.7 &mgr;m. In contrast, at the edge of the lesion, the functional capillary density was significantly reduced to 20 ± 14 cm/cm 2, whereas the diameter of the vessels that were present did not differ. The total number of vessels stained in vitro was also significantly reduced at the edge of the lesion compared with the number of vessels in the tendon insertion zone. Conclusions: Quantitative in vivo analysis of human microcirculation during arthroscopy demonstrated that the functional capillary density at the edge of a degenerative rotator cuff lesion was significantly reduced compared with that in the control tissue. The capacity to assess microcirculatory flow in vivo may help to identify specific repair strategies based on knowledge of individual perfusion patterns.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"114 1","pages":"475–480"},"PeriodicalIF":0.0,"publicationDate":"2003-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89553950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Femoral Anteversion in Children with Cerebral Palsy: Assessment with Two and Three-Dimensional Computed Tomography Scans","authors":"J. Davids, Amanda D. Marshall, E. Blocker, S. Frick, D. Blackhurst, E. Skewes","doi":"10.2106/00004623-200303000-00013","DOIUrl":"https://doi.org/10.2106/00004623-200303000-00013","url":null,"abstract":"Background: Assessment of femoral anteversion in children with cerebral palsy with two or three-dimensional computed tomography scans may be limited by both positional and anatomic variables. Three-dimensional computed tomography techniques are considered to be more accurate than two-dimensional imaging when the femur is not optimally positioned in the gantry or when the neck-shaft angle is increased. Methods: Computed tomography scanning was performed on a series of nine model femora with anteversion ranging from 20° to 60° and neck-shaft angles ranging from 120° to 160°. Each femoral model was scanned in two holding devices, the first of which held the femur in optimal alignment (normal model) and the second of which held the femur in flexion, adduction, and internal rotation (cerebral palsy model) relative to the gantry. Femoral anteversion was calculated for each model from two and three-dimensional computed tomography scans by four examiners on two separate occasions. The intraobserver and interobserver reliability, the accuracy, and the effect of increasing the neck-shaft angle on the accuracy of the measurements made on the two and three-dimensional scans of the normal and cerebral palsy models were then examined. Results: The mean differences in the measurements of femoral anteversion made by the same examiner (intraobserver reliability) were <2° for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <4° for the three-dimensional scans of the cerebral palsy models. The mean differences among examiners (interobserver reliability) were <3° for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <6° for the three-dimensional scans of the cerebral palsy models. The accuracy of the assessments of femoral anteversion of the normally aligned models was comparable between the two and three-dimensional scans. However, the three-dimensional assessment was significantly more accurate than the two-dimensional assessment for measurement of anteversion of the cerebral palsy models (p = 0.003). Accuracy within 5° was comparable between the two and three-dimensional scans for measurement of the normally aligned models, with 86% of the two-dimensional measurements and 78% of the three-dimensional measurements falling within 5° of the actual measurements. However, the accuracy within 5° was significantly compromised when the models were placed in cerebral palsy alignment. Only 3% of the two-dimensional measurements and 14% of the three-dimensional measurements fell within 5° of the actual measurements, with three-dimensional assessment being significantly better than two-dimensional assessment (p = 0.006). Increasing the neck-shaft angle did not significantly compromise the accuracy of measurement of femoral anteversion with either the two-dimensional or the three-di","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"31 1","pages":"481–488"},"PeriodicalIF":0.0,"publicationDate":"2003-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73728337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Tibial Plafond Fractures: How Do These Ankles Function Over Time?","authors":"J. Marsh, Dennis P. Weigel, D. Dirschl","doi":"10.2106/00004623-200302000-00016","DOIUrl":"https://doi.org/10.2106/00004623-200302000-00016","url":null,"abstract":"Background: The intermediate outcome of fractures of the tibial plafond treated with current techniques has not been reported, to our knowledge. The purpose of this study, performed at a minimum of five years after injury, was to determine the effect of these fractures on ankle function, pain, and general health status and to determine which factors predict favorable and unfavorable outcomes.Methods: Fifty-six ankles (fifty-two patients) with a tibial plafond fracture were treated