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AimsWe report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.Patients and MethodsBetween November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year.ResultsA total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up.ConclusionSTAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.

AimsTotal ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.Patients and MethodsA total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.ResultsThere were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature.ConclusionTotal ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent.Cite this article: Bone Joint J2018;100-B:1352–8.

The dynamic responses of a railway bridge members due to vehicletrackbridge interaction were investigated for the effects of vertical and lateral track irregularities, approach track quality, and bridge damping. In each case, a train consisting of three vehicles moving at constant speed was simulated traveling on the bridge. It was found that: 1 Greater approach irregularities produce higher impact factors and dynamic forces in bridge members; 2 impact factors in members with low static stress are high, but the dynamic stresses produced are low; 3 in general, impact factors reduce slightly due to bridge damping; and 4 the dynamic forces in lower lateral bracing members are small as compared to their allowable values.

As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.

Introduction: Initiation of warfarin therapy is complicated by its narrow therapeutic index and inter‐patient dose‐effect variability. A ‘10‐mg nomogram’ warfarin initiation protocol permits safe therapeutic anticoagulation in outpatients started on warfarin. We aimed to develop a safe and effective warfarin maintenance dose prediction tool in these patients. Methods: Baseline potential predictor variables were collected on a retrospective cohort of outpatients initiated on warfarin for venous thromboembolism treatment. The primary outcome was the warfarin maintenance dose, defined as mean warfarin dose over the last 10 days of the first month of warfarin treatment. Univariate and multivariate analyses were performed to determine which baseline variables were warfarin maintenance dose predictors. An independent cohort of patients validated the derived warfarin maintenance dose prediction rule. Results: Patient’s age and weight, cumulative dose of warfarin over the first week of induction and international normalized ratio (INR) on days 3, 5 and 8 were statistically significant predictors of the warfarin maintenance dose. Our final prediction rule reads: maintenance dose (in mg) = 2.5 + 10% of the first week cumulative dose ‐ INR value at day 8 + 1.5 if INR was below 2.0 at day 5. In the validation cohort, the predicted dose was strongly correlated with the actual maintenance dose (r = 0.88, P < 0.0001). The mean difference between observed and predicted dose was not clinically significant: −0.1 ± 1.1 mg. Conclusion: In outpatients initiated on warfarin using a ‘10‐mg nomogram’, a simple prediction rule can accurately predict warfarin maintenance dose. Prospective studies employing the rule are indicated.

Acute rheumatic fever is initiated by group A streptococcal pharyngitis. This is followed by a latent period of 2-6 weeks, after which the clinical syndrome of acute rheumatic fever evolves, characterized by polyarthritis, carditis, chorea, erythema marginatum and subcutaneous nodules. These features may occur singly or in any combination.

During a period of 9 years (December, 1980, through November, 1989), 407 Group A streptococcal strains were isolated from 294 children with acute rheumatic fever and 303 of their family contacts, 234 children with acute post-streptococcal glomerulonephritis and 242 of their family contacts and 219 children with uncomplicated Group A streptococcal pharyngitis. Of the 407 straisn 216 (53) were M and/or serum opacity factor typable, 143 (35) were only T typable and 48 (12) were nontypable. Throughout the period of study the M12 and M1 were the most prevalent strains; however, important changes among the prevalent strains were observed. Although the study started in 1980 the serotypes M18, M81, M3, M15 and M58 made their first appearance 7 to 9 years later. These findings show the value of long term studies in detecting the changes in the prevalence of streptococcal strains in the community. M18 was isolated from three children with nephritis but not from children with rheumatic fever; this association has not been reported before. M12 was isolated from 26 of the nephritic children and their families vs.7 from the rheumatic children and their families (P< 0.05) vs.17 from children with uncomplicated streptococcal pharyngitis. M49 was isolated from 7 of the nephritic children and their families vs.none from rheumatic children and their families vs.1.4 from children with uncomplicated streptococcal pharyngitis. These findings support the concept of nephritogenicity of some streptococcal strains. the serotypes M9, M33, M5, and M29 were exclusively isolated from rheumatic children and their family contacts, whereas the serotypes M49, M4, M81 and M18 were exclusively isolated from nephritic children and their family contacts. These findings are in favor of the concept of rheumatogenicity. Our data are compared with those of similar recent studies.

The clinical profile, course and complications of familial Mediterranean fever (recurrent hereditary polyserositis) seen in 88 children over a period of 11 years are presented. Forty eight children (55%) started their illness below the age of 5 years, and the mean age of onset was 4.9 years. Peritonitis occurred in 85% of children, arthritis in 50%, pleuritis in 33% and erysipelas-like lesions in 16%. Two children developed renal amyloidosis, and one third of the children were subjected to unnecessary operative surgery, reflecting the diagnostic difficulties. The arthritis was mono-articular in 80% and polyarticular in 20% of children with arthritis, and was seronegative (rheumatoid factor and antinuclear antibodies). Human leucocyte antigen (HLA) typing for the B-27 antigen carried out in ten children with arthritis was negative. The synovial attack showed a wide variation in the clinical presentation, course and duration of arthritis, causing diagnostic difficulties. The difficulties in the differentiation of recurrent hereditary polyserositis (familial Mediterranean fever) arthritis from the common causes of acute and chronic juvenile arthritis and the seronegative spondyloarthropathies are discussed. Of 45 children treated with colchicine, 42 children (93%) achieved a therapeutic response.

Background: Acute colonic pseudo‐obstruction is an acute non‐mechanical colonic obstruction. Twenty patients with this condition presenting between 1988 and 1996 were retrospectively reviewed to identify the incidence and potential aetiologic factors, and to establish a uniform therapeutic approach.

We investigated the in vitro lymphoproliferative responses to a streptococcal mitogen and erythrogenic toxin A of children with acute rheumatic fever (ARF) and patients with chronic rheumatic heart disease (CRHD). Antibody levels to the streptococcal products were also analyzed in the sera of those with ARF or chronic rheumatic heart disease as well as in the sera of children with streptococcal pharyngitis or poststreptococcal glomerulonephritis. Our results demonstrated that the individuals had depressed lymphoproliferative responses during the active stage of rheumatic fever. The depressed responses were not found either to be induced by time-sensitive mitogen-specific suppressor cells or to be related to a dose-response phenomenon. On the other hand, antibody levels to the extracellular mitogens were significantly elevated in the sera of children with ARF compared