Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients.

INTRODUCTION: Tibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients. MATERIALS AND METHODS: A systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture. RESULTS: Of the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20-48%, revision rate 8-20%) but higher than after elective primary TKR. CONCLUSION: Based on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.

Trends in the Incidence, Etiology, Treatment, and Outcomes of Pleural Infections in Adults Over a Decade in a Finnish University Hospital.

BACKGROUND AND AIMS: The aim of the study was to ascertain changes in the incidence, etiology, treatment, and outcomes of pleural infections over a decade in a Finnish University Hospital. MATERIALS AND METHODS: All patients treated for pleural infections in Tampere University Hospital during 2000-2008 and 2012-2016 were included. The incidence rates and the epidemiologic data and medical history of patients, etiology of infection, and treatment trends and outcomes were compared between the cohorts. RESULTS: The incidence of pleural infections increased from 4.4 during 2000-2008 to 9.9 during 2012-2016 per 100.000 patient-years, p < 0.001. The patients in the latter group were older, 63 versus 57 years, p = 0.001, and the prevalence of chronic lung disease, hypertension, heart failure, dyslipidemia, and immunosuppressive medication were higher. The causes of infection remained similar and pneumonia accounted for 70% of all cases. The identification rate of the microbe pathogens increased from 49% to 64%, p = 0.002, while the distribution of identified pathogens was unchanged. More patients in the latter cohort were treated operatively, 88.3% versus 80.9%, p = 0.005, and, in these, the proportion of thoracoscopic surgery was higher, 57.4% versus 8.0%, p < 0.001, and the delay to surgery shorter, 5 versus 7 days, p < 0.001. Radiologic outcomes were similar. The 30-day mortality rate was 3.1% during 2000-2008 and 5.1% during 2012-2016, p = 0.293. CONCLUSION: The overall incidence of pleural infections has increased significantly while the causes of pleural infections and the distribution of pathogens remain unchanged. Contemporary patients are older with higher prevalence of comorbidities and more frequently undergo thoracoscopic surgery.

Repeated metal ion measurement in patients with bilateral metal on metal (ASR™) hip replacements.

BACKGROUND: Blood metal ion measurements have become a cornerstone in the surveillance of metal-on-metal (MoM) hip replacements. Interpretation of these levels in patients with bilateral MoM hip replacements, however, is challenging. We therefore asked (1) if there is a clinically significant change in whole blood (WB) Co or Cr levels in repeated WB assessment in patients operated on with bilateral ASR hip replacements, and (2) what proportion of patients has WB Co or Cr level below the previously established safe upper limits (SUL) (Co<5.0µg/L, Cr<7.4µg/L) in the repeated WB metal ion assessment. HYPOTHESIS: We hypothesized that there is a significant difference between repeated Co and Cr level measurement performed within one year±4 months interval in patients with bilateral ASR hip replacements. MATERIALS AND METHODS: We identified all patients (n=139) who had received bilateral ASR hip replacements (278 hips). Patients (n=76, 152 hips) who had undergone two blood metal ion measurements within eight to sixteen months' time interval were included in the study analysis. Study cohort included 38 patients with bilateral ASR hip resurfacings (mean age 53 years, median follow-up 4.6 years, median femoral diameter 51mm) and 38 patients with bilateral ASR XL total hip replacements (mean age 60 years, median follow-up 3.6 years, median femoral diameter 49mm). RESULTS: There was no significant change in Co and Cr levels between the repeated measurements in the HR cohort. Both Co and Cr were significantly higher in the THR cohort in the repeated measurement (Co: 8.3µg/L vs. 12.6µg/L, Cr: 3.15µg/L vs. 3.4µg/L, both P<0.001). WB Co and Cr levels remained below SUL and within their initial values during a mean one-year measurement interval in the majority of patients with bilateral high risk HR device. In contrast to this, 21.1% of patients with THRs had WB Co ion levels exceeding the SUL in the first measurement. WB Co values significantly increased over the measurement interval in the THR group. DISCUSSION: Annual blood metal ion measurement is not useful in patients with bilateral hip resurfacings who have undergone at least one preliminary screening including both metal ion measurement and cross-sectional imaging. It seems, however, to be beneficial in patients with bilateral high risk MoM THR. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Circulating Dendritic Cells, Farm Exposure and Asthma at Early Age.

