Faculty Bibliography

This study examines the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF-36) in patients undergoing total hip arthroplasty. Eighty-nine patients completed the WOMAC and SF-36 preoperatively and postoperatively. Standardized response means (SRMs) and effect sizes (ES) were used to measure responsiveness. Mean follow-up was 17 months. The SRMs for the WOMAC ranged from -0.93 to -1.49, and the ES ranged from -1.02 to -1.53. The SRMs for the SF-36 ranged from 0.22 to 1.64, and the ES ranged from 0.20 to 1.97. The highest values occurred with the physical functioning, bodily pain, and Physical Component Summary Scales. This study demonstrates a similar level of responsiveness of the WOMAC and several components of the SF-36. This suggests that the isolated use of the SF-36 may be adequate to monitor outcomes after total hip arthroplasty. There may still be a role for the WOMAC when comparing outcomes of specific designs or techniques of total hip arthroplasty.

A patient with Apert syndrome who underwent a monobloc osteotomy with distraction advancement sustained partial unilateral vision loss as a complication from a direct carotid-cavernous fistula. Successful embolization was used to treat the fistula. Precaution should be taken by craniofacial surgeons in performing similar procedures in patients with Apert syndrome because of their unique skull abnormalities.

The etiology of failed degenerative lumbar spine surgery may include a wide array of conditions. There is a group of patients who have recurrence of back pain despite a solid fusion in the absence of any obvious pain generator. Implant removal in those patients is a controversial optional treatment. The purpose of this study was to evaluate the efficacy and safety of implant removal and to determine the possible predictors of its efficacy. Twenty-five patients (10 M, 15 F) with an average age of 44 (18 to 74) were retrospectively evaluated. All patients had prior titanium posterior pedicle screw instrumentation and fusion for lumbar degenerative disorders. Twenty patients with increase in pain during palpation of the operative side underwent a preoperative anesthetic injection at the site of their trigger points. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the percent Visual Analog Scale (VAS) pain change due to implant removal. Functional improvement was rated on a five-point scale. Predictors of pain relief were analyzed by using bivariate analysis. A P value <0.05 was considered significant. Average follow-up period was 20 (12 to 37) months. The median time after the index operation and the recurrence of pain was 13.5 (1 to 119) months. VAS decrease after implant removal was 50% (P<0.001). Functional improvement was reported by 84% of patients. One patient developed a superficial infection managed successfully. Bivariate analysis showed that percent VAS change after injection, months free of pain after the index operation, and provocation of pain by palpation were significant predictors for pain relief (P<0.05). Removal of the implant may be an efficient and safe procedure for carefully selected patients and the most consistent predictor of its efficacy is the percent pain relief after the diagnostic injection of the painful operative side.

BACKGROUND: The management of the mildly to moderately dilated ascending aorta (3.5 to 4.9 cm) in cardiac surgery remains controversial. Therapeutic options have included radical aortic resection with synthetic graft substitution, external aortic reinforcement or wrap, with or without partial aortic wall excision, and a watch-and-wait approach. We reviewed our institutional experience with Dacron (DuPont, Wilmington, DE) mesh wrap support of dilated ascending aortas. METHODS: During the last 20 years, 102 patients with aneurysmal dilatation of the ascending aorta underwent wrapping of the ascending aorta with a fine Dacron mesh from the ventricular-aortic junction to the origin of the innominate artery. For the last 10 years, the wrap was anchored to the aortic annulus with pledgeted sutures. Aortic diameters up to 6 cm, without focal areas of thinning, were wrapped. Aortic diameters exceeding 6 cm, or with focal thinning, underwent tailored aortic wall resection and wrapping. Primary end points of the study included mortality, aortic diameter growth, dissection or rupture, or both. RESULTS: The mean age of the group was 54.7 +/- 19 years (range, 12 to 90 years). A single patient underwent aortic wrapping without cardiopulmonary bypass. Sixty-six patients (65%) required additional aortic valve surgery. Five patients (5%) had reinforcement of dilated sinuses with glutaraldehyde-treated pericardial patches combined with wrapping. Twenty-seven patients (26%) had combined coronary and valve surgery, and 2 patients had coronary revascularization alone. There was neither early nor hospital mortality. Among the 81 patients (79%) we were able to contact, 7 (7%) late deaths had occurred at 0.5, 1, 3, and 9 years after operation that were unrelated to aortic pathology. Various levels of follow-up were obtained in the 88 patients (86.2%). In 78 patients, echocardiograms, computed tomography angiograms, or magnetic resonance angiograms were obtained. In 2 of these patients, aneurysmal dilatation of the sinuses developed below the wrap and reoperation was required. No patient in whom the mesh wrap was anchored to the aortic annulus required reoperation. All 81 patients that were contacted by us and monitored by referring physicians were asymptomatic and free of problems related to the aorta. The mean (+/- SD) preoperative diameter of the ascending aorta was 49.2 +/- 7.8 mm (range, 35 to 87 mm), the postwrap intraoperative diameter was 32.9 +/- 3.4 mm (range, 20 to 40 mm), and the follow-up postoperative aortic diameter was 35.6 +/- 12.7 mm (range, 27 to 52 mm). The mean average change in the aortic diameter during the follow-up period was 2.6 +/- 14.8 mm (range, -7 to 22 mm), a mean of 8%. The mean follow-up period was 5.7 years (median, 4.77 years; range, 9 days to 21 years). There were no infections or other early complications related to the wrap. CONCLUSIONS: Dacron mesh support of the moderately dilated aneurysmal ascending aorta, alone or in conjunction with coronary revascularization, aortic root surgery, or valvular operations, or both, is safe and durable. Dacron mesh is transparent and stretchable, permitting tight girdling of the aorta. These properties prevent hematoma formation, facilitate proximal vein graft anastomoses, and provide visualization and access to aortic suture lines. Finally, this technique retards further aortic dilation, altering the natural history of aortic aneurysms.

