Observations of increased gastroesophageal reflux symptomology in an anhydrous ammonia exposed population.

OBJECTIVE: This case series describes a cohort of patients exposed to anhydrous ammonia vapors with clinical findings of laryngopharyngeal reflux (LPR). The study characterizes the identification of LPR as a consequence of vapor inhalation and the utility of PPI therapy in LPR secondary to inhalational ammonia exposure. METHODS: This is a case series of 15 patients exposed to anhydrous ammonia from a single chemical spill who experienced LPR several months after exposure. Symptoms of LPR were assessed at their initial consultation and by phone at least 30 days after treatment with low-dose PPI or diet modification. At this visit, patients underwent complete head and neck examination and flexible direct laryngoscopy. RESULTS: 15 patients were available for analysis before and after treatment. 93.3 % experienced at least three cardinal symptoms of LPR. 66 % of these patients had at least one LPR finding on flexible laryngoscopy. 73 % were treated with daily standard dose PPI, and 82 % of these patients experienced reduction of symptoms after 30 days of PPI treatment. Four of 15 patients were not taking the PPI as prescribed, and only one of these patients had resolution of LPR symptoms. CONCLUSION: We conclude that there is an association between anhydrous ammonia exposure and the development of LPR symptoms. In this study, treatment with PPIs was successful in reducing symptoms for most patients, and patients who did not receive PPIs experienced symptoms for a longer time.

The use of a modular titanium baseplate with a press-fit keel implanted with a surface cementing technique for primary total knee arthroplasty.

Little data exists regarding outcomes following TKA performed with surface-cementation for the fixation of modular tibial baseplates with press-fit keels. Thus, we retrospectively reviewed the clinical and radiographic outcomes of 439 consecutive primary TKAs performed with surface cemented tibial components. There were 290 female patients and 149 male patients with average age of 62 years (range 30-84). Two tibial components were revised for aseptic loosening (0.5%) and four tibial components (0.9%) were removed to improve instability (n = 2) or malalignment (n = 2). Complications included 13 deep infections treated with 2-stage revision (12) and fusion (1). These results support the surface cement technique with a modular grit-blasted titanium surface and cruciform stem during primary TKA.

No difference in 90-day complications between bilateral unicompartmental and total knee arthroplasty.

This study compares the 90-day complication rate of 28 patients who underwent simultaneous bilateral unicompartmental knee arthroplasty (UKA) with a matched control group of 56 patients who underwent simultaneous total knee arthroplasty (TKA.) We matched the groups 2:1 for age, gender, and American Society of Anesthesiologists scores and reviewed their medical records to identify complications, reoperations, and hospital readmission during the first 90 days after surgery as well as the operative times and length of hospital stay. The bilateral UKA group had shorter operative times (P = 0.06) and shorter length of hospital stay (P < 0.001). Ninety-day complications in the UKA group included 1 wound infection and 1 deep vein thrombosis (3.57%). The TKA group had 2 complications including 1 superficial wound infection and 1 pulmonary embolism (1.79%) (P = 0.60). One knee in each group required irrigation and debridement for wound infection. These patients requiring additional surgery for wound infection were the only 2 patients that required readmission within 90 days. Despite being a less invasive procedure, we found that the bilateral UKA group had a similar risk of complications to a matched group of bilateral TKA patients.

Spinal fractures in recreational bobsledders: an unexpected mechanism of injury.

STUDY DESIGN: Retrospective case series and literature review. OBJECTIVE: To report and discuss spinal fractures occurring in recreational bobsledders. SUMMARY OF BACKGROUND DATA: Spinal fractures have been commonly described following traumatic injury during a number of recreational sports. Reports have focused on younger patients and typically involved high-impact sports or significant injuries. With an aging population and a wider array of recreational sports, spinal injuries may be seen after seemingly benign activities and without a high-impact injury. METHODS: A retrospective review of two patients and review of the literature was performed. RESULTS: Two patients with spinal fractures after recreational bobsledding were identified. Both patients, aged 57 and 54 years, noticed a simultaneous onset of severe back pain during a routine turn on a bobsled track. Neither was involved in a high-impact injury during the event. Both patients were treated conservatively with resolution of symptoms. An analysis of the bobsled track revealed that potential forces imparted to the rider may be greater than the yield strength of vertebral bone. CONCLUSIONS: Older athletes may be at greater risk for spinal fracture associated with routine recreational activities. Bobsledding imparts large amounts of force during routine events and may result in spinal trauma. Older patients, notably those with osteoporosis or metabolic bone disease, should be educated about the risks associated with seemingly benign recreational sports.

Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study.

