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NEAR-INFRARED SPECTROSCOPY (NIRS) FOR APPLICATION IN UROLOGY
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
during urodynamics (UDS). Our objective was to develop a NIRS system capable of monitoring ambulant children and adults to allow for home and long term study. METHODS: The miniature wireless device has 3 light emitting diodes (785, 808 and 830 nm); a 1 emitter 3 receiver spatially resolved configuration; internal memory, telemetric capacity with Bluetooth, and adheres to the suprapubic skin. Data is broadcast on demand to a computer for graphic display. Subjects were asymptomatic and fully ambulant during bladder filling, remote from investigators and monitored during natural filling, voiding and uroflow. NIRS (O2Hb, HHb & tHb) and UDS data was collected at 10 Hz and graphs of patterns of change during voiding compared. RESULTS: 20 subjects 5 - 65 yrs repeated 3 separate trials. O2Hb, HHb & tHb concentrations were successfully obtained, stored and transmitted for graphic display in all 60 trials. Similar trends of chromophore change were seen during each voiding and between subjects. Fig 1 is a representative graph from a female 5 yrs old.
In one subject with a 127 sec. delay between permission to void with urge and uroflow start, tHb & O2Hb showed a typical initial rise. During sustained urge without uroflow, changes compatible with oxygen consumption and haemodynamic effects are evident during constant bladder volume Fig 2.
601
and deoxyhemoglobin (HHb), combined with Qmax and PVR provide discriminant ability between subjects with and without obstruction. We report a mathematical method where NIRS data can be used alone to derive such classification with comparable accuracy. METHODS: Data collected during simultaneous UDS and NIRS evaluation of male subjects with LUTS was analyzed. Conventional pressure flow nomograms classified subject’s urodynamic data as obstructed or unobstructed. Linear discriminant (LD) analysis and classification and regression tree (CART) analysis of NIRS parameters followed using MATLAB software and a learning sample of data, to which a learning set was applied comprising the relative concentrations of O2Hb and HHb for patients classified by UDS as obstructed or unobstructed. Elements in the learning set were paired (HHb (t), O2Hb (t)) for every time t in the time series of recorded data. The total number of pairs in the learning set was 37540. RESULTS: Data sets from 46 patients were evaluated. UDS identified 30 as obstructed and 16 as unobstructed. For NIRS data CART methodology was superior to LD analysis, and the CART algorithm generated was able to use NIRS derived parameters alone to classify subjects as obstructed or unobstructed, as compared to the conventional Abrahams-Griffiths nomogram. The following classification responses were obtained: True-Positive fraction (TP) = 30, True-Negative fraction (TN) = 14, False-Positive fraction (FP) = 2, False-negative fraction (FN) = 0. These fractions indicate 88% specificity, 84% precision and a misclassification error of 4% for CART analysis of NIRS data. CONCLUSIONS: Using a CART algorithm, non-invasive NIRS data obtained during voiding has independent discriminant ability for classifying subjects with LUTS as either obstructed or unobstructed. CART is probably superior to LDA as NIRS data are non-linear, and because CART uses all NIRS data points obtained throughout the voiding cycle rather than a single point related to Qmax. Source of Funding: Post Doctoral Funding, Vancouver Hospital foundation
1667 NEAR-INFRARED SPECTROSCOPY (NIRS) FOR APPLICATION IN UROLOGY Alexis E Te*, Doreen E Chung, Richard I Lee, Steven A Kaplan, New York, NY
CONCLUSIONS: Wireless NIRS monitoring is feasible in children and adults with reproducible trends of chromophore change during voiding. The NIRS data indicating effects on oxygenation during sustained urge may contribute insight into the physiologic basis of urge in some patients, and NIRS monitoring when movement of the bladder due to volume change is absent. Source of Funding: Ph D candidate research fellow salary, Vancouver Hospital Foundation
1666 ALGORITHM CONSTRUCTION METHODOLOGY FOR DIAGNOSTIC CLASSIFICATION OF BLADDER-DERIVED NEARINFRARED SPECTROSCOPY DATA. Ramon Gueverra, Lynn Stothers, Andrew J Macnab*, Vancouver, BC, Canada INTRODUCTION AND OBJECTIVES: Progressive functional impairment in bladder outlet obstruction (BOO) is associated with hemodynamic changes. Patients with lower urinary tract symptoms (LUTS) currently require diagnostic evaluation with invasive urodynamics (UDS). Non-invasive voiding studies are now described using near-infrared spectroscopy (NIRS), an optical method of monitoring tissue oxygenation and hemodynamics. Changes in concentration of oxyhemoglobin (O2Hb)
