Anterior lumbar interbody fusion with threaded fusion cages and autologous bone grafts. (65/2728)

The goal of this study was to evaluate the ability of Ray threaded fusion cages, when used in an anterior approach, to restore intervertebral height and to improve the functional and occupational performance of the patients. The present study was initiated because insertion of fusion cages through a posterior approach causes destruction of facet joints and violation of the spinal canal. The anterior approach for insertion of threaded fusion cages to accomplish lumbar interbody fusion was evaluated in a series of 13 patients suffering monosegmental disc disease. The patients' functional and occupational performance was evaluated using the Prolo score. Radiological measurements were used to evaluate disc height and degree of penetration into the endplates, and to confirm fusion. Seven of the 13 patients were short-term failures and had to be revised within 2 years. The study found that revised patients had poorer Prolo scores than non-revised patients. Although for the non-revised patients, the mean Prolo scores remained relatively stable during the 1st year, they dropped after 3 years. We were not able to identify any further clinical or radiological differences between the groups. These results indicate that although the anterior approach seems technically suitable for insertion of threaded fusion cages, destruction of the anterior longitudinal ligament and the anterior part of the annulus fibrosis appears to result in destabilisation of the motion segment.  (+info)

Incomplete and inaccurate death certification--the impact on research. (66/2728)

BACKGROUND: The objectives of this study were (1) to investigate the extent of erroneous and/or omitted information on death certificates of patients-implanted with Bjork-Shiley Convexo-Concave (BSCC) heart valves; (2) to determine whether this information could be associated with a possible under-reporting of acute mechanical failure of this valve. METHODS: A review was carried out of death certificates and clinical notes for patients implanted in the United Kingdom with BSCC valves. This was a multicentre study (38 hospitals) based at the Cardiothoracic Department, NHLI, Imperial College School of Medicine at Hammersmith Hospital, London. The subjects were 478 patients implanted with a BSCC valve between 1979 and 1986 who died in the following years: 1984, 1987, 1990, 1993 and 1996. The main outcome measures were: (1) percentage of death certificates that record the presence of a valve prosthesis; (2) percentage of death certificates that record the presence of a valve prosthesis for patients who had a post mortem; (3) percentage of death certificates that record inaccurate or incomplete information related to the surgery; (4) percentage of death certificates that do not record a post mortem where one is known to have been performed. RESULTS: Twenty-one per cent (101/478) of the total number of death certificates record the presence of the valve prosthesis. Thirty-five per cent (43/123) of the death certificates for patients who had a post mortem record the presence of a valve prosthesis. Six per cent (30/478) of death certificates report inaccurate information related to the valve surgery. Twenty-five per cent (118/478) of the total number of death certificates recorded a single cause of death. Twenty-three per cent (110/478) of all death certificates reviewed recorded only the mode of dying. Eight per cent (10/123) of the total number of death certificates for patients who had a post mortem did not record a post mortem. CONCLUSIONS: The relatively high number of death certificates that do not record the presence of a valve prosthesis and the observed under-reporting of post mortems may lead to inaccurate reporting of the number of BSCC valves that fail. Previous recommendations to improve accuracy in death certification appear to have gone unheeded, and changes in the way certificates are completed for patients with implanted cardiac devices should be considered.  (+info)

Crushed stents in benign left brachiocephalic vein stenoses. (67/2728)

Two hemodialysis patients presenting with left venous arm congestion due to benign catheter-induced stenosis of the left brachiocephalic vein were treated by angioplasty and stent placement. External compression of the stents was responsible for rapid recurrence of the symptoms. No osseous or vascular malformation could be identified. Mechanical constraints induced by respiratory chest wall motion and aortic arch flow-related pulsation are proposed to explain this observation. This potential hazard should be considered when stent placement into the left brachiocephalic vein is advocated.  (+info)

Cementless acetabular revision arthroplasty. (68/2728)

OBJECTIVE: To evaluate the effects of clinical factors on outcome after acetabular revision with a cementless beaded cup. DESIGN: Retrospective case series. SETTING: Tertiary care referral centre. PATIENTS: Forty-one patients who underwent acetabular revision with a cementless cup were followed up for a mean of 3.4 years. INTERVENTIONS: Acetabular revision with a beaded cementless cup in all patients. A morcellized allograft was used in 10 patients. OUTCOME MEASURES: A modified Harris hip score (range of motion measurement omitted), the SF-36 health survey, and the Western Ontario McMaster (WOMAC) osteoarthritis index. Multivariate analysis was used to evaluate the effects of age, gender, morcellized allografting, time to revision from the previous operation, acetabular screw fixation and concurrent femoral revision on outcome. RESULTS: Gender accounted for a significant portion of the variation seen in the SF-36 physical component scores (r = 0.36, p = 0.02), with women tending to have worse results. Increasing age was associated with lower WOMAC index function scores (r = 0.36, p = 0.03), whereas concurrent femoral revision tended to have a positive effect on WOMAC index function (r = 0.39, p = 0.01). None of the potential clinical predictors had any significant effect on the SF-36 mental component scores, or WOMAC index pain and stiffness scores. CONCLUSIONS: In cementless acetabular revision arthroplasty, physical function, as measured by generic and limb-specific scales, may be affected by gender, age and the presence of a concurrent femoral revision. Time to revision from the previous operation, morcellized allografting and screw fixation of the acetabulum did not affect outcomes. This information may provide some prognostic value for patients' expectations.  (+info)

Functional outcome after acetabular revision with roof reinforcement rings. (69/2728)

