Biomedical subjects
R J Friedman
Publications and source records attributed to R J Friedman.
Non-constrained total shoulder replacement in patients who have rheumatoid arthritis and class-IV function.
The results of twenty-four non-constrained total shoulder replacements that were done in twenty patients who had treatment of rheumatoid arthritis were retrospectively reviewed to determine how those results were affected by the severity of the disease. All of the patients had Class-IV functional capacity, and 92 per cent had Stage-III or IV rheumatoid progression. Nine (38 per cent) of the shoulders had a tear of the rotator cuff. The mean length of clinical follow-up was 4.5 years (range, two to ten years). Preoperatively, all of the patients had disabling pain and limited function. Postoperatively, twenty-two (92 per cent) of the patients had no appreciable pain, and eighteen (75 per cent) had no significant functional limitation (p less than 0.001). Active elevation improved by 88 per cent, and external and internal rotation also improved significantly. Motion, relief of pain, and functional improvement were not significantly greater in the patients who had an intact rotator cuff. Radiolucent lines developed around ten (42 per cent) of the glenoid prostheses, but only two of the prostheses were surrounded by a complete line and were thought to be loose. No revisions were done. We believe that a non-constrained total shoulder replacement affords excellent relief of pain, satisfactorily improves range of motion, and improves function in patients who have severe rheumatoid involvement of the shoulder. However, because motion and function are severely restricted preoperatively, the end-results are not comparable with those that have been reported for patients who have less severe rheumatoid disease.
Displacement of an uncemented femoral component after dislocation of a total hip replacement. A case report.
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Risk gradient for malignant melanoma in individuals with dysplastic naevi.
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Infection in total joint arthroplasty from distal intravenous lines. A case report.
Prevention of late hematogenous infection of a total joint arthroplasty is of great importance because of the catastrophic consequences. Any situation that can lead to a bacteremia should be avoided and appropriate prophylactic antibiotics given in anticipation of a bacteremic episode. This report documents a bacteremia and total joint infection secondary to a routine intravenous line placed in an extremity distal to a total knee arthroplasty. Routine intravenous infusion lines should not be placed in extremities with proximal total joint arthroplasties. Educating both patients and physicians about the risks to a prosthetic joint is important.
The temporal island scalp flap for management of facial burn scars.
Facial burn scars are difficult to conceal and often preclude an aesthetic rehabilitation of the patient. Multistaged scalp and neck flaps have been described to provide hair-bearing skin to resurface burn scars in men. We have been resurfacing the upper lip and cheek in a one-stage procedure using a temporal artery island scalp flap. The temporoparietal fascia has been well described in recent years, and the understanding of this anatomy has facilitated the use of the island scalp flap for more distal transfers.
Economic impact of total hip arthroplasty.
Since the first successful total hip arthroplasty (THA) 28 years ago, this procedure has enabled millions of people to walk without pain. The overall incidence of THA has more than tripled in the last five years, now exceeding 196,000 cases annually. The direct and indirect costs of THA exceed $4.9 billion annually. Though the economic benefits of THA offset this figure by $1.85 billion, the costs nevertheless have a significant impact on the health care system. Although THA is expensive, the excellent long-term results make it well worth the expense.
Risk factors for the development of malignant melanoma--I: Review of case-control studies.
Data concerning risk factors for the development of cutaneous malignant melanoma (MM) were abstracted from published case-control studies. Relative risks (more appropriately "odds ratios") and 95% confidence intervals were quoted or calculated for each risk factor in each study. Those risk factors that were reported to be significant in over half of the studies include: phenotypic factors (blue eyes, blond or red hair, light complexion, freckles, sun sensitivity, and inability to tan); personal history of non-melanoma cutaneous cancer or precancer; higher socioeconomic status; increased numbers of nevocytic nevi; and bursts of sun exposure. Further study is needed on family history and personal history of MM; these were not found to be significant risk factors in over half the reviewed case-control studies. This review leaves out other undoubtedly important risk factors such as dysplastic nervus syndrome and race, which need investigation by the case-control method. Determination of risk factors allows the identification of that subset of the population most at risk for the development of MM. Given the continued increase in the incidence of MM, these data can help to focus preventive measures on the more susceptible subgroups of the population.
Skin types in dysplastic nevus syndrome.
In order to determine if individuals with dysplastic nevi (DN) are relatively more sun-sensitive than controls who do not have DN, the sun-reactivity skin types (based on the Harvard classification) were determined in these two groups. Compared with controls, sun-sensitive types were significantly overrepresented in the DN group. This is consistent with the hypothesis that the fundamental defect in the dysplastic nevus syndrome is the genetically unstable melanocyte, which is susceptible to neoplastic transformation induced by sunlight.
Osteonecrosis of the femoral head.
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Revision total knee arthroplasty in patients with osteoarthritis.
