Outcomes and survivorship of unicondylar knee arthroplasty in patients with severe deformity.

Purpose Patients with severe deformity beyond the standard indications for unicompartmental knee arthroplasty (UKA) may be suitable and benefit from UKA. This study investigated their outcomes to determine whether good function and quality of life (QOL) can be achieved. MATERIALS AND METHODS: Fifty-three patients with severe deformity (40 patients with FFD ≥15° and 13 patients with varus deformity ≥15°, Group A) were matched with 53 patients with less severe deformities who underwent UKA (Group B/controls) in terms of age, sex, BMI and duration of follow-up. Their flexion range, Knee Society scores (KSS), Oxford knee scores (OKS) and SF-36 QOL scores were analysed pre-operatively and at 2 years. RESULTS: Group A patients were largely similar to Group B patients pre-operatively in terms of maximum flexion angle, OKS and SF-36 scores except for knee score and mental health component of SF-36. At 2 years, Group A reported largely similar results compared with Group B in all outcome scores (OKS, KSS, SF-36) and flexion angle. Post-operative mechanical alignment was better for the control group though it is not statistically significant. There were no revisions in the patients with severe pre-operative deformity at 5 years post-operatively. (Survivorship 100 % at 5 years). CONCLUSION: Selected patients with severe deformity can achieve good function and QOL with UKA if satisfactory mechanical alignment is restored. This study supports a broadening of the indications of UKA; however, further follow-up is needed to assess the longer-term durability of the operation. LEVEL OF EVIDENCE: IV.

Simultaneous versus staged bilateral unicompartmental knee replacement.

We prospectively followed 171 patients who underwent bilateral unicompartmental knee replacement (UKR) over a period of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral procedure and 47 (27.5%) underwent a staged procedure. The mean cumulative operating time and length of hospital stay were both shorter in the simultaneous group, by 22.5 minutes (p < 0.001) and three days (p < 0.001), respectively. The mean reduction in haemoglobin level post-operatively was greater by 0.15 g/dl in the simultaneous group (p = 0.023), but this did not translate into a significant increase in the number of patients requiring blood transfusion (p = 1.000). The mean hospital cost was lower by $8892 in the simultaneous group (p < 0.001). There was no significant difference in the rate of complications between the groups, and at two-year follow-up there was no difference in the outcomes between the two groups. We conclude that simultaneous bilateral UKR can be recommended as an appropriate treatment for patients with bilateral medial compartment osteoarthritis of the knee.

Evaluation of the relationship between anteroposterior translation of a posterior cruciate ligament-retaining total knee replacement and functional outcome.

The success of total knee replacement (TKR) depends on optimal soft-tissue balancing, among many other factors. The objective of this study is to correlate post-operative anteroposterior (AP) translation of a posterior cruciate ligament-retaining TKR with clinical outcome at two years. In total 100 patients were divided into three groups based on their AP translation as measured by the KT-1000 arthrometer. Group 1 patients had AP translation < 5 mm, Group 2 had AP translation from 5 mm to 10 mm, and Group 3 had AP translation > 10 mm. Outcome assessment included range of movement of the knee, the presence of flexion contractures, hyperextension, knee mechanical axes and functional outcome using the Knee Society score, Oxford knee score and the Short-Form 36 questionnaire. At two years, patients in Group 2 reported significantly better Oxford knee scores than the other groups (p = 0.045). A positive correlation between range of movement and AP translation was noted, with patients in group 3 having the greatest range of movement (mean flexion: 117.9° (106° to 130°)) (p < 0.001). However, significantly more patients in Group 3 developed hyperextension > 10° (p = 0.01). In this study, the best outcome for cruciate-ligament retaining TKR was achieved in patients with an AP translation of 5 mm to 10 mm.

Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial.

INTRODUCTION: Post total knee replacement pain control using parenteral opioids results in significant side effects like nausea and vomiting. Periarticular injections are used to control pain without these side effects. This study aimed to evaluate the safety and efficacy of periarticular steroid injection in patients undergoing total knee arthroplasty, as well as assess the patient's functional outcomes over a period of two years. METHODS: A total of 100 patients who underwent total knee arthroplasty were randomised into two groups. The treatment group received periarticular infiltration with triamcinolone acetonide, bupivacaine and epinephrine. The control group received only bupivacaine and epinephrine. The postoperative analgesic regime was standardised for all patients. The immediate postoperative outcomes evaluated included pain score, morphine consumption, time to ambulation, straight leg raise, range of motion and duration of hospital stay. Longer-term outcomes were assessed at 1, 3, 6 and 24 months using the SF-36 questionnaire and Oxford Knee Score. RESULTS: Patients in the treatment group had significantly lower pain scores, reduced morphine consumption and earlier discharge. They also had better range of knee motion and were able to regain muscular strength earlier. There was no increase in major complications such as infection or tendon rupture in the treatment group. There was no difference between the groups with regard to the medium-term outcomes of up to two years. CONCLUSION: This modality of pain control is safe and efficacious for post total knee replacement pain control.

Thromboembolic prophylaxis for total knee arthroplasty in Asian patients: a randomised controlled trial.

