Christine Kilgore

WASHINGTON — Growing public demand for minimally invasive hip and knee replacement—and increasing hype over small incisions—is driving a wedge in the orthopedic community, exciting some surgeons and fueling anxiety and anger among others.

At the annual meeting of the American Academy of Orthopaedic Surgeons, discussions of minimally invasive joint replacement and “mini” incisions drew crowds. Physicians shared surgical techniques, reported outcomes, described learning curves, and discussed what most—if not everyone—agreed are a lack of long-term effectiveness data, a paucity of randomized controlled studies, and unrealistically high public expectations fueled by direct-to-patient advertising.

“Surgeons have readily adapted these techniques despite the lack of evidence to support better outcomes,” said Jay Lieberman, M.D., of the University of California, Los Angeles. “We've all done this because of patient interest, the potential for improved function and cosmetics, and, though we don't like to admit it, the fear of lost income and market share.”

There are no commonly accepted definitions for “minimally invasive” total joint replacement surgery. Published studies define the incisions for less invasive knee replacement surgery as approximately one-half the length of traditional incisions.

Most single-incision techniques for less invasive hip replacement allow for surgery through an incision that's one-half or less of the 10- to 12-inch length of a traditional total hip incision. A newer two-incision technique, the one technique that completely spares the muscles, utilizes incisions that are about 2-4 inches in length.

Potential Advantages

The promise of the minimally invasive techniques is that reduced trauma—to the skin, soft tissue, and muscle, for example—can lead to quicker recoveries, shorter hospital stays, less pain, and less blood loss. The potential risks, physicians said, include malposition or instability of the prostheses, skin necrosis and maceration, fracture, and nerve palsy. So far, none of the claims have been substantiated in prospective, randomized, long-term trials.

Nearly 250,000 hip replacements and 300,000 knee replacements are done annually—increasingly in younger, active patients—according to the AAOS.

“Several years ago, when less invasive approaches were introduced, many surgeons felt it was a foolish idea,” said Aaron Rosenberg, M.D., of Rush University Medical Center in Chicago. “Ask today how many are doing small incisions, and everybody raises their hands.

Scar appearance “is real for patients, and early recovery is real, and if you provide that, patients will line up at your door,” Dr. Rosenberg said.

In its 2004 “physician advisory statement” on minimally invasive joint replacement surgery, the American Association of Hip and Knee Surgeons said that “most positive results have been demonstrated by a small number of [high-volume] total joint centers in selected patient populations.”

Two Incisions Better Than One?

At the AAOS meeting, orthopedic surgeons spoke of positive results at their own institutions.

Richard A. Berger, M.D., reported that all of his patients undergoing two-incision hip replacement at Rush University Medical Center in Chicago now leave for home the same day of surgery, with no risk of readmission or postdischarge complications.

“There's nothing magic about two incisions. That's just the only way we could figure out how to do it without disturbing any muscles or tendons. … It's a completely muscle-sparing approach,” said Dr. Berger, who, according to the AAOS, was the first surgeon to perform total hip replacements and knee replacements as outpatient procedures.

Rather than making a single smaller incision using either a posterior or anterolateral approach, Dr. Berger makes one 4- to 5-cm incision directly over the femoral neck, which allows for preparation and placement of the femoral component of the hip prosthesis. The acetabular component is placed through a second incision, also 4-5 cm. Unique instruments and fluoroscopic guidance help ensure accurate component position and alignment.

In a presentation on “learning curve complications,” Alan E. Gross, M.D., who also uses the two-incision technique, said the technique represents “a dramatic paradigm shift” from traditional approaches and thus has a steep learning curve. It takes about 50 cases to perform the procedure successfully.

A single-incision “mini” operation uses the “same technique as traditional (surgery) except that it's a shorter incision with less muscle dissection,” said Dr. Gross of Mt. Sinai Hospital in Toronto. The learning curve, he said, is “probably about 10 cases.”

An important difference between the two techniques is that “the bail-out with the single-incision mini is easy. You just make the incision longer,” he said.

“The bail-out with the two-incision mini is very stressful and very difficult,” Dr. Gross said. “Basically, you have to close up and start all over again.”

Positive Outcomes

Lawrence D. Dorr, M.D., of the Arthritis Institutes in Los Angeles and Inglewood, Calif., said that his mini-incision total hip replacements result in improved gait analysis results 6 weeks postoperatively and improved patient pain scores. “These operations as I perform them now are the best hip replacements I've ever done,” he said.

Alfred J. Tria, M.D., of St. Peter's University Hospital at Robert Wood Johnson Medical School, New Brunswick, N.J., reported that those of his patients who had minimally invasive knee replacements (about 300) have recovered three times faster, have one-third less pain, one-third less time in the hospital, 30% less blood loss, and an increased range of motion, compared with patients who underwent standard procedures.

Other physicians presented cohort studies and case studies, most of them published, that provide short-term outcome data. Some showed benefits in terms of early recovery and cosmetics, but others showed no differences in any factor—from functional recovery to complications.

“That's not better, but if you're an advocate, it's not worse either. If you're not having more complications, perhaps it's not an unreasonable thing to continue doing,” said William Hozack, M.D., of Thomas Jefferson University Hospital, Philadelphia.

Long-term durability remains a key question for many physicians. “If we are malpositioning components even slightly, are those implants going to last as long?” Dr. Gross asked. “If it's an 80-year-old lady, it wouldn't matter. But if it's a 50-year-old male or female … it does.”

Criticism and Complications

Several speakers cited a retrospective study published last year showing no difference in blood loss and hospital stay between small-incision and conventional hip replacement surgery, and a higher risk of soft-tissue complications and component malposition with the “mini” incisions.

Richard Rothman, M.D., of the Rothman Institute and the Thomas Jefferson University Hospital in Philadelphia, argued in a pro-con session that many recent reports have shown complication rates with minimally invasive hip replacement surgery that are three times higher than with the conventional approach.

“There's no demonstrable advantage, and there's increased risk to your patients,” Dr. Rothman said. “So, when I look at the facts, the nails are in the coffin.”

He and other critics of the new techniques argue that the high rate of success with traditional hip and knee replacement surgery renders the newer techniques unnecessary.

Patients are being bombarded, however, with information about the minimally invasive techniques from hospitals, companies, and some surgeons. They also find plenty on the Internet.

“I did a Google search on minimally invasive total knee placement and found 66,000-plus sites. I did a Medline search and found 13,” said Thomas Thornhill, M.D., who still uses a traditional-length incision for many of his knee replacements at Brigham and Women's Hospital in Boston.

Ryan S. Labovitch, M.D., an orthopedic resident at the University of California, San Francisco, reported at the meeting that much of the online information about minimally invasive hip replacement surgery is marketing oriented and often incomplete or inaccurate. Only 13% of Web sites described the potential risks with either the standard or the minimally invasive surgery, he said.

Patients' expectations and satisfaction with the outcome—even if that outcome is scar size—are important, however, as long as surgeons are up-front and honest, others argued.

“I tell patients, I will do what I can to make the operation as minimally invasive as possible, but I will prioritize the long- and short-term results over the cosmetics,” Dr. Rosenberg said. “I also tell them, your scar size will be different if you're a size 3 than if you're a size 14.”

Complications, Dr. Rosenberg told his colleagues, are an inevitable part of any new surgical technique. “No doubt, minimally invasive [joint replacement] surgery has introduced a whole raft of complications,” he said. “But they will decrease with experience, better patient selection, implant selection, and [physician] training.

“Progress comes at a price,” he added.

The challenge in future research, he and others said, will be to accurately tease out the effects of less invasive surgical techniques from other changes—such as new protocols for anesthesia, pain management, rehabilitation, and patient education—that have been introduced at the same time as minimally invasive joint replacement surgery.

One incision, over the femoral neck, allows for placement of the femoral component; the other, the acetabular component. Courtesy Dr. Richard A. Berger

WASHINGTON — Growing public demand for minimally invasive hip and knee replacement—and increasing hype over small incisions—is driving a wedge in the orthopedic community, exciting some surgeons and fueling anxiety and anger among others.

At the annual meeting of the American Academy of Orthopaedic Surgeons, discussions of minimally invasive joint replacement and “mini” incisions drew crowds. Physicians shared surgical techniques, reported outcomes, described learning curves, and discussed what most—if not everyone—agreed are a lack of long-term effectiveness data, a paucity of randomized controlled studies, and unrealistically high public expectations fueled by direct-to-patient advertising.

“Surgeons have readily adapted these techniques despite the lack of evidence to support better outcomes,” said Jay Lieberman, M.D., of the University of California, Los Angeles. “We've all done this because of patient interest, the potential for improved function and cosmetics, and, though we don't like to admit it, the fear of lost income and market share.”