OBJECTIVE: Despite substantial progress in the treatment of community-acquired pneumonia, there are limited data on dietary risk factors. Fatty acid intake may influence community-acquired pneumonia risk by modulating the immune system. Our study prospectively examined the association between fatty acid intake and community-acquired pneumonia risk. METHODS: The study population included 83165 women from the Nurses' Health Study II cohort who were 27 to 44 y old in 1991. The women reported lifestyle habits on biennial questionnaires and dietary intake every 4 y by validated semiquantitative food frequency questionnaires. There were 925 pneumonia cases over 10 y of follow-up. We examined independent associations for six fatty acids using Cox's proportional hazards regression. RESULTS: Women in the highest quintile of palmitic acid intake had a 54% greater risk of pneumonia compared with those in the lowest quintile (multivariate relative risk 1.54, 95% confidence interval 1.12-2.12, P for trend = 0.002). Oleic acid intake was inversely associated with pneumonia risk (highest quintile multivariate relative risk 0.75, 95% confidence interval 0.55-1.04, P for trend = 0.02). Women in the highest quintile of docosahexanoic acid and eicosapentaenoic acid intake had a 24% greater risk of community-acquired pneumonia than did those in the lowest quintile (multivariate relative risk 1.24, 95% confidence interval 1.00-1.55, P for trend = 0.08). No significant associations were found for linoleic acid, alpha-linolenic acid, or docosahexanoic acid alone. CONCLUSION: Fatty acid intake may affect the risk of community-acquired pneumonia in young and middle-aged women. Higher dietary intake of palmitic acid and possibly docosahexanoic and eicosapentaenoic acids may increase the risk of community-acquired pneumonia in women, whereas higher oleic acid intake may decrease the risk.

OBJECTIVES: To quantify tissue remodeling induced by static and cyclical application of tensional forces in a living perfused tissue. BACKGROUND: Cells are able to respond to mechanical cues from the environment and can switch between proliferation and quiescence. However, the effects of different regimens of tension on living, perfused skin have not been characterized. METHODS: The ears of living rats were mechanically loaded by applying tensile forces (0.5 Newtons) either statically or cyclically and then analyzing tissue responses using in vivo microscopy, immunohistochemistry, and corrosion casting. RESULTS: Quantitative immunohistochemistry showed that in the static group (4-day continuous tension) there was up to 4-fold increase in cellular proliferation in the epidermis after 4 days and a 2.8-fold increase in the vascularity in the dermis that peaked after 2 days. Comparable effects could be achieved in just 8 hours using a cyclic loading protocol. We also modeled the resultant stress produced in the ear using a linear finite element model and demonstrated a correlation between the level of applied stress and both epidermal cell proliferation and blood vessel density. CONCLUSIONS: Mechanical forces stimulate cell proliferation and vascular remodeling in living skin. As cell growth and vascular supply are critical to wound healing and tissue expansion, devices applying controlled mechanical loads to tissues may be a powerful therapy to treat tissue defects.

The authors present a case of late postoperative infection after augmentation gluteoplasty in a 32-year-old pregnant woman. The case is unique in that it is the first documented example of a gluteal implant infection in a pregnant woman and because the infection was not preceded by trauma to the anatomic region.

Ankyloglossum superius (or ankyloglossia superior) is a rare congenital craniofacial condition characterized by tongue tip adherence to the hard palate and associated limb abnormalities. There have been few reports of this condition in the literature. We present a patient with ankyloglossum superius syndrome and discuss diagnosis and surgical management.

Former Surgeon General David Satcher's report, Oral Health in America, documents the higher burden of oral diseases and conditions borne by those with relatively low social standing at each stage of life. When an entire community suffers from a health concern, that concern becomes a social justice issue. Racial and ethnic minorities, prisoners, and seniors suffer disproportionately from oral diseases and conditions due to societal prejudices that place them at risk over and above any risk associated with their economic means. Community-based delivery models that involve the community in planning and implementation, build upon the existing health safety net to link oral health services with primary care, and change public or institutional policy to support the financing and delivery of oral health care have proven successful. Here we champion the need for a national health plan that includes oral health care to promote social justice and oral health for all.