Toxic shock syndrome complicating orthopaedic manipulation of bone. A report of two cases

We studied prospectively 81 consecutive patients undergoing hip surgery using the Hardinge (1982) approach. The abductor muscles of the hip in these patients were assessed electrophysiologically and clinically by the modified Trendelenburg test. Power was measured using a force plate. We performed assessment at two weeks, and at three and nine months after operation. At two weeks we found that 19 patients (23%) showed evidence of damage to the superior gluteal nerve. By three months, five of these had recovered. The nine patients with complete denervation at three months showed no signs of recovery when reassessed at nine months. Persistent damage to the nerve was associated with a positive Trendelenburg test.     

Fluorescence in situ hybridization with a synthetic (T2AG3)n polynucleotide detects several intrachromosomal telomere-like repeats on human chromosomes

The relevance of clinical signs of infant hip dysplasia and the importance of a sonographic newborn-hip screening are often discussed. Between 1984 and 1990 at our department 6532 infant hips were examined both clinically and sonographically. Sonographic hip findings were pathological in 71.7% of the hips with positive clinical Roser-Ortolani sign and in 100% of the hips with positive Hilgenreiner sign. In contrast, pathological hip types according to Graf were seen only in 18% of the hips with limitations of the abductions of the hip joint. Examining other clinical signs for infant hip dysplasia within this study, as well we can conclude, that only the Roser-Ortolani sign and that of Hilgenreiner showed a high specificity for infant hip dysplasia, while most of the clinical signs e.g. limitation of abduction in the hip joint are rather unspecific.     

Idiopathic hip instability. An unrecognized cause of coxa saltans in the adult

The painful, snapping hip often presents a diagnostic dilemma having many potential etiologies. An understanding of the precise cause increases the potential for successful treatment. Five patients with no prior history of significant trauma were evaluated, all of whom had longstanding painful snapping in the groin and consistent symptoms of gait disturbance and increased pain in the provocative position of hip flexion, adduction, and internal rotation. Multiple prior tests and procedures had been nondiagnostic. Simple manual longitudinal traction under fluoroscopy showed subluxation with appearance of a vacuum sign in the symptomatic hip, whereas no such finding was observed on the asymptomatic side. This strongly suggests atraumatic hip instability as a previously unrecognized cause of the painful, snapping hip. The easily obtainable diagnostic traction radiograph is described.     

Congenital hip dysplasia in the light of early and very early diagnosis

Ortolani summarizes 40 years of experience with about 8,000 children with congenital hip dysplasia, treated from birth or at a very early age. All newborns should be screened and examined for congenital hip dysplasia and this exam should be repeated at one month and again in 3 months. The most reliable sign for the diagnosis of congenital hip dysplasia at birth is the "click" sign. The etiology of congenital hip dysplasia is in a localized fault in embryonic development. The treatment started just as early as the condition was suspected. Surgical treatment is recommended for all complete congenital hip dislocations not amenable to treatment by closed methods.     

Distribution of serum lipoprotein(a) levels--a non-parametric analysis

Persisting postoperative pain of the thigh is a common problem of cementless hip endoprostheses occurring in about 15-20% of the patients. We performed a comparative study including patients with (n = 40) and without (n = 45) pain of the thigh. 85 cementless porous-coated anatomic (PCA) hip endoprostheses in 74 patients were examined. All patients underwent clinical examination including a standardized questionnaire, x-ray, and 3-phase bone scintigraphy. Slight or moderate 99mTc-MDP uptake in the area of the greater and lesser trochanter as well as at the tip was a common finding in PCA prostheses in patients without pain and was not a sign of loosening of the hip. Radiologically, there was no difference between patients with and without pain. However, persisting pain of the thigh in patients with PCA prosthesis corresponded with an increased uptake at the tip and the medial and lateral femur, not being a sign of loosening even in this group. The special biomechanical conditions of cementless prostheses causing inhomogeneous intraosseous stress distribution are supposed to be the reason for that.     

Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy

We have measured cardiovascular changes associated with insufflation of carbon dioxide and the reverse Trendelenburg position during laparoscopic cholecystectomy, using transoesophageal echocardiography in 13 healthy patients. End-tidal carbon dioxide values increased after insufflation of carbon dioxide, with values significantly (P < 0.05) increased after lateral tilt positioning. Creation of a pneumoperitoneum was associated with increases (P < 0.05) in left ventricular end-systolic wall stress, concomitant with increases (P < 0.01) in peak airway pressure and systemic arterial pressure. In addition, left ventricular end-diastolic area decreased (P < 0.05) after reverse Trendelenburg positioning. Left ventricular ejection fraction was maintained throughout the study.     

Unenhanced helical CT of ureterolithiasis: value of the tissue rim sign

OBJECTIVE: The tissue rim sign-a rim or halo of soft-tissue attenuation seen around the circumference of an intraureteral calculus on unenhanced axial CT-has been described as useful in differentiating ureteral calculi from extraurinary abdominal or pelvic calcifications. The purpose of this study was to determine the prevalence of the tissue rim sign in patients with ureterolithiasis and extraurinary calcifications and to determine the relationship between the tissue rim sign, the size of a calculus, and the degree of urinary obstruction. MATERIALS AND METHODS: Unenhanced helical CT studies followed by excretory urography were obtained in 59 patients with suspected acute ureterolithiasis. Each calcification along the expected course of the ureter seen on axial CT scans was categorized as a ureteral calculus or as an extraurinary calcification. Each categorization was based on CT, urographic, and clinical findings and the presence or absence of a tissue rim sign. When the outer wall of the ureter could not be seen because there was no clear fat plane at the level of the calcification on CT, the sign was categorized as "indeterminate." The size of the calculus was measured on CT, and the degree of urinary obstruction was estimated on the basis of the urograms. RESULTS: Thirty-two patients each had a single ureteral calculus. Of these patients, CT revealed a positive tissue rim sign in 16 patients (50%), was negative in five patients (16%), and was indeterminate in 11 patients (34%). In addition, we saw 57 extraurinary calcifications in 18 patients (11 patients with ureteral calculi and seven patients without ureteral calculi). None of the 57 extraurinary calcifications was associated with a positive tissue rim sign. The tissue rim sign was negative in 39 (68%) of the 57 extraurinary calcifications and indeterminate in the remaining 18 (32%). Ureteral calculi with a negative tissue rim sign were larger than ureteral calculi with a positive tissue rim sign (p < .01). A high degree of obstruction was present in four of five patients with ureteral calculi for which CT showed a negative tissue rim sign. Conversely, six of 16 patients in whom CT revealed a positive tissue rim sign also had a high degree of obstruction. Therefore, no clear relationship was found between the degree of obstruction and the presence of a positive tissue rim sign. CONCLUSION: A positive tissue rim sign is specific for the diagnosis of ureterolithiasis. However, a negative tissue rim sign does not preclude such a diagnosis. The presence or absence of this tissue rim sign correlates with the size of a calculus but not with the degree of urinary obstruction. When CT reveals an indeterminate tissue rim sign, careful inspection for other CT findings, such as ipsilateral ureteral dilatation, perinephric edema, dilatation of the intrarenal collecting system, and renal swelling, is necessary.     

The CT halo sign: a new finding in intestinal lymphangiectasia

A "halo sign" has been described in patients with Crohn disease, ulcerative colitis, radiation enteritis, ischemic colitis, and pseudomembranous colitis. This sign is characterized by an inner ring of low CT attenuation surrounded by a higher attenuation outer ring. We present a patient with primary intestinal lymphangiectasia in whom CT demonstrated a halo sign correlated with mucosal biopsy.     

Isolated superior gluteal nerve injury: two case reports

Isolated superior gluteal nerve injury has been infrequently described in the literature, mainly from injections or hip surgery. Its course through the greater sciatic foramen renders it at risk in pelvic or hip trauma. We report 2 cases of electromyographically documented isolated superior gluteal nerve injury following pelvic trauma. These cases illustrate that weakness in hip abduction following pelvic trauma may indicate the presence of a superior gluteal nerve injury, warranting further clinical and electrodiagnostic evaluation.     

