Mid-term outcome of total elbow replacement for rheumatoid arthritis.

PURPOSE: To review the outcome of total elbow replacement (TER) in 21 patients after a mean of 64 months. METHODS: Records of 12 women and 9 men aged 32 to 78 (mean, 59.1) years who underwent 22 TERs for rheumatoid arthritis by a single surgeon were reviewed. Functional outcome was assessed using the disability of the arm, shoulder and hand (DASH) questionnaire. The range of movement and Kaplan- Meier survival curve was determined. Adequacy of cementation was assessed on immediate postoperative radiographs. Aseptic loosening was assessed on radiographs using the Mayo clinic scoring system. RESULTS: After a mean follow-up of 64 (range, 10-145) months, the mean DASH score improved from 72.3 to 46.8, mean flexion improved from 96.9º to 128.1º, and mean extension lag from 37.3º to 24.0º. The 5-year survival rate with symptomatic aseptic loosening as the end point was 100%, and the revision rate for all reasons was 69%. Cement mantle was adequate in 17, marginal in 4 (most lacked cement around the prosthesis tip), and inadequate in one who was clinically asymptomatic. At the latest follow-up, 4 patients had a type-1 radiolucent line and one had a type-2 radiolucent line of both components; all remained clinically asymptomatic. Two patients developed transient radial nerve neuropraxia. One patient underwent revision for peri-operative fracture. One patient underwent a 2-stage revision for deep infection. One patient underwent revision for bilateral periprosthetic fracture. One patient underwent revision for symptomatic aseptic loosening. No patient had elbow dislocation. CONCLUSION: TER is a viable option for pain relief and functional improvement in patients with rheumatoid arthritis.

Gastric protection and gastrointestinal bleeding with aspirin thromboprophylaxis in hip and knee joint replacements.

INTRODUCTION: Upper gastrointestinal (GI) bleeding in patients who undergo hip and knee arthroplasty tends to be associated with non-steroidal anti-inflammatory drug use, steroid intake, pre-existing peptic ulcers and smoking. The use of aspirin for thromboprophylaxis is an added risk for the occurrence of GI bleed. The aim of this study was to determine the incidence of upper GI bleeding and whether the use of peri-operative oral ranitidine reduces the incidence of upper GI bleeding when aspirin thromboprophylaxis is used for hip and knee arthroplasty. PATIENTS AND METHODS: Data from 1491 and 886 patients who underwent hip and knee replacements at the James Cook University Hospital (group 1) and at Friarage Hospital, Northallerton (group 2), respectively, were analysed in retrospect. All patients received 150 mg of aspirin per day for a period of 6 weeks from the day of surgery. Additionally, patients operated at the Friarage Hospital received 300 mg of oral ranitidine per day, for three postoperative days. RESULTS: We observed that patients in group 1 had a higher incidence of overt upper GI haemorrhage, which was statistically significant (P <0.014) compared to patients in group 2. CONCLUSIONS: Based on this experience, we recommend the use of peri-operative gastric protection with ranitidine when aspirin is used for thromboprophylaxis in hip and knee arthroplasty.

Clinical examination, MRI and arthroscopy in meniscal and ligamentous knee Injuries - a prospective study.

Data from 565 knee arthroscopies performed by two experienced knee surgeons between 2002 and 2005 for degenerative joint disorders, ligament injuries, loose body removals, lateral release of the patellar retinaculum, plica division, and adhesiolysis was prospectively collected. A subset of 109 patients from the above group who sequentially had clinical examination, MRI and arthroscopy for suspected meniscal and ligament injuries were considered for the present study and the data was reviewed. Patients with previous menisectomies, knee ligament repairs or reconstructions and knee arthroscopies were excluded from the study. Patients were categorised into three groups on objective clinical assessment: those who were positive for either meniscal or cruciate ligament injury [group 1]; both meniscal and cruciate ligament injury [group 2] and those with highly suggestive symptoms and with negative clinical signs [group 3]. MRI was requested for confirmation of diagnosis and for additional information in all these patients. Two experienced radiologists reported MRI films. Clinical and MRI findings were compared with Arthroscopy as the gold standard. A thorough clinical examination performed by a skilled examiner more accurately correlated at Arthroscopy. MRI added no information in group 1 patients, valuable information in group 2 and was equivocal in group 3 patients. A negative MRI did not prevent an arthroscopy. In this study, specificity, positive and negative predictive values were more favourable for clinical examination though MRI was more sensitive for meniscal injuries. The use of MRI as a supplemental tool in the management of meniscal and ligament injuries should be highly individualised by an experienced surgeon.