There are no commonly accepted definitions for “minimally invasive” total joint replacement surgery. Published studies define the incisions for less invasive knee replacement surgery as approximately one-half the length of traditional incisions.

Most single-incision techniques for less invasive hip replacement allow for surgery through an incision that's one-half or less of the 10- to 12-inch length of a traditional total hip incision. A newer two-incision technique, the one technique that completely spares the muscles, utilizes incisions that are about 2-4 inches in length.

Potential Advantages

The promise of the minimally invasive techniques is that reduced trauma—to the skin, soft tissue, and muscle, for example—can lead to quicker recoveries, shorter hospital stays, less pain, and less blood loss. The potential risks, physicians said, include malposition or instability of the prostheses, skin necrosis and maceration, fracture, and nerve palsy. So far, none of the claims have been substantiated in prospective, randomized, long-term trials.

Nearly 250,000 hip replacements and 300,000 knee replacements are done annually—increasingly in younger, active patients—according to the AAOS.

“Several years ago, when less invasive approaches were introduced, many surgeons felt it was a foolish idea,” said Aaron Rosenberg, M.D., of Rush University Medical Center in Chicago. “Ask today how many are doing small incisions, and everybody raises their hands.

Scar appearance “is real for patients, and early recovery is real, and if you provide that, patients will line up at your door,” Dr. Rosenberg said.

In its 2004 “physician advisory statement” on minimally invasive joint replacement surgery, the American Association of Hip and Knee Surgeons said that “most positive results have been demonstrated by a small number of [high-volume] total joint centers in selected patient populations.”

Two Incisions Better Than One?

At the AAOS meeting, orthopedic surgeons spoke of positive results at their own institutions.

Richard A. Berger, M.D., reported that all of his patients undergoing two-incision hip replacement at Rush University Medical Center in Chicago now leave for home the same day of surgery, with no risk of readmission or postdischarge complications.

“There's nothing magic about two incisions. That's just the only way we could figure out how to do it without disturbing any muscles or tendons. … It's a completely muscle-sparing approach,” said Dr. Berger, who, according to the AAOS, was the first surgeon to perform total hip replacements and knee replacements as outpatient procedures.

Rather than making a single smaller incision using either a posterior or anterolateral approach, Dr. Berger makes one 4- to 5-cm incision directly over the femoral neck, which allows for preparation and placement of the femoral component of the hip prosthesis. The acetabular component is placed through a second incision, also 4-5 cm. Unique instruments and fluoroscopic guidance help ensure accurate component position and alignment.

In a presentation on “learning curve complications,” Alan E. Gross, M.D., who also uses the two-incision technique, said the technique represents “a dramatic paradigm shift” from traditional approaches and thus has a steep learning curve. It takes about 50 cases to perform the procedure successfully.

A single-incision “mini” operation uses the “same technique as traditional (surgery) except that it's a shorter incision with less muscle dissection,” said Dr. Gross of Mt. Sinai Hospital in Toronto. The learning curve, he said, is “probably about 10 cases.”

An important difference between the two techniques is that “the bail-out with the single-incision mini is easy. You just make the incision longer,” he said.

“The bail-out with the two-incision mini is very stressful and very difficult,” Dr. Gross said. “Basically, you have to close up and start all over again.”

Positive Outcomes

Lawrence D. Dorr, M.D., of the Arthritis Institutes in Los Angeles and Inglewood, Calif., said that his mini-incision total hip replacements result in improved gait analysis results 6 weeks postoperatively and improved patient pain scores. “These operations as I perform them now are the best hip replacements I've ever done,” he said.

Alfred J. Tria, M.D., of St. Peter's University Hospital at Robert Wood Johnson Medical School, New Brunswick, N.J., reported that those of his patients who had minimally invasive knee replacements (about 300) have recovered three times faster, have one-third less pain, one-third less time in the hospital, 30% less blood loss, and an increased range of motion, compared with patients who underwent standard procedures.

Other physicians presented cohort studies and case studies, most of them published, that provide short-term outcome data. Some showed benefits in terms of early recovery and cosmetics, but others showed no differences in any factor—from functional recovery to complications.

“That's not better, but if you're an advocate, it's not worse either. If you're not having more complications, perhaps it's not an unreasonable thing to continue doing,” said William Hozack, M.D., of Thomas Jefferson University Hospital, Philadelphia.

Long-term durability remains a key question for many physicians. “If we are malpositioning components even slightly, are those implants going to last as long?” Dr. Gross asked. “If it's an 80-year-old lady, it wouldn't matter. But if it's a 50-year-old male or female … it does.”

Criticism and Complications

Several speakers cited a retrospective study published last year showing no difference in blood loss and hospital stay between small-incision and conventional hip replacement surgery, and a higher risk of soft-tissue complications and component malposition with the “mini” incisions.

Richard Rothman, M.D., of the Rothman Institute and the Thomas Jefferson University Hospital in Philadelphia, argued in a pro-con session that many recent reports have shown complication rates with minimally invasive hip replacement surgery that are three times higher than with the conventional approach.

“There's no demonstrable advantage, and there's increased risk to your patients,” Dr. Rothman said. “So, when I look at the facts, the nails are in the coffin.”

He and other critics of the new techniques argue that the high rate of success with traditional hip and knee replacement surgery renders the newer techniques unnecessary.

Patients are being bombarded, however, with information about the minimally invasive techniques from hospitals, companies, and some surgeons. They also find plenty on the Internet.

“I did a Google search on minimally invasive total knee placement and found 66,000-plus sites. I did a Medline search and found 13,” said Thomas Thornhill, M.D., who still uses a traditional-length incision for many of his knee replacements at Brigham and Women's Hospital in Boston.

Ryan S. Labovitch, M.D., an orthopedic resident at the University of California, San Francisco, reported at the meeting that much of the online information about minimally invasive hip replacement surgery is marketing oriented and often incomplete or inaccurate. Only 13% of Web sites described the potential risks with either the standard or the minimally invasive surgery, he said.

Patients' expectations and satisfaction with the outcome—even if that outcome is scar size—are important, however, as long as surgeons are up-front and honest, others argued.

“I tell patients, I will do what I can to make the operation as minimally invasive as possible, but I will prioritize the long- and short-term results over the cosmetics,” Dr. Rosenberg said. “I also tell them, your scar size will be different if you're a size 3 than if you're a size 14.”

Complications, Dr. Rosenberg told his colleagues, are an inevitable part of any new surgical technique. “No doubt, minimally invasive [joint replacement] surgery has introduced a whole raft of complications,” he said. “But they will decrease with experience, better patient selection, implant selection, and [physician] training.

“Progress comes at a price,” he added.

The challenge in future research, he and others said, will be to accurately tease out the effects of less invasive surgical techniques from other changes—such as new protocols for anesthesia, pain management, rehabilitation, and patient education—that have been introduced at the same time as minimally invasive joint replacement surgery.

One incision, over the femoral neck, allows for placement of the femoral component; the other, the acetabular component. Courtesy Dr. Richard A. Berger

WASHINGTON — Growing public demand for minimally invasive hip and knee replacement—and increasing hype over small incisions—is driving a wedge in the orthopedic community, exciting some surgeons and fueling anxiety and anger among others.

At the annual meeting of the American Academy of Orthopaedic Surgeons, discussions of minimally invasive joint replacement and “mini” incisions drew crowds. Physicians shared surgical techniques, reported outcomes, described learning curves, and discussed what most—if not everyone—agreed are a lack of long-term effectiveness data, a paucity of randomized controlled studies, and unrealistically high public expectations fueled by direct-to-patient advertising.

“Surgeons have readily adapted these techniques despite the lack of evidence to support better outcomes,” said Jay Lieberman, M.D., of the University of California, Los Angeles. “We've all done this because of patient interest, the potential for improved function and cosmetics, and, though we don't like to admit it, the fear of lost income and market share.”

There are no commonly accepted definitions for “minimally invasive” total joint replacement surgery. Published studies define the incisions for less invasive knee replacement surgery as approximately one-half the length of traditional incisions.

Most single-incision techniques for less invasive hip replacement allow for surgery through an incision that's one-half or less of the 10- to 12-inch length of a traditional total hip incision. A newer two-incision technique, the one technique that completely spares the muscles, utilizes incisions that are about 2-4 inches in length.

Potential Advantages

The promise of the minimally invasive techniques is that reduced trauma—to the skin, soft tissue, and muscle, for example—can lead to quicker recoveries, shorter hospital stays, less pain, and less blood loss. The potential risks, physicians said, include malposition or instability of the prostheses, skin necrosis and maceration, fracture, and nerve palsy. So far, none of the claims have been substantiated in prospective, randomized, long-term trials.

