Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases.

Patellar tendon rupture after removal of the central third for ACL reconstruction is a rare complication. Only nine cases have been previously reported, and all of these occurred within the first 10 months after surgery. We report two cases of late patellar tendon ruptures occurring at more than 3 and 6 years, respectively, after surgery. A review of the literature has suggested but not conclusively supported that devascularization, an alteration in tendon healing and remodeling, or injury to the remaining tendon at the time of graft harvest may be possible causes of this rare complication. Biopsy tissue from any future patellar tendon ruptures after removal of its central third could contribute to a better understanding of this anomaly.

Geriatric training needs of family physicians.

Family physicians provide the majority of medical care to the elderly population throughout the country. These physicians require accessible Continuing Medical Education (CME) programs that meet their specific educational needs. This study provides information on the perceived training needs and preferred training modalities reported by a sample of community based family medicine faculty preceptors in a Southeastern state. Respondents preffered short courses focusing on organ system diseases common in the elderly population but also wanted more training in managing some of the more complex nonmedical problems that can adversely affect the delivery of medical care. Findings have implications for CME planners who want to provide family physicians training in geriatrics and gerontology that will positively impact their care of the elderly.

Use of comprehensive geriatric assessment techniques by community physicians.

BACKGROUND: Research has shown that comprehensive assessment techniques have several clinical benefits for geriatric patients. The purpose of this study was to determine how frequently community practitioners used comprehensive geriatric assessment techniques to identify factors related to use of those techniques. METHODS: The study group included 54% of the 100 community-based family physician preceptors who participate in the University of Mississippi's family medicine training programs. On-site interviews were conducted in each physician's office to measure the percentage of physicians who performed comprehensive geriatric assessment. RESULTS: The majority of physicians employed some selected age-related assessment techniques, but less than 25% performed functional assessment techniques considered unique to the geriatric patient, such as mental status assessment and evaluation of activities of daily living. Most physicians' personal and practice characteristics were unrelated to the use of assessment techniques. CONCLUSIONS: Although many physicians use some techniques of geriatric assessment, most practicing physicians do not perform comprehensive assessment of geriatric patients.

Sickle cells modified by an osmotic pulse in the presence of inositol hexaphosphate have decreased intracellular hemoglobin concentration and decreased in vitro sickling without prolonged in vivo survival.

An osmotic pulse was used to modify red blood cells (RBC) from two patients with sickle cell disease, resulting in an increased volume and decreased hemoglobin content. This treatment yielded cells which were divided into two populations, one in which RBC had markedly decreased hemoglobin concentration and another in which the cells appeared to be unmodified. Morphological sickling at low oxygen partial pressure was markedly decreased. However, there was no evidence for increased RBC lifespan when the 51Cr-labeled, modified cells were reinfused.

The in vivo survival of human red cells with low oxygen affinity prepared by the osmotic pulse method of inositol hexaphosphate incorporation.

The purpose of this study was to determine the posttransfusion survival of low-affinity red cells (RBCs) containing the hemoglobin modifier, inositol hexaphosphate (IHP). An osmotic pulse technique was used to incorporate IHP, a compound that normally does not cross the RBC membrane. Two groups of six volunteers were studied. RBCs were treated under conditions that resulted in a relatively large increase in mean corpuscular volume (delta MCV = 11.8 +/- 4.0, 1 SD) in Group I, but a relatively small increase (delta MCV = 5.5 +/- 1.9) in Group II. The groups had a similar decrease in mean corpuscular hemoglobin (delta MCH = -3.8 +/- 0.9 for Group I and -3.1 +/- 1.1 for Group II). The 24-hour posttransfusion RBC survival, measured with 3 mL of 51Cr-labeled autologous RBCs, correlated with the induced change in oxygen affinity, and larger shifts were associated with poorer survival. An acceptable 75-percent 24-hour posttransfusion survival was achieved for p50 increases up to approximately 15 torr. Cells that survived 24 hours appeared to have a normal lifespan. This study is the first demonstration of adequate survival for human RBCs with a potentially long-lasting decrease in oxygen affinity.

The potential unreliability of indium 111 oxine labeling in studies of endothelial cell kinetics.