with a uniform technique consisting of application of a monolateral hinged transarticular external fixator coupled with screw fixation of the articular surface. Thirty-one patients with thirty-five involved ankles returned between five and twelve years after the injury for a physical examination, assessment of ankle pain and function with the Iowa Ankle Score and Ankle Osteoarthritis Scale, assessment of general health status with the Short Form-36 (SF-36), and radiographic examination of the ankle.Results: Arthrodesis had been performed on five of the forty ankles for which the outcome was known at a minimum of five years after the injury. Other than removal of prominent screws (two patients), no other surgical procedure had been performed on any patient. The average Iowa Ankle Score was 78 points (range, 28 to 96 points). The scores on the SF-36 and Ankle Osteoarthritis Scale demonstrated a long-term negative effect of the injury on general health and on ankle pain and function when compared with those parameters in age-matched controls. The degree of osteoarthrosis was grade 0 in three ankles, grade 1 in six, grade 2 in twenty, and grade 3 in six. The majority of patients had some limitation with regard to recreational activities, with an inability to run being the most common complaint (twenty-seven of the thirty-one patients). Fourteen patients changed jobs because of the ankle injury. Fifteen ankles were rated by the patient as excellent; ten, as good; seven, as fair; and one, as poor. Nine patients with previously recorded ankle scores had better scores after the longer follow-up interval. The patients perceived that their condition had improved for an average of 2.4 years after the injury.Conclusions: Although tibial plafond fractures have an intermediate-term negative effect on ankle function and pain and on general health, few patients require secondary reconstructive procedures and symptoms tend to decrease for a long time after healing.Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"9 1","pages":"287–295"},"PeriodicalIF":0.0,"publicationDate":"2003-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84738901","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patellar Resurfacing in Total Knee Arthroplasty: A Prospective, Randomized Study","authors":"T. Waters, G. Bentley","doi":"10.2106/00004623-200312000-00039","DOIUrl":"https://doi.org/10.2106/00004623-200312000-00039","url":null,"abstract":"Background: Anterior knee pain following total knee arthroplasty is a common complaint and typically is attributed to the patellofemoral joint. The purpose of the present study was to compare the outcome of resurfacing and nonresurfacing of the patella, particularly with regard to anterior knee pain, and to clarify the indications for patellar resurfacing at the time of total knee arthroplasty.Methods: We performed a prospective, randomized study of 514 consecutive primary press-fit condylar total knee replacements. The patients were randomized to either resurfacing or retention of the patella. They were also randomized to either a cruciate-substituting or a cruciate-retaining prosthesis as part of a separate trial. The mean duration of follow-up was 5.3 years (range, two to 8.5 years), and the patients were assessed with use of the Knee Society rating, a clinical anterior knee pain score, and the British Orthopaedic Association patient-satisfaction score. The assessment was performed without the examiner knowing whether the patella had been resurfaced. At the time of follow-up, there were 474 knees. Thirty-five patients who had a bilateral knee replacement underwent resurfacing on one side only.Results: The overall prevalence of anterior knee pain was 25.1% (fifty-eight of 231 knees) in the nonresurfacing group, compared with 5.3% (thirteen of 243 knees) in the resurfacing group (p < 0.0001). There was one case of component loosening. Ten of eleven patients who underwent secondary resurfacing had complete relief of anterior knee pain. The overall postoperative knee scores were lower in the nonresurfacing group, and the difference was significant among patients with osteoarthritis (p < 0.01). There was no significant difference between the resurfacing and nonresurfacing groups with regard to the postoperative function score. Patients who had a bilateral knee replacement were more likely to prefer the resurfaced side.Conclusions: As the present study showed a significantly higher rate of anterior knee pain following arthroplasty without patellar resurfacing, we recommend patellar resurfacing at the time of total knee replacement when technically possible.Level of Evidence: Therapeutic study, Level I-1a (Randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"7 1","pages":"212–217"},"PeriodicalIF":0.0,"publicationDate":"2003-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88878959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Outcomes After Lumbar Discectomy for Sciatica: The Effects of Fragment Type and Anular Competence","authors":"E. Carragee, Michael Han, Patrick W. Suen, David