Complications after concomitant bilateral total knee arthroplasty in elderly patients.

OBJECTIVE: To determine the risks associated with performance of bilateral total knee arthroplasty (TKA) in elderly patients. MATERIAL AND METHODS: Ninety-eight patients with osteoarthritis who were 80 years of age or older and underwent concomitant cemented bilateral TKA were matched (on the basis of gender, surgeon, year of surgical treatment, age, and diagnosis) with 98 patients who underwent cemented unilateral TKA to compare the number and types of complications in these two groups. The groups did not differ in the number and type or severity of premorbid medical conditions, anesthetic risk, and type of anesthesia. RESULTS: One hundred nineteen postoperative complications occurred in 63 patients in the bilateral TKA group; in contrast, 72 complications occurred in 49 patients in the unilateral TKA group. The difference between the two groups in the total number of complications was significant. Specifically, significant differences between the two groups were noted in the occurrence of cardiovascular and neurologic complications. On paired analysis, congestive heart failure and acute delirium were found to be significantly more frequent in the bilateral TKA group than in the unilateral TKA group. We noted a trend toward an increased mortality rate in the bilateral group (four patients) versus the unilateral group (no deaths). CONCLUSION: Patients 80 years of age or older who undergo concomitant bilateral TKA are at increased risk for cardiovascular and neurologic complications during the postoperative period in comparison with matched patients who undergo unilateral TKA.

Corrective osteotomy for scaphoid malunion: technique and long-term follow-up evaluation.

Five patients with dorsal intercalated segment instability underwent corrective osteotomy for symptomatic scaphoid malunion. Follow-up examination at an average of nearly 9 years after the procedure (range, 1.5-19 years) revealed that all had improvement in range of motion (ROM). Total active ROM improved from a mean of 127 degrees (range, 95 degrees-165 degrees) to a mean of 156 degrees (range, 95 degrees-214 degrees). Grip strength increased from a mean of 16 kg (range, 14-35 kg) to a mean of 32 kg (range, 24-48 kg). The wrist score improved from an average of 19 to 75. The preoperative intrascaphoid and carpal malalignments were reduced, as demonstrated by trispiral tomography. Symptomatically, all patients reported improvement. All osteotomies healed within 5.5 months of the procedure. No case of avascular necrosis was noted. Mild radioscaphoid arthrosis is apparent in four patients and a preexisting midcarpal arthrosis persists in one patient. Corrective osteotomy for scaphoid malunion may have a role in the prevention or slowing of the onset of premature arthritis in young patients with high functional demands. A technique is described.

Neurologic complications after total shoulder arthroplasty.

Three hundred sixty-eight patients underwent 417 total shoulder arthroplasties between 1975 and 1989. Seventeen patients with 18 operated shoulders had a neurologic deficit after surgery. Osteoarthritis and rheumatoid arthritis were the most common diagnoses. Twelve patients (13 shoulders) had neurologic deficits localized to the brachial plexus; the upper and middle trunks were most commonly affected. Three patients had idiopathic brachial plexopathy. One patient had an exacerbation of preexisting dysesthesias in the lower trunk/medial cord distribution. Another patient had a median neuropathy at the wrist. Four patients had lesions that interfered significantly with shoulder rehabilitation and general activity; six had lesions that temporarily interfered with their scheduled rehabilitation program. All but two of these patients were monitored to a point of maximum improvement. Neurologic recovery at 1 year was graded as good in 11 shoulders and fair in five shoulders. The long deltopectoral approach leaving the deltoid attached to the clavicle and acromion was found to be significant in the development of a postoperative neurologic complication (p = 0.003). Use of methotrexate was also significant (p < 0.0001). A correlation was found between operative time and postarthroplasty neurologic complication (p = 0.02), with shorter operative times being associated with more neurologic complications. No other statistically significant risk factors were identified. In most cases the presumed mechanism of injury was traction on the plexus occurring during the operation. In most cases the prognosis for neurologic recovery was good. In this series neurologic injury after total shoulder arthroplasty did not interfere with the long-term outcome of the arthroplasty itself.

Measurement of occult upper gastrointestinal tract blood loss: a direct comparison of radiochromium and haem-porphyrin assay techniques.

