What are the implications of withholding total joint arthroplasty in the morbidly obese? A prospective, observational study.

AIMS: The aim of this study was to observe the implications of withholding total joint arthroplasty (TJA) in morbidly obese patients. PATIENTS AND METHODS: A total of 289 morbidly obese patients with end-stage osteoarthritis were prospectively followed. There were 218 women and 71 men, with a mean age of 56.3 years (26.7 to 79.1). At initial visit, patients were given information about the risks of TJA in the morbidly obese and were given referral information to a bariatric clinic. Patients were contacted at six, 12, 18, and 24 months from initial visit. RESULTS: The median body mass index (BMI) at initial visit was 46.9 kg/m2 (interquartile range (IQR) 44.6 to 51.3). A total of 82 patients (28.4%) refused to follow-up or answer phone surveys, and 149 of the remaining 207 (72.0%) did not have surgery. Initial median BMI of those 149 was 47.5 kg/m2 (IQR 44.6 to 52.5) and at last follow-up was 46.7 kg/m2 (IQR 43.4 to 51.2). Only 67 patients (23.2%) went to the bariatric clinic, of whom 14 (20.9%) had bariatric surgery. A total of 58 patients (20.1%) underwent TJA. For those 58, BMI at initial visit was 45.3 kg/m2 (IQR 43.7 to 47.2), and at surgery was 42.3 kg/m2 (IQR 38.1 to 46.5). Only 23 patients (39.7%) of those who had TJA successfully achieved BMI < 40 kg/m2 at surgery. CONCLUSION: Restricting TJA for morbidly obese patients does not incentivize weight loss prior to arthroplasty. Only 20.1% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and coordinated care are required to optimize patients prior to surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):28-32.

MIC mitigation in a 100 MW district heating peak load unit.

During inspection of AISI316 stainless steel plate heat exchangers in a district heating peak load unit, localised corrosion attacks along with indications of microbiological activity were found on the boiler side beneath patches of sturdy black deposits. Bacteria and sulphide were detected within black deposits. Thorough investigation of the boiler system revealed several incidents of localised corrosion on low alloy steel along with deposits of organic matter and bacteria primarily in places with stagnant water or places operating at a low flow rate. A relatively large amount of bacteria was detected within the system, primarily in deposits and around corrosion sites. The observations suggested the combination of deposits and bacterial activity, being the major reason for the observed corrosion. Prior to the investigation, the boiler system had operated with cat-/anion-exchanged, de-aerated water for 3 years, during which the water fulfilled strict chemical limits set to minimise corrosion. Based on these findings, the system has been modified in order to minimise the risk of microbiologically influenced corrosion and a monitoring program for fouling and corrosion has been established.

Monitoring and characterisation of bacteria in corroding district heating systems using fluorescence in situ hybridisation and microautoradiography.

Presence of biofilm and biocorrosion has been observed in Danish district heating (DH) systems despite very good water quality that was expected to prevent significant microbial growth. The microbiological water quality was investigated in order to identify the dominating bacterial groups on surfaces with corrosion problems. Water samples from 29 DH systems were investigated for the total number of bacteria and presence of sulphate reducing bacteria (SRBs). SRBs were found to be present in more than 80% of the DH systems. The microbial population in samples from 2 DH system (biofilm from a test coupon and an in situ sample from a heat exchanger) was investigated with fluorescence in situ hybridisation, and the results showed significant differences in population composition. Betaproteobacteria was the dominant population in both samples. SRBs were present in both samples but were most numerous in the biofilm from the test coupon. Examination of functional groups based on uptake of radiolabelled acetate (microautoradiography) showed presence of both aerobic and anaerobic bacteria despite the fact that oxygen is not anticipated in DH systems.

Affective correlates of trichotillomania.

