Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l (13ppb, 221nmol/l). Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Global longitudinal strain (GLS) is an
An audit of fractured neck of femur patients indicated that the delay in acquiring an echocardiogram was delaying surgery (time to echo 5.4 days ± 3.4SD (n=72), time to surgery 7.5 days ± 5.5SD (n=72)). This instigated a change in policy with the introduction of routine ‘targeted’
Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery. Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013. 62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy).
Using an established canine model of fat embolization, the effect of temporary mechanical blockade of embolic load during medullary canal pressurization was studied. Haemodynamic measurements,
Aim: To evaluate the morbidity and mortality in the perioperative period of patients with aortic stenosis following fractures of the proximal femur. Patients and Methods: A retrospective review was undertaken of medical notes of all patients (n=20) admitted to our trauma unit over an 18 month period with fractures of the proximal femur and concomitant aortic stenosis confirmed by transthoracic
Introduction and Aims: Acute intramedullary stabilisation of femoral shaft fractures in multiply injured patients remains controversial. Intravasation of medullary fat during nailing has been suspected to trigger ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurisation in a canine experiment. Method: Using an established model, 12 mongrel dogs were randomised into two groups. Under general anesthesia, cannulations were performed to measure left and right-sided pressures. Transoesophageal
Introduction:. Although the risk of pulmonary embolism (PE) or other embolic events associated with total joint arthroplasty have been recorded for some time, to date no direct means of these events in human arthroplasty have reported. This prospective study was designed to clarify the pathophysiologic mechanism of PE after total knee arthroplasty (TKA). Methods:. Nine patients fulfilling the following selection criteria were included in this prospective study: diagnosis of osteoarthosis, age 60 to 75 years, cemented primary TKA. All patients had a baseline pulmonary perfusion scan 2 days prior to the surgery. TKA was performed in the standard manner under general anesthesia. Monitoring of the heart chambers during the course of the TKA was performed using a 5 MHz ultrasonic transducer placed into the esophagus. The 4-chamber view plane of the heart was then imaged using a 2-dimensional
Introduction: Early stabilization of the skeleton in multiply injured patients has shown to reduce mortality and chest morbidity. Reamed intramedullary nailing is the current method of choice for stablizing femoral and tibial shaft fracture. However several investigators have highlighted the adverse effect of early reamed nailing in polytrauma patients. Intravasation of medullary fat during canal pressurizaton has been suspected to produce a ‘second hit’ and trigger pneumonia and ARDS. The objective of this study is to investigate the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization. Methods: Using an established model of fat embolization, twelve mongrel dogs were randomized into two groups. Under general anaesthesia, cannulations of carotids and jugular veins and transesophageal echo-cardiography were performed in all animals. Under fluoroscopy control, a special filter was inserted percutaneously into the left common iliac vein in half the animals, where as the other half served as controls. In all dogs, the left knee was exposed; the femor and tiiba were sequentially reamed and then pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and trans-esophageal
Aim. The incidence of hematogenous periprosthetic joint infections (hPJI) is unknown and the cases probably largely underreported. Unrecognized and untreated primary infectious foci may cause continuous bacteremia, further spread of microorganisms and thus treatment failure or relapse of infection. This study aimed at improving knowledge about primary foci and microbiological characteristics of this entity to establish preventive measures and improve diagnostic and therapeutic strategies to counteract hPJI. Method. We retrospectively analysed all consecutive patients with hPJI, who were treated at our institution from January 2010 until December 2016. Diagnosis of PJI was established if 1 of the following criteria applied:(i) macroscopic purulence, (ii) presence of sinus tract, (iii) positive cytology of joint aspirate (>2000 leukocytes/μl or >70% granulocytes), (iv) significant microbial growth in synovial fluid, periprosthetic tissue or sonication culture of retrieved prosthesis components, (v) positive histopathology. PJI was classified as hematogenous if the following criteria were fulfilled additionally: (1) onset of symptoms more than 1 month after arthroplasty AND (2) i) isolation of the same organism in blood cultures OR ii) evidence of a distant infectious focus consistent with the