Faculty Bibliography

Spine surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). The goal of this study was to determine which symptoms and risk factors were associated with spiral CT scans positive for PE and/or DVT in the postoperative spine surgery patient. We conducted a retrospective review of all spine patients who underwent a postoperative CT to rule out PE during the period of March 2004-February 2006. The type of surgical procedure, risk factors, symptoms prompting scan ordering, anticoagulation, and treatment were recorded. Logistic regression models were used to determine significant predictors of a positive CT in this patient population. Of the 3,331 patients that had spine surgery during the study period, 130 (3.9%) had a spiral CT scan to rule out PE and/or proximal DVT. Thirty-three of the 130 (25.4%) CT scans were positive for PE only, five (3.8%) for PE and DVT, and three (2.3%) for DVT only. Only 24.5% (32) patients had risk factors for thromboembolic disease, and of these, a history of PE and/or DVT was the only significant risk factor for a positive scan (p = 0.03). No presenting symptoms or demographic variables were noted to have a significant association with PE and/or DVT. The type of surgical procedure (i.e., anterior, posterior, and percutaneous) was not associated with an increased risk for PE and/or DVT. Patients who are undergoing spine surgery with a history of thromboembolic disease should be carefully monitored postoperatively and may benefit from more aggressive prophylaxis.

Orthopedic surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). This study was performed to compare the clinical presentations of a suspected versus a documented PE/DVT and to determine the actual incidence of PE/DVT in the post-operative orthopedic patient in whom CT was ordered. All 695 patients at our institution who had a postoperative spiral CT to rule out PE/DVT from March 2004 to February 2006 were evaluated and information regarding their surgical procedure, risk factors, presenting symptoms, location of PE/DVT, and anticoagulation were assessed. Statistical analysis was performed using an independent samples t test with a two-tailed p value to examine significant associations between the patient variables and CT scans positive for PE. Logistic regression models were used to determine which variables appeared to be significant predictors of a positive chest CT. Of 32,854 patients admitted for same day surgery across all services, 695 (2.1%) had a postoperative spiral CT based on specific clinical guidelines. The incidence of a positive scan was 27.8% (193/695). Of these, 155 (22.3%) scans were positive for PE only, 24 (3.5%) for PE and DVT, and 14 (2.0%) for DVT only. The most common presenting symptoms were tachycardia (56%, 393/695), low oxygen saturation (48%, 336/695), and shortness of breath (19.6%, 136/695). Symptoms significantly associated with DVT were syncope and chest pain. A past medical history of PE/DVT was the only significant predictor of a positive scan. Patients who have a history of thromboembolic disease should be carefully monitored in the postoperative setting.

BACKGROUND: There has been limited in-vivo assessment of rotator cuff vascularity following repair. This study aims to characterize the vascularity of the shoulder 3 months following supraspinatus tendon repair. METHODS: Twenty-nine patients (average age, 61.4 years) underwent Perflutren lipid microsphere contrast-enhanced shoulder ultrasound examinations 3 months after arthroscopic rotator cuff repair. Each shoulder was scanned at rest and following exercise using linear phased array 9-MHz transducer optimized to detect the contrast agent. Blood flow was quantified off-line using ultrasound imaging quantification and analysis software (QLAB, Philips, Andover, MA). Peak enhancement (vascular volume) and rate of rise (perfusion) were determined for 3 regions of interest: peribursal area, supraspinatus tendon, and anchor site. RESULTS: Peak enhancement and rate of rise were greatest in the peribursal soft tissue and anchor site. Resting peak enhancement and rate of rise were significantly lower within the tendon compared to the other 2 regions (P < .001). Exercise resulted in increased enhancement and rate-of-rise to all 3 regions, but had a significant predilection towards increasing vascular volume within the peri-bursal region (P = .026). CONCLUSION: At 3 months following repair, the majority of blood flow to the repair is derived from the peribursal soft tissues and the anchor site. The tendon, particularly those with a defect at 3 months, is relatively avascular. Though limited by inclusion of only a single time point, this study introduces a new technique to quantify vascularity following supraspinatus repairs and suggests that the surrounding vascular milieu may play a role in tendon healing. LEVEL OF EVIDENCE: Basic Science.

BACKGROUND: Retears of the rotator cuff are not uncommon after arthroscopic and mini-open rotator cuff repairs. In most studies, the clinical results in patients with persistent defects demonstrated significantly less pain and better function and strength compared with their preoperative state at an early follow-up. HYPOTHESIS: The clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L'Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound. RESULTS: At the 7.9 year follow-up the average scores were 95 (American Shoulder and Elbow Surgeons), 95 (L'Insalata), 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (P < .001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm(2) to 467 mm(2) (P < .001). Finally, the size of the defect increased in all patients, and no defects healed structurally. CONCLUSION: At an average of 7.9 years, patients with recurrent defects after rotator cuff repair still had an improvement in terms of pain, function, and satisfaction. However, the rotator cuff defect significantly increased in size, and there was a progression of strength deficits. These findings suggest that patients with recurrent defects can remain asymptomatic over the long term but will predictably lose strength in the involved extremity. Furthermore, the study demonstrated that defects after rotator cuff repair increase in size but often remain asymptomatic.

OBJECTIVE: To ascertain whether magnetic resonance angiography (MRA) can reliably detect synovial neovascularization in subjects with early inflammatory arthritis. METHODS: Subjects with 6 weeks to 6 months of clinical evidence of inflammatory hand arthritis had a radiograph, power Doppler ultrasound (PDU) scan, magnetic resonance imaging (MRI), and contrast enhanced MRA performed on the more symptomatic hand. Ultrasound examination of the wrist and 2nd-5th metacarpophalangeal (MCP) joints was scored for erosions, synovial thickening, and synovial blood flow. MRI were assessed using the OMERACT Rheumatoid Arthritis MRI Score (RAMRIS). MRA was used to assess the number of abnormal vessels in the 2nd-5th MCP and in the wrist. RESULTS: Of 30 subjects, 66.7% showed abnormal vasculature on MRA in the MCP and/or wrist; mean number of abnormal vessels was 5.24 (range 0-22). Number of abnormal vessels on MRA was strongly correlated with degree of blood flow seen in the corresponding area on PDU (r = 0.79, p

PMID: 20360190

ISSN: 0315-162x

CID: 157804