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Dillon M.T.,The Permanente Medical Group | Inacio M.C.S.,Kaiser Permanente | Burke M.F.,Kaiser Permanente | Navarro R.A.,Southern California Permanente Medical Group | Yian E.H.,Southern California Permanente Medical Group
Journal of Shoulder and Elbow Surgery | Year: 2013

Background: While shoulder arthroplasty is a well established treatment for a variety of conditions about the shoulder, the results of shoulder replacement in younger patients are not as predictable. The purpose of this study is to examine the indications for shoulder arthroplasty in patients 59 years old and younger, and to analyze revision rates between younger and older patients. Methods: This is a retrospective cohort study of shoulder arthroplasties performed within a statewide integrated healthcare system between 2005 and 2010. Patients were stratified into 2 groups based on age at time of index replacement procedure: younger patients (≤59 years) and older patients (>59 years). Results: There were 2981 primary arthroplasties followed for a median time of 2.2 years (interquartile range, 1.0-3.8), 90 (3.0%) of which required revisions. After adjusting for procedure type and diagnosis, younger patients had a two times higher risk (95% CI 1.2-3.5, P = .007) of revision than older patients. When looking at the risk of revision in younger and older patients separately, the risk of revision in hemiarthroplasty (RR = 4.5 vs RR = 1.7) and reverse total shoulder arthroplasty (RR = 33.6 vs RR = 3.0) compared to total shoulder arthroplasty were higher in younger patients compared to older patients. Conclusion: This study suggests patients 59 years and younger have an increased risk of revision at early follow-up. The higher risk of revision in younger patients receiving hemiarthroplasty may support the use of total shoulder arthroplasty in patients 59 years of age and younger. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

Khatod M.,Southern California Permanente Medical Group | Inacio M.C.S.,Southern California Permanente Medical Group | Bini S.A.,The Permanente Medical Group | Paxton E.W.,Southern California Permanente Medical Group
Journal of Arthroplasty | Year: 2012

Prophylaxis for pulmonary embolism (PE) prevention in total knee arthroplasty remains controversial. A joint registry evaluated venous thromboembolism prophylaxis and anesthesia impact on the incidence of PE, fatal PE, and death. Patients received mechanical prophylaxis alone or chemical with or without mechanical prophylaxis. The overall PE incidence was 0.45%; fatal PE, 0.01%; and death, 0.31%. The only significant difference in any outcome was the incidence of PE between Coumadin and mechanical prophylaxis alone. Variables associated with a higher incidence of PE were age, an American Society of Anesthesiologists score of 3 or higher, and the use of general anesthesia. Based on the findings, general anesthesia can be discouraged, and only Coumadin fared better than mechanical prophylaxis alone, whereas other forms of chemical prophylaxis revealed no significant differences. © 2012 Elsevier Inc.

Dillon M.T.,The Permanente Medical Group
American journal of orthopedics (Belle Mead, N.J.) | Year: 2010

In the study reported here, we sought to determine the interobserver reliability and the intraobserver reproductibility of the Mason classification. We also evaluated the effect of having an external rotation oblique view on agreement in radiographic readings. Four readers reviewed 50 radial head fracture radiographs approximately 2 months apart. Half the radiographs had an anteroposterior view and a lateral view; the other half had an additional external rotation oblique view. There was a trend toward improved interobserver agreement in the 3-view radiographs. Three of the 4 readers demonstrated substantial intraobserver reproducibility, which was noted to be higher when 3 views were available.

Sagray B.A.,The Permanente Medical Group | Steinberg J.S.,Georgetown University
Clinics in Podiatric Medicine and Surgery | Year: 2014

Treatment of the patient with a diabetic foot infection and underlying osteomyelitis is currently an evolving process, often complicated by neuropathy, peripheral vascular disease, and renal insufficiency. Understanding which patients require hospitalization, intravenous antibiotic therapy, and urgent operative intervention may ultimately prevent the spread of infection or major limb amputation. The treating surgeon should focus on accurate and early diagnosis, proper antibiosis, and appropriate surgical debridement to eradicate infection while preserving function with a plantar-grade foot. © 2014 Elsevier Inc.

Bauer J.L.,Southern California Permanente Medical Group | Miklos A.Z.,The Permanente Medical Group | Thompson L.D.R.,Southern California Permanente Medical Group
Head and Neck Pathology | Year: 2012

Solitary fibrous tumors (SFTs) are rare tumors in the head and neck, and even more so in the parotid gland. The mass-like clinical presentation and histologic features result in frequent misclassification, resulting in inappropriate clinical management. There are only a few reported cases in the English literature. Twenty-one patients with parotid gland solitary fibrous tumor were compiled from the English literature (Medline 1960-2011) and integrated with this case report. The patients included 11 males and 11 females, aged 11-79 years (mean, 51.2 years), who presented with a parotid gland painless mass gradually increasing in size or with compression symptoms, with a mean duration of symptoms of 24.7 months. The mean tumor size was 4.5 cm. Grossly, all tumors were described as well-circumscribed to encapsulated, firm, homogenous white to tan masses. Seven patients had a preoperative fine needle aspiration performed, with the majority interpreted to represent pleomorphic adenoma or cementifying fibroma. Histologically, the tumors were well circumscribed, although many tumors showed focally entrapped normal salivary gland acini and ducts at the edge. The tumors were cellular, arranged in haphazard short interlacing fascicles of spindled to epithelioid cells. The spindled cells showed tapering cytoplasm with monotonous, round to oval nuclei with coarse nuclear chromatin distribution. Keloid-like to wiry collagen was present between the neoplastic cells. Mitoses were identified in most cases, while necrosis was absent. Isolated, patulous vessels were present, but a well developed "hemangiopericytoma-like" vascular pattern was not seen. Three tumors were classified as malignant, showing marked nuclear pleomorphism and increased mitoses. When immunohistochemistry was performed, all tumors showed strong and diffuse vimentin, with a majority showing CD34, bcl-2 and CD99 immunoreactivity; all cases tested were negative for S100 protein, cytokeratin, EMA, CAM5. 2, smooth muscle actin, muscle specific actin, desmin, MYOD1, myogenin, CD117, GFAP, CD31, FVIII-RAg, collagen IV, p63, p53, calponin, caldesmon, CD56, NFP, and ALK-1. The principle differential diagnoses include pleomorphic adenoma, myoepithelioma, nodular fasciitis, schwannoma, fibromatosis coli, spindle cell "sarcomatoid" carcinoma, and spindle cell melanoma. All patients were managed with surgery, while two patients also received radiation therapy. Metastatic disease was identified in one patient immediately after excision. All patients with follow-up were alive without evidence of disease (n = 18), but the average follow-up is only 1. 9 years. One patient is alive with disease at 12 months. Parotid gland SFT is a rare tumor, usually presenting in middle aged adults as a slowly growing mass. Characteristic histologic appearance with CD34 and bcl-2 immunoreactivity support the diagnosis. Surgery is the treatment of choice to yield a good outcome. © 2011 Springer Science+Business Media, LLC 2011(outside the USA).

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