A New Harvest Site for Bone Graft in Anterior Cruciate Ligament Revision Surgery

During revision anterior cruciate ligament (ACL) surgery, femoral interference screws frequently require removal. This may lead to significant tunnel widening and possible graft fixation failure as a result. Solutions include drilling the revision tunnel in a different location, using stacked interference screws, or using bone graft to fill the defect. Autogenous iliac crest graft and allograft are both used, but there are significant comorbidities associated with each. We developed a new technique for harvesting autogenous bone graft that avoids many of the complications associated with other graft sources. By use of the existing surgical incision from the initial harvest of the bone–patellar tendon–bone autograft, bone from the medial tibial metaphyseal safe zone is harvested via an OATS tube harvester (Arthrex, Naples, FL). A bone plug 1 mm larger in size than the femoral defect is harvested and arthroscopically inserted via a press-fit technique. At 3 months after bone grafting, patients undergo revision ACL reconstruction. The proximal tibial metaphysis is a safe bone graft harvest site in revision ACL surgery and offers an effective method for filling large bony defects, allowing anatomic reconstruction of the ACL after bone healing has occurred. Furthermore, it eliminates the problems associated with allograft or use of a remote graft donor site.     

Comparison of Sawchuk-Zaske and Bayesian forecasting for aminoglycosides in seriously ill patients.

1. Individual pharmacokinetic parameters and predicted steady-state serum concentrations of aminoglycosides were calculated by Sawchuck-Zaske (SZ) and Bayesian methods. 2. Predicted concentrations were compared with observed steady-state concentrations for 36 seriously ill patients with systemic infections. Four aminoglycoside concentrations were used for the SZ method. Differing numbers of serum aminoglycoside samples were used in the Bayesian parameter estimation: one sample Bayesian used one post-infusion concentration, two sample Bayesian used a trough plus one post-infusion concentrations and four sample Bayesian used a trough plus three post-infusion concentrations. 3. 79% of the SZ predictions were with +/- 2 mg l-1 of the observed peak concentrations, and 72% of the two sample Bayesian predictions were within the same range. 82% of SZ and the two sample Bayesian predictions were within +/- 1 mg l-1 of the observed trough concentrations. 4. A confidence interval comparison of estimated pharmacokinetic parameters and precision for the predicted concentrations showed no important differences between the SZ and the two sample Bayesian. The four sample Bayesian was the most precise method. 5. We conclude that the Bayesian forecasting method utilizing a trough plus one post-infusion concentrations is as useful as the SZ method which requires three to four serum concentrations in individualizing aminoglycoside therapy for seriously ill patients.     

Infections in orthopaedic surgery - risk factors and prophylaxis

The authors describe prophylaxis of infections in orthopaedic surgery caused by various factors:- accurate selection of patients (evaluation of diabetes, hemopathies, nephropathies, iatrogenic and acquired immune deficits); - operating room and surgical technique risk factors (endogenous and exogenous contamination, skin preparation, surgeon's skill in performing non aggressive surgery, duration of surgery); - antibiotic prophylaxis with specific pharmacological characteristics (wide spectrum drugs with low toxicity) and chronological criteria (time and duration of prophylaxis). The main preventive measures against infection are reported. The high percentage of infections (11 %) in prosthetic surgery has been due to risk factors existing before surgery (diabetes, hemopathy, immune deficiency).     

In vitro activity of MDL 62,879 against gram-positive bacteria andBacteroides species

The new thiazolyl peptide antibiotic MDL 62,879 (GE2270 A) showed excellent in vitro activity in testing against staphylococci and streptococci, with MIC90s ranging from 0.23 to 0.9 mg/l. It was very active againstClostridium difficile andPropionibacterium acnes (MIC90 0.06 mg/l in each case) and had variable activity againstBacteroides spp. MDL 62,879 had exceptionally good activity againstEnterococcus faecalis, including against a collection of high-level aminoglycoside-resistant isolates where it had an MIC90 of 0.047. The antibiotic was bacteriostatic for enterococcal isolates but bactericidal for a methicillin-resistant isolate ofStaphylococcus aureus.     

Bilateral complete discoid medial meniscus combined with posterior cyst formation

Bilateral discoid medial menisci is an extremely rare condition of the knee and it can be associated to other pathological findings, including anterior portion cyst formation. We report on the clinical features, radiographic findings, treatment and results of one patient who presented a bilateral medial discoid meniscus combined with posterior portion cyst of the left knee. To the best of the author’s knowledge, this is the first case of bilateral medial discoid meniscus associated with posterior portion cyst formation.     

