Thursday, July 07, 2005

Larry Brown's Hip: Occupational Injury?

BrooklynDodger is struck by this crossover of work related musculoskeletal disorders, medical malpractice and return to work legal issues.

Not to put too pendantic a point on it, the headline "diagnosis" [newspaper post below] might be more precisely "prognosis." The Dodger presumes there's a diagnosis, if there was a surgery to correct the bladder problem, there was a diagnosis to collect the insurance.

There's a decent literature on physical activity and osteoarthritis of the hip, leading to hip replacement surgery. Probably easy to mount a case-control study with good occupational histories from someone who specializes in hip replacements, although it might be hard to identify controls from the same practice. Ignoring occupation, the Dodger expects that an exposure response relationship for runners could be easily derived.

It's kind of a no-brainer to think Larry Brown would be at high risk: a playing career followed by decades of running up and down the floor during practice. Another study, quantitative lower extremity physical activity of participants and coaches in various sports; other than chess, baseball is probably least active [even with pitchers and catchers], football next, soccer and then basketball the most. Another study, using a cohort of player's association members.

Having defined the risk, which of Larry Brown's employers is responsible for the injury? It seems unfair to the Pistons to absorb all the cost of the surgery of a 64 year old employee with as many prior employers as Larry Brown, not to mention the high school on Long Island, University of North Carolina, and all the sanctioned and non-sanctioned pick up games Larry played.

Below we find that nerve damage is a "rare" side effect of the hip replacement surgery. The Dodger concedes it's more of a reach to diagnose nerve damage impacting urination from a sports page article than for Dr. Frist to rule out persistent vegetative state from a videotape. But let's assume that's what Larry Brown has, and that it's secondary to physical trauma to the nerve during surgery. Quality theory tells us that if it's a 1% side effect, then it's outside the normal distribution of results, therefore a special cause rather than a system cause result. Which equates to malpractice.

Now comes the return to work problem. Millions saw Larry Brown at work on TV. He was doing the job. If he were to claim disability, and try to collect workers comp, they'd show that tape to the referee [workers' comp judge, not the striped shirt kind] and get Larry disqualified, just like the worker who can do 1/2 hour in the garden once a week but can't sustain 10 hours of pounding steel on the assembly line.

Maybe the economic solution is that the Pistons sue the hip replacement surgeon for the $18 million they would have to pay to buy Larry Brown out.

Uncertain diagnosis drags on
Brown in the dark on agent talking to Dumars

July 5, 2005

Larry Brown's future remains cloudy. And it might not clear up today.
Brown's agent, Joseph Glass, planned to have a phone conversation with Joe Dumars, the Pistons' president of basketball operations, today. But Glass said Monday the conversation will just be an update about Brown's condition.

He also said it wouldn't involve a possible buyout by Brown from the remaining three years of his contract with the Pistons.

Brown, who is vacationing in the Hamptons with his family, said Monday, "I don't know anything about that" conversation.

Brown said he isn't healthy and doesn't know when he'll be better.

J Arthroplasty. 2004 Jun;19(4 Suppl 1):104-7.

Neurovascular injury: avoiding catastrophe.

Barrack RL.Tulane University Health Sciences Center, Department of Orthopaedic Surgery, New Orleans, Louisiana 70112, USA.

Major neurovascular injury is the least common, but most distressing, complication of total hip arthroplasty (THA). The keys to minimizing the incidence of these complications are recognizing patients at risk and knowledge of the relevant anatomy. Partial sciatic palsy is the most common nerve injury. At least partial recovery can be expected in 70% to 80% of cases, with the remainder frequently displaying dissatisfaction with their surgery. Vascular injury is most frequently associated with the use of screws for fixation of structural grafts, acetabulur components, and protrusio rings or cages. An understanding of the acetabular quadrant system is crucial in minimizing these potentially catastrophic complications.

Orthopedics. 2004 Jan;27(1):73-81; quiz 82-3.

Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications.

Rue JP, Inoue N, Mont MA.Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions Baltimore, MD, USA.

Total hip arthroplasty is a common and relatively safe procedure with consistently good results. Despite its popularity and excellent results, THA is a major operation with several major neurovascular structures within reach of retractors, scalpel blades, drills, screws, and reamers. A thorough knowledge of their anatomic location and proximity to the operative field, along with a basic understanding of the principles of vascular surgery can help avoid potentially devastating consequences. Specifically, the surgeon should avoid placement of screws in the anterior-superior quadrant, be vigilant when placing retractors, and avoid excessive tension on the sciatic nerve.

1 comment:

Anna said...

I don't actually have time to look up any evidence for this (being on the clock at work) but I've heard that running is no longer considered a cause of osteoarthritis, and that in fact it's the best option for someone trying to avoid hip replacement because it strengthens the muscles involved and lessens the burden on the hip socket. Any thoughts?