Acquired heterotopic ossification of the temporomandibular joint.

Although the risk factors and diagnosis of heterotopic ossification (HO) are discussed in the orthopedics literature, the etiology of HO, as well as its prevention and management, remain theoretical. Furthermore, there is a lack of information in the literature regarding HO in temporomandibular joint replacement (TMJR). This article provides a qualitative review of information relative to the etiology, diagnosis, and management of HO to inform and encourage further investigation in TMJR. The orthopedic HO literature considered for this qualitative review was drawn from a comprehensive examination of the subject published previously by one of the authors. Using the key words "heterotopic ossification" or "heterotopic bone", citations in the PubMed database from both the dental and oral and maxillofacial surgery literature were reviewed. Based on this, it appears that the etiology, diagnosis, imaging, laboratory testing, risk factors, prophylaxis, and non-surgical and surgical options available for the management of TMJR-related HO are similar to those for orthopedic HO, but further elucidation is required for TMJR. There is a lack of published information in the literature on TMJR. Therefore, using the literature from this review as a foundation, studies should be developed and reported so that alloplastic TMJ surgeons have evidence-based protocols that will lead to the early detection and potential prevention of HO.

Evaluation of fever in the immediate post-operative period following shoulder arthroplasty.

AIMS: To determine the incidence and timing of post-operative fevers following shoulder arthroplasty and the resulting investigations performed. PATIENTS AND METHODS: A retrospective review was conducted of all patients undergoing shoulder arthroplasty over a nine-year period. The charts of all patients with a post-operative fever (≥ 38.6°C) were reviewed and the results of all investigations were analysed. RESULTS: A total of 2167 cases (in 1911 patients) were included of whom 92 (4.2%) had a documented fever. Obese cases had a significantly greater risk for fever (relative risk 1.53; 95% confidence interval 1.02 to 2.32; p = 0.041). Investigations were performed in 43/92 cases (46.7%), with a diagnosis being made in six cases (6.6% of the total, two of whom had their diagnosis made post-discharge). CONCLUSION: Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology. These patients may be being over-investigated; investigations should be performed in patients with persistent fever or on those with an identifiable source of infection on clinical examination. Cite this article: Bone Joint J 2017;99-B:1515-19.

Biomechanical testing of the reconstructed ulnar collateral ligament: a systematic review of the literature.

PURPOSE: The purpose was to perform a systematic review of the literature investigating biomechanical studies of ulnar collateral ligament reconstruction (UCLR) techniques to summarize the most commonly analyzed methods of fixation (at both the ulna and humerus), the degree of elbow flexion at the time of fixation, graft characteristics, and modes of failure with these techniques. MATERIALS AND METHODS: A systematic review was performed. All cadaveric biomechanical studies that tested a reconstruction method for UCLR were included. Descriptive statistics were calculated for each study and parameter/variable analyzed. RESULTS: Twenty-three studies were included with a total of 397 elbows in 242 cadavers (mean age 54.8 ± 20 years, range 16-96). The majority of studies (65 %) used a palmaris longus graft. The docking technique (37.2 %) was the most commonly tested reconstruction method. Significant heterogeneity between studies precluded assimilation of specific techniques (each of the 23 studies utilized a unique technique). Fixation was performed at 30°-90° of elbow flexion. The most common mode of failure was suture failure (51 %), followed by midsubstance rupture (27.00 %), and bone tunnel fracture (14.00 %). No significant differences were observed amongst techniques for all measures analyzed. CONCLUSION: This study found the docking technique to be the most commonly tested technique, while the mode of reconstruction failure was most commonly at the suture interface. If the graft failed at the bone interface, it was most likely to occur at the ulna. Surgeon preference and comfort level with a specific technique should dictate choice.

Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review.