Intervertebral disc regeneration: from the degenerative cascade to molecular therapy and tissue engineering

Low back pain is one of the major health problems in industrialized countries, as a leading source of disability in the working population. Intervertebral disc degeneration has been identified as its main cause, being a progressive process mainly characterized by alteration of extracellular matrix composition and water content. Many factors are involved in the degenerative cascade, such as anabolism/catabolism imbalance, reduction of nutrition supply and progressive cell loss. Currently available treatments are symptomatic, and surgical procedures consisting of disc removal are often necessary. Recent advances in our understanding of intervertebral disc biology led to an increased interest in the development of novel biological treatments aimed at disc regeneration. Growth factors, gene therapy, stem cell transplantation and biomaterials‐based tissue engineering might support intervertebral disc regeneration by overcoming the limitation of the self‐renewal mechanism. The aim of this paper is to overview the literature discussing the current status of our knowledge from the degenerative cascade of the intervertebral disc to the latest molecular, cell‐based therapies and tissue‐engineering strategies for disc regeneration. Copyright © 2013 John Wiley & Sons, Ltd.     

Efficacy of cardiac resynchronization therapy in very old patients: the Insync/Insync ICD Italian Registry.

AIMS: To assess the effects of cardiac resynchronization therapy (CRT) in > or =80-year-old patients vs. patients <80 years, in terms of clinical, functional, and echocardiographic parameters after 12 month of CRT, survival, and incidence of arrhythmic events. METHODS AND RESULTS: The study population consisted of 1181 CRT patients (85 were > or =80 years old). They were enrolled in a national observational registry and underwent baseline evaluation and periodical follow-up visits. In the overall population, New York Heart Association class and ejection fraction (EF) improved and ventricular diameters decreased. Similar changes were observed in the two groups. In the study population, 157 patients died, 144 (13%) in the <80 years group and 13 (15%) in the > or =80 years group. There was a higher all-cause mortality (log-rank test, P = 0.015) among > or =80 years patients, with a trend towards higher sudden cardiac death (SCD) (P = 0.057), but similar non-SCD (P = 0.293). Using the combined endpoint of SCD or appropriate shock from a defibrillator for ventricular fibrillation, no significant differences resulted between groups (P = 0.455). In both groups, lower EF was associated with higher mortality. CONCLUSION: Cardiac resynchronization therapy demonstrated similar efficacy in patients aged > or =80 years and in those under 80, in terms of clinical and functional parameters and reverse remodelling. Similarly, CRT resulted in comparable effects on death for heart failure and on SCD.     

Combination therapy for Cushing’s disease: effectiveness of two schedules of treatment. Should we start with cabergoline or ketoconazole?

Cushing’s disease (CD) is associated with increased morbidity and mortality. Until now, no medical treatment has been shown to be totally satisfactory when administrated alone. This study aimed to assess the effectiveness of cabergoline with added ketoconazole and of the same combination in reverse, using urinary free cortisol (UFC) and late night salivary cortisol (LNSC) levels as biochemical markers of the treatments’ efficacy in CD patients. A prospective analysis conducted on 14 patients (f/m = 12/2; median age 52, range 33–70 years) divided into two groups: 6 patients initially treated with cabergoline for 4–6 months (rising from 0.5–1 mg/week up to 3.0 mg/week), after which ketoconazole was added (group A); and 8 patients first took ketoconazole alone for 4–6 months (rising from 200 mg/day to 600 mg/day), then cabergoline was added (group B). Patients were compared with 14 age-matched patients in prolonged remission after effective neurosurgery for CD. The combination therapy led to UFC normalization in 79 % of patients with no differences between the groups; only one patient failed to respond at all. Neither drug succeeded in controlling the disease when taken alone. LNSC dropped when compared to baseline levels, but not to a significant degree (p = 0.06), and it remained significantly higher than in controls (p = 0.0006). Associating cabergoline with ketoconazole may represent an effective second-line treatment, achieving a satisfactory reduction in UFC levels and clinical improvement. Although the combined treatment lowered patients’ LNSC levels, they remained higher than normal, indicating a persistent subclinical hypercortisolism; the implications of this condition need to be considered. No differences emerged between the two treatment schedules.