INTRODUCTION AND OBJECTIVES: Near-infrared spectroscopy (NIRS) is a non-invasive optical technique that uses light to monitor changes in blood flow and concentrations of oxygenated and deoxygenated hemoglobin to assess physiologic and metabolic conditions. NIRS is an established technology used in a range of organs and tissues. An instrument has been developed for urological applications, and specifically for the interrogation of the bladder detrusor (Tetra NIRS, Laborie Medical Technologies Inc.). This current application of NIRS evaluates male patients with lower urinary tract symptoms (LUTS) as obstructed or unobstructed. The purpose of this study is to use NIRS to classify male patients with LUTS as obstructed or unobstructed when compared to pressure flow studies, and to confirm the results of a previous pivotal study, which reported >85% concordance with pressure flow studies. METHODS: Male patients referred for urodynamic (UDS) testing for evaluation of LUTS were simultaneously evaluated with NIRS. The NIRS classification of obstructed and unobstructed is derived from a customized algorithm which analyzes the pattern of change in hemodynamics and incorporates measurements of PVR and maximum flow. The results were compared to the diagnosis derived from simultaneous standard pressure flow testing. RESULTS: A total of 42 patients were enrolled and 36 (86%) had evaluable data. 5 subjects were excluded for: communication error with NIRS (2); patch could not adhere to subject (1); communication error with urodynamic instruments (1); data saving error (2). The NIRS algorithm correctly identified those diagnosed with obstruction in 28 out of 31 patients (90%) and correctly identified unobstructed cases in 4 out of 5 (80%) patients, which provides an 89% concordance with the
602
THE JOURNAL OF UROLOGY®
diagnosis made with conventional UDS testing. CONCLUSIONS: This is the first independent study to validate the positive results of a previous pivotal trial. The overall concordance of NIRS with pressure flow studies is 89% in diagnosing male patients referred for LUTS as obstructed or unobstructed. Larger multicenter studies are in progress to further validate these findings and to establish clinical utility. Source of Funding: Laborie Medical/ Urodynamix Technology
1668 DEFINING THE EDUCATIONAL GAP IN URODYNAMICS TRAINING BETWEEN RESIDENCY AND THE FIRST 18 MONTHS IN PRACTICE Elizabeth R Mueller*, Maywood, IL INTRODUCTION AND OBJECTIVES: Fifty percent of graduating urology residents report that their urodynamic training was less than adequate and over 66% have not performed urodynamic (UDS) procedures during their residency. The objective of this analysis was to analyze the procedure logs of post-residency urologists who are applying for American Board of Urology (ABU) certification from 2004 to 2007 to better understand the practice patterns of “new” urologists METHODS: Applicants for part II ABU certification must submit a procedure log from a period within 18 months of the certification process. The log lists all of the procedures by CPT code performed during 6 consecutive months. We extracted the following data from certification and recertification logs; the number of procedures with UDS CPT codes (51725, 51726, 51741, 51772, 51784, 51785, 51792, 51795, and 51797) and the patient gender. Video-urodynamic procedures were defined by identifying the above CPT codes that were performed on the same day as the fluoroscopy codes 74330, 74450, 74455, 76000, 76001. RESULTS: The 6-month logs of 878 urologists applying for ABU part II certification during the period of 2004 to 2007 were analyzed. Seven hundred and seventy urologists (88%) performed UDS procedures. The percentage of urologists performing urodynamics increased from 82% to 93% from 2004 to 2007. The most common UDS procedure performed was complex uroflowmetry (34.8%) followed by complex cystometry (CMG) (20.2%), bladder voiding pressures(13.7%), electromyography of the urethral/anal sphincter (12.6%) and abdominal (11.4%) pressures during voiding. The 2007 certification applicant’s 50th and 90th percentile data for number of UDS procedures performed in 6 months for complex uroflow was 30 and 192 procedures and for CMG was 22 and 88. Videourodynamics were performed by ~ 7.2% of certifying urologists and were used primarily during complex CMG (7.7%) and complex uroflow (6.7%). CONCLUSIONS: Although only 33% of graduating urologists perform UDS during their residency training, more than 88% perform and interpret UDS within the first 18 months of graduating. Standardized UDS curricular content, learning objectives and outcome evaluations may better prepare residents for clinical practice. Source of Funding: SUFU/SUCPD Educational Grant
