A randomized comparison of transfusion triggers in elective orthopaedic surgery using leucocyte-depleted red blood cells.

OBJECTIVE: In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. STUDY DESIGN AND METHODS: A randomized, controlled study. A new uniform, restrictive transfusion policy was compared with standard care, which varied among the three participating hospitals. Only prestorage leucocyte-depleted RBC(s) were used. Primary end-point was RBC usage, related to length of hospital stay. Secondary end-points were Hb levels, mobilization delay and postoperative complications. RESULTS: Six hundred and three patients were evaluated. Adherence to the protocol was over 95%. Overall mean RBC usage was 0.78 U/patient in the new policy group and 0.86 U/patient in the standard care policy group (mean difference 0.08;95% CI [-0.3; 0.2]; P = 0.53). In two hospitals, the new transfusion policy resulted in a RBC reduction of 30% (0.58U RBC/patient) (P = 0.17) and 41% (0.29 U RBC/patient) (P = 0.05) respectively. In the third hospital, however, RBC usage increased by 39% (0.31 U RBC/patient) (P = 0.02) with the new policy, due to a more restrictive standard care policy in that hospital. Length of hospital stay was not influenced by either policy. CONCLUSIONS: Implementation of a uniform transfusion protocol for elective lower joint arthroplasty patients is feasible, but does not always lead to a RBC reduction. Length of hospital stay was not affected.

Only MR can safely exclude patients from arthroscopy.

OBJECTIVE: The aim of this study was to determine in patients with subacute knee complaints and normal standardized physical examination the fraction of magnetic resonance imaging (MRI) studies showing arthroscopically treatable intra-articular pathology. MATERIAL AND METHODS: There were 290 consecutive patients (between 16 and 45 years) with at least 4 weeks of knee complaints and low clinical suspicion of intra-articular pathology based on physical exam. Two hundred seventy-four patients were included. Sixteen patients with prior knee surgery, rheumatic arthritis, or severe osteoarthritis were excluded. MRI was used to assign patients to group 1 (treatable abnormalities) or group 2 (normal or no treatable findings), depending on whether MR demonstrated treatable pathology. Arthroscopy was performed in group 1 patients. If symptoms persisted for 3 months in group 2 patients, cross over to arthroscopy was allowed. RESULTS: MR showed treatable pathology in 73 patients (26.6%). Arthroscopy was performed in 64 patients of 73 patients (group 1). In 52 patients (81.3%, 95% confidence interval (CI) 71.4-91.1%), arthroscopy was therapeutic. Of the 13 arthroscopies (6.5%) in group 2, four were therapeutic (30.8%, 95% CI 1.7-59.8). The highest fraction of MR studies showing treatable pathology was found in males, aged over 30 years, with a history of effusion (54.5%, six of 11 patients). CONCLUSION: Authors believe that the negative predictive value of clinical assessment in patients with subacute knee complaints is too low to exclude these patients from MR. MR should at least be considered in male patients aged 30 years and over with a history of effusion.

Bone marrow edema-like lesions change in volume in the majority of patients with osteoarthritis; associations with clinical features.

It has been suggested that bone marrow edema-like (BME) lesions in the knee are associated with progression of osteoarthritis (OA). The purpose of our study in patients with OA was to evaluate prospectively changes of BME lesions over 2 years and their relationship with clinical features. Magnetic resonance (MR) images of the knee were obtained from 182 patients (20% male; aged 43-76 years; mean age 59 years) who had been diagnosed with familial symptomatic OA at multiple joint sites. MR images were made at baseline and at 2 years follow-up. BME lesions in 2 years were associated with clinical features assessed by Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scores. A total of 327 BME lesions were recorded. Total size of BME lesions changed in 90 patients (66%). Size of individual lesions changed in 147 foci (45%): new lesions appeared in 69 (21%), existing lesions disappeared in 32 (10%), increased in size in 26 (8%) and decreased in size in 20 (6%) lesions. Increase or decrease of BME lesions, over a 2-year time period, was not associated with severity of WOMAC scores. BME lesions fluctuated in the majority of patients with OA over a 2-year time period. These changes were not associated with severity of WOMAC scores at the study end point.

MR imaging: effectiveness and costs at triage of patients with nonacute knee symptoms.

