Bilateral Lower Limb Research Articles

Effect of different concentrations of tranexamic acid on blood loss after total knee arthroplasty: A randomized controlled clinical trial

Objective To investigate the effect and safety of intraarticular injection of tranexamic acid (TXA) at 2 concentrations on blood loss after total knee arthroplasty (TKA). Methods For this single blinded prospective randomised controlled trial, according to our inclusion and exclusion criteria we chose 24 patients diagnosed with degenerative joint disease who would receive bilateral TKA from October 2014 through July 2015. Comparisons were conducted between their bilateral knees. The knees were randomized into 2 groups to receive intraarticular injection of TXA at concentrations of either 15 g/L or 30 g/L before the tourniquet was released post-surgery. The TXA concentrations for each pair of knees were randomized by flipping a coin. The drainage, range of motion (ROM), visual analogue scale (VAS) and thigh circumference for each knee were recorded post-surgery. Blood routine examination and prothrombin time test were conducted for each patient at pre-surgery and 1, 3 and 5 days post-surgery. Vascular B-ultrasonography was performed for all the bilateral lower limbs at 5 days and one month post-surgery to assess incidence of thrombosis. Results The drainage for the 50 mL sides (65.4±33.4 mL) was significantly less than for the 100 mL sides (86.1±53.6 mL) (t=-3.873, P=0.001). There were no significant differences between the 50 mL and 100 mL sides regarding knee ROM (14.9°±3.1° versus 15.3°±3.3°), VAS (6.2±0.9 versus 6.0±1.0), or thigh circumference (46.8±3.0 cm versus 46.9±2.6 cm) (P>0.05). In this cohort, the post-surgery prothrombin time was significantly longer than the pre-surgery one (P<0.05). No deep infection, pulmonary embolism or deep vein thrombosis was observed in our trial. Conclusions Intraarticular injection of TXA can reduce blood loss after TKA and is safe. A higher concentration of TXA is more effective in decreasing post-surgery hemorrhage. Key words: Tranexamic acid; Arthroplasty, replacement, knee; Postoperative hemorrhage; Embolism and thrombosis

ANTERIOR APPROACH DEBRIDEMENT AND BONE GRAFTING WITH SELF-LOCKED TITANIUM PLATE INTERNAL FIXATION FOR TREATING LUMBOSACRAL TUBERCULOSIS

To explore the effectiveness of stage I anterior approach debridement and autologous iliac crest graft with single self-locked titanium plate internal fixation for the treatment of lumbosacral tuberculosis. Seven cases of lumbosacral tuberculosis were treated by stage I anterior approach debridement, autologous iliac crest graft, and single self-locked titanium plate internal fixation between February 2010 and October 2014. There were 5 males and 2 females, aged 18-65 years (mean, 41.6 years). The disease duration was 5-21 months (mean, 8 months). The patients had signs and symptoms of pain in lumbosacral region, radiating pain in unilateral lower limb or bilateral lower limbs, decreased muscular strength and disorders of superficial sensation. According to Frankel classification for spinal injury, 1 case was rated as grade C, 3 cases as grade D, and 3 cases as grade E. Preoperative imaging examination suggested L5, S1 lesions in line with the manifestations of tuberculosis; the lumbosacral angle was 16.4-28.5° (mean, 18.6°). The erythrocyte sedimentation rate was 28-105 mm/1 hour (mean, 61 mm/1 hour). All patients received 4-drug antituberculosis therapy. All patients underwent the operation successfully and all incisions healed at stage I, without relevant complication. All patients were followed up 14-70 months (mean, 25.6 months). All symptoms of tuberculosis disappeared and the erythrocyte sedimentation rate returned to normal. At last follow-up, Frankel classification was returned to E from D in 3 cases, returned to D from C in 1 case. Two cases suffered from pains in the lumbosacral region and at the donor site, 1 case suffered from upper abdominal discomfort and poor appetite,but these symptoms disappeared after symptomatic treatment. At last follow-up, X-ray examination indicated that the lumbosacral angle was 23.4-34.2° (mean, 28.6°). According to Bridwell criteria, 5 cases gained grade I bone fusion, and 2 cases gained grade II bone fusion, without migration of bone graft, or loosening or breakage of titanium plate or bolt. Stage I anterior approach debridement and autologous iliac crest graft with single self-locked titanium plate internal fixation is safe and effective in treating lumbosacral tuberculosis. It can achieve good bone fusion and stable lumbosacral stability, and maintain good deformity correction.