Degeneration of stroma reduces retention of homed cells in bone marrow of lethally irradiated mice.

Cytotoxic drugs or irradiation are generally administered before bone marrow (BM) transplantation because of the idea that host bone marrow 'niches' become available to the donor cells for engraftment. How BM stromal cells respond to the radiation, which ultimately modulates grafting of donor cells, is poorly understood. In this study, we examined homing and marrow retention of PKH26+ donor cells in BM of age-matched C57BL/6J mice conditioned at different doses of irradiation. When we injected donor cells into mice that received 900 cGy, the percent homing was highest (15.8 +/- 1.5%) as compared to the lower doses of radiation. Despite the highest levels of homing of donor cells in these mice, about 70% (p < 0.005) homed cells were detached from the marrow within 72 h of transplantation. In contrast, a 2- to 2.5-fold (p < 0.03) multiplication of homed PKH-26+ Sca-1+ cells was observed in sublethally irradiated mice. While determining that CD45- CD106+ cells in BM of the mice received 900 cGy, we found that more than 80% of cells were depleted. It was also revealed from this investigation that grafted cells conferred partial protection to the endogenous myeloid colony-forming cells from radiation injury. Collectively, the present study implicates radiation-induced degeneration of stroma as a cause of poor retention of donor cells in BM of lethally irradiated mice. These results may have important clinical implications in designing conditioning regimens for BM transplantation.

Hematopoietic stem cells: clinical requirements and developments in ex-vivo culture.

Ex vivo expansion of hematopoietic stem cells is a promising technology for many potential applications from marrow reconstitution to gene therapy. Considerable progress has been made during the past ten years in understanding the biology of hematopoietic stem cells and its ex vivo expansion; despite this, the cultured cell is still between pre-clinical and phase I clinical trials. This review summarizes recent progress in the ex vivo expansion of hematopoietic stem cells and its requirements for clinical applications. The second section covers hematopoiesis and the bone marrow microenvironment. The third and fourth sections deal with therapeutic applications of stem cells and transplantation requirements, respectively. Biological alteration of expanded stem cells, molecular control of hematopoiesis, characterization of cells, and bioreactors for culture of stem cells and its operational parameters are the subjects of the fifth section. The next section covers pre-clinical and clinical studies on expanded stem cells. Ex vivo expansion of stem cells in three-dimensional culture system is the subject matter for the last section.

An in vitro model for grafting of hematopoietic stem cells predicts bone marrow reconstitution of myeloablative mice.

Homing and engraftment of hematopoietic stem cells (HSCs) to bone marrow (BM) is a complex process that primarily depends on the cell-surface expression of adhesion molecules on stem and stromal cells. Here we report an in vitro model for homing of stem cells on pre-established stromal layer; the stroma-adhered cells were found to engraft, multiply, and differentiate in BM of age-matched mice. In vitro study revealed that initially the adhesion of BM cells on irradiated stroma was increased with time, and it attained a peak at 2 h of contacts. During that time, 44.1 +/- 6.5% (n = 8) cells were adhered, and this value was maintained up to 6 x 10(6) cells. The adhered cell fraction was enriched by 3.9-, 2.5-, and 1.7-fold Sca-1, colony forming cell (CFC), and cobblestone area forming cells (CAFC), respectively, as compared to the fresh BM cells. These adhered cells homed to BM with an engraftment efficiency of 11.8 +/- 2.5% (n = 6). The homed cells reconstituted BM of myeloablative mice by self-renewing and differentiating into myeloid cells. Overall, a simple in vitro model system has been described to study homing and grafting of HSCs that can be deployed to any possible experimental conditions to investigate the interactions between stromal and stem cells.