Observations of increased gastroesophageal reflux symptomology in an anhydrous ammonia exposed population

OBJECTIVE

This case series describes a cohort of patients exposed to anhydrous ammonia vapors with clinical findings of laryngopharyngeal reflux (LPR). The study characterizes the identification of LPR as a consequence of vapor inhalation and the utility of PPI therapy in LPR secondary to inhalational ammonia exposure.

METHODS

This is a case series of 15 patients exposed to anhydrous ammonia from a single chemical spill who experienced LPR several months after exposure. Symptoms of LPR were assessed at their initial consultation and by phone at least 30 days after treatment with low-dose PPI or diet modification. At this visit, patients underwent complete head and neck examination and flexible direct laryngoscopy.

RESULTS

15 patients were available for analysis before and after treatment. 93.3 % experienced at least three cardinal symptoms of LPR. 66 % of these patients had at least one LPR finding on flexible laryngoscopy. 73 % were treated with daily standard dose PPI, and 82 % of these patients experienced reduction of symptoms after 30 days of PPI treatment. Four of 15 patients were not taking the PPI as prescribed, and only one of these patients had resolution of LPR symptoms.

CONCLUSION

We conclude that there is an association between anhydrous ammonia exposure and the development of LPR symptoms. In this study, treatment with PPIs was successful in reducing symptoms for most patients, and patients who did not receive PPIs experienced symptoms for a longer time.

Stepwise surgical correction of instability in flexion after total knee replacement

Instability in flexion after total knee replacement (TKR) typically occurs as a result of mismatched flexion and extension gaps. The goals of this study were to identify factors leading to instability in flexion, the degree of correction, determined radiologically, required at revision surgery, and the subsequent clinical outcomes. Between 2000 and 2010, 60 TKRs in 60 patients underwent revision for instability in flexion associated with well-fixed components. There were 33 women (55%) and 27 men (45%); their mean age was 65 years (43 to 82). Radiological measurements and the Knee Society score (KSS) were used to assess outcome after revision surgery. The mean follow-up was 3.6 years (2 to 9.8). Decreased condylar offset (p < 0.001), distalisation of the joint line (p < 0.001) and increased posterior tibial slope (p < 0.001) contributed to instability in flexion and required correction at revision to regain stability. The combined mean correction of posterior condylar offset and joint line resection was 9.5 mm, and a mean of 5° of posterior tibial slope was removed. At the most recent follow-up, there was a significant improvement in the mean KSS for the knee and function (both p < 0.001), no patient reported instability and no patient underwent further surgery for instability. The following step-wise approach is recommended: reduction of tibial slope, correction of malalignment, and improvement of condylar offset. Additional joint line elevation is needed if the above steps do not equalise the flexion and extension gaps.

No difference in 90-day complications between bilateral unicompartmental and total knee arthroplasty

This study compares the 90-day complication rate of 28 patients who underwent simultaneous bilateral unicompartmental knee arthroplasty (UKA) with a matched control group of 56 patients who underwent simultaneous total knee arthroplasty (TKA.) We matched the groups 2:1 for age, gender, and American Society of Anesthesiologists scores and reviewed their medical records to identify complications, reoperations, and hospital readmission during the first 90 days after surgery as well as the operative times and length of hospital stay. The bilateral UKA group had shorter operative times (P = 0.06) and shorter length of hospital stay (P < 0.001). Ninety-day complications in the UKA group included 1 wound infection and 1 deep vein thrombosis (3.57%). The TKA group had 2 complications including 1 superficial wound infection and 1 pulmonary embolism (1.79%) (P = 0.60). One knee in each group required irrigation and debridement for wound infection. These patients requiring additional surgery for wound infection were the only 2 patients that required readmission within 90 days. Despite being a less invasive procedure, we found that the bilateral UKA group had a similar risk of complications to a matched group of bilateral TKA patients.

Spinal fractures in recreational bobsledders: an unexpected mechanism of injury

Study design: Retrospective case series and literature review.

Objective: To report and discuss spinal fractures occurring in recreational bobsledders.

Summary of background data: Spinal fractures have been commonly described following traumatic injury during a number of recreational sports. Reports have focused on younger patients and typically involved high-impact sports or significant injuries. With an aging population and a wider array of recreational sports, spinal injuries may be seen after seemingly benign activities and without a high-impact injury.

Methods: A retrospective review of two patients and review of the literature was performed.

Results: Two patients with spinal fractures after recreational bobsledding were identified. Both patients, aged 57 and 54 years, noticed a simultaneous onset of severe back pain during a routine turn on a bobsled track. Neither was involved in a high-impact injury during the event. Both patients were treated conservatively with resolution of symptoms. An analysis of the bobsled track revealed that potential forces imparted to the rider may be greater than the yield strength of vertebral bone.

Conclusions: Older athletes may be at greater risk for spinal fracture associated with routine recreational activities. Bobsledding imparts large amounts of force during routine events and may result in spinal trauma. Older patients, notably those with osteoporosis or metabolic bone disease, should be educated about the risks associated with seemingly benign recreational sports.

Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years

Total hip arthroplasty (THA) in the adolescent patient has historically shown relatively poor survivorship. This study reports the results of THA in young patients using contemporary ceramic bearings. Twenty-four THAs were performed using ceramic bearing surfaces in patients 20 years old or younger (mean, 16.4; range, 12-20). Average follow-up was 52 months (range, 25-123 months). The survival rate was 96%, with 1 revision for a loose acetabular component. Other complications included a peroneal nerve palsy that resolved and 2 dislocations in 1 patient. Postoperatively, the Modified Harris Hip Score mean was 93.4 (range, 66-100). This study shows promising results at short-term to midterm follow-up in very young patients who undergo THA using ceramic-on-ceramic components.

Bilateral total knee arthroplasty in patients 70 years and older

Recently an increase has been shown in perioperative morbidity and mortality in patients older than 70 years undergoing sequential or simultaneous total knee arthroplasty (TKA) using 1 anesthetic. This study prospectively compared perioperative morbidity, mortality, and functional outcomes in patients 70 years and older undergoing sequential bilateral TKA under 1 anesthetic vs a control undergoing only unilateral TKA. Seventy patients (140 knees), 70 years and older, who underwent sequential bilateral TKA under 1 anesthetic were matched with a control series of 312 patients undergoing unilateral TKA during the same time period. All patients were evaluated pre- and postoperatively at regular time intervals. No mortalities were noted in either group. Perioperative complication rates were not statistically different between groups. Knee Society scores and SF-36v2 scores were better at 6-month and 1-year follow-up in the sequential bilateral knee group. Results from this study were not as expected based on previous reports in the literature. Although functional outcomes in this study were consistent with previous reports, patients did not demonstrate the expected difference in complications. This study is the first prospective study looking specifically at patients 70 years and older undergoing unilateral vs bilateral TKA under 1 anesthetic. According to our data, age alone is not a reason to exclude patients from sequential bilateral TKA under 1 anesthetic.

Highly crosslinked polyethylene is safe for use in total knee arthroplasty

Highly cross-linked polyethylene (XLPE) has been used with good initial success in hip arthroplasty to reduce wear. However, the process of crosslinking reduces fracture toughness, raising concerns as to whether it can be safely used in total knee arthroplasty (TKA). We therefore asked whether XLPE can be used safely in TKA. We performed a retrospective review of 100 subjects receiving XLPE and compared them to 100 subjects who received standard polyethylene in the setting of TKA. The standard polyethylene group had a mean age of 70 with a minimum follow up of 82 months. The highly cross-linked polyethylene group had a mean age of 67 and a minimum follow up of 69 months (mean, 75 months; range, 69-82 months). On radiographic review, the standard group demonstrated 20 TKAs with radiolucencies; 4 of these had evidence of a loose tibial component. The standard group required three revisions related to loose tibial components. The XLPE group had 2 subjects that demonstrated radiolucencies on radiograph and no subjects with evidence of tibial loosening. There were no reoperations related to osteolysis. The data suggest XLPE in TKA can be used safely at least short- to midterm. Our study provides an impetus for further long-term investigation.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Results of bilateral combined hip and knee arthroplasty in very young patients with juvenile rheumatoid arthritis

INTRODUCTION

We evaluated the long-term outcomes for combined, bilateral total knee and hip arthroplasty performed on a group of very young patients with juvenile rheumatoid arthritis.

MATERIALS AND METHODS

Six consecutive patients with a mean age of 14 years at the time of hip replacement and 16 years at knee replacement were analyzed. Five of the six patients were wheelchair dependent pre-operatively. All knee components had uncemented fixation, while the hip replacements were a mixed group of cemented and uncemented prostheses.

RESULTS

Clinical and radiographic follow-up at a mean duration of 13.8 years for the hips and 17.3 years for the knees demonstrated four of the six patients were unlimited community ambulators, one a limited community ambulator and the remaining patient a household ambulator. Failure, defined as revision of any of the components or definite radiographic loosening, occurred in three knees (two patients) and five hips (three patients).

CONCLUSIONS

These good long-term functional results in a relatively very young population indicate that an early and aggressive approach to multiple joint disease is an appropriate option at a young age for patients with juvenile rheumatoid arthritis with severe disability and pain refractory to conservative management.

Total knee arthroplasty in juvenile rheumatoid arthritis

BACKGROUND

There is a paucity of reports regarding the long-term results of total knee arthroplasty in patients with juvenile rheumatoid arthritis. The purpose of this study was to evaluate the outcome of total knee arthroplasty in patients with juvenile rheumatoid arthritis who had been followed for a minimum of twelve years.

METHODS

Eight consecutive patients (fifteen knees) with juvenile rheumatoid arthritis underwent total knee arthroplasty at an average age of 16.8 years. Clinical evaluation of pain status, range of motion, and the ability to walk and radiographic evaluation of the alignment of the knees and component loosening were performed preoperatively and at a mean of 15.5 years postoperatively.

RESULTS

All patients had substantial pain and functional limitation before the surgery, and seven of the eight patients used a wheelchair. At the time of the latest follow-up, which was after revision surgery in three patients, all of the knees were pain-free and six patients were able to walk about the community. The mean arc of motion had increased from 36 degrees to 79 degrees . The final radiographic evaluation showed that thirteen of the fifteen knees were in neutral alignment and two were in valgus. Failure, defined as revision of any of the components or definite loosening as seen radiographically, occurred in three knees.

CONCLUSIONS

Good results, in terms of pain relief and restoration of function, were seen at a minimum of twelve years following total knee arthroplasty in our series of patients with juvenile rheumatoid arthritis. This procedure is a reasonable option when nonoperative therapy has been inadequate for patients with severe disability and pain in this relatively young population.