[Foreign body reaction in carbon fiber prosthesis implantation in the knee joint--case report and review of the literature]

We present the clinical radiological and pathological data of a patient who underwent carbon fiber implantation of the right knee. Within half a year a total knee replacement had to be performed due to persistent pain. Apart from the intraoperative, macroscopically visible, massive sclerosis around the drill holes and an obvious synovial reaction, we histopathologically found a severe granulomatous foreign body reaction around the carbon fibers. Experimental data point toward a negative influence of a foreign body reaction on attempted cartilage repair. The implantation of carbon fibers can be recommended neither for biomechanical nor for pathophysiological reasons. Before this treatment can be recommended, prospective randomized trials are mandatory.

[Left distal femoral diaphysis-metaphyseal injury in a 13-year-old patient]

This paper aims to present the usefulness of the different diagnosis imaging methods (anatomical and functional) in the characterization of bone injury. Any data, however insignificant, is justified and should be specified. In this case, the discrepancy between the vascular and pool phases in the bone scintigraphy with 99mTc-MDP reveals revealed a lesion with an intense reaction secondary to the "foreign body effect", which is not necessarily malignant.

Talcosis associated with IV abuse of oral medications: CT findings

OBJECTIVE

Our objective was to evaluate the CT appearance of talcosis associated with IV abuse of oral medications and to compare the findings of talcosis related to methylphenidate with those findings seen with other drugs.

MATERIALS AND METHODS

The CT scans of 12 patients with talcosis (seven men, five women), 33-54 years old (mean age, 44 years), were analyzed retrospectively. Seven patients had abused methylphenidate; five patients had no history of abuse. The diagnosis of talcosis was made histologically in 11 patients and at funduscopy in one patient. CT was performed with 1- to 1.5-mm collimation (n = 10 patients) or 5- to 10-mm collimation (n = 2).

RESULTS

The predominant abnormalities seen on CT consisted of a diffuse fine nodular pattern (n = 2), a combination of nodules and lower lobe panacinar emphysema (n = 3), and ground-glass attenuation (n = 2). Emphysema was the only abnormality seen in the remaining five patients (lower lobe panacinar, n = 4; upper lobe centrilobular, n = 1). No significant difference in the prevalence of nodules and ground-glass attenuation was seen between the methylphenidate and non-methylphenidate groups. Lower lobe panacinar emphysema was more common in methylphenidate abusers (six [86%] of seven patients) than in non-mnethylphenidate drug abusers (one [20%] of five, p<0.05, Fisher's exact test).

CONCLUSION

The CT manifestations of talcosis consist of a fine micronodular pattern, ground-glass attenuation, and emphysema. A significantly increased prevalence of lower lobe panacinar emphysema is seen in IV drug addicts who abuse methylphenidate.

Hepatic inflammatory mass secondary to toothpick perforation of the stomach: triphasic CT appearances

Unintentional ingestion of foreign bodies is common in daily life. The unintentional ingestion of sharp foreign bodies such as toothpicks, fish bones and chicken bones carries a significant risk of perforation of the gastrointestinal tract. Herein, we report a case of hepatic inflammatory mass complicated by the perforation of an ingested toothpick that had a distinctive enhancement pattern on dynamic computed tomograms (CT). Understanding the phenomenon of enhancement in triphasic CT study is the basis in differentiating liver neoplasms.

Ionogran in revision arthroplasty

Glass ionomer cement (Ionocem) was developed for use in bone surgery and is reported to be notably biocompatible. Between 1991 and 1994 we performed revision operations for aseptic loosening of arthroplasties of the hip on 45 patients using this material in its granulate form (Ionogran) mixed with homologous bone as a bone substitute. Of these 45 patients, 42 were followed up for a mean of 42 months. Early reloosening of the acetabular component has occurred in ten after a mean of 30 months. Histological examination showed large deposits of aluminium in the adjacent connective tissue and bone. Osteoblastic function and bone mineralisation were clearly inhibited. The serum levels of aluminium were also increased. The toxic damage at the bone interface caused by high local levels of aluminium must be seen as an important factor in the high rate of early reloosening. Our findings cast doubt on the biocompatibility of this material and we do not recommend continuation of its further use in orthopaedic surgery.