Kim","doi":"10.2106/00004623-200301000-00016","DOIUrl":"https://doi.org/10.2106/00004623-200301000-00016","url":null,"abstract":"Background: The surgical treatment of sciatica with discectomy is ineffective in a sizable percentage of patients, and reherniation occurs after 5% to 15% of such procedures. The purpose of the present study was to determine if competence of the disc anulus and the type of herniation could be used to predict postoperative clinical outcomes following lumbar discectomy.Methods: A prospective observational study of 187 consecutive patients undergoing single-level primary lumbar discectomy was conducted. A single surgeon performed all of the procedures, and an independent examiner evaluated 180 of the patients clinically at a minimum of two and a median of six years after surgery. The extent of anular deficiency and the presence of disc fragments were determined. On the basis of these intraoperative findings, disc herniations were classified into four categories: (1) Fragment-Fissure herniations (eighty-nine patients), (2) Fragment-Defect herniations (thirty-three patients), (3) Fragment-Contained herniations (forty-two patients), and (4) No Fragment-Contained herniations (sixteen patients). The effects of disc herniation morphology and preoperative variables on subsequent clinical outcome were determined with the Student t test for continuous variables and chi-square analysis for categorical variables.Results: Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001).Conclusion: Intraoperative findings, as described in the present study, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy.Level of Evidence: Prognostic study, Level I-1 (prospective study). See p. 2 for complete description of levels of evidence.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"155 1","pages":"102–108"},"PeriodicalIF":0.0,"publicationDate":"2003-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85018182","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sustained Spinal Cord Compression: Part II: Effect of Methylprednisolone on Regional Blood Flow and Recovery of Somatosensory Evoked Potentials","authors":"G. Carlson, C. Gorden, S. Nakazawa, E. Wada, Jeremy S. Smith, J. LaManna","doi":"10.2106/00004623-200301000-00015","DOIUrl":"https://doi.org/10.2106/00004623-200301000-00015","url":null,"abstract":"Background: The efficacy of methylprednisolone in the treatment of traumatic spinal cord injury is controversial. We examined the effect of methylprednisolone on regional spinal cord blood flow and attempted to determine whether recovery of electrophysiological function is dependent on reperfusion, either during sustained spinal cord compression or after decompression.Methods: The effects of methylprednisolone therapy on recovery of somatosensory evoked potentials and on spinal cord blood flow were examined in a canine model of dynamic spinal cord compression. Methylprednisolone (30 mg/kg intravenous loading dose followed by 5.4 mg/kg/hr intravenous infusion) or saline solution was administered to thirty-six beagles (eighteen in each group) five minutes after cessation of dynamic spinal cord compression and loss of all somatosensory evoked potentials. After ninety minutes of sustained compression, the spinal cords were decompressed. Somatosensory evoked potentials and spinal cord blood flow were evaluated throughout the period of sustained compression and for three hours after decompression.Results: Seven dogs treated with methylprednisolone and none treated with saline solution recovered measurable somatosensory evoked potentials during sustained compression. After decompression, three more dogs treated with methylprednisolone and seven dogs treated with saline solution recovered somatosensory evoked potentials. Four dogs treated with methylprednisolone lost their previously measurable somatosensory evoked potentials. In the methylprednisolone group, spinal cord blood flow was significantly higher (p < 0.05) in the dogs that had recovered somatosensory evoked potentials than it was in the dogs that had not. Reperfusion blood flow was significantly higher (p < 0.05) in the saline-solution group than it was in the methylprednisolone group. Spinal cord blood flow in the saline-solution group returned to baseline levels within five minutes after decompression. It did not return to baseline levels in the dogs treated with methylprednisolone.Conclusions: The methylprednisolone administered in this study did not provide a large or significant lasting benefit with regard to neurological preservation or restoration. Methylprednisolone may reduce regional spinal cord blood flow through mechanisms affecting normal autoregulatory blood-flow function.Clinical Relevance: This study suggests that a major drawback of methylprednisolone therapy may be the reduction in regional spinal cord blood flow after decompression.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"1 1","pages":"95–101"},"PeriodicalIF":0.0,"publicationDate":"2003-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91237808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}