Heel pain triad (HPT): the combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome

Between 1996 and 1999, we evaluated 286 patients with chronic heel pain. We identified 14 patients who were diagnosed and surgically treated for a unique combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome. We postulate that failure of the static (plantar fascia) and dynamic (posterior tibial tendon) support of the longitudinal arch of the foot has resulted in traction injury to the posterior tibial nerve, i.e., tarsal tunnel syndrome. The combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome was recognized and treated. We have called this combination the "Heel Pain Triad (HPT)." Using the AOFAS hindfoot rating system, retrospective chart review and patient examination revealed marked improvement in 85.7% of patients. Follow-up was done four to 33 months (mean follow-up was 17.1 months). Marked improvement was noted in the categories of pain, activity level, walking distance, walking surface and limp. Improvement was statistically significant for all categories.     

Human fetal neurons in culture: Intercellular communication and voltage- and ligand-gated responses

We established high density primary cultures of neural cells from dissociated second trimester human fetal brains using a novel spin seeding method. Under our culture conditions, the majority of the cells exhibited neuronal phenotypes as evidenced by morphological criteria, immunoreactivity to the 66 kDa neurofilament protein and expression of TTX-sensitive Na⁺ channels and cell excitability. These cultures were enriched in glutamic acid decarboxylase (GAD), the synthetic enzyme of the neurotransmitter GABA, and responded with Ca²⁺ influx to acute application of glutamate. Interestingly, the human fetal neurons in culture did not express either dopaminergic or cholinergic phenotypes. In addition, the population of neurons obtained express a high incidence of gap junction-mediated intercellular communication. These studies provide evidence that functional neuronal properties arise early during prenatal development in humans and offer the potential to evaluate pharmacological agents on primary human neurons. © 1994 Wiley-Liss, Inc.     

Variation in orthopaedic surgeons' perceptions about the indications for rotator cuff surgery

BACKGROUND: Epidemiologic studies have demonstrated substantial variations in per capita rates of many surgical procedures, including rotator cuff repair. The purpose of the current study was to characterize orthopaedic surgeons' attitudes concerning medical decision-making about rotator cuff surgery and to investigate the associations between these beliefs and reported surgical volumes. METHODS: A survey was mailed to randomly selected orthopaedic surgeons listed in the American Academy of Orthopaedic Surgeons directory. Only individuals who had treated patients for a rotator cuff tear, or had referred patients for such treatment, within the previous year were asked to complete the two-page survey. The survey comprised fifteen questions regarding clinical opinion, including four regarding hypothetical cases. Clinical agreement was defined as >80% of the respondents answering similarly. RESULTS: Of the 1100 surveys that were mailed, 539 were returned (a response rate of 49%). Of the 539 respondents, 316 (58.6%) had treated or referred patients with a rotator cuff tear in the previous year. There was a significant negative correlation between the surgeon's estimation of the failure rate of cuff repairs in the United States and that surgeon's procedure volume (r = -0.21, p = 0.0003), indicating that surgeons with a lower procedure volume are more pessimistic about the results of surgery than are those with a higher procedure volume. Arthroscopic, mini-open, and open cuff repairs were preferred by 14.5%, 46.2%, and 36.6% of the respondents, respectively. Surgeons who performed a higher volume of procedures were less likely to perform open surgery (p < 0.0001). There was clinical agreement regarding only four of the nine clinical questions and none of the four questions about the hypothetical vignettes. CONCLUSIONS: We found significant variation in surgical decision-making and a lack of clinical agreement among orthopaedic surgeons about rotator cuff surgery. There was a positive correlation between the volume of procedures performed by the surgeon and the surgeon's perception of outcome, with surgeons who had a higher procedure volume being more enthusiastic about rotator cuff surgery than those who had a lower procedure volume.     

