The side-to-side difference found in maximal heel-rise height can be explained by a difference in Achilles tendon length in patients recovering from an Achilles tendon rupture. Minimizing tendon elongation appears to be an important treatment goal when aiming for full return of function.

Background: Total hip arthroplasty (THA) is traditionally associated with a low complication rate, with complications such as infection, fracture and dislocation requiring readmission or reoperation. We seek to identify the complication rate among the anterior, direct lateral and posterior surgical approaches. Methods: We reviewed all THAs performed at the Epworth Healthcare from 1 July 2014 to 30 June 2016. There were 2437 THAs performed by a variety of approaches. No hips were excluded from this study. We surveyed the hospital database and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to identify those patients who had been readmitted and/or reoperated on. Details collected included age, gender, laterality of the surgery (left/right/bilateral), surgical approach utilised, complications which occurred. Results: There were 29 peri-prosthetic fractures detected (13 anterior, 9 lateral, 7 posterior) and 10 underwent revision of implant, 19 were fixed. The increased rate of revision in the anterior group was statistically significant. There were 14 dislocations (5 anterior, 1 lateral, 8 posterior) of which 8 prostheses were revised. Three cases operated via the anterior approach and 1 by the lateral had early subsidence without fracture, necessitating revision of the femoral prostheses. Operative site infection occurred in 12 cases (2 anterior, 4 lateral, 6 posterior) with 6 requiring revision of implants. Conclusion: The complication rates between the 3 main approaches are similar, but individual surgeons should be vigilant for complications unique to their surgical approaches, such as femoral fractures in the anterior approach and dislocations in the posterior approach.

Mega-aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare complications of bypass surgery. We report the development of superior vena cava syndrome secondary to an SVG mega-aneurysm with concomitant fistulous communication to the right atrium. Successful treatment was achieved by coil embolization and chronic anticoagulation.

Positron emission tomography with`50-labeled water (H2150) can be used to delineate abnormal regional myocardial blood flow in experimental animals. To determine the feasibility of this method in humans, we studied 33 subjects (9 normal volunteers and 24 patients with angiographically documented coronary artery disease) at rest and after myocardial hyperemia induced with intravenous infusion of dipyridamole. At rest, the myocardial region demonstrating the lowest relative H2`50 activity exhibited 71 + 8% of activity in the region with peak activity in control subjects and 62 + 17% in patients (p = NS). After the dipyridamole infusion, differences between the two groups were accentuated. In control subjects, activity in the region with lowest relative radioactivity averaged 77 5% of that in the region with peak activity. In patients, it averaged 55 ±+22% of activity in the region with peak activity (p<0.01). Results in patients with ischemia with or without a history of remote myocardial infarction were not significantly different. In 22 of the 24 patients, the region with lowest relative perfusion corresponded anatomically to the region of myocardium distal to a stenosis. Thus, delineation of regional myocardial perfusion in patients with coronary artery disease is possible with positron emission tomography and H215O. Further studies will be necessary to prospectively determine sensitivity and specificity. (Circulation 1988;78:612- Received July 27, 1987; revision accepted May 5, 1988.`3 N-labeled ammonia2-4 and 52Rb5-7 have been successfully used to estimate regional myocardial blood flow in experimental animals and in patients. 82Rb is particularly attractive in the clinical setting because it is generator produced, which obviates the need for an on-site cyclotron. However, the use of these tracers for quantification of flow entails some limitations. Single-pass extraction and myocardial retention of`3N-labeled ammonia are influenced by flow23,8 as well as by cell membrane integrity9 and the metabolic state of the myocardium.8 9 Extraction of 82Rb also varies with flow and metabolism. 5,6,10 An ideal perfusion tracer should be either freely diffusible or completely extractable and retainable by myocardium on a single pass through the coronary circulation without having its kinetics altered throughout the range of flow studied or by the metabolic status of the myocardium. 150-labeled water (H2`50) is essentially a freely diffusible tracer in the heart with uptake that does not vary despite wide variations in flow rate11 or changes in the metabolic state of myocardium associated with prolonged ischemia or reperfusion. 11-14 150 is a useful