PURPOSE: To compare the efficacy and safety of different modes of thromboembolic prophylaxis for elective total knee arthroplasty (TKA) in Asian patients. METHODS: 440 low-risk patients undergoing TKA were randomised into 4 equal groups: (1) no prophylaxis (control), (2) graduated compression stockings (GCS), (3) intermittent pneumatic compression (IPC), and (4) low-molecular-weight heparin (enoxaparin). Duplex ultrasonography was used as an assessment tool. RESULTS: The deep vein thrombosis point prevalence was highest in the control group (22%), which was significantly higher than in patients receiving IPC (8%, p=0.032) or enoxaparin (6%, p=0.001). One patient each in the control and GCS groups developed a non-fatal pulmonary embolism. Patients on enoxaparin received more blood transfusions and 2 of them had major bleeding complications. CONCLUSION: IPC is the preferred method of thromboprophylaxis for TKA in Asian patients.

Epigenetic inactivation of a RAS association domain family protein from the lung tumour suppressor locus 3p21.3.

Allelic loss at the short arm of chromosome 3 is one of the most common and earliest events in the pathogenesis of lung cancer, and is observed in more than 90% of small-cell lung cancers (SCLCs) and in 50-80% of non-small-cell lung cancers (NSCLCs). Frequent and early loss of heterozygosity and the presence of homozygous deletions suggested a critical role of the region 3p21.3 in tumorigenesis and a region of common homozygous deletion in 3p21.3 was narrowed to 120 kb (ref. 5). Several putative tumour-suppressor genes located at 3p21 have been characterized, but none of these genes appear to be altered in lung cancer. Here we describe the cloning and characterization of a human RAS effector homologue (RASSF1) located in the 120-kb region of minimal homozygous deletion. We identified three transcripts, A, B and C, derived from alternative splicing and promoter usage. The major transcripts A and C were expressed in all normal tissues. Transcript A was missing in all SCLC cell lines analysed and in several other cancer cell lines. Loss of expression was correlated with methylation of the CpG-island promoter sequence of RASSF1A. The promoter was highly methylated in 24 of 60 (40%) primary lung tumours, and 4 of 41 tumours analysed carried missense mutations. Re-expression of transcript A in lung carcinoma cells reduced colony formation, suppressed anchorage-independent growth and inhibited tumour formation in nude mice. These characteristics indicate a potential role for RASSF1A as a lung tumour suppressor gene.

Esthetic reconstruction after mastectomy for inflammatory breast cancer: is it worthwhile?

BACKGROUND: Because inflammatory breast cancer (IBC) has been viewed as a malignancy with a poor likelihood of longterm survival, few women have been offered esthetic reconstruction after mastectomy for IBC. Recent advances in multimodality therapy have improved the outcomes for women with this disease. The purpose of this review was to assess the results of esthetic breast reconstruction in the population with IBC. STUDY DESIGN: Review of medical records at the City of Hope National Medical Center for the 10-year period ending in May 1997, revealed 23 women who underwent elective esthetic breast reconstruction after mastectomy for IBC. The records of these patients were reviewed retrospectively. Patients requiring reconstruction for large surgical chest wall defects were not included in the review. RESULTS: Treatment for IBC included mastectomy in all patients, chemotherapy in 22, and chest wall radiation therapy in 14. Immediate reconstruction was performed at the time of mastectomy (n = 14) or was delayed (n = 9). The types of reconstruction included transverse rectus abdominis musculocutaneous flap (n = 18), latissimus dorsi flap (n = 2), or prosthetic mammary implant reconstruction (n = 3). Seven women chose to undergo additional reconstruction procedures (ie, nipple reconstruction) after their initial reconstruction. With a median followup of 44 months for survivors, 16 patients developed recurrence after reconstruction. Of these, 6 were local recurrences and 10 were distant failures. Seven patients are currently alive with no evidence of disease, 4 are currently alive with disease, and 12 have died as a result of breast cancer. The median disease-free survival after reconstruction was 19 months. The median overall survival after reconstruction for all patients was 22 months. The only negative predictor of survival was a positive surgical margin at mastectomy. CONCLUSIONS: The significant emotional and esthetic benefits of breast reconstruction should be available to women with IBC. In light of the improving prognosis of IBC with current aggressive multimodality treatment, reconstructive procedures should be offered as part of comprehensive therapy.

Use of the sentinel lymph node to determine metastases of gastrointestinal malignancies: a word of caution.

Identifying the sentinel lymph node has been shown to carry prognostic and therapeutic implications in the surgical treatment of solid tumors. Recently, sentinel lymphadenectomy has been described for gastrointestinal malignancies, but its clinical value remains uncertain. We describe the case of a patient with appendiceal carcinoid who underwent a right hemicolectomy 4 months after appendectomy, out of concern over residual local or regional disease. One sentinel lymph node was identified in the colonic mesentery using the blue dye technique. This sentinel node and 35 others were negative for metastases, but one lymph node not identified through blue dye carried evidence for micrometastatic disease on hematoxylin and eosin (H&E) and immunohistochemical chromogranin stains. The case raises some issues about the value and limitations of sentinel lymph node biopsies in gastrointestinal cancer. Aspects related to technique, learning curve, gastrointestinal lymphatic drainage patterns, the impact of prior operations, and the limited therapeutic implications compared to cutaneous or subcutaneous solid malignancies are discussed. We conclude that at this point in time, the information obtained from biopsies of sentinel lymph nodes during the surgical treatment of gastrointestinal cancer should be utilized with due caution.

