Three-dimensional assessment of the dimensions of the osteoarthritic glenoid

Osteoarthritis results in changes in the dimensions of the glenoid. This study aimed to assess the size and radius of curvature of arthritic glenoids. A total of 145 CT scans were analysed, performed as part of routine pre-operative assessment before total shoulder replacement in 91 women and 54 men. Only patients with primary osteoarthritis and a concentric glenoid were included in the study. The CT scans underwent three-dimensional (3D) reconstruction and were analysed using dedicated computer software. The measurements consisted of maximum superoinferior height, anteroposterior width and a best-fit sphere radius of curvature of the glenoid. The mean height was 40.2 mm (SD 4.9), the mean width was 29 mm (SD 4.3) and the mean radius of curvature was 35.4 mm (SD 7.8). The measurements were statistically different in men and women and had a Gaussian distribution with marked variation. All measurements were greater than the known values in normal subjects. With current shoulder replacement systems using a unique backside radius of curvature for the glenoid component, there is a risk of undertaking excessive reaming to adapt the bone to the component resulting in sacrifice of subchondral bone or under-reaming and instability of the component due to a 'rocking horse' phenomenon.

Reverse shoulder arthroplasty in patients with pre-operative impairment of the deltoid muscle

The indications for reverse shoulder arthroplasty (RSA) continue to be expanded. Associated impairment of the deltoid muscle has been considered a contraindication to its use, as function of the RSA depends on the deltoid and impairment of the deltoid may increase the risk of dislocation. The aim of this retrospective study was to determine the functional outcome and risk of dislocation following the use of an RSA in patients with impaired deltoid function. Between 1999 and 2010, 49 patients (49 shoulders) with impairment of the deltoid underwent RSA and were reviewed at a mean of 38 months (12 to 142) post-operatively. There were nine post-operative complications (18%), including two dislocations. The mean forward elevation improved from 50° (sd 38; 0° to 150°) pre-operatively to 121° (sd 40; 0° to 170°) at final follow-up (p < 0.001). The mean Constant score improved from 24 (sd 12; 2 to 51) to 58 (sd 17; 16 to 83) (p < 0.001). The mean Single Assessment Numeric Evaluation score was 71 (sd 17; 10 to 95) and the rate of patient satisfaction was 98% (48 of 49) at final follow-up. These results suggest that pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. This form of treatment can yield reliable improvement in function without excessive risk of post-operative dislocation.

"Hairy blobs:" microbial suspects preserved in modern and ancient extremely acid lake evaporites

"Hairy blobs" are unusual clumps of organic bodies and sulfate crystals that have been found in evaporite minerals grown in acid saline lakes. Here, we document modern hairy blobs in halite and gypsum from 5 modern acid saline lakes in southern Western Australia, and Permian hairy blobs trapped in halite from the mid-Permian Opeche Shale in the subsurface of North Dakota. These are among the first microbial remains described from acid saline lake environments. They give clues about the role of microorganisms in the acidity, geochemistry, and mineralogy of these extreme environments. This study also may add to the inventory of life in extreme environments and help predict possible martian life-forms and the method of preservation.

Reliability of the quadriceps angle measurement

The quadriceps angle (Q-angle) is used to determine patellofemoral alignment. Although this measurement has been used to evaluate and treat patellofemoral joint pathology, few studies have examined its reliability. This study evaluated the interobserver and intraobserver reliability of the Q-angle measurement. To investigate the interobserver reliability of the Q-angle, 25 individuals of varying levels of training served as observers and participants as each measured the other 24 participants. To investigate the intraobserver reliability of the Q-angle, 3 of the observers measured 13 of the participants an additional 2 times. Additionally, clinically derived Q-angle measurements were compared with radiographically derived measurements. The reliability analysis was performed using intraclass correlation coefficients. For interobserver measurements, the intraclass correlation coefficients ranged from 0.17-0.29 for the four variables evaluated (right and left, extension and flexion). For intraobserver measurements, the intraclass correlation coefficients ranged from 0.14-0.37. The average intraclass correlation coefficient between the clinically and radiographically derived measurements ranged from 0.13-0.32. This study demonstrates poor interobserver and intraobserver reliability of Q-angle measurement and poor correlation between clinically and radiographically derived Q-angles.

