To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre. Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank. 26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant ( Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.
It has been shown that a cognitive function (CF) loss can occur after hip or knee arthroplasty procedures, with an incidence of 40 to 70%. The pathogenesis remains unclear but studies suggest some form of brain emboli; although both trans-cranial doppler and trans-oesophageal doppler have both shown emboli per-operatively a correlation has never been shown with CF loss post-operatively. In contrast, in the cardiothoracic literature an embolic cause is widely accepted for detectable post-operative CF drop. The purpose of this study was to ascertain whether MRI could show evidence of embolic phenomena in patients undergoing hip or knee arthroplasty. Twenty-five patients presenting for hip or knee arthroplasty procedures were consented for this study. Brain MRI scans and MR angiograms were performed 1 week pre-operatively and within 1 week post-operatively using a Phillips 1.5Tesla MRI unit. All scans recorded were independently reviewed by 2 radiologists. A series of tests to examine several modes of cognitive function were carried out by a clinical psychologist pre-operatively, and at 1 week post-operatively. The CF tests showed a clinically significant drop following surgery in 64% of cases – this is in keeping with other recently published data. None of the post-operative scans or angiograms showed overt evidence of new lesions. Three Scans had equivocal tiny brainstem hypodensities on a single slice with no correlating abnormality on diffusion images to support the presence of new ischaemia. We conclude that either the aetiology of post-operative CF drop following arthroplasty is not embolic in nature, or that with current technology MRI brain scans even with angiograms are not sensitive enough to show the corresponding abnormality. With currently available equipment there appears to be no benefit from using MRI as a tool to evaluate post-operative CF loss in this group of patients.
Hyaluronic acid (Hyalunan, HA), β-1,4-linked D-glucuronic acid and β-1,3 N-acetyl-D-glucosamine polysaccharide, is a nonsulfated glycosaminoglycan(GAG) conserved in the extracellular matrix (ECM). Due to its biocompatibility, biodegradable properties, HA is widely applied for tissue engineering. However, HA also has defects for tissue engineering such as mechanical properties, difficulty of handling. Thus, it is various modified by chemical reaction to produce HA derivative. HA plays an important role in tissue morphogenesis, proliferation and cell differentiation. Ascorbic acid (AA) has an effect on collagen synthesis and bone mineralization. Ascorbate levels also have a significant effect on osteoblast proliferation and alkaline phosphatase (ALP) expression. However AA is weak to heat and light, thus it is easily degradable. Consequently, we conjugated HA with AA in order to make it more stable and effective. In this study, we prepared HA-AA conjugate and evaluated activity of products in pre-osteoblast. To produce more effective conjugation, we synthesised HA derivative, HA-N-hydroxysuccinimide, an activated ester of the glucuronic acid moiety. This HA-active ester intermediate is a precursor for drug-polymer conjugates. The degree of substitution was calculated by NMR analysis. The modified HA was dialysed and lyophilised. The yield of conjugation is calculated by Gel Permeation Chromatography (GPC). After the process, HA was conjugated with AA once again as previously mentioned. In this study, the resultant HA-AA conjugate was tested on MC3T3-E1, murine pre-osteoblast cells. We examined cellular viability (cytotoxicity), proliferation and gene expression. The expression of Type 1 collagen was examined by RT-PCR and western blot. Osteocalcin (OCN), osteopontin (OPN) and bone sialoprotein (BSP), bone proliferation and differentiation marker were detected by RT-PCR. Alkaline phosphatase assay was also performed. For confirmation on bone mineralization, alizarin red staining and von Kossa staining was performed. In conclusion, the in vitro data demonstrate that HA-AA conjugate has an important role in bone formation, as it can increase proliferation and osteogenic differentiation of MC3T3-E1 cells. These observations further support the use of in vivo system for tissue engineering applications.
Constrained condylar knee (CCK) prosthesis offers an implant option for complex revision total knee arthroplasties in which stable varus-valgus constraint as well as rotational control is needed for severe bone defect and ligament insufficiency. The aim of this study was to evaluate the clinical and radiological outcome of CCK prosthesis in revision TKA. Fify-one revision TKAs performed using CCK prosthesis between Jan. 1998 and Feb. 2006 were performed. The mean follow-up period was 5 years and 3 months (2 to 9 years) and the interval between initial and revision TKA was 8 years (4 months to 21 years). The mean age was 67 years. Range of motion (ROM), knee society (KS) score, hospital for special surgery (HSS) score, complication rate and failure rate was evaluated. The tibiofemoral angle and radiolucent line was also evaluated on plain radiograph. The mean ROM improved from 81.9° to 102°. The mean KS score improved from 49.3° to 79.7°, and KS function score from 50.3 to 71.0 (P<
.001). The mean HSS score improved from 50.7 to 78.7 (P<
.001). Tibiofemoral angle improved from valgus 3.1° to valgus 5.6° (P<
.001). Radiolucent line more than 2mm was observed around 4 femoral and 4 tibial components. Complications including 1 skin necrosis, 1 tibial tubercle nonunion, 2 infections, 3 periprosthetic fractures and 5 arthrofibrosis were observed. Overall rating was excellent or good in 88% at the last follow up. Revision TKA using CCK prosthesis showed comparable results with other reports in average 5 years follow-up.