pathogen. Results. A total of 70 episodes of hPJI were included. Median age was 74 years (32–89 years), 36 were women and 29 men. Sites of PJI included 39 knees, 29 hips, one shoulder and one elbow joint. The pathogen was identified in 99% (n=69), the majority of episodes was monomicrobial (n=64, 91%). Blood cultures were collected in 39 cases (56%) and identified the pathogen in 67% (n=26). Isolated pathogens were Staphylococcus aureus (n=29), Streptococcus spp. (n=20) and Enterococcus faecalis (n=12), coagulase-negative staphylococci (n=6) and gram-negative bacilli (n=5). In 55% the primary focus was identified and included an intravascular (endocarditis, endoplastitis, thrombophlebitis; n=15), urogenitary (n=8), dental (n=6), gastrointestinal (n=5) and osteoarticular (n=2) and skin and soft tissue origin (n=1). The primary focus could not be identified in 29 cases (41%), primarily due to underuse of diagnostic workup. Conclusions. Causative agents were identified in the vast majority of hPJI with a predominance (75%) of high virulent microorganisms such as staphylococci, streptococci and gram-negative bacilli. Our results highlight the importance of a meticulous diagnostic workup including collection of blood cultures and performance of
Circulating cobalt and chromium from metal-on-metal implants cause rare but fatal autopsy-diagnosed cardiotoxicity. Concern exists that milder cardiotoxicity may be common and under-recognized. Unacceptably high failure rates of metal-on-metal hip implants have prompted regulatory authorities to issue worldwide safety alerts. Despite this, approximately 1 million patients continue to live with metal-on-metal implants, putting them at risk of systemic toxicity. Although blood cobalt and chromium levels are easily measured and track local toxicity, no non-invasive tests for organ deposition exist. We recently demonstrated the utilisation of a T2* protocol (cardiovascular MRI) to detect cobalt and chromium deposition within the liver of a patient with elevated blood cobalt levels (confirmed by liver biopsy tissue analysis and X-ray fluorescence spectroscopy). We sought to detect and constrain the correlation between blood metal ions and a comprehensive panel of established markers of early cardiotoxicity. In addition we applied T2* protocols with the aim of detecting cardiac metal deposition. 90 patients were recruited through RNOH clinics into this prospective single centre blinded study. Patients were divided into 3 age and gender-matched groups according to type of implant and blood metal ion levels as follows: [Group A] Non-metal bearing hip implants; [Group B] Metal-on-metal implants, low blood metal ion levels (<7ppb); and [Group C] Metal-on-metal implants, high blood levels (>7ppb). All underwent detailed cardiovascular phenotyping using cardiac MRI (with T2*, T1 and ECV mapping, in addition to LV size and ejection fraction), advanced
Elevated levels of circulating cobalt ions have been linked with a wide range of systemic complications including neurological, endocrine, and cardiovascular symptoms. Case reports of patients with elevated blood cobalt ions have described significant cardiovascular complications including cardiomyopathy. However, correlation between the actual level of circulating cobalt and extent of cardiovascular injury has not previously been performed. This review examines evidence from the literature for a link between elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties and cardiomyopathy. Correlation between low, moderate, and high blood cobalt with cardiovascular complications has been considered. Elevated blood cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications and published case reports document cardiomyopathy, cardiac transplantation, and death in patients with severely elevated blood cobalt ions. However, it is not clear that there is a hard cut-off value and cardiac dysfunction may occur at lower levels. Clinical and laboratory research has found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Further work needs to be done to clarify the link between severely elevated blood cobalt ions and cardiomyopathy. Cite this article:
Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic
Systemic embolic phenomena are well recognised during total knee replacement (TKR) and are widely believed to be the cause of intra-operative hypotension and reduced cardiac output, which may lead to circulatory collapse and sudden death. We undertook a prospective, double-blind, randomised study comparing the cardiac embolic load during computer-assisted and conventional (intramedullary-aligned) TKR, as measured by transoesophageal
The mortality following surgery in patients with a recent MI is high. Standard advice is to wait for a minimum of 6 months. In urgent situations, this may not be possible. From Jan 2003 to Aug 2004, 10 patients were admitted with fracture neck of femur and a recent MI proven by ECG changes or raised troponin. There were 7 females. The mean age was 79.5 yrs (59–95yrs). The premorbid mobility and co-morbidities were noted.
