Randomized trial of hypotensive epidural anesthesia in older adults.

BACKGROUND: Data are sparse on the incidence of postoperative cognitive, cardiac, and renal complications after deliberate hypotensive anesthesia in elderly patients. METHODS: This randomized, controlled clinical trial included 235 older adults with comorbid medical illnesses undergoing elective primary total hip replacement with epidural anesthesia. The patients were randomly assigned to one of two levels of intraoperative mean arterial blood pressure management: either to a markedly hypotensive mean arterial blood pressure range of 45-55 mmHg or to a less hypotensive range of 55-70 mmHg. Cognitive outcome was assessed by within-patient change on 10 neuropsychologic tests assessing memory, psychomotor, and language skills from before surgery to 1 week and 4 months after surgery. Prospective standardized surveillance was performed for cardiovascular and renal outcomes, delirium, thromboembolism, and blood loss and replacement. RESULTS: The two groups were similar at baseline in terms of age (mean, 72 yr), sex (50% women), comorbid conditions, and cognitive function. After operation, no significant differences in the incidence of early or long-term cognitive dysfunction were observed between the two blood pressure management groups. There were no significant differences in the rates of other adverse consequences, including cardiac, renal, and thromboembolic complications. In addition, no differences occurred in the duration of surgery, intraoperative estimated blood loss, or transfusion rates. CONCLUSIONS: Elderly patients can safely receive controlled hypotensive epidural anesthesia with this protocol. There was no evidence of greater risks, or early benefits, with the use of the more markedly hypotensive range.     

Long-term results of dorsal stabilization in the rheumatoid wrist

Dorsal stabilization was performed on 85 rheumatoid wrist in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.     

Survivorship analysis and results of total condylar knee arthroplasty. Eight- to 11-year follow-up period

This study deals with survivorship of total condylar knee arthroplasties in 87 consecutive patients (112 knees) with follow-up periods of up to 11 years. The end point of the survivorship was defined as: (1) the need for revision due to septic or aseptic loosening; (2) roentgenographic loosening evidenced by a shift of component position; or (3) radiolucency extending under the condyle of the tibial component and partially along the peg, when associated with clinical symptoms. Life table calculations predict 88.7% survivorship of total condylar knee arthroplasty. Using revision for septic or aseptic loosening and recommendation for surgery as an end point, the survivorship was 94.1% 11 years after operation in this series. Seventy-two patients (90 knees) of 87 were available for clinical and roentgenographic study at eight to 11 years. Eight patients (12 knees) had died and seven patients (ten knees) were lost to follow-up study. The results were excellent to good in 93%, fair in 3%, and poor in 4%. Roentgenographic evaluation revealed well-fixed components in 36 knees (40%). Radiolucencies of varying degrees were present in 54 knees (60%). Of the 54 knees, seven had radiolucency under the tibial condyle in Zones I-IV and partially along the peg in Zones V and VI. Two knees had component loosening, one with a loose patella and the other a loose tibial component; both of these patients were symptomatic. Variables such as the patient's age, sex, diagnosis, alignment and position of the prosthesis, and level of bone cut did not correlate with the development of radiolucencies at the cement-bone interface.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sciatic nerve palsy after primary total hip arthroplasty: a new perspective

More than half of sciatic nerve palsies after primary total hip arthroplasties are unexplained. In 2 such cases, magnetic resonance imaging localized compressive injury between the ischial tuberosity and femoral insertion of the gluteus maximus. After these cases, we hypothesized that during limb positioning, the sciatic nerve is compressed by the gluteus maximus tendon. We present the magnetic resonance imaging findings from these 2 cases and compare the number of sciatic nerve palsies in patients with release of the gluteus maximus tendon to patients without release during primary total hip arthroplasty. There were no cases of sciatic nerve palsy when the gluteus maximus was released, compared with 3 cases in the control group.     