Affective correlates of hair pulling were investigated in a sample of 44 participants diagnosed with trichotillomania (TM). Participants completed the Hair Pulling Survey on which they rated the intensity of ten different affective states across three different phases of hair pulling (before, during and after). Repeated measures analysis of variance was used to examine the change of emotional experience across the hair pulling cycle. Results indicated significant decreases in boredom, anxiety and tension, and significant increases in guilt relief, sadness and anger across time (p<0.005). The role of co-existent anxiety and mood disorders also was examined using repeated measures analysis of variance. Results of these analyses indicated that patients with and without co-existent disorders differed only on patterns of anger across time, and therefore do not support affective subtypes of TM patients based on co-existent diagnosis. Implications of these findings for conceptualization and treatment of TM are discussed.

Early failures in total knee arthroplasty.

Total knee arthroplasty is a predictable operation. Unfortunately, there is a subset of patients who do not do well and require revision surgery within the first 5 years. The purpose of the current study was to analyze the mechanisms of failure in patients who had revision surgery within 5 years of their index arthroplasty. Between 1986 and 1999, 440 patients with total knee arthroplasties were referred for revision surgery. An analysis of patients in whom the arthroplasties failed within 5 years of the index arthroplasty and the reasons for early failure were documented. Of the 440 patients who had revision surgery, 279 (63%) had revision surgery within 5 years of their index arthroplasty: 105 of the 279 patients with early failures (38%) had revision surgery because of infection; 74 (27%) had revision surgery because of instability; 37 (13%) had revision surgery because of failure of ingrowth of a porous-coated implant; 22 (8%) had revision surgery because of patellofemoral problems; and 21 (7%) had revision surgery because of wear or osteolysis. Only eight of the 279 patients with early failures (3%) had revision surgery because of aseptic loosening of a cemented implant. The remaining 12 patients had revision surgery because of miscellaneous problems. Host factors may prevent infection from ever being eradicated totally. The two other major patterns of failure in this series were failure of cementless fixation and instability. If all of the arthroplasties in the patients in this early failure group would have been cemented routinely and balanced carefully, the total number of early revisions would have decreased by approximately 40%, and the overall failures would have been reduced by 25%.

Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award.

Antibiotic laden spacer blocks frequently are used to treat an infected total knee arthroplasty. Static spacer blocks make exposure at reimplantation difficult secondary to quadriceps shortening. Unexpected bone loss attributable to migration of the spacer block also has been reported. To avoid these problems, a temporary articulating molded implant made of antibiotic cement was used in a consecutive series. The authors sought to determine whether its use would affect the reinfection rate, improve functional results, or prevent bone loss compared with static spacers. Twenty-five patients were treated with static nonarticulating spacers. Since 1996, 30 patients have been treated with tobramycin-laden articulating spacers. The knee arthroplasties in three patients treated with a static spacer became reinfected (12%). The knee arthroplasty in one patient with an articulating spacer became reinfected (7%). Fifteen of the 25 patients with static spacers had unexpected bone loss between stages. No appreciable bone loss could be measured in the patients who received articulating spacers. The average Hospital for Special Surgery score was 83 points in the patients with static spacers and 84 points for the patients with articulating spacers. Range of motion at final followup averaged 98 degrees in the patients who received static spacers and 105 degrees in the patients who received articulating spacers. Articulating spacers seem to facilitate reimplantation of infected total knee arthroplasty without additional risk of infection. Unexpected bone loss is no longer a concern with this two-stage technique. Articulating spacers offered no functional advantage over static spacers in this study group.

Alterations in intestinal structure, fat absorption and body weight after intestinal bypass for morbid obesity.

Eleven patients underwent jejunoileal bypass for morbid obesity. Serial intestinal biopsies were obtained prior to, and at timed intervals following, operation in both fasted and fat-fed states. Villus height increased asymptotically, reaching a plateau one year after operation, with an increase of 80 per cent in mean villus length. The postbypass body weight reached a plateau at 63.9 per cent of initial body weight and correlated linearly with villus height following an asymptotic curvilinear course. The time required to attain 90 per cent of total body weight loss was 15.9 months. A study of intestinal fat absorption at both the light microscopic and ultrastructural levels showed that the enlarged villi are lined along the entire villus by functionally mature epithelium capable of transporting lipid. Villus hypertrophy is an important mechanism in the plateauing of weight loss after jejunoileal bypass for morbid obesity.