PURPOSE: To prospectively evaluate the cost and effectiveness of magnetic resonance (MR) imaging performed to exclude the need for arthroscopy in patients with nonacute knee symptoms who are highly suspected clinically of having intraarticular knee abnormality. MATERIALS AND METHODS: The study was approved by the institutional review boards of three hospitals; informed patient consent was obtained. All 584 included patients (406 male, 178 female; mean age, 31.1 years+/-8.0 [standard deviation]) underwent MR imaging. Patients with an MR result positive for the diagnosis of intraarticular knee abnormality underwent arthroscopy (group A). Patients with a negative MR result were randomly assigned to undergo either conservative (group B) or arthroscopic (group C) treatment. Treatment was considered effective if the Noyes function score had increased 10% or more at 6 months. A cost analysis was performed from a societal perspective to compare the treatment strategy involving MR imaging with the strategy not involving MR imaging. RESULTS: Of the 584 patients, 294 (50.3%) were assigned to group A; 149 (25.5%), to group B; and 141 (24.1%), to group C. At 6 months, the number of patients effectively treated in group B (conservative treatment) was a mean of 5.1%+/-10.0 larger than the number of patients effectively treated in group C (arthroscopy). Owing to savings in productivity costs, total societal costs were lower with use of the strategy involving MR imaging by a mean of $153+/-488 (P=.54). CONCLUSION: MR imaging can be used without additional costs or disadvantageous effects on function to obviate arthroscopy in patients with nonacute knee symptoms who are highly suspected of having intraarticular knee abnormality.

Intracranial penetration of a halo pin causing an epileptic seizure.

A 71-year-old man with ankylosing spondylitis and an unstable fracture of the 6th and 7th cervical vertebrae was managed with a halo vest. Eight weeks following application the halo had shifted because of a loose pin. The patient's only complaint at the time was a headache but this was followed two days later by a seizure. An MR scan of the brain showed a swollen cortex under the right dorsal pin as a result of a perforation of the internal lamina by the pin. The halo was removed and anti-epileptic medication commenced. The patient had no further seizures.

Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial.

OBJECTIVE: To evaluate the effect of a brace intended to reduce load in patients with medial or lateral compartmental osteoarthritis (OA) and concurrent varus or valgus alignment, respectively. DESIGN: This multi-centre randomized controlled trial (performed 2001-2003) studies the additive effect of a brace intended to reduce load in conservative treatment of unicompartmental OA of the knee. SETTING: Orthopedic department of a university medical centre and of one general hospital. The follow-up was 12 months. PATIENTS: 117 patients with unicompartmental OA of the knee. Intervention group (n=60) comprising conservative treatment with additional brace treatment and a control group (n=57) comprising conservative treatment alone. PRIMARY OUTCOME MEASURES: Pain severity and knee function score. SECONDARY OUTCOME MEASURES: Walking distance and quality of life. ANALYSIS: Multiple linear regression models according to the intention-to-treat-principle were used to assess outcome differences for the entire group of patients. In addition, we performed explorative subgroup analyses on primary overall outcomes stratified for alignment, degree of OA, origin of OA, and age. RESULTS: Although the primary outcome measures were improved in the intervention group in comparison with the controls at each assessment point, the differences reached only borderline significance. The reported walking distances at 3 months, 12 months and overall were significantly longer in the brace group (P=0.03, P=0.04 and P=0.02, respectively). Subgroup analysis showed a better effect in the varus group, in patients with severe OA, in patients with secondary OA and in patients younger then 60 years. In total 25 patients in the brace group and 14 in the control group changed their initial treatment, mostly (74%) because of a lack of beneficial effect. CONCLUSIONS: The results indicate that a brace intended to reduce load shows small effects in patients with unicompartmental OA. However, many patients do not adhere in the long run to this kind of conservative treatment.

Colloid carcinoma arising in an anorectal fistula in Crohn's disease: a case report.

