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PubMed2005

The effect of simvastatin on polyethylene particle-induced osteolysis.

This study aimed to investigate the effects of the HMG-CoA reductase inhibitor simvastatin on ultra-high molecular weight polyethylene (UHMWPE) particle-induced osteolysis. The murine calvarial osteolysis model was used in 21 C57BL/J6 mice randomized to three groups. Group I underwent sham surgery only, group II received UHMWPE particles, and group III, particles and simvastatin treatment. After two weeks, calvaria were processed for histomorphometry. Bone resorption was measured as resorption within the midline suture using Giemsa staining. Osteoclast numbers were determined per high-power field using TRAP-staining. Statistical analysis was performed using one-way ANOVA and Student's t-test. Bone resorption in midline suture was 0.094+/-0.007 mm(2) in sham controls (group I), 0.25+/-0.025 mm(2) after particle implantation without further intervention (group II), and 0.131+/-0.02 mm(2) with particle implantation and additional simvastatin treatment (group III) (p=0.00003). Osteoclast numbers were 15.3+/-3.6 in group I, 48.7+/-7.1 in group II and 6.2+/-3.1 in group III (p=0.00002). In conclusion, simvastatin treatment markedly decreased UHMWPE particle-induced osteolysis in a murine calvarial model. This finding suggests that simvastatin may have a role for noninvasive prevention and treatment of wear debris-mediated periprosthetic osteolysis after total joint arthroplasty.

Animals↗
PubMed2004

Are all echocardiographic findings equally predictive for diagnosis in prosthetic endocarditis?

OBJECTIVE: The purpose of this study was to analyze the predictive value of different anatomic echocardiographic findings for diagnosis of prosthetic endocarditis. BACKGROUND: Prognosis in endocarditis has improved in recent years after the wide acceptance of new clinical diagnostic criteria. One of the most important issues in clinical diagnosis is to use echocardiography for identification of endocardial involvement, but prosthetic material impairs echo quality. METHODS: In all, 49 patients with 58 episodes of suggested prosthetic endocarditis were prospectively studied using transthoracic and transesophageal echocardiography. The patients were divided into two groups: group A, patients with 34 episodes of definite endocarditis according to Durack's criteria; and group B, patients with 24 episodes who were eventually classified as not having endocarditis, either by surgical exploration or by a mean of 32.6 months (range: 8-38 months) of follow-up. RESULTS: In group A, valve dehiscence was observed in 4 episodes of suggested endocarditis, pseudoaneurysms in 3, fistulae in 2, and moderate to severe perivalvular regurgitation in 15. No patient in group B had these abnormalities (P <.001). Vegetations were present in 17 episodes in group A (50%) versus 1 in group B (9%; P <.001); perivalvular abscesses were seen in 19 episodes in group A (56%) versus 1 in group B (P <.001). Mild perivalvular regurgitation was observed in only 1 episode for group A (3%) and in 14 episodes for group B (58%; P <.01). The presence of any of the above echocardiographic finding, when used in combination with the exclusion of mild perivalvular regurgitation, had a positive and negative predictive value for diagnosing endocarditis of 94% and 96%, respectively. Isolated mild perivalvular regurgitation had a poor positive predictive value (6%). CONCLUSION: Isolated mild perivalvular regurgitation should not be used as diagnostic criteria in patients with suggested prosthetic valve endocarditis.

Adult↗
PubMed2005

Imaging of knee arthroplasty.

Knee replacement surgery, either with unicompartmental or total systems, is common. The purpose of this manuscript is to review the appearance of normal knee arthroplasty and the appearances of complications such as infection, polyethylene wear, aseptic loosening and particle-induced osteolysis, patellofemoral abnormalities, axial instability, and periprosthetic and component fracture. Knowledge of the potential complications and their imaging appearances will help the radiologist in the diagnostic evaluation of the patient with a painful knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMed2005

Improved outcomes in the recent management of secondary aortoenteric fistula.