Case of McLeod syndrome with a novel genetic mutation

AbstractMcLeod syndrome is a rare neuroacanthocytosis caused by mutation of the XK gene. Acanthocytes in peripheral blood, systemic chorea, neuropathy, myopathy and increased serum levels of creatine kinase are observed in this syndrome, and mental manifestations and cardiomyopathy can also arise as complications. Various mutations in the XK gene have been reported, but the pathological condition in McLeod syndrome is unclear because of a lack of reports. We report a 64‐year‐old man with McLeod syndrome who showed increased levels of creatine kinase, and muscle atrophy and weakness in bilateral lower limbs. Peripheral blood smear showed numerous acanthocytes, and reduced levels of Kell antigen and the absence of XK protein suggested McLeod syndrome. Genetic analysis showed a mutation of c.del724_729TGTAGinsGGTCCTCTTTACC on exon 3 of the XK gene. To our knowledge, this is a novel genetic mutation in the XK gene.

Peak activation of lower limb musculature during high flexion kneeling and transitional movements

Few studies have measured lower limb muscle activation during high knee flexion or investigated the effects of occupational safety footwear. Therefore, our understanding of injury and disease mechanisms, such as knee osteoarthritis, is limited for these high-risk postures. Peak activation was assessed in eight bilateral lower limb muscles for twelve male participants, while shod or barefoot. Transitions between standing and kneeling had peak quadriceps and tibialis anterior (TA) activations above 50% MVC. Static kneeling and simulated tasks performed when kneeling had peak TA activity above 15% MVC but below 10% MVC for remaining muscles. In three cases, peak muscle activity was significantly higher (mean 8.9% MVC) when shod. However, net compressive knee joint forces may not be significantly increased when shod. EMG should be used as a modelling input when estimating joint contact forces for these postures, considering the activation levels in the hamstrings and quadriceps muscles during transitions.Practitioner Summary: Kneeling transitional movements are used in activities of daily living and work but are linked to increased knee osteoarthritis risk. We found peak EMG activity of some lower limb muscles to be over 70% MVC during transitions and minimal influence of wearing safety footwear.

Effects of Different Limb Remote Ischaemic Preconditioning on Ischaemia Reperfusion Injury in an Acute Left Anterior Descending Artery Occlusion Rat Model

The aim is to compare effects of three different protocols of limb remote ischaemic preconditioning (LRIP) on ischaemia reperfusion injury in an acute left anterior descending artery (LAD) occlusion model rat. Forty adult male Wistar rats were randomly assigned into four groups: group A, control; group B, LRIP in bilateral upper-limb (BUL) IP; group C, LRIP in bilateral lower-limb (BLL) IP; group D, LRIP in bilateral upper and lower limbs (ULL) IP. The 60min ligation and 180min reperfusion in LAD were applied to all rats. Limb remote ischaemic preconditioning was performed using 5min occlusion and 15min reperfusion (six cycles). Heart rate, blood pressure and electrogastrography (EGG) were recorded. Creatine kinase isoenzyme (CK-MB) level and infarct size were measured. Limb remote ischaemic preconditioning did not significantly affect heart rate, systolic blood pressure and arrhythmia score. However, LRIP significantly increased DBP value and decreased CK-MB levels and infarct size in group B, C, and D. Moreover, LRIP in ULL had a significantly better effect on reducing infarct size than LRIP in BUL and BLL. Limb remote ischaemic preconditioning at limbs could significantly reduce reperfusion injury in the heart. Moreover, LRIP in ULL indicated a better effect in reducing infarct size than LRIP in BUL and BLL.