Technical note: a "new" arthroscopic sliding knot

Sliding knots are an essential element of arthroscopic shoulder surgery. The authors have been using a previously undescribed arthroscopic sliding knot with good clinical success. This knot has been used in arthroscopic rotator cuff repair, arthroscopic shoulder stabilization, and arthroscopic SLAP repair. The technique of this knot is illustrated.

The effect of polymethyl methacrylate on latex-free surgical gloves

In the current medical environment of increased awareness about latex sensitivity, more patients are presenting with known latex allergy. One such patient presented to us for total knee arthroplasty. During this procedure, we noticed holes in our latex-free surgical gloves when polymethyl methacrylate (PMMA) was being handled. Through subsequent testing of different brands of latex-free surgical gloves with various brands of bone-cement, we found that Allergard latex-free surgical gloves are destroyed by contact with PMMA. Biogel Neotech and Duraprene latex-free gloves show no such destruction. These results indicate that Allergard gloves should not be used in procedures in which bone-cement is employed. Biogel Neotech and Duraprene latex-free gloves are an acceptable alternative.

The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis

BACKGROUND

Midsubstance tears of the anterior cruciate ligament in skeletally immature patients are increasingly common and are a challenging problem. The results of nonoperative treatment are no better in children than they are in adults. Physeal-sparing reconstructive procedures have yielded poor results. Reconstructive procedures that are utilized in adults violate the physis, potentially resulting in growth abnormalities. The objective of this study was to provide a model for reconstruction of the anterior cruciate ligament in skeletally immature patients by evaluating the effects of a tensioned connective-tissue graft placed across the canine physis.

METHODS

Twelve ten-week-old beagles underwent reconstruction of the anterior cruciate ligament consisting of placement of fascia lata autograft through drill-holes across the femoral and tibial physes, tensioning of the graft to 80 N, and fixing it with screws and washers. The contralateral limb served as a control. One dog was eliminated from the study secondary to a postoperative infection. Four months postoperatively, the dogs were killed and were inspected grossly, radiographically, and histologically for any evidence of growth disturbance.

RESULTS

Significant valgus deformity of the distal part of the femur (p < 0.001) and significant varus deformity of the proximal part of the tibia (p = 0.03) developed in the treated limbs. Neither radiographic nor histologic examination demonstrated any evidence of physeal bar formation.

CONCLUSIONS

Significant growth disturbances occur with excessively tensioned transphyseal reconstruction of the anterior cruciate ligament in the canine model. These growth disturbances occur without radiographic or histologic evidence of physeal bar formation.

Results of latissimus dorsi and teres major transfer to the rotator cuff in the treatment of Erb's palsy

A retrospective study of the results of latissimus dorsi and teres major transfer in the treatment of Erb's palsy was conducted in 10 patients. All patients underwent release of the pectoralis major and transfer of the latissimus dorsi and teres major tendons to the rotator cuff at a mean age of 7 years and 2 months. Range of motion, patient satisfaction, and presence of any complications were evaluated postoperatively at a mean of 3 years. Active shoulder abduction improved from a mean of 72 degrees preoperatively to 136 degrees postoperatively. Postoperative shoulder active external rotation averaged 64 degrees. Subjectively, all patients participating in a questionnaire thought use of the operated-on extremity had improved since surgery. All but one patient were satisfied with the final outcome. Complications included one hypertrophic scar. Transfer of the latissimus dorsi and teres major to the rotator cuff in treatment of persistent Erb's palsy improves shoulder abduction and external rotation and results in a high degree of patient satisfaction.

Administration of budesonide once daily by means of turbuhaler to subjects with stable asthma

BACKGROUND

Optimal management of chronic, mild-to-moderate asthma with inhaled steroids may include use of the lowest possible doses, as recommended in guidelines, and a reduction in the frequency of daily administration for greater convenience. Lower doses and once daily treatment with inhaled steroids must be rigorously evaluated in controlled clinical trials.

