Henri Horoszowski

The Use of Fibrin Tissue Adhesive to Reduce Blood Loss and the Need for Blood Transfusion After Total Knee Arthroplasty. A Prospective, Randomized, Multicenter Study*

BACKGROUND Total knee arthroplasty is associated with major postoperative blood loss of approximately 800 to 1200 milliliters, and blood transfusion is frequently required. With the increased concern about the risks of blood transfusion, various methods of blood conservation in orthopaedic surgery have been studied. The most appropriate solution, however, is to reduce the loss of blood during and after an operation. The present prospective, controlled, randomized study was designed to evaluate the hemostatic efficacy of the use of fibrin tissue adhesive in patients managed with total knee arthroplasty. METHODS Fifty-eight patients who were scheduled to have a total knee arthroplasty were randomly divided into two groups: a control group, in which the standard means of hemostasis were applied, and a treatment group, in which the standard means to control local bleeding were applied and a fibrin tissue adhesive was sprayed on the internal aspects of the operative field before skin closure. All operations were performed in a bloodless field with use of a pneumatic tourniquet. All patients received low-molecular-weight heparin as thromboprophylaxis twelve hours before the operation and every twelve hours postoperatively. Blood loss during the operation was evaluated by measuring the volume in the suction apparatus and by estimating the amount of lost blood in the swabs at the end of the operation. The apparent postoperative lost blood was determined by measuring the volume in the suction-drain bottles. All blood transfusions were recorded. RESULTS The mean apparent postoperative blood loss (and standard deviation) in the fibrin-tissue-adhesive group was 360+/-287.7 milliliters compared with 878+/-403.0 milliliters in the control group, with a mean difference of 518 milliliters (p<0.001). The decrease in the level of hemoglobin was 25+/-10 grams per liter in the treatment group compared with 37+/-12 grams per liter in the control group (p<0.001). Sixteen patients (55 percent) in the control group required a blood transfusion and eight (28 percent) required two units of blood, whereas only five (17 percent) of the patients in the fibrin-tissue-adhesive group required a blood transfusion and only one (3 percent) required two units (p = 0.004). The number of adverse events was comparable between the two groups. None of the adverse events were considered to be related to the use of fibrin tissue adhesive. One death, which was due to massive pulmonary embolism, was reported in the control group. No seroconversion was reported at three and six months after the operation. CONCLUSION The use of fibrin tissue adhesive in total knee arthroplasty seems to be an effective and safe means with which to reduce blood loss and blood-transfusion requirements. Furthermore, the importance of these findings was enhanced by a significant reduction in blood loss, in the postoperative decrease in the level of hemoglobin, and in blood-transfusion requirements despite preoperative thromboprophylaxis with low-molecular-weight heparin.

Monteggia and equivalent lesions. A study of 41 cases.

Forty-one patients who suffered from a Monteggia fracture and were treated between 1984 and 1993 were reviewed retrospectively using a new motion score of the elbow joint. There were 14 children and 27 adults of whom 34 were available for review. The results in children were significantly better than those of the adults. Among the adults, the final results of the patients who had a Bado Type 1 equivalent injury were significantly worse than those of the other groups, especially when associated with a fracture of the radial head. The type of fracture, open or closed, the presence of a fracture of the olecranon, and the energy level of the trauma did not have any significant prognostic value. Good correlation was shown between the new motion score and the Figgie elbow score. The Bado Type 1 equivalent injuries should be considered as a special subgroup of the Monteggia lesion, necessitating extra attention in treatment and rehabilitation, and a close followup of the patient.

Role of fibrin sealants in surgical procedures on patients with hemostatic disorders.

Fibrin sealants have until now been used to a very limited extent in patients with a bleeding diathesis. The authors have accumulated experience from 8 minor and 40 major surgical procedures, plus 10 circumcisions and 118 tooth extractions in 106 patients suffering from hemophilia A, B, or von Willebrands disease. Most of the patients had the severe form of the disease. The authors were able to show a reduction of blood loss and of requirements for replacement therapy with factor concentrates. The literature on the application of fibrin sealants in this group of patients, which mainly deals with dental procedures, is reviewed and compared with data from the current study. The composition of the glue is of major significance and is discussed in detail.

A simple method for removal of a fractured intramedullary nail

Fatigue failure of an intramedullary nail may occur if there is delayed or nonunion of the fracture (Zimmerman and Klasen 1983; Winquist, Hansen and Clawson 1984; Bucholz, Ross and Lawrence 1987) and the distal end of the fractured nail is then difficult to remove. Several methods have been described (B#{246}hler 1968; Yoslow and LaMont 1986; Mooney, Chabon and Poehling 1991) to which we add a simple and reliable technique. Patients. From 1986 to 1991 we treated five patients with fractured femoral intramedullary nails, all associated with painful delayed union or nonunion. Four nails were of the locking type and one was a K#{252}ntscherpattern. They had been in place for one to four years. Technique. The operation is performed with the patient on a fracture table with image-intensifier control. The intramedullary canal is opened at the greater trochanter (Taylor 1992) and any locking screws are removed. The proximal part of the nail is removed and a nail which is 1 mm smaller in diameter than the fractured nail is passed down the intramedullary canal and gently impacted into the opening ofthe distal nail fragment. Both nails are then removed (Fig. 1). If there is delayed or nonunion the intramedullary canal is then reamed and a nail of larger diameter is inserted. Results. In all five cases the removal of the distal nail fragment was easy and uneventful with no difficulties during extraction. The average time taken was ten minutes (7 to 15).

