[The use of antibiotic prophylaxis prior to dental procedures for the prevention of prosthetic joint infection].

Prosthetic joint infection (PJI) is a severe illness which may cause pain and discomfort, may damage the quality of life and may even be life-threatening. A variety of studies have demonstrated the presence of bacteria in a small but potentially dangerous number of prosthetic joint infections that may have originated in the oral cavity. Some dental treatments such as calculus removal, extractions, dental implants placements etc. and daily oral hygiene routines such as tooth brushing may cause bacteremia. Recently the American Academy of Orthopaedic Surgeons (AAOS) published updated guidelines for antibiotic prophylaxis to prevent prosthetic joint infections. These guidelines suggest a direct and established connection between dental treatments and prosthetic joint infections, and expand the criteria to prescribe antibiotic prophylaxis prior to dental procedures associated with bacteremia. The purpose of this review is to introduce these new guidelines, and to review the literature regarding the relationship between dental care and prosthetic joint infections.

[Injury from fireworks and firecrackers during holidays].

BACKGROUND: Every year during the holidays of the Arab and Druze population, and especially during Id el-Adha, scores of injured from firecrackers, crackers, skyrockets and other homemade explosive devices arrive at the Western Galilee Hospital. Similar casualties present during the Jewish Purim Festival. OBJECTIVES: To characterize the population of the injured and to analyze various aspects of this kind of accidents, in order to reduce injury and minimize disability. METHODS: A retrospective survey of records of all injured from firecrackers and similar devices during holidays that arrived at our hospital between 1999 and 2003 was conducted. Between 2001 and 2002 the trauma team, in cooperation with the local leadership, directed an education and information campaign in the community, in an attempt to reduce these injuries. RESULTS: During the study period, a decrease in the rate of injury was observed, which in the year 2003, reached a level of 50% of the 1999 figures. Of the injured, 53% were children (< or = 15 years old), 93% were Arab or Druze, and 93% were males. The rate of injuries from fireworks in 2003 was significantly lower than the mean rate of the years 1999, 2001, 2002 (p=0.045). The major cause of injury was firecrackers (67%) followed by fireworks (21%). Major injuries were to the extremities (58%), followed by facial and eye trauma (24%) and burns (11%). Of the casualties, 54% were lightly injured, 46% were hospitalized, 24% required surgical intervention and 7% lost fingers. Two individuals lost eyesight in one eye, but no fatalities occurred. CONCLUSIONS: The reduced rate of injury from fireworks and similar devices can be attributed to two major reasons: intervention by the trauma team and enforcement by the police and the Ministry of Trade and Industry. We recommend conducting a combined campaign of education and parental guidance with the involvement of community leaders and local media, and to increase law-enforcement. The organization of central firework displays in each community during this holiday should be considered.

Cytological diagnosis of primary leiomyosarcoma of bone: case report.

We report on a case of primary leiomyosarcoma of the bone in a 77-yr-old man. The patient presented with a painful, enlarging mass in the left shoulder of 6 mo duration. Radiography and computed tomography (CT) revealed a large destructive intramedullary lesion of the proximal humerus, with massive extension into the surrounding soft tissues. CT-guided fine-needle aspiration biopsies (FNAB) of both the bony and soft-tissue lesions were performed. Cytological examination showed a neoplastic process composed of spindle cells mixed with pleomorphic cells. The smooth muscle origin of the neoplastic cells was confirmed by immunocytochemical analysis. We describe the cytological features of this rare primary tumor of bone, and consider the differential diagnosis of spindle-cell neoplasms.

A comparison of minidose lidocaine-fentanyl and conventional-dose lidocaine spinal anesthesia.

The syndrome of transient neurologic symptoms (TNS) after spinal lidocaine has been presumed to be a manifestation of local anesthetic neurotoxicity. Although TNS is not associated with either lidocaine concentration or dose, its incidence has never been examined with very small doses of spinal lidocaine. One hundred ten adult ASA physical status I and II patients presenting for arthroscopic surgery of the knee were randomly assigned to receive spinal anesthesia with either 1% hypobaric lidocaine 50 mg (Group L50) or 1% hypobaric lidocaine 20 mg + 25 microg fentanyl (Group L20/F25). Hemodynamic data, block height and regression, and time to first micturition and discharge were recorded. Follow-up phone calls were made by a blinded researcher at 48-72 h using a standardized questionnaire. Both groups had a median peak cephalad block level of T10. Lidocaine 50 mg was associated with a greater decrease in systolic blood pressure and a greater need for ephedrine. Time until block regression to the S2 dermatome (80 vs. 110 min) and outpatient time to void (130 vs 162 min) and discharge (145 vs. 180 min) were faster in the L20/F25 group. Complaints of TNS were found in 32.7% of the patients in the L50 group and in 3.6% of the patients in the L20/F25 group. We conclude that spinal anesthesia with lidocaine 20 mg + fentanyl 25 microg provided adequate anesthesia with greater hemodynamic stability and faster recovery than spinal anesthesia with lidocaine 50 mg. The incidence of TNS after spinal lidocaine 20 mg + fentanyl 25 microg was significantly less than that after spinal lidocaine 50 mg.

Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged.

BACKGROUND: Spinal anesthesia for surgical repair of hip fracture in the elderly is associated with a high incidence of hypotension. The synergism between intrathecal opioids and local anesthetics may make it possible to achieve reliable spinal anesthesia with minimal hypotension using a minidose of local anesthetic. METHODS: Twenty patients aged > or = 70 yr undergoing surgical repair of hip fracture were randomized into two groups of 10 patients each. Group A received a spinal anesthetic of bupivacaine 4 mg plus fentanyl 20 microg, and group B received 10 mg bupivacaine. Hypotension was defined as a systolic pressure of < 90 mmHg or a 25% decrease in mean arterial pressure from baseline. Hypotension was treated with intravenous ephedrine boluses 5-10 mg up to a maximum 50 mg, and thereafter by phenylephrine boluses of 100-200 microg. RESULTS: All patients had satisfactory anesthesia. One of 10 patients in group A required ephedrine, a single dose of 5 mg. Nine of 10 patients in group B required vasopressor support of blood pressure. Group B patients required an average of 35 mg ephedrine, and two patients required phenylephrine. The lowest recorded systolic, diastolic, and mean blood pressures as fractions of the baseline pressures were, respectively, 81%, 84%, and 85% versus 64%, 69%, and 64% for group A versus group B. CONCLUSIONS: A "minidose" of 4 mg bupivacaine in combination with 20 microg fentanyl provides spinal anesthesia for surgical repair of hip fracture in the elderly. The minidose combination caused dramatically less hypotension than 10 mg bupivacaine and nearly eliminated the need for vasopressor support of blood pressure.

Anterior interosseous nerve palsy associated with Galeazzi fracture.

Galeazzi fracture is more common in adults than in children. Associated neurologic deficits are rare and easily missed at the first clinical examination. The authors describe a case of anterior interosseous nerve palsy after closed Galeazzi fracture. Conservative treatment resulted in complete return of normal nerve function, suggesting that this is a neurapraxia type of injury.

Muscle recovery after immobilisation by external fixation.

We immobilised the right hindlimbs of six-month-old female Wistar rats for four weeks using a biplanar external fixation bridging the knee. The untreated left limbs served as a control group. An additional group of rats was allowed to recover for four weeks after removal of the frame. Immobilisation caused reduction in the wet weights of approximately 50% in the gastrocnemius, quadriceps, soleus and plantaris muscles; this was not restored completely after remobilisation. There was an increase in the activity of acid phosphatase of approximately 85% in the gastrocnemius and quadriceps muscles whereas that of creatine phosphokinase was reduced by about 40%. These values returned to nearly normal after remobilisation. Histological and ultrastructural examination showed a marked myopathy of the gastrocnemius muscle after immobilisation although the morphology was largely restored after remobilisation. We conclude that after four weeks of remobilisation, hind-limb muscles do not return to preimmobilisation weights, although biochemical activities and ultrastructural appearance are largely restored.

Intraarticular fentanyl compared with morphine for pain relief following arthroscopic knee surgery.

PURPOSE: To compare the analgesia produced by comparable doses of intra-articular (IA) morphine and fentanyl. METHODS: Sixty-nine healthy patients undergoing arthroscopic surgery received a standardized general anesthetic of 4 mg x kg(-1) thiopental and 2 microg x kg(-1) fentanyl followed by 2 mg x kg(-1) succinylcholine prior to tracheal intubation and controlled ventilation. Maintenance of anesthesia was achieved with N2O/O2 and isoflurane. At the conclusion of surgery intra-articular injection was: Group I (n=23) 50 microg fentanyl in 20 ml saline; Group II (n=24) 3 mg morphine in 20 ml saline; Group III (n=22) 20 ml saline. Pain scores at rest using a visual analogue scale were recorded by a separate blinded observer at one, two, four, and eight hours postoperatively. RESULTS: Pain scores at one, two, four, and eight hours were 36, 26.3, 20.9, and 12.8 vs 35.8, 33.8, 28.8, and 21.9 vs 70.5, 57.7, 58.4, and 53.6 for the IA-fentanyl, IA-morphine, and control groups respectively. Pain scores were greater at all times for Group III. Pain scores for Groups I and II were similar at one hour, but thereafter were less (P < 0.001) for the IA-fentanyl group. CONCLUSION: Better postoperative analgesia was achieved with 50 microg intraarticular fentanyl than with 3 mg intraarticular morphine.

[Ilizarov reconstructive surgery--a solution for complex problems of the musculoskeletal system].

The Ilizarov technique is an important modality of reconstructive surgery for limb deformities, such as malunion and nonunion of fractures, persistent osteomyelitis, and bone loss following complex limb injuries, as well as in limb-lengthening procedures. It has received wide recognition in the Western world over the past decade. In MEDLINE we found 537 articles published between 1971-1995 that describe the use of this technique. Of these, only 18 were published between 1971-1975, while 261 were published between 1991-1995. The present paper describes the developments and updates in this method, as a result of the large experience gained by the authors in a number of centers in Israel using this technique. The Ilizarov apparatus is a circular frame that allows accurate control, much more than any other external fixator, during correction of limb deformities and limb-lengthening. It is minimally invasive, and open techniques and use of internal hardware and bone grafts are not needed. Based on our experience, we suggest that this method requires careful preoperative planning and meticulous surgical technique. More important, cooperation between surgeon and patient throughout the lengthy treatment is a prerequisite to ensure complete success, even in the most complicated cases.