Long-term results of out-of-the-bag intraocular lens implantation

PURPOSE

To evaluate long-term results of out-of-the-bag intraocular lens (IOL) implantation.

SETTING

Department of Ophthalmology, Tenri Yorozu Hospital, Nara, Japan.

METHODS

This study comprised 22 patients, 13 women and 9 men, who had cataract surgery by phacoemulsification and out-of-the-bag IOL implantation because of a posterior lens capsule rupture. Sixteen patients had in-the-bag IOL implantation in the fellow eye, and these eyes were used as a control group. The IOL's position was determined by ultrasound biomicroscopy (UBM). Anterior chamber flare counts were measured by a laser flare meter. The corneal endothelium was observed by specular microscopy.

RESULTS

Mean follow-up after cataract surgery was 35 months +/- 22 (SD). The UBM revealed that in the 19 eyes with sulcus-to-sulcus IOL fixation, the optics touched the iris. In 3 eyes, 1 haptic was fixated at the sulcus and the other at the ciliary body. In 2 of these eyes, the optics did not touch the iris. Anterior chamber flare counts in eyes with sulcus-to-sulcus IOL fixation were significantly higher than in eyes with in-the-bag or sulcus-to-ciliary-body fixation (P < .05). There were no statistical differences in corneal endothelial cell counts based on haptic placement.

CONCLUSION

Rubbing between the IOL optic and iris seems to contribute to the high flare counts in eyes with a sulcus-to-sulcus IOL fixation. A larger haptic angle may be needed to prevent contact between the iris and IOL optic in such cases.

[Experiences with the alloplastic joint prosthesis of the interphalangeal joint]

The replacement of finger joints, especially of the proximal interphalangeal joint (PIP), remains an unsolved problem. Long-term results of conventional reconstructive procedures as well as previously available artificial joint implants have been disappointing. In a controlled study, 12 PIP-joints were replaced by a new type of total endoprosthesis as an alternative to joint fusion. The cementless prosthesis is unhinged and consists of metal joint surfaces. After a follow-up of 18 months, implantation of this metal prosthesis resulted in almost complete pain relief and an active range of movement of 58 degrees. The absolute gain in mobility, however, was only 6 degrees. A swan-neck deformity was found in nine out of 12 cases but corrective surgery was not required. The proximal half of the implant had to be exchanged in two cases due to loosening. All patients were satisfied with the result. The disparity between subjective acceptance by the patients, who clearly prefer joint replacement to fusion, and objective results demonstrates the necessity for further development in this field. The type of prosthesis used in this study seems to be a useful baseline tool which could be turned into a ingenious PIP-joint replacement by further development aiming at reduced abrasion, increased initial stability, a more individual configuration, to name just a few goals.

Abdominal retained surgical sponges: CT appearance

Retention of surgical sponges is rare. They cause either an aseptic reaction without significant symptoms or an exudative reaction which results in early but nonspecific symptoms. Computed tomography is very useful for recognition of retained sponges. The appearance of retained sponges is widely variable. Air trapping into a surgical sponge results in the spongiform pattern which is characteristic but unfortunately uncommon. A low-density, high-density, or complex mass is found in the majority of cases, but these patterns are not specific. Sometimes, a thin high-density capsule may be seen. Rim or internal calcification is a rare finding. Finally, a radiopaque marker is not a reliable sign. Differentiation from abscess and hematoma is sometimes difficult.

Imaging findings in a cow with a retropharyngeally displaced magnet

This report describes the ultrasonographic and radiographic findings and the treatment of a Swiss Brown cow with a retropharyngeal abscess caused by improper administration of a magnet.