The aim of this study was to evaluate the rotational axis of the tibia and the association of its axis to tibial coronal alignment after TKR. TKRs were performed using navigated mobile bearing system (40 knees), conventional mobile bearing (48 knees) and conventional fixed bearing (40 knees) and preoperative and postoperative CT scans were assessed using 3D image reconstruction-analysis program. The tibial AP axis which was defined as the line connecting the middle of the PCL and the medial edge of the patellar tendon attachment was measured relative to the AP axis of distal femur preoperatively and postoperatively, as well as the coronal angle of the tibia and posterior slope. The tibial coronal alignments in navigation, postoperative plain radiograph and CT were compared. The AP axis of the tibia was in 2.10° internally rotated position relative to the AP axis of the femur preoperatively and 3.54° postoperatively (range, 19.5° internal rotation to 16.8° external rotation). The coronal angle of the tibia was 0.46° varus on plain radiograph, 0.72° varus on CT, 0.37° valgus in navigation (p=0.005). Posterior slope was 2.53° on plain radiograph and 0.67° in navigation (p<
0.001). There was no correlation between postoperative rotational position of the tibia relative to the femur and the difference in the tibial coronal angle between navigation data and CT. The proposed anteroposterior axis of the tibia centered between 0 to 5 degrees internally rotated position relative to the femur but showed wide range of deviation. The rotation angle of the tibial cutting in navigated TKR did not influence on the postoperative measurement discrepancy between navigation and CT.
The aim of this study was to evaluate passive kinematics of a mobile-bearing, ultracongruent (UC) total knee design compared with a mobile-bearing, posterior stabilised (PS) design intraoperatively using navigation system. Thirty-four knees of 24 patients which had undergone total knee arthroplasty with UC prosthesis (E-motion®, Aesculap, Tuttlingen, Germany) for primary osteoarthritis and fifteen knees of 14 patients with PS prosthesis (E-motion®) were included in this study. Thirty-one female and seven male patients were included and the mean age was 70.4 years. Patients were followed up for 7.26 months (6 to 12 months). Intraoperative kinematics including valgus/varus rotation, internal/external rotation, and anterior/posterior translation was assessed from 10° to 120° of passive flexion before and after total knee replacement using a surgical navigation system (Orthopilot®, Aesculap). The range of motion (ROM) was measured preoperatively and at the final follow up. The tibiofemoral alignment in 10° flexion changed from varus 5.85° to valgus 0.38° in UC group and changed from varus 7.45° to valgus 1.08° in PS group (p>
0.05), the magnitude of varus rotation during flexion was 0.01° in UC group and 4.08° in PS group (p<
0.05). PS knee showed the tendency to slight varus alignment during flexion but UC knee showed the tendency toward valgus alignment fter midflexion. The mean internal rotation during flexion was 10.3° in UC group and 13.2° in PS group (p>
0.05). The translation of the femur was 4.99mm posteriorly in UC group and 3.24mm posteriorly in PS group at 120° flexion (p>
0.05). The maximum flexion angle at the final follow up was 123° in UC group and 118° in PS group (p>
0.05). Total knee arthroplasty with high flexion PS prosthesis showed good ROM and satisfactory early clinical results. UC total knee design showed less varus rotation during flexion, more valgus pattern in higher flexion angle than PS design, similar internal rotation angle and pattern, and similar posterior translation at 120° flexion with PS design.
Clinical experience has shown the needs for high flexion. The aim of this study was to evaluate the clinical and radiological results of a fixed bearing high flexion posterior stabilized (PS) total knee arthroplasty (TKA). Between July 2001 and December 2005, 422 TKAs in 288 patients were performed with high flexion PS prosthesis and 378 knees of 258 patients had been followed up for 2 to 6.5 years (mean: 3 years 11 months). We evaluated range of motion (ROM), Knee rating system of the Hospital for Special Surgery (HSS) and Knee Society (KS) score, and radiological results. The mean flexion improved from 110.1 degrees to 126.7 degrees at the latest follow-up. 333 knees (88 %) showed more than 120 degrees of flexion, 105 knees (28 %) more than 140 degrees of flexion. The mean KS clinical score improved from 39 to 93 points (p<
0.01) and KS function score, from 40 to 85.4 points (p<
0.01). The mean HSS score improved from 41.2 to 86.3 points (p<
0.01). In 28 knees, radiolucent line of 1–2 mm in width was observed at zone 1 without symptoms. Aseptic loosening in 4 knees, Mid-flexion instability in 2 knees, superficial infection in 3 knees and deep infection in 3 knees were observed. Total knee arthroplasty with high flexion PS prosthesis showed good ROM and satisfactory early clinical results. Complication rate was similar to those of other series. Close observation and serial radiological evaluation are needed for long term results.
