Arm versus forearm tourniquet for carpal tunnel decompression - Which is better? A randomized controlled trial.

UNLABELLED: Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used. There is little evidence to suggest benefit of one position over another. Our aim was to compare patient and surgeon experience of forearm and arm tourniquets. Following a power calculation, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomized to either an arm or a forearm tourniquet. Measurements of blood pressure, heart rate and pain were taken at 2.5 min intervals. The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet. There was no statistically significant inter-group difference in patient pain or physiological response, tourniquet time, bloodless field or length of procedure. The degree of obstruction caused by the tourniquet was significantly higher in the forearm group. LEVEL OF EVIDENCE: I. Prospective Randomized Controlled Trial.

Effects of limb immobilization on cytochrome c oxidase activity and GLUT4 and GLUT5 protein expression in human skeletal muscle.

1. We investigated the effects of limb immobilization (for 1 or 6 weeks) in a long leg cast after a closed tibial fracture (n = 11). Biopsies of vastus lateralis were taken on admission and after either 1 week (n = 5) or 6 weeks (n = 6) and analysed for muscle fibre type characteristics, cytochrome c oxidase activity and the abundance of GLUT4 and GLUT5 hexose transporters. 2. After 1 week of immobilization there was a significant decrease (8%) in the cross-sectional area of type I, but not type II, muscle fibers and in the protein-DNA ratio (16%) compared with the initial biopsy. Six weeks of immobilization led to further muscle atrophy compared with the initial biopsy and a further reduction in the cross-sectional area of both type I and II fibres (29% and 36% decrease respectively) and in the protein-DNA ratio (25%). No changes were observed in the free leg after 1 week. However, at th end of the 6 week study period, the cross-sectional area of boty type I and II fibres of the free leg were increased (7% and 5%) and there was significant increase in the protein-DNA ratio (14%), indicating a net increase in muscle protein content. 3. Assay for cytochrome c oxidase activity showed significant reduction after 1 (30%) or 6 weeks (36%) of immobilization, reflecting a reduced capacity for oxidative metabolism. No significant changes in activity were observed in muscle from the free leg after 1 or 6 weeks of study. 4. The concentrations of GLUT4 and GLUT5 protein were determined by Western blot analysis. Limb immobilization induced a marked (50%) reduction in muscle GLUT4 protein concentration after 1 week that persisted for 6 weeks. A transient but significant increase (approximately twofold) in GLUT4 concentration was detected in muscle from the free leg after 1 week, but this returned to pre-imobilization values at 6 week. Unlike GLUT4, no significant changes in the abundance of the GLUT5 protein were detected in either the immobilized or free leg at the end of the 1 or 6 week periods. 5. The present findings indicate that disuse rapidly induces a selective loss of activity and abundance of some non-myofibrillar proteins in humans. The decrease in GLUT4 protein abundance and cytochrome c oxidase activity during muscle disuse is consistent with a decreased capacity for glucose uptake and with a lower oxidative potential of inactive muscle. The lack of any major changes in GLUT5 protein abundance during limb immobilization indicates that the expression of some non-myofibrillar proteins is differentially regulated in response to muscle disuse.

A 5-10 year follow-up of the Sheehan total knee endoprosthesis in Tayside.

The Sheehan total knee endoprosthesis has been widely used since 1971. It takes the form of a semi-constrained hinge with intramedullary stems cemented into the femur and tibia for fixation. In Tayside the prosthesis has been in use since 1980. The clinical impression was that the prosthesis was not performing well and formal assessment of surviving prostheses was therefore carried out using the Hospital for Special Surgery (HSS) scoring system. Thirty-seven patients were available for follow-up, 15.6% of whom had good results while 40% had poor results according to this assessment. At review, 31% of patients had undergone revision surgery or were awaiting such surgery. This compares poorly with reported results of surface joint replacements. In the light of these results the authors feel that the Sheehan knee replacement is now obsolete.

Invasive pituitary adenoma presenting with nasal obstruction.

We report two cases of massive invasive pituitary adenoma with the unusual presentation of nasal obstruction. In both cases the diagnosis was only made when the obstructing tissue was removed. Cases reported previously have usually presented with severe focal neurological signs or a long history of neurological symptoms. These two cases are unusual in having minimal neurological deficits despite the extension of tumour into the nasopharynx and the middle and posterior cranial fossae. These extensions were well illustrated by computerised tomography. This unusual presentation is discussed with reference to the literature.