Cementless versus cemented Oxford unicompartmental knee arthroplasty: early results of a non-designer user group.

PURPOSE: Although fewer tibial radiolucent lines are observed in cementless Oxford unicompartmental knee arthroplasty (UKA) compared with cemented Oxford UKA, an independent comparative study on this topic is lacking. METHODS: In this multicentre retrospective study, a cohort of 60 consecutive cases of cementless Oxford UKA is compared with a cohort of 60 consecutive cases of cemented Oxford UKA. Radiolucent lines, survival, perioperative data and clinical results were compared. RESULTS: No complete tibial radiolucent lines were observed in either group. Seventeen per cent of partial tibial radiolucent lines were observed in the cementless group versus 21 % in the cemented group (n.s.). The percentage of tibial radiolucent zones was 4 versus 9 %, respectively (p = 0.036). Survival rates were 90 % at 34 months for the cementless group and 84 % at 54 months for the cemented group (n.s.). Mean operation time was 10 min shorter in the cementless group (p < 0.001), and clinical results were not significantly different. CONCLUSIONS: Although no significant differences in radiolucent lines were found between both groups, they appear to be more common in the cemented group. This confirms previous results from reports by prosthesis designers. The presence of radiolucent lines after cemented Oxford UKA does not correlate with clinical outcome or survival. LEVEL OF EVIDENCE: III.

Overexpression of erbB-2 or EGF receptor proteins present in early stage mammary carcinoma is detected simultaneously in matched primary tumors and regional metastases.

Membrane protein levels of erbB-2 and epidermal growth factor (EGF) receptor as well as gene aberrations affecting these proto-oncogenes in human mammary cancer were determined in primary and metastatic lesions. Among 57 patients erbB-2 gene amplification was detected in 11 tumors (19%). In 10 of these patients where expression levels could be assayed gene amplification was associated with a high level of erbB-2 protein. In contrast, EGF receptor gene amplification with over-expression of the protein product was observed in 2 tumors (4%). In addition, 14 out of 53 (26%) primary tumors exhibited moderately increased erbB-2 protein levels in the absence of gene amplification. Similar aberrations resulting in overexpression of EGF receptor protein without detectable gene amplification were associated with 2 tumors (4%) among 47 patients analyzed. In 7 patients, expression level and gene copy numbers of erbB-2 or EGF receptor were similarly altered in the primary tumor and metastatic lesions derived from the same patient. Concordance of increased receptor gene expression in primary and metastatic lesions combined with the observation that such alterations are detectable as early as stage I and II mammary tumors, suggests that overexpression of erbB protooncogene family members can develop early in breast cancer and is maintained during tumor progression. Comparison of erbB-2 overexpression with clinical disease parameters revealed a correlation of this alteration with inflammatory mammary carcinoma (P = 0.042) implying an association of elevated erbB-2 protein levels with enhanced malignancy of the tumor cell in vivo.

A randomized study comparing cisplatin or carboplatin with etoposide in patients with advanced non-small-cell lung cancer: European Organization for Research and Treatment of Cancer Protocol 07861.

The European Organization for Research and Treatment of Cancer (EORTC) Lung Cancer Working Party conducted a randomized trial comparing cisplatin (CDDP; 120 mg/m2, day 1) and carboplatin (CBDCA; 325 mg/m2, day 1) in combination with etoposide (VP16; 100 mg/m2, days 1, 2, and 3) in advanced non-small-cell lung cancer (NSCLC). Two hundred twenty-eight patients were eligible for survival and 202 assessable for response. We obtained 27 of 100 objective responses (ORs; 27%) in the CDDP arm and 16 of 102 (16%) in the CBDCA arm (P = .07). There was no significant difference in survival. Toxicity, consisting mainly of myelosuppression and renal function impairment, was significantly increased in the patients receiving the CDDP treatment. We conclude that CDDP plus VP16 was more active but also more toxic than CBDCA plus VP16 in advanced NSCLC.

Treatment of scaphoid non-union with a percutaneous corticocancellous bone graft.

