Decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a mixed methods exploration of carer experience and level of burden.

PURPOSE: This study explores the experiences and sense of burden of family carers of survivors of malignant middle cerebral artery infarctions who had undergone decompressive hemicraniectomy. To date, there have been no studies examining carer outcomes among this unique population. This study, taken alongside an already published study of survivor outcomes, provides a more holistic picture with regard to sequelae within the sample. METHOD: Six family carers completed the Sense of Competence Questionnaire and the Hospital Anxiety and Depression Scale. These results were compared with existing normative data. Carers also consented to a semi-structured interview. Interview data were examined using thematic content analysis. Consistent with the mixed methods design, quantitative and qualitative findings were integrated for further analysis. RESULTS: While carers experienced many losses, their overall sense of burden was not outside 'Average' limits, nor did they experience clinically significant symptoms of depression. All carers identified methods of coping with the demands of caregiving. These included intrapersonal, interpersonal and practical strategies. All carers apart from one were able to identify areas of post-traumatic growth. CONCLUSION: Carers will benefit from information, support and care. In addition, problem solving skills are essential in managing the myriad difficulties that arise in the aftermath of stroke.

Long-term neuropsychological and psychosocial outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions.

PURPOSE: This study examines long-term neuropsychological and psychosocial outcomes of survivors of malignant middle cerebral artery infarction treated via decompressive hemicraniectomy. METHOD: A case series design facilitated a detailed analysis of the outcomes among five participants. Neuropsychological domains assessed included premorbid and current IQ, sustained, selective and divided attention, visual and auditory memory, executive functioning and visuo-spatial ability. Psychosocial domains assessed included self-rated depression, anxiety and quality of life. Participants and their main carer were asked about their retrospective view of surgery. RESULTS: All participants showed neuropsychological impairments in multiple cognitive domains, with preserved ability in others. Effects of laterality of brain function were evident in some domains. Clinically significant depression was evident in two participants. Overall quality of life was within average limits in three of four assessed participants. Four participants retrospectively considered surgery as having been a favourable course of action. CONCLUSION: While neuropsychological impairments are highly likely post-surgery, preserved abilities and social support may serve a protective function against depression and an unacceptably poor quality of life. Results do not support the suggestion that decompressive hemicraniectomy following malignant middle cerebral artery infarction necessarily leads to unacceptable neuropsychological or psychosocial outcomes. [ IMPLICATIONS FOR REHABILITATION: • Malignant middle cerebral artery infarction is a life threatening condition.• The neurosurgical procedure, "decompressive hemicraniectomy" has been shown to be life-saving among patients with this condition.• There is little known about the long-term neuropsychological and psychosocial outcomes following decompressive hemicraniectomy for malignant middle cerebral artery infarction.• This study concludes that neuropsychological impairments are highly probable post-surgery. However, preserved abilities and social support may serve a protective function against depression and an unacceptably poor quality of life.]

Fresh osteochondral allografts: results in the patellofemoral joint.

UNLABELLED: Twenty knees in 18 patients were treated (mean age, 42 years; range, 19-64 years) with fresh osteochondral allografting limited to the patellofemoral joint. The knees were analyzed retrospectively to determine the rate of successful outcomes. The trochlea and patella were treated in 12 patients and the patella was treated in eight patients. There were 11 women and seven men. The primary outcome measures were revision allografting, arthrodesis, or arthroplasty, and clinical scoring using a modified Merle D'Aubigné-Postel 18-point scale. Radiographs were available for 12 knees. There were five failures. For the remaining knees, the clinical scores increased from a mean of 11.7 points (range, 7-15 points) to 16.3 points (range, 12-18 points). Of the knees evaluated radiographically, four had no evidence of patellofemoral arthrosis, and six had only mild arthrosis. Fresh osteochondral allografting is a salvage procedure for the young, active patient with severe articular cartilage disease of the patellofemoral joint. The results of this procedure are comparable to results of described other techniques in the literature. If allograft incorporation does occur, the procedure is associated with improved pain, function, range of motion, and a low risk of progressive arthritis. LEVEL OF EVIDENCE: Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts.

We report on tibiotalar osteochondral shell allografts for post-traumatic ankle arthropathy in seven patients. Average follow-up was 148 months (range, 85 to 198). Patients were evaluated by a questionnaire, SF-12 survey, ankle score, physical exam and radiographs. The ankle score increased from 25 preoperatively to 43 at latest follow-up (maximum score 100). SF-12 scores increased from 30 to 38 (Physical Component) and 46 to 53 (Mental Component). The failure rate was 42%. Four of seven patients reported good or excellent results. Five patients stated they would undergo a similar procedure again. Complications included graft fragmentation, poor graft fit, graft subluxation, and non-union. Follow-up radiographs demonstrated joint space narrowing, osteophytes, and sclerosis, even in cases with excellent clinical status. Fresh osteochondral shell allografting may provide a viable alternative for the treatment of post-traumatic ankle arthrosis in selected individuals.

