The Genesis total knee prosthesis: a 10-year followup study.

This current author reports on the results of 100 consecutive patients with osteoarthritis who underwent a primary cemented total knee replacement using the Genesis prosthesis and who have been followed up for at least 10 years after surgery. In patients in whom the posterior cruciate ligament was sacrificed (combined flexion and angular deformities > 15 degrees to 20 degrees) a posterior-stabilized cam module was affixed to the femoral component and a posterior-stabilized polyethylene was used. More than 95% of patients in both groups had excellent pain relief. The mean flexion was 114 degrees in the group of patients in whom the posterior cruciate ligament was sacrificed and 117 degrees in the group of patients in whom the posterior cruciate ligament was retained. Partial bone cement tibial radiolucencies were seen in 12% of the patients in whom the posterior cruciate ligament was retained and 2% of the patients in whom the posterior cruciate ligament was sacrificed. At 10 years, 76% of the group in whom the posterior cruciate ligament was retained had excellent results and 20% had good results. In the group in whom the posterior cruciate ligament was sacrificed 75% had excellent results and 23% had good results. The survivorship was 96% in the group of patients in whom the posterior cruciate ligament was retained and 97% in the group of patients in whom the posterior cruciate ligament was sacrificed.     

A possible mechanism of psoralen phototoxicity not involving direct interaction with DNA.

Psoralens in combination with ultraviolet light (UVA; 320-400 nm) are used in the photochemical treatment of a variety of skin diseases including vitiligo, a skin depigmentational disorder, and psoriasis, a disease of accelerated epidermal cell proliferation. Although it is generally assumed that the major site of action of the psoralens is DNA, we have obtained evidence that another site may be the primary target for these compounds. We have identified specific, saturable, high-affinity binding sites for 8-methoxypsoralen on HeLa cells and have detected specific binding of 8-methoxypsoralen to four other human cell lines and five mouse cell lines. In HeLa cells, specific binding is reversible and independent of the ability of the compound to intercalate into DNA. In addition, binding sites become covalently modified by the psoralen after UVA exposure. Specific binding of 8-[methoxy-3H]methoxypsoralen constitutes 79% of the label bound to the cells. Scatchard analysis indicated two classes of psoralen binding sites: high-affinity sites with a Kd of 19 X 10(-9) M (1.8 X 10(5) sites per cell) and low-affinity sites with a Kd of 4 X 10(-6) M (7.1 X 10(6) sites per cell). Four structurally related psoralen analogs block 8-methoxypsoralen binding in a manner that parallels their biological activity. Based on these findings, we hypothesize that specific binding sites for psoralens on mammalian cells mediate, at least in part, psoralen-induced phototoxicity.     

Ligament Tension in the ACL-deficient Knee: Assessment of Medial and Lateral Gaps

Obtaining symmetric and balanced gaps under equilateral loads is a common goal in posterior cruciate ligament (PCL)-retaining and -sacrificing TKAs. Owing to limitations in existing surgical tensors, however, tensing knee ligaments with standardized and symmetric loads has been possible only with the patella subluxated or everted. We therefore determined the influences of (1) patellar eversion versus complete reduction, (2) PCL resection, and (3) load magnitude on gap symmetry and balance in the anterior cruciate ligament (ACL)-deficient knee. We used a novel computer-controlled tensioner to measure gaps in 10 cadavers with an applied force of 50 N, 75 N, and 100 N per side. Gap data were acquired at 0o, 30o, 60o, 90o, and 120o flexion with the patella reduced and everted and with the PCL intact and resected. Everting the patella tightened the medial and lateral flexion gaps between 90o and 120o by 0.7 mm to 2.7 mm. PCL resection increased gaps from 30° to 120° by 1 mm to 3 mm. Increasing the force from 50 N to 100 N increased the mean gap by 0.5 mm. Everting the patella and resecting the PCL influenced gap balance and symmetry. Surgeons should be aware of how these conditions affect gaps during assessment and balancing. Richard Laskin—Deceased. One of the authors (CP) is employed by Praxim Inc, Walpole, MA. Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.     

