2- to 9-year outcome of stemmed total knee arthroplasty: Similar failure rates in patients when used primary or as a revision

Background and purpose —

There is an increase in demand for primary and revision total knee joint procedures. We studied implant survival and functional outcome of patients operated with a constrained condylar knee (CCK) or a rotating hinge implant (RH) as a primary or a revision total knee arthoplasty (TKA).

Patients and methods —

We evaluated clinically and radiographically 65 surgical procedures with a mean follow-up time of 5 (2–9) years (40 CCK and 25 RH). There were 24 primary TKAs—due to instability—and 41 revision TKAs, mostly due to aseptic loosening. Mean age at the index operation was 68 (31–88) years.

Results —

Overall, there were 12 failures, including 8 reoperations due to deep infection. The overall 5-year survival rate with reoperation as the endpoint was 82% (95% CI: 72–99). Radiolucent lines on either the femoral or the tibial side were seen in 36 cases. When comparing the cases that were operated as a primary TKA or as a revision TKA, function, health-related quality of life, and survival were similar. However, after primary TKA the patients generally had less pain and a higher proportion of patients were very satisfied or satisfied.

Interpretation —

Although a high rate of severe complications was observed, most patients improved in function after surgery regardless of whether it was a primary or a revision TKA. We found narrow radiolucent lines—mainly on the tibial side—in nearly half of the cases, but none of the implants were loose radiographically. Overall patient satisfaction and health-related quality of life were high, and a minority had problems with persistent pain.There will be an increase in demand for primary and revision total knee joint arthroplasties over the coming decades (Kurtz et al. 2007, Hossain et al. 2010). The function of the soft-tissue envelope and possible bone deficiency guide implant choice. Revision implants are used in patients with severe valgus-varus instability and/or increased laxity in flexion gap (Hossain et al. 2010). There are constrained condylar prostheses (CCK) and linked rotating hinge (RH) designs. In the majority of cases, these designs are saved for revision surgery, but they may be used in primary TKA as well, especially if severe deformity or ligament instability is present (Petrou et al. 2004, Hossain et al. 2010).The main purpose of this retrospective study was to gain information on implant survival and functional outcome in 65 consecutive procedures using stabilizing TKAs with stemmed components (CCKs and RHs). Secondary outcome measures were complication rate, patient satisfaction, health-related quality of life, and radiographic results. We also wanted to determine whether there were any differences in patient outcome when these implants were used as a primary knee replacement or as a revision total knee replacement.     

Multiple system aging‐related tau astrogliopathy with complex proteinopathy in an oligosymptomatic octogenarian

The combination of multiple neurodegenerative proteinopathies is increasingly recognized. Together they can potentiate neuronal dysfunction and contribute to complex neurological symptoms. We report an octogenarian female case of multiple extraneural metastases of a rectal carcinoma. She attempted suicide, which ultimately led to cardiorespiratory failure nine days after hospital admission. Apart from the suicide attempt and late‐onset depression, other psychiatric or neurological symptoms were not reported. Unexpectedly, histopathologic examination revealed prominent aging‐related tau astrogliopathy (ARTAG) of all five types (subpial, subependymal, grey and white matter, and perivascular) affecting cortical and subcortical brain regions. This pathology was associated with intermediate Alzheimer's disease neuropathologic change (A2B2C2 score), cerebral amyloid angiopathy, Lewy body‐type α‐synuclein proteinopathy (Braak stage 4), and a multiple system transactivation response DNA‐binding protein of 43 kDa (TDP‐43) proteinopathy also involving the astroglia. In summary, we report a complex and extensive combination of multiple proteinopathies with widespread ARTAG of all five types in a patient who had attempted suicide. Although longitudinal psychometric tests and neuropsychological evaluations were not performed, this report poses the question of thresholds of cognition and pathology load, describes ARTAG affecting unusually widespread brain regions, and supports the notion that complex proteinopathies should be regarded as a frequent condition in the elderly.     

A prospective study of anxiety with respect to seizure outcome after epilepsy surgery.