OBJECTIVES

The objective of this study was to assess the efficacy and safety of once daily treatment with budesonide in subjects with stable asthma.

METHODS

Once daily budesonide was assessed in 309 adult subjects, including those who were and were not using an inhaled steroid at baseline. The subjects were stratified by inhaled steroid use and randomly assigned to one of 3 treatments: 200 microgram budesonide, 400 microgram budesonide, or placebo administered by means of Turbuhaler once daily in the morning for 6 weeks. Beyond this point, treatment was continued unchanged for another 12 weeks (maintenance) in those receiving 200 microgram budesonide once daily and placebo. In those who received 400 microgram budesonide once daily, the dose was reduced to 200 microgram once daily at week 6 and held constant for the remaining 12 weeks (400/200 microgram group). Primary efficacy endpoints were mean change from baseline in FEV1 and morning peak expiratory flow.

RESULTS

Once daily budesonide was well tolerated and resulted in significant improvements in all efficacy endpoints, even though baselines were well stabilized. Baseline lung function was elevated with little room for improvement; however, mean increases in FEV1 during the maintenance period were 0.10 L and 0.11 L in the 200 microgram and 400/200 microgram groups, respectively, versus a decrease of -0.09 L in the placebo arm (P <.001). Results for peak expiratory flow were similar. Significant improvements in secondary endpoints, including symptoms, beta-agonist use, and quality of life, also developed with budesonide 200 and 400 microgram once daily.

CONCLUSION

Inhaled budesonide, in doses as low as 200 microgram, may be an appropriate introductory or maintenance dose in subjects with stable, mild-to-moderate asthma.

In vitro comparison of elongation of the anterior cruciate ligament and single- and dual-tunnel anterior cruciate ligament reconstructions

This study evaluated strain in the normal anterior cruciate ligament (ACL) and compared it to four different double-strand hamstring tendon reconstructive techniques. Seventeen fresh-frozen knees from 11 cadavers were tested. The strain in the anteromedial and posterolateral bands of the native ACL and their equivalents in four autograft techniques were measured using differential variable reluctance transducers. The anteromedial band of the intact ACL shortened from 0 degree -30 degrees of flexion, then lengthened to 120 degrees; the posterolateral band of the intact ACL shortened from 0 degree - 120 degrees of flexion. Following ACL excision, these knees underwent reconstruction with double-strand hamstring tendons with either single tibial and femoral tunnels, single tibial and dual femoral tunnels, dual tibial and single femoral tunnels, or dual tibial and dual femoral tunnels. With the exception of the dual-band, dual-tunnel technique, all of the procedures placed greater strain on the reconstructive tissues than was observed on the native ACL, after approximately 30 degrees of flexion. These results indicate that dual-band hamstring tendon reconstructions placed with single tibial and femoral tunnels do not address the complexity of the entire ACL. Rather, these procedures appear to only duplicate the effect of the anteromedial band, while perhaps overconstraining the joint as a result of its inability to reproduce the function of the posterolateral band. During rehabilitation following ACL reconstruction, therefore, only from 0 degree - 30 degrees of the graft tissues are not significantly strained. Dual tibial and femoral tunnel techniques should be evaluated further to more closely recreate knee kinematics following ACL reconstruction.

Montelukast, a once-daily leukotriene receptor antagonist, in the treatment of chronic asthma: a multicenter, randomized, double-blind trial. Montelukast Clinical Research Study Group

OBJECTIVES

To determine the clinical effect of oral montelukast sodium, a leukotriene receptor antagonist, in asthmatic patients aged 15 years or more.

DESIGN

Randomized, multicenter, double-blind, placebo-controlled, parallel-group study. A 2-week, single-blind, placebo run-in period was followed by a 12-week, double-blind treatment period (montelukast sodium, 10 mg, or matching placebo, once daily at bedtime) and a 3-week, double-blind, washout period.