Nearly 250,000 hip replacements and 300,000 knee replacements are done annually—increasingly in younger, active patients—according to the AAOS.

“Several years ago, when less invasive approaches were introduced, many surgeons felt it was a foolish idea,” said Aaron Rosenberg, M.D., of Rush University Medical Center in Chicago. “Ask today how many are doing small incisions, and everybody raises their hands.

Scar appearance “is real for patients, and early recovery is real, and if you provide that, patients will line up at your door,” Dr. Rosenberg said.

In its 2004 “physician advisory statement” on minimally invasive joint replacement surgery, the American Association of Hip and Knee Surgeons said that “most positive results have been demonstrated by a small number of [high-volume] total joint centers in selected patient populations.”

Two Incisions Better Than One?

At the AAOS meeting, orthopedic surgeons spoke of positive results at their own institutions.

Richard A. Berger, M.D., reported that all of his patients undergoing two-incision hip replacement at Rush University Medical Center in Chicago now leave for home the same day of surgery, with no risk of readmission or postdischarge complications.

“There's nothing magic about two incisions. That's just the only way we could figure out how to do it without disturbing any muscles or tendons. … It's a completely muscle-sparing approach,” said Dr. Berger, who, according to the AAOS, was the first surgeon to perform total hip replacements and knee replacements as outpatient procedures.

Rather than making a single smaller incision using either a posterior or anterolateral approach, Dr. Berger makes one 4- to 5-cm incision directly over the femoral neck, which allows for preparation and placement of the femoral component of the hip prosthesis. The acetabular component is placed through a second incision, also 4-5 cm. Unique instruments and fluoroscopic guidance help ensure accurate component position and alignment.

In a presentation on “learning curve complications,” Alan E. Gross, M.D., who also uses the two-incision technique, said the technique represents “a dramatic paradigm shift” from traditional approaches and thus has a steep learning curve. It takes about 50 cases to perform the procedure successfully.

A single-incision “mini” operation uses the “same technique as traditional (surgery) except that it's a shorter incision with less muscle dissection,” said Dr. Gross of Mt. Sinai Hospital in Toronto. The learning curve, he said, is “probably about 10 cases.”

An important difference between the two techniques is that “the bail-out with the single-incision mini is easy. You just make the incision longer,” he said.

“The bail-out with the two-incision mini is very stressful and very difficult,” Dr. Gross said. “Basically, you have to close up and start all over again.”

Positive Outcomes

Lawrence D. Dorr, M.D., of the Arthritis Institutes in Los Angeles and Inglewood, Calif., said that his mini-incision total hip replacements result in improved gait analysis results 6 weeks postoperatively and improved patient pain scores. “These operations as I perform them now are the best hip replacements I've ever done,” he said.

Alfred J. Tria, M.D., of St. Peter's University Hospital at Robert Wood Johnson Medical School, New Brunswick, N.J., reported that those of his patients who had minimally invasive knee replacements (about 300) have recovered three times faster, have one-third less pain, one-third less time in the hospital, 30% less blood loss, and an increased range of motion, compared with patients who underwent standard procedures.

Other physicians presented cohort studies and case studies, most of them published, that provide short-term outcome data. Some showed benefits in terms of early recovery and cosmetics, but others showed no differences in any factor—from functional recovery to complications.

“That's not better, but if you're an advocate, it's not worse either. If you're not having more complications, perhaps it's not an unreasonable thing to continue doing,” said William Hozack, M.D., of Thomas Jefferson University Hospital, Philadelphia.

Long-term durability remains a key question for many physicians. “If we are malpositioning components even slightly, are those implants going to last as long?” Dr. Gross asked. “If it's an 80-year-old lady, it wouldn't matter. But if it's a 50-year-old male or female … it does.”

Criticism and Complications

Several speakers cited a retrospective study published last year showing no difference in blood loss and hospital stay between small-incision and conventional hip replacement surgery, and a higher risk of soft-tissue complications and component malposition with the “mini” incisions.

Richard Rothman, M.D., of the Rothman Institute and the Thomas Jefferson University Hospital in Philadelphia, argued in a pro-con session that many recent reports have shown complication rates with minimally invasive hip replacement surgery that are three times higher than with the conventional approach.

“There's no demonstrable advantage, and there's increased risk to your patients,” Dr. Rothman said. “So, when I look at the facts, the nails are in the coffin.”

He and other critics of the new techniques argue that the high rate of success with traditional hip and knee replacement surgery renders the newer techniques unnecessary.

Patients are being bombarded, however, with information about the minimally invasive techniques from hospitals, companies, and some surgeons. They also find plenty on the Internet.

“I did a Google search on minimally invasive total knee placement and found 66,000-plus sites. I did a Medline search and found 13,” said Thomas Thornhill, M.D., who still uses a traditional-length incision for many of his knee replacements at Brigham and Women's Hospital in Boston.

Ryan S. Labovitch, M.D., an orthopedic resident at the University of California, San Francisco, reported at the meeting that much of the online information about minimally invasive hip replacement surgery is marketing oriented and often incomplete or inaccurate. Only 13% of Web sites described the potential risks with either the standard or the minimally invasive surgery, he said.

Patients' expectations and satisfaction with the outcome—even if that outcome is scar size—are important, however, as long as surgeons are up-front and honest, others argued.

“I tell patients, I will do what I can to make the operation as minimally invasive as possible, but I will prioritize the long- and short-term results over the cosmetics,” Dr. Rosenberg said. “I also tell them, your scar size will be different if you're a size 3 than if you're a size 14.”

Complications, Dr. Rosenberg told his colleagues, are an inevitable part of any new surgical technique. “No doubt, minimally invasive [joint replacement] surgery has introduced a whole raft of complications,” he said. “But they will decrease with experience, better patient selection, implant selection, and [physician] training.

“Progress comes at a price,” he added.

The challenge in future research, he and others said, will be to accurately tease out the effects of less invasive surgical techniques from other changes—such as new protocols for anesthesia, pain management, rehabilitation, and patient education—that have been introduced at the same time as minimally invasive joint replacement surgery.

One incision, over the femoral neck, allows for placement of the femoral component; the other, the acetabular component. Courtesy Dr. Richard A. Berger

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991, the investigators reported.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more then 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991, the investigators reported.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more then 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991, the investigators reported.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more then 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask to have items corrected, deleted, or changed that are errors or that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “there's a federal right of access” to records.

Moreover, President Bush's emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally more concerned about the content of electronic records than paper records, said Mr. Annas, who is professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

There are “lots of mistakes in medical records,” making it likely that in the future, many changes will address errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to records, saying “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask to have items corrected, deleted, or changed that are errors or that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “there's a federal right of access” to records.

Moreover, President Bush's emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally more concerned about the content of electronic records than paper records, said Mr. Annas, who is professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

There are “lots of mistakes in medical records,” making it likely that in the future, many changes will address errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to records, saying “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask to have items corrected, deleted, or changed that are errors or that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “there's a federal right of access” to records.

Moreover, President Bush's emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally more concerned about the content of electronic records than paper records, said Mr. Annas, who is professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

There are “lots of mistakes in medical records,” making it likely that in the future, many changes will address errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to records, saying “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

WASHINGTON — Osteocapsular arthroscopy aimed at reshaping the glenoid bone may—with more long-term experience—be proven an effective treatment for patients with glenohumeral osteoarthritis who do not desire total shoulder replacement, Scott Steinmann, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

At this point, it's clear that younger patients with more severe arthritis do not benefit much from debridement, making other alternatives to total shoulder replacement desirable, said Dr. Steinmann of the Mayo Clinic in Rochester, Minn.

There are few reports in the literature and no significant long-term follow-up of patients who have undergone arthroscopic glenoidplasty, a new, relatively aggressive arthroscopic procedure.

However, a 3-year mean follow-up of 14 patients whom Dr. Steinmann and his colleagues treated with the procedure has revealed significant pain relief and high patient satisfaction.

“When we've asked patients how they felt, they [have said] they liked the procedure,” said Dr. Steinmann. “I think they liked a couple small holes and being told they could do whatever they want afterward. They agree the surgery was worthwhile. … But we definitely need to follow them longer.”

Total shoulder replacement remains the standard treatment, but a significant number of replacements show that the glenoid loosens over time.

Some patients—like the ranchers and farmers who Dr. Steinmann treats—are young and active and “could put a prosthesis in jeopardy,” he said. “Some also tell me, 'I don't want any metal or plastic in my body.'”