OBJECTIVE: We reviewed the presentation, management, and late events in a recent experience with aortic graft-enteric communications (secondary aortoenteric fistula) to identify variables associated with poor outcomes. METHODS: Since 1991, 29 patients (19 men, 10 women; mean age, 70) presented with a secondary aortoenteric fistula. The duration from aortic graft implantation to aortoenteric fistula development ranged from 8 months to 180 months (mean, 47 months). Presenting symptoms included gastrointestinal bleeding (n = 25), sepsis and retroperitoneal abscess (n = 3), and ruptured para-anastomotic aneurysm (n = 1). One third (10/29) of patients were hypotensive at presentation. Repair was accomplished by graft excision with axillobifemoral bypass (17 simultaneous, 8 staged), graft excision with in situ deep vein replacement (n = 2), or graft excision with rifampin-treated prosthetic replacement (n = 2). Mean follow-up was 51 months, and the incidence of late events was reported by life table methods. RESULTS: The operative (< or = 30-day) mortality rate was 21%, with shock at presentation (P < .01), the need for preoperative transfusion (P < .01), and use of suprarenal aortic clamping during aortoenteric fistula repair (P = .03) associated with lethal outcome. Cumulative mortality related to aortoenteric fistula management was only 24% within an overall 5-year survival rate of 61%. Freedom from recurrent infection or amputation was 86% and 88% at 5 years, respectively, and assisted graft patency was 79%. Presence of staphylococcal species in 22% of patients and occasional operative findings of adjacent perigraft "biofilm" suggests that underlying indolent graft infection may contribute to the development of aortoenteric fistula in some cases. CONCLUSION: Outcomes associated with aortoenteric fistula repair were surprisingly favorable in the absence of preoperative hemodynamic instability.

Aged↗
PubMed2005

Fractures above and below a modular nail for knee arthrodesis. A case report.

Several techniques have been advocated for knee arthrodesis, and there has been an increasing interest in modular intramedullary nails in the recent last years. We report a case of femoral and tibial fractures at each end of a modular nail in a solidly fused knee 8 months after an arthrodesis.

Accidental Falls↗
PubMed2005

Complications associated with hip resurfacing arthroplasty.

Hip resurfacing arthroplasty is an old orthopedic concept that has undergone a resurgence of interest in the past decade. Because of the rapid increase in the number of procedures being performed, previously recognized complications have begun to recur. This article focuses on complications that are related to the hip resurfacing procedure such as femoral neck fractures, avascular necrosis, raised metal ion levels, and sound initial and durable long-term fixation of an all-metal monoblock cobalt/chrome acetabular component. Dislocation rates after resurfacing and other complications are briefly discussed.

Arthroplasty, Replacement, Hip↗
PubMed1996

Lessons learned from the DIASTAT vascular access graft.

BACKGROUND: The vascular community continues to search for the ideal vascular access graft that will allow early cannulation and avoid temporary central venous catheters. METHODS: This is a review of the Cranley Surgical Associates' experience with the use of the Gore-Tex DIASTAT (W.L. Gore & Associates, Inc., Flagstaff, Arizona) vascular access graft in 20 patients compared with 20 control patients matched for age, sex and risk factors. RESULTS: Although the DIASTAT graft is touted for early accessibility and decreased need for central venous access, that was not found to be the case as 14 patients in the DIASTAT group received temporary access catheters. There was significantly more edema in the DIASTAT patients (P = 0.0048). Comparing the time to the first thrombosis or to revision revealed an average of 18 weeks for the DIASTAT group and 56 weeks for the control group. The length of time to thrombosis or revision was significantly longer in the control group (P = 0.0058). Comparison of the number of weeks of function and serviceability of the grafts revealed the average DIASTAT graft functioned for 34 weeks and that of the control group for an average of 70 weeks (P = 0.0131). Comparison of the two groups showed a significant increase in early thrombotic events (< 90 days) in the DIASTAT grafts (P = 0.0013). CONCLUSIONS: The DIASTAT vascular access graft does not appear to be the ideal hemodialysis access graft.

Adult↗
PubMed2000

Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis.

BACKGROUND: The objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis. METHODS: A retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute. RESULTS: Seventy-seven patients (57 men and 20 women, mean age 48 +/- 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 70% +/- 9%, 59% +/- 10%, and 55% +/- 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 45% +/- 10%, 40% +/- 10%, and 36% +/- 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% +/- 9% following aortic valve replacement and 79% +/- 9% following mitral valve replacement. Five-year survival for PVE averaged 66% +/- 12% following aortic valve replacement and 43% +/- 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2. CONCLUSIONS: Prosthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.

Adult↗
PubMed2001

Fracture-embolization of duromedics valve prosthesis and microscopic uncommon lesions.

