Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for treatment of osteoarthritis and rheumatoid arthritis.

BACKGROUND: The functional and clinical results to support the choice whether or not to retain the posterior cruciate ligament (PCL) during total knee arthroplasty have not been gathered and analysed so far. There are at least some trials showing no difference. OBJECTIVES: To identify the difference in functional, clinical, and radiological outcome between retention and sacrifice of the PCL in total knee arthroplasty in patients with osteoarthrosis and other non-traumatic diseases. SEARCH STRATEGY: A search was conducted in MEDLINE(Through PubMed; 1966 - March 2004), EMBASE (1980 - March 2004), Cochrane Central Register of Controlled Trials (CENTRAL Issue 2004 - 1), and Current Contents (1996 - March 2004). Also, references of selected articles were checked and citation tracking on the articles selected was performed. SELECTION CRITERIA: Randomised controlled trials comparing retention to sacrifice of the PCL during total knee arthroplasty with regard to functional, radiological and clinical outcome in patients with osteoarthritis and other non-traumatic diseases were selected by two independent reviewers. DATA COLLECTION AND ANALYSIS: Methodological quality was assessed with the checklist by van Tulder and the Jadad list. Data was collected with a predeveloped form. Meta-analysis was performed with subgroup analyses on age, gender, disease severity, and follow-up time, if allowed by adequate power. MAIN RESULTS: Eight randomised controlled trials were found. Two treatment options were compared against PCL retention: PCL sacrifice without additional stabilisation (post and cam mechanism) (2 studies), and PCL sacrifice with posterior stabilized design (5 studies). One study included all three options. Range of motion was found to be 8.1 degrees higher in the posterior stabilized group compared to the PCL retention group (p=0.01, 95% confidence interval [1.7, 14.5]), although the heterogeneity was high (I(2 )= 66.3%). PCL resection without substituting the PCL with a posterior stabilised prosthesis showed no difference compared to PCL retention (p=0.31, I(2) = 83.2%). On clinical scores, only Hospital for Special Surgery score revealed a significant difference of 1.6 points (p=0.03, 95% confidence interval [-3.1, -0.1]) between PCL retention versus PCL sacrifice and substitution combined favouring the latter group. The necessary subgroup analyses could not be performed for the clinical scores. AUTHORS' CONCLUSIONS: These results should be interpreted with caution as the methodological quality of the studies was highly variable. We conclude that there is, so far, no solid base for the decision to either retain or sacrifice the PCL with or without use of a posterior stabilized design during total knee arthroplasty. The technique of PCL retention is difficult because the normal configuration and tension need to be reproduced with ligament tensioners. Knowledge of the technique needs to be improved before it can yield superior results compared to the more straightforward techniques of PCL sacrifice or use of a posterior stabilized design. Also, studies evaluating the effect of both techniques should address the right outcome parameters such as range of motion, contact position, and anterior-posterior stability. Suggestions are given to improve future research on this specific topic of knee arthroplasty.

Current practice in the management of anterior cruciate ligament injuries in the United Kingdom.

OBJECTIVE: To outline the current practice in the management of anterior cruciate ligament (ACL) injuries in the United Kingdom. METHODS: A postal questionnaire designed to include various clinical scenarios was sent out to the 321 orthopaedic surgeons in the United Kingdom who, being affiliated to one of the specialist societies of the British Orthopaedic Association, namely the British Association for Surgery of the Knee (BASK) or the British Orthopaedic Sports Trauma Association (BOSTA), have a manifested interest in treating such injuries. RESULTS: The response rate was 60% (192/321). Most surgeons diagnose and operate on less than 50 ACL injuries a year. The following results were obtained: 58% (76/132) use bone-patellar tendon-bone autografts, whereas 33% (44/132) use semitendinosis/gracilis autografts; 84% (108/129) would not incorporate the ACL remnant in the reconstruction; 14% (19/135) would perform an ACL reconstruction in an 8 year child with an acute rupture; 30% (42/141) would perform an ACL reconstruction in a 14 year old with an acute ACL rupture. CONCLUSIONS: There is wide variation in the management of acute and chronic ACL injuries among orthopaedic surgeons in the British Isles. Future research and randomised controlled trials should address the issues that this investigation has raised.

