Primary cup stability in THA with augmentation of acetabular defect. A comparison of healthy and osteoporotic bone.

BACKGROUND CONTEXT: Reconstruction of acetabular defect has been advocated as standard procedure in total hip arthroplasty. The presence of bony defects at the acetabulum is viewed as a cause of instability and acetabular wall augmentation is often used without proper consideration of surrounding bone density. The initial cup-bone stability is, however, a challenge and a number of studies supported by clinical follow-ups of patients suggested that if the structural graft needs supporting more than 50% of the acetabular component, a reconstruction cage device spanning ilium to ischium should be preferred to protect the graft and provide structural stability. This study aims to (1) investigate the relationship between cup motion and bone density and (2) quantify the re-distribution of stress at the defect site after augmentation. HYPHOTESIS: Paprosky type I or II, acetabular defects, when reconstructed with bone screws supported by bioabsorbable calcified triglyceride bone cement are significantly less effective for osteoporotic bone than healthy bone. MATERIALS AND METHODS: Acetabular wall defects were reconstructed on six cadaveric subjects with bioabsorbable calcified triglyceride bone cement using a re-bar technique. Data of the specimen with higher bone density was used to validate a Finite Element Model. Values of bone apparent density ranging from healthy to osteoporotic were simulated to evaluate (1) the cup motion, through both displacement and rotation, (2) and the von Mises stress distribution. RESULTS: Defect reconstruction with bone screws and bioabsorbable calcified triglyceride bone cement results in a re-distribution of stress at the defect site. For a reduction of 65% in bone density, the cup displacement was similar to a healthy bone for loads not exceeding 300 N, as load progressed up to 1500 N, the reconstructed defect showed increase of 99 µm (128%) in displacement and of 0.08° in rotation angle. CONCLUSIONS: Based on the results, we suggest that an alternative solution to wall defect augmentation with bone screws supported by bioabsorbable calcified triglyceride bone cement, be used for osteoporotic bone. LEVEL OF EVIDENCE: Level IV, experimental and cadaveric study.

Clarification of projective identification.

This paper clarifies the various current usages of the term "projective identification." The author presents a broad reference model of projective identification based on the work of Ogden. This model divides projective identification into three steps. Step 1 is the projection of a part of oneself onto an external object. Step 1a is the blurring of self and object representations. Step 2 is an interpersonal interaction in which the projector actively pressures the recipient to think, feel, and act in accordance with the projection. Step 3 is the reinternalization of the projection after it has been psychologically processed by the recipient. The different definitions of projective identification are shown to relate to exactly how the term "projection" is conceptualized (in step 1), to whether step 1a is deemed necessary, and to how many of the three steps are required for the definition of projective identification. The author reviews the work of Ogden, Kernberg, Meissner, Sandler, Malin and Grotstein, Porder, and Zinner et al. Six detailed case examples are provided from within and outside psychotherapy to illustrate all three steps of projective identification.

Hoarseness secondary to left atrial myxoma.

A 62-year-old woman presented with a history of hoarseness. Although stable for ten years, she recently showed signs of deterioration. Investigations revealed left vocal cord paralysis and a large left atrial tumor displacing the left pulmonary artery under the arch of the aorta. The lesion was removed and the normal aortopulmonary window on computed tomography (CT) scan was restored. On review of the literature, this case appears to be the first to suggest that myxomas cause recurrent laryngeal nerve palsy through direct effects.

Long-term clinical results with the Ionescu-Shiley pericardial xenograft.

From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued.

Ischemic contracture of the left ventricle. Production and prevention.

Ischemic contracture of the left ventricle ("stone heart") is a recognized complication of prolonged periods of interruption of the coronary circulation during open-heart surgery. We have examined the effects of moderate hypothermia (28 degrees C.) and preoperative beta-adrenergic blockade (propranolol, 0.5 mg. per kilogram; 1.0 mg. per kilogram) on contracture development during ischemic arrest of the heart. Four groups of 8 dogs each were placed on total cardiopulmonary bypass, and ischemic arrest of the heart was produced by cross-clamping the ascending aorta and venting the left ventricle. Intramyocardial carbon dioxide tension was continuously monitored by mass spectrometry. When anaerobic energy production ceased, as indicated by a final plateau in the intramyocardial carbon dioxide accumulation curve, the ischemic arrest was terminated and the contractile state of the heart observed. These results are given in the text. We conclude that beta-adrenergic blockade delays, but does not prevent, the onset of ischemic contracture of the left ventricle under normothermic conditions. Moderate hypothermia appears to prevent this complication completely.

