An uncemented metal-backed glenoid component in total shoulder arthroplasty for osteoarthritis: factors affecting survival and outcome.

BACKGROUND: The reported survivorship of total shoulder replacement (TSR) is variable. This is probably related to implant design. We report the outcome and survivorship of the uncemented glenoid in patients with osteoarthritis receiving a TSR with an intact or repairable rotator cuff at surgery. METHODS: Thirty-two consecutive patients were analysed after TSR using a screw-fixed porous coated metal-back glenoid performed by a single surgeon, with a minimum follow-up of five years. Thirty-three TSRs in 32 patients (19 women) with a mean age of 67 years were analysed, two of whom died before five years of follow-up. Thirty patients (31 shoulders) were monitored for a mean of 95 months (60-173 months). RESULTS: The Constant score improved by 22 points (p < 0.001). The only significant predictor of outcome on logistic regression analysis was the preoperative Constant score, with better scores resulting in a lesser improvement at last follow-up (p < 0.0001). Implant survivorship at ten years was 93 %. Three were revisions: two for polyethylene wear (both at six years) but with a well-fixed glenoid, and another for loosening of the glenoid at 11 years postoperatively. Univariate analysis identified that younger age (56 year vs. 68 years, p = 0.03) and a higher combined preoperative Constant score (35.7 vs. 21.5, p = 0.03) were both predictors of failure. CONCLUSION: The uncemented glenoid performs well in the medium term for osteoarthritis of the shoulder in older patients, giving improved and sustained functional outcome. Age and preoperative level of function are predictors of outcome and survival.

Assessment of shoulder function using the coronal plane angle.

BACKGROUND: Assessment of shoulder function is an essential part of clinical practice. Current scoring relies on multiple subjective and / or objective components. We present a single angular measurement, the coronal plane angle, which relates to the functional assessment of the shoulder. MATERIALS AND METHODS: One hundred patients were prospectively enrolled and assessed using the Constant-Murley score and the Oxford shoulder questionnaire, and the coronal plane angle was measured for both symptomatic and asymptomatic shoulder. RESULTS: NINE PATIENTS WERE EXCLUDED FROM THE STUDY: Four had apprehension and five were not able to get their hand to head. The mean coronal plane angle on the symptomatic side was +11.3 degrees and the asymptomatic side -1.5 degrees (P

Flow-induced enhancement of vasoconstriction and blockade of endothelium-derived hyperpolarizing factor (EDHF) by ascorbate in the rat mesentery.

BACKGROUND AND PURPOSE: We previously reported that ascorbate inhibits flow- and agonist-induced, EDHF-mediated vasodilatation in the bovine ciliary circulation. This study examined whether ascorbate had similar actions in the rat mesenteric vasculature. EXPERIMENTAL APPROACH: The effects of ascorbate were examined both in rat second order mesenteric arterial rings suspended in a static wire myograph and the rat mesentery perfused at different rates of flow. KEY RESULTS: Ascorbate (50 microM) had no effect on U46619-induced tone or acetylcholine-induced, EDHF-mediated vasodilatation in either rings of mesenteric artery or the perfused mesentery at rates of flow below 10 ml min(-1). At higher rates of flow, ascorbate produced two distinct effects in the rat mesentery: a rapid and maintained enhancement of vasoconstrictor tone and a slow (max at 3 h) inhibition of acetylcholine-induced, EDHF-mediated vasodilatation. The enhancement of vasoconstrictor tone appeared to be due to inhibition of flow-induced EDHF-like activity, since it was endothelium-dependent, but could be elicited during blockade of nitric oxide synthase and cyclooxygenase. Despite this, the classical inhibitors of EDHF, apamin and charybdotoxin, failed to affect the ascorbate-induced enhancement of tone, although they inhibited acetylcholine-induced vasodilatation. CONCLUSIONS AND IMPLICATIONS: Ascorbate inhibits both flow- and agonist-induced EDHF in the rat mesentery. The strikingly different timecourses of these two effects, together with their differential sensitivity to apamin and charybdotoxin, suggest that the flow- and agonist-induced EDHFs in the rat mesenteric vasculature may either be different entities or operate by different mechanisms.