Mineral trioxide aggregate: a new material for endodontics.

BACKGROUND: Mineral trioxide aggregate, or MTA, is a new material developed for endodontics that appears to be a significant improvement over other materials for procedures in bone. It is the first restorative material that consistently allows for the overgrowth of cementum, and it may facilitate the regeneration of the periodontal ligament. CASE DESCRIPTION: The authors present five cases in which MTA was used to manage clinical problems. These included vertical root fracture, apexification, perforation repair and repair of a resorptive defect. In each case, MTA allowed bone healing and elimination of clinical symptoms. CLINICAL IMPLICATIONS: Materials such as zinc oxide-eugenol cement and resin composite have been used in the past to repair root defects, but their use resulted in the formation of fibrous connective tissue adjacent to the bone. Because it allows the overgrowth of cementum and periodontal ligament, MTA may be an ideal material for certain endodontic procedures.

Effect of sterilization on cyclic fatigue of rotary nickel-titanium endodontic instruments.

The ability of heat treatment as a result of autoclave sterilization to extend the life of nickel-titanium rotary endodontic instruments by reducing the effect of cyclic fatigue was evaluated using 280 size 40 Lightspeed instruments. Instruments were cycled in artificial canals with angles of curvature of 30 degrees and either 2 or 5 mm radii of curvature. In a pilot study, instruments were sterilized or not sterilized and cycled to failure to obtain mean cycles-to-failure values for each group. In the first experimental protocol, instruments were cycled to either 25%, 50%, or 75% of the mean cycles-to-failure limit determined in the pilot study, then sterilized or not sterilized before being cycled to failure. In the second experimental protocol, instruments were cycled to 25% of the mean cycles-to-failure determined in the pilot study, and sterilized or not sterilized. The sequence of cycling to 25% of the predetermined cycles-to-failure limit followed by sterilization was repeated until the instruments failed. No significant increases in cycles to failure were observed between groups for either experimental protocol when instruments were evaluated at a similar radius. Significant differences in cycles to failure were only observed when instruments cycled to failure in the artificial canal with 2 mm radius were compared with instruments cycled to failure in the artificial canal of 5 mm radius. Scanning electron microscopic photos showed crack initiation and propagation in all instruments that were cycled to a percentage of the predetermined cycles-to-failure limit. It is concluded that heat treatment as a result of autoclave sterilization does not extend the useful life of nickel-titanium instruments.

Cyclic fatigue testing of nickel-titanium endodontic instruments.

Cyclic fatigue of nickel-titanium, engine-driven instruments was studied by determining the effect of canal curvature and operating speed on the breakage of Lightspeed instruments. A new method of canal curvature evaluation that addressed both angle and abruptness of curvature was introduced. Canal curvature was simulated by constructing six curved stainless-steel guide tubes with angles of curvature of 30, 45, or 60 degrees, and radii of curvature of 2 or 5 mm. Size #30 and #40 Light-speed instruments were placed through the guide tubes and the heads secured in the collet of a Mangtrol Dynamometer. A simulated operating load of 10 g-cm was applied. Instruments were able to rotate freely in the test apparatus at speeds of 750, 1300, or 2000 rpm until separation occurred. Cycles to failure were determined. Cycles to failure were not affected by rpm. Instruments did not separate at the head, but rather at the point of maximum flexure of the shaft, corresponding to the midpoint of curvature within the guide tube. The instruments with larger diameter shafts, #40, failed after significantly fewer cycles than did #30 instruments under identical test conditions. Multivariable analysis of variance indicated that cycles to failure significantly decreased as the radius of curvature decreased from 5 mm to 2 mm and as the angle of curvature increased greater than 30 degrees (p < 0.05, power = 0.9). Scanning electron microscopic evaluation revealed ductile fracture as the fatigue failure mode. These results indicate that, for nickel-titanium, engine-driven rotary instruments, the radius of curvature, angle of curvature, and instrument size are more important than operating speed for predicting separation. This study supports engineering concepts of cyclic fatigue failure and suggests that standardized fatigue tests of nickel-titanium rotary instruments should include dynamic operation in a flexed state. The results also suggest that the effect of the radius of curvature as an independent variable should be considered when evaluating studies of root canal instrumentation.