Submammary skin incision as a cosmetic approach to median sternotomy.

Median sternotomy is the incision of choice to allow access to the anterior mediastinum, heart, or both lungs. The vertical skin incision leaves an unsightly scar for many female patients. A bilateral submammary horizontal skin incision with dissection of a flap including the subcutaneous tissue and breasts allows exposure of the sternum so that a median sternotomy can be performed. Since November 1981, we have used this incision 40 times in female patients undergoing open heart surgery. The exposure of the mediastinum was excellent, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Complications associated with this incision are insignificant if close attention is paid to details.

Pulmonary resection and contralateral anomalous venous drainage: a lethal combination.

A 72-year-old acyanotic woman had development of acute right heart failure with systemic hypotension 2 hours after a curative right intrapericardial pneumonectomy for primary lung cancer. A postoperative pulmonary angiogram revealed a major left to right shunt through previously unsuspected partial anomalous venous drainage of the left upper lobe of the lung.

Ionescu-Shiley pericardial xenografts: follow-up of up to 6 years.

The results of valve replacement with the Ionescu-Shiley pericardial xenograft compare favorably with results obtained with other bioprostheses. From March, 1977, to July, 1983, 497 Ionescu-Shiley pericardial valves were implanted in 463 patients at the University of Ottawa Heart Institute. There were 292 patients who had aortic valve replacement (AVR), 140 with mitral valve replacement (MVR), 28 with double valve replacement, and 3 with triple valve replacement. The survivors were followed regularly. Actuarial analysis of late results indicates an expected survival of 71% at 6 years for patients who underwent AVR and 72% at 3 years for patients who had MVR. The only valve-related deaths were due to endocarditis, which occurred at a rate of 3.9% per patient-year for aortic valves and 0.6% per patient-year for mitral valves. Despite a low usage of formal anticoagulation, embolic complications occurred at a rate of 1.4% per patient-year for aortic valves and 4.0% per patient-year for mitral valves. Five valves were removed for intrinsic failure after 36 to 72 months of follow-up. New York Heart Association Functional Class improved an average of 1.28 classes per patient.

Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy.

The senior author altered his surgical technique during total hip arthroplasty from capsulectomy and capsulotomy with closure of the external rotator muscles to capsulotomy and capsulorrhaphy. One thousand patients (500 treated with each procedure) were studied retrospectively in order to determine the prevalences of dislocation after surgery with the two different techniques. The prevalence of dislocation was 2.8% after the capsulectomy and capsulotomy, whereas it was 0.6% after the new technique; this was a significant decrease in the rate of dislocation (p < 0.005, [symbol: see text] = 0.10).

Temporary articulating methylmethacrylate antibiotic spacer (TAMMAS). A new method of intraoperative manufacturing of a custom articulating spacer.

A temporary articulating antibiotic-impregnated cement spacer for use during the first stage of a two-stage revision of a total knee replacement that had failed because of infection was developed by one of us (W.M.G.). It is simply a knee prosthesis made of methylmethacrylate and antibiotics that is manufactured intraoperatively with use of instruments, medications, and supplies that are already available at most hospitals. This construct allows for motion of the knee during treatment of the infection, thereby reducing the risk of loss of motion after subsequent revision. The technique has been successfully utilized in five patients since 1999 and has now become our standard treatment method.

Histopathologic changes in the aging human cricoarytenoid joint.

Detrimental effects of the natural aging process on the human cricoarytenoid joint have been hypothesized as a possible etiology for the voice changes seen in the aging population. Cellular events occurring at the histologic level, such as cricoarytenoid joint erosion or arthritis may lead to alterations in laryngeal structure which ultimately affect its function and performance. Seven normal human larynges of varying ages ranging from 29 to 69 years of age were examined histopathologically for changes in the cricoarytenoid joint. The synovium, joint space, periarticular muscle, and respiratory epithelium were evaluated for the presence of inflammatory changes or edema and degree of vascularity. The location and amount of ossification, elastin, and collagen formation were also noted. There were no appreciable changes noted in the synovium or joint space itself with increasing age. No differences were observed in the degree of elastin or collagen formation. However, there was progressive cricoid and arytenoid ossification and periarticular muscular atrophy and fibrosis. These findings suggest that other laryngeal changes may play a greater role in determining senescent vocal quality rather than changes within the cricoarytenoid joint itself.