Intramedullary spinal cord metastasis arising from papillary thyroid carcinoma: A case report and review of literature

Background:Intramedullary spinal cord metastases (IMSCM) are typically drop lesions from intracranial metastases and are a rare manifestation of systemic malignancy (8.5% of central nervous system metastases). They arise from primaries such as the lungs, breast, kidney, melanoma, or lymphoma. On the other hand, they arise very rarely from papillary thyroid carcinoma (PTC), even though it is the most common type of primary thyroid malignancy.Case Description:A 54-year-old male presented with pain in the lower back along with tingling, numbness, and weakness in the bilateral lower limbs. This was associated with urine incontinence for 1½ months. In the previous month, he developed a left-sided solitary thyroid nodule. Fine needle aspiration cytology and ultrasonography were suggestive of metastasis. Furthermore, the thoracolumbar magnetic resonance imaging showed T1-hypo and T2-hyper-intense D11-D12 level intramedullary lesion, with intense enhancement, which was consistent with an intramedullary lesion involving the conus. At surgery, a firm, brownish yellow, friable, vascular tumour was removed en toto. Upon discharge, the patient was neurologically intact except for residual bladder incontinence.Conclusion:In an extensive literature review (pubmed), IMSCM metastasis from PTC primary is confirmed as a rarity and this may be the fourth documented case. Moreover, this may be the first report of a case of PTC metastatic neurological deterioration “even before the treatment of the primary was undertaken.” Early diagnosis and microsurgical resection can result in improvement of neurological deficits and in the quality of life of patients with IMSCM.

0103: Cardiovascular involvement in Behçet disease: a retrospective study

Behçet disease (BD) is a multisystemic inflammatory disorder classified among the vasculitides which can affect all types and sizes of blood vessels. Our aim is to study the characteristics of cardio vascular involvement in BD. Methods medical records of 180 patients diagnosed BD according to the International Study Group of Behcet Disease, in the Internal Medicine Department of F.Bourguiba hospital in Monastir, were retrospectively analyzed. The diagnosis of vascular involvement was made by Doppler ultrasonography and/ or computed tomography. Results there were 65% males and 35% females. The mean age at diagnosis was 30 years. Familiar history of BD was found in 22.5% of cases. Vascular involvement was found in 32% of patients revealing the diagnosis in 3% of cases. Superficial venous thrombosis was found in 25% of cases. Deep venous thrombosis was diagnosed in 62.5% of patients as following: upper limb in 3.1%, lower limb in 34.4%, bilateral lower limb in 6.3% and inferior vena cava in 18.7%. Arterial manifestations were found in 21.9% of cases with pulmonary embolism in 12.5% of patients and pulmonary arterial aneurysm in 9.4%. Cardiac involvement was as following: myocardial infarction and coronary aneurysm in 1.6% and intracardiac thrombosis in 1.6%. The medical treatment was based on anticoagulants and colchicine in all cases; corticosteroids in 45.2% of cases with immunosuppressive drugs in 15.6%. Arterial pulmonary embolisation was performed in two cases. Surgical treatment was necessary in 6 cases: IVC filter (3 cases), lobectomy (2 cases). Conclusion vascular involvement is a common complication of Behcet’s disease which could lead to worse prognosis if not diagnosed early.