The impact of modern cement techniques on acetabular fixation in cemented total hip replacement

A radiographic study was performed to assess acetabular fixation in 78 total hip replacements performed between 1971 and 1980. In 1979, the technique of acetabular component insertion was modified to include water-pik lavage, preservation of subchondral bone of the acetabulum during reaming, multiple fixation holes in the pubis ischium and ilium, and devices that improve pressurization of the cement into the cancellous bone surfaces. The impact of these techniques was studied. A cumulative radiolucency score was calculated for each acetabulum from 5-year follow-up radiographs, and the mean cup radiolucency scores for two chronologic groups were compared using the t-test for independent samples. No significant differences in patient age, weight, or sex, type of prosthesis, or approach used was found between groups. The acetabular components inserted between 1979 and 1980 had significantly lower cup radiolucency scores than those inserted between 1971 and 1978, at 5-year follow-up evaluation. Modern cement technique may be responsible for significantly enhanced durability of acetabular fixation in cemented total hip replacement.     

The nine- to fifteen-year follow-up of one-stage bilateral total hip arthroplasty

Careful selection and preoperative evaluation of patients with bilateral hip disease for one-stage bilateral total hip arthroplasty can yield satisfactory results consistent with those published for unilateral hip disease. These patients are generally younger and more active than patients undergoing unilateral total hip arthroplasty and require meticulous attention to both technique and prosthetic design. The authors found that the Charnley design remains the gold standard against which other prostheses must be measured in the long-term follow-up.     

Clinical and Radiographic Results of Attune and PFC Sigma Knee Designs at 2-Year Follow-Up: A Prospective Matched-Pair Analysis

Background

Anterior knee pain (AKP) and/or crepitation are important causes of dissatisfaction after total knee arthroplasty (TKA). Aim of this prospective, matched-pair study was to compare 2 different designs of patellofemoral (ie, trochlear groove) TKA. The Attune knee has an anatomic trochlear groove with a medialized dome patellar component vs the PFC Sigma with a single radius trochlear groove with a domed shaped patella.

Total condylar knee replacement: a 20-year followup study.

Between 1976 and 1979, 220 total knee replacements were done on 164 patients using the Total Condylar Knee replacement. The diagnosis was rheumatoid arthritis in 111 knees and osteoarthritis in 109 knees. Patients with 157 knees are known to have died as of December 1998, leaving 63 knees in patients who are still alive. Twelve patients with 18 knees were lost to followup. The average 20-year followup data (range, 18-22 years) are presented for 45 knees in 30 patients using Knee Society evaluations. The average Knee Society clinical score for the surviving patients was 88 points, and the average functional score was 58 points. The radiographic followup averaged 19 years. The average overall alignment was 3 degrees valgus. Femoral lucencies were present in 17 of 40 adequate lateral views, most commonly about the anterior and posterior surfaces. Two femoral components were loose. Twenty-two tibial components had radiolucencies; four radiolucencies were circumferential. The remaining 41 knees retained a well-fixed cemented central peg despite proximal interface lucencies. From the group of 220 knees, 14 revisions have been done at an average of 11.4 years postoperative. Two knee replacements were revised for isolated tibial loosening, whereas one knee replacement had isolated femoral loosening. Three knee replacements were revised for loosening of both components, and one was revised for isolated patellar loosening. Four patients had sepsis develop; three of these four patients were treated with two-stage revision, and one underwent fusion. Three patients were treated for supracondylar fractures. The Total Condylar Knee replacement maintains excellent durability at 20-years followup.     

A New Perspective on the Quercetin Paradox in Male Reproductive Dysfunction

Dietary bioflavonoids represent a large class of polyphenolic compounds found in most plants. A significant number of flavonoids are reported to have beneficial health effects. Quercetin is one such flavonoid which has been reported to possess strong antioxidant properties. However, as far as male reproduction and fertility are concerned, controversial reports exist in the literature highlighting the antioxidant as well as a prooxidant character of quercetin, leaving much to the researcher's speculation. The present review therefore, aimed at addressing this paradoxical behavior of quercetin by taking into account the in vitro and in vivo studies conducted till date regarding its role in the maintenance of male reproductive potential. From the detailed survey of the published data, it appears that the conflicting biological effects of quercetin might relate to its dose and the redox state of the cell. Thus, the cellular toxicity of quercetin metabolites might overshadow the beneficial effects of its supplementation in subjects having reproductive dysfunction coupled with elevated oxidative stress leading to the paradoxical behavior of the flavonoid. Copyright © 2012 John Wiley & Sons, Ltd.