The spectrum of electrophysiological abnormalities in Bell's palsy.

BACKGROUND: As part of an investigation of a suspected "outbreak" of Bell's palsy in the Greater Toronto Area, a population-based sample of patients with Bell's palsy was investigated electrophysiologically to help understand the spectrum of abnormalities that can be seen in this setting. METHODS: Two hundred and twenty-four patients were surveyed, of whom 91 underwent formal neurological assessment. Of the latter, 44 were studied electrophysiologically using standard techniques. Thirty-two of the 44 patients fulfilled clinical criteria for Bell's palsy. RESULTS: A wide range of electrophysiological changes was observed. Blink responses were the most useful test showing diagnostic sensitivity of 81% and specificity of 94% compared to the contralateral control side. Needle electromyography was additionally helpful in only one patient of six with normal conduction studies. CONCLUSIONS: There is a wide spectrum of electrophysiological abnormalities in Bell's palsy. Blink reflex latencies may be under-utilized in the assessment of the facial nerve in Bell's palsy. Facial EMG is not generally useful in routine assessment.

Surgery for cardiac tumours: the University of Ottawa Heart Institute experience (1980-91).

OBJECTIVE: To review the University of Ottawa Heart Institute's experience with surgery for cardiac tumours. Case series of all patients who had surgical exploration of cardiac tumours from 1980-91 inclusive. Hospital charts, surgical pathology reports, gross photographs and glass microscopic slides were reviewed in each case. SETTING: Tertiary care, specialized cardiac referral centre. PATIENTS: All patients were diagnosed and treated surgically for heart tumours at the University of Ottawa Heart Institute over the 11-year period. The group consisted of 29 adults (14 male, 15 female) aged 15 to 76 years (mean 48) and one male newborn (six days old). Follow-up was available in 24 of 30 cases and averaged three years and four months (range four days to seven years). RESULTS: Twenty-six patients had primary cardiac tumours; 24 were benign (18 myxomas and seven nonmyxomas [one patient with lipomatous hypertrophy had coexistent myxoma]) and two were malignant. Four patients had involvement of the heart by tumours elsewhere: one benign and three malignant. Twenty-two of 24 benign primary tumours were resected successfully with relief of symptoms; two tumours were not resectable. None of the resected benign tumours recurred. Both patients with malignant primary tumours died from their disease. Three of the four patients with tumours arising elsewhere died, while the patient with benign hepatic vein leiomyoma extending into the heart remains well. CONCLUSIONS: Therefore, surgical resection of benign cardiac tumours, whether primary or secondary, is safe and usually curative. Surgery for malignant tumours is diagnostic at best.

Observations of the vacuum ultraviolet and x-ray brightness profiles of Fe, Ni, and Ge in magnetically confined fusion plasmas.

The spatial brightness profiles of emission lines for the K-like through He-like ionization states of Fe, Ge, and Ni have been measured during a set of experiments in which Fe and Ge were introduced into FTU tokamak plasmas by using the laser blowoff technique. Nickel was an intrinsic impurity observed during these experiments that was sputtered from the inconel limiter. The brightness profiles were measured by spatially scanable, photometrically calibrated vaccum ultraviolet and x-ray spectrometers that covered the 1 to 1700 A region. Simulations of these profiles and the time evolution of the laser blowoffs were performed with the MIST transport code using several sets of atomic physics compilations [ADPAK (originally in MIST), Arnaud and Raymond (AR92), Arnaud and Rothenflug (AR85), Mazzotta et al., and Mattioli (an extension to Mazzotta)]. The goal was to determine which set of available rates could best simulate the measured spatial brightness profiles and the charge state balance in the plasma. The Mazzotta et al. (for Fe and Ni), the Mattioli (for Ge), and the AR92 (for Fe only) rates adequately simulated the He-, Li-, Be-, Na-, Mg-like ionization states. The F- to B-like charge states could not be simulated by these compilations unless the relevant dielectronic rates were multiplied by a factor of 2. The ADPAK rates could not adequately predict any of the charge states of Fe, Ge, or Ni.

A comparison between arthrotomy and irrigation and multiple aspirations in the treatment of pyogenic arthritis: a histological study in a rabbit model.

Staphylococcus aureus pyogenic arthritis was produced in a group of eight rabbits. After 24 hours, all rabbits were treated with systemic procaine and benzathine penicillin for five days. Four rabbits were treated with daily aspiration, and four rabbits were treated with arthrotomy and irrigation. A study of the histology of cartilage of the lateral femoral condyle was made in the two groups. Animals treated with aspiration showed a greater degree of thinning of cartilage, acelluiarity, and cloning of chondrocytes than animals treated with arthrotomy and irrigation.

