The Prevention of Occupational Low Back Pain Disability: Evidence-Based Reviews Point in a New Direction -- Jeffrey B. Feldman, PhD

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The findings of recent extensive evidence-based reviews of the literature on occupational low back pain disability (OLBPD) are examined. There is strong evidence that variables other than biomedical or biomechanical factors have more impact on OLBPD. Nevertheless, the multitude of interacting physical, psychological, social, occupational, financial, and legal variables has confounded, and is likely to continue to confound, efforts to develop simple checklists to predict disability. In contrast, a shift toward conceptualizing and differentially treating OLBP according to its duration postinjury provides a promising new direction. Increasing evidence points to the subacute stage postinjury (4–12 weeks) as a critical period in preventing disability. In limited studies to date, interventions implemented in the subacute stage that address maladaptive cognitions and behavior and focus on return to work have demonstrated reductions in lost work time and disability. Collaborative approaches that combine the proactive efforts of the physician, rehabilitation professionals, and the workplace hold the most promise for future prevention of OLBPD. (Journal of Surgical Orthopaedic Advances 13(1):1–14, 2004) Key words: cognitive beliefs, occupational low back pain disability, psychosocial factors, subacute intervention

Safety Syringes Can Reduce the Risk of Needlestick Injury in Venous Thromboembolism Prophylaxis -- James E. Muntz, MD and Roy Hultburg, BA, NMCC

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Patients undergoing major orthopaedic surgery of the lower extremities are at high risk of developing venous thromboembolism (VTE). Pharmacologic thromboprophylaxis has greatly reduced the likelihood of VTE. The most effective medications are administered once or twice daily by subcutaneous injection, a drug delivery route associated with an increased risk of needlestick injury. Awareness of the potential lethality of needlestick injuries has increased during the past decade, resulting in the development of national safety guidelines from the Occupational Safety and Health Administration on the handling and management of needles and other sharps. This article reviews the potential risks and costs associated with needlestick injury during the administration of VTE prophylaxis in patients undergoing major orthopaedic surgery. The development of novel anticoagulants and accompanying devices to prevent needlestick injury is also discussed. (Journal of Surgical Orthopaedic Advances 13(1):15–19, 2004) Key words: deep vein thrombosis, hepatitis, medication safety, syringe safety

Cheilectomy of the Hip in Children -- Michael C. Erard, MA, OPA-C, and David M. Drvaric, MD

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Cheilectomy of the hip is a salvage operation for patients with pain and limitation of motion caused by a mechanical blockage of an abnormally shaped femoral head. Eight patients ranging in age from 8 to 15 years were retrospectively reviewed in order to evaluate the intermediate-term results of cheilectomy to address the separate problems of pain, range of motion, and function. A mean follow-up of 5 years is reported. Clinical records and radiographs were analyzed. All patients were found to have short-term relief of pain and an increase in hip motion. Six of the eight patients regressed in terms of increased pain and loss of range of motion 2–4 years after cheilectomy. Children with an abnormally shaped femoral head causing pain and limitation of motion can benefit for a short time from cheilectomy, even if the physes are closed. (Journal of Surgical Orthopaedic Advances 13(1):20–23, 2004) Key words: cheilectomy, dysplasia, hip, Perthes disease

Is the Absence of the Ossific Nucleus Prognostic for Avascular Necrosis After Closed Reduction of Developmental Dysplasia of the Hip? -- Brian T. Carney, MD; David Clark, DO, and Christin L. Minter, MA

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The presence of the ossific nucleus before reduction of developmental dysplasia of the hip may reduce the rate of avascular necrosis. Forty-eight hips in 45 children who underwent successful closed reduction had at least a 2-year follow-up. Medical records were reviewed for sex, side, Pavlik harness, traction, age at reduction, adductor tenotomy, cast duration, length of follow-up, and subsequent surgery. Prereduction radiographs were reviewed for presence or absence of the ossific nucleus. Avascular necrosis was noted as present if there was evidence of Bucholz and Ogden type II, III, or IV on the postreduction radiographs. Avascular necrosis was noted postreduction in 17 hips. Adductor tenotomy may reduce the rate of avascular necrosis following closed reduction. Delaying closed reduction until the presence of the ossific nucleus can be detected radiographically may reduce the rate of avascular necrosis. The presence of avascular necrosis increases the need for subsequent surgery. (Journal of Surgical Orthopaedic Advances 13(1):24–29, 2004) Key words: avascular necrosis, closed reduction, developmental dislocater, hip, ossific nucleus