1669 URODYNAMIC PROCEDURES ARE ON THE RISE Elizabeth R Mueller*, Maywood, IL INTRODUCTION AND OBJECTIVES: Most of the urodynamic literature focuses on the indications for urodynamic studies (UDS) for treatment of urinary incontinence and voiding dysfunction. Much less is known about the frequency with which UDS is being performed and trends in UDS practice among urologists. The objective of this analysis was to describe trends in the practice of UDS among urologists who applied for American Board of Urology (ABU) certification and recertification from 2004 to 2007. METHODS: Procedure logs submitted by applicants for part II ABU certification or ABU recertification during 2004-2007 were reviewed. The log lists all of the procedures by CPT code performed
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
during 6 consecutive months. The number of procedures with UDS CPT codes (51725, 51726, 51741, 51772, 51784, 51785, 51792, 51795, and 51797) were abstracted. RESULTS: Logs of 2650 urologists (1072 (67%) recertifying and 878 (33%) first time applicants) were analyzed. Total number of UDS performed by urologists applying for certification and recertification more than doubled (k129.5%) from 86,840 to 199,272 procedures/6 months. This was in part due to an increase in the number of applicants from 473 to 655 applicants (k38%). The percent of certifying and recertifying urologists performing UDS also increased over 4 years by 50% and 32%, respectively. The table details percent increase by specific UDS performed in (2007 compared to 2004) by certification status. CPT
Description
Cert
ReCert
51772
Urethral pressure profile
683%
279%
51792
Stimulus evoked response
495%
250%
51785
Needle EMG
384%
550%
51797
Voiding abdominal pressure
376%
324%
51784
Any EMG
294%
360%
51795
Voiding bladder pressure
279%
307%
51741
Electronic flow rate
121%
78%
51726
Electronic cystogram
101%
132%
51725
Manometer cystogram
-80%
-41%
CONCLUSIONS: New and practicing urologists are increasingly performing more UDS. Further studies are warranted to determine the efficacy of UDS in diagnosis and treatment of lower urinary tract dysfunction. Source of Funding: SUFU/SUCPD Educational Grant
Oncology (Bladder and Others) Video Session 6 Tuesday, April 28, 2009
1:00 pm - 3:00 pm
V1670 OBTURATOR NERVE INJURY DURING ROBOTIC ASSISTED RADICAL CYSTECTOMY: RECOGNITION OF INJURY AND ROBOTIC REPAIR. Ali Moinzadeh*, Jessica DeLong, Ingolf A Tuerk, Andrea Sorcini, Burlington, MA INTRODUCTION AND OBJECTIVES: Obturator nerve injury is a rare complication of pelvic lymph node dissection. Great care is taken to identify the nerve using anatomic landmarks to avoid injury. We present two cases of obturator nerve injury during left side extended pelvic lymph node dissection for bladder carcinoma. METHODS: Two patients had obturator nerve injury during extended pelvic lymph node dissection during robotic-assisted radical cystectomy for high risk bladder cancer. During the first case, the obturator nerve was ligated with a hem-o-lock clip. The injury was recognized prior to transection and the clip was removed by the assistant with a clip remover. In the second case, during dissection of a metastatic lymph node packet, the obturator nerve was ligated with a hem-o-lock clip and transected with cold Endoshears. The hem-o-lock clip was removed with the harmonic scalpel, and the nerve re-approximated with 7-0 prolene interrupted sutures apposing the perineural sheath. RESULTS: The first patient had no post operative sequela from the nerve clipping and removal. A total of 25 lymph nodes were removed. Final pathology demonstrated 1/6 positive lymph nodes on the left (15 nodes total). The patient started immediate physical therapy. On postoperative day #1 he had 2/5 adduction strength. He was able to ambulate with out assistance by pos operative day #3. At two months, the patient was at his baseline strength with adduction and stopped
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
during urodynamics (UDS). Our objective was to develop a NIRS system capable of monitoring ambulant children and adults to allow for home and long term study. METHODS: The miniature wireless device has 3 light emitting diodes (785, 808 and 830 nm); a 1 emitter 3 receiver spatially resolved configuration; internal memory, telemetric capacity with Bluetooth, and adheres to the suprapubic skin. Data is broadcast on demand to a computer for graphic display. Subjects were asymptomatic and fully ambulant during bladder filling, remote from investigators and monitored during natural filling, voiding and uroflow. NIRS (O2Hb, HHb & tHb) and UDS data was collected at 10 Hz and graphs of patterns of change during voiding compared. RESULTS: 20 subjects 5 - 65 yrs repeated 3 separate trials. O2Hb, HHb & tHb concentrations were successfully obtained, stored and transmitted for graphic display in all 60 trials. Similar trends of chromophore change were seen during each voiding and between subjects. Fig 1 is a representative graph from a female 5 yrs old.