Thirty-three symptomatic scaphoid non-unions were treated by a simple, minimally invasive procedure using a percutaneous autologous corticocancellous bone graft. After an average follow-up of 3.5 years, union was observed in 29 cases. These patients had no, or mild, pain at work and an almost normal range of motion and grip strength. No progression to osteoarthritis was observed.

Mineral bioavailability and bone mineral contents in pigs given calcium carbonate postprandially.

We have further investigated the "meal effect" on mineral bioavailability in pigs by mineral balance studies and measurements of bone ash contents and bending moment. A group of seven pigs (CAA) was given all its dietary Ca as CaCO3 5 h after the first daily meal for 8 weeks. The control group of seven pigs received CaCO3 in the meal. Both groups were given normal P within the meals. Ca and P absorption and retention were evaluated by a 10-day balance trial. Several bones were collected at slaughter to determine bone ash, Ca, and P contents and bending moment (three-point bending test). Ingesting Ca after the meal did not affect Ca bioavailability or phosphorus absorption, but did reduce P retention, which in turn decreased the bone scores. Osteopenia, indicated by decreased total mineral contents of bones (and decreased ash:bone volume ratio), was associated with elevated plasma osteocalcin in the CAA group. Thus, CaCO3 need not be incorporated into a meal for high Ca absorption, provided that Ca is given after a meal, but simultaneous intakes of Ca and P are required for the best mineral retention.

In vivo bone metabolism and ex vivo bone marrow osteoprogenitors in vitamin D-deprived pigs.

Vitamin D insufficiency is still a concern in countries where there is no routine food supplementation, such as France. A low vitamin D status is clearly associated with an increased risk of fracture in the elderly, but the long-term consequences of latent vitamin D insufficiency in young people and adults are not known. We fed 26 growing pigs a high calcium diet (1.1%) with a 1000 IU cholecalciferol/kg diet (controls), or without vitamin D (0D) for 4 months. We then analyzed the overall impact of low vitamin D status on osteotropic hormones (calcitriol and immunoreactive parathyroid hormone), plasma markers of bone remodeling (alkaline phosphatase [ALP] activity, carboxyterminal propeptide of type I procollagen [PICP], osteocalcin, hydroxyproline), whole bone parameters (ash content, bending moment), histomorphometry, and the populations of marrow osteoblastic and osteoclastic precursors by ex vivo cultures. The fall in plasma 25-dihydroxyvitamin [25(OH)D] in the 0D pigs indicated severe depletion of their vitamin D stores. However, they remained normocalcemic, were mildly hyperparathyroid after 2 months of vitamin D deprivation, and showed only a slight decrease in plasma calcitriol. The bone mineral content and bending moment of metatarsals decreased and they had increased osteoblastic (+59%, p < 0.05 0D vs. controls) and osteoclastic (+31%, p < 0.1 0D vs. controls) surfaces. This was not paralleled by increased bone turnover, because plasma hydroxyproline and ALP were unchanged and PICP and osteocalcin were decreased. The adherent fraction of bone marrow cells showed a great increase in the number of total stromal colony-forming units (CFU-F; +93%, p < 0.05 0D vs. controls) and in the percent of ALP(+) CFU-F (+58%, p < 0.01 0D vs. controls) in cultures from 0D pigs. More tartrate-resistant acid phosphatase-positive (TRAP(+)) multinucleated cells were generated in cultures of nonadherent marrow cells from 0D pigs, and the area of resorption was 345% greater than in controls. Thus, vitamin D deprivation caused only moderate hormonal changes in growing pigs fed a high-calcium diet, but affected their bone characteristics and greatly enhanced the pool of osteoblasts and osteoclasts by stimulating the commitment of their precursors in bone marrow.

Phase I/II study of gemcitabine and cisplatin in the treatment of advanced non-small cell lung cancer: preliminary results.