Farm environment has been shown to protect from childhood asthma. Underlying immunological mechanisms are not clear yet, including the role of dendritic cells (DCs). The aim was to explore whether asthma and farm exposures are associated with the proportions and functional properties of DCs from 4.5-year-old children in a subgroup of the Finnish PASTURE birth cohort study. Myeloid DCs (mDCs), plasmacytoid DCs (pDCs) and CD86 expression on mDCs ex vivo (n = 100) identified from peripheral blood mononuclear cells (PBMCs) were analysed using flow cytometry. MDCs and production of interleukin (IL)-6 and tumour necrosis factor alpha (TNF-α) by mDCs were analysed after 5 h in vitro stimulation with lipopolysaccharide (LPS) (n = 88). Prenatal and current farm exposures (farming, stables, hay barn and farm milk) were assessed from questionnaires. Asthma at age 6 years was defined as a doctor's diagnosis and symptoms; atopic sensitization was defined by antigen-specific IgE measurements. Asthma was positively associated with CD86 expression on mDCs ex vivo [adjusted odds ratio (aOR) 4.83, 95% confidence interval (CI) 1.51-15.4] and inversely with IL-6 production in mDCs after in vitro stimulation with LPS (aOR 0.19, 95% CI 0.04-0.82). In vitro stimulation with LPS resulted in lower percentage of mDCs in the farm PBMC cultures as compared to non-farm PBMC cultures. Our results suggest an association between childhood asthma and functional properties of DCs. Farm exposure may have immunomodulatory effects by decreasing mDC proportions.

Monocyte-derived dendritic cells from Crohn's disease patients exhibit decreased ability to activate T helper type 17 responses in memory cells.

An increased activation of interleukin (IL)-17A-producing immune cells is a well-established feature of Crohn's disease (CD). Mechanisms that contribute to this aberrant immune activation are, however, less clear. Given that an enhanced induction of innate-immunity associated cytokines IL-6 and IL-23, which promote IL-17 immunity, is also clearly implicated in CD, we hypothesized that monocyte-derived dendritic cells (moDCs) of CD patient origin would mount exaggerated IL-17A responses in T cells. However, we found a significantly attenuated up-regulation of the IL-17A response in allogeneic T helper memory cells in the presence of culture media from lipopolysaccharide (LPS)-stimulated moDCs of CD patients when compared with moDCs of control subjects (median fold-increase in IL-17A mRNA expression 1·09 versus 1·44, P = 0·038). This was accompanied by a lower expression of IL-1ß and IL-6 transcripts in the LPS-treated moDCs (median 9·55 versus 13·9 relative units, P = 0·042, and 2·66 versus 9·06 relative units, P = 0·049, respectively). In addition, the up-regulation of autophagy-related LC3 transcripts was decreased in moDCs of CD patients (median fold-increase in mRNA expression 1·22 versus 1·52, P = 0·029). Our findings reveal similar immunological aberrancies in CD in the general population as reported in CD patients with mutated intracellular bacterial sensor NOD2, namely attenuated activation of innate cytokines and impaired autophagy, combined with a reduced capacity to up-regulate the T helper type 17 (Th17) response. The results presented here emphasize a defective anti-microbial response in the pathogenesis of CD. The increased mucosal Th1 and Th17 responses, which may contribute to the pathogenesis, could be the consequences of primary defects in the innate immunity.

Orthopaedic reconstruction of complex pelvic bone defects. Evaluation of various treatment methods.

Despite major developments in the field of revision surgery in recent decades, the management of severe acetabular deficiency at revision arthroplasty, complex primary total hip replacement or after pelvic tumour resection remains a complex problem. The options available for the management of severe bone loss include the use of uncemented press-fit cups with or without metal augments, impaction allografts, allograft-prosthesis composites, custom-made triflange cups, hip transposition, reconstruction prostheses or various combinations of these. This paper describes defect classification, various treatment options, clinical outcomes, survival of reconstruction, and typical complications in relation to treatment.

Randomized clinical trial of Lichtenstein patch or Prolene Hernia System for inguinal hernia repair.

BACKGROUND: In this randomized prospective study the short- and long-term outcomes of patients undergoing inguinal hernia repair with either Lichtenstein mesh or the Prolene Hernia System (PHS) were evaluated. METHODS: Postoperative pain and time to return to work, driving and sporting hobbies were recorded after 300 inguinal hernia repairs done by one of the two methods. Long-term sequelae and complications were assessed at follow-up visits 1 week, 1 month and 1 year after the operation. RESULTS: The median duration of operation for unilateral primary hernia was 37 min for the Lichtenstein operation and 27 min for the PHS procedure (P < 0.001). Postoperative pain was similar after both operations. Median sick leave was 7 days in both groups. Time to driving a car was 4 versus 3 days, and time to return to sporting hobbies 13 versus 11 days, in the Lichtenstein and PHS groups, respectively. Apart from a residual femoral hernia after Lichtenstein repair, no recurrent inguinal hernias were detected. CONCLUSION: Both Lichtenstein and PHS methods resulted in rapid recovery and low recurrence rates. The PHS operation was significantly quicker.

