Biomedical subjects
R H Fitzgerald
Publications and source records attributed to R H Fitzgerald.
Saksenaea vasiformis osteomyelitis.
A 24-year-old man sustained a crush injury to the tibia, which subsequently became infected with Saksenaea vasiformis. He was treated with debridement and a free myocutaneous flap, but amputation was necessary because of mycotic osteomyelitis. S. vasiformis was recovered and identified on the basis of its characteristic morphology on cornmeal agar.
Epidemiology of ankle fractures in Rochester, Minnesota.
The epidemiology of ankle fractures was examined among Rochester, Minnesota, residents during the 3-year period 1979-1981. Ankle fractures occurred with an overall age- and sex-adjusted incidence rate of 187 per 100,000 person-years; this is higher than in earlier population-based studies. The most frequent cause of ankle fractures was sports-related trauma. The incidence of fractures associated with moderate trauma, on the other hand, increased markedly in middle-aged women, but declined in elderly women. Diabetes mellitus and obesity were associated with fractures in middle-aged and older adults. Of accepted classifications, the Lauge-Hansen system provided the most clinically relevant information.
Multiple revisions for failed total hip arthroplasty not associated with infection.
Forty-five patients (forty-five hips) underwent repeat revisions of a total hip arthroplasty that had failed but was not associated with infection; seven of these patients had a third revision. The mean length of follow-up was approximately three years, and no patients were lost to follow-up. Twenty-eight of the forty-five patients had no or slight pain after the second revision, and thirty reported that their condition was improved. After the third revision, six patients had no or only slight pain, and five said that their condition was improved. On final roentgenographic examination, there was probable loosening (migration or subsidence of a component, lucency at the prosthesis-cement interface, fracture of the cement, or complete radiolucency at the bone-cement, or complete radiolucency at the bone-cement interface of more than one millimeter in at least one zone) of eight of the acetabular components and thirteen of the femoral components after the second revision and three acetabular components and one femoral component after the third. There was symptomatic loosening (moderate or severe pain and probable roentgenographic loosening) in six patients after the second revision and one after the third. Significant postoperative complications were noted in nineteen of the forty-five patients, and treatment was considered to be a failure in eleven hips after the second revision and in two after the third.
The John Charnley Award paper. Efficacy of using a bone graft substitute to enhance biological fixation of a porous metal femoral component.
The efficacy of using hydroxyapatite/tricalcium phosphate (HAP/TCP) particles to enhance the biological fixation of a canine cementless femoral component with a noninterference fit was evaluated with a custom-designed collarless, wedge-shaped femoral component with titanium fiber metal pads along the anteroposterior surfaces of the stem. A polyethylene acetabular component was cemented into the pelvis. Three groups of dogs were employed: group I (n = 7) had a femoral component with an interference fit; group II (n = 6) had a component with a noninterference fit with uniform voids along the anteroposterior stem surfaces; and group III (n = 6) had a component with a noninterference fit including uniform voids filled with HAP/TCP particles. All dogs were harvested after 12 weeks of unrestricted weight bearing. Cross-section specimens from three different levels from each bone-component composite were evaluated histologically to determine the type and extent of tissue ingrowth and the percentage of peripheral bone or HAP/TCP particles adjacent to the fiber metal pad surfaces. Three other cross-section specimens, adjacent to the histological section levels of the same composites, were assessed for shear strength at the fiber metal-tissue interface and for biochemical composition of the ingrown tissue.
Indium-111 leukocyte imaging. The skeletal photopenic lesion.
Photon-deficient lesions in the skeleton occasionally are seen in In-111 leukocyte imaging. Although the findings usually indicate past surgery, previous infections, or radiation therapy effect, they may be due to metastatic disease or active or partially treated infection.
Medical facilities and needs aboard a cruise ship: points to ponder before an ocean cruise.
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Sequential technetium-99m HMDP-gallium-67 citrate imaging for the evaluation of infection in the painful prosthesis.