Safety of a clinical surveillance protocol with 3- and 6-week warfarin prophylaxis after total joint arthroplasty.

The charts of 1869 patients were reviewed for the occurrence of deep venous thrombosis (DVT) and pulmonary embolism after total hip or knee arthroplasty. Prophylaxis consisted of 3 (group 1; n=1235) or 6 (group 2; n=634) weeks low-dose warfarin, pneumatic compression boots worn by patients in the hospital, mobilization on the first postoperative day, and a clinical surveillance protocol. Venous ultrasound or ventilation/perfusion lung scintigraphy (V/Q) was performed only if patients became symptomatic. patients. Twenty-three (1.8%) patients were positive for DVT. Ventilation/perfusion lung scintigraphy was performed on 25 patients, and 5 (0.4%) patients were positive for pulmonary embolism. In group 2, 117 patients were evaluated for DVT, and 19 (3%) patients had positive results determined by ultrasound. Twenty-five patients were evaluated with V/Q and only 1 (0.16%) patient was positive for pulmonary embolism. No patient developed a fatal pulmonary embolism or postphlebitic syndrome. This prophylaxis protocol is an efficient and cost-effective method for the prevention of significant events after surgery.

The borderline patient: update on the diagnosis, theory, and treatment from a psychodynamic perspective.

This paper presents an overview regarding the borderline patient including historical background, diagnosis, developmental theory, prognosis, and psychotherapy, all from a psychodynamic perspective. The overview is succinct, current, and practical; it is comprehensive although certainly not all-inclusive. Five clinical vignettes are presented, reflecting various aspects of borderline patients. These vignettes are used to illustrate phenomena elaborated later in the paper. Regarding diagnosis, an approach based on ego strengths and ego weaknesses is detailed. This "ego-psychological diagnostic approach" leans on the ideas of Kernberg, but simplifies and occasionally modifies his work, in addition to including aspects of the borderline patient not stressed by him. It provides a simple, integrated summary of current psychodynamic diagnostic thinking. The paper compares and contrasts two of the most useful developmental theories regarding the borderline patient, those of Kernberg and Adler. The clinical usefulness of the two theories is noted, as is their relationship to etiology. Relying on the work of Stone, there is a brief section on prognosis, followed by an even briefer discussion of referral yield. The paper concludes with a discussion of psychotherapy. A continuum of psychodynamically related psychotherapies is detailed, then related to borderline individuals.

Psychotherapy with the borderline patient: an introduction.

This paper serves as an introduction and orientation to six articles written by renowned experts on psychotherapy with borderline patients: Adler, Meissner, Chessick, Giovacchini, Kernberg, and Stone. Because the articles focus most explicitly on treatment and only touch on diagnosis, a brief excursion into diagnosis is provided. A section on conceptual framework for psychotherapy is presented, helping the reader to place the different authors' approaches into a continuum of exploratory psychotherapy. Finally brief summaries of this six articles are offered.

Dynamically oriented psychotherapy with borderline patients.

This article outlines a basic framework and strategy for a dynamically oriented psychotherapy with borderline patients. Focus includes arrangements and guidelines for psychotherapy, neutrality, the stability of the therapeutic environment, the therapeutic alliance, transference, the countertransference, activity of the therapist, types of interventions, style of interventions, interventions regarding core difficulties, the conceptual framework of anxiety and defense, trends in the psychotherapy, and termination. A differentiation between analytically oriented psychotherapy and dynamically oriented psychotherapy is provided. For one group of borderline patients, a modified analytically oriented approach is utilized throughout the entire treatment. For a second group, there is a switch from analytically oriented psychotherapy to a dynamically oriented psychotherapy, after the therapeutic alliance has become reasonably stable. Two clinical vignettes are provided.

Obsessive-compulsive behavior, DSM-III, and a psychodynamic classification of psychopathology.

This paper reviews obsessive-compulsive behavior, both neurosis and character, and relates these to DSM-III, as well as to a psychodynamic classification of psychopathology. The DSM-III obsessive-compulsive disorder and the classical obsessive-compulsive neurosis are found to be very similar descriptively. In contrast, the DSM-III compulsive-personality disorder is found to be a much more psychopathological entity than the classical obsessive-compulsive character.