Secondary resurfacing of the patella for persistent anterior knee pain after primary knee arthroplasty.

Out of a total of 623 patients who, over a ten-year period, underwent primary total knee replacement (TKR) without patellar resurfacing, 20 underwent secondary resurfacing for chronic anterior knee pain. They were evaluated pre- and postoperatively using the clinical and radiological American Knee Society score. The mean follow-up was 36.1 months (12 to 104). The mean knee score improved from 46.7 to 62.2 points and the mean functional score from 44.7 to 52.2 points. Only 44.4% of the patients, however, reported some improvement; the remainder reported no change or deterioration. The radiographic alignment of the TKR did not influence the outcome of secondary resurfacing of the patella. Complications were noted in six of the 20 patients including fracture and instability of the patella and loss of movement. Anterior knee pain after TKR remains difficult to manage. Secondary resurfacing of the patella is not advocated in all patients since it may increase patient dissatisfaction and hasten revision.

Single or double plating for nonunion of the clavicle.

Between January 1982 and January 1999, 684 patients presented with a fracture of the clavicle to the accident and emergency departments of the Tamside and Bury District General Hospitals. Twenty patients (3%) subsequently developed symptomatic nonunion of the clavicle. The original injury resulted from a road traffic accident in 13 patients, from a fall on an outstretched hand in five patients, and two patients had sports related injuries. Mean age of the patients was 39 years (range, 17 to 76 years). Mean time from injury to surgery was 2.5 years (range, 6 months to 8 years). Fifteen patients underwent open reduction and internal fixation of the nonunion of the clavicle with a single plate (DCP or AO plate) and in the remaining five patients two plates were used. The clavicle went on to unite both clinically and radiographically in all patients. Mean time for clinical recovery of symptoms was 4 weeks (range, 3 to 15 weeks) and mean time for radiological union was 17 weeks (range, 15 to 35 weeks). The Constant score component for pain rose from a preoperative score of 0.71 to 13.8 +/- 3.5 (p < 0.0001, paired t-test). There was significant improvement for the level of activity of daily living from a preoperative score of 2.95 +/- 1.63 to 19.0 +/- 3.9. (p < 0.0001, paired t-test). The Imatani score for shoulder function rose from a preoperative score of 56.75 +/- 5.9, to a postoperative score of 98.39 +/- 4.0. No complications related to surgery were noted in the immediate postoperative period. Three patients required removal of the metal work. After removal of the plates there were no refractures of the clavicle. In conclusion, single or double plating of the clavicle is an effective technique in dealing with nonunions of both middle and distal thirds of the clavicle.

Effects of induced mast cell activation on prostaglandin E and metalloproteinase production by rheumatoid synovial tissue in vitro.

OBJECTIVE: To determine whether induced mast cell activation/degranulation in rheumatoid synovial explants modulates the production of prostaglandin E (PGE2), and the matrix metalloproteinases (MMPs) collagenase 1, gelatinase A, and stromelysin 1. METHODS: Synovial explant cultures were treated either with rabbit IgG anti-human IgE as a mast cell (MC) secretagogue or with non-immune rabbit IgG as controls. After 20 hours conditioned medium was assayed for the release of MC tryptase, PGE2, collagenase 1, gelatinase A, and stromelysin 1 using radioimmunoassay, enzyme linked immunosorbent assay, western blot, and zymogram techniques; tissue explants were examined immunohistologically for the relative distributions of MC tryptase, collagenase 1, and stromelysin 1. RESULTS: Over a 20 hour incubation period the MC secretagogue treated explants showed a significant increase in the quantities of released tryptase and PGE2 compared with controls. By contrast, the three MMPs showed variable values between experiments in response to MC activation; no reproducible trend of either an increased or decreased production of each MMP over control values was evident. Each MMP initially appeared as an inactive precursor form; collagenase 1 and stromelysin 1 were more effectively processed to active forms in the MC activated cultures. Immunolocalisation studies of MC activated explants showed that areas of extracellular tryptase were commonly associated with the local production of both collagenase 1 and stromelysin 1. CONCLUSION: MC degranulation induced artificially in rheumatoid synovial explant cultures consistently resulted in an increased production of PGE2 but had variable effects on the quantification of released collagenase 1, gelatinase A, and stromelysin 1. Such observations support the concept that activated synovial MCs within their native environment stimulate the production of non-MC derived PGE2 and may contribute to the regulation and processing of specific MMPs; both aspects represent important components of the inflammatory and degradative processes of the rheumatoid lesion.

The treatment of Sudeck's atrophy in the upper limb by sympathetic blockade.

The incidence of Sudeck's atrophy as a sequel to injury in the upper limb has been estimated in relation to casualty attendances in a 3-year period. Seventeen patients were treated at varying intervals after the onset of the condition either by stellate ganglion block or by regional intravenous guanethidine. The results are compared and the advantages of each method are discussed.

Capsular arthroplasty of the hip for congenital dislocation.

During a 20-year period, capsular arthroplasty was performed on 32 congenitally dislocated hips (28 patients). The Colonna procedure was used, except that prereduction traction was omitted. Capsular arthroplasty was a primary surgical procedure for 12 patients (15 hips) in whom a late diagnosis of CDH was made (mean age at diagnosis, 3.9 years). The same operation was performed as a secondary, or salvage, procedure in a group of 16 patients (17 hips) who had undergone one or more previous operations that failed to secure reduction. The results of treatment in the two groups did not differ significantly. Long-term stability was achieved in 27/32 hips (84%). Excellent or good results were obtained in 17/32 hips (53%). Fair or poor results were obtained in 15/32 hips (47%). In 10/32 hips, there was marked stiffness and in 5/32 hips, redislocation occurred.

Periureteric fibrosis complicating kidney transplantation.

Impairment of renal function developed in a kidney transplant recipient three years after the transplant due to ureteric obstruction. At operation this was found to be due to periureteric fibrosis. Ureterolysis was performed with subsequent return of renal function.