In one subject with a 127 sec. delay between permission to void with urge and uroflow start, tHb & O2Hb showed a typical initial rise. During sustained urge without uroflow, changes compatible with oxygen consumption and haemodynamic effects are evident during constant bladder volume Fig 2.
601
and deoxyhemoglobin (HHb), combined with Qmax and PVR provide discriminant ability between subjects with and without obstruction. We report a mathematical method where NIRS data can be used alone to derive such classification with comparable accuracy. METHODS: Data collected during simultaneous UDS and NIRS evaluation of male subjects with LUTS was analyzed. Conventional pressure flow nomograms classified subject’s urodynamic data as obstructed or unobstructed. Linear discriminant (LD) analysis and classification and regression tree (CART) analysis of NIRS parameters followed using MATLAB software and a learning sample of data, to which a learning set was applied comprising the relative concentrations of O2Hb and HHb for patients classified by UDS as obstructed or unobstructed. Elements in the learning set were paired (HHb (t), O2Hb (t)) for every time t in the time series of recorded data. The total number of pairs in the learning set was 37540. RESULTS: Data sets from 46 patients were evaluated. UDS identified 30 as obstructed and 16 as unobstructed. For NIRS data CART methodology was superior to LD analysis, and the CART algorithm generated was able to use NIRS derived parameters alone to classify subjects as obstructed or unobstructed, as compared to the conventional Abrahams-Griffiths nomogram. The following classification responses were obtained: True-Positive fraction (TP) = 30, True-Negative fraction (TN) = 14, False-Positive fraction (FP) = 2, False-negative fraction (FN) = 0. These fractions indicate 88% specificity, 84% precision and a misclassification error of 4% for CART analysis of NIRS data. CONCLUSIONS: Using a CART algorithm, non-invasive NIRS data obtained during voiding has independent discriminant ability for classifying subjects with LUTS as either obstructed or unobstructed. CART is probably superior to LDA as NIRS data are non-linear, and because CART uses all NIRS data points obtained throughout the voiding cycle rather than a single point related to Qmax. Source of Funding: Post Doctoral Funding, Vancouver Hospital foundation
1667 NEAR-INFRARED SPECTROSCOPY (NIRS) FOR APPLICATION IN UROLOGY Alexis E Te*, Doreen E Chung, Richard I Lee, Steven A Kaplan, New York, NY
CONCLUSIONS: Wireless NIRS monitoring is feasible in children and adults with reproducible trends of chromophore change during voiding. The NIRS data indicating effects on oxygenation during sustained urge may contribute insight into the physiologic basis of urge in some patients, and NIRS monitoring when movement of the bladder due to volume change is absent. Source of Funding: Ph D candidate research fellow salary, Vancouver Hospital Foundation
1666 ALGORITHM CONSTRUCTION METHODOLOGY FOR DIAGNOSTIC CLASSIFICATION OF BLADDER-DERIVED NEARINFRARED SPECTROSCOPY DATA. Ramon Gueverra, Lynn Stothers, Andrew J Macnab*, Vancouver, BC, Canada INTRODUCTION AND OBJECTIVES: Progressive functional impairment in bladder outlet obstruction (BOO) is associated with hemodynamic changes. Patients with lower urinary tract symptoms (LUTS) currently require diagnostic evaluation with invasive urodynamics (UDS). Non-invasive voiding studies are now described using near-infrared spectroscopy (NIRS), an optical method of monitoring tissue oxygenation and hemodynamics. Changes in concentration of oxyhemoglobin (O2Hb)