Septic arthritis of the acromioclavicular joint.

SummaryA patient with isolated pyogenous arthritis of the acromioclavicular joint (A-C joint) caused by Streptococcus viridans is described. The patient had no underlying disease. Minor trauma preceded shortly the development of the septic process. The patient was treated successfully with surgical drainage and antibiotics. To our knowledge this is the first case report of septic arthritis of the A-C joint caused by Streptococcus viridans. The A-C joint is rarely involved in septic processes. Even conditions such as intravenous drug abuse [3, 6] and renal dialysis [4, 7] which tend to infect unusual joints [5] have only rarely been described in association with A-C septic arthritis.ZusammenfassungEin Patient mit einer isolierten pyogenen Arthritis des Acromioclavicular-Gelenks, hervorgerufen durch Streptococcus viridans, wind beschrieben. Der Patient hatte keine zugrunde liegende Krankheit. Ein leichtes Trauma ging den Entwicklung des septischen Prozesses voraus. Der Patient wurde erfolgreich mit chirurgischer Drainage und Antibiotica behandelt. Nach unserem Wissen ist dies der erste Bericht über septische Arthritis des Acromioclavicular-Gelenks, hervorgerufen durch Streptococcus viridans. Das Acromioclavicular-Gelenk ist selten von septischen Prozessen betroffen. Sogar Bedingungen wie intravenöser Drogenmißbrauch und Nierendialyse, die zur Infektion ungewöhnlicher Gelenke führen können, wurden nun selten in Verbindung mit septischen Arthritis des Acromioclavicular-Gelenks beschrieben.

DISTAL TRANSFER OF THE GREATER TROCHANTER IN COXA VARA

Seven patients (nine hips) who suffered from coxa vara were treated by distal transfer of the greater trochanter. The operation eliminated or markedly diminished the preoperative Trendelenburg sign, thus improving gait. In three patients (four hips) operated upon at the aged of 9 and 12 years, the initial coxa vara was converted into an almost normal valgus kemoral neck. There was one poor result due to technical failure.

Cost-Utility Analysis of Total Hip Arthroplasties: Technology Assessment of Surgical Procedures by Mailed Questionnaires

A retrospective study comparing 700 consecutive total hip arthroplasties, utilizing four types of implants, was performed. Questionnaires based on hip scores were sent to 593 living patients. Useful responses were received from 363 (61%) patients. Hip scores and quality-adjusted life-years were calculated. Multiple regression analysis, controlling for all possible biases, demonstrated one cementless implant as superior to all others. We believe that the use of mailed questionnaires is a simple and convenient system of follow-up, saving patients the need for outpatient clinic visits. The validity of such replies, however, has yet to be established.

Multiple joint procedures in a single operative session on hemophilic patients.

Hemophilia is a coagulation disorder wherein frequent hemarthroses result in premature joint degradation. This hemophilic osteoarthropathy is polyarticular, and despite modern coagulation possibilities, acute hemarthroses and chronic synovitis are common. Because repair of a single joint in polyarthritic conditions may not improve the patients functional ability a policy has been adopted to create a functional limb. This therapeutic protocol succeeded in gaining the objectives of a functional limb, and it was noted that the complication rate was less than expected and that the rehabilitation period was relatively short.

Disc space infection and vertebral osteomyelitis as a complication of percutaneous lateral discectomy

Percutaneous lateral discectomy (PLD) in a 32-year-old man was followed by postoperative disc space infection and adjacent vertebral osteomyelitis caused by Staphylococcus aureus. The simplicity and decreased morbidity associated with PLD may be offset by severe infections. The small incision made in the annulus during PLD may not allow adequate drainage in the case of infection and may subsequently direct the infective process to the adjacent vertebral endplates. Meticulous aseptic technique, and possibly the use of prophylactic antibiotic therapy, is important in PLD.

Primary reconstruction of traumatic bony defects using allografts.

Abstract We retrospectively reviewed 207 patients suffering from traumatic bone defect who had been treated at our institution between 1973 and 1993. Three types of traumatic bone defects were identified: I, minor; II, major cortical; III, major articular. Each type was further subdivided into: A, open injury; B, closed injury. The proposed treatment modality of each type was included within each classification. Types II and III posed the greatest difficulties in management. However, massive bone allografts can be successfully used in these situations, even in the early phases of treatment, but only given specific prerequisites.