Aseptic lymphocytic vasculitis-associated lesion in a well-fixed total knee arthroplasty: a case report.

Adverse reactions to metal debris in relation to metal-on-metal hip arthroplasty has been heavily discussed in the literature. In contrast, few cases have been reported in the context of total knee arthroplasty. A 77-year-old woman presented with a painful total knee arthroplasty. At the time of revision surgery, intra-articular cream-coloured fluid and material was found in association with a well-fixed prosthesis. Synovial and capsular samples were obtained for histological assessment and a diagnosis of aseptic lymphocytic vasculitis associated lesion was confirmed. The patient went on to have an uncomplicated recovery following a two-stage revision to a constrained knee prosthesis.

Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines.

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient's target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

Quantitative radiographic assessment of cancellous bone changes in the proximal tibia after total knee arthroplasty: a 3-year follow-up study.

The objective of this study was to determine whether fractal signature analysis (FSA) of digitized macroradiographs of knees with prosthetic implants quantifies alterations in tibial trabecular structure surrounding the implant over a 3-year period. Nineteen knees (16 patients) with arthroplasty had macroradiographs (x4) at baseline and annually for 3 years. The regions of interest (ROIs) were located in the medial and lateral plateau, midstem, and apical sites. FSA of horizontal and vertical trabecular organization was measured at each ROI, and the changes at the yearly visits were compared to the baseline values. Compared to the baseline values, FSA of the first-year radiographs detected a significant ( P < 0.05) decrease in the number of vertical trabeculae in the medial compartment, and vertical, and horizontal trabeculae in the lateral compartment. During the second year, bone remodeling led to an increase in the number of horizontal trabeculae in the medial compartment, and vertical, and horizontal trabeculae in the lateral compartment. During the third year, there was a significant increase ( P < 0.05) in the number of vertical and some horizontal trabeculae in both the medial and lateral compartments. Overall trabecular changes were significantly greater in the lateral than in the medial compartment. Following total knee arthroplasty, the response of bone showed that the first year was characterized by trabecular loss in response to posttraumatic osteopenia following surgery. By the third year, this process had reversed, with a significant increase in mainly vertical and some horizontal trabeculae in both the medial and lateral compartments, with only the lateral compartment showing an overall loss in small- and medium-sized trabeculae by the end of the study period.

The London nail bombings: the St. Thomas' Hospital experience.

At 18:00 h on 17 April 1999 a nail bomb exploded outside a supermarket in Brixton, London. This was the first of a series of three identical nail bombs. The injuries were due to penetrating nails, most were relatively minor, with only three patients requiring general anaesthesia for removal of nails and debridement. One 6-year-old child subsequently underwent onward referral for neurosurgical treatment. At 18:40 h on 30 April 1999, the third bomb exploded (there were no casualties at our hospital from the second bomb, that in Brick Lane on 24 April 1999) in the confined environment of the Admiral Duncan public house in Soho. The injuries were much more severe than those seen from the Brixton bomb. Two persons died on the scene and 81 were injured; 27 were transferred to our hospital. Three primary lower limb amputations were performed. Within the first 24h, four patients required ITU care and two onward referral to the regional burns unit. Injuries such as those seen in these two bombings are common in war situations. In peacetime it is rare to see this spectrum of injury and hence surgeons can be unaware of optimal management protocols. Our approach in these patients, based on thorough initial debridement and delayed closure/split skin grafting is similar to that advocated by the International Committee of the Red Cross based on their war surgery experience. We emphasise debridement without any initial reconstructive procedures. We also discuss some logistic problems of major incidents.

Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament.

Our objectives were to establish the envelope of passive movement and to demonstrate the kinematic behaviour of the knee during standard clinical tests before and after reconstruction of the anterior cruciate ligament (ACL). An electromagnetic device was used to measure movement of the joint during surgery. Reconstruction of the ACL significantly reduced the overall envelope of tibial rotation (10 degrees to 90 degrees flexion), moved this envelope into external rotation from 0 degrees to 20 degrees flexion, and reduced the anterior position of the tibial plateau (5 degrees to 30 degrees flexion) (p < 0.05 for all). During the pivot-shift test in early flexion there was progressive anterior tibial subluxation with internal rotation. These subluxations reversed suddenly around a mean position of 36 +/- 9 degrees of flexion of the knee and consisted of an external tibial rotation of 13 +/- 8 degrees combined with a posterior tibial translation of 12 +/- 8 mm. This abnormal movement was abolished after reconstruction of the ACL.