Sixty-six patients with advanced non-small cell lung cancer have been entered into a phase I/II study of a combination of gemcitabine and cisplatin. An initial phase I portion of the study has been completed, and 16 patients have been entered using a fixed dose of gemcitabine 1,000 mg/m2 as a 30-minute intravenous infusion weekly for 3 weeks. Cisplatin was administered on day 15 following gemcitabine with appropriate prehydration and posthydration. The study was designed to allow for sequential groups of three patients to receive three dose levels of cisplatin (60 mg/m2, 75 mg/ m2, and 100 mg/m2). Dose modification and patient numbers were to be increased at any dose level if significant toxicity was observed. The regimen was well tolerated at all doses, and the final level of cisplatin 100 mg/m2 was expanded to 10 patients before the phase II portion was opened. Neutropenia (World Health Organization grade 4 in three patients) and thrombocytopenia (grade 3 or 4 in five patients) were the main hematologic toxicities recorded. These episodes were brief and uncomplicated. Grade 3 nausea and vomiting occurred in 12 patients, but was no worse than would be expected from cisplatin alone. Alopecia, when it occurred, was minimal (no hair loss in 10 patients and grade 1 or 2 in six patients). No significant renal toxicity or neurotoxicity was seen. A phase II study with cisplatin 100 mg/m2 and gemcitabine 1,000 mg/m2 has been opened, and to date 43 patients are evaluable for response. Eighteen (42%) patients have achieved partial remissions. The study will close when 50 evaluable patients have been entered.

Outcome and one year follow-up of intra-arterial staphylokinase in 191 patients with peripheral arterial occlusion.

Wild-type or equipotent variants of recombinant staphylokinase (rSak) were given intra-arterially (as a 2 mg bolus injection followed by an infusion of 1 mg/h or 0.5 mg/h overnight, with concomitant heparin [1000 IU/h]) to 191 patients of less than 80 years (62 +/- 1 years, mean +/- SEM), with a peripheral arterial occlusion (PAO) of less than 120 days (mean 14 +/- 1 days, median 11 days, 5 to 95 percentiles 3 to 30 days). Ninety nine patients presented with acute or subacute ischemia, 57 with severe claudication, 33 with chronic rest pain and 2 with gangrene. Occlusion occurred in 122 native arteries and in 69 grafts. Revascularization was complete in 83 percent (158/191), partial in 13 percent (24/191) and absent in 4 percent (7/191) after administration of 12 +/- 0.5 mg rSak over 14 +/- 0.7 h. Complete revascularization of acute occlusions of popliteal or more distal arteries was less frequent (60 percent, 15/25) than of acute occlusions of more proximal native arteries (95 percent, 37/39, p <0.001) or grafts (89 percent, 50/56, p = 0.005). Additional endovascular procedures were performed in 47 percent and subsequent elective bypass surgery in 23 percent of patients. Major bleeding occurred in 12 percent (23/191), one month mortality was 3.1 percent (6/191) and one year mortality was 6.9 percent (12/174). However, four patients (2.1 percent) had an intracranial bleeding following therapy: a 85 year old woman with severe diabetic arteriopathy, who was included in violation of the protocol, a 79 and a 74-year-old woman and a 74-year-old man, all with severe hypertension and limb threatening ischemia; these four patients died within two months after treatment. Amputations were performed within the first year in 16 of 162 surviving patients (9.8 percent): in 7 percent (7/96) with an occluded native artery and 14 percent (9/66) with an occluded graft (p = 0.19). No significant difference in lysis rate, one month mortality or one year amputation-free survival was observed in occlusions of recent onset (< or =14 days, n = 126) as compared to occlusions of longer duration (>14 days, n = 65). Treatment was interrupted prematurely in 4 patients because of a suspected allergic reaction. Fibrinogen levels remained unaffected during treatment (3.3 +/- 0.1 g/l before vs. 3.3 +/- 0.1 g/l after infusion, n = 167). In conclusion, rSak appears to be a highly effective thrombolytic agent in patients with PAO, resulting in a low one month mortality (3.1 percent) and a high one year amputation free survival (84 percent), with an acceptable incidence of major bleedings, but with occasional fatal intracranial hemorrhages.

