Decision making for knee replacement: variation in treatment choice for late stage medial compartment osteoarthritis.

BACKGROUND: Patients with medial unicompartmental osteoarthritic disease of the knee requiring arthroplasty can be treated with either Total or Unicompartmental Knee Replacement (TKR or UKR). Currently, the decision to choose one operation over another is not well defined and may depend on the profile of the surgeon consulted. We tested the hypothesis that different surgeons will select different treatment for identical patients requiring knee replacement. METHOD: Four different surgeons, representing four different levels of expertise, made a forced choice decision of whether they would perform TKR or UKR based on radiographs alone and subsequent additional clinical information including gender and age, in 140 patients. Individual surgeon repeatability was tested by repeat assessment 3 months later. RESULTS: The knee surgeon from the UKR design centre would have performed a UKR in up to 88% of the patients. The remaining surgeons would have performed UKR in 29-48% of patients; a variation in decision making of up to 59%. Additional clinical information had little effect on decision making with surgeons maintaining their radiographic based choice in 80 to 87% of cases. The repeatability study showed high within surgeon consistency for treatment choice. CONCLUSION: Surgeons, given identical information, do not concur on treatment for patients with the same pathology. The decision making process appears heavily influenced by radiographic findings but individual surgeons are consistent with their own treatment choice. The study shows that consensus treatment for medial osteoarthritis of the knee remains in question.

Microtubule-associated targets in chlorpyrifos oxon hippocampal neurotoxicity.

Prolonged exposure to organophosphate (OP) pesticides may produce cognitive deficits reflective of hippocampal injury in both humans and rodents. Recent work has indicated that microtubule trafficking is also adversely affected by exposure to the OP pesticide chlorpyrifos, suggesting a novel mode of OP-induced neurotoxicity. The present studies examined effects of prolonged exposure to chlorpyrifos oxon (CPO) on acetylcholinesterase (AChE) activity, immunoreactivity (IR) of microtubule-associated proteins, neuronal injury, and tubulin polymerization using in vitro organotypic slice cultures of rat hippocampus and bovine tubulin. Cultures were exposed to CPO (0.1-10 microM) in cell culture medium for 1-7 days, a regimen producing progressive reductions in AChE activity of 15-60%. Cytotoxicity (somatic uptake of the non-vital marker propidium iodide), as well as IR of alpha-tubulin and microtubule-associated protein-2 (a/b) [MAP-2], was assessed 1, 3, and 7 days after the start of CPO exposure. As early as 24 h after the start of exposure, CPO-induced deficits in MAP-2 IR were evident and progressive in each region of slice cultures at concentrations as low as 0.1 microM. CPO exposure did not alter alpha-tubulin IR at any time point. Concentration-dependent injury in the cornu ammonis (CA)1 pyramidal cell layer and to a lesser extent, CA3 and dentate cells, was evident 3 days after the start of CPO exposure (>or=0.1 microM) and was greatest after 7 days. Tubulin polymerization assays indicated that CPO (>or=0.1 microM) markedly inhibited the polymerization of purified tubulin and MAP-rich tubulin, though effects on MAP-rich tubulin were more pronounced. These data suggest that exposure to CPO produces a progressive decrease in neuronal viability that may be associated with impaired microtubule synthesis and/or function.

Is anyone too old for a total knee replacement?

UNLABELLED: The decision on whether to perform a total knee replacement in extremely elderly patients is controversial. To assess the influence of age as an independent factor for early postoperative morbidity and mortality, we did a case-control study comparing a group of 22 patients 85 years or older that was matched for known predictive factors of nonsurgical postoperative complications with a younger control group. Both groups received the same perioperative and postoperative management. We then compared the number of postoperative complications. Standardized mortality ratios were performed to assess the influence of knee replacement on mortality. The 11 patients (50%) in the elderly group had one or more medical complications, which was similar to those of the five patients (23%) in the control group. Mortality in the elderly group who had knee replacements was almost (1/2) that of the general population (standardized mortality ratio, 0.53). We think age should not be a limitation for total knee replacements in elderly patients, although they should be given consideration for special care while in the hospital. LEVEL OF EVIDENCE: Therapeutic study, Level III (Case control study). See the Guidelines for Authors for a complete description of levels of evidence.

Mobile versus fixed-bearing total knee arthroplasty: mid-term comparative clinical results of 216 prostheses.

Since the late 1970s, mobile-bearing total knee designs have been advocated as having theoretical advantages over fixed-bearing total knee replacements. At present there is no consensus as to whether there are any differences in clinical results between the two designs. We present the results of two consecutive cohorts each of over 100 prosthesis. The first cohort underwent a fixed-bearing prosthesis, whilst the second cohort received the mobile bearing variant of the same prosthesis. Both groups were assessed pre- and post-operatively using the American Knee Society knee and function scores as well as range of movement and the presence or absence of anterior knee pain. No difference was found statistically significant between the groups, either for the knee score (P=0.068), the function score (P=0.26), the range of movement (P=0.11) or the proportions of anterior knee pain (P=0.06). It is our opinion that mobile bearing knee prosthesis have still to prove their theoretical advantages in clinical practice.

Spinal and pelvic parameters in Marfan's syndrome and their relevance to surgical planning.