Our objective was to compare outcomes (anesthesia time, total operative time, tourniquet time, duration of hospital stay, 90-day complication rate, and transfusion rates) of patients with total knee arthroplasty (TKA) who underwent bariatric surgery before or after TKA. One hundred twenty-five patients were included: TKA before bariatric surgery (group 1; n = 39), TKA within 2 years of bariatric surgery (group 2; n = 25), and TKA more than 2 years after bariatric surgery (group 3; n = 61). Patients with TKA more than 2 years after bariatric surgery had shorter anesthesia and total operative and tourniquet times than other groups; differences were significant between groups. Ninety-day complication and transfusion rates approached but did not meet statistical significance. Ninety-day complication rates and duration of hospital stay did not differ significantly between the 3 groups. The level of evidence was level II (cohort study).

Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years.

Total hip arthroplasty (THA) in the adolescent patient has historically shown relatively poor survivorship. This study reports the results of THA in young patients using contemporary ceramic bearings. Twenty-four THAs were performed using ceramic bearing surfaces in patients 20 years old or younger (mean, 16.4; range, 12-20). Average follow-up was 52 months (range, 25-123 months). The survival rate was 96%, with 1 revision for a loose acetabular component. Other complications included a peroneal nerve palsy that resolved and 2 dislocations in 1 patient. Postoperatively, the Modified Harris Hip Score mean was 93.4 (range, 66-100). This study shows promising results at short-term to midterm follow-up in very young patients who undergo THA using ceramic-on-ceramic components.

Sequelae of Perthes disease: treatment with surgical hip dislocation and relative femoral neck lengthening.

BACKGROUND: Sequelae of Perthes disease commonly manifests as complex hip pathomorphology including coxa magna, coxa brevis, and acetabular dysplasia. These abnormalities contribute to femoroacetabular impingement and early osteoarthritis. This report describes our experience with correction of the proximal femoral deformity associated with Perthes disease through surgical dislocation, osteochondroplasty (SDO), trochanteric advancement, and treatment of intraarticular chondrolabral injury. METHODS: Between January 2003 and January 2009, 14 patients with Perthes disease (4 female and 10 male patients) with an average age of 19.6 years (range 14 to 28 y) were treated with SDO and trochanteric advancement. One patient had a subsequent staged periacetabular osteotomy to improve acetabular coverage. Patient histories, physical examinations, operative findings, and preoperative and postoperative radiographs were evaluated. RESULTS: Operative findings showed 6 acetabular cartilage lesions, 6 labral lesions, and 4 femoral osteochondritis dissecans (OCD) lesions treated with autografts. The mean of center-trochanteric distance improved from -20 mm to -1 mm. Approximately 4 of 14 hips deteriorated to Tönnis grade 1 and 1 of 14 hips deteriorated 2 Tönnis grades. The Harris hip scores improved from an average of 62 preoperatively (range 51 to 72) to 95 postoperatively (range 93 to 97) with OCD lesions versus 71 (range 65 to 76) to 88.6 (range 63 to 100) in the hips without OCD lesions. There was no statistically significant difference in the age, preoperative or postoperative HHSs between the OCD and non-OCD groups. The mean follow-up was 45 months. There were no major perioperative complications, and all the patients in both the groups have their native hip to date. CONCLUSIONS: The typical adult sequelae of Perthes disease predispose the hip to the development of chondrolabral injury and poor clinical function. Treatment with SDO and trochanteric advancement reduces impingement, improves hip biomechanics, and allows the treatment of intraarticular pathology. This approach is associated with clinical improvement without major perioperative complications. In addition, we have found a high rate of OCD lesions of the femoral head in Perthes hips undergoing surgical dislocation. Osteochondral autograft transfer from the resected femoral head-neck junction been found in the 4 patients treated thus far to be safe and effective with comparable clinical and radiographic outcomes to those hips without OCD lesions. LEVEL OF EVIDENCE: Level IV (Case series).

Complex Achilles reconstruction for massive soft tissue loss: allograft, autograft, and use of a temporary cement spacer.

A 36-year-old male sustained loss of the Achilles mechanism secondary to a crush injury. The patient was treated with early placement of a cement spacer in the superficial posterior compartment, which allowed for successful late reconstruction.

Discontinuation of warfarin is unnecessary in total knee arthroplasty.

UNLABELLED: Patients with medical comorbidities that necessitate chronic anticoagulation therapy frequently present as candidates for total knee arthroplasty (TKA). We asked whether it was necessary to stop warfarin preoperatively to avoid postoperative bleeding complications. We retrospectively reviewed 77 preoperatively anticoagulated patients undergoing TKA. Thirty-eight of these 77 patients were maintained on their routine therapeutic warfarin regimen throughout the perioperative period. The remaining 39 patients had their routine preoperative warfarin regimen discontinued preoperatively and then restarted after surgery. We compared rates of comorbid illness, blood transfusions, wound complications, and reoperations. The demographic data and the ratio of primary to revision arthroplasties were similar in the two groups. The age-adjusted risk ratios for blood transfusions, wound complications, and reoperations were 0.61, 0.29, and 0.43, respectively. The data presented suggest maintaining a therapeutic warfarin regimen throughout the perioperative period for high-risk patients is not associated with an increase risk of complications after TKA. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Bilateral total knee arthroplasty in patients 70 years and older.