In order to evaluate the clinical utility of sequential technetium-99m HMDP-gallium-67 scanning in patients with painful orthopedic prosthesis, a retrospective review was made of 154 sequential scans performed in 130 patients. Criteria for a positive study included spatially incongruent gallium-technetium uptake or gallium uptake that was congruent but more intense than technetium. Images were interpreted as negative if gallium was congruent and less intense than technetium. Sixty-six patients underwent surgery (31 infected, 35 aseptic), and 64 were evaluated clinically (3 infected, 61 aseptic). The combined results of the surgical and nonsurgical patients yielded a sensitivity of 66%, a specificity of 81%, and an accuracy of 77%. In this series, the technetium-gallium scan combination has proven to be helpful but more recent techniques such as indium-111-labeled leukocytes may prove to be superior to sequential technetium-gallium imaging.
Problems associated with the infected total hip arthroplasty.
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Ionizing radiation: nondefense, non-power-generating, and nonmedical uses.
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Magnetic resonance imaging.
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Hip implant infection. Treatment with resection arthroplasty and late total hip arthroplasty.
In 131 patients with an infected hip implant, treatment was surgical excision of the implant (resection arthroplasty) and delayed reconstruction with a total hip arthroplasty. Most of the patients had low-grade infections: only 5 percent had a temperature of 37.8 degrees C or higher and only 20 percent had wound drainage. Hip pain was the primary symptom of a deep infection in 90 percent. Staphylococci were the most frequently isolated causal organisms, recovered from deep tissue specimens in 84 patients. The hip was reconstructed six days to 32 years (mode, 429 days) after resection arthroplasty. At follow-up two to nine years after reconstruction, 88 percent of the 131 patients were free of infection. Recurrent sepsis was more common (p less than 0.05) in patients with incomplete acrylic cement removal or patients in whom reconstruction was performed less than 429 days after resection arthroplasty. Risk of recurrent sepsis was increased when gram-negative bacilli in pure or mixed cultures were found, but the difference was not statistically significant.
Magnetic resonance imaging: application in musculoskeletal infection.
Forty-two patients with clinically suspected osteomyelitis were examined using magnetic resonance imaging (MRI). Twenty-seven patients (64%) had previous surgery or fracture, and 15 (36%) were referred for differentiation of acute osteomyelitis from bone tumors or other pathologic conditions. MRI was compared with computed tomography in 12 cases and with 111In-labeled leukocytes scans in 22. With MRI, 92% of proved infections were detected, and bone and soft-tissue changes were more evident than with routine radiographs, tomography, or computed tomography. In patients with negative cultures and no previous surgery or fracture, it was difficult for MRI to differentiate operative changes from infection. In these patients, 111In-labeled leukocyte images were more specific than MRI.
Medical consequences of the earthquake of 1886 in Charleston, South Carolina.
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Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis. A prospective study.
We prospectively compared sequential technetium-gallium imaging with indium-labeled-leukocyte imaging in fifty patients with suspected low-grade musculoskeletal sepsis. Adequate images and follow-up examinations were obtained for forty-two patients. The presence or absence of low-grade sepsis was confirmed by histological and bacteriological examinations of tissue specimens taken at surgery in thirty of the forty-two patients. In these thirty patients, the sensitivity of sequential Tc-Ga imaging was 48 per cent, the specificity was 86 per cent, and the accuracy was 57 per cent, whereas the sensitivity of the indium-labeled-leukocyte technique was 83 per cent, the specificity was 86 per cent, and the accuracy was 83 per cent. When the additional twelve patients for whom surgery was deemed unnecessary were considered, the sensitivity of sequential Tc-Ga imaging was 50 per cent, the specificity was 78 per cent, and the accuracy was 62 per cent, as compared with a sensitivity of 83 per cent, a specificity of 94 per cent, and an accuracy of 88 per cent with the indium-labeled-leukocyte method. In patients with a prosthesis the indium-labeled-leukocyte image was 94 per cent accurate, compared with 75 per cent accuracy for sequential Tc-Ga imaging. Statistical analysis of these data demonstrated that the indium-labeled-leukocyte technique was superior to sequential Tc-Ga imaging in detecting areas of low-grade musculoskeletal sepsis.