Arthroscopic options for glenohumeral arthritis range from the simplest option of synovectomy and removal of loose bodies, to the more extensive option of capsular resection and recontouring of the glenoid and humerus.

Dr. Steinmann said he believes the more aggressive approach may prove the most promising for patients with extensive arthritis.

It usually involves synovectomy, osteophyte removal, and capsule release but goes further by involving the conversion of a biconcave glenoid into a single concavity—a change that, theoretically, can restore the position of the humeral head, reducing the posterior subluxation and helping to relax contracted soft tissues.

Restoration of a single concavity may also increase the surface area of the glenohumeral articulation, decreasing joint pressure, he said.

Axillary radiographs taken in his 14 patients show that glenoid depth can be increased by about 3 mm—“a rough measurement, but something to hang our hat on,” he said.

Dr. Steinmann's patients were about 50 years old, on average; 10 of the 14 had previous osteoarthritis. They all had impingement pain at the end of motion, and about half had rest pain, indicating the presence of synovitis. They had no pain with glenohumeral compression or rotation.

The return of function is much less predictable with this procedure than pain relief, Dr. Steinmann said. “Essentially, the range of motion, we're telling patients, will be very similar to what they have,” he said. In a total shoulder replacement, “I usually try to restore much more motion.”

What impact, if any, the surgery may have on a surgeon's ability to perform total shoulder replacement later on is unclear.

“One question is, what happens when you cut out that cartilage and start burring down the glenoid? Does it ruin the chance to do a total shoulder later? We need to follow patients longer.”

WASHINGTON — Osteocapsular arthroscopy aimed at reshaping the glenoid bone may—with more long-term experience—be proven an effective treatment for patients with glenohumeral osteoarthritis who do not desire total shoulder replacement, Scott Steinmann, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

At this point, it's clear that younger patients with more severe arthritis do not benefit much from debridement, making other alternatives to total shoulder replacement desirable, said Dr. Steinmann of the Mayo Clinic in Rochester, Minn.

There are few reports in the literature and no significant long-term follow-up of patients who have undergone arthroscopic glenoidplasty, a new, relatively aggressive arthroscopic procedure.

However, a 3-year mean follow-up of 14 patients whom Dr. Steinmann and his colleagues treated with the procedure has revealed significant pain relief and high patient satisfaction.

“When we've asked patients how they felt, they [have said] they liked the procedure,” said Dr. Steinmann. “I think they liked a couple small holes and being told they could do whatever they want afterward. They agree the surgery was worthwhile. … But we definitely need to follow them longer.”

Total shoulder replacement remains the standard treatment, but a significant number of replacements show that the glenoid loosens over time.

Some patients—like the ranchers and farmers who Dr. Steinmann treats—are young and active and “could put a prosthesis in jeopardy,” he said. “Some also tell me, 'I don't want any metal or plastic in my body.'”

Arthroscopic options for glenohumeral arthritis range from the simplest option of synovectomy and removal of loose bodies, to the more extensive option of capsular resection and recontouring of the glenoid and humerus.

Dr. Steinmann said he believes the more aggressive approach may prove the most promising for patients with extensive arthritis.

It usually involves synovectomy, osteophyte removal, and capsule release but goes further by involving the conversion of a biconcave glenoid into a single concavity—a change that, theoretically, can restore the position of the humeral head, reducing the posterior subluxation and helping to relax contracted soft tissues.

Restoration of a single concavity may also increase the surface area of the glenohumeral articulation, decreasing joint pressure, he said.

Axillary radiographs taken in his 14 patients show that glenoid depth can be increased by about 3 mm—“a rough measurement, but something to hang our hat on,” he said.

Dr. Steinmann's patients were about 50 years old, on average; 10 of the 14 had previous osteoarthritis. They all had impingement pain at the end of motion, and about half had rest pain, indicating the presence of synovitis. They had no pain with glenohumeral compression or rotation.

The return of function is much less predictable with this procedure than pain relief, Dr. Steinmann said. “Essentially, the range of motion, we're telling patients, will be very similar to what they have,” he said. In a total shoulder replacement, “I usually try to restore much more motion.”

What impact, if any, the surgery may have on a surgeon's ability to perform total shoulder replacement later on is unclear.

“One question is, what happens when you cut out that cartilage and start burring down the glenoid? Does it ruin the chance to do a total shoulder later? We need to follow patients longer.”

WASHINGTON — Osteocapsular arthroscopy aimed at reshaping the glenoid bone may—with more long-term experience—be proven an effective treatment for patients with glenohumeral osteoarthritis who do not desire total shoulder replacement, Scott Steinmann, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

At this point, it's clear that younger patients with more severe arthritis do not benefit much from debridement, making other alternatives to total shoulder replacement desirable, said Dr. Steinmann of the Mayo Clinic in Rochester, Minn.

There are few reports in the literature and no significant long-term follow-up of patients who have undergone arthroscopic glenoidplasty, a new, relatively aggressive arthroscopic procedure.

However, a 3-year mean follow-up of 14 patients whom Dr. Steinmann and his colleagues treated with the procedure has revealed significant pain relief and high patient satisfaction.

“When we've asked patients how they felt, they [have said] they liked the procedure,” said Dr. Steinmann. “I think they liked a couple small holes and being told they could do whatever they want afterward. They agree the surgery was worthwhile. … But we definitely need to follow them longer.”

Total shoulder replacement remains the standard treatment, but a significant number of replacements show that the glenoid loosens over time.

Some patients—like the ranchers and farmers who Dr. Steinmann treats—are young and active and “could put a prosthesis in jeopardy,” he said. “Some also tell me, 'I don't want any metal or plastic in my body.'”

Arthroscopic options for glenohumeral arthritis range from the simplest option of synovectomy and removal of loose bodies, to the more extensive option of capsular resection and recontouring of the glenoid and humerus.

Dr. Steinmann said he believes the more aggressive approach may prove the most promising for patients with extensive arthritis.

It usually involves synovectomy, osteophyte removal, and capsule release but goes further by involving the conversion of a biconcave glenoid into a single concavity—a change that, theoretically, can restore the position of the humeral head, reducing the posterior subluxation and helping to relax contracted soft tissues.

Restoration of a single concavity may also increase the surface area of the glenohumeral articulation, decreasing joint pressure, he said.

Axillary radiographs taken in his 14 patients show that glenoid depth can be increased by about 3 mm—“a rough measurement, but something to hang our hat on,” he said.

Dr. Steinmann's patients were about 50 years old, on average; 10 of the 14 had previous osteoarthritis. They all had impingement pain at the end of motion, and about half had rest pain, indicating the presence of synovitis. They had no pain with glenohumeral compression or rotation.

The return of function is much less predictable with this procedure than pain relief, Dr. Steinmann said. “Essentially, the range of motion, we're telling patients, will be very similar to what they have,” he said. In a total shoulder replacement, “I usually try to restore much more motion.”

What impact, if any, the surgery may have on a surgeon's ability to perform total shoulder replacement later on is unclear.

“One question is, what happens when you cut out that cartilage and start burring down the glenoid? Does it ruin the chance to do a total shoulder later? We need to follow patients longer.”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

WASHINGTON — Gait analysis is a promising outcomes assessment tool for children undergoing orthopedic surgery, Norman Y. Otsuka, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Results of a study comparing three-dimensional computerized gait analysis with various measures of function and quality of life suggest that gait analysis “reflects real functional abilities, and improvement [in gait analysis] reflects real functional improvement,” said Dr. Otsuka of Shriners Hospitals for Children, Los Angeles.

Gait analysis is designed to provide objective, quantitative information about all aspects of gait, from overall walking to specific joint-related ranges of motion.

Children with cerebral palsy have shown improvement in gait analysis results following multilevel orthopedic surgery, but it has not been clear whether such improvements accurately reflect changes in function and quality of life.

In the study, 25 children with cerebral palsy underwent gait analysis and functional testing and participated in validated questionnaires preoperatively and at 1 year after multilevel lower extremity orthopedic surgery. The children, 8-16 years old, all had hip flexion contractures and were part of a larger trial of surgical techniques.

To make gait analysis results more easily interpretable, Dr. Otsuka and his colleagues used a summary gait analysis variable, called the “Normalcy Index,” which reflects the extent to which a child's gait deviates from the normal. The index is calculated from 16 kinematic and temporal parameters measured by gait analysis.

They compared the Normalcy Index with the total score for dimensions D (standing) and E (walking, running, jumping) of the Gross Motor Function Measure (GMFM), the walking score from the Gillette Functional Assessment Questionnaire (FAQ), and scores from the Pediatric Outcomes Data Collection Instrument (PODCI).