We conducted a systematic review of studies reporting clinical outcomes after proximal row carpectomy or to four-corner arthrodesis for scaphoid non-union advanced collapse or scapholunate advanced collapse arthritis. Seven studies (Levels I-III; 240 patients, 242 wrists) were evaluated. Significantly different post-operative values were as follows for four-corner arthrodesis versus proximal row carpectomy groups: wrist extension, 39 (SD 11º) versus 43 (SD 11º); wrist flexion, 32 (SD 10º) versus 36 (SD 11º); flexion-extension arc, 62 (SD 14º) versus 75 (SD 10º); radial deviation, 14 (SD 5º) versus 10 (SD 5º); hand grip strength as a percentage of contralateral side, 74% (SD 13) versus 67% (SD 16); overall complication rate, 29% versus 14%. The most common post-operative complications were non-union (grouped incidence, 7%) after four-corner arthrodesis and synovitis and clinically significant oedema (3.1%) after proximal row carpectomy. Radial deviation and post-operative hand grip strength (as a percentage of the contralateral side) were significantly better after four-corner arthrodesis. Four-corner arthrodesis gave significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side. Wrist flexion, extension, and the flexion-extension arc were better after proximal row carpectomy, which also had a lower overall complication rate.

Additional evidence for lack of transmission of HIV infection by close interpersonal (casual) contact.

To further study the possibility of transmission of HIV infection by close personal but non-sexual, non-parenteral contact we have continued to enroll and evaluate household contacts of adult patients with AIDS. Two hundred and six household contacts of 90 patients with AIDS were evaluated with detailed interviews, physical examinations, and detection of HIV antibodies and p24 antigen from 1984 to 1987; 118 of these contacts were re-evaluated 6-12 months after cessation of household contact or death of the patient. The median duration of household contact from 18 months prior to symptoms in the AIDS patients to last contact was 23 months (range 3-101 months). The median time elapsed from first contact during this period to the last evaluation was 38 months (range 13-66 months). No household contact had signs or symptoms suggesting HIV infection. All 206 were negative for serum antibodies to HIV and HIV p24 antigen, despite extensive sharing of household facilities and items and personal interactions with AIDS patients. This study continues to show that household members without other risks remain at minimal to no risk for HIV transmission (95% confidence interval, 0-1.44) despite prolonged and substantial close non-sexual contact with AIDS patients, and after re-evaluation at a median of 10.9 months after initial evaluation.

Finasteride therapy does not alter bone turnover in men with benign prostatic hyperplasia--a Clinical Research Center study.

Benign prostatic hyperplasia is often treated with finasteride, which inhibits the conversion of testosterone to dihydrotestosterone (DHT). Aside from the prostate, other androgen-dependent tissues seem to be unaffected by selective DHT deficiency, but the effect on bone density in humans has not yet been defined. To study this question, we compared indices of bone turnover and bone mineral density in 35 men treated with finasteride with controls. Bone resorption was assessed by measuring urinary excretion of N-telopeptide cross-links of type I collagen and hydroxyproline, and bone formation was assessed by measuring serum osteoncalcin and bone-specific alkaline phosphatase. Bone density of the spine and hip were assessed by dual energy x-ray absorptiometry. We found that finasteride-treated patients had mean DHT levels 81% lower than controls (P < 0.0001). There were no significant differences between the two groups in any of the markers of bone turnover or measures of bone density. These results suggest that testosterone can maintain bone density in men even in the absence of DHT. Although long term studies are needed, our results suggest that men who take finasteride are not at increased risk for bone loss.

Survival differences in patients with AIDS.

To define the clinical, demographic, and behavioral variables that may influence survival in patients with AIDS, we studied 526 patients with AIDS diagnosed through September 1987 who were cared for at a single medical center. A diversity of racial and ethnic backgrounds, ages, both men and women, and all risk behaviors except hemophilia were well represented. The initial AIDS defining diagnosis was the most powerful predictor of survival. The median survival was 12.8 months for patients presenting with Kaposi's sarcoma (p less than 0.001), 10.9 months for patients presenting with Pneumocystis carinii pneumonia (p less than 0.001), and 4.8 months for patients presenting with other infections or neoplasms (p less than 0.02). For the entire series, male sex and younger age were associated with more favorable survival (p less than 0.025). For those presenting with Pneumocystis carinii pneumonia, in addition to younger age (p less than 0.025), black race (p less than 0.025) and the combination of male sex and intravenous drug use (p less than 0.005) were associated with a more favorable survival. Within a setting of comparable clinical care, survival from the point of diagnosis of AIDS is associated most strongly with the initial AIDS diagnosis, but differences in age, gender, race, and risk behavior also exert an influence on survival.