We report a multi-centre prospective clinical trial. 231 hips in 223 patients have been entered into the study. 151 of these have reached 3 years follow-up.
In particular, the RSA subsidence characteristics, cement pressurisation and rotational stability already associated with this implant in-vitro have been supported by excellent survivorship analysis, and the authors believe that increasing familiarity with the concepts raised by this implant will result in clinical benefits in relation to polished taper cemented stem longevity.
Dissociation of the polyethylene liner of modular acetabular components is a rare occurrence, and previous reports have commented on the difficulty in diagnosis from plain radiographs. The radiograph is often incorrectly reported by radiologists as showing advanced polyethylene wear, causing delay in referral and increasing the complexity of treatment required. We report 9 cases of late polyethylene liner dissociation of the cementless Harris-Galante II porous-coated acetabular component (Zimmer Inc, Warsaw, IN) which occurred without trauma or injury. This is the largest reported series to date. In all cases, there was a common pattern of clinical symptoms and signs which is described. Radiographs showed a distinct appearance with a radiolucency medial to the femoral neck in association with an eccentrically placed femoral head lying in contact with the acetabular metal shell. We have termed this the ‘crescent sign’. We believe that the diagnosis can be made from a single antero-posterior pelvic radiograph without the need for previous films for comparison, or the need for arthrography. Clinicians should look specifically for the crescent sign when an eccentrically placed femoral head has been noted, in order to differentiate the more unusual diagnosis of dissociation from that of polyethylene wear. Early diagnosis and prompt referral prevents further damage to the femoral head and metal acetabular shell, thus reducing the complexity of revision surgery.
Highly selective CT-guided epidural steroid injection was then carried out at the level of spondylolithesis by an experienced interventional radiologist. The pain diagram, VAS of pain severity and ODI were all completed again by the subjects themselves or by telephone at 1 and 3 months after injection in the presence of an independent assessor (nurse) and then reviewed and discussed with the treating doctor. All subjects were also asked to complete a functional questionnaire.
We retrospectively reviewed 45 hip arthroplasties which were performed over a period of 20 years in 38 patients with cirrhosis of the liver. There was a high perioperative 30-day complication rate (26.7%). Advanced cirrhosis was associated with a higher risk of complications (p = 0.004) as also was increased age, a high level of creatinine, a low level of albumin, a low platelet count, ascites, encephalopathy and an increased operative blood loss. The survival of the prosthesis at five years was 77.8% and infection was a major cause of failure. In view of the high rate of early complications and the limited longevity of the prosthesis, surgeons who perform hip arthroplasty on such patients should counsel them appropriately preoperatively.
We report the results of seventy-six Harris Galante Porous Cups (HGP 1) in sixty-three patients treated by Total Hip Arthroplasty (THA) with a diagnosis of avascular necrosis (AVN) of the femur (grade III and IV). The cups were inserted between 1986 and 1994 and followed prospectively. Seventy hips with a follow up of more than five years (mean 7.6 years) were reviewed. At last review the mean Harris Hip Score was 94 (standard deviation (&
dcl001;) .8), preoperatively the mean had been 29 (&
dcl001;14.7). Radiographically there was no evidence of acetabular migration. The revision rate of the femoral prosthesis was 8.6%, however only three stems (4.3%) were revised for loosening the rest being revised to allow down sizing of the femoral head. The revision rate for the acetabular prosthesis was 7.1%, (five cups). At the time of revision none of the cups were clinically loose and only required the liner to be changed. The complication rate was low with no deep infections or dislocations and only nine hips, (11.8%) with grade III heterotopic ossification. Survival analysis for both stem and cup at 8 years is 96.3% (confidence interval 91 – 100%), with a worst-case survival of 93.6%, (C.I 87.4 – 99.9%) Previous studies of patients undergoing cemented THA for the treatment of advanced AVN have reported a high incidence of component loosening. This study shows good medium term results using the Harris Galante Porous cup for acetabular reconstruction with cemented femoral components for the treatment of this difficult problem.
There are several techniques for the accurate measurement of the migration of components after arthroplasty some of which require the operative placement of tantalum balls. We have reviewed the position and migration of these markers in 64 patients after total hip arthroplasty. In 40% of cases, one or more balls was seen to be outside the proximal femur on the postoperative radiograph, although all were considered to be within the bone at operation. In two hips, one ball appeared to have migrated towards the joint, although none was seen within the joint. Misplacement was not related to the experience of the surgeon or the operative approach. Migration analysis which necessitates the insertion of tantalum balls requires careful technique to avoid a potential source of third-body wear. It should probably be used only for research in small series of patients.