SETTING/PATIENTS

Fifty clinical centers randomly allocated 681 patients with chronic, stable asthma to receive placebo or montelukast after demonstrating a forced expiratory volume in 1 second 50% to 85% of the predicted value, at least a 15% improvement in forced expiratory volume in 1 second (absolute value) after inhaled beta-agonist administration, a minimal predefined level of daytime asthma symptoms, and inhaled beta-agonist use. Twenty-three percent of the patients used concomitant inhaled corticosteroids. PRIMARY END POINTS: Forced expiratory volume in 1 second and daytime asthma symptoms.

RESULTS

Montelukast improved airway obstruction (forced expiratory volume in 1 second, morning and evening peak expiratory flow rate) and patient-reported end points (daytime asthma symptoms, "as-needed" beta-agonist use, nocturnal awakenings) (P<.001 compared with placebo). Montelukast provided near-maximal effect in these end points within the first day of treatment. Tolerance and rebound worsening of asthma did not occur. Montelukast improved outcome end points, including asthma exacerbations, asthma control days (P<.001 compared with placebo), and decreased peripheral blood eosinophil counts (P<.001 compared with placebo). The incidence of adverse events and discontinuations from therapy were similar in the montelukast and placebo groups.

CONCLUSIONS

Montelukast, compared with placebo, significantly improved asthma control during a 12-week treatment period. Montelukast was generally well tolerated, with an adverse event profile comparable with that of placebo.

Oral glucocorticosteroid-sparing effect of budesonide administered by Turbuhaler: a double-blind, placebo-controlled study in adults with moderate-to-severe chronic asthma. Pulmicort Turbuhaler Study Group

OBJECTIVE

To determine the ability of budesonide via an inhaler (Pulmicort Turbuhaler; Astra Draco AB) to replace oral glucocorticosteroids (GCSs) in adult subjects with moderate-to-severe asthma.

DESIGN

Double-blind, randomized, and placebo-controlled study, with parallel groups.

SETTING

Multicenter study in outpatient setting.

PARTICIPANTS

Eighty men and 79 women, aged 20 to 69 years, with moderate-to-severe asthma and a mean FEV1 of 58.3% predicted normal. All subjects were receiving oral GCS treatment and 79% of subjects were also receiving inhaled beclomethasone dipropionate (BDP). The mean daily doses of prednisone at baseline, including converted dose of BDP, for the placebo, budesonide 400 microg, and budesonide 800 microg, respectively, were 19.7 mg, 19.5 mg, and 18.7 mg.

MEASUREMENTS AND INTERVENTIONS

After a 2-week baseline period, subjects entered a 20-week treatment period, during which the oral dose of prednisone was reduced by forced down-titration at 2-weekly intervals.

RESULTS

Subjects receiving 400 microg or 800 microg bid of budesonide achieved a significantly greater reduction (82.9% and 79.0% respectively) in oral GCS dose compared with placebo-treated subjects (27%; p<0.001). Two thirds of the subjects receiving budesonide were able to achieve sustained oral corticosteroid cessation, compared with 8% in the placebo group. Additionally, both doses of budesonide resulted in significant improvement in results of pulmonary function tests and asthma symptoms scores, and a significant decrease in the use of bronchodilator therapy. The mean plasma cortisol levels before and after adrenocorticotropic hormone stimulation increased most toward the normal range in the budesonide-treated groups compared with placebo-treated subjects.

CONCLUSION

Budesonide administered via Turbuhaler has a significant oral GCS-sparing capacity with maintained or improved asthma control in adult subjects with moderate-to-severe asthma.

Patellar tendon and tibial tubercle reconstruction using quadriceps tendon with patellar bone plug autograft

This report describes a technique for the reconstruction of a patellar tendon-tibial tubercle deficiency. This technique uses an easy-to-harvest, low-morbidity graft (autogenous quadriceps tendon), while allowing aggressive rehabilitation as a result of the strength of the graft.

Efficacy of once daily extended-release theophylline in decreasing the use of inhaled beta 2-agonists in stable, mild-to-moderate asthma patients

BACKGROUND/OBJECTIVE

The purpose of this study was to determine whether the addition of extended-release theophylline to the daily treatment regimen of inhaled beta 2-agonist users would result in decreased use of beta 2-agonist while maintaining similar efficacy for treatment of asthma.