Carcinoma arising in a chronic anorectal fistula in Crohn's disease is rare, but the association has been reported in the literature. In most cases, it concerns a colloid carcinoma. Probably chronic irritation at either end of a fistula can trigger the degeneration of scar tissue into cancer. The diagnosis is difficult, due to lack of specificity of symptoms and signs, and is often delayed, resulting in a poor prognosis. A 70-year-old female, diagnosed with Crohn's disease at the age of 45, developed a pararectal colloid carcinoma in an anorectal fistula that had existed for years. She was treated with an abdominoperineal resection and adjuvant chemotherapy (5-fluorouracil and levofolinate) but died. A high index of suspicion and regular surveillance is recommended in chronic anorectal fistulas in Crohn's disease. In case of doubt, repeated biopsies should be performed to rule out malignancy.

[Rapidly destructive hip disease with resultant iliopectineal bursitis]. / Snel destructieve heupziekte met een ontstoken bursa iliopectinea als gevolg.

A man aged 72 years developed complete destruction of his right hip joint within 12 weeks: 'rapidly destructive hip disease' (RDHD). Analysis of weight loss also revealed iliopectineal bursitis. Nine months after total hip arthroplasty, the patient was free of complaints and the bursitis had disappeared. The cause of RDHD is unclear. Associations have been made with osteonecrosis, chondrocalcinosis and arthropathies of other joints. The destruction of the acetabulum and the femoral head can lead to hydrops in the hip joint and, via a communication between the joint and the iliopectineal bursa, to inflammation of the bursa. This combination of diagnoses has not been described before.

Comparative prospective trial of 3 intramedullary plugs in cemented total hip arthroplasty.

We assessed the occlusion and stability of 3 intramedullary plugs used to restrict the femoral canal before primary cemented arthroplasty. In a prospective, randomized trial the Biosem (SEM, Montrouge, France), Cemlock (Sulzer Orthopaedic Ltd, Baar, Switzerland), and Thackray (DePuy International Ltd, Leeds, England) plug were compared in 93 hip joints replaced by the Stanmore hip prosthesis. We considered a range of 1 cm on the postoperative radiograph a measuring fault. According to the definition, 43% (40/93) were not stable. The percentages of deficient plugs were: Biosem 78% (25/32), Cemlock 32% (9/28), and Thackray 18% (6/33). The differences found between the Biosem and Cemlock and between the Biosem and Thackray were significant. No significant effect was seen regarding the sizes of the plugs used. Comparison of the smaller sizes of the prosthesis versus the larger sizes showed a significant effect on the stability of the plugs.

Nerve lesions in proximal humeral fractures.

In the literature nerve injury is not frequently considered a problem in proximal humeral fractures. Only a few studies exist concerning traction injury of nerves in fractures of the proximal humerus after low-velocity trauma. Almost all of them are retrospective and did not use electromyography. Patients with identical fractures can show quite different outcomes, which vary between complete recovery and severely limited shoulder function. On the assumption that nerve lesions can play a role in the recovery of conservatively and operatively treated proximal humeral fractures, we started a prospective follow-up study with electromyographic investigation. For this study, 143 consecutive proximal humeral fractures due to low-velocity trauma were included. According to the Neer classification, 93 were nondisplaced and 50 were displaced fractures. Denervation on the electromyogram was found in 96 patients (67%). The nerves most frequently involved were the axillary nerve (83 [58%]) and the suprascapular nerve (69 [48%]). Frequently a combination of nerve lesions was seen. Nerve lesions were much more frequent in displaced fractures (82% [41/50]) than in nondisplaced fractures (59% [55/93]). Complicating nerve lesions in patients older than 20 years of age were seen in about the same percentage of patients per decade. Nerve injury and the corresponding loss of muscle strength recovered well in all patients; however, the duration of the recovery was prolonged in cases with nerve lesions. Restoration of the function of the shoulder was less favorable. It is important to realize that, in both conservative and operative treatment of proximal humeral fractures, a paresis due to nerve injury can affect the restoration of shoulder motions. An electromyogram can be useful in the investigation of nerve lesions, because detection only by clinical examination proved to be very difficult. Because of the favorable electrophysiological recovery, no indication for exploration of nerve lesions was present in this series of fractures due to low-velocity trauma.

Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: comparison with clinical neurological examination.