Total knee replacement (TKR) is a technically demanding surgical procedure, which is becoming more reliable and durable than total hip replacements. The authors describe the mechanisms of failure, the clinical evaluation of the painful TKR, the surgical planning techniques, and the overall results of revision TKR to date.
False positive indium-111 white blood cell scan in a closed clavicle fracture.
Aggressive treatment of the multiply injured patient often requires early fixation of many fractures, some of which may be open. Often, patients develop postoperative fevers requiring a thorough workup to rule out infection. Recently, indium-111 white blood cell (WBC) imaging has become a valuable adjunct in the diagnosis of acute infection. The patient described had a simple, closed clavicle fracture with markedly increased activity on an indium-111 WBC scan obtained for fever workup. This subsequently proved to be a normal, healing, noninfected fracture by other diagnostic techniques. Noninfected, simple closed fractures should be added to the list of causes for a false-positive indium-111 WBC scan.
Heterotopic brain presenting as a lip lesion.
Heterotopic brain tissue in the upper lip of a newborn child is presented and discussed. This rare developmental anomaly is usually present at birth and may simulate hemangioma. Before any surgical procedure can be performed, thorough radiographic and neurosurgical examination is essential to rule out eventual communication of the tumor with intracranial space.
The relationship between melanocytic nevi and malignant melanoma.
In conclusion, although there are data, some quite convincingly implicating dysplastic nevi and congenital nevi (particularly "giant") as "precursors" of malignant melanomas, our ability to predict the magnitude of these associations is lacking. Thus, until additional basic and clinical research data are forthcoming, any recommendation to prophylactically remove all congenital nevi or all dysplastic nevi in order to decrease the incidence of malignant melanoma is premature. In regard to congenital nevi, evidence exists that giant (larger than 20 cm in diameter) congenital nevi may have a significant risk factor so as to warrant, when feasible, prophylactic excision of such lesions. In our opinion, no uniform recommendation can be made at this time for the management of small and medium-sized congenital nevi. Patients with familial dysplastic nevus syndrome should be followed carefully and educated concerning the early detection of malignant melanoma. Patients with sporadic dysplastic nevus syndrome deserve further study to enable us to accurately determine their risk of developing malignant melanoma.
Total shoulder replacement. Exciting progress in a rapidly developing field.
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Prognostic index for malignant melanoma.
This report verifies the ability of a Prognostic Index (PI) to accurately predict 5-year survival rates for 879 Stage I cutaneous malignant melanoma (MM) patients seen at New York University Medical Center. The PI used in this study was first reported from Munich, West Germany, and is calculated from standard histologic sections by multiplying the MM thickness in millimeters (Breslow method) by the number of MM mitoses per square millimeter. A PI value of less than 19 versus greater than or equal to 19 was found to be a significant and independent prognostic variable for Stage I MM when compared with seven other predictive variables (including Breslow thickness). These PI intervals identified a subgroup of patients with MM of intermediate thicknesses (1.50-3.49 mm) whose significantly worse survival would not have been anticipated if prognosis were determined by Breslow thickness alone. For example, patients with MM 1.50 to 2.49 mm thick have a 5-year survival rate of 84.1% determined by Breslow thickness alone; however, among these patients exists a subgroup with PI greater than or equal to 19 whose survival rate is only 57.6%. This study verifies the additive usefulness of the PI in predicting survival rates of patients with Stage I cutaneous MM.
A clinical and electrophysiological investigation of anterior transposition for ulnar neuropathy at the elbow.
Previous studies have shown good clinical results following anterior transposition of the ulnar nerve for compression neuropathy. However, no studies have examined all patients pre- and post-operatively with both clinical and electrophysiological studies to determine if a correlation exists. Twenty-three of 24 (96%) anterior transpositions performed consecutively over 6 years were followed up at a mean of 33.2 months with clinical and electrophysiological examinations. All patients were male "blue-collar" workers with a mean age of 52.1 years. The mean duration of preoperative symptoms was 11.3 months. Preoperatively, 30% were graded moderate and 70% severe. The motor conduction velocity (MCV) across the elbow and electromyography (EMG) correlated with the severity of the clinical findings. Postoperatively, 70% of patients improved, with 40% having a good result and 30% fair, and the MCV improved to a highly significant degree (P less than 0.0005). Thirty percent had a poor result with no clinical improvement, yet the MCV improved to a significant degree (P less than 0.05). There was no correlation between the clinical result and the distal motor or sensory latencies, MCV below the elbow, or EMG. Advanced age, duration of preoperative symptoms, diabetes, hypertension, alcoholism, etiology, type of transposition, tourniquet time, and atrophy did not correlate with a poor result, either clinically or electrophysiologically. Severe clinical findings confirmed by electrophysiological studies do not contraindicate surgery and have a reasonable success rate. In conclusion, preoperative electrophysiological studies correlate with the clinical findings but postoperative ones do not, including the MCV. The MCV improves after anterior transposition of the ulnar nerve regardless of the clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
The rate of malignant melanoma in the United States: are we making an impact?
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