We report a sudden leaflet fracture of a Duromedics mitral valve 6 years after implantation. The patient had cardiogenic shock and complained of asthenia, orthopnea, and tachycardia. Transesophageal echocardiography showed the lack of one leaflet of the prosthesis and regurgitation. An emergency mitral replacement was successfully performed. Angiographic computed tomography scan localized the sequestrum that embolized the common iliac arteries. Examination of the deficient prosthesis showed multiple lesions and, in particular, a subsurface lesion that may be characteristic of carbon pyrolytic valves.

Adult↗
PubMed2002

Surgical lead-preserving procedures for pacemaker pocket infection.

BACKGROUND: In the treatment of pacemaker pocket infection, removal of the entire pacing system has been considered necessary to avoid recurrent infection. We report a series of patients treated surgically by our lead-preserving procedures. METHODS: Between 1990 and 2001, a total of 18 patients underwent one of two types of lead-preserving procedures. Procedure 1 preserves the full length of the lead, and procedure 2 preserves only the distal part of the lead. Signs of bacteremia, endocarditis, or purulent material within the lead insulation preclude application of these procedures in patients with potential or definite pacemaker pocket infection. RESULTS: Seventeen patients who met the indications for our procedures were discharged 7 to 14 days (8.9 +/- 2.4 days, mean +/- SD) postoperatively without signs of infection and were followed up for a total of 987 patient-months until the close of the study or death without recurrent infection. The remaining 1 patient, who did not meet the indications, suffered reinfection soon after the operation. CONCLUSIONS: The follow-up data suggest that our lead-preserving procedures should be considered as alternatives to conventional removal of the entire pacing system in cases of pocket infection that meet specific criteria.

Adult↗
PubMed1998

Onlay cortical allografting for the femur.

Failed femoral total hip replacement components are frequently associated with bone loss. At the time of revision surgery, the goals are to create a construct that relieves pain, is stable, and preserves and enhances bone stock. This article discusses Materials and Methods, Indications, Operative Technique, and Results regarding onlay cortical allografting for the femur.

Arthroplasty, Replacement, Hip↗
PubMed2001

Penile prosthesis in the organ transplant recipient.

OBJECTIVES: To determine whether pelvic organ transplant recipients are at a higher risk of developing complications after placement of a penile prosthesis relative to those receiving a penile prosthesis who did not undergo pelvic organ transplantation. METHODS: Two hundred eleven men underwent placement of a penile prosthesis by a single urologist at our institution between July 1994 and March 2000. Of these, 46 patients had undergone pelvic organ transplantation before placement of the penile prosthesis. The average time from transplantation was 43 months. The average follow-up after prosthesis placement was 23 months. These patients were monitored for various complications, including infection, malfunction, autoinflation, and injury to the prosthesis. They were compared with a cohort of men who had had a prosthesis placed but had not received pelvic organ transplantation. RESULTS: The overall complication rate was significantly higher in the transplant patients (22%) than in the nontransplant patients (7.9%) receiving prostheses (P <0.01). Infection was seen in 2 transplant patients (4.3%) and in 7 nontransplant patients (4.2%) (P <1). Malfunction occurred in 4 of the transplant patients (8.7%) and 6 of the nontransplant patients (3.6%) (P <0.2). In those patients with a prosthesis malfunction, 9 of 10 involved a three-piece prosthesis. All four malfunctions in the transplant group occurred in three-piece prostheses. The difference in the rate of malfunction was statistically significant (P <0.001) when comparing the three-piece prosthesis in the transplant and nontransplant patients (P <0.001). Surgical injury to the retroperitoneal reservoir occurred in 4 transplant patients (8.7%) (all with three-piece prostheses) and in none of the nontransplant patients (P <0.001). CONCLUSIONS: The risk of infection after insertion of penile prostheses in patients with pelvic organ transplantation was similar to that in nontransplant patients. The risk of malfunction and injury to the prosthesis (three-piece) was higher in transplant patients. The overall complication rate was significantly higher in patients after transplantation and can be attributed to the reservoir complications related to three-piece prostheses. In patients with a prosthesis that did not have a retroperitoneal reservoir, no significant difference in the overall complication rate was observed. Pelvic organ transplant recipients in whom traditional conservative therapy for erectile dysfunction fails should be considered candidates for penile prosthesis placement. However, three-piece prostheses should be avoided, as these patients are best served with prostheses that do not require a retroperitoneal reservoir.

Adult↗