Anesthetic management of a geriatric patient with situs inversus totalis with bilateral varicose veins for left-sided Trendelenburg's operation with bilateral superficial ligation of perforators

Situs inversus is featured by the switching of the organs to the opposite side of the body. When associated with dextrocardia, it is known as situs inversus totalis. This disease is a uncommon congenital anomaly and can lead to a diagnostic misperception for surgeons because of infrequent location of symptoms resulting in late diagnosis of known pathologies and operative complications because of changed anatomy. Varicose veins of leg, although being commonly reported, to be diagnosed specially in elderly can be notorious if associated with its complications such as ulcers, bleeding, and so on, and when associated with underlying medical illness. We report a rare case where these conditions coexisted. A 62-year-old woman presented with swelling in bilateral lower limbs with pain on walking with hypertension, type-2diabetes mellitus, and situs inversus totalis electively posted for left-sided Trendelenburg’s operation with bilateral superficial ligation of perforators, which we managed successfully under sole epidural anesthesia.

Uncommon clinical presentation of cryoglobulinemia vasculitis successfully treated with rituximab and mycophenolate mofetil

We report the case of a 80-year-old woman with a severe mononeuritis multiplex over bilateral lower limb, with no other clinical signs or symptoms of vasculitis. Laboratory test showed elevated erythrocyte sedimentation rate and C reactive protein, low C4 levels, positive rheumatoid factor and polyclonal IgG and IgA cryoglobulins at a high cryocrit. Malignancies disorders and infectious diseases screening was negative. Nerve biopsy revealed signs of vasculitis with inflammatory infiltrate of epineural vessels, axonal degeneration and moderate loss of myelinated fibres. The diagnosis of essential mixed cryoglobulinemia vasculitis was established. She received treatment with plasmapheresis and high doses of steroids with progression of the symptoms to the upper limbs and persistence of positive cryoglobulins, low C4 levels and high acute phase reactants. She required treatment with rituximab and mycophenolate mofetil to control the disease. In conclusion we report an uncommon clinical presentation of a cryoglobulinemia vasculitis successfully treated with two B- cell depleting therapies.

An Unusual Case of Corpulmonale Due to a Common Iliac Artery Aneurysm Fistulating to the Common Iliac Vein

This is an unusual case presenting as bilateral lower limb edema and corpulmonale secondary to left ilio-ilial fistula. A 70-year-old man with a background history of hypertension and ischemic heart disease presented to the medical team with bilateral leg swelling and deranged liver and kidney function. An abdominal ultrasound scan detected an aneurysm of the left common iliac artery. A CT angiogram revealed that this aneurysm was fistulating into the left common iliac vein causing right heart failure. This was repaired endovascularly. The procedure was successful and resulted in complete resolution of symptoms and restoration of normal liver function. J Med Cases. 2016;7(1):18-21 doi: http://dx.doi.org/10.14740/jmc2375w

English

English

A Missed Diagnosis of Cervical Spine Fracture in Alcohol Intoxicated Patient

Introduction: A significant cervico-thoracic spondylolisthesis with bilateral facet joint dislocation is very unstable and can lead to devastating consequences if not diagnosed early. Symptomatic spondylolisthesis is frequently missed at Emergency Department (ED) due to various reasons. Besides inadequate radiographs, lack of cooperation by patients who are under alcohol intoxication is also one of the causative factors resulting in missed diagnosis of cervical spine fracture during the clinical assessment. Case Presentation: Forty three year old man, a chronic alcoholic presented to our emergency department with a missed diagnosis of C7-T1 anterolisthesis with bilateral facet joint dislocation. He had a fall from a height and sustained neck pain. Patient had multiple visits to our ED for the same complaint and was noted intoxicated with alcohol during both his visits. The radiograph images of the cervical spine did not include the vertebral spine below C6 in lateral view. It was interpreted as negative for fracture or dislocation, therefore the patient was discharged with analgesics. Subsequently, the patient developed bilateral lower limb weakness and loss of function of his fingers. Conclusion: An accurate and detailed history, physical examination and diagnostic imaging are essential for the diagnosis of cervical spine injury in alcohol intoxicated patients. These are not to be missed in order to avoid medico legal issues in the future. This case will not be missed if the fundamental rules of assessing a cervical lateral x-ray are followed.

