Posterior distal cement extrusion during primary total hip arthroplasty: a cause for concern?

Manually operated injection systems are routinely used to deliver polymethyl methacrylate during cemented femoral component primary total hip arthroplasty (THA). The goal of cement delivery is to achieve sufficient intrusion of cement into the trabecular bone of the prepared femur so that the femoral component is securely bonded to the femur. We have observed posterior distal cement extrusion (PDCE), which appears to be secondary to too-successful pressurization. We sought to quantify and offer a possible explanation for this phenomenon. Eight patients with PDCE were identified, with an estimated incidence range of 0.90%, to 1.6% of primary cemented femoral component THA. All occurred in female patients of small stature. Endosteal canal diameters were also small, averaging 11 mm, 10 cm from the lesser trochanter. The PDCE occurred at an average distance of 9.8 cm from the midpoint of the lesser trochanter, and was most easily visualized on the lateral radiograph where it resided in the posterior soft tissues. Examination of 49 human femora showed 1 or more vascular channels in the posterior aspect of the femur in all specimens. The most proximal vascular channel averaged 10.1 cm distal to the lesser trochanter and had an average lumen diameter of 1 mm. The vascular channel contained an artery and 2 veins by histologic examination. We postulate that PDCE represents the escape of low-viscosity cement out of the vascular channel, and laboratory simulation supports this possibility. Because this finding has not previously been reported, we hoped that other centers will look closely for this phenomenon.     

Corns and calluses in athletes’ feet: a cause for concern

The risk of suffering disorders of the skin and underlying tissue in the lower extremities is one of the few adverse effects of a physically active lifestyle. Engagement in a physically challenging sport, demanding and repetitive physical activity or high-impact exercising has particularly been linked to hyperkeratotic lesions such as corns and calluses. Corn and callus formation is the skin's natural attempt to compensate for prolonged or excessive pressure, friction and other forms of local irritation by increasing its thickness at sites of excessive mechanical stress. Initially this thickening of the skin is helpful, but over time it builds up and becomes a source of morbidity. Increased mass of the lesion results in increased pressure and discomfort. Thus, a vicious cycle develops which is only broken by decreasing the size of the hyperkeratotic growth and relieving or eliminating pressure on the affected area of the skin. Failure to treat these conditions appropriately and adequately may contribute to the development of serious and disabling skin pathology. This paper considers the incidence of corns and calluses pertaining to athletes’ feet, describes their clinical characteristics, outlines the underlying causes or etiology of their formation, provides an overview of the pathogenetic mechanism responsible for their development and addresses certain diagnostic procedures used to identify them. The therapeutic means available for the treatment of corns and calluses along with their potential complications are further presented and discussed.     

Gadolinium use in patients with kidney disease: a cause for concern

Gadolinium is widely used as a magnetic resonance imaging contrast agent and is considered to have a good overall safety profile. Recently, both renal and extra-renal toxicities have been reported following exposure to gadolinium in patients with underlying kidney disease. Gadolinium-related contrast-induced nephropathy appears to be a risk in patients with advanced kidney disease and especially those with diabetic nephropathy. Even more concerning is the strong association of gadolinium with nephrogenic systemic fibrosis (NSF), a devastating fibrosing disorder of the skin and other systemic organs. Although cause and effect have not been proven for the NSF-gadolinium link, the impaired renal elimination of gadolinium in patients with kidney disease and the instability of gadolinium-chelate binding may expose tissues to toxic free Gd(3+) and promote this fibrosing disorder. Caution should be exercised when utilizing gadolinium as a contrast agent in patients with advanced CKD or ESRD.     

Severe anemia after Roux-en-Y gastric bypass: a cause for concern

Background

The current popularity of metabolic surgery has led to increasing attention to long-term nutritional complications.

Severe hyponatraemia in elderly patients: cause for concern.

An increased incidence of severe hyponatraemia in an orthopaedic unit led to an investigation into the possible causes. Routine perioperative administration of ''hypotonic'' intravenous fluid to an elderly population emerged as the most important aggravating factor. Care is necessary in prescribing intravenous fluid regimens in order to avoid potentially serious complications.     

Theatre delay for emergency general surgical patients: a cause for concern?

The delay involved in operating on emergency general surgical patients is often excessive. This problem has been examined prospectively in a district general hospital with a catchment population of 450,000. Over a 16-week period, the details of 204 consecutive general surgical emergency operations were recorded and analysed. Following essential resuscitation, the median delay in operating on emergency general surgical patients was 3 h. Eighty-eight patients had to wait in excess of 1 h, with 15% experiencing a delay of over 6 h. In only 10% of cases was a theatre required after midnight, yet 26% of all emergency general surgical operating was performed between midnight and 8 am. The majority of delays were due to a combination of factors; theatre delay was mentioned in 47% of cases, anesthetic delay in 30% and the overrunning of routine lists in 14% of cases. Our results suggest that unnecessary theatre delay results in an unacceptable number of emergency general surgical operations occurring after midnight. It is important that routine afternoon lists do not overrun, as this contributes directly to evening theatre delay. If both theatre and anaesthetic availability could be ensured in the afternoon and early evening, the after midnight workload could be cut from 26% to 10%, and staff sleep deprivation reduced.     

Factors responsible for the high perforation rate seen in early childhood appendicitis

The incidence of perforated appendicitis has remained high in the infant and young child resulting in substantial morbidity. The purpose of the present study was to investigate the factors contributing to the high perforation rate seen in this age group. A retrospective analysis was done on 77 patients under the age of seven who underwent appendectomy for appendicitis. The perforation rate was 72.7 per cent. Duration of pain correlated with patient age and perforation rate. Under the age of five, only 17 per cent had symptoms for less than 36 hours. Children with symptoms that lasted longer than 48 hours had a perforation rate of 98 per cent. Associated illnesses including respiratory infections, otitis media, and gastroenteritis were common in both simple and perforated appendicitis, often leading to a delay in diagnosis. Of patients with perforation, 36 per cent were seen at least once by the primary physician and discharged. The keys to the diagnosis of appendicitis in this young age group were history and physical exam. Right lower quadrant findings were present in 95 per cent of patients with simple appendicitis and 71 per cent of patients with perforation. The primary-care physician and consulting surgeon have crucial roles in diagnosing the disease early in its course.     

Bile duct injury following laparoscopic cholecystectomy: a cause for continued concern.

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74, 46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.     

Salmonella typhimurium: a rare cause of colonic ulceration and perforation in infancy

A rare case of a healthy infant with colonic ulcers caused by Salmonella typhimurium infection that presented with colonic perforation, hypovolemic, and septicemic shock is discussed. It stresses the importance of considering an infective process such as salmonellosis in the differential diagnosis of colonic ulceration in an infant and illustrates the unique histologic finding of colonic inflammatory changes with sparing of the small intestine.     

Glove perforation in hip and knee arthroplasty

Background  

The transmission of blood-borne pathogens during surgery is a major concern. Surgical gloves are the primary barrier between the surgeon and the patient. Surgical procedures that need manual handling of bony surfaces or sharp instruments have the highest risk of glove perforations. The frequencies and the sites of surgical glove perforations in arthroplasty procedures were assessed.