Studies on an immunosuppressive macrolactam, ascomycin: synthesis of a C-33 hydroxyl derivative

Coagulase-negative staphylococci are important agents of infected hip arthroplasties, but sample contamination from the skin flora may confuse the diagnosis. Recovery of multiple identical strains has been regarded as indication of true infection. We have evaluated 29 total hip replacement operations with cultures positive for coagulase-negative staphylococci in a prospective study, 16 with > or = 3 isolates available for strain identity analysis. In 26 episodes, > or = 3 cultures were positive for coagulase-negative staphylococci, but only 19 of them had strong or intermediate clinical evidence of infection. Negative clinical evidence of infection coincided with the absence of a predominating strain according to plasmid profile analysis. A reliable identity analysis may help to rule out infection when multiple cultures are positive in patients who lack clinical evidence of infection.     

Sensitivity to metals in 40 patients with failed hip endoprosthesis

Hypersensitivity to metals and tissue reaction around a failed implant were investigated in 40 patients undergoing revision hip arthroplasty. Metal sensitivity was tested using a standard cutaneous patch test. Nine patients were positive for chromium, nickel, cobalt, metal rust or endoprosthesis scrapings, or combinations of these allergens. Patients with positive or negative patch test did not differ in terms of their age, sex, primary diagnosis, number of endoprosthesis revisions, length of implant function, presence of other metal parts around the implant, circulating immunocomplexes, and histological appearance of the tissue around the implant. We conclude that stainless steel endoprostheses may be safely used for repeated revision hip arthroplasty, and that hypersensitivity to metals probably does not play a significant role in the loosening of the endoprosthesis.     

Diseases not completely understood

BACKGROUND: Shifting dullness and fluid wave are two techniques commonly used to detect ascites. However, these may fail to detect moderate or minimal ascites. Ultrasonography is a good non-invasive method to detect ascites but may not be available in distant rural areas of India. We assessed the utility of the puddle sign and auscultatory percussion for detecting ascites. METHODS: Sixty-six patients with suspected ascites were included in the study. Those with a previous history of ascites, or therapeutic paracentesis and in whom ascites was detected by shifting dullness or fluid wave were excluded. The puddle sign and auscultatory percussion were elicited in all the patients. Ultrasonography was used as the gold standard. To eliminate any observer bias the investigators were blinded to each others' findings. RESULTS: Auscultatory percussion had a greater sensitivity (65.7% v. 45%, p < 0.05) but a lower specificity than the puddle sign (48.4% v. 67.7%, p < 0.05). There were no significant differences between positive and negative predictive values and the positive and negative likelihood ratios. CONCLUSION: Auscultatory percussion is a better method than puddle sign for detecting ascites as it has a greater sensitivity.     

Variations in white blood count, thromboxane B2 levels and hematocrit in chronic venous hypertension

OBJECTIVE: To analyze variations in leukocyte count and thromboxane B2 production in the femoral vein of patients with chronic venous hypertension (CVH). DESIGN: Prospective clinical study, controlled, non randomized and open. LOCATION: Hospital das Clínicas, Faculdade de Medicina da Universidade de S?o Paulo, referral center, university hospital. PARTICIPANTS: 15 patients with recurring stasis ulcer were analyzed, selected randomly from the venous diseases outpatient center, and 4 without lower limb venous alterations were also analyzed. INTERVENTION: Blood samples from the femoral and brachial veins were drawn following supine and 45 degrees reverse Trendelenburg. MAIN OUTCOMES MEASURES: Direct leukocyte count and analysis of the thromboxane B2 with enzyme linked immunosorbent assay test. RESULTS: After 30 minutes in reverse Trendelenburg, patients with CVH showed a leukocyte count reduced by +/- 27% (p = 0.02) and thromboxane B2 levels increased by +/- 158% (p = 0.02). CONCLUSIONS: We suggest that future studies of medications for stasis ulcers include their effects on leukocyte entrapment and thromboxane B2 production in the lower limb venous system.     

Fatal intraoperative pulmonary embolism from a hepatic hydatid cyst

A 43-yr-old woman was operated for recurring hydatid cysts of the liver. One of the cysts was located in segment 8 adjacent to both inferior vena cava and right hepatic vein. During the operation, after application of traction on the liver the patient suddenly went into cardiac arrest. After applying open heart massage a Trendelenburg operation was performed, revealing a massive embolus of echinococcal material into the paracentral branches of the pulmonary artery. Resuscitation was unsuccessful. In the literature only four similar cases have been described. The conclusions from these deaths are that an adequate incision is mandatory, no traction on the liver should be necessary, and total vascular exclusion of the liver before cyst drainage and extracorporal bypass are necessary. Interventional techniques should be avoided.     