Injury to the axillary artery, a complication of fixation using a locking plate.

The proximal humerus internal locking system is an internal fixation device consisting of a low-profile plate and locking screws, which is used for the fixation of three- and four-part fractures of the proximal humerus. We describe a case in which the screws cut out of the humeral head causing injury to the axillary artery necessitating urgent removal of the implant.

Souter-Strathclyde total elbow arthroplasty in rheumatoid arthritis: medium-term results.

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124 degrees to 136 degrees was noted (p < 0.001). Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients.

Potent vasodilator responses to human urotensin-II in human pulmonary and abdominal resistance arteries.

The peptide human urotensin-II (hUT-II) and its receptor have recently been cloned. The vascular function of this peptide in humans, however, has yet to be determined. Vasoconstrictor and vasodilator responses to hUT-II were investigated in human small muscular pulmonary arteries [approximately 70 microm internal diameter (ID)] and human abdominal resistance arteries (approximately 200 microm ID). Vasodilator responses were investigated in endothelin-1 (3 nM) precontracted vessels and, in the small pulmonary vessels, compared with the known vasodilators adrenomedullin, sodium nitroprusside, and acetylcholine. In human small pulmonary arteries, hUT-II did not induce vasoconstriction but was a potent vasodilator [-log M concentration causing 50% of the maximum vasodilator effect (pIC(50)) 10.4 +/- 0.5; percentage of reduction in tone (E(max)) 81 +/- 8% (vs. 23 +/- 11% in time controls), n = 5]. The order of potency for vasodilation was human urotensin-II = adrenomedullin (pIC(50) 10.1 +/- 0.4, n = 6) > sodium nitroprusside (pIC(50) 7.4 +/- 0.2, n = 6) = acetylcholine (pIC(50) 6.8 +/- 0.3, n = 6). In human abdominal arteries, hUT-II did not induce vasoconstriction but was a potent vasodilator [pIC(50) 10.3 +/- 0.7; E(max) 96 +/- 8% (vs. 43 +/- 16% in time controls), n = 4]. This is the first report that hUT-II is a potent vasodilator but not a vasoconstrictor of human small pulmonary arteries and systemic resistance arteries.

Contractile responses to human urotensin-II in rat and human pulmonary arteries: effect of endothelial factors and chronic hypoxia in the rat.

Responses to human urotensin-II (hU-II) were investigated in human and rat pulmonary arteries. Rat pulmonary arteries: hU-II was a potent vasoconstrictor of main pulmonary arteries (2 - 3 mm i.d.) (pEC(50), 8.55+/-0.08, n=21) and was approximately 4 fold more potent than endothelin-1 [ET-1] (P<0.01), although its E(max) was considerably less (approximately 2.5 fold, P<0.001). The potency of hU-II increased 2.5 fold with endothelium removal (P<0.05) and after raising vascular tone with ET-1 (P<0.01). E(max) was enhanced approximately 1.5 fold in the presence of N(omega)-nitro-L-arginine methylester (L-NAME, 100 microM, P<0.01) and approximately 2 fold in vessels from pulmonary hypertensive rats exposed to 2 weeks chronic hypoxia (P<0.05). hU-II did not constrict smaller pulmonary arteries. Human pulmonary arteries ( approximately 250 microm i.d.): in the presence of L-NAME, 3 out of 10 vessels contracted to hU-II and this contraction was highly variable. hU-II is, therefore, a potent vasoconstrictor of rat main pulmonary arteries and this response is increased by endothelial factors, vascular tone and onset of pulmonary hypertension. Inhibition of nitric oxide synthase uncovers contractile responses to hU-II in human pulmonary arteries.

Genetic heterogeneity of Escherichia coli O157:H7 in Scotland and its utility in strain subtyping.