The current widespread use of indium 111 oxine for labeling endothelial cells to study their interaction with various bioprosthetic flow surfaces presupposes a high retention of the radioisotope within the cell and a lack of significant adherence of any marker released from the cell to the surface under study. We measured the loss of indium 111 from freshly harvested, canine, venous endothelial cells, and their viability in cell culture, for varying intervals up to 24 hours. At prescribed intervals, aliquots of the radiolabeled endothelial cell suspension were centrifuged, and the supernatant was separated from the cell pellet. The relative radioactivity of each was measured in a gamma well counter and the spontaneous loss of marker from the endothelial cells was calculated. Spontaneous loss of indium 111 was 7.8% +/- 1.9% at 1 hour and 47.6% +/- 1.8% at 24 hours. Loss of activity was virtually constant between 14 and 24 hours. Endothelial cell viability was 80% at 24 hours. We next studied the in vitro affinity of indium 111 oxine and indium 111 transferrin for untreated expanded polytetrafluoroethylene vascular grafts and for similar grafts treated with two surfactants commonly used to increase the "wetability" of expanded polytetrafluoroethylene, a nonionic sufectant (Nonidet) and tridodecylmethylammonium chloride, and with two glycoproteins, fibronectin and basement membrane gel. A minimum of three graft segments were studied in each group. The affinity of graft material for indium 111, in both its oxine and transferrin complex, was significantly increased by treating the graft with a wetting agent, and it was further increased by the addition of a glycoprotein.(ABSTRACT TRUNCATED AT 250 WORDS)

Thromboembolism after hip surgery. Comparison of screening methods.

Venous thromboembolism is a serious and, often, asymptomatic complication of hip surgery. A reliable screening test is needed to detect thrombi early to prevent death from pulmonary emboli. Noninvasive screening tests were ineffective in our study of 453 patients. We recommend early use of ventilation/perfusion lung scanning in all patients after hip surgery. In those who have positive results, ascending venography can be used to localize the thrombus and anticoagulation therapy can be started early.

Thromboembolism following hip fracture.

Two hundred forty-eight patients following hip fracture were studied for deep venous thrombosis and pulmonary embolus. Ventilation-perfusion lung scans and contrast ascending venography were performed on the sixth to eighth postoperative days. Low-dose intravenous heparin (3,000-5,000 units every 6 hours) was followed by a decreased incidence of pulmonary embolism more than twofold. Although heparin administration was not associated with a significantly decreased incidence of deep venous thrombosis as assessed by venographic studies, thrombi in the nonheparin-treated patients were more likely to occur above the knee and were at higher risk for pulmonary embolus. Pneumatic and mechanical compression devices alone did not protect patients from deep venous thrombosis above the knee, but were associated with a decreased incidence of pulmonary embolus compared to control.

Indium 111 toxicity in the human lymphocyte.

Indium-labeled lymphocytes were examined for response to a variety of mitogens, ability to synthesize immunoglobulins, mitotic index, and presence of chromosome aberrations at a range of exposures from 0.2 to 500 muCi/10(8) cells. Results of all four tests were found to be abnormal when the lymphocytes were labeled with 111In activities well within those employed for diagnostic testing.

In vivo chemotaxis and body compartment distribution of indium-111 labelled polymorphonuclear leukocytes in burned guinea pigs.

The in vivo chemotactic response of Indium-111 labelled polymorphonuclear leukocytes (PMNL) and their body compartment distribution have been studied in burned (30% TBSA full-thickness burn) and normal guinea pigs. The in vivo chemotactic response to FMLP 10(-5) M and to zymosan-activated serum of the burned PMNL was not significantly different from that of normal PMNL. However, the burned PMNL leave the circulation more rapidly and localize in the burn area and in the liver to a greater extent. No evidence of increased destruction of burned PMNL by the spleen or by the lungs was found.

Pilot study on the absolute and relative bioavailability of Synthroid and Levothroid, two brands of sodium levothyroxine.

The absolute and relative bioavailability of levothyroxine was determined in young, healthy male subjects after administration of i.v. solution, p.o. solution, or one of two brand-name, commercially available tablets. The mean dose size was about 0.18 mg. Serum concentration-time data were obtained over a period of 50 h. The absolute bioavailabilities of the two tablet preparations were 66% and 72%, respectively.

A quantitative method to measure human platelet chemotaxis using indium-111-oxine-labeled gel-filtered platelets.