Sudden onset bilateral lower limb weakness in a female patient with no significant past medical history: answer

Sudden onset bilateral lower limb weakness in a female patient with no significant past medical history: answer

Clinical characteristics and outcomes of unilateral and bilateral lower limb deep vein thrombosis: ultrasonography-based study of 6420 cases

Blocking bromoand extra-terminal bromodomains mitigates intimal hyperplasia in rat carotid arteries: role of epigenetic reader in vascular disease Mengxue Zhang, MD, Bowen Wang, Toshio Takayama, MD, PhD, Xudong Shi, MD, PhD, Drew Al Roenneburg, K Craig Kent, MD, FACS, Lian-Wang Guo, PhD Wisconsin Institute for Medical Research, Madison, WI; University of Wisconsin School of Medicine and Public Health, Madison, WI

Unusual splitting of cord defying the Pang's classification

A 2-year-old boy presented to us with history of inability to walk without support. There was no associated wasting or history of cuts and burns on lower limbs. He seemed unable to detect the urge to urinate or defecate. There was no history of deformity of feet, limbs or spine. On examination of spine, the spinous processes could not be felt in lumbar region. The power in lower limbs was 3–4/5. The sensations were preserved in bilateral lower limbs and deep tendon reflexes were diminished, there was no deformity of feet. Perianal sensations were intact and anal reflex and tone was also normal. The child was subjected to urodynamic testing, where compliance and bladder capacity was reported to be normal. Suspecting a diagnosis of tethered cord syndrome, a magnetic resonance imaging (MRI) of craniospinal axis was done. MRI revealed a split cord malformation at L3–4 levels with malformation of posterior elements of spine and low-lying cord at L4 level. A fibrocartilaginous septum was dividing the cord into two halves on MRI (Figs 1 and 2). An associated hydromyelia was present at D7 to L1 level. A radiological diagnosis of split cord malformation (SCM) type I with proximal hydrosyrinxwas made and surgery

Guillain Barre syndrome – Spinal MR findings

A 10 yr old male child presented with history of acute onset rapidly progressive weakness of bilateral lower limbs. There was no history of associated fever or trauma. No bowel or bladder involvement was noted. On examination there was bilateral lower limb areflexia with little sensory involvement. The rest of the systemic examination was unremarkable. Cerebrospinal Fluid (CSF) examination revealed elevated protein level (800 mg/dl, normal range is 20–40 mg/dl) consistent with albumin cytological dissociation with nerve conduction study showing slow conduction consistent with demyelinating polyneuropathy. Based on clinical signs, symptoms and lab investigation diagnosis of Guillain Barre syndrome (GBS) was made and patient was put on intravenous immunoglobulin therapy. Before starting the treatment magnetic resonance imaging (MRI) spine was performed to rule out compressive myelopathy or myelitis. Pre contrast images were normal however post contrast images of spine revealed enhancement of cauda equina nerve roots and conus medullaris (Fig. 1) with preferential enhancement of ventral spinal nerve roots as compared to dorsal nerve roots (Fig. 2) GBS is an acute symmetrical inflammatory demyelinating polyneuropathy [1] that involves the peripheral nervous system. Patients generally present with acute