Results showed a strong correlation overall between the gait analysis Normalcy Index and the other scores, both before and after surgery, Dr. Otsuka said. Change in the Normalcy Index was most strongly correlated with change in the GMFM score; it did not correlate significantly with the PODCI score.

WASHINGTON — Gait analysis is a promising outcomes assessment tool for children undergoing orthopedic surgery, Norman Y. Otsuka, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Results of a study comparing three-dimensional computerized gait analysis with various measures of function and quality of life suggest that gait analysis “reflects real functional abilities, and improvement [in gait analysis] reflects real functional improvement,” said Dr. Otsuka of Shriners Hospitals for Children, Los Angeles.

Gait analysis is designed to provide objective, quantitative information about all aspects of gait, from overall walking to specific joint-related ranges of motion.

Children with cerebral palsy have shown improvement in gait analysis results following multilevel orthopedic surgery, but it has not been clear whether such improvements accurately reflect changes in function and quality of life.

In the study, 25 children with cerebral palsy underwent gait analysis and functional testing and participated in validated questionnaires preoperatively and at 1 year after multilevel lower extremity orthopedic surgery. The children, 8-16 years old, all had hip flexion contractures and were part of a larger trial of surgical techniques.

To make gait analysis results more easily interpretable, Dr. Otsuka and his colleagues used a summary gait analysis variable, called the “Normalcy Index,” which reflects the extent to which a child's gait deviates from the normal. The index is calculated from 16 kinematic and temporal parameters measured by gait analysis.

They compared the Normalcy Index with the total score for dimensions D (standing) and E (walking, running, jumping) of the Gross Motor Function Measure (GMFM), the walking score from the Gillette Functional Assessment Questionnaire (FAQ), and scores from the Pediatric Outcomes Data Collection Instrument (PODCI).

Results showed a strong correlation overall between the gait analysis Normalcy Index and the other scores, both before and after surgery, Dr. Otsuka said. Change in the Normalcy Index was most strongly correlated with change in the GMFM score; it did not correlate significantly with the PODCI score.

WASHINGTON — Gait analysis is a promising outcomes assessment tool for children undergoing orthopedic surgery, Norman Y. Otsuka, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Results of a study comparing three-dimensional computerized gait analysis with various measures of function and quality of life suggest that gait analysis “reflects real functional abilities, and improvement [in gait analysis] reflects real functional improvement,” said Dr. Otsuka of Shriners Hospitals for Children, Los Angeles.

Gait analysis is designed to provide objective, quantitative information about all aspects of gait, from overall walking to specific joint-related ranges of motion.

Children with cerebral palsy have shown improvement in gait analysis results following multilevel orthopedic surgery, but it has not been clear whether such improvements accurately reflect changes in function and quality of life.

In the study, 25 children with cerebral palsy underwent gait analysis and functional testing and participated in validated questionnaires preoperatively and at 1 year after multilevel lower extremity orthopedic surgery. The children, 8-16 years old, all had hip flexion contractures and were part of a larger trial of surgical techniques.

To make gait analysis results more easily interpretable, Dr. Otsuka and his colleagues used a summary gait analysis variable, called the “Normalcy Index,” which reflects the extent to which a child's gait deviates from the normal. The index is calculated from 16 kinematic and temporal parameters measured by gait analysis.

They compared the Normalcy Index with the total score for dimensions D (standing) and E (walking, running, jumping) of the Gross Motor Function Measure (GMFM), the walking score from the Gillette Functional Assessment Questionnaire (FAQ), and scores from the Pediatric Outcomes Data Collection Instrument (PODCI).

Results showed a strong correlation overall between the gait analysis Normalcy Index and the other scores, both before and after surgery, Dr. Otsuka said. Change in the Normalcy Index was most strongly correlated with change in the GMFM score; it did not correlate significantly with the PODCI score.

WASHINGTON — An astute physical examination and the appearance of deep soft tissue swelling on imaging are key to a prompt diagnosis of pediatric acute hematogenous osteomyelitis, John P. Dormans, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Soft tissue swelling can be seen on plain radiographs, but MRI—especially advanced MRI—is overall the best diagnostic tool for the infection. “Have the presence of mind to order advanced MRI—it will be very helpful in determining whether there's purulent material that needs to be drained,” said Dr. Dormans, chief of orthopedic surgery at The Children's Hospital of Philadelphia.

In describing his approach to diagnosis—which he said is “still a problem” today, with missed cases of osteomyelitis and with Ewing's sarcoma presumed to be osteomyelitis—Dr. Dormans also emphasized the value of aspiration and excisional biopsies.

Early diagnosis is important because medical treatment alone—not surgery—is now an accepted course of action early on. Studies have shown a 90% response rate to medical management alone when treatment is initiated within the first few days after the onset of symptoms, he said.

“If the diagnosis is made before an abscess [has formed], you can start antibiotics and watch closely and, if the patient is getting better, just continue [with the antibiotic treatment],” he said.

“Unexplained bone pain with fever means osteomyelitis until proven otherwise,” he stressed.

Overall, he advised, “culture everything, go by the rules, don't take short cuts, and you'll do fine.”

Technetium diphosphonate bone scans are “not very accurate [for early diagnosis], since it takes a while for bone to be stimulated,” he said. Gallium citrate tests take 48-72 hours to complete and “we almost always equivocate [over the results],” and CT scans are “really not that helpful,” he said.

Asked about the cost-effectiveness of using advanced MRI, Dr. Dormans acknowledged that he takes “an aggressive approach” but said it's worth it. He warned physicians to “think of zebras”—particularly Ewing's sarcoma in patients with presumed osteomyelitis.

He recalled treating a boy with ankle pain. “The orthopedist encountered pus, started antibiotics, and the symptoms continued … What looked like purulent material ended up being chronic Ewing's sarcoma tissue.

“We all know that patients with Ewing's sarcoma get fevers and elevated white counts,” he said. “That's why I like to do excisional biopsies—we do them in the OR and tend to hand-carry out frozen sections to the pathologist. … I want to establish the diagnosis, and then everyone sleeps better at night.”

Dr. Dormans said that attention to the three stages of pediatric acute hematogenous osteomyelitis—and recognition of the fact that there are “no real bone changes for the first 7-10 days” will “help you differentiate [pediatric osteomyelitis] from tumor or Ewing's sarcoma.”

Stage 1 (within the first 3 days) of pediatric osteomyelitis is characterized by deep soft tissue swelling next to a metaphysis. Swelling of muscles and obliteration of deep soft tissue planes develops later, during stage 2 (3-7 days); purulent material under the periosteum also collects during this time.

Stage 3 (10-14 days) is characterized by the “classical picture” of involucrum and sequestrum, he said.

Symptoms of pediatric acute hematogenous osteomyelitis include swelling, redness, pseudoparalysis, tenderness to palpation, increased warmth, and limited range of motion. Patients with osteomyelitis do not present with joint irritability unless they have concurrent septic arthritis, Dr. Dormans said.

Antibiotic treatment entails 3 weeks of intravenous antibiotics followed by at least 3 weeks of oral therapy.

WASHINGTON — An astute physical examination and the appearance of deep soft tissue swelling on imaging are key to a prompt diagnosis of pediatric acute hematogenous osteomyelitis, John P. Dormans, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Soft tissue swelling can be seen on plain radiographs, but MRI—especially advanced MRI—is overall the best diagnostic tool for the infection. “Have the presence of mind to order advanced MRI—it will be very helpful in determining whether there's purulent material that needs to be drained,” said Dr. Dormans, chief of orthopedic surgery at The Children's Hospital of Philadelphia.

In describing his approach to diagnosis—which he said is “still a problem” today, with missed cases of osteomyelitis and with Ewing's sarcoma presumed to be osteomyelitis—Dr. Dormans also emphasized the value of aspiration and excisional biopsies.

Early diagnosis is important because medical treatment alone—not surgery—is now an accepted course of action early on. Studies have shown a 90% response rate to medical management alone when treatment is initiated within the first few days after the onset of symptoms, he said.

“If the diagnosis is made before an abscess [has formed], you can start antibiotics and watch closely and, if the patient is getting better, just continue [with the antibiotic treatment],” he said.

“Unexplained bone pain with fever means osteomyelitis until proven otherwise,” he stressed.

Overall, he advised, “culture everything, go by the rules, don't take short cuts, and you'll do fine.”

Technetium diphosphonate bone scans are “not very accurate [for early diagnosis], since it takes a while for bone to be stimulated,” he said. Gallium citrate tests take 48-72 hours to complete and “we almost always equivocate [over the results],” and CT scans are “really not that helpful,” he said.