There is no consensus of opinion about the frequency of associated nerve lesions in anterior shoulder dislocations and fractures of the proximal humerus. We undertook a prospective study to assess the incidence, the severity of the nerve injury and the diagnostic value of electromyographic examination; 215 patients were included. We performed neurological examination and needle electromyography (EMG). Nerve injury was graded according to a denervation score at the EMG. EMG disorders were seen in 133 patients (62%). Testing of sensibility and clinical reflexes proved not to be a reliable indicator for EMG abnormalities. Detection of axonal lesions by grading muscle strength based on the MRC score after these shoulder traumas is difficult. The findings of this study imply that by clinical examination alone a large number of axonal lesions remain undetected.

The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study.

Opinion varies as to the incidence of nerve lesions in anterior dislocation of the shoulder after low-velocity trauma. Most studies are retrospective or do not use EMG. We have investigated the incidence and the clinical consequences of nerve lesions in a prospective study by clinical and electrophysiological examination. Axonal loss was seen in 48% of 77 patients. The axillary nerve was most frequently involved (42%). Although recovery as judged by EMG and muscle strength was almost complete, function of the shoulder was significantly impaired in patients with lesions of the axillary and suprascapular nerves. Unfavourable prognostic factors are increasing age and the presence of a haematoma. It is not necessary to carry out EMG routinely; an adequate programme of physiotherapy is important. In patients with a severe paresis, EMG is essential after three weeks.

Hepatoblastoma: actual therapeutic strategies. A case report.

Starting from a case report of a six-month-old boy with a hepatoblastoma, we discuss this topic. New virologic and cytogenetic findings in hepatoma are mentioned in the chapter "epidemiology". In "diagnosis" we focus on history, physical examination, echography, conventional RX, the role of CT-scan of abdomen and thorax, of fine needle aspiration, arteriography and magnetic resonance. In "therapy" we emphasize the new therapeutical means: chemotherapy, orthotopic liver transplantation, resection of pulmonary metastases, as well as radiotherapy and immunotargeting chemotherapy. We conclude that surgery still is the cornerstone of treatment, but the new therapeutical means create hopeful perspectives in outcome.

Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study.

The incidence of nerve injuries in primary shoulder dislocation and humeral neck fracture is uncertain. We made a prospective study of 101 patients, using clinical examination and extensive electrophysiological assessment when there was suspicion of nerve damage. We found electrophysiological evidence of nerve injury in 45%, most involving the axillary, suprascapular, radial and musculocutaneous nerves. There were significantly more nerve injuries in older patients and those with a haematoma. Most patients recovered partially or completely in less than four months, and only eight had persistent motor loss. Early diagnosis and physiotherapy are recommended.

Mechanisms of brachial plexus lesions.

The main causes of brachial plexus palsies are traction, due to extreme movements, and heavy impact. In downward traction of the arm and forcible widening of the shoulder-neck angle the lesion will occur in the upper roots and trunk. Forcible upward traction will cause avulsion of T1 and C8. The most violent trauma will result in a lesion at all levels. Rupture of the cords and/or individual infraclavicular nerves will be produced by traction and/or forcible widening of the scapulohumeral angle. Vascular structures are subjected to the same mechanism and injuries of these structures give information about the site and severity of nerve lesions; fractures of the skull, cervical spine, clavicle, first rib or arm yield further data on the mechanism of trauma that has produced the brachial plexus palsy. Heavy impact or crush lesions are caused by direct trauma to the (supra)clavicular region and are nearly always associated with fracture of the clavicle.

Operative management of lesions of the axillary nerve, isolated or combined with other nerve lesions.

Sixty-six surgically treated lesions of the axillary nerve were reviewed and 57 were followed up over 1 year. Patients were divided into 4 groups: isolated axillary nerve lesions (n = 23), axillary and suprascapular nerve lesions (n = 15), axillary and infraclavicular nerve/plexus lesions (n = 26), and axillary nerve lesions and lower root avulsions (n = 2). Of 34 patients operated upon within 6 months after the trauma, 24 (71%) recovered a force of M4 or M5. Of 17 patients operated upon within 1 year, 10 (59%) had M4 or M5. Of 6 patients operated upon after 1 year, only one had M4. Good shoulder function was only regained when the spinati muscles had recovered good force.

Traumatic disruption of the sacral root sheath.

An unusual case of sacral nerve root injury in a boy aged 6 years is described. Surgical intervention was not undertaken. Recovery of function was complete.