Feasibility of collecting buccal cell DNA by mail in a cohort study.

This study assessed the feasibility of obtaining buccal cell DNA by mail from participants in a large, community-based cohort study in Hawaii. Mouthwash collection kits were sent to a total of 355 randomly selected Japanese, Caucasian, and Hawaiian cohort members. Subjects were requested to swish 10 ml of mouthwash in their mouth for 60 s and expel it into a collection cup, which they mailed back to our laboratory. Half of the subjects were requested to collect a second sample. After up to two mailings and two reminder phone calls, two-thirds of the subjects returned a sample. The participation rate was lower for Hawaiians (59.0%) than for Caucasians (68.1%) and Japanese (76.3%). Participation was not affected by requesting two specimens. Participants did not differ from the total sample in terms of education and smoking status. The mean DNA yield was lower in females (41.7 microg) than males (53.4 microg) and in Japanese (37.8 microg) as compared with Hawaiians (51.9 microg) and Caucasians (54.5 microg). For subjects who returned two samples, the DNA yields were similar when both specimens were extracted in the same batch. All samples were successfully genotyped for polymorphisms in the CYP1A1, CYP2E1, GSTM1, GSTT1, and NQO1 genes by PCR-RFLP. From these and previous data, we conclude that, in situations where blood samples cannot be obtained, mail collection of mouthwash samples should be considered because it yields substantial amounts of high-quality genomic DNA for large numbers of study subjects.

Pyomyositis in patients with the human immunodeficiency virus: an unusual form of disseminated bacterial infection.

PURPOSE AND PATIENTS: Pyomyositis, a common disease in the tropics, is rare in the continental United States, with approximately 83 cases described in the literature in the past two decades. The occurrence of pyomyositis complicating human immunodeficiency virus (HIV) infection has been reported in 10 patients since 1986. We report six cases of this entity in patients with advanced HIV disease seen in our institution over a 20-month period. A common denominator in all of our patients was muscle injury, induced by either exercise or trauma. Unlike most previous reports of HIV-associated pyomyositis, the clinical picture in our cases was complicated by the development of abscesses in multiple muscle groups, requiring prolonged antimicrobial therapy and repeated drainage procedures for successful management. Interestingly, one patient developed concomitant rhabdomyolysis--an otherwise rare event in classical pyomyositis. Staphylococcus aureus was the predominant infecting organism in this as well as all other series. Of note, we also observed and report the first case, to our knowledge, of gram-negative pyomyositis in an HIV-infected individual. The pathogenic implications of this catalase-producing gram-negative isolate are discussed in the context of neutrophil abnormalities in HIV disease. CONCLUSION: Like tropical pyomyositis, its HIV-associated counterpart appears to be multifactorial in origin. Its recent recognition suggests that, in addition to underlying abnormalities of host defense, factors relating to the prolonged survival of patients with late-stage disease, including myopathy, might play an important contributory role.

The recovery of Mycobacterium avium complex and Mycobacterium tuberculosis from blood specimens of AIDS patients using the nonradiometric BACTEC NR 660 medium.

The ability of the nonradiometric BACTEC NR 660 aerobic 6A blood culture medium to support mycobacterial growth was investigated. During a 19-month period blood cultures from 140 AIDS patients were sent to the microbiology laboratory. After the cultures were incubated for seven days, aliquots of medium from the vials were centrifuged, sediments examined microscopically for mycobacteria, and cultured to mycobacterial media. Seventy-one AIDS patients (51%) had at least one blood culture positive for mycobacteria. There was a significant difference in the percent of female AIDS patients positive for mycobacteria compared to male patients (72% vs. 44%, P less than 0.01). Forty-four percent of all subsequently positive cultures were detected by an acid fast stain of the specimen sediment. Subcultures from the BACTEC 6A suspensions were positive on mycobacterial media at one-seven weeks (mean three weeks) after planting. Sixty-nine of the isolates were Mycobacterium avium complex, while two were Mycobacterium tuberculosis. Some bacteremias with M. tuberculosis may have been undetected because growth experiments with a reference strain showed that, in contrast to M. avium complex, M. tuberculosis did not increase in concentration in 6A medium.