Local muscle flaps in the treatment of chronic osteomyelitis.
When large soft-tissue and osseous defects remain after débridement of a chronic osteomyelitic lesion, application of a local muscle flap can be an effective way to achieve wound closure. Utilizing this surgical technique and specific antimicrobial therapy for the causal microorganisms, the infectious process was eradicated in thirty-nine of forty-two patients with osteomyelitis who were followed for at least two years after treatment. The osteomyelitic process was post-traumatic in origin--that is, a complication of a fracture or its treatment--in twenty-eight patients, the result of soft-tissue trauma without a fracture in eight, a complication of elective surgery in three, and the result of hematogenous seeding in three patients. Nine of the forty-two patients had an infected non-union. The infectious process involved the tibia in 62 per cent of the patients. Pseudomonas aeruginosa was the most frequently isolated causal organism. A soleus or gastrocnemius muscle flap was most frequently utilized to achieve closure. In five patients, a combination of two muscle flaps was utilized. Although this technique successfully eradicated the infectious process in 93 per cent of the patients, twenty-two patients required additional surgical treatment. Six required such treatment for a persistent non-union and two, for weakened diaphyseal bone after eradication of the septic process. A cancellous bone-grafting procedure was performed in all eight patients after the muscle flap had healed, and union was achieved in six of them. One patient eventually requested an amputation for a persistent non-union, and the remaining patient had a fibular synostosis performed for a persistent tibial non-union. A local muscle flap can be used in patients with a large defect of soft tissue and bone after débridement of an osteomyelitic lesion if the flap can be elevated and transposed into the defect without compromising its vascular supply. Although they are not applicable to the treatment of all patients with osteomyelitis, local muscle flaps can be extremely useful in the treatment of this lesion. When combined with thorough débridement and specific antimicrobial therapy, it has become a successful technique in the management of chronic osteomyelitis.
Clinical and roentgenographic assessment of total hip arthroplasty. A new hip score.
A new total hip scoring system is presented and applied in a group of patients who were treated by revision of total hip arthroplasty. The Mayo hip score combines clinical (80 points) and roentgenographic (20 points) data in a 100-point score. The roentgenographic input into the score decreased the percentage of good-to-excellent results because of the high frequency of roentgenographic signs of loosening. With the Harris rating, there were 63% good-to-excellent results, 12% fair results, and 26% poor results a mean of 4.25 years after component revision of total hip arthroplasty. With the Mayo system, there were 52% good-to-excellent results, 19% fair results, and 29% poor results a mean of 4.25 years after revision. A modification of the roentgenographic rating system would apply the Mayo hip score to noncemented total hip arthroplasties.
Revision total hip arthroplasty.
Two hundred and ten hips in 206 patients who had an initial total hip arthroplasty performed at the Mayo Clinic between 1969 and 1978 required revision of the arthroplasty at the Mayo Clinic for reasons other than infection. One hundred and sixty-two of the patients (166 hips) were followed both clinically and roentgenographically for two years or more. One hundred and forty-five (90 per cent) reported that they had improvement after the surgical revision. Complications that occurred with revision included deep sepsis, superficial would infection, dislocation, intraoperative femoral fracture, and postoperative femoral fracture. Roentgenographic analysis showed probable loosening in thirty-three acetabular components (20.1 per cent) and seventy-two femoral components (44 per cent). Symptomatic loosening (moderate to severe pain and probable roentgenographic loosening) was seen in thirty-five patients. Eight patients required a second revision for this reason, and seven others required a second revision for other reasons. Modified Harris hip scores, calculated for 108 hips, showed a good or excellent result in sixty-seven hips (62 per cent), a fair result in twelve (11 per cent), and a poor result in twenty-nine (27 per cent). Using a new Mayo Clinic hip score that incorporates roentgenographic data (which will be described) in the evaluation of 165 revised hips, there was a good or excellent result in eighty-five (52 per cent), a fair result in thirty-two (19 per cent), and a poor result in forty-eight hips (29 per cent). Although 90 per cent of the patients thought that their condition had improved, the high incidence of roentgenographic signs of probable loosening of a component is of serious concern.