Effect of tip design of nickel-titanium and stainless steel files on root canal preparation.

The purpose of this study was to evaluate the effect of modified and non-modified tip designs of both stainless steel and nickel-titanium endodontic hand files on root canal preparation. Root canals of mesial roots of extracted mandibular molars were prepared using a quarter-turn-pull technique. The experimental design permitted comparison of the effects of nickel-titanium alloy construction or file tip modification alone, with effects when these two factors were incorporated into a single file design. Transportation, centering ratio, and dentin removal were evaluated using a modified Bramante technique. Nickel-titanium files, regardless of tip design, remained significantly more centered and demonstrated less apical transportation than stainless steel files at size 25. When instrumentation was continued to size 40 apically with step-back, there were no significant differences in transportation in the apical or coronal sections. However, during instrumentation to size 40 with step-back, the combination of modified tip and nickel-titanium alloy produced significantly more transportation and dentin removal, as well as greater deviation from the center at the mid-root level than did other file designs. Thus, of the file design parameters evaluated in this study, construction from nickel-titanium was most important in defining canal configuration at small file sizes in the apical region. Although the combination of nickel-titanium and modified tip design resulted in more transportation at larger file sizes in the midroot region, such alterations in canal configuration may be of little importance clinically. Nonetheless, it is suggested that other factors, such as tactile sensation and instrumentation technique, should be considered as important as the type of alloy or tip design.

A comparison of sealer placement techniques in curved canals.

Sealer placement techniques have not been examined in teeth with curved canals prepared with Lightspeed instruments. Three traditional methods of placing sealer were studied, using 45 extracted human single-rooted teeth, divided into 3 groups of 15. Root canal preparations were made with Light-speed nickel-titanium, engine-driven instruments. AH26 sealer was applied with either K-file, lentulo spiral, or master gutta-percha cone. Radiographs were taken after sealer placement and analyzed for amount of canal sealer fill. The teeth were then obturated with laterally condensed gutta-percha, chemically cleared, photographed, and analyzed for total canal wall sealer coverage. The results showed a statistically significant difference in canal sealer fill among the three groups before obturation, but there was no statistical difference in canal wall coverage among the three groups after obturation. None of the examined methods exceeded an average of 62.5% wall coverage of sealer after obturation. This suggests that complete wall coverage after obturation may not be possible.

Torsional testing of the Lightspeed nickel-titanium instrument system.

Revolutions to separation and maximum torque at failure of 216 Lightspeed instruments were determined in an instron using a clockwise rotation. After instruments failed, the distance the instrument separated from the tip was measured. Comparison of the results with existing ANSI/ADA specification no. 28 showed that the Lightspeed far exceeded the values of the specification for revolution to failure. On the other hand, torque to failure results showed that instrument sizes 20 and 25 exceeded the specification, whereas instrument sizes 30 through 50 were below the minimum values. Half-size instruments were not compared, because specifications for half-sizes do not exist. Comparison between mean torque values and instrument shaft diameters of the Lightspeed previously reported showed a near linear relationship up to and including instrument size 50, but overall torque to failure increased exponentially when related to shaft diameter (coefficient of determination = 0.9923). Lightspeed instruments separated 2.32 +/- 0.60 mm from the tip, generally within the land area or at the beginning of the shaft. Scanning electron microscopic observation of the Lightspeed instrument fracture site showed two distinct areas. There was a striated concentric area in the periphery of the fracture characteristic of a brittle or cleavage fracture and a corrugated area in the center of the fracture characteristic of a ductile fracture.

Morphometric video analysis of the engine-driven nickel-titanium Lightspeed instrument system.