Asked about the cost-effectiveness of using advanced MRI, Dr. Dormans acknowledged that he takes “an aggressive approach” but said it's worth it. He warned physicians to “think of zebras”—particularly Ewing's sarcoma in patients with presumed osteomyelitis.

He recalled treating a boy with ankle pain. “The orthopedist encountered pus, started antibiotics, and the symptoms continued … What looked like purulent material ended up being chronic Ewing's sarcoma tissue.

“We all know that patients with Ewing's sarcoma get fevers and elevated white counts,” he said. “That's why I like to do excisional biopsies—we do them in the OR and tend to hand-carry out frozen sections to the pathologist. … I want to establish the diagnosis, and then everyone sleeps better at night.”

Dr. Dormans said that attention to the three stages of pediatric acute hematogenous osteomyelitis—and recognition of the fact that there are “no real bone changes for the first 7-10 days” will “help you differentiate [pediatric osteomyelitis] from tumor or Ewing's sarcoma.”

Stage 1 (within the first 3 days) of pediatric osteomyelitis is characterized by deep soft tissue swelling next to a metaphysis. Swelling of muscles and obliteration of deep soft tissue planes develops later, during stage 2 (3-7 days); purulent material under the periosteum also collects during this time.

Stage 3 (10-14 days) is characterized by the “classical picture” of involucrum and sequestrum, he said.

Symptoms of pediatric acute hematogenous osteomyelitis include swelling, redness, pseudoparalysis, tenderness to palpation, increased warmth, and limited range of motion. Patients with osteomyelitis do not present with joint irritability unless they have concurrent septic arthritis, Dr. Dormans said.

Antibiotic treatment entails 3 weeks of intravenous antibiotics followed by at least 3 weeks of oral therapy.

WASHINGTON — An astute physical examination and the appearance of deep soft tissue swelling on imaging are key to a prompt diagnosis of pediatric acute hematogenous osteomyelitis, John P. Dormans, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Soft tissue swelling can be seen on plain radiographs, but MRI—especially advanced MRI—is overall the best diagnostic tool for the infection. “Have the presence of mind to order advanced MRI—it will be very helpful in determining whether there's purulent material that needs to be drained,” said Dr. Dormans, chief of orthopedic surgery at The Children's Hospital of Philadelphia.

In describing his approach to diagnosis—which he said is “still a problem” today, with missed cases of osteomyelitis and with Ewing's sarcoma presumed to be osteomyelitis—Dr. Dormans also emphasized the value of aspiration and excisional biopsies.

Early diagnosis is important because medical treatment alone—not surgery—is now an accepted course of action early on. Studies have shown a 90% response rate to medical management alone when treatment is initiated within the first few days after the onset of symptoms, he said.

“If the diagnosis is made before an abscess [has formed], you can start antibiotics and watch closely and, if the patient is getting better, just continue [with the antibiotic treatment],” he said.

“Unexplained bone pain with fever means osteomyelitis until proven otherwise,” he stressed.

Overall, he advised, “culture everything, go by the rules, don't take short cuts, and you'll do fine.”

Technetium diphosphonate bone scans are “not very accurate [for early diagnosis], since it takes a while for bone to be stimulated,” he said. Gallium citrate tests take 48-72 hours to complete and “we almost always equivocate [over the results],” and CT scans are “really not that helpful,” he said.

Asked about the cost-effectiveness of using advanced MRI, Dr. Dormans acknowledged that he takes “an aggressive approach” but said it's worth it. He warned physicians to “think of zebras”—particularly Ewing's sarcoma in patients with presumed osteomyelitis.

He recalled treating a boy with ankle pain. “The orthopedist encountered pus, started antibiotics, and the symptoms continued … What looked like purulent material ended up being chronic Ewing's sarcoma tissue.

“We all know that patients with Ewing's sarcoma get fevers and elevated white counts,” he said. “That's why I like to do excisional biopsies—we do them in the OR and tend to hand-carry out frozen sections to the pathologist. … I want to establish the diagnosis, and then everyone sleeps better at night.”

Dr. Dormans said that attention to the three stages of pediatric acute hematogenous osteomyelitis—and recognition of the fact that there are “no real bone changes for the first 7-10 days” will “help you differentiate [pediatric osteomyelitis] from tumor or Ewing's sarcoma.”

Stage 1 (within the first 3 days) of pediatric osteomyelitis is characterized by deep soft tissue swelling next to a metaphysis. Swelling of muscles and obliteration of deep soft tissue planes develops later, during stage 2 (3-7 days); purulent material under the periosteum also collects during this time.

Stage 3 (10-14 days) is characterized by the “classical picture” of involucrum and sequestrum, he said.

Symptoms of pediatric acute hematogenous osteomyelitis include swelling, redness, pseudoparalysis, tenderness to palpation, increased warmth, and limited range of motion. Patients with osteomyelitis do not present with joint irritability unless they have concurrent septic arthritis, Dr. Dormans said.

Antibiotic treatment entails 3 weeks of intravenous antibiotics followed by at least 3 weeks of oral therapy.

WASHINGTON — Heterotopic ossification of the elbow usually occurs within 6 weeks of fractures and other injuries, and surgery is best timed at about 6 months after the problem becomes apparent, Thomas Fischer, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

While most heterotopic ossification forms as a result of trauma, it also can develop in patients who have had repetitive interventions on the elbow or prolonged immobilization, as well as in patients with ankylosing spondylitis or hypertrophic osteoarthritis, noted Dr. Fischer of Indiana University Medical Center and Indiana Hand Center, Indianapolis.

Physicians have routinely delayed surgical resection for years, but now it appears that initiating surgery at 6 months—or possibly even earlier—is ideal, he said.

Muscle atrophy, cartilage degeneration, and capsular and ligamentous contracture tend to be less severe with earlier intervention. Resection is easier, and patients recover faster. Patients must have enough time before surgical resection, however, to recover from the often numerous orthopedic injuries and trauma—either local or systemic—that cause the heterotopic ossification, and the area must be well demarcated, he said.

Six months gives most patients time to resolve many of their injuries, Dr. Fischer explained in a later interview. It gives the extremity time to resolve injury edema, and by 6 months, the heterotopic ossification is not usually going to grow in extent or spread; “the limits of its area are well determined.”

“My partner does [surgery] at 3-4 months,” he said. Dr. Fischer told physicians at the meeting that he prefers to wait 6 months. Patients need to be recovered and cooperative enough to participate in an “immediate and fast-paced postop functional aftercare program,” Dr. Fischer said. It's helpful if therapists get involved preoperatively, he noted, partly to assess patients' ability to persist with exercises after surgery.

The incidence of heterotopic ossification has varied significantly from study to study and by the type of precipitating injury or trauma. The literature indicates that about 3% of those with simple dislocation, 1%-3% of those with burns, 16%-38% of those with fracture and dislocation, and 76%-89% of those with head injury and elbow trauma, for instance, develop it.

“I don't have a good number to quote my patients for what their risk of [heterotopic ossification] is, but whenever I see fractures and injuries around the elbow, I tell them that the 2- to 6-week period after injury is the chief period of incidence,” said Dr. Fischer, adding that most of his patients with heterotopic ossification have been critically injured. “I personally haven't seen the onset of [heterotopic ossification] after 6 weeks.”

The mere presence of heterotopic ossification is “not necessarily an indication for surgery,” he said. “I'm talking about [ossification] that results in a significant loss of motion, and loss of function of the upper extremity.”

A 50% reduction in elbow mobility can reduce upper extremity function by almost 80%, he noted. In addition to local swelling, edema, and warmth, the physical exam reveals a “doorstop effect” with flexion and extension, “where you feel a mechanically rigid end point,” Dr. Fischer said.

With the exception of pediatric patients, who can “sometimes spontaneously resorb heterotopic ossification,” most cases involving the elbow result in progressive loss of motion, he said.

Knowledge of the pathophysiology of heterotopic ossification is improving. Ectopic bone is known to be more metabolically active than native bone and is not covered by periosteum. In some cases, up to two times the normal number of osteoblasts have been found in ectopic bone.

Bone scans used to be routine for the evaluation of possible heterotopic ossification, but “based on the latest literature, I can't see a reason to use [them] anymore,” Dr. Fischer said. “It's not the meter we thought it was.”

MRIs “don't help me a lot either because I can't tell the difference between dark spots from calcium and dark spots from other things,” he said. High-definition CT is more useful. “I can use this as a map in the operating room—the definition of the planes between bone and soft tissue is much better,” Dr. Fischer said.