Shell osteochondral allografts of the knee: comparison of mr imaging findings and immunologic responses.

PURPOSE: To define the magnetic resonance (MR) imaging appearance of shell osteochondral allografts of the knee and compare the MR findings with antibody responses. MATERIALS AND METHODS: Thirty-six grafts were evaluated with a 1.5-T unit with T1-, intermediate-, and T2-weighted, and three-dimensional spoiled gradient-recalled MR imaging at 3, 6, 12, 24, and/or 36 months after surgery. Nineteen patients underwent imaging serially. Two osteoradiologists scored by consensus host marrow edema, thickness of graft-host interface, signal intensity of graft marrow, cyst formation, joint effusion, articular cartilage defects, and surface collapse. Patients were divided into antibody-positive (AP) (n = 11) and antibody-negative (AN) (n = 25) groups evenly distributed across the different time points on the basis of results of anti-human leukocyte antigen antibody screening. MR findings for the two groups were compared. RESULTS: AP patients demonstrated greater mean edema (P<.002), thicker interface (P<.03), and more abnormal graft marrow (P<.04) than AN patients, and they had a higher proportion of surface collapse (P<.03). CONCLUSION: Humoral immune responses were associated with more inflammation and less complete incorporation after allograft placement. MR imaging shows promise as a surrogate biomarker for success of shell osteochondral allograft implantation.

Polydioxanone biodegradable pins in the knee: MR imaging.

OBJECTIVE: Biodegradable solid implants have been developed as an alternative to metallic orthopedic fixation. In animal models, implants degrade within and are replaced by bone. This study documents the resorption of these devices in human patients with MR imaging. SUBJECTS AND METHODS: One hundred seventy-five 1.3-mm biodegradable pins made of polydioxanone were used to secure a total of 59 osteochondral allografts of the knee. Patients with the pins underwent scanning on a 1.5-T unit with 3.3- to 4-mm contiguous T1-weighted spin-echo (TR/TE, 600/15), fat-saturated proton density-weighted (3000/40), T2-weighted fast spin-echo (3000/63), and three-dimensional spoiled gradient-recalled (47/7; flip angle, 60 degrees ) sequences at 3, 6, 12, 24, or 36 months after surgery. Eighty-nine pins were imaged on multiple occasions. Two osteoradiologists interpreted the MR examinations. RESULTS: More than 80% of the pin channels were visible at 3 and at 6 months after surgery. By 24 months, only 20% of the pin channels were visible, with the remainder having been replaced by bone. At 3 months, nearly 40% of the pins were associated with adjacent marrow edema. Edema generally diminished, involving less than 20% of pins at later time points. Focal cartilage defects were evident at 32% of the pin insertion sites during the first 6 months, but these defects were present in only 4% of the insertion sites thereafter. CONCLUSION: Biodegradable polydioxanone pins usually resorb completely by 24 months. Marrow edema, presumably representing inflammation related to pin resorption, is infrequent and tends to resolve. Cartilage defects related to pin placement heal spontaneously.

Articular cartilage transplantation. Clinical results in the knee.

Between December 1983 and August 1991, 55 consecutive patients (55 knees) who underwent articular cartilage transplantation to their damaged knees were enrolled in the study. Average followup was 75 months (range, 11-147 months). Eight-two percent were younger than 45 years of age. Patients were evaluated through an 18-point scale, with 6 points each allocated to pain, range of motion, and function. An excellent knee was pain free, had full range of motion, and permitted unlimited activity. A good knee allowed full time employment and moderate activity. Eleven of 15 (73%) allografts transplanted 10 or more years ago were still good or excellent at the time of last followup. Overall, 45 of 55 (76%) knees that received the transplants were rated good or excellent. Specifically, 36 of 43 (84%) patients with unipolar transplants regained normal use of their resurfaced knee. The results after bipolar resurfacing were less encouraging, with only six of 12 (50%) knees rated good or excellent. The described technique of osteochondral shell allograft resurfacing of the knee capitalize on the different healing potentials of bone and cartilage by transplanting the viable articular cartilage organ in its entirety along with just enough of the underlying bone to allow for graft incorporation through creeping substitution. The results support the use of fresh osteochondral shell allograft transplantation for the treatment of large, full thickness articular cartilage defects to the medial or lateral femoral condyles and to the patella.

Osteochondral allograft transplantation.