Cepharanthine mitigates lung injury in lower limb ischemia–reperfusion

BackgroundOxidation and inflammation caused by lower limb ischemia–reperfusion (I/R) readily induce lung injury. We elucidated whether cepharanthine, a potent antioxidative and anti-inflammatory drug, can mitigate lung injury induced by lower limb I/R. Role of heme oxygenase 1 (HO-1) was also investigated. Materials and methodsAdult male Sprague–Dawley rats were randomized to receive I/R, I/R plus cepharanthine, or I/R plus cepharanthine plus the HO-1 activity inhibitor tin protoporphyrin (SnPP; n = 12 in each group). Sham control groups were run simultaneously. I/R was induced by applying rubber band tourniquets high around each thigh for 3 h followed by reperfusion for 24 h. ResultsRats receiving I/R had significant increases in concentrations of nitric oxide, malondialdehyde (lipid peroxidation marker), and inflammatory molecules (including interleukin 6, macrophage inflammatory protein 2, and prostaglandin E2) in plasma, and the lungs, indicating that I/R caused significant oxidation and inflammation in rats. Rats receiving I/R also had significant increases in concentration of phosphorylated inhibitor-κB, indicating that I/R caused significant nuclear factor κB activation. Assays of arterial blood gas, biochemistry, and histopathology confirmed that I/R-induced significant lung injury in rats. Cepharanthine significantly reduced the oxidation, inflammation, nuclear factor κB activation, and lung injury induced by I/R. Of note, cepharanthine significantly enhanced pulmonary HO-1 expression after I/R. Moreover, these previously mentioned effects of cepharanthine were partially reversed by inhibiting the activity of HO-1. ConclusionsCepharanthine mitigates lung injury induced by bilateral lower limb I/R in rats. The mechanisms may involve its effects on reducing oxidation and inflammation. The mechanisms may also involve enhancing HO-1 expression.

An inferior vena cava filter causing perforation with all six legs

A 52-year-old male patient with past medical history most significant for recurrent unprovoked bilateral lower limb deep vein thrombosis in 2010 as well as diabetes, hypertension, and smoking. Although the patient was appropriately anti-coagulated, on warfarin, he presented with sub-massive pulmonary embolism in 2011, hence a …

Rising trend of proximal femoral nail in therapy of Extracapsular Hip Fractures

Spontaneous spinal epidural hematoma (SSEH) is a rare entity.SSEH is an accumulation of blood in the vertebral epidural space in the absence of trauma or iatrogenic procedure like lumbar puncture.The incidence of SSEH has been estimated at 0.1 patients per 100,000 individuals and represents less than 1% of spinal space-occupying lesions .Here we are presenting case of a 65year old female hypertensive on treatment with controlled blood pressure, who presented with sudden onset paraplegia and weakness of muscles of hand, associated with urinary and bowel incontinence that started 6 hours before presenting to Emergency Room .Patient was subjected to MRI spine that revealed a collection in spinal epidural space ,hypointense in T1W images and hyperintense in T2W images, extending from C6-C7 to T1-T2 suggestive of acute / subacute epidural hematoma (fig 1).In our case all possible causes of an epidural haematoma were ruled out by relevant investigations.Patient was subjected to surgical evacuation of hematoma after 48 hours of presentation.Perioperative and Postoperative period was uneventfull . Sensations over involved areas improved. Motor weakness also improved from Grade III to Grade IV+ in bilateral lower limbs and from Grade II to Grade IV in small muscles of hand and triceps, however Patient persisited with urinary incontinence.CONCLUSION: When a patient receiving anticoagulant therapy complains of sudden and unexplained neck or back pain, we should suspect the possibility of SSEH. For early diagnosis, immediate MRI is essential .In addition, we should consider SSEH as one of the important differential diagnoses in elderly patients who have developed acute myelopathy.

Metallosis-induced Facet Joint Synovial Cyst after Spinal Instrumentation Surgery

Metallosis is an uncommon complication of metal implantation. It most commonly occurs after knee and hip joint replacement, but it has also been reported in other joints such as the shoulder, wrist, and elbow. A 43-year-old man with L4-5 spondylolisthesis underwent L4-5 laminectomy and posterolateral fusion with pedicle screw instrumentation 7 years previously. Low back pain radiating to the bilateral lower limbs developed 2 months prior to presentation. The L3-4 facet joint synovial cyst compressing dura was diagnosed via magnetic resonance imaging. We removed the pedicle screws and performed a total excision of the cystic mass. At the 1-year follow-up, the patient was pain-free. Metallosis should be considered as a late complication of spinal implantation surgery. It can induce synovial cysts that cause radicular symptoms. Surgical intervention produced good results in this case.