Postoperative orthopedic autotransfusion. Successful management for the total knee arthroplasty patient.

Orthopedic autotransfusion is an effective technique that should be available to patients having total knee arthroplasty. Patient safety, however, must not be compromised simply because the blood is autologous. Blood products, in any form, require close observation and careful administration. The best results are achieved when the physician and all nursing departments involved have comprehensive knowledge of the system and the guidelines for its safe use.

The double-contrast barium meal: a correlation with endoscopy.

The radiological and endoscopic findings are described in 214 patients with 252 lesions in whom endoscopy had been requested by a radiologist either to confirm or clarify a radiological opinion. There was radiological and endoscopic agreement about the presence or absence of oesophagitis in 73% of patients, but there was agreement about the presence or absence of duodenitis in only 48%. There were only two cases of early gastric cancer, and no early gastric cancers were found in a group of 43 patients on whom endoscopy had been specifically requested because of an abnormal gastric mucosal pattern. Endoscopy failed to detect 13% of gastric ulcers at the initial endoscopic examination.

Rotator cuff tears: the role of surgery.

The indications for operative intervention in patients with rotator cuff tears and the reasonable expectations of such surgery are not well defined. This retrospective study of 37 such patients treated operatively at Ottawa General Hospital showed good results in 65% of cases. However, efforts to re-establish continuity of the cuff did not always result in a permanent cuff reconstruction. The persisting defect did not impede functional recovery as long as the edges of the tear were debrided along with division of the coracoacromial ligament, acromioplasty, or excision of osteophytes at the greater tuberosity. Impingement plays a major role in the disability associated with this condition.

Extrinsic compression of the third part of the duodenum.

The clinical findings in 12 patients who exhibited marked to-and-fro peristalsis in the duodenum with extrinsic compression of the third part and proximal dilatation at barium meal examination are described. In nine cases the compression was thought to be due to the superior mesenteric artery and its mesentery. In two of these cases there was associated duodenal ulceration and in another patient there was evidence of chronic idiopathic intestinal pseudo-obstruction. In the remaining three cases, the duodenal compression was caused either by tumour or malignant glands in the root of the mesentery. It is emphasised that vigorous to-and-fro peristalsis in the proximal duodenum seen at fluoroscopy is an abnormal radiological feature which is associated in most cases with significant pathology.

Rectus femoris myocutaneous flaps for trochanteric ulcers.

The local skin flaps traditionally used to repair trochanteric ulcers in paraplegics are usually thin, have poor padding qualities and often break down. The rectus femoris myocutaneous flap was used to repair trochanteric ulcers in eight paraplegic patients. Three flaps healed primarily. In three there was some necrosis at the distal corner of the flap but this healed spontaneously. The cutaneous portion of two flaps necrosed and had to be excised but the muscle remained viable. All eight flaps remain healed with no evidence of breakdown. The repetitive shear forces over the prominent mobile hip joint cause particular problems in providing a stable flap repair, but the rectus femoris myocutaneous flap has demonstrated, in this series, its stability and durability.

The stoicheiometry of the absorption of protons with phosphate and L-glutamate by yeasts of the genus Saccharomyces.

1. A study was made of the pH changes occurring when 0.1-4 mumol of glutamate, phosphate and certain phosphate esters was added at about pH 4.8 to washed cell preparations (50 mg dry wt.) of strains of Saccharomyces. The system also contained deoxyglucose and antimycin to inhibit energy metabolism and so prevent proton ejection from the yeast. 2. A strain of Sacc. carlsbergensis was grown in a chemostat with a limiting supply of phosphate in order to enhance the subsequent rate of phosphate transfer into the yeast. These preparations absorbed 0.2 mumol of phosphate with about 3 equiv. of protons/mol of phosphate. The charge balance was maintained by the efflux of 2 equiv. of K-+ from the yeast. 3. Larger amounts of phosphate were absorbed with fewer proton equivalents. 4. Arsenate and phosphate caused similar pH changes. 5. Glucose 6-phosphate, ATP and certain order phosphate esters each initiated a rise in pH, possibly because hydrolytic extracellular enzymes released phosphate that was subsequently absorbed. 6. Four strains of yeast were grown with glutamate as principal source of nitrogen. Each absorbed extra protons in the presence of L-glutamate. 7. One of them, a strain of Sacc. cerevisiae, absorbed 0.2 mumol of glutamate with 3equiv. of protons/mol of glutamate, and in these circumstances 1-2 equiv. of K-+ left the yeast cells. 8. The role of ionic gradients in the transport of these anions is discussed.