Identifying risk factors in development of clinically significant post-shock-wave lithotripsy subcapsular hematomas.

A retrospective study of 1,012 shock-wave lithotripsy treatments was performed to identify and analyze the risk factors for the development of six clinically significant post-extracorporeal shock-wave lithotripsy (ESWL) subcapsular hematomas. The patients studied had clinical signs and symptoms that on evaluation were confirmed as originating from a subcapsular hematoma. Common factors identified which we believe may put patients at increased risk for the development of subcapsular hematoma included hypertension, diabetes mellitus, coronary artery disease, and obesity.

Measurement of renal pelvis pressures during endourologic procedures.

Twenty-five kidneys underwent nephrostomy puncture with placement of a pigtail catheter into an upper pole calyx for manometric recording during nephroscopy without a working sheath and with an Amplatz sheath with and without a Rutner adapter. Intrarenal pressures remained below 16 cm of water (H2O) at all times with the Amplatz sheath with or without a Rutner adapter, whereas without a sheath the pressures ranged from 15 to 31 cm H2O (i.e., pressures associated with significant pyelovenous and pyelosinus backflow). Similar results were obtained in monitoring intrarenal pressures during clinical procedures. A working sheath should be utilized for all percutaneous nephroscopic procedures to minimize the incidence of pyelovenous and pyelosinus backflow as well as of perirenal extravasation of the irrigation solution. Even with a wide-lumen ureteral catheter in place, drainage via the ureter is not sufficient to maintain the intrapelvic pressure in the physiologic range.

Renal pelvic pressures during extracorporeal shock-wave lithotripsy.

Renal pelvic pressures were studied in 4 patients with indwelling nephrostomy tubes undergoing extracorporeal shock-wave lithotripsy (ESWL). The pressures were monitored by attaching the patients' nephrostomy tubes to an electrical pressure transducer. Three of these patients had ureteral stents placed to prevent outflow obstruction from disintegrated stone fragments. The mean pelvic pressure increased from 17.0 cm H2O at the start to 52 cm H2O at the conclusion of ESWL. Two hours post-ESWL, the pressures declined to a mean of 27.0 cm H2O. The maximum pelvic urine volume as determined by aspirating the nephrostomy tubes at the conclusion of the procedure was 6 cc. The observed rise in pelvic pressure may be explained by a sustained contraction of the pelvic smooth musculature.

Epispadias: contending with continence.

Forty-seven patients with epispadias not associated with bladder exstrophy were treated at our institution over the last half decade. There were 8 female and 39 male patients, 37 of whom had retrosymphyseal epispadias. Of the 20 male patients with subsymphyseal epispadias and incontinence 13 had a fair to excellent result. Of the 7 females with retrosymphyseal epispadias and incontinence, all but 1 came to urinary diversion. An analysis of our data suggests that premature operative intervention precludes obtaining maximal functional and cosmetic results. In addition, the discrepancy in our overall success rate utilizing a one-stage technique versus a staged procedure favored by others may support the latter.

Characteristics of bladder leiomyoma as noted on magnetic resonance imaging.

Leiomyoma of the bladder is a rare benign mesenchymal tumor that can be evaluated preoperatively with magnetic resonance imaging. Small tumors that appear to be leiomyomas on magnetic resonance imaging can be treated conservatively with transurethral resection.

Exstrophy of bladder: evolution of management.

Eighty-nine patients with bladder exstrophy were seen at our institution over the last fifty years. There were 63 males and 26 females. Cloacal exstrophy constituted 9 per cent of our experience. Twenty-seven patients underwent primary urinary diversion with subsequent genital reconstruction early on in our series. Of the 57 children operated on since 1951, 50 were judged eligible for and underwent a planned multistaged reconstruction. We realized a 50 per cent success rate. The majority of failures were diverted into an ileal conduit for persistent incontinence.