SR-PLLA and SR-PGA miniscrews: biodegradation and tissue reactions in the calvarium and dura mater

The biocompatibility and degradation of self-reinforced poly-L-lactide (SR-PLLA) and polyglycolide (SR-PGA) miniscrews, vs titanium miniscrews, was studied in frontal bone osteotomies in 20 lambs, where they were used for plate fixation. At follow-up at 4, 6, 12, 26, 52 and 104 weeks, no clinical foreign body reaction, infection or other complications had occurred. Histologically, PGA material was hydrolyzed and fragmented at 4-6 weeks and was resorbed by 12 weeks, whereas the SR-PLLA miniscrews retained their integrity and holding power for 26 weeks and were mostly resorbed at 2 years. According to histological and histomorphometric analyses and plain film radiography, the degradation of PGA miniscrews was accompanied by a typical non-specific foreign-body reaction and initial transient osteolysis with decreased osteoid formation around the screw channel, but compensatory intense osteoid formation and bone remodelling followed after resorption of the polymer. The foreign body reactions to PLLA and titanium were considerably milder. All miniscrews were commendably strong and could be satisfactorily tightened against the plate. SR-PLLA miniscrews offer fixation stability for half a year, whereas rapidly degrading SR-PGA miniscrews may be used when short-term fixation is needed.

The fate of the dropped gallstones during laparoscopic cholecystectomy

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1-14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall.

A fluid-filled condom causing intestinal obstruction: nonsurgical therapy of an ileus by ultrasound-guided transabdominal tapping

Ingested foreign bodies are rare causes of intestinal obstruction in the adult. Condoms, if swallowed, are usually filled with drugs and found in body packers as a vehicle for drug smuggling. We report the case of 31-year-old male who presented with symptoms and signs of intestinal obstruction. He had swallowed a fluid-filled condom the day before. Ultrasonography of the abdomen revealed a fluid-filled foreign body within the small bowel. Due to radiological signs of an ileus and due to the fact that the patient's symptoms did not resolve after spasmolytic therapy the condom was tapped transcutaneously under ultrasonographical guidance. This procedure immediately relieved his symptoms. The further course was uneventful.

Osteoarthritis of the ankle after foreign-body reaction to absorbable pins and screws: a three- to nine-year follow-up study

Between 1985 and 1994, 1223 patients with malleolar fractures of the ankle were treated by open reduction and internal fixation with absorbable pins and screws, of whom 74 (6.1%) had an obvious inflammatory foreign-body reaction to the implants. Of these 74, ten later developed moderate to severe osteoarthritis of the ankle despite no evidence of incongruity of the articular surface. The implants used in these patients were made from polyglycolide, polylactide or glycolide-lactide copolymer. The joint damage seemed to be due to polymeric debris entering the articular cavity through an osteolytic extension of an implant track. The ten patients had a long clinical course which included a vigorous local foreign-body reaction, synovial irritation and subsequent degeneration. At a follow-up of three to nine years, ankle arthrodesis had been necessary in two patients and is being considered for another two. The incidence of these changes in the whole series was 0.8%, which is not high, but awareness of this possible late complication is essential.

Retained wooden foreign body in a child's parotid gland: a case report

Foreign bodies can present a diagnostic challenge to even the experienced surgeon. In one review of 200 surgical cases involving retained foreign bodies, one-third of the cases had been initially missed. Wooden foreign bodies in particular pose a challenge to the physician. In the review cited above, only 15% of wooden foreign bodies were well visualized on plain radiographs. Acutely, on computed tomography (CT) scans, wooden foreign bodies will usually mimic air. However, with time, the attenuation value of a wooden foreign body may increase as moisture is absorbed from the surrounding tissues. Once this occurs, the wooden foreign body may mimic fat, water or muscle. We present an interesting case of a wooden foreign body in the parotid gland in order to illustrate a common presentation of such a foreign body, to review current guidelines for their clinical and radiologic diagnosis, and to suggest strategies for the management of their unique complications.

Scintigraphic evaluation in total knee failure secondary to severe metallosis

The scintigraphic findings are described for a patient with severe metallosis in a failed noninfected total knee arthroplasty secondary to metal-metal friction between the femoral and tibial components as a result of polyethylene wear. Technetium-99m phosphate and gallium-67 citrate scans were positive in incongruent uptake areas. This uptake is classically associated with septic loosening. The recommendation is made that metallosis be suspected before surgery as a possible cause of a false positive scan where sequential technetium-gallium scans are employed.