Prevention of fracture at the distal locking site of the gamma nail. A biomechanical study.

To investigate the origin of fractures at the distal locking site of the Gamma nail, we loaded ten paired human cadaver femora fixed with a Gamma nail in torsion until they fractured. When an awl was hammered in to start the hole for distal locking a fissure appeared in the lateral cortex of all the femora, and the mean torsional load to create a fracture was reduced by 57.8% compared with that in a control group in which the distal locking hole had been started with a centre drill. When an additional drill hole was made, the mean failure load in torsion decreased by 35.7%. We strongly recommend that an awl should not be used at the distal locking site of the Gamma nail; we recommend the use of a centre drill. Additional drill holes should be avoided because they act as stress raisers.

Local thrombolysis for occluded arterial grafts: is the yield worth the effort?

This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.

The value of dipyridamole thallium scintigraphy and dobutamine stress echocardiography as predictors of cardiac complications following reconstruction of the abdominal aorta.

BACKGROUND: The aim of this study was to evaluate the ability of dipyridamole thallium scintigraphy and dobutamine stress echocardiography to predict cardiac complications following elective reconstruction of the abdominal aorta in patients with a stable preoperative cardiac condition and to compare this with information obtained from the medical history, ECG and resting echocardiography alone. METHODS: This evaluation was performed from January 1993 until December 1995 as part of a prospective, randomised study in 200 patients, with a mean age of 65 (5% women). Dipyridamole thallium scintigraphy was performed on 195 patients and dobutamine stress echocardiography was added to the protocol in the last 83 patients. Cardiac complications were defined before the start of the study. RESULTS: In the postoperative period 62 cardiac complications occurred (31%). In patients clinically suspected of having coronary artery disease the incidence of complications was 40% (51/126), compared to 15% (11/74) when no coronary pathology was suspected (p<0.001). When reversible defects were present on dipyridamole thallium scintigraphy the incidence of complications was 36% (20/55), compared to 29% (41/140) when no reversible defects had been found (NS). Dobutamine stress echocardiography was impossible or contraindicated in 21 patients. In the remaining patients the incidence of complications was 71% (5/7) when new regional wall motion abnormalities were found, compared to 16% (9/55) when such abnormalities had not been detected (p<0.005). CONCLUSIONS: These data suggest that cardiac complications following reconstruction of the abdominal aorta in patients with a stable cardiac condition are best predicted by dobutamine stress echocardiography. Dipyridamole thallium scintigraphy, however, does not seem to be useful in this respect.

The clinical value of duplex surveillance following internal carotid artery reconstruction.

BACKGROUND: The purpose of this retrospective analysis was to evaluate the benefit of a yearly duplex ultrasonography of both the reconstructed and the contralateral internal carotid artery (ICA). METHODS: From 1985 to 1994, 1210 unilateral, primary ICA reconstructions were performed. Although these patients received yearly invitations, duplex follow-up was not available in 114 patients (9%). RESULTS: At 5 years a stenosis of 50% or more was found in 9% and at 10 years in 14% of patients. During the follow-up period 20 patients developed a stenosis of 80-99%. Ten patients had a redo-procedure. The others remained asymptomatic, even though one patient developed an occlusion. A stroke occurred in 96 patients. 58 of these had no significant stenoses. 57% of all patients had no significant contralateral lesion at the time of the first procedure. In only 4% of these a contralateral CAE was performed during the follow-up. CONCLUSIONS: In view of the above data, we would conclude that the clinical benefit of duplex surveillance is doubtful.

[Chemotherapy in non-small cell bronchial carcinoma. 12 years' experience in an international cooperative group: EORTC Lung Cancer Working Party]. / Chimiothérapie et carcinome bronchique non à petites cellules. Douze ans d'expérience au sein d'un groupe coopératif international: l'EORTC Lung Cancer Working Party.