Aims: The aim of the study was to evaluate the clinical characteristics of patients with infective spondylodiscitis and concomitant endocarditis. Methods: In the present study clinical features of patients with infective spondylodiscitis and endocarditis were compared to those without endocarditis. Case records of patients with infective spondylodiscitis treated at the Department of Infectious Diseases in Ljubljana in years 1991 to 2007 were reviewed. The following data were recorded: age, sex, underlying disease, previous or concomitant infections, previous operations, clinical features, causative agents, results of x-ray and other diagnostic examinations, complications and outcome of the disease. The Duke criteria were used for the diagnosis of endocarditis. The data were analysed using Epi Info 6 statistical programme. Patients with endocarditis were compared with others using Chi square, t-test and Mann-Whitney test. Results: During the study period 149 patients with infective spondylodiscitis were diagnosed. There were 92 (61.7%) males and 57 (38.3%) females, aged 13 to 95 years, mean 61.0 ± 14 years. Eleven (7.0%) out of 149 patients with infective spondylodiscitis had concomitant endocarditis, two of them on prosthetic valves. The causative pathogen in patients with endocarditis was Staphylococcus aureus in seven (MRSA in two), mixed infection, Streptococcus viridans, Pseudomonas aeruginosa and coagulase negative staphylococci in one each. Staphylococcus aureus was the most common causative agent of infective spondylodiscitis. Among the three patients with MRSA spondylodiscitis, endocarditis was also present in two. Patients with concomitant endocarditis were similar to those without it but the two groups differed in mortality which was significantly higher in the group of patients with endocarditis (36% vs. 10%.; p <
0.05). In three patients (who died) spondylodiscitis presented at the same time as acute endocarditis and the clinical picture was predominantly that of severe endocarditis. In five patients (one of whom died) spondylodiscitis manifested late in the course of endocarditis and in one patient spondylodiscitis preceded endocarditis. In two patients endocarditis was diagnosed on routine
Prior to TJR, clinical cardiovascular risk assessment is typically limited by severe exercise restrictions. Noninvasive pharmacological cardiovascular stress tests may predict major perioperative cardiovascular events in patients undergoing orthopaedic surgery. We undertook a pilot study to inform the feasibility of a large prospective cohort study. Patients were eligible if they were aged >
forty-five, undergoing elective TJR, and had known atherosclerotic disease or risk factors for atherosclerotic disease. We recruited patients at the Hamilton Health Sciences, Henderson Hospital. Prior to surgery patients underwent dipyridamole stress perfusion imaging and dobutamine stress
Introduction: Vertebroplasty (VP) is a relatively new procedure to treat osteoporotic compression fractures of vertebral bodies. During this procedure polymethyl-methacrylate (PMMA) is injected into vertebral bodies. However there is the concern, that fat embolism (FE) and acute hypotension could occur as in a variety of other orthopaedic procedures. Aim: To investigate whether FE and acute hypotension are potential complications of VP using an animal model. Methods: In six sheep, 6.0 ml PMMA were injected unilaterally into the L1 vertebral body. Transœsophageal
Vertebroplasty (VP) is a new prophylactic treatment for preventing osteoporotic compression fractures of vertebral bodies. During this procedure polymethylmethacrylate (PMMA) is injected into several vertebral bodies. However, there is the concern, that fat embolism (FE) and acute hypotension could occur as in a variety of other orthopaedic procedures. This study was undertaken to investigate whether FE and acute hypotension are potential complications of VP using an animal model. In six sheep 6.0 ml PMMA were injected unilaterally into L1. Transesophageal