Two hundred and sixteen Lightspeed instruments were evaluated microscopically for the presence of corrosion, surface debris, and alloy defects. The instruments were assessed morphometrically for consistency of physical design and dimensions by measuring and analyzing eight parameters of the instrument pilot tips, heads, and shafts. Results from visual inspection showed that none of the instruments were corroded; 23 presented surface porosities, and 17 had sharp strips of alloy. Data obtained by morphometric analysis indicated the mean diameter of the head of only 7 of 18 sizes met the +/- 0.02 mm allowable tolerance set forth by the American Dental Association (ADA) Specification No. 28. Observation and video analysis indicated that instruments of the same size adhere to the same basic design, but that morphometric variations do exist. The visual and intersize analysis indicated that the Lightspeed is not an instrument of any one determined shape that changes only in diameter. Rather, it is a series of instruments that show gradual shifts in both size and shape as the instrument size increases. Lightspeed instruments are a new type of nickel-titanium endodontic instrument that cannot be evaluated using the standards proposed by the American National Standards Institute/ADA Specification No. 28 for files and reamers.

Evidence for sltA1 as a salt-sensitive allele of the arginase gene (agaA) in the ascomycete Aspergillus nidulans.

Strains of Aspergillus nidulans carrying the sltA1 mutation, conferring sensitivity to KCl and NaCl, also showed an arginine-sensitive phenotype whereby concentrations of the L-amino acid at or above 10 mM were toxic to growth. Sexual progeny of a cross between a sltA1 mutant and a wild-type strain showed a co-segregation of salt and arginine sensitivity. Similarly, revertants to salt tolerance showed a loss of arginine sensitivity as did sltA1 strains that were transformed with a cosmid carrying the putative sltA1+ wild-type allele. In addition, arginine sensitivity could be relieved by L-ornithine. It is suggested that sltA1 is a salt-sensitive allele of the arginase gene (agaA).

A prospective evaluation of successful terminal ileum intubation during routine colonoscopy.

This study prospectively evaluated a dedicated effort to intubate the terminal ileum in an unselected population of patients undergoing colonoscopy in conjunction with our training program. The influence of the visual appearance of the terminal ileal mucosa on patient management was assessed subjectively. The cecum was reached in 270/295 (91%) patients, with successful terminal ileal intubation being accomplished in 213/270 (79%) examinations. The time required to intubate the terminal ileum (x = 3.4 minutes; range, 30 seconds to 10 minutes) was not significantly different (p < 0.05) between the several levels of training in our fellowship program. The terminal ileum was considered to be visually abnormal in 4 cases, but only 1 of these was abnormal on histologic examination. In this unselected population, routine ileoscopy was unrewarding for finding an incidental positive diagnosis; however, brief attempts at terminal ileal intubation may be useful to improve or maintain endoscopic skills, especially in a training setting.

Serum alanine aminotransferase (ALT) elevation in asymptomatic US Air Force basic trainee blood donors.

The purpose of this study was to determine the etiology of elevated alanine aminotransferase (ALT) in a population of asymptomatic volunteer blood donors. Subjects with an ALT value > 2.25 sd above norm (> 55 IU/liter) from the donated unit, were prospectively evaluated over a six-week interval. The subjects consisted of blood donors (78% male, 22% female) beginning basic military training at Lackland Air Force Base. Of 44,160 individuals screened, 19,877 (45%) voluntarily donated blood, 99 (0.5%) of which had confirmed ALT elevation. Of these (90 male/9 female), an associated condition or explanation was made in 12%: four with acute hepatitis B, four positive for anti-HCV, two with autoimmune disease, one with cholelithiasis and one associated with acute appendicitis. In 87 the ALT elevation could not be explained using available testing methods but may represent individual variation from a non-Gaussian distribution, be of nonhepatic origin (muscle), or of hepatic disease not detected by the diagnostic algorithm used. To increase the diagnostic yield, it is suggested that at least two elevated ALT values be established in this population over a period of time (yet undefined), before an extensive hepatic investigation is pursued.