Physicians and Health Professionals with Osteonecrosis of the Femoral Head: Results of Management With Free Vascularized Fibular Grafting -- Marco Rizzo, MD; Philip E. Clifford, MD; Eunice E. Gunneson, PA-C, and James
R. Urbaniak, MD

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Outcomes of free vascularized fibular grafting for the treatment of femoral head (FH) osteonecrosis between 1) physicians/health professionals and 2) a comparison group of the population at large was performed. Twenty-one healthcare providers (32 hips) were treated: 10 stage II, 7 stage III, and 15 stage IV were treated over a 13-year period. The control group consisted of 1257 hips: 221 with stage II, 220 with stage III, and 816 with stage IV. All patients were followed for a minimum of 2 years. The end point for failure was conversion to total hip arthroplasty. The physician group demonstrated a high degree of postoperative compliance. The conversion rate to total hip arthroplasty was significantly lower in the physician group (6.25%) compared to the control group (20.6%). Outstanding postoperative compliance appears to be related to favorable outcomes. Further evaluation of failure in both groups may help better understand FH osteonecrosis and improved patient outcomes. (Journal of Surgical Orthopaedic Advances 13(1):30–37, 2004) Key words: femoral head, free vascularized fibular grafting, osteonecrosis

Hip Arthroplasty After Extracapsular Hip Fracture: A Matched Pair Cohort Analysis -- Jeffrey R. Lyman, MD, Scott S. Kelley, MD, and Paul F. Lachiewicz, MD

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Eighteen patients with a prior intertrochanteric or basicervical hip fracture had a total or bipolar hip arthroplasty. The clinical and radiographic results of these patients were compared to a control group of patients (matched for age, gender, associated diagnoses, and length of follow-up) who had a primary total hip arthroplasty. There was a significant increase in intraoperative blood loss, operative time, and number of units of blood transfused in the fracture group compared to the primary arthroplasty group. The mean preoperative Harris hip scores were not significantly different between the two groups, but the postoperative scores were significantly lower for the fracture group (p < .001). There was no notable difference in the rates of radiographic loosening or heterotopic ossification between the two groups. The results of this study suggest that patients should be counseled preoperatively that the functional outcome of hip arthroplasty after internal fixation of extracapsular hip fractures is decreased compared to control patients with a primary total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 13(1):38–41, 2004) Key words: conversion hip arthroplasty, hip fracture

An Incidental Finding of Chondroid Lipoma at Total Hip Arthroplasty -- Con Vasili, MD, Mordechai Kligman, MD, and George Kirsh, MD

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Chondroid lipoma is a rare benign lipomatous soft tissue tumor which presents as a painless lump. This case report presents the incidental finding of such a tumor at total hip replacement and briefly reviews the literature regarding the histopathological features of this recently described neoplasm. (Journal of Surgical Orthopaedic Advances 13(1):42–43, 2004) Key words: chondroid lipoma

Multiple Dislocations of the Proximal Interphalangeal Joint in Three Adjacent Digits--Mark H. Gonzalez, MD, and Bassem T. Elhassan, MD

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A case is described of a simultaneous dorsal radial dislocation of the proximal interphalangeal joints of the second third and fourth digits. The injury occurred when a slow-moving automobile struck the patient. A closed reduction was performed and the hand was splinted for 4 weeks. The patient regained a full range of motion of all digits. (Journal of Surgical Orthopaedic Advances 13(1):44–46, 2004) Key words: closed reduction, dislocation, hand, joint hyperextension, proximal interphalangeal joint

Intraosseous Ganglia of Glenoid--Mordechai Kligman, MD, and M. Roffman, MD

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Intraosseous ganglia are uncommon in skeletal sites including carpal bones, wrist, proximal femur, distal tibia, and glenoid bone (1–7). While the medial malleolus and proximal femur are the common sites, the intraosseous ganglia of the glenoid have been reported only in 11 patients in the literature (7, 8). To the best of our knowledge, there is no report on a ganglion cyst involving the entire glenoid in the English language medical literature. We present a patient with large intraosseous ganglion cyst occupying almost the entire subchondral bone that was treated effectively by curettage and autocorticocancellous bone graft.

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