The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics.

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.

Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency.

We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency. Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4 degrees and mean abduction improved by 35 degrees . There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications. The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss.

Pulmonary function studies in healthy non-smoking adults in Sri Aurobindo Ashram, Pondicherry.

BACKGROUND & OBJECTIVES: Pulmonary functions are used for diagnosis, assessment and clinical management of breathlessness, and, as epidemiological and research tools. In India the wide range of geographical and climatic conditions is associated with regional differences in lung functions. Most of the studies have restricted themselves to specific regions/ethnicities and a relatively short age span of 15-40 yr. The purpose of the present study is to fill these two lacunae by studying the pulmonary functions of the inmates (17-70 yr and of different ethnicities) of Sri Aurobindo Ashram, Pondicherry. METHODS: A total of 397 non-smoking, healthy individuals aged 17 to 70 yr (195 men, 202 women) were investigated. The parameters measured included forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1, FEV1%), peak expiratory flow rate (PEF) and mean expiratory flow rate (MEF). The standing height and weight were also recorded. RESULTS: In both men and women, age showed significant negative correlations with all spirometric functions, the height showed significant positive correlations with all pulmonary function test (PFT) parameters except FEV1 per cent while the weight did not show any significant correlation with any of the parameters except PEF. Men had significantly (P < 0.001) higher values than those of women for all parameters except FEV1 per cent. Prediction equations for all PFT parameters based on the age and height were derived for men and women. INTERPRETATION & CONCLUSION: The ventilatory norms of both men and women based on age and height appear reliable for the FVC and FEV1. They can therefore be used to derive the normal values for healthy, non-smoking Indian adults between 17 and 70 yr. The coefficient for age obtained from the regression equations for FVC were found to be consistently smaller than those of others indicating that in the Ashram environment, age seems to have a lesser negative influence on pulmonary functions.

Oxygen consumption, blood lactate and inter-individual variation in the gulf killifish, Fundulus grandis, during hypoxia and recovery.

Rates of oxygen consumption (M(O(2))) for Fundulus grandis, the gulf killifish, were measured in air-saturated water, at four progressively lower levels of oxygen and upon normoxic recovery. The pattern of M(O(2)) versus oxygen partial pressure (P(w)O(2)) was that of an oxygen regulator, with a critical oxygen pressure (P(c)) of 34 torr (1 torr=133.3 Pa). Below this value, M(O(2)) decreased and the concentration of blood lactate increased, indicating anaerobic metabolism during hypoxia. Recovery was characterized by elevated M(O(2)) compared to the initial normoxic exposure, coupled with the rapid clearance of blood lactate. Variation in M(O(2)) among the individual fish was appreciable and, in general, it was greater at higher levels of P(w)O(2). This inter-individual variation was significantly larger than the variation between replicate measures of M(O(2)) for a given individual, i.e. it cannot be attributed solely to random error. Furthermore, values for M(O(2)) during normoxia were found to be repeatable when the same fish were used in multiple experimental trials. The observation of significant, repeatable inter-individual variation in M(O(2)) suggests that such variation is a real and potentially important feature of fish metabolism.

Delayed presentation: dislocation of the proximal tibiofibular joint after knee dislocation.

Attention is brought to a unique case of an anterior dislocation of the proximal tibiofibular joint detected 1 month following closed reduction of a posterior knee dislocation. Open reduction and internal fixation were necessary to achieve a stable proximal tibiofibular joint. Additional attention should be paid to the proximal tibiofibular joint when evaluating acute or chronic knee dislocation.

Rapid detection of Pneumocystis carinii using a direct fluorescent monoclonal antibody stain.

A collaborative study was undertaken at two institutions to assess the performance of a direct fluorescent-antibody stain for the detection of Pneumocystis carinii in respiratory specimens from patients with known or suspected human immunodeficiency virus type 1 infections. A total of 163 specimens (125 induced sputa, 37 bronchoalveolar lavage fluids, and 1 tracheal aspirate) from 124 patients were examined by using modified Giemsa (Diff-Quik; Baxter American Scientific Products, Chicago, Ill.) and direct fluorescent-antibody stains. A total of 73 specimens contained P. carinii, which was detected in 66 (92%) of the specimens by using the modified Giemsa and in 71 (97%) of the specimens by using the fluorescent-antibody stain. One bronchoalveolar lavage fluid specimen in which P. carinii was detected only with the fluorescent-antibody stain was determined to be a false-positive based on subsequent clinical evaluation of the patient. Although the overall time for processing and examining specimens stained with either stain was not significantly different for those specimens containing P. carinii, considerably less time was required for microscopic examination of those fluorescent-antibody-stained specimens lacking P. carinii.

The production in culture of metalloproteinases and an inhibitor by joint tissues from normal rabbits, and from rabbits with a model arthritis. II. Articular cartilage.

During the development of proliferative arthritis in the knee joints of rabbits, there was a large increase in the ability of articular cartilage explants to produce latent collagenase in culture. In parallel, the normally high levels of collagenase inhibitor produced by cartilage in culture fell, but active collagenase was never detectable. Characterisation of the collagenase and other proteinase activities produced by rabbit articular cartilage in culture showed that two activities could be separated by gel filtration, one with activities on gelatin and cartilage proteoglycan and the other degrading collage. Under the conditions employed in this paper no resolution of the gelatin and proteoglycan activities could be achieved. All the activities were in a latent form, activated by 4-aminophenylmercuric acetate (APMA), and inhibited by 1,10-phenanthroline or EDTA, but not by di-isopropylfluorophosphate (DFP), indicating that they are metalloproteinases. Characterization of the collagenase inhibitor showed a single peak of activity of apparent molecular weight of 28,000 on gel filtration. The inhibitor was sensitive to APMA and also inhibited other rabbit metalloproteinases, analogous to the system described for rabbit bone. The physiological significance of the synthesis by articular cartilage of proteinases that destroy connective tissue macromolecules and the presence of an enzyme-inhibitor control system is discussed.