Midterm results in metal-backed patella revisions for metallosis

Nine patients underwent isolated patellar revisions and synovectomies for metallosis secondary to the mechanical failure of metal-backed patellar components. These patients were followed for an average of 5 years (range, 2 to 8 years). In all cases, the femoral and tibial components were left in place, and in one patient the patellar bone was deemed too thin to resurface. Two patients (22%) developed deep infection. One infection (enterococcal) required arthrodesis, and the other (staphylococcal) was successfully managed with a two-staged reimplantation. A third patient sustained an inferior patella pole fracture that was treated conservatively. The remaining six patients are functioning satisfactorily. Metallosis is a serious complication in knee arthroplasty, and these patients merit close follow-up.

Mammography of breasts in which catheter cuffs have been retained: normal, infected, and postoperative appearances

OBJECTIVE

The purpose of this report is to show that Dacron (DuPont, Wilmington, DE) cuffs retained in breasts after the removal of Hickman catheters may result in complications requiring radiographic evaluation for subsequent management. We also describe potential complications, including infection, associated with a retained cuff and changes after the removal of a retained cuff.

CONCLUSION

Because of the increased use of Hickman catheters for central vein access, Dacron cuffs more frequently are retained in breasts and are likely to be seen on mammograms. Radiologists need to be aware of the mammographic findings of a normal cuff, infected cuff, and the site of a surgically excised cuff.

Hip and knee arthroplasty infection. In-111-IgG scintigraphy in 102 cases

We studied indium-111-labeled immunoglobulin G (In-111-IgG) scintigraphy for evaluation of total hip and knee arthroplasty infection in 100 patients (102 arthroplasties) where infection was suspected (85 total hip and 17 total knee replacements, 23 of which proved to be infected, all but 2 late infections). The sensitivity of In-111-IgG scintigraphy for infection was 1.0, for hip and knee arthroplasties the specificities were 0.8 and 0.5, respectively. False-positive results for infection occurred in cementless total hip arthroplasties up to 14 months after implantation. Aseptic inflammation due to formation of ectopic ossification and foreign-body response, following wear of the polyethylene socket, was responsible for false-positive results. The images should be read in conjunction with radiographs, which reduces the rate of false-positive results. In-111-IgG is a highly sensitive and fairly specific tool for detecting of late infection of total hip and total knee arthroplasties.

Neurogenic claudication, a delayed complication of a retained bullet

STUDY DESIGN

A case report is presented of a 31-year-old man who visited the authors' neurosurgical department in 1993, complaining of neurogenic claudication. History revealed a gunshot incident 11 years ago, with a bullet left in situ.

OBJECTIVES

To determine whether to operate on patients who have a bullet in situ near the spinal cord without initial neurologic deficits.

SUMMARY OF BACKGROUND DATA

In the literature, only four publications report an epidural chronic inflammatory mass as a reaction to a retained bullet, thereby causing delayed neurologic symptoms. Previous to this report, only one case is described of a patient with a bullet lodged in the paravertebral musculature.

METHODS

Clinically, the patient had pain radiating from his lower back to both his thighs, provoked by walking, standing, and the Valsalva maneuver. Comparison of radiographs made in 1990 and in 1993 showed the lead bullet still completely intact in 1990, whereas in 1993, a partial disintegration and displacement of the bullet, causing a chronic inflammatory reaction (extraspinal and intraspinal), as well as cyst formation, was seen. Particularly notable was the radiographic feature of a sort of "fallen leaf sign" at the level of L5-S1.

RESULTS

The preoperative complaints were still absent 1 year after surgery.

CONCLUSIONS

It is argued that with regard to a retained bullet in the vicinity of the spinal canal, the presence or absence of neurologic symptoms should be the guide for further diagnostic procedures. Only if a neurologic deficit develops, which is possible after many years, should surgical intervention be considered, depending on the severity and type of the deficit, as presented in this case report.