Spinal deformities are a common feature of Marfan's syndrome and can be a significant cause of morbidity. The morphology of the scoliosis associated with this condition was previously described by Sponseller, but no correlation with the pelvic parameters has been seen. We performed a retrospective radiological study of 58 patients with scoliosis, secondary to Marfan's syndrome and related the findings in the thoracolumbar spine to the pelvic parameters, including pelvic version (tilt), pelvic incidence and sacral slope. Our results showed marked abnormalities in the pelvic values compared with those found in the unaffected population, with increased retroversion of the pelvis in particular. In addition we found a close correlation between the different patterns of pelvic parameters and scoliosis morphology. We found that pelvic abnormalities may partially dictate the spinal disorders seen in Marfan's syndrome. Our results supplement the well-established Sponseller classification, as well as stressing the importance of considering the orientation of the pelvis when planning surgery.

The management of avascular necrosis after slipped capital femoral epiphysis.

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).

The biomechanics of wire fixation in the Ilizarov system.

The purpose of this study was to establish the optimal fixation of tensioned wires to the frame construct in the Ilizarov system. The usual torque to which the fixation bolts were tightened in clinical practice was established by serial testing of orthopaedic surgeons' work in our unit. The force required to produce wire slippage from the different types of wire fixation bolts, tightened to a predetermined torque, was measured using a testing rig. Analysis of the usual torque to which bolts were tightened in clinical practice, revealed values in the range of 5-10Nm. The load required to cause failure of the tensioned wire varied considerably depending on the bolt configuration used and the applied torque. In clinical practice, wires are tensioned using a dynamometer to a variety of loads, depending on the clinical situation, up to 1275N. In applying multiple wires across a single ring, as is normal practice, these loads may be increased still further. The total load transmitted by single wires in weightbearing may be up to 2000N. Utilising the results of our work has enabled us to choose, where practically possible, the optimal bolt configuration for wire fixation. In addition, this work has revealed that in order to withstand the loads seen in clinical practice, wire fixation bolts should be tightened to at least 10Nm. Post-operatively, we now tighten all our wire fixation bolts to 10Nm, using a calibrated torque wrench.

Roller-blades: should they carry a government health warning?

Rollerblading is increasingly popular in the UK. Over 12 weeks, we treated 29 patients of whom 34 per cent required operative intervention. There was a wide range of injuries, those of the radius being most common, and some (e.g. femoral and pelvic fractures) being quite severe. The value of protective equipment is discussed.

Body fluid volumes in prehypertensive spontaneously hypertensive rats.

To ascertain the effect of aldosterone on body fluid volumes in neonatal, prehypertensive spontaneously hypertensive rats (SHR), we studied these animals at 12 days using age-matched Wistar-Kyoto (WKY) as normotensive controls. Some pups of each strain were treated with spironolactone (1.5 micrograms/g body wt) on days 10-12. Total body water (TBW, by dessication) and extracellular fluid (ECF, Na2 35SO4 space) volumes were significantly larger in SHR than in WKY, whereas plasma volumes (125I-serum albumin space) were not different. Thus the enlarged ECF was due to preferential expansion of the interstitial fluid (ISF) space. Treatment of SHR with spironolactone reduced TBW and ISF to values not different from untreated WKY and also reduced plasma volume to some extent. These results indicate 1) significant ISF volume expansion occurs in SHR prior to elevation of blood pressure, and 2) the previously observed elevation in plasma aldosterone in SHR at this age probably mediates the volume expansion.

Failure of atrial myocardial extract to inhibit renal Na+, K+-ATPase.

The effects of a natriuretic factor contained in extracts of the atrial myocardium on an isolated renal Na+, K+-ATPase enzyme system were evaluated. Ultrafiltrates (molecular weight less than 30,000) of boiled extract of rat atria and ventricles were prepared. Infusion of 100 microliters of the atrial ultrafiltrate into bioassay rats resulted in a prompt, short-lived natriuresis and diuresis. However, addition of 100 microliters of the atrial ultrafiltrate to 900 microliters of a suspension containing Na+, K+-ATPase had no significant effect on enzymatic activity. Similarly, ultrafiltrates of ventricular extract also had no significant effect on Na+, K+-ATPase activity. These results indicate that the atrial natriuretic factor does not alter renal tubular sodium reabsorption by directly inhibiting the Na+, K+-ATPase enzyme system.

Age-related changes in Na+ excretion in saline-loaded spontaneously hypertensive rats.

The ability of 6- to 7-, 12- to 13-, and 16- to 17-wk-old spontaneously hypertensive rats (SHR) to excrete an acutely administered, isotonic saline load (equivalent to 4.5% body wt) was evaluated. Female SHR from two different colonies were studied. Age-matched female Wistar (W) and Wistar-Kyoto (WKY) rats served as controls. At age 6 wk, the fraction of administered Na+ load excreted by either SHR colony after 60 min was significantly lower than in the Wistar rats but not significank, one colony of SHR excreted significantly more sodium after 60 min than the other rats. Glomerular filtration rate during control periods was positively correlated with age in one SHR colony; no age-related changes were observed in glomerular function in the other groups. These data 1) suggest that WKY rats are more appropriate than the Wistar rats as controls for renal function in the SHR, 2) demonstrate that the ability of the SHR to excrete an acutely administered sodium load is equal to or greater than normotensive WKY controls, and 3) demonstrate that with respect to renal function parameters, the SHR is not a homogenous strain.