Ethnic differences in the behavior of hepatocellular carcinoma.

BACKGROUND: The purpose of this study was to examine the clinical presentation, prognostic factors, and survival rates of patients with hepatocellular carcinoma (HCC) and to examine differences between Asian and non-Asian patients with HCC. METHODS: A review of the clinical characteristics and laboratory evaluations for 76 patients in two different broad ethnic groups (Asians [Group 1] and non-Asians [Group 2]) who underwent treatment for HCC from 1977-1995 was performed. Chi-square and Cox regression analyses were performed to assess factor interaction and association with survival. RESULTS: A total of 24 patients in Group 1 and 52 patients in Group 2 were reviewed. Of the clinical variables examined, a higher rate of a history of hepatitis B positivity was observed in Group 1 compared with Group 2 (32% vs. 6%; P=0.001). Among the 76 patients with HCC, a 1-year survival estimate of 41.4% was found. There was a borderline significant difference in survival between Group 1 and Group 2 with a 1-year survival estimate of 29.5% versus 46.9%, respectively (P=0.08). Better overall survival was found in patients who had tumors that were resectable (P=0.0001), had an alpha-fetoprotein level <10 ng/mL (P=0.02), or were a younger age at the time of diagnosis (P=0.01). There was a trend for Asian race (P=0.08) to be associated with poorer survival. When these risk factors were entered into a multivariate analysis, tumor resectability and non-Asian race were most predictive of improved survival (model P value = 0.007). When controlling for the multiple variables most often reported to be associated with HCC, Asians had a significantly lower survival than non-Asians (P<0.01). CONCLUSIONS: In this study it appears that the outcome for Asian patients with hepatoma is worse than for non-Asian patients, even when controlling for factors commonly associated with HCC. Biologic or social factors that are not appreciated currently may be involved in Asian patients with HCC, contributing to a poorer clinical outcome.

In vivo evidence for binding of p53 to consensus binding sites in the p21 and GADD45 genes in response to ionizing radiation.

The tumor suppressor protein p53 has a transcriptional activation activity thought to mediate its biologic function including G1 arrest and perhaps apoptosis. To learn more about p53's transactivator function in vivo, we performed genomic footprinting experiments examining p53-DNA interactions in the regulatory regions of the p53-regulated genes p21, GADD45, and MDM2. Using ionizing radiation to induce DNA damage in human ML-1 myeloblastic leukemia cells, the promoter and intronic regions of these genes containing p53-consensus binding sites were examined for in vivo footprints. There was a uniform and sustained expression of p53 protein as well as a strong induction of p21, GADD45, and MDM2 mRNA following irradiation. At the two p53 consensus binding sites in the p21 promoter, reduced DNaseI cleavage was observed in irradiated cells beginning 1 to 2h after irradiation, being most pronounced after 2 h and diminishing after 8 h. A partial in vivo footprint was also observed in the third intron of the GADD45 gene beginning 2 h after irradiation. No in vivo footprints were seen at the two p53 binding sites in the MDM2 gene. Our study provides direct evidence that the DNA damage-induced activity of p53 is mediated by its consensus DNA binding sites in the p21 and GADD45 genes. We suggest that the transient nature and relative instability of p53-DNA interactions in vivo may make the p53 protein more accessible to a rapid turnover pathway which might be impaired under conditions when the protein is stably bound to DNA.

Removal of retained urinary catheters.

In a 1-year register, retained urinary catheters were encountered on 23 occasions. In vitro tests showed that 2 ml of ether or chloroform injected through the inflation channel of catheter balloons caused disruption within a few seconds but liquid paraffin took over 20 min, leaving an unacceptable amount of debris. A new method of removal using diagnostic ultrasound to identify the balloon of the retained catheter is described, together with suggestions for removal of retained catheters occurring under different circumstances.

Myocardial infarction coincident with cerebrovascular accidents in the elderly.

In a three-year prospective study of acute cerebrovascular accident patients admitted to a geriatric unit within 72 hours of the onset, 12.7% had what was considered to be an associated acute myocardial infarction. In the majority of cases, 71%, there was no clinical indication of an acute myocardial infarction and, had it not been for electrocardiographic and enzyme studies, the concurrence of these two conditions might not have come to light. The possible explanations for the concurrence of these two conditions are explored. Patients were followed-up for five years. The mortality rate for the combined acute myocardial and cerebral infarction cases admitted to hospital was 53% in six weeks, and 64% in one year, compared with 26% and 42%, respectively, in those strokes uncomplicated by a cardiac infarction. Only one patient has survived for five years. The recognition of such cases is important in terms of management and prognosis and this may be achieved by ECG recordings followed by enzyme studies in all cases of acute stroke admitted to hospital.