Extragonadal retroperitoneal germ cell tumors without apparent testicular involvement. A search for the source.

Extratesticular germ cell neoplasms without apparent testicular primary tumors are rare. The origin of these neoplasms has been debated in the literature for decades. With the advent of effective chemotherapy for extratesticular germ cell neoplasms, the origin of these tumors becomes more than academic. We report on 3 cases of retroperitoneal germ cell neoplasms with microscopic intratesticular primary tumors. All patients with extragonadal germinal cell tumors of the testes should undergo thorough investigation for an occult testicular primary tumor despite a normal testis examination. We review previously reported cases of extratesticular germ cell neoplasms without an apparent testicular primary tumor.

Comparison of extracorporeal shock-wave lithotripsy and surgical lithotomy regarding patient satisfaction.

A series of 19 patients who underwent extracorporeal shock-wave lithotripsy (ESWL) for urolithiasis was compared with 26 patients who were treated with surgical lithotomy (SL). A historical clinical trial was conducted using hospital chart records and telephone interviews to determine differences in outcome between the two groups. The ESWL group had significantly (p less than 0.05) shorter duration of post-procedural pain, fewer requirements for pain medications, and decreased anxiety toward repetition of the procedure than did the SL group. In addition, the ESWL group had significantly (p less than 0.05) shorter hospital stays, faster return to work on discharge from the hospital, and less physical limitation after the procedure. There was no appreciable difference in the occurrence of post-procedure urinary tract infections or in the patient's perception of the effectiveness of the procedure. These findings support the conclusion that treatment of urolithiasis by ESWL, is preferable to open flank SL.

Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia. PLESS Study Group.

OBJECTIVES: Prostate-specific antigen (PSA) is produced exclusively in the prostate gland and is currently the most useful clinical marker for the detection of prostate cancer. In this report, we examine whether serum PSA is also a predictor of important benign prostatic hyperplasia (BPH)-related outcomes, acute urinary retention (AUR), and the need for BPH-related surgery. METHODS: Three thousand forty men were treated with either placebo or finasteride in a double-blind, randomized study of 4-year duration. Serum PSA was measured at baseline, and baseline prostate volume was measured in a 10% subset of 312 men. Probabilities and cumulative incidences of AUR and BPH-related surgery, as well as reduction in risk of events with finasteride, were calculated for the entire patient population, stratified by treatment assignment, baseline serum PSA, and prostate volume. RESULTS: The risk of either needing BPH-related surgery or developing AUR ranged from 8.9% to 22.0% during the 4 years in placebo-treated patients stratified by increasing prostate volume and from 7.8% to 19.9% when stratified by increasing serum PSA. In comparison with symptom scores, flow rates, and residual urine volume, receiver operating characteristic curve analyses showed that serum PSA and prostate volume were the most powerful predictors of spontaneous AUR in placebo-treated patients (area under the curve 0.70 and 0.81, respectively). Finasteride treatment reduced the relative risk of needing surgery or developing AUR by 50% to 74% and by 43% to 60% when stratified by increasing prostate volume and serum PSA, respectively. CONCLUSIONS: Serum PSA and prostate volume are powerful predictors of the risk of AUR and the need for BPH-related surgery in men with BPH. Knowledge of baseline serum PSA and/or prostate volume are useful tools to aid physicians and decision makers in predicting the risk of BPH-related outcomes and choosing therapy for BPH.

Second-generation shock-wave lithotripters. Variations, indications, and efficacy in the treatment of ureteral calculi.

Second-generation lithotripters offer significant advances in the technology and delivery of high-energy shock waves. The final position that ultrasonographically guided machines will earn in the spectrum of lithotripters can be determined only as more clinical series are reported. Nonetheless, their compromised ability to handle ureteral calculi casts a shadow on the acquisition of such instruments by facilities that cannot afford to own and operate both x-ray and sonographically guided lithotripters.