[Nerve palsies in a soldier with penetrating injuries following prolonged use of limb tourniquets].

Nerve paralysis following the use of tourniquets, regular or pneumatic, for limb surgery is rare. We describe a 19-year-old male soldier who had tourniquets applied for 3 1/4 hours to his arm and both legs due to penetrating injuries. As a result, he suffered palsy of the radial nerve and both common peroneal nerves. Nerve palsy in such cases has not been described in the literature. It is not clear whether the cause is direct mechanical pressure on the nerve, nerve ischemia, or a combination of both. We recommend that tourniquets should not be used continuously for more than 2 hours. If evacuation of the injured is delayed, the medical team should consider loosening tourniquets for short intervals or changing for a pressure bandage. This is providing the patient's condition is stable and bleeding does not start again on release of the tourniquet.

Hand infections due to non-cholera Vibrio after injuries from St Peter's fish (Tilapia zillii).

We report 49 patients with a wide variety of hand infections, which developed after injuries from St Peter's fish (Tilapia zillii). Twenty-eight of 36 patients who had been operated on had non-cholera Vibrio infections, all identified as Vibrio vulnificus. The course in these patients was characterized by rapid spread of the infection with progressive necrosis of the tendon sheath, subcutaneous tissues and the skin. Two of them required amputations but the others had satisfactory functional results. Thirteen other patients were managed nonoperatively with intravenous antibiotics and all of them recovered completely.

Complete displacement of the femoral stem during dislocation of a THR.

We report an unusual complication of late dislocation of a total hip replacement. The femoral stem had completely migrated from the shaft. The insertion of a new long-stem prosthesis was successful.

[Conservative therapy in carpal tunnel syndrome].

A prospective study was designed to determine which patients with carpal tunnel would respond to conservative therapy (splinting and local injection of corticosteroids). The study included 50 hands of 34 patients, aged 25-80 years, with a mean follow-up of 18 months. Conservative therapy was effective in 82% of hands after 8 weeks, but symptoms subsequently recurred, so that by the end of a year only 20% remained asymptomatic. Failure of conservative therapy was predicted by long duration of symptoms, older age, permanent paresthesia, 2-point discrimination threshold above 6 mm, positive Phalen test within 30 seconds, and long motor and sensory distal latency.

[Impingement syndrome following direct injuries of the shoulder joint].

Impingement is the most common cause of pain and limitation of movement in the shoulder, with painful arc syndrome its major clinical sign. It usually becomes manifest at between 70 degrees-120 degrees of abduction, but in severe cases, this may be reduced to only 50 degrees-70 degrees. We studied 22 patients who had developed shoulder impingement following direct injuries and who had been treated by anterior acromioplasty and decompression, with an average follow-up of 32 months. 5 had sustained fractures of the greater tuberosity of the humerus at the time of injury, 14 had tears of the rotator cuff of various sizes (1 in both shoulders) and 3 had developed fibrotic scars of the subacromial bursa. Excellent or good results were achieved in 86.6%. Healing time was shorter, and there was return of full range of shoulder movement in those with subacromial scars, undisplaced fractures of the greater tuberosity, or those with a small tear of the rotator cuff. Recovery took longer in those with larger tears of the rotator cuff and in those with displaced fractures of the greater tuberosity. Recovery time was proportional to the size of the rotator cuff tear. It is concluded that direct trauma to the shoulder bears a direct relationship to the development of impingement syndrome, and that at surgery a concomitant tear in the rotator cuff is seen more than 2/3. Because of the high rate of success in surgical treatment of this syndrome, operation is indicated when a few months of physical therapy and analgesics fail to provide relief. In the presence of fractures, decompression surgery should be postponed until the fracture has united.

Musculoskeletal manifestations of Crohn's disease.

The prevalence of musculoskeletal system complaint and involvement in a group of 54 Crohn's disease patients, with a follow-up of 2 to 40 years, was studied and compared to that of a control group of patients with a similar distribution of sex and age. Twenty-four (44%) with Crohn's disease complained of arthralgia in various joints, but only 7.4% had objective findings compatible with joint pathology such as swelling, tenderness, and decreased range of motion. None of them had any serological or radiological evidences of joint damage. No significant correlation was found between patients' complaints/physical signs and age, sex, duration, or severity of Crohn's disease or mode of medical or surgical treatment. In the control group, 46% complained of arthralgia in various joint. The differences in the percentages of arthralgia between the two groups was not significant, although they differed in location of the affected joint. In the Crohn's disease group, a significantly higher proportion of knee, hip, and wrist involvement was observed, while backache was very common in the control group. It is suggested that arthritis in patients with Crohn's disease is an uncommon finding and that arthralgia is just as prevalent as in a matched control group. The pathogenesis of arthralgia in such a condition may be caused by soft tissue involvement.