The Classic: Total Condylar Knee Replacement in Patients Who Have Rheumatoid Arthritis. A Ten-Year Follow-Up Study

Eighty knee replacements with a total condylar prosthesis in patients who had rheumatoid arthritis were followed for ten years. At ten years, nineteen knees needed revision and sixty-one prostheses were still functioning. The major reasons for revision were loosening of the tibial component or late bacteremic seeding from another site. Radiolucency at the bone-cement interface adjacent to the tibial component was statistically related to malposition of the tibial component. According to the system of The Hospital for Special Surgery, the mean scores were 64 points preoperatively and 85 points postoperatively. Synovitis recurred in only 3 per cent of the knees. When revision, pain, or radiographic evidence of loosening were considered an indication of failure, the ten-year cumulative survival was 75 per cent.     

Benign epithelioid peripheral nerve sheath tumors of the soft tissues: clinicopathologic spectrum of 33 cases

Benign epithelioid peripheral nerve sheath tumors (BEPNSTs) have not been fully characterized, and their relationship to conventional schwannoma and neurofibroma has not been satisfactorily established. Herein, we detail the clinicopathologic features of 33 examples of BEPNST. The study included 22 females and 11 males ranging in age from 2 to 68 years (median, 31.5 years). Only one patient probably has neurofibromatosis type 1. The tumors were predominantly dermal/subcutaneous in location (85%) and involved the lower limb (n=15), upper limb (n=11), trunk (n=4), and head/neck (n=3). The lesions ranged in size from 0.3 to 6.8 cm (median, 1.1 cm). Microscopically, the tumors were generally well-circumscribed, uninodular, or multinodular masses. Twenty-six lesions were encapsulated. Tumors consisted of trabeculae, loosely arranged nodules, and cohesive nests of epithelioid tumor cells immersed in collagenous, myxohyaline, or chiefly myxoid stroma. A bland spindled cell component comprising 5% to 40% of the tumor was noted in 15 cases. Mitotic activity ranged from 0 to 6 mitoses/50 high power fields (mean, 1.5 mitoses/50 high power fields) with no abnormal division figures identified. Five lesions were considered atypical based on presence of focal nuclear/nucleolar enlargement and hyperchromasia. Immunohistochemical reactivity for Schwann cell-related markers in tumor cells included S-100 protein (20 of 20 cases), collagen type IV (10 of 10), laminin (8 of 8), nerve growth factor receptor, p75(7 of 8), CD57 (6 of 9), and glial fibrillary acidic protein (8 of 15). CD34-positive fibroblast-like cells were identified in all 12 neoplasms tested. Anti-epithelial membrane antigen highlighted perineurial cells in 9 of the 11 encapsulated tumors. Anti-neurofilament protein did not identify intralesional neuraxons in the 10 tumors evaluated. Eighteen tumors were subtyped as epithelioid neurofibromas. The remaining 15 cases showed some histologic features suggestive of schwannoma, but their uniform cellularity, absence of nuclear palisading, and presence of a significant CD34-positive spindled cell population in 5 cases led to their classification as "BEPNST of indeterminate histogenesis." Evaluation for loss of heterozygosity in 2 cases demonstrated deletion of genetic material on chromosome 22q and 17q involving NF2 and NF1 loci. However, sequencing of NF2 coding sequences revealed no mutations. Follow-up for 18 patients (median interval, 13.5 years), including 4 patients with tumors exhibiting cytologic atypia, revealed a nondestructive recurrence or persistent disease in 3 patients whose tumors lacked atypia, but no evidence of metastatic spread or tumor-related death. BEPNSTs are usually small neoplasms located in superficial soft tissue and have an excellent prognosis after complete local excision. Accurate subclassification of some of these lesions is difficult based on currently available techniques.     

Do Patients Fear Undergoing General Anesthesia for Oral Surgery?

Many patients undergoing major surgery have more fear of the general anesthesia than the procedure. This appears to be reversed with oral surgery. Therefore, patients need to be as well informed about this aspect as the surgical operation.A study by the American Society of Anesthesiologists (ASA), reported in 2010, found that a lack of understanding and fear about general anesthesia has led to as many as 25% of patients postponing necessary surgery.¹ However, the attitude of patients about having general anesthesia specifically for oral surgery procedures has never been investigated. The purpose of this study was to determine if patients who need to undergo a general anesthetic for oral surgery have the same apprehension as those needing major surgery. It was hypothesized that a similar lack of knowledge and fear about general anesthesia would be found. If this were true, it could lead to protocols being developed that would make it possible for patients to undergo such treatment in a less stressful manner.