INTRODUCTION AND OBJECTIVES: Near-infrared spectroscopy (NIRS) is a non-invasive optical technique that uses light to monitor changes in blood flow and concentrations of oxygenated and deoxygenated hemoglobin to assess physiologic and metabolic conditions. NIRS is an established technology used in a range of organs and tissues. An instrument has been developed for urological applications, and specifically for the interrogation of the bladder detrusor (Tetra NIRS, Laborie Medical Technologies Inc.). This current application of NIRS evaluates male patients with lower urinary tract symptoms (LUTS) as obstructed or unobstructed. The purpose of this study is to use NIRS to classify male patients with LUTS as obstructed or unobstructed when compared to pressure flow studies, and to confirm the results of a previous pivotal study, which reported >85% concordance with pressure flow studies. METHODS: Male patients referred for urodynamic (UDS) testing for evaluation of LUTS were simultaneously evaluated with NIRS. The NIRS classification of obstructed and unobstructed is derived from a customized algorithm which analyzes the pattern of change in hemodynamics and incorporates measurements of PVR and maximum flow. The results were compared to the diagnosis derived from simultaneous standard pressure flow testing. RESULTS: A total of 42 patients were enrolled and 36 (86%) had evaluable data. 5 subjects were excluded for: communication error with NIRS (2); patch could not adhere to subject (1); communication error with urodynamic instruments (1); data saving error (2). The NIRS algorithm correctly identified those diagnosed with obstruction in 28 out of 31 patients (90%) and correctly identified unobstructed cases in 4 out of 5 (80%) patients, which provides an 89% concordance with the
602
THE JOURNAL OF UROLOGY®
diagnosis made with conventional UDS testing. CONCLUSIONS: This is the first independent study to validate the positive results of a previous pivotal trial. The overall concordance of NIRS with pressure flow studies is 89% in diagnosing male patients referred for LUTS as obstructed or unobstructed. Larger multicenter studies are in progress to further validate these findings and to establish clinical utility. Source of Funding: Laborie Medical/ Urodynamix Technology
1668 DEFINING THE EDUCATIONAL GAP IN URODYNAMICS TRAINING BETWEEN RESIDENCY AND THE FIRST 18 MONTHS IN PRACTICE Elizabeth R Mueller*, Maywood, IL INTRODUCTION AND OBJECTIVES: Fifty percent of graduating urology residents report that their urodynamic training was less than adequate and over 66% have not performed urodynamic (UDS) procedures during their residency. The objective of this analysis was to analyze the procedure logs of post-residency urologists who are applying for American Board of Urology (ABU) certification from 2004 to 2007 to better understand the practice patterns of “new” urologists METHODS: Applicants for part II ABU certification must submit a procedure log from a period within 18 months of the certification process. The log lists all of the procedures by CPT code performed during 6 consecutive months. We extracted the following data from certification and recertification logs; the number of procedures with UDS CPT codes (51725, 51726, 51741, 51772, 51784, 51785, 51792, 51795, and 51797) and the patient gender. Video-urodynamic procedures were defined by identifying the above CPT codes that were performed on the same day as the fluoroscopy codes 74330, 74450, 74455, 76000, 76001. RESULTS: The 6-month logs of 878 urologists applying for ABU part II certification during the period of 2004 to 2007 were analyzed. Seven hundred and seventy urologists (88%) performed UDS procedures. The percentage of urologists performing urodynamics increased from 82% to 93% from 2004 to 2007. The most common UDS procedure performed was complex uroflowmetry (34.8%) followed by complex cystometry (CMG) (20.2%), bladder voiding pressures(13.7%), electromyography of the urethral/anal sphincter (12.6%) and abdominal (11.4%) pressures during voiding. The 2007 certification applicant’s 50th and 90th percentile data for number of UDS procedures performed in 6 months for complex uroflow was 30 and 192 procedures and for CMG was 22 and 88. Videourodynamics were performed by ~ 7.2% of certifying urologists and were used primarily during complex CMG (7.7%) and complex uroflow (6.7%). CONCLUSIONS: Although only 33% of graduating urologists perform UDS during their residency training, more than 88% perform and interpret UDS within the first 18 months of graduating. Standardized UDS curricular content, learning objectives and outcome evaluations may better prepare residents for clinical practice. Source of Funding: SUFU/SUCPD Educational Grant