METHODS

This was a single-blind, multicenter (six sites) study. Sixty-one patients with a history of mild-to-moderate asthma treated with inhaled beta 2-agonist were randomized to treatment with Theo-24 (anhydrous extended-release capsules) plus inhaled beta 2-agonist or placebo plus beta 2-agonist. Patients kept daily symptom diaries, measured peak flow rates, recorded puffs of inhaled beta 2-agonist, and adverse events during a 4-week treatment period.

RESULTS

Fifty-five patients were included in the efficacy analysis. The primary efficacy variable in this study was the mean number of puffs (adjusted for baseline differences) of beta 2-agonist inhaled per day. In this study, the addition of theophylline to the daily regimen of inhaled beta 2-agonist for 4 weeks significantly reduced the total daily dose of inhaled beta 2-agonist at weeks 3 and 4 of treatment compared with placebo. The differences were significant at the P < .05 level. For patients in the theophylline group, the number of puffs decreased from an unadjusted mean of 9.81 at baseline to an adjusted mean of 6.78 after 4 weeks of treatment compared with 9.91 at baseline and 8.17 for the placebo group. There were no unexpected or serious adverse events.

CONCLUSIONS

In this study, the addition of once daily, extended-release theophylline to the daily regimen of inhaled beta 2-agonist for 4 weeks significantly reduced the total daily dose of inhaled beta 2-agonist at weeks 3 and 4 of treatment compared with placebo, while maintaining acceptable asthma symptom scores.

Effectiveness and safety of beclomethasone dipropionate, an intranasal corticosteroid, in the treatment of patients with allergic rhinitis

There is an increasing trend toward topical intranasal corticosteroids as the preferred treatment for seasonal or perennial allergic rhinitis. This trend is based on the fact that the chronic, mucosal inflammation that accompanies allergic rhinitis responds to anti-inflammatory drugs such as topical corticosteroids. Intranasal corticosteroids, given before the natural antigen challenge, reverse preexisting inflammation and prevent nasal priming by antigens. One intranasal corticosteroid, beclomethasone dipropionate, has been available by prescription in the United States for more than a decade and has an established efficacy and safety profile in patients with allergic rhinitis. Beclomethasone dipropionate has become the standard to which other intranasal corticosteroid preparations are compared. In comparison with earlier corticosteroids (eg, hydrocortisone, prednisolone, dexamethasone, betamethasone) that caused adrenal suppression and other systemic adverse reactions, the actions of new corticosteroids, including beclomethasone dipropionate, are confined to the site of application. These drugs are also more rapidly metabolized, less irritating to the nasal mucosa, and have a longer duration of action. When given intranasally to relieve the sneezing, congestion, and rhinorrhea associated with seasonal and perennial allergic rhinitis, the newer corticosteroids have proved safe and effective. Despite the fact that topical nasal corticosteroids such as beclomethasone dipropionate are responsible for important improvements in the treatment of both allergic and nonallergic rhinitis as well as nasal polyposis and chronic sinusitis, these drugs may be underused, particularly in the pediatric population. Because of the concern of systemic side effects in younger children, less effective therapies are sometimes used.

Polycythemia as a complication of human immunodeficiency virus infection

HIV infection is commonly associated with cytopenias. The occurrence of erythrocytosis is rare, with only one report in the medical literature. We have described the case of an asymptomatic patient found to be seropositive for HIV. The blood counts were initially normal except for mild eosinophilia and thrombocytopenia. Over the next 18 months erythrocytosis developed and thrombocytopenia worsened. Workup at that time revealed elevated red cell mass, suppressed erythropoietin, normal arterial oxygen saturation, and splenomegaly documented by abdominal computed tomography. Zidovudine therapy was started in April 1990, when the CD4 cell count dropped below 500/mm3. Over the next 4 months the hematologic indexes returned to normal levels. The patient remains asymptomatic.