Experience with fresh osteochondral allografting for cartilage defects in the knee now extends two decades. Clinical outcomes and basic scientific investigations have supported the theoretic basis for this procedure. At the University of California, San Diego, our experience has encouraged us to continue to offer this procedure as a primary treatment for both large and small articular cartilage defects in the young knee. The success rate of fresh osteochondral allografting, particularly in isolated femoral condylar defects, compares favorably with other presently available cartilage repair and resurfacing techniques. In our second hundred cases, which we are currently evaluating, failure of monopolar allografts has been exceedingly rare in short-term follow-up. Fresh osteochondral allografting also appears to be effective in treating larger osteochondral lesions, where there are few other attractive alternatives. Fresh osteochondral allografts can thus be used to treat a wide spectrum of articular pathology. Technical refinements, and improvement in our understanding of graft-host interaction, as well as chondrocyte biology, should continue to improve clinical results. Disadvantages of fresh osteochondral allografting include the relative paucity of donor tissue, complexities in procurement and handling, and the possibility of disease transmission through the transplantation of fresh tissue. At present, only institutions that have overcome these obstacles seem capable of routinely performing this type of articular cartilage transplantation. In the future, as tissue banking and cartilage storage technology advance, fresh allograft tissue may become more available, allowing more widespread use of fresh osteochondral allografting in the treatment of articular cartilage lesions.

Effect of tissue culture storage on the in vivo survival of canine osteochondral allografts.

In vitro studies in our laboratory have shown that the biomechanical and biochemical characteristics of osteochondral grafts can be preserved for as long as 28 days under tissue culture conditions. This study represents an attempt to extend these results to an in vivo model. In adult mongrel dogs, either an autograft, a fresh allograft, or a stored allograft was placed in a standardized defect on the weight-bearing surface of the medial femoral condyle. The stored grafts were kept at 4 degrees C in tissue culture medium for 14 days prior to implantation. The animals were killed at 12 weeks. Cartilage from the contralateral knee served as a control. The modulus and permeability of the cartilage were assessed with confined compression creep tests. The collagen and glycosaminoglycan contents were measured, and the cartilage was analyzed histologically with hematoxylin and eosin and safranin O stains. Grossly, the cartilage appeared viable at harvest. The histologic results were similar in the treatment groups, with the same spectrum of mild degenerative changes being noted in each group. The glycosaminoglycan content was significantly less in the autograft group than in its control group and than in the fresh allograft group. The glycosaminoglycan content did not differ significantly between fresh and stored allografts. The collagen content, modulus, and permeability did not differ either between experimental and control groups or between graft types. Our results support the conclusion that osteochondral allografts can be stored for as many as 14 days without significantly affecting the results of the procedure.

In vivo effect of pressurization of polymethyl methacrylate bone-cement. Biomechanical and histologic analysis.

Sixteen goats underwent total hip arthroplasty, half with pressurized and half with unpressurized bone-cement. The animals underwent hemiarthroplasty of the contralateral hip immediately prior to sacrifice 6 weeks later. Samples were tested for interface strength and evaluated histologically. Pressurization of polymethyl methylacrylate improves the strength of the bone-cement interface in vivo, as well as in vitro. There is a regional variation in the strength of the bone-cement interface both in vivo and in vitro. The regional variation in the in vivo model is at least in part due to a biologic effect. Membranes forming at the bone-cement interface are usually fibrous and incomplete, allowing direct cement-to-bone contact. Membranes appear to be involved in the remodeling of bone. Polymethyl methacrylate causes significant necrosis of the cortex, with ensuing resorption of the cortical bone. There is a small, statistically insignificant trend toward increased resorption and decreased bone formation with pressurized cement. The amount of necrosis appears to be similar with pressurized and nonpressurized cement. Bone remodels to fill defects in the cement mantle.

Chondral defects of the knee.

The surgical treatment of a young adult with a localized defect in the articular cartilage of the knee most commonly employs arthroscopic shaving and/or subchondral drilling. Fresh osteochondral allografting is an alternative that is being performed with increasing frequency. As of June 1993, fresh osteochondral allografts have been used in 90 knees in our institution. Thirty-eight of these knees have been evaluated two or more years postoperatively, and a successful result was obtained in 76%. If the lesion was confined to the medial condyle, the success rate was 86%, but when both reciprocal surfaces were replaced (bipolar) the success rate was 56%.

Fresh osteochondral allografting of the femoral condyle.