The association between hospital volume and total shoulder arthroplasty outcomes

The purpose of this study was to evaluate the relationship between increasing hospital volume and the following outcomes for total shoulder arthroplasties done in the state of New York: length of stay, hospital costs, readmission within 60 days, revision surgery within 24 months, and death within 60 days. The Statewide Planning and Research Cooperative System (SPARCS) database from the New York State Department of Health, a census of all hospital discharges in the state, was used to evaluate the relationship between hospital volume and outcomes for total shoulder arthroplasties for 1996 to 1999. One thousand three hundred seven total shoulder arthroplasties were done in New York from 1996 to 1999. Nearly (1/2) were done at the five highest-volume hospitals. Middle-volume hospitals has the least lengths of stay and hospital costs. Independent of age and comorbidities, patients at hospitals with greater volumes of total shoulder arthroplasties were at reduced risk of patients being readmitted within 60 days. No other outcomes were significantly associated with hospital volume. The finding that greater hospital volume decreases risk of readmission may have important public health implications, but additional research is needed before implementing policy changes.     

Multirater agreement of arthroscopic grading of knee articular cartilage

BACKGROUND: Acute and chronic cartilage injury of the knee has an important impact on prognosis. The validity of the classification of such injuries is critical for prospective multicenter studies. The agreement among multiple surgeons at different institutions for articular cartilage lesions has not been established. HYPOTHESIS: Arthroscopic classification of articular cartilage lesions is reliable and reproducible and can be used for multicenter studies involving multiple surgeons. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: A total of 6 surgeons from 5 centers reviewed 31 videos of articular cartilage lesions. With grade 2 and grade 3 combined for the analysis, observed agreement ranged from 81% to 94%, and kappa ranged from 0.34 to 0.87. An additional 22 videos comprising grade 2 and grade 3 lesions were analyzed, and the observed agreement was 80%, with an overall kappa of 0.47. CONCLUSION: Arthroscopic grading of articular cartilage lesions is reproducible among surgeons at different centers. CLINICAL RELEVANCE: Articular cartilage lesions can be reliably classified among surgeons at different sites. Such reliability is important for multicenter clinical research studies involving arthroscopic knee surgery.     

The effect of anterior cruciate ligament reconstruction on the risk of knee reinjury

BACKGROUND: Although there is evidence that very active, young patients are better served with anterior cruciate ligament reconstruction, there is a lack of objective data demonstrating that future knee injury is prevented by these procedures. HYPOTHESIS: Anterior cruciate ligament reconstruction protects against reinjury of the knee that would require reoperation. STUDY DESIGN: Retrospective cohort study. METHODS: A cohort of 6576 active-duty army personnel who had been hospitalized for anterior cruciate ligament injury from 1990 to 1996 were identified. Using the Total Army Injury and Health Outcomes Database, the authors followed these individuals for up to 9 years and collected clinical, demographic, and occupational data. These data were evaluated with bivariate and multivariable analyses to determine the effect of anterior cruciate ligament reconstruction on the rate of knee reinjury that required operation. RESULTS: Of the 6576 study subjects, 3795 subjects (58%) underwent anterior cruciate ligament reconstruction and 2781 (42%) did not. The rate of reoperation was significantly lower among the anterior cruciate ligament reconstruction group (4.90/100 person-years) compared with those treated conservatively (13.86/100 person-years; P < .0001). Proportional hazard regression analyses adjusted for age, race, sex, marital status, education, and physical activity level confirmed that anterior cruciate ligament reconstruction was protective against meniscal and cartilage reinjury (P < .0001). Secondary medial meniscal injury was more common than secondary lateral meniscal injury (P < .003). Younger age was the strongest predictor of failure of conservative management leading to late anterior cruciate ligament reconstruction (P < .0001). CONCLUSIONS: Anterior cruciate ligament reconstruction protected against reoperation in this young, active population; younger subjects were more likely to require late anterior cruciate ligament reconstruction. CLINICAL RELEVANCE: Strong consideration should be given to anterior cruciate ligament reconstruction after anterior cruciate ligament injury in young, active individuals.