WASHINGTON — Heterotopic ossification of the elbow usually occurs within 6 weeks of fractures and other injuries, and surgery is best timed at about 6 months after the problem becomes apparent, Thomas Fischer, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

While most heterotopic ossification forms as a result of trauma, it also can develop in patients who have had repetitive interventions on the elbow or prolonged immobilization, as well as in patients with ankylosing spondylitis or hypertrophic osteoarthritis, noted Dr. Fischer of Indiana University Medical Center and Indiana Hand Center, Indianapolis.

Physicians have routinely delayed surgical resection for years, but now it appears that initiating surgery at 6 months—or possibly even earlier—is ideal, he said.

Muscle atrophy, cartilage degeneration, and capsular and ligamentous contracture tend to be less severe with earlier intervention. Resection is easier, and patients recover faster. Patients must have enough time before surgical resection, however, to recover from the often numerous orthopedic injuries and trauma—either local or systemic—that cause the heterotopic ossification, and the area must be well demarcated, he said.

Six months gives most patients time to resolve many of their injuries, Dr. Fischer explained in a later interview. It gives the extremity time to resolve injury edema, and by 6 months, the heterotopic ossification is not usually going to grow in extent or spread; “the limits of its area are well determined.”

“My partner does [surgery] at 3-4 months,” he said. Dr. Fischer told physicians at the meeting that he prefers to wait 6 months. Patients need to be recovered and cooperative enough to participate in an “immediate and fast-paced postop functional aftercare program,” Dr. Fischer said. It's helpful if therapists get involved preoperatively, he noted, partly to assess patients' ability to persist with exercises after surgery.

The incidence of heterotopic ossification has varied significantly from study to study and by the type of precipitating injury or trauma. The literature indicates that about 3% of those with simple dislocation, 1%-3% of those with burns, 16%-38% of those with fracture and dislocation, and 76%-89% of those with head injury and elbow trauma, for instance, develop it.

“I don't have a good number to quote my patients for what their risk of [heterotopic ossification] is, but whenever I see fractures and injuries around the elbow, I tell them that the 2- to 6-week period after injury is the chief period of incidence,” said Dr. Fischer, adding that most of his patients with heterotopic ossification have been critically injured. “I personally haven't seen the onset of [heterotopic ossification] after 6 weeks.”

The mere presence of heterotopic ossification is “not necessarily an indication for surgery,” he said. “I'm talking about [ossification] that results in a significant loss of motion, and loss of function of the upper extremity.”

A 50% reduction in elbow mobility can reduce upper extremity function by almost 80%, he noted. In addition to local swelling, edema, and warmth, the physical exam reveals a “doorstop effect” with flexion and extension, “where you feel a mechanically rigid end point,” Dr. Fischer said.

With the exception of pediatric patients, who can “sometimes spontaneously resorb heterotopic ossification,” most cases involving the elbow result in progressive loss of motion, he said.

Knowledge of the pathophysiology of heterotopic ossification is improving. Ectopic bone is known to be more metabolically active than native bone and is not covered by periosteum. In some cases, up to two times the normal number of osteoblasts have been found in ectopic bone.

Bone scans used to be routine for the evaluation of possible heterotopic ossification, but “based on the latest literature, I can't see a reason to use [them] anymore,” Dr. Fischer said. “It's not the meter we thought it was.”

MRIs “don't help me a lot either because I can't tell the difference between dark spots from calcium and dark spots from other things,” he said. High-definition CT is more useful. “I can use this as a map in the operating room—the definition of the planes between bone and soft tissue is much better,” Dr. Fischer said.

WASHINGTON — Heterotopic ossification of the elbow usually occurs within 6 weeks of fractures and other injuries, and surgery is best timed at about 6 months after the problem becomes apparent, Thomas Fischer, M.D., said at the annual meeting of the American Academy of Orthopaedic Surgeons.

While most heterotopic ossification forms as a result of trauma, it also can develop in patients who have had repetitive interventions on the elbow or prolonged immobilization, as well as in patients with ankylosing spondylitis or hypertrophic osteoarthritis, noted Dr. Fischer of Indiana University Medical Center and Indiana Hand Center, Indianapolis.

Physicians have routinely delayed surgical resection for years, but now it appears that initiating surgery at 6 months—or possibly even earlier—is ideal, he said.

Muscle atrophy, cartilage degeneration, and capsular and ligamentous contracture tend to be less severe with earlier intervention. Resection is easier, and patients recover faster. Patients must have enough time before surgical resection, however, to recover from the often numerous orthopedic injuries and trauma—either local or systemic—that cause the heterotopic ossification, and the area must be well demarcated, he said.

Six months gives most patients time to resolve many of their injuries, Dr. Fischer explained in a later interview. It gives the extremity time to resolve injury edema, and by 6 months, the heterotopic ossification is not usually going to grow in extent or spread; “the limits of its area are well determined.”

“My partner does [surgery] at 3-4 months,” he said. Dr. Fischer told physicians at the meeting that he prefers to wait 6 months. Patients need to be recovered and cooperative enough to participate in an “immediate and fast-paced postop functional aftercare program,” Dr. Fischer said. It's helpful if therapists get involved preoperatively, he noted, partly to assess patients' ability to persist with exercises after surgery.

The incidence of heterotopic ossification has varied significantly from study to study and by the type of precipitating injury or trauma. The literature indicates that about 3% of those with simple dislocation, 1%-3% of those with burns, 16%-38% of those with fracture and dislocation, and 76%-89% of those with head injury and elbow trauma, for instance, develop it.

“I don't have a good number to quote my patients for what their risk of [heterotopic ossification] is, but whenever I see fractures and injuries around the elbow, I tell them that the 2- to 6-week period after injury is the chief period of incidence,” said Dr. Fischer, adding that most of his patients with heterotopic ossification have been critically injured. “I personally haven't seen the onset of [heterotopic ossification] after 6 weeks.”

The mere presence of heterotopic ossification is “not necessarily an indication for surgery,” he said. “I'm talking about [ossification] that results in a significant loss of motion, and loss of function of the upper extremity.”

A 50% reduction in elbow mobility can reduce upper extremity function by almost 80%, he noted. In addition to local swelling, edema, and warmth, the physical exam reveals a “doorstop effect” with flexion and extension, “where you feel a mechanically rigid end point,” Dr. Fischer said.

With the exception of pediatric patients, who can “sometimes spontaneously resorb heterotopic ossification,” most cases involving the elbow result in progressive loss of motion, he said.

Knowledge of the pathophysiology of heterotopic ossification is improving. Ectopic bone is known to be more metabolically active than native bone and is not covered by periosteum. In some cases, up to two times the normal number of osteoblasts have been found in ectopic bone.

Bone scans used to be routine for the evaluation of possible heterotopic ossification, but “based on the latest literature, I can't see a reason to use [them] anymore,” Dr. Fischer said. “It's not the meter we thought it was.”

MRIs “don't help me a lot either because I can't tell the difference between dark spots from calcium and dark spots from other things,” he said. High-definition CT is more useful. “I can use this as a map in the operating room—the definition of the planes between bone and soft tissue is much better,” Dr. Fischer said.

WASHINGTON — Elbow contractures can be treated arthroscopically with better efficacy and faster patient recovery than traditional open surgical techniques, Shawn W. O'Driscoll, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

It's no longer a given that complicated procedures must be converted to open surgery, said Dr. O'Driscoll, professor of orthopedics at the Mayo Clinic in Rochester, Minn. Instead, the deciding factor should be the surgeon's level of experience.

Published data on efficacy are limited, and indications for the arthroscopic approach “are still evolving,” he said during a session on elbow stiffness and arthritis. But “it's pretty clear that [arthroscopic contracture release] is effective.”

An analysis of results from 10 reports of open procedures and 6 small reports of arthroscopic procedures shows that more significant improvements are gained in extension, flexion, and total arc of elbow motion with the arthroscopic approach, compared with the open surgical approach.

Average flexion, for instance, increased from 107 degrees preoperatively to 123 degrees postoperatively when contractures were treated with open surgery.

In comparison, with the arthroscopic approach, flexion increased from 114 degrees before the operation to 133 degrees after the operation, Dr. O'Driscoll said.

The main consideration—and the “one factor that creates anxiety and limits the indications for this operation”—is the risk of ulnar nerve injury, he said.

The arthroscopy procedure involves a straightforward, predictable sequence of steps, but it is “more complex … the difficulty in learning it is higher [than with open surgery], and the risk is higher when you're learning it,” Dr. O'Driscoll noted.

“There was a time when I thought this would never be a safe operation in anyone's hands,” he said. “Now, I think it's an unsafe operation” in the hands of surgeons who do not have the necessary skills and experience.