The EORTC Lung Cancer Working Party investigates various chemotherapeutic regimens in patients with bronchogenic cancer. Within 12 years our Group has conducted 8 international co-operative studies in patients with non small cell lung cancer. We have demonstrated that Cis-platin was an active agent and its activity increases in association with Etoposide, mainly in limited disease. Lastly, we tested regimens including Carboplatin. This agent does not improve results in terms of objective response. We are now testing regimens including radiotherapy after chemotherapy in limited disease.

[Efficacy of the combination of mitomycin, ifosfamide and cisplatin with irradiation for the treatment of cerebral metastasis in non small cell lung carcinoma]. / Efficacité de l'association mitomycine, ifosfamide, cisplatine avec irradiation pour le traitement des métastases cérébrales des cancers bronchiques non à petites cellules.

We initiated prospective study testing efficacy of multidrug chemotherapy (cisplatin, ifosfamide, mitomycin) with irradiation in brain metastases of non small cell lung cancer at first diagnosis. Among 22 patients we obtained ten objective local responses (45%). Median survival was 7 months. Toxicity was mild (> 2 - OMS): hematologic = five patients; gastrointestinal = one patient. Among 11 patients who received chemotherapy before radiotherapy we had seven objective responses (patients evaluated after three courses of chemotherapy and before radiotherapy). This result indicates the interest of this protocol of chemotherapy in brain metastases. The association of this protocol of chemotherapy and radiotherapy appears effective, well tolerated and few toxic.

Lymphedema of the leg associated with rheumatoid arthritis.

A 14-year-old boy with a two year history of seronegative rheumatoid arthritis developed left leg lymphedema and subsequently a severe episode of lymphangitis. The diagnosis of "rheumatoid lymphedema" was confirmed by lymphscintigraphy and conventional lymphography. Treatment consisted of bedrest and antibiotic drugs. When the signs of inflammation had subsided, therapy with corticosteroids was started with improvement of both joint pain and leg swelling. Whereas lymphedema associated with rheumatoid arthritis has been described in the upper limb of adults, to our knowledge this is the first report of the coexistent condition in the lower leg of a child.

[Effect of oral propafenon on accessory pathways of atrioventricular conduction]. / Effet de la propafénone administrée par voie orale sur les voies accessoires de conduction atrio-ventriculaires.

Fifteen consecutive patients with accessory AV pathways comprising 12 cases of the Wolff-Parkinson-White syndrome and 3 cases with exclusively retrograde conduction diagnosed by endocavitary electrophysiological investigation were studied. 5 patients had paroxysmal atrial fibrillation and the other 10 had reciprocating orthodromic tachycardia. 12 patients underwent electrophysiological investigation to measure the refractory periods and anterograde and retrograde conduction times in sinus rhythm and induced reciprocating tachycardia treatment with oral propafenone at a dose of 900 mg/day for 3 to 6 days. The refractory periods of anterograde conduction and the conduction times were then measured using an endocavitary atrial recording electrode left in position after the initial investigation. The anterograde Wenckebach point decreased from 259 +/- 35/min to 158 +/- 13/min (p less than 0.001). The refractory periods were increased from 270 +/- 45 ms to 371 +/- 100 ms (p less than 0.05). Atrial fibrillation could only be initiated in 2 cases with a mean rate which had decreased from 258 to 130/min. Reciprocating tachycardia could only be initiated in 5 cases and then with a slower rate (average cycle length increasing from 352 +/- 52 ms to 430 +/- 41 ms). Eight of these patients continued the treatment for over one year without recurrence of their arrhythmias, confirming the long-term efficacy of propafenone in the prevention of arrhythmias complicating accessory AV conduction pathways.

[Right ventricular fibroma. Value of different methods of invasive and noninvasive exploration]. / Fibrome ventriculaire droit. Intérêt des différents modes d'exploration invasifs et non invasifs.