1669 URODYNAMIC PROCEDURES ARE ON THE RISE Elizabeth R Mueller*, Maywood, IL INTRODUCTION AND OBJECTIVES: Most of the urodynamic literature focuses on the indications for urodynamic studies (UDS) for treatment of urinary incontinence and voiding dysfunction. Much less is known about the frequency with which UDS is being performed and trends in UDS practice among urologists. The objective of this analysis was to describe trends in the practice of UDS among urologists who applied for American Board of Urology (ABU) certification and recertification from 2004 to 2007. METHODS: Procedure logs submitted by applicants for part II ABU certification or ABU recertification during 2004-2007 were reviewed. The log lists all of the procedures by CPT code performed
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
during 6 consecutive months. The number of procedures with UDS CPT codes (51725, 51726, 51741, 51772, 51784, 51785, 51792, 51795, and 51797) were abstracted. RESULTS: Logs of 2650 urologists (1072 (67%) recertifying and 878 (33%) first time applicants) were analyzed. Total number of UDS performed by urologists applying for certification and recertification more than doubled (k129.5%) from 86,840 to 199,272 procedures/6 months. This was in part due to an increase in the number of applicants from 473 to 655 applicants (k38%). The percent of certifying and recertifying urologists performing UDS also increased over 4 years by 50% and 32%, respectively. The table details percent increase by specific UDS performed in (2007 compared to 2004) by certification status. CPT
Description
Cert
ReCert
51772
Urethral pressure profile
683%
279%
51792
Stimulus evoked response
495%
250%
51785
Needle EMG
384%
550%
51797
Voiding abdominal pressure
376%
324%
51784
Any EMG
294%
360%
51795
Voiding bladder pressure
279%
307%
51741
Electronic flow rate
121%
78%
51726
Electronic cystogram
101%
132%
51725
Manometer cystogram
-80%
-41%
CONCLUSIONS: New and practicing urologists are increasingly performing more UDS. Further studies are warranted to determine the efficacy of UDS in diagnosis and treatment of lower urinary tract dysfunction. Source of Funding: SUFU/SUCPD Educational Grant
Oncology (Bladder and Others) Video Session 6 Tuesday, April 28, 2009
1:00 pm - 3:00 pm
V1670 OBTURATOR NERVE INJURY DURING ROBOTIC ASSISTED RADICAL CYSTECTOMY: RECOGNITION OF INJURY AND ROBOTIC REPAIR. Ali Moinzadeh*, Jessica DeLong, Ingolf A Tuerk, Andrea Sorcini, Burlington, MA INTRODUCTION AND OBJECTIVES: Obturator nerve injury is a rare complication of pelvic lymph node dissection. Great care is taken to identify the nerve using anatomic landmarks to avoid injury. We present two cases of obturator nerve injury during left side extended pelvic lymph node dissection for bladder carcinoma. METHODS: Two patients had obturator nerve injury during extended pelvic lymph node dissection during robotic-assisted radical cystectomy for high risk bladder cancer. During the first case, the obturator nerve was ligated with a hem-o-lock clip. The injury was recognized prior to transection and the clip was removed by the assistant with a clip remover. In the second case, during dissection of a metastatic lymph node packet, the obturator nerve was ligated with a hem-o-lock clip and transected with cold Endoshears. The hem-o-lock clip was removed with the harmonic scalpel, and the nerve re-approximated with 7-0 prolene interrupted sutures apposing the perineural sheath. RESULTS: The first patient had no post operative sequela from the nerve clipping and removal. A total of 25 lymph nodes were removed. Final pathology demonstrated 1/6 positive lymph nodes on the left (15 nodes total). The patient started immediate physical therapy. On postoperative day #1 he had 2/5 adduction strength. He was able to ambulate with out assistance by pos operative day #3. At two months, the patient was at his baseline strength with adduction and stopped