Efficacy and tolerability of fluticasone propionate nasal drops 400 microgram once daily compared with placebo for the treatment of bilateral polyposis in adults.

BACKGROUND: Chronic eosinophilic rhinosinusitis underlies a range of respiratory disorders including nasal polyposis. Surgical and medical methods are used to control polyps, with topical steroids commonly being used for their anti-inflammatory properties. Fluticasone propionate nasal drops (FPND) is a formulation developed specifically for an effective and well tolerated corticosteroid treatment of nasal polyposis. OBJECTIVES: To assess efficacy and tolerability of FPND in the treatment of bilateral nasal polyposis in adults. METHODS: This multicentre, randomized, parallel-group study compared FPND 400 microgram once daily (o.d.) with placebo for 12 weeks in adult patients with mild to moderate bilateral polyposis. The primary efficacy endpoint was visual assessment of polyp size by the physician at monthly clinic visits. Nasal blockage, rhinitis, peak nasal inspiratory flow (PNIF), olfactory function and requirement for polypectomy were also assessed at visits. The patients kept diary card records of symptoms, PNIF, and use of rescue antihistamine. Additional safety data were provided by a 12-week open extension, when all patients received FPND 400 microgram o.d. RESULTS: After 12 weeks double-blind treatment with FPND (n = 52) or placebo (n = 52), polyp size was reduced in 27% and 16% of patients, respectively; clinical reduction of nasal blockage significantly favoured FPND over placebo (55% vs 22%; P = 0.002), and clinic PNIF had increased significantly with FPND (by 52 L/min vs -3 L/min for placebo; P < 0.001). Diary card measurements showed significant benefits of FPND vs placebo for daily PNIF, nasal blockage, rhinitis and use of loratadine rescue medication. Both treatments were well tolerated and no serious adverse events occurred during randomized treatment. Epistaxis was more frequent with FPND than placebo but was generally mild and did not result in withdrawals. Mean serum cortisol levels did not change significantly with either treatment. CONCLUSION: This study showed FPND 400 microgram o.d. to be an effective and well tolerated treatment for bilateral nasal polyposis in adults.

Electron spin resonance (ESR) probe for interventional MRI instrument localization.

This article presents a miniaturized electron spin resonance (ESR) probe for deducing the position of a surgical instrument on an MR image. The ESR probe constructed was small enough to fit inside a 14-G biopsy needle sheath, and position information of the sheath could be acquired using a simple gradient sequence. The position accuracy was estimated from needle trajectories as inferred from the needle artifact, the actual physical trajectory, and measured coordinates. The probe was able to track the tip of a biopsy needle quickly (10 samples/sec) and precisely with accuracy better than +/-2 mm. J. Magn. Reson. Imaging 1999;10:216-219.

Endurance training associated with slightly lowered serum estradiol levels decreases mineral density of canine skeleton.

The effects of long-term running exercise were studied in 20 beagle dogs. A total of 10 dogs ran from the age of 15 weeks to the age of 70 weeks in a progressive program for up to 40 km/day. A total of 10 sister dogs spent the study period in individual cages. When the dogs were 70 weeks old, bone mineral density of the vertebrae, hip, and radius was analyzed by dual-energy x-ray absorptiometry (DEXA; Lunar) and the vertebrae were also assessed by quantitative computed tomography (QCT; Siemens DR 1). Mineral density was lower in the running dogs than in the controls. The difference was greatest in the spine in the QCT analysis. Blood chemistry analyses revealed that the metabolism of the bone was significantly accelerated. The estradiol levels showed the trend to be reduced in the running group. The beneficial effect of exercise on mineral density has been shown in many earlier studies. However, in this study we demonstrate the possibility of adverse effects of long-term exercise on bone tissue. The change was associated with a decrease of serum estradiol level.

Gonococcal perihepatitis in a surgical ward.

Within a three-year period six female patients with gonococcal perihepatitis were encountered. In the acute stage they had clinical symptoms indistinguishable from acute cholecystitis. In all six patients the diagnosis was established by positive growth of Neisseria gonorrhoeae from cervix specimens. Evidence of previous gonococcal pelvic infection was disclosed in three of the patients. In two patients the gonococcal aetiology of the disease was suggested by papular skin lesion and arthritis. Of the annual mean number of patients admitted to the emergency ward with suspicion of acute cholecystitis within the same three year period, 2.6% presented with gonococcal perihepatitis. As the incidence of gonorrhoea is increasing, complications such as perihepatitis are seen more frequently among young female patients admitted to surgical emergency wards because of acute abdominal pains.