Fresh osteochondral shell allografting is conceived as an interim response to the localized loss of articular cartilage in young patients for whom there is no reasonable alternative after conservative procedures have failed. The concept is not new and has been investigated extensively in in vivo animal investigations. The functional and anatomic results of these studies, however, have been consistently unsatisfactory because of technical deficiencies and supposed immunogenic responses. The results of early clinical studies were variable, and despite more recent clinical work, the procedure has been considered at least investigational by some. The purpose of this study is to retrospectively review a series of patients treated with osteochondral allografting of the femoral condyle with particular emphasis on those done more than five years ago. No tissue-typing blood-group matching or gender distinction was made and immunosuppressant agents were not used. Size matching of the donor and recipient were essential to provide an orthotopic graft. Twelve knees were operated on more than five years ago. Of these twelve, three are not available for review. Nine knees have been observed for an average of 66 months and eight are rated good or excellent by a standardized rating scale. One knee rated poor seems to be the result of a technical deficiency. Since 1983, 37 fresh osteochondral allografts of the femoral condyle have been performed in 36 patients. Twenty-five of these have been performed in the last five years and the results to date are summarized.

The calcar femorale. An anatomic, radiologic, and surgical correlative study.

In order to define the anatomy of the calcar femorale, a radiologic and surgical study was done on ten paired cadaver femurs. After radiography and computed tomographic (CT) scans, the specimens were subjected to medullary reaming by an experienced orthopedist, simulating total hip arthroplasty procedures. The imaging studies were repeated and compared with the prereaming studies. The calcar femorale was dissected from surrounding medullary bone, and sections of this structure were examined histologically. The calcar femorale is a condensation of cancellous bone. It is not affected by the reaming procedure but may play a role in guiding the reamer. This structure is separate from the calcar area described in relation to bone resorption after hip arthroplasty.

Acetabular augmentation in primary and revision total hip arthroplasty with cementless prostheses.

Twenty-four consecutive cementless hip arthroplasties (13 autografts and 11 allografts) have been done in which large bone grafts were used to augment major acetabular deficiencies and have been followed for a minimum of 24 months with a mean of 34 and a maximum follow-up period of 55 months. The autograft augmentations were uniformly successful. Two fixation failures occurred in the allograft group. Considering the extreme deficiency in the acetabulae encountered and the absence of sufficient autograft material in this group of patients, the use of frozen allografts (although less successful in this series) seems justified. Graft resorption as determined by direct roentgenographic measurements was less than might be expected but may be a manifestation of the short-term follow-up period. Resorption, however, was greater in the allograft group and, when marked, was associated with fixation failure.

Resurfacing of the knee with fresh osteochondral allograft.

Fifty-nine fresh osteochondral allografts were consecutively transplanted into the knees of fifty-eight patients. The preoperative diagnoses were chondromalacia or degenerative arthritis of the patella, osteochondritis dissecans, a traumatic defect or osteonecrosis of the femoral condyle, a painful healed depressed fracture or traumatic defect of the tibial plateau, and unicompartmental traumatic arthritis of the knee. All of the patients had disabling pain after the failure of previous attempts to correct the problem surgically. Thirty-nine patients (forty knees) were available for follow-up at two to ten years after the allograft was transplanted. Nine transplants (22.5 per cent) failed and thirty-one (77.5 per cent) were successful. The result was rated excellent after thirteen of the successful transplants, good after fourteen, and fair after four. Transplantation of a fresh osteochondral allograft proved to be a satisfactory intermediate procedure for the treatment of the disabling conditions, except unicompartmental traumatic arthritis, in the young patients in this series. For the patients who had unicompartmental traumatic arthritis, the rate of success was only 30 per cent.

Intramedullary plugs in cemented hip arthroplasty.

The use of intramedullary plugs in cemented total joint arthroplasty is currently considered standard practice by most surgeons. In this in vitro study, the authors evaluated the holding power, migration, and leakage of four commonly used plug types--bone, acrylic bone cement, and two polymeric plugs from different manufacturers. Only acrylic bone cement plugs prevented distal leakage of cement and did not migrate under the influences of pressurized cement injection.

Sustained pressurization of polymethylmethacrylate: a comparison of low- and moderate-viscosity bone cements.

There is at present great uncertainty relating to the fixation of joint implants. The deficiencies of acrylic bone cement are well documented, but the limitations of cementless fixation are as yet imcompletely identified. The purpose of this study was to investigate the potential of sustained external pressurization to improve the mechanical characteristics of conventional acrylic bone cement. The effect of serially increasing sustained pressurization of two commerically available acrylic bone cements (Simplex-P and LVC) was evaluated in human cadaver femora. A new method for determination of the shear strength of the bone-cement interface in place of the traditional pushout tests was used. In this model, there was a significant increase in the bone-cement interfacial shear strength with increasing pressure, but no difference in the shear strength was found between the two cements. At all pressure levels, the shear strength of the cement was greater than that previously reported. Increased cement penetration into the cortical bone was demonstrated with increasing pressure and low-viscosity cement, but the extent of cement penetration did not correlate with the shear strength of the bone-cement interface.