Faecal haem-porphyrin assay by the HemoQuant method has many practical advantages over the well-validated, radiochromium (51Cr-tagged red cell) method for measuring gastrointestinal blood loss. Because haem may be absorbed but the chronic ion is not, the two measures were directly compared in low-grade bleeding from the proximal gastrointestinal tract. Blood loss was measured by both methods simultaneously in 40 patients with osteoarthritis before and during medication with aspirin preparations. Mean (geometric) daily blood loss before aspirin usage measured 0.60 mL radiochromium (range 0.13-1.62) and 0.47 mL (0.14-1.40) by HemoQuant (P = 0.042). On aspirin, bleeding rose to 1.57 mL/day (0.43-4.85) by radiochromium and to 0.72 mL/day (0.23-3.0) by HemoQuant (P < 0.0001). The two measures correlated well, r = 0.847 (P << 0.0001), but the regression coefficient was 0.417, reflecting the lower estimates of bleeding by HemoQuant. In four normal subjects who ingested 51Cr-labelled red cells (26-41 mL) over 3 days, recovery of 51Cr was complete (103 +/- 2%, +/- s.e.), but recovery of haem-porphyrins was only 63 +/- 13% (P = 0.01), presumably because of absorption of haem. Although faecal haem-porphyrin assay is of considerable clinical utility, it is a quantitative index rather than an absolute measure when low amounts of bleeding originate from the proximal gastrointestinal tract.

A pair of monozygotic twins who are concordant for myasthenia gravis but became discordant for systemic lupus erythematosus post-thymectomy.

We describe a pair of monozygotic twins who are concordant for myasthenia gravis but discordant for systemic lupus erythematosus (SLE). SLE developed in twin 1 18 years post-thymectomy and has been characterized by recurrent transverse myelitis and optic neuritis. Twin 2 remains well post-thymectomy, except for a skin rash and persistent leukopenia. Both twins have developed autoimmune thyroid disease. We review genetic and environmental factors of importance in the pathogenesis of SLE and discuss the possible role of thymectomy in the etiology of the disease.

Mechanical measures in the prophylaxis of postoperative thromboembolism in total knee arthroplasty.

Total knee arthroplasty patients are at high risk for deep venous thrombosis and pulmonary embolism. Prophylaxis against deep venous thrombosis and pulmonary embolism in these patients seems mandatory. Pharmacologic agents such as dextran 40, aspirin, and warfarin are effective but may be associated with significant complications such as drug reaction, bleeding, hematoma, and hemarthrosis. Heparin was not effective and was associated with significant bleeding complications. Mechanical methods such as continuous passive motion and sequential pneumatic compression stockings were without complications and seemed equal to or more effective than pharmacologic agents. Adding warfarin to mechanical methods did not seem to augment the antithromboembolic effect of the mechanical methods.

Gastrointestinal blood loss from a new buffered aspirin (Ostoprin): measurement by radiochromium and Hemoquant techniques.

Occult gastrointestinal blood loss induced by a new buffered aspirin preparation (Ostoprin, 4.0 g per day) was compared with that from an enteric-coated aspirin (Ecotrin, 3.9 g per day) in 40 patients with osteoarthritis. Blood loss was measured by the radiochromium method and compared with the HemoQuant assay of fecal heme and heme-derived porphyrins. By radiochromium, mean daily blood loss during the first week of treatment with Ostoprin increased 1.6 ml above basal compared to 0.8 ml above basal with Ecotrin (p = 0.06). When aspirin was ceased, blood loss returned more rapidly towards normal in the Ostoprin group (p less than 0.01). By HemoQuant, mean fecal hemeporphyrin excretion rose 0.63 mg hemoglobin equivalent per g feces during the first week of treatment by Ostoprin compared with 0.40 mg/g for Ecotrin (p = 0.06). There was a significant linear relationship between the two methods (r = 0.65, p less than 0.001). Serum salicylate levels achieved with both preparations were almost identical and encompassed the therapeutic range. HemoQuant is sufficiently sensitive to detect low-level aspirin-induced bleeding. Ostoprin appears to be a safe alternative to Ecotrin and has similar bioavailability.

Disabling neurological complications of amiodarone.

Five patients developed neurological symptoms during treatment with amiodarone for intervals ranging between five and 40 months. In each case the daily maintenance dose did not exceed 600 mg. The neurological manifestations included gait ataxia, tremor, polyneuropathy, and myopathy. In all five patients, the neurological symptoms were severe and disabling. In one patient with a myopathy, there was no improvement after amiodarone was withdrawn. The neurological side effects of amiodarone may be disabling and are not always reversible with drug withdrawal. Neurological complications may arise during treatment with usual maintenance doses.