Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

 Objective. The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses. Design. Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard. Results. Digital subtraction arthrography was best (P<0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P=0.24) and scintigraphy (P=0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P=0.001), while the plain radiograph was of significant (P=0.04) additional value and scintigraphy was of no additional value (P=0.13) on multivariate analysis. Conclusion. Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.     

ADVERSE EVENTS AFTER PROSTATECTOMY IN VICTORIAN PUBLIC HOSPITALS

Background : A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was conducted to analyse trends in prostatectomy rates in Victorian public acute-care hospitals from 1989/90 to 1994/95. The study also sought to identify predictors of adverse events (AE) after prostatectomy, and to compare in-hospital complications between open prostatectomy and transurethral resection of prostate (TURP). Methods : All patients who had undergone any prostatectomy were identified according to the relevant ICD-9-CM procedure codes (60.2–60.4) documented in the VIMD. The main outcome measures, AE, were identified using the ICD-9-CM supplementary classification of external cause of injury (E850–858, E870–876, E878–879, E930–949). The variables used as predictors were year of prostatectomy, type of admission (planned, emergency), location of the hospital (rural, metropolitan), type of procedure (TURP, open), and teaching status of the hospital. Crude and adjusted odds ratios (OR) were based on univariate and multivariate logistic regression. Results : The rates of prostatectomies have significantly increased over the 6-year study period (P for trend < 0.0001). The percentage of AE after prostatectomy increased simultaneously from 6.1 to 12.9% (P < 0.0001). During the same period, the in-hospital mortality rate after prostatectomy decreased from 1.2 to 0.5%, and length of stay decreased from 10.3 to 6.1 days (Kruskal–Wallis P < 0.0001). The significant predictors of outcome were year of prostatectomy (P for trend < 0.0001), emergency admissions (OR = 1.57; P < 0.0001), metropolitan hospitals (OR = 0.81; P= 0.0003), non-teaching hospitals (OR = 0.78; P < 0.0001), and open prostatectomy (OR = 1.52; P= 0.04). More in-hospital complications were associated with open prostatectomy than with TURP. Conclusions : The rise in AE rate after prostatectomy is unlikely to reflect poor quality of care, because in the same period there was a significant decrease in in-hospital mortality after prostatectomy. A more likely explanation is heightened awareness of AE with a lower threshold for reporting such events. Important factors other than variations in quality of care can result in an increase in AE. Hence the reported increase should be interpreted with caution before attempting to conclude that changes in clinical practice could have a direct impact on these rates.     

Intestinal plethora: An early sign of acute posttraumatic hepatic artery-portal vein arteriovenous fistula

Traumatic communications between the hepatic artery or its branches and the portal vein or its tributaries usually are clinically occult until the late sequelae of portal hypertension, such as esophageal and mesenteric varices, ascites, or congestive heart failure, become manifest. The authors describe the early diagnosis of such a lesion by computed tomography. The CT findings included a hepatic hematoma and, more significantly, diffuse thickening of the small and large bowel wall. This thickening represents vascular congestion of the bowel caused by acute portal hypertension prior to the development of decompressing portal collateral circuits. When this CT finding is not associated with other signs of intestinal ischemia or infarction, it should suggest portal hypertension and lead to arteriography for diagnosis and therapy of arterioportal fistula.     

Abdominal zygomycotic thromboangiitis in a patient with AML and t(1;13;14)

 The case report of a 61 year-old man with AML M2 FAB, t(1; 13; 14) and zygomycotic mesenterial thromboangiitis is presented. Two induction cycles of chemotherapy were administered due to primary drug resistance. They were complicated by pneumonia, colonic pseudo-obstruction and perforation with peritonitis. The patient died on the 40th day of therapy, 4 days after undergoing palliative surgery. Zygomycotic thromboangiitis, which very probably contributed to the intestinal perforation, was confirmed morphologically at necropsy. The novel complex chromosomal translocation t(1; 13; 14) (q31; q32; q24) and the problems connected with the diagnosis of invasive fungal infections are discussed. Received: 26 January 1996 / Accepted: 12 June 1996     

Mediastinal teratoma in a neonate

A neonate with severe respiratory distress due to a benign mediastinal teratoma (MT) is reported. Despite early and easy surgical excision of the tumor, the child died due to poor cardiac function. Only ten cases of MT in neonates have been reported in the literature so far. While the tumor has been known to interfere with lung development in utero, postnatal myocardial dysfunction due to poor heart development has not been previously documented. Accepted: 22 September 1997     

Osteotomy at the knee for advanced cases of Kashin-Beck disease

Summary. The results of 247 osteotomies at the knee were analysed in 195 patients with Kashin-Beck disease. Since 1983, 37 varus and 210 valgus deformities have been operated on. Supracondylar osteotomy was carried out so that there is a cortical spike in the distal metaphysis which is impacted into the femoral condyle. A U-shaped tibial osteotomy is made 0.5 cm below the growth plate and around the insertion of the patellar ligament. The mechanical axis is corrected and stability obtained by impacting the fragments; internal fixation is not used. Correction of the initial angular deformities was achieved after the osteotomies, and function was improved.

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Résumé. Les résultats de 247 ostéotomies du genou sont analysés sur 195 patients atteints de la maladie de Kashin-Beck. La technique d’ostéotomie utilisée se caractérise, au niveau de la métaphyse distale du fémur, par la réalisation d’une section supracondylienne présentant un ergot cortical et au niveau de la métaphyse proximale du tibia par une section respectant l’insertion du ligament rotulien en la contournant distalement. Vu l’absence de matériel de fixation interne ou externe, l’impaction des fragments permet de stabiliser efficacement la correction de l’axe mécanique. Depuis 1983, 37 genu vara et 210 genu valga ont été ostéotomisés. Les résultats présentent la distribution des déformations angulaires initiales et les corrections obtenues après ostéotomie. L’amélioration fonctionelle confirme l’intérêt de cette technique en l’absence de matériel d’ostéosynthèse.

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Accepted: 23 October 1997