Increased plasma levels of substance P and disturbed water excretion in patients with liver cirrhosis

We describe a surgical technique for replacing the hip joint capsule using synthetic mesh after oncological resections of the proximal femur that resulted in gross intraoperative instability of the prosthetic reconstruction. The results of its use in 13 patients, 6 of whom also had pelvic resections, are described. These patients were selected from a total group of 88 patients undergoing proximal femoral replacement, 75 of whom did not require capsular replacement (none of these 75 patients have experienced dislocation). In the group requiring capsular reconstruction, 1 of 4 patients with bipolar hemiarthroplasty and 4 of 9 patients with total hip replacements experienced dislocation after operation. Of the dislocated total hip replacements, 1 remains chronically dislocated, and 3 were successfully stabilized by open reduction with further capsular augmentation. Given that the resections involved removal of most of the soft tissues stabilizing the hip joint, we believe that the technique of capsular reconstruction is useful in this difficult group of patients.     

Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs'' teeth

Upper motor neuron lesion in adults is usually associated with spasticity and "extensor toe sign" on plantar stimulation (extensor plantar response). There are various methods of eliciting this sign including the classic method by Babinski. Other methods produce this response when the area of reflexogenic zone is increased due to upper motor neuron lesion. There are varying reports of Babinski positivity in spastic cerebral palsy. This study was undertaken to assess the sensitivity of different methods of eliciting "extensor toe sign." An attempt has also been made to correlate the severity of spasticity with the combined "extensor toe sign" positivity by various methods and with the increase in reflexogenic zone. Eighty-one children with spastic cerebral palsy were examined. Twelve had hemiplegia; therefore, a total of 150 limbs were tested. "Extensor toe sign" was elicited by 12 different methods in each patient. The sensitivity of each method was calculated and compared with each other one. The assessment of spasticity was done using the Ashworth Tone Scale. The severity of spasticity was correlated with "extensor toe sign" positivity using various methods. Classic Babinski reflex was positive in 75% of cases, whereas Gonda-Allen sign was positive in 90% of cases followed by Allen-Cleckley (82%), Chaddock (74%), and Cornell (54%). All other signs had sensitivity of less than 30%. There was no increase in sensitivity after combining them. There was significant negative correlation between the spasticity and the combined "extensor toe sign" positivity (by all the methods). This study, therefore, suggests that the majority of patients with spastic cerebral palsy have positive "extensor toe sign." The Gonda-Allen method is more sensitive than the classic Babinski method. A positive "extensor toe sign" is negatively correlated to the degree of spasticity.     

History of surgical instruments: 5. The development of tangentially closing vascular clamps

We demonstrate the historical development of tangential occlusion clamps, which by partially clamping the vessels and by partially maintaining the blood flow, allow to reconstruct or to anastomose large vessels in the side-by-side-technique. The first tangential occlusion clamp was developed by Friedrich Trendelenburg (1844-1924) in 1908, when he performed the operative treatment of embolism of the pulmonary artery. This clamp was modified later by A.W. Meyer [1927] and V.P. Satinsky [ca. 1950].     

Latent tetany associated with the hypokalaemia of Conn''s syndrome

We describe the case of an asymptomatic patient with primary hyperaldosteronism, who was diagnosed fortuitously following the demonstration of a positive Trousseau's sign during routine blood pressure assessment. Further investigations revealed that the carpal spasm was due solely to the associated profound hypokalaemia.     

Tripolar hip replacement for recurrent prosthetic dislocation

An innovative treatment is described for unstable total hip arthroplasty that uses a large inside diameter acetabular cup and a bipolar femoral head sized to approximate the diameter of the normal hip. Eight consecutive patients with recurrent prosthetic dislocations were treated with this tripolar hip. Joint stability was achieved in all patients, who have an average of 4.2-years' followup (range, 2.6-6.3 years).     

Periprosthetic acetabular fracture associated with extensive osteolysis

Periprosthetic fracture of the acetabulum is an uncommon complication of total hip arthroplasty. The management is reported to be difficult, and complications such as nonunion and implant loosening are common. We described herein a case of nontraumatic periprosthetic acetabular fracture associated with significant osteolysis, which was successfully managed by addressing the fracture and osteolysis independently.