PURPOSE: To evaluate if degree of anxiety proneness is affected by seizure outcome after epilepsy surgery. METHODS: Five scales related to anxiety, which are part of the Karolinska Scales of Personality (KSP), were administered pre-operatively and 2-8 years post-operatively to 31 female and 26 male patients. High scores indicate a high degree of anxiety. Seizure outcome was either Engel I or Engel II-IV. RESULTS: Mean age of the patients was 39 years (S.D. 10). Forty-seven patients had temporal surgery and 10 patients had extra-temporal surgery. The outcome in 34 patients was classified as Engel I and in 23 patients as Engel II-IV. There were statistically significant decreases (paired t test) in t scores for the Somatic Anxiety scale (expected mean 50, from 55.4 to 50.2, P = 0.001) and the Psychic Anxiety scale (expected mean 50, from 56.2 to 51.6, P = 0.006) in patients in Engel I. No other significant differences were observed. After taking baseline imbalances into account (ANCOVA), there were no statistically significant differences in the change in degree of anxiety proneness between patients in the two outcome groups. CONCLUSION: Patients undergoing successful epilepsy surgery experienced small decreases in somatic anxiety and psychic anxiety. Since there were important pre-operative imbalances between the two outcome groups, these differences could not be attributed to the effect of seizure freedom after epilepsy surgery.     

Renal and cardiovascular effects of acute and chronic administration of felodipine to SHR

Renal function and salt and water turnover were studied in SHR during acute and chronic administration of felodipine, which is an efficient antihypertensive vasodilating Ca2+ antagonist. In conscious SHR acute administration of felodipine in hypotensive doses increased renal sympathetic nerve activity but caused renal vasodilation, increases in GFR and a 2-3 fold increase in urinary flow rate and sodium excretion. The fraction of filtered sodium excreted (FENa) was approximately doubled. The diuretic and natriuretic effects of felodipine are therefore suggested to be due to a direct inhibitory action on the renal tubular cells, resulting in reduced sodium reabsorption. Nifedipine also induced diuresis and natriuresis in this system, while minoxidil reduced water and sodium excretion. Throughout 6 months of felodipine treatment, the mean arterial pressure (MAP), remained 25-20 per cent reduced. Felodipine in combination with metoprolol reduced MAP 25-30 per cent and also caused regression of left ventricular hypertrophy, while felodipine alone prevented its further progression. Also during chronic administration, felodipine induced diuresis but had no effect on plasma volume and on sodium or potassium excretion in SHR. It is concluded that in SHR felodipine induces diuresis; on acute treatment this is secondary to reduced tubular sodium reabsorption, although during chronic treatment the sodium loss is compensated for while the diuresis remains. Thus, the cardiovascular and renal effects of Ca2+ antagonists like felodipine differ substantially from those of other potent antihypertensive vasodilators e.g. minoxidil.     

Pharmacokinetics of Imipenem/Cilastatin Sodium in Children with Peritonitis

Abstract: Fifteen children (3-12 years) with peritonitis were given imipenem/cilastatin intravenously (15 or 25 mg/kg) every six hours for 3-14 days. One day during treatment days 2-8, multiple blood and urine samples were collected from each individual over a six hour dosing interval. Twelve children completed the study. The urinary recovery of imipenem and cilastatin averaged 50-70% of the administered dose. The plasma t_1/2 for imipenem averaged 55 min. while that for cilastatin was even more rapid (~ 38 min.). Little or no accumulation of either imipenem or cilastatin was observed for this regimen in this age group of paediatric patients. Steady state conditions prevailed within 2 days of initiation of therapy. The pharmacokinetics of imipenem and cilastatin in paediatric patients 3-12 years of age appear similar to those observed for adults.     

The potential role of cyclin-dependent kinase 5 in focal cortical dysplasia

Focal cortical dysplasia (FCD) is the most common malformation of cortical development found in epilepsy surgical series. Characterised by cortical mislamination, dysplastic neurons and, in a subgroup of cases, balloon cells, FCD is potently epileptogenic. Despite decades of study, the underlying aetiology of FCD remains uncertain and research has been hampered by the lack of a good animal model in which to simulate the condition. In this article we review some of the potential molecular mechanisms that might underpin human FCD. In particular we examine the potential role of cyclin-dependent kinase 5 and its principal activator p35 in FCD and estimate the contribution that deregulation of cyclin-dependent kinase 5 might make to the pathogenesis of this condition.