Periprosthetic tibial bone mineral density changes after total knee arthroplasty: one-year follow-up study of 69 patients

BACKGROUND: The critical structure supporting the prosthetic components in total knee arthroplasty (TKA) is tibial trabecular bone. The quality of tibial bone can be evaluated by bone mineral density (BMD) measurements. PATIENTS AND METHODS: We prospectively measured changes in BMD in the proximal tibia after cemented TKA in osteoarthrotic knees. 69 patients were scanned by dual-energy X-ray absorptiometry (DXA) within a week after surgery, and after 3, 6 and 12 months. RESULTS: At baseline, the medial region of interest (ROI) BMD was higher in the varus knees than in the valgus aligned knees (p=0.02). The medial metaphyseal ROI showed a decrease in BMD during the follow-up in preoperatively varus knee joints (p<0.001). In preoperatively valgus knees, there was a slight increase in medial compartment BMD which was not significant (p=0.2). Alignment correction in both groups showed bone remodeling giving similar medial and lateral BMD values, suggesting that the bone became equally strong in both compartments of the metaphysis. There was no association between increasing American Knee Society (AKS) scores and bone remodeling. INTERPRETATION: We suggest that this remodeling is caused by postoperative changes in tibial loading. Our results support the clinical importance of recreating proper valgus alignment of the knee joint in the TKA operation, thus possibly providing better conditions for longevity of the tibial component.     

Indentation stiffness of repair tissue after autologous chondrocyte transplantation

Our main hypothesis was that indentation stiffness of the repair tissue approaches the values of adjacent cartilage 1 year after autologous chondrocyte transplantation. We also wanted to investigate the differences between osteochondritic lesions and full-thickness lesions. Thirty patients with cartilage lesions were operated on with autologous chondrocyte transplantation. The repair was evaluated arthroscopically, indentation stiffness was measured, and clinical evaluations were done. The stiffness of the repair tissue improved to 62% (mean 2.04 +/- 0.83 N, mean +/- SD) of adjacent cartilage (3.58 +/- 1.04 N). Fifty-three percent of the patients graded their knee as excellent or good and 47% of the patients graded their knee as fair at the followup. In six patients the normalized stiffness was at least 80%, suggesting hyaline-like repair. The indentation stiffness of the osteochondritis dissecans lesion repairs (1.45 +/- 0.46 N; n = 7) was less than that of the nonosteochondritis dissecans lesion repair sites (2.37 +/- 0.72 N; n = 19). Gadolinium-enhanced magnetic resonance imaging of the cartilage (dGEMRIC) during followup of four patients suggested proteoglycan replenishment, although all grafts showed low indentation values. Low stiffness values may indicate incomplete maturation or predominantly fibrous repair. The indentation analysis showed that the repair tissue stiffness could, in some cases, reach the same level as the adjacent cartilage, but there was a large variation among the grafts.     

Long-term outcome after mitral valve repair

BACKGROUND: Several studies reported excellent long-term results after mitral valve repair for regurgitation, however a number of patients still experience recurrent mitral valve regurgitation which requires reoperation. We have evaluated the long-term outcome of a consecutive series of patients who underwent mitral valve repair for regurgitation in an attempt to identify the risk factors associated with late failures. PATIENTS AND METHODS: One-hundred and sixty-four patients underwent mitral valve repair for ischemic and degenerative mitral valve regurgitation. Seventy-two patients underwent echocardiographic evaluation a median of 5.6 years after surgery. RESULTS: Ten-year survival freedom from any fatal cardiac event was 75.9% and survival freedom from redo mitral valve surgery was 93.8%. Multivariable analysis showed that residual mitral valve regurgitation grade>1 as assessed during the immediate postoperative period (at 10-year, 60.6% vs. 95.7%, p=0.001, RR 20.7, 95%C.I. 3.4-125.3) and chronic obstructive pulmonary disease/asthma (at 10-year 66.8% vs. 95.2%, p=0.013, RR 12.0, 95%C.I. 1.7-85.2) were predictors of redo mitral valve surgery. The same findings were observed also among patients with myxomatous degenerative disease. At echocardiographic follow-up, no significant improvement was detected in terms of left ventricular ejection fraction, whilst mitral valve regurgitation grade (median, 3 to 1), New York Heart Association class (median, 2 to 1) and left atrium diameter (median, 50 to 44 mm) decreased significantly. CONCLUSIONS: This study confirms the excellent clinical long-term results after mitral valve repair. An adequate repair technique is advocated in order to decrease the immediate postoperative rate of residual regurgitation>1 as this is a main determinant of late failures requiring redo mitral valve surgery. Further studies are required to better define the possible causative role of chronic obstructive pulmonary disease and any underlying connective tissue metabolic disorder in late failures after mitral valve repair.     

