Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement: a minimum ten-year follow-up study

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan-Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE(®), Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL(®)), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.

The case for removing the subchondral bone plate in preparation of the acetabulum

Aseptic loosening of the acetabular component continues to be the most common indication for revision of total hip replacements in younger patients. Early in the evolution of the cemented hip, arthroplasty surgeons switched from removal to retention of the acetabular subchondral bone plate, theorizing that unfavourable mechanical forces were the cause of loosening at the bone-cement interface. It is now known that the cause of aseptic loosening is probably biological rather than mechanical and removing the subchondral bone plate may enhance biological fixation of cement to bone. With this in mind, perhaps it is time to revive removal of the subchondral bone as a standard part of acetabular preparation.

Progression of HIV disease is associated with increased expression of Fc gammaRI and CR1 on alveolar macrophages

The expression of receptors for complement and the Fc region of immunoglobulin by alveolar macrophages (AM) constitutes a valuable aid to effector function of these cells. However, during HIV infection such expression may also act to increase binding of immune complexes, thus facilitating viral infection of these cells. This study was designed to determine whether changes in the expression of these receptors occurs in situ during HIV infection. Lung macrophages were isolated by bronchoalveolar lavage in groups of HIV+ subjects segregated on the basis of peripheral CD4 count. A group of normal subjects was also investigated. Expression of CR1 and Fc gammaRI was quantified by measuring the optical density of reaction product following controlled immunoperoxidase staining with MoAbs CD35 and CD64. Both CR1 and Fc gammaRI were increased over normal in all HIV+ subjects. This increase was progressive with advancing disease as determined by correlation with declining peripheral CD4 count. Comparison of asymptomatic and symptomatic subjects with HIV infection showed no difference in CR1 expression but a rise in Fc gammaRI expression in the latter group. An overall inverse correlation was also found between peripheral CD4 count and Fc gammaRI expression, but not CR1 expression. These data demonstrate a significant increase in the expression of these receptors on AM from HIV+ subjects, and show that this increase may occur before any symptoms in these patients.

Differential cardiovascular effects of propranolol, atenolol, and pindolol measured by impedance cardiography

We have evaluated Sramek's method of impedance cardiography as a non-invasive way of detecting the cardiovascular effects of drugs. We made cardiovascular measurements using the method during passive tilting and exercise 2 h after the oral administration of atenolol (50 and 100 mg), propranolol (40 and 80 mg), pindolol (5 and 10 mg), and placebo in seven separate studies involving eight healthy male volunteers. Equivalent doses of the pure antagonists atenolol (beta 1) and propranolol (beta 1, beta 2) produced similar reductions in heart rate, systolic blood pressure, and cardiac index, and increases in stroke volume and total peripheral resistance, particularly during exercise. In contrast the partial agonist pindolol produced increases in heart rate and cardiac index, and reductions in peripheral resistance at rest. During passive tilting and exercise pindolol reduced heart rate, but cardiac output and total peripheral resistance were unchanged except at the highest levels of exercise. The similar cardiovascular effects of atenolol and propranolol, but differing effects of pindolol, are consistent with reports using other methods of measurement. This suggests that impedance cardiography may have a place in the non-invasive assessment of the cardiovascular effects of drugs.