Recently an increase has been shown in perioperative morbidity and mortality in patients older than 70 years undergoing sequential or simultaneous total knee arthroplasty (TKA) using 1 anesthetic. This study prospectively compared perioperative morbidity, mortality, and functional outcomes in patients 70 years and older undergoing sequential bilateral TKA under 1 anesthetic vs a control undergoing only unilateral TKA. Seventy patients (140 knees), 70 years and older, who underwent sequential bilateral TKA under 1 anesthetic were matched with a control series of 312 patients undergoing unilateral TKA during the same time period. All patients were evaluated pre- and postoperatively at regular time intervals. No mortalities were noted in either group. Perioperative complication rates were not statistically different between groups. Knee Society scores and SF-36v2 scores were better at 6-month and 1-year follow-up in the sequential bilateral knee group. Results from this study were not as expected based on previous reports in the literature. Although functional outcomes in this study were consistent with previous reports, patients did not demonstrate the expected difference in complications. This study is the first prospective study looking specifically at patients 70 years and older undergoing unilateral vs bilateral TKA under 1 anesthetic. According to our data, age alone is not a reason to exclude patients from sequential bilateral TKA under 1 anesthetic.

Highly crosslinked polyethylene is safe for use in total knee arthroplasty.

UNLABELLED: Highly cross-linked polyethylene (XLPE) has been used with good initial success in hip arthroplasty to reduce wear. However, the process of crosslinking reduces fracture toughness, raising concerns as to whether it can be safely used in total knee arthroplasty (TKA). We therefore asked whether XLPE can be used safely in TKA. We performed a retrospective review of 100 subjects receiving XLPE and compared them to 100 subjects who received standard polyethylene in the setting of TKA. The standard polyethylene group had a mean age of 70 with a minimum follow up of 82 months. The highly cross-linked polyethylene group had a mean age of 67 and a minimum follow up of 69 months (mean, 75 months; range, 69-82 months). On radiographic review, the standard group demonstrated 20 TKAs with radiolucencies; 4 of these had evidence of a loose tibial component. The standard group required three revisions related to loose tibial components. The XLPE group had 2 subjects that demonstrated radiolucencies on radiograph and no subjects with evidence of tibial loosening. There were no reoperations related to osteolysis. The data suggest XLPE in TKA can be used safely at least short- to midterm. Our study provides an impetus for further long-term investigation. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Results of bilateral combined hip and knee arthroplasty in very young patients with juvenile rheumatoid arthritis.

INTRODUCTION: We evaluated the long-term outcomes for combined, bilateral total knee and hip arthroplasty performed on a group of very young patients with juvenile rheumatoid arthritis. MATERIALS AND METHODS: Six consecutive patients with a mean age of 14 years at the time of hip replacement and 16 years at knee replacement were analyzed. Five of the six patients were wheelchair dependent pre-operatively. All knee components had uncemented fixation, while the hip replacements were a mixed group of cemented and uncemented prostheses. RESULTS: Clinical and radiographic follow-up at a mean duration of 13.8 years for the hips and 17.3 years for the knees demonstrated four of the six patients were unlimited community ambulators, one a limited community ambulator and the remaining patient a household ambulator. Failure, defined as revision of any of the components or definite radiographic loosening, occurred in three knees (two patients) and five hips (three patients). CONCLUSIONS: These good long-term functional results in a relatively very young population indicate that an early and aggressive approach to multiple joint disease is an appropriate option at a young age for patients with juvenile rheumatoid arthritis with severe disability and pain refractory to conservative management.

Total knee arthroplasty in juvenile rheumatoid arthritis.

BACKGROUND: There is a paucity of reports regarding the long-term results of total knee arthroplasty in patients with juvenile rheumatoid arthritis. The purpose of this study was to evaluate the outcome of total knee arthroplasty in patients with juvenile rheumatoid arthritis who had been followed for a minimum of twelve years. METHODS: Eight consecutive patients (fifteen knees) with juvenile rheumatoid arthritis underwent total knee arthroplasty at an average age of 16.8 years. Clinical evaluation of pain status, range of motion, and the ability to walk and radiographic evaluation of the alignment of the knees and component loosening were performed preoperatively and at a mean of 15.5 years postoperatively. RESULTS: All patients had substantial pain and functional limitation before the surgery, and seven of the eight patients used a wheelchair. At the time of the latest follow-up, which was after revision surgery in three patients, all of the knees were pain-free and six patients were able to walk about the community. The mean arc of motion had increased from 36 degrees to 79 degrees . The final radiographic evaluation showed that thirteen of the fifteen knees were in neutral alignment and two were in valgus. Failure, defined as revision of any of the components or definite loosening as seen radiographically, occurred in three knees. CONCLUSIONS: Good results, in terms of pain relief and restoration of function, were seen at a minimum of twelve years following total knee arthroplasty in our series of patients with juvenile rheumatoid arthritis. This procedure is a reasonable option when nonoperative therapy has been inadequate for patients with severe disability and pain in this relatively young population.