OBJECTIVE: To evaluate the role for potential predictors of functional outcome after acetabular arthroplasty and to assess the results of revision with the use of a roof reinforcement ring. DESIGN: A retrospective case series. SETTING: A tertiary-care referral centre. PATIENTS: Twenty-four patients (average age 72.7 years) who had undergone acetabular revision with a roof reinforcement ring were followed up for an average of 2.8 years. INTERVENTIONS: Revision acetabular arthroplasty was performed using either the Mueller or Burch Schneider roof reinforcement ring, bone grafting and a cemented polyethylene cup. OUTCOME MEASURES: A modified Harris hip score (range of motion omitted), the SF-36 health survey and the Western Ontario McMaster (WOMAC) osteoarthritis index measured outcome. Multivariate analysis was used to determine the effects of certain clinical factors (age, sex, time to revision from previous hip operation and number of previous revisions) on outcome. RESULTS: Patients reported disability both on hip-specific and general health measures. The time to revision from previous operation positively correlated with SF-36 mental component scores (p = 0.003), WOMAC function (p = 0.04) and WOMAC pain (p = 0.03). Age, gender and number of past revisions did not affect outcome. CONCLUSIONS: Patients who undergo acetabular revision with a roof ring will continue to have some disability in the first 3 years after the procedure. A greater time between the previous operation and the revision operation is associated with a better outcome. Patients' expectations of postoperative results should be realistic in the face of a challenging reconstructive procedure.  (+info)

Pressure damping, a "billowing" septum, and an eerie silence: perioperative, intermittent obstruction of a mitral valve prosthesis. (70/2728)

This case, involving a 74 year old man who underwent mitral valve and aortic valve replacements, provides detailed insight into the perioperative echocardiographic and haemodynamic changes occurring when a mitral valve prosthesis intermittently obstructs. It illustrates the early sequence of electromechanical dissociation which would lead to cardiac arrest should a tilting disc prosthesis be immobilised in the closed position.  (+info)

The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts. (71/2728)

OBJECTIVES: Although there are numerous reports comparing saphenous vein (SV) and polytetrafluoroethylene (PTFE) with respect to the patency rates for femoropopliteal bypass grafts, the clinical consequences of failed grafts are not as well described. This study compares the outcomes of failed SV and PTFE grafts with a specific emphasis on the degree of acute limb ischemia caused by graft occlusion. METHODS: Over a 6-year period, 718 infrainguinal revascularization procedures were performed, of which 189 were femoropopliteal bypass grafts (SV, 108; PTFE, 81). Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) standardized runoff scores were calculated from preoperative arteriograms. Clinical categories of acute limb ischemia resulting from graft occlusion were graded according to SVS/ISCVS standards (I, viable; II, threatened; III, irreversible). Primary graft patency and limb salvage rates at 48 months were calculated according to the Kaplan-Meier method. RESULTS: Patients were well matched for age, sex, and comorbidities. Chronic critical ischemia was the operative indication in most cases (SV, 82%; PTFE, 80%; P =.85). Runoff scores and preoperative ankle-brachial index measurements were similar for the two groups (SV, 6.0 +/- 2.5 [SD] and 0.51 +/- 0.29; PTFE, 5.3 +/- 2.8 and 0.45 +/- 0.20; P =.06 and P =.12). The distal anastomosis was made below the knee in 60% of SV grafts and 16% of PTFE grafts (P <.001). Grade II ischemia was more likely to occur after occlusion of PTFE grafts (78%) than after occlusion of SV grafts (21%; P =.001). Emergency revascularization after graft occlusion was required for 28% of PTFE failures but only 3% of SV graft failures (P <.001). Primary graft patency at 48 months was 58% for SV grafts and 32% for PTFE grafts (P =.008). Limb salvage was achieved in 81% of SV grafts but only 56% of PTFE grafts (P =.019). CONCLUSIONS: Patients undergoing femoropopliteal bypass grafting with PTFE are at greater risk of ischemic complications from graft occlusion and more frequently require emergency limb revascularization as a result of graft occlusion than patients receiving SV grafts. Graft patency and limb salvage are superior with SV in comparison with PTFE in patients undergoing femoropopliteal bypass grafting.  (+info)

Changes in the proportions of peripheral blood lymphocytes in patients with worn implants. (72/2728)

We compared the peripheral blood and periprosthetic tissues of 53 patients at revision arthroplasty with those of 30 patients at primary arthroplasty to determine whether there is a systemic difference in lymphocytes in patients with worn hip implants. The absolute number and relative proportion of lymphocytes bearing CD2, CD3, CD4, CD8, CD16, CD19, HLA-DR, kappa and lambda antigens were compared with the levels of IL-1beta, IL-6 and PGE2 in the pseudosynovial membrane as well as with a semiquantitative estimate of metal and polyethylene particles, necrosis and chronic inflammation and the total concentration of metals within the periprosthetic tissues. There was a significant increase in the relative proportion of CD2-positive T-cells and CD16-positive natural killer cells in the peripheral blood at revision arthroplasty compared with primary arthroplasty and an increased proportion of CD8-positive T-cells and a decreased ratio of CD4 to CD8 (helper inducer/suppressor cytotoxic cells). Three control patients, who went on to have revision surgery, had values at primary arthroplasty which were similar to those of patients at the time of revision surgery. These differences did not correlate with the local concentration of metal, plastic or cement or inflammatory response or the type of prosthesis. An inverse correlation was noted between the necrosis in the periprosthetic tissue and both the local production of IL-6 and the absolute numbers of T-cells in peripheral blood. We conclude that there may be several cell-mediated systemic immune responses to aseptic loosening, at least one of which may be directly related to events in the periprosthetic tissues. We cannot exclude the possibility that the changes in the proportion of CD8-positive cells reflected a predisposition, rather than a reaction, to loosening of the implant.  (+info)