Effects of coronary angioplasty on myocardial flow reserve have been difficult to characterize noninvasively because conventional imaging techniques cannot quantitate blood flow in absolute terms. The effects of coronary angioplasty on myocardial perfusion and perfusion reserve were delineated with positron emission tomography and oxygen-15-labeled water (H2(15)O) in 13 patients before and after single vessel angioplasty. In 11 patients, angioplasty was successful (minimal cross-sectional area increased from 0.60 +/- 0.59 to 3.45 +/- 1.09 mm2, p less than 0.001). In these patients, regional H2(15)O radioactivity (the ratio of nutritional perfusion in regions distal to the stenosis compared with regions supplied by angiographically normal arteries) at rest before angioplasty was 55 +/- 22% of peak myocardial radioactivity and did not increase significantly afterward (70 +/- 16%, p = NS). However, after administration of intravenous dipyridamole, hyperemic perfusion in regions distal to a stenosis averaged only 39 +/- 18% of peak myocardial counts before angioplasty, but increased to 66 +/- 22% after angioplasty (p less than 0.02). Perfusion reserve in the two patients in whom angioplasty was angiographically unsuccessful showed no change. Quantitative estimates of perfusion in absolute rather than relative terms were obtained with positron emission tomographic data from seven of the patients with successful angioplasty. At rest, perfusion in regions distal to a stenosis was not different from the values in regions supplied by normal coronary arteries (1.54 +/- 0.54 compared with 1.46 +/- 0.38 ml/g per min, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Large aneurysms (> 4 cm) of saphenous vein grafts (SVG) to coronary arteries are a rare complication of coronary artery bypass graft surgery (CABG). A 64-year-old male, status post-CABG 14 years ago, presented with dyspnea and diaphoresis. Pneumonia and non-Q-wave myocardial infarction (MI) were diagnosed. Cardiac catheterization and chest computed tomography demonstrated a 5 x 7-cm aneurysm of a SVG. At the time of surgery, the left internal mammary artery (grafted to the left anterior descending artery) was found to be stretched tautly over the aneurysm, resulting in impaired flow. The aneurysm was successfully resected. This is the first published case implicating a SVG aneurysm as the direct cause of a MI by mass effect.

Custom cutting guides based on pre-operative imaging have been introduced for total knee arthroplasty (TKA). The aim of this prospective cohort study was to assess the reliability of repeated placement of custom cutting guides by multiple surgeons in a group of patients undergoing TKA.Custom cutting guides (ShapeMatch Õ , Stryker Orthopaedics) were designed from pre-operative MRI scans. The treating surgeon placed each guide on the femur and tibia of each patient three times without pinning the block. The threedimensional position and orientation of the guide was measured for each repetition using a computer navigation system. The surgeon was blinded to the navigation system display.Data from 24 patients and 6 surgeons were analyzed. Intraclass correlation coefficients for all measurement parameters were in the range 0.889-0.997 (excellent), and all comparisons were statistically significant (p < 0.001). The range for femoral varus/valgus was 0.0-1.5, with 96% of patients being within 0.5 . For femoral flexion/extension the range was 0.0-3.5 (92% within 2.5 ). On the tibia, varus/valgus had a range of 0.0-1.0 (92% within 0.5 ), and for slope the range was 0.0-3.5 (92% within 2.5 ). The high degree of agreement indicated that intra-surgeon variation was minimal and that the technique is reliable.

Aims The mid-term results of kinematic alignment (KA) for total knee arthroplasty (TKA) using image derived instrumentation (IDI) have not been reported in detail, and questions remain regarding ligamentous stability and revisions. This paper aims to address the following: 1) what is the distribution of alignment of KA TKAs using IDI; 2) is a TKA alignment category associated with increased risk of failure or poor patient outcomes; 3) does extending limb alignment lead to changes in soft-tissue laxity; and 4) what is the five-year survivorship and outcomes of KA TKA using IDI? Methods A prospective, multicentre, trial enrolled 100 patients undergoing KA TKA using IDI, with follow-up to five years. Alignment measures were conducted pre- and postoperatively to assess constitutional alignment and final implant position. Patient-reported outcome measures (PROMs) of pain and function were also included. The Australian Orthopaedic Association National Joint Arthroplasty Registry was used to assess survivorship. Results The postoperative HKA distribution varied from 9° varus to 11° valgus. All PROMs showed statistical improvements at one year (p < 0.001), with further improvements at five years for Knee Osteoarthritis Outcome Score symptoms (p = 0.041) and Forgotten Joint Score (p = 0.011). Correlation analysis showed no difference (p = 0.610) between the hip-knee-ankle and joint line congruence angle at one and five years. Sub-group analysis showed no difference in PROMs for patients placed within 3° of neutral compared to those placed > 3°. There were no revisions for tibial loosening; however, there were reports of a higher incidence of poor patella tracking and patellofemoral stiffness. Conclusion PROMs were not impacted by postoperative alignment category. Ligamentous stability was maintained at five years with joint line obliquity. There were no revisions for tibial loosening despite a significant portion of tibiae placed in varus; however, KA executed with IDI resulted in a higher than anticipated rate of patella complications. Cite this article: Bone Jt Open 2022;3(8):656–665.