From April 1994 to March 1995, seven outbreaks of Escherichia coli O157:H7 infection occurred throughout Scotland, including the largest milk-borne outbreak to date worldwide. Various vehicles of infection were identified, and there were 144 confirmed cases in total. All isolates associated with the outbreaks were subjected to detailed subtyping: phage typing, testing for carriage of verotoxin genes (VT), and pulsed-field gel electrophoresis. The outbreak strains were of three different phage types (2, 4, and 28). Those of phage type 2 and 28 were VT1-/VT2+, those of phage type 4 were VT1+/VT2+. To discriminate outbreak-associate isolates from the high sporadic background, real-time pulsed-field gel electrophoresis analyses were performed. The results demonstrated that, within each of the seven outbreak groups, the macrorestriction profiles observed were indistinguishable, whereas profiles for sporadic isolates were not. The consistent genetic heterogeneity observed within the Scottish Escherichia coli O157 population can be exploited in epidemiological investigations.

The consequences of punching glass.

We carried out a retrospective and prospective study of 67 patients who had sustained hand injuries from punching glass over a period of 33 months. All had consumed alcohol and had argued with a partner. The mean age was 25 years, 90% were male and 56% were unemployed. Seventy per cent of injuries occurred between 23.00 and 04.00 hours. Total damage included division of 149 tendons, 33 nerves and nine arteries. Fifty-two per cent of patients required admission for more than 1 day. The mean number of follow-up visits was 3.6 and the majority needed hand therapy and occupational therapy services. Cost per injury was estimated as 1,120 pounds. Such injuries cause major disability in an already disadvantaged section of society. The challenge is to educate the susceptible patient group.

Repair of acute scapho-lunate dissociation facilitated by the "TAG" suture anchor.

A case of acute scapho-lunate dissociation is described in which the operative treatment was facilitated by the use of the "TAG" suture anchor.

Freeze-thawed muscle grafting for painful cutaneous neuromas.

We used freeze-thawed muscle grafts to restore continuity to the affected nerve in 22 painful cutaneous neuromas. In 11 of the 15 neuromas in the upper limb, pain was partially or completely relieved; in six of these there was some recovery of distal sensation. Partial pain relief was achieved in only two of the seven neuromas in the lower limb. The difference is attributed to the longer grafts required in the lower limb.

Surgery of the rheumatoid cervical spine. Correlation of the pathology and prognosis.

Twenty-eight rheumatoid arthritis patients with symptomatic subluxation of the cervical spine had 34 operative procedures in the period from 1983 to 1989. Two distinct groups are noted with regard to management and prognosis. The treatment of isolated atlantoaxial instability has been straightforward and the morbidity low. Subaxial instability and combined atlantoaxial and subaxial instability were more difficult to manage: The incidence of preoperative neurologic deficit was higher and the operative technique more demanding. There have been two late deaths of quadriparesis. Half of the other patients were ambulant and independent. The halo jacket has been used to reduce subaxial subluxation and neurologic deficit before surgery. Both anterior and posterior approaches have been successfully employed.

The terminal branch of posterior interosseous nerve: a useful donor for digital nerve grafting.

The anatomical relationships of the terminal branch of posterior interosseous nerve have been studied in 57 cadaver and amputation specimens. Removal of the nerve leaves the patient with no apparent sensory deficit. In all dissections the nerve was present and its location was constant. The mean obtainable length was 3.7 cm (range 2.7-5.1 cm) and its cross-sectional area made the nerve suitable for grafting of digital nerves.

Follow-up studies in 50 totally colectomised children.

We report on 50 totally colectomised children, most of whom suffered from Hirschsprung's disease. Of the 50, one child died postoperatively of enteritis. On an average, the children were re-examined 5 1/2 years after the colectomy. The findings were as follows: With the exception of four, the size and weight of the patients were within the norm; 20 passed frequent stools of pulpy consistency; 16 suffered from disturbances of continence; 14 developed severe, partially recurrent enteritis. We did not find any advantage of a single method of operation, e.g. Martin's operation.