Late QRS Activity in Signal‐Averaged Magnetocardiography,Body Surface Potential Mapping,and Orthogonal ECG in Postinfarction Ventricular Tachycardia Patients

Background: Delayed electrical activity necessary for re‐entrant ventricular tachycardia (VT) is detectable noninvasively with high resolution techniques. We compared high resolution signalaveraged analysis of magnetocardiography (MCG), body surface potential mapping (BSPM), and orthogonal three‐lead ECG (SA‐ECG) in the identification of patients prone to VT after myocardial infarction (Ml). Methods: Patients with remote myocardial infarction and cardiac dysfunction were studied, 22 with (VT group) and 22 without VT (control group). MCG with seven channels and BSPM with 63 and SA‐ECG with three orthogonal leads were registered. After signal‐averaging and highpass filtering, three time domain analysis (TDA) parameters describing late electrical activity were computed: QRS duration (QRSd), root mean square amplitude (RMS) of the last 40 ms of QRS, and the duration of the low‐amplitude QRS end (LAS). Results: All parameters by each method were significantly different between the patients’groups. For example, LAS parameter in MCG was 59 (SD 22) ms in the VT group vs. 37 (SD 13) ms in controls (P < 0.001), 77 (SD 22) ms vs. 56 (SD 19) ms in BSPM (P = 0.002), and 60 (SD 24) ms vs. 39 (SD 22) ms in SA‐ECG (P = 0.005). The combination of LAS parameter in MCG and SA‐ECG resulted in improved performance in comparison to any single parameter with 95% sensitivity and 68% specificity. Conclusions: All three high resolution methods identified VT propensity among post‐Mi patients with cardiac dysfunction and between‐method differences were small. Information in MCG and SA‐ECG may be complementary and their combination could be of value in postinfarction arrhythmia risk assessment. A.N.E. 2002;7(4):389–398     

Structural Signaling Regulates Inflammation-Induced Enhanced Restitution and Increased Mib-1 and Bax-Indexes After Superficial Injury in Isolated Guinea Pig Gastric Mucosa

Several growth factors and cytokines are involved in regulation of the immediate repair of gastrointestinal mucosa, a process also called restitution. Few data exist on the effect of inflammation on this process using an explant model, where the folded basal lamina is included. The aim of the present study was to investigate the effect of simulated inflammation on restitution and on concomitant proliferation and apoptosis in isolated guinea pig gastric mucosa. Paired gastric mucosae were mounted in Ussing chambers (37 degrees C) and a superficial injury was induced (1.25 M NaCl/5 min) followed by a 4-hr restitution (pH 7.3-7.5). During perfusion, simulated inflammation was induced (with 0.5 or 5.0 ng/ml IL-1beta or with activated polymorphonuclear [PMN] cells). The PI (proliferative index) and AI (apoptotic index) are expressed as the number of Mib-1- or Bax-immunopositive cells per 300 foveolar cells, respectively. The mean recovery of electrophysiological resistance of tissues (R) after injury and exposure to serosal IL-1beta during restitution was 95.2 +/- 5.3% (mean +/- SD), whereas the value for control tissues was 89.6 +/- 6.9% (P = 0.016; N = 9). The mean recovery of R in tissues exposured to activated serosal PMN cells during restitution was 97.6 +/- 2.7%, whereas the value for unexposed control tissues was 93.8 +/- 2.9 (P = 0.004; N = 9). The enhancing effect of PMN cells was partially eliminated by serosal anti-ICAM, whereas serosal cytochalasin D abolished the process completely. The PI of tissues exposed to serosal PMN cells was 34.6 +/- 17.3, whereas the value for unexposed controls was 24.7 +/- 15.5 (P = 0.04; N = 5). The corresponding AI values were 17.0 +/- 2.8 and 12.0 +/- 5.7, respectively (NS; N = 4). Simulated inflammation either with serosal IL-1beta or with activated PMN cells enhances restitution and proliferation, whereas their effect on AI is only suggestive. Exogenous serosal anti-ICAM modulates restitution, whereas cytochalasin D abolishes it completely, suggesting that the structural signaling system including focal adhesions and cytoskeleton plays a significant role in the regulation of restitution.     

Clinical management of voice and breathing problems in two patients with vagus nerve stimulation therapy

We report two cases highlighting the diversity of vagal nerve stimulation (VNS)‐related effects on voice and breathing in patients with refractory epilepsy. The patients had both implantation and stimulation‐related side effects, which lasted for several months, impacting on their quality of life. The adverse effects appear to be due to recurrent laryngeal nerve paralysis‐related vocal cord hypofunction and stimulation‐related vocal fold spasms, however, their inter‐relationship is complex. In one of the patients, we were able to utilize the novel programming capabilities of the VNS device to reduce the laryngeal side effects without compromising therapeutic efficacy. [Published with video sequences].