“I've done over 300 cases now, and my complication rate is lower than it is with open surgery. Patient recovery is faster, and efficacy is better, from my experience,” he said.

Dr. O'Driscoll uses an anterior approach to arthroscopic release that involves synovectomy before osteectomy, and then capsulectomy. He recommended using a scope in the anterolateral or proximal anteromedial portal and a retractor in the proximal anterolateral portal. A second retractor can be used in the anteromedial portal if necessary.

“It's necessary for safety and predictability reasons to use a retractor,” he said. Although some say otherwise, “you need to retract the tissues and create a space within which to work.

“And we don't rely on capsular distension, because in the stiff elbow, it's not possible to distend the capsule by very much,” he noted. “If you try to do it, you get a big fat swollen elbow. You want to avoid that; the elbow should be soft until near the end of the operation.”

A study reported more than 10 years ago showed that the capsular volume capacity is about 25 mL in the normal elbow but only about 6 mL in the contracted elbow, he said.

Dr. O'Driscoll strips the capsule off the proximal humerus and immediately releases tissue along the lateral supracondylar ridge, which “gives you some space to work, to move the scope back farther and get a bigger, better perspective.”

He removes loose bodies as they are encountered and debrides the capsule, defining it as a structure, before cutting it. He incises the capsule starting medially and progresses across laterally.

A distal lateral capsulectomy is the final and most risky step. “You need to be able to see the nerve … or know with absolute certainty where the nerve is and isn't,” Dr. O'Driscoll said. “If you have that degree of confidence, then you're safe to do it.”

A capsulotomy is performed from medial to lateral. The final strip of capsule over the radial nerve is released with a reverse cutting punch biopsy, as shown above. Courtesy Dr. Shawn W. O'Driscoll

WASHINGTON — Elbow contractures can be treated arthroscopically with better efficacy and faster patient recovery than traditional open surgical techniques, Shawn W. O'Driscoll, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

It's no longer a given that complicated procedures must be converted to open surgery, said Dr. O'Driscoll, professor of orthopedics at the Mayo Clinic in Rochester, Minn. Instead, the deciding factor should be the surgeon's level of experience.

Published data on efficacy are limited, and indications for the arthroscopic approach “are still evolving,” he said during a session on elbow stiffness and arthritis. But “it's pretty clear that [arthroscopic contracture release] is effective.”

An analysis of results from 10 reports of open procedures and 6 small reports of arthroscopic procedures shows that more significant improvements are gained in extension, flexion, and total arc of elbow motion with the arthroscopic approach, compared with the open surgical approach.

Average flexion, for instance, increased from 107 degrees preoperatively to 123 degrees postoperatively when contractures were treated with open surgery.

In comparison, with the arthroscopic approach, flexion increased from 114 degrees before the operation to 133 degrees after the operation, Dr. O'Driscoll said.

The main consideration—and the “one factor that creates anxiety and limits the indications for this operation”—is the risk of ulnar nerve injury, he said.

The arthroscopy procedure involves a straightforward, predictable sequence of steps, but it is “more complex … the difficulty in learning it is higher [than with open surgery], and the risk is higher when you're learning it,” Dr. O'Driscoll noted.

“There was a time when I thought this would never be a safe operation in anyone's hands,” he said. “Now, I think it's an unsafe operation” in the hands of surgeons who do not have the necessary skills and experience.

“I've done over 300 cases now, and my complication rate is lower than it is with open surgery. Patient recovery is faster, and efficacy is better, from my experience,” he said.

Dr. O'Driscoll uses an anterior approach to arthroscopic release that involves synovectomy before osteectomy, and then capsulectomy. He recommended using a scope in the anterolateral or proximal anteromedial portal and a retractor in the proximal anterolateral portal. A second retractor can be used in the anteromedial portal if necessary.

“It's necessary for safety and predictability reasons to use a retractor,” he said. Although some say otherwise, “you need to retract the tissues and create a space within which to work.

“And we don't rely on capsular distension, because in the stiff elbow, it's not possible to distend the capsule by very much,” he noted. “If you try to do it, you get a big fat swollen elbow. You want to avoid that; the elbow should be soft until near the end of the operation.”

A study reported more than 10 years ago showed that the capsular volume capacity is about 25 mL in the normal elbow but only about 6 mL in the contracted elbow, he said.

Dr. O'Driscoll strips the capsule off the proximal humerus and immediately releases tissue along the lateral supracondylar ridge, which “gives you some space to work, to move the scope back farther and get a bigger, better perspective.”

He removes loose bodies as they are encountered and debrides the capsule, defining it as a structure, before cutting it. He incises the capsule starting medially and progresses across laterally.

A distal lateral capsulectomy is the final and most risky step. “You need to be able to see the nerve … or know with absolute certainty where the nerve is and isn't,” Dr. O'Driscoll said. “If you have that degree of confidence, then you're safe to do it.”

A capsulotomy is performed from medial to lateral. The final strip of capsule over the radial nerve is released with a reverse cutting punch biopsy, as shown above. Courtesy Dr. Shawn W. O'Driscoll

WASHINGTON — Elbow contractures can be treated arthroscopically with better efficacy and faster patient recovery than traditional open surgical techniques, Shawn W. O'Driscoll, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

It's no longer a given that complicated procedures must be converted to open surgery, said Dr. O'Driscoll, professor of orthopedics at the Mayo Clinic in Rochester, Minn. Instead, the deciding factor should be the surgeon's level of experience.

Published data on efficacy are limited, and indications for the arthroscopic approach “are still evolving,” he said during a session on elbow stiffness and arthritis. But “it's pretty clear that [arthroscopic contracture release] is effective.”

An analysis of results from 10 reports of open procedures and 6 small reports of arthroscopic procedures shows that more significant improvements are gained in extension, flexion, and total arc of elbow motion with the arthroscopic approach, compared with the open surgical approach.

Average flexion, for instance, increased from 107 degrees preoperatively to 123 degrees postoperatively when contractures were treated with open surgery.

In comparison, with the arthroscopic approach, flexion increased from 114 degrees before the operation to 133 degrees after the operation, Dr. O'Driscoll said.

The main consideration—and the “one factor that creates anxiety and limits the indications for this operation”—is the risk of ulnar nerve injury, he said.

The arthroscopy procedure involves a straightforward, predictable sequence of steps, but it is “more complex … the difficulty in learning it is higher [than with open surgery], and the risk is higher when you're learning it,” Dr. O'Driscoll noted.

“There was a time when I thought this would never be a safe operation in anyone's hands,” he said. “Now, I think it's an unsafe operation” in the hands of surgeons who do not have the necessary skills and experience.

“I've done over 300 cases now, and my complication rate is lower than it is with open surgery. Patient recovery is faster, and efficacy is better, from my experience,” he said.

Dr. O'Driscoll uses an anterior approach to arthroscopic release that involves synovectomy before osteectomy, and then capsulectomy. He recommended using a scope in the anterolateral or proximal anteromedial portal and a retractor in the proximal anterolateral portal. A second retractor can be used in the anteromedial portal if necessary.

“It's necessary for safety and predictability reasons to use a retractor,” he said. Although some say otherwise, “you need to retract the tissues and create a space within which to work.

“And we don't rely on capsular distension, because in the stiff elbow, it's not possible to distend the capsule by very much,” he noted. “If you try to do it, you get a big fat swollen elbow. You want to avoid that; the elbow should be soft until near the end of the operation.”

A study reported more than 10 years ago showed that the capsular volume capacity is about 25 mL in the normal elbow but only about 6 mL in the contracted elbow, he said.

Dr. O'Driscoll strips the capsule off the proximal humerus and immediately releases tissue along the lateral supracondylar ridge, which “gives you some space to work, to move the scope back farther and get a bigger, better perspective.”

He removes loose bodies as they are encountered and debrides the capsule, defining it as a structure, before cutting it. He incises the capsule starting medially and progresses across laterally.

A distal lateral capsulectomy is the final and most risky step. “You need to be able to see the nerve … or know with absolute certainty where the nerve is and isn't,” Dr. O'Driscoll said. “If you have that degree of confidence, then you're safe to do it.”

A capsulotomy is performed from medial to lateral. The final strip of capsule over the radial nerve is released with a reverse cutting punch biopsy, as shown above. Courtesy Dr. Shawn W. O'Driscoll

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete [items from the record], as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of HIPAA(the Health Insurance Portability and Accountability Act of 1996), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patients' requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete [items from the record], as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of HIPAA(the Health Insurance Portability and Accountability Act of 1996), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patients' requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete [items from the record], as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of HIPAA(the Health Insurance Portability and Accountability Act of 1996), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patients' requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said. “It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you tell me? Is it right?'”