The authors report the case of a 20 year old man with a primary cardiac tumour. The relative usefulness of invasive (catheterisation and angiography), and non-invasive investigations (echocardiography, computerised axial tomography, myocardial scintigraphy and digitalised angiography) in determining operability and the benign or malignant nature of the tumour was evaluated. The patient was admitted to hospital for severe incapacitating effort dyspnoea. Cardiac auscultation was suggestive of pulmonary stenosis associated with tricuspid regurgitation. M mode and 2D echocardiography demonstrated a large mass within the right ventricular cavity and also its size shape, mobility and its relationship to the interventricular septum, tricuspid valve and the main pulmonary artery. Echo contrast studies confirmed tricuspid regurgitation and also demonstrated a patent foramen ovale. The cardiac CAT scan confirmed the preceding data. Myocardial scintigraphy demonstrated the vascular character of the tumour. Digitalised angiography showed the presence of a tumour in the right ventricle and the rest of the morphological information was identical to that obtained by conventional angiography. Cardiac catheterisation demonstrated an obstruction to right ventricular ejection and abnormal filling of both ventricles. It was the association of 2D echocardiography and Technetium 99 myocardial scintigraphy which provided the most information. The results of the other investigations were not essential in deciding the operative indications. A 230 g tumour was excised at surgery and the tricuspid valve replaced by a Hancock n 33 bioprosthesis. Anatomopathological examination showed the tumour to be a fibroma. The finding of a tricuspid diastolic rumble led to control catheter and angiographic studies 13 days after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Emergency treatment of chronic ventricular tachycardia after myocardial infarction by endocavitary fulguration]. / Traitement d'urgence de la tachycardie ventriculaire chronique après infarctus du myocarde par la fulguration endocavitaire.

Endocavitary catheter ablation consists of delivering an impulse of 160 to 240 joules via a catheter used for electrophysiological investigation resulting in an electrical discharge which, in addition to its thermal effects may alter the arrhythmogenic substrate mechanically. This method was used in 2 patients with resistant and recurrent VT after myocardial infarction complicated by ventricular aneurysm. Two sessions of catheter ablation were necessary in both patients, but in the second one a single shock was successful in critically ill patients with VT. The first patient has been followed up for 20 months and the second for 13 months. Under prophylactic antiarrhythmic therapy, neither patient has had recurrence of the ventricular arrhythmias which had previously led to their hospitalisation. Catheter ablation is therefore presented as a technique which may be performed in the electro-physiological laboratory and repeated in cases of incomplete efficacy. This method may be used successfully in the treatment of chronic VT after myocardial infarction complicated by ventricular aneurysm.

[Morbidity and mortality after elective surgery of complicated aneurysms]. / Morbidité et mortalité après chirurgie réglée des anévrysmes compliqués.

The post-operative mortality and morbidity after elective surgery of a complicated (difficult) infrarenal abdominal aortic aneurysm are reported. The authors compare a group of 126 patients with a simple uncomplicated aneurysm to a group of 126 patients with a complicated aneurysm. Mortality (3.2%) is similar in both groups but the morbidity is very high in the group of patients with difficult aneurysms. The most frequent complication was renal insufficiency determined by preoperative renal insufficiency. The length of the hospital stay was much longer for the patients after a surgery for a difficult aneurysm. A preoperative correct diagnosis is always possible and the surgical technique varies according the type of anomaly. Even elective surgery of a complicated aneurysm remains a challenge.

[Approach to aortic aneurysms including the renal arteries: retroperitoneal method]. / Abord des anévrismes aortiques englobant les artères rénales: voie rétropéritonéale.

A pararenal aneurysm is a rare type of an abdominal aortic aneurysm. The authors report 25 cases out of 429 abdominal aneurysms. The diagnosis was based on a CT-scan and subsequent biplane arteriography. The most common type was the dorsal proximal aortic dilatation, involving the origin of 1 or 2 renal arteries. A retroperitoneal approach was used in 18 of the 25 patients. The most common complication was the retroperitoneal hemorrhage, necessitating reintervention. None of these patients died or developed renal insufficiency despite a suprarenal clamping during the proximal reconstruction.