Human blood platelets have been shown to migrate directionally and specifically toward collagen in plasma in vitro. We have developed a new system to monitor this behavior using a linear 7-compartment chamber with 111In-oxine-labeled gel-filtered platelets. The compartments are separated by various Nuclepore and Millipore filter membranes. Radiolabeled platelets suspended in plasma are placed in the central compartment and the other compartments are filled with platelet-free plasma. When collagen is added to an end compartment, platelets migrate toward that end. The degree of this directed movement or chemotaxis can be measured by counting the radioactivity of the contents of each compartment and then comparing the counts from radiolabeled platelets that have moved to the end that holds the chemotactic inducer with those that have randomly migrated to the opposite end, containing only plasma. This assay system allows quantitative comparisons between the chemotaxis-inducing abilities of different substances and permits the study of soluble materials. Experiments to determine the optimal conditions for the procedure are reported, and the advantages of this new method for the investigation of platelet chemotaxis and the identification of chemotaxins are discussed.

Internal contamination of laboratory personnel by 131I1.

Internal contamination by 131I among the personnel in a nuclear medicine laboratory was surveyed from January to July, 1979. Because of the formulation change made by the manufacturer in April to reduce volatility, it was possible to study two different therapeutic solutions of 131I. Internal contamination of personnel who administered 131I was found to be 90 times less after the reformulation. Compliance with a recent NRC regulatory guide of less than 40 nCi (1.48 kB1) of 131I thyroid burden as a quarterly average should not be difficult using the new, less volatile 131I; however, strict precautionary measures are essential to minimize contamination, which is common in the nuclear medicine environment.

Popliteus tendon tenosynovitis.

This series of case suggests that the entity of tenosynovitis of the popliteus tendon is more common than once recognized. A high index of sucpicion and accurate palpation of the lateral aspect of the knee lead one to the diagnosis. Knowledge of this entity may prevent future misdiagnosis of tear of the lateral meniscus and unnecessary meniscectomy as experienced by Helfet, Holden, and myself. There is a definite correlation with activities requiring downhill walking or running. The runners invariably complained of the oneset of symptoms during downhill running rather than uphill running. Back packing enthusiastscomplained of no symptoms for several days after ascending into the mountains, only to experience the symptoms at the end of a long, rapid descent out of the mountains. The pathomechanics of this inflammation of the popliteus tendon is not fully understood. Preliminary analysis of gait movies suggests that in downhill running there is an increased vector to displace the weight-bearing femur forward on the relatively fixed tibia as the knee is increasingly flexed (Fig. 5). Previously mentioned EMG functional studies indicate that the popliteus muscle is active during this weight-bearing phase of gait and may act to retard the femur from forward displacement on the tibia in conjunction with the quadriceps. More specifically, it may help to retard the lateral femoral condyle from rotating forward off the lateral tibial plateau. Downhill running or walking therefore may cause increased stress on the popliteus muscle-tendon unit in an effort to decelerate the body weight against the altered angle of gravitational pull, with resultant tenosynovitis and symptoms. In this series there were no top flight competitive runners. The typical patient was a 31-year-old physician who was jogging 1 to 5 miles and decided to increase his pace and distance, particularly while jogging downhill. The average age of this series of patients (31 years) at the time of onset, coupled with the fact many of these persons were relatively sedentary until stressing the knee by increased activity, suggests that there will be an increasing number of these patients in the future as jogging and running are prescribed for cardiovascular system conditioning.

The upper-extremity amputee. Early and immediate post-surgical prosthetic fitting.

The results of immediate and early post-surgical prosthetic fitting in eighty-seven upper-extremity amputees as well as the results in nine patients with shoulder dislocation who were fitted with temporary devices were reviewed. No local wound complications occurred and the rate of prosthetic acceptance was high. A practice prosthesis, with a filler insert formed from liquid Silastic foam allowed to set between the walls of the practice prosthesis and the amputation stump, was used extensively in this series. With the Silastic insert and practice prosthesis, prosthetic training could be instituted during healing of the amputation wounds, proximal wounds, or fractures.

The functional treatment of pyogenic arthritis of the adult knee.

A method of treatment of pyogenic arthritis of the adult knee employing wide open arthrotomy and early active motion, as well as synovectomy in some knees, was used in thirty-four patients with pyogenic arthritis of the knee. Of these patients, sixteen had a good result, twelve had a fair result, and six had a poor result. This method of treatment was used as a salvage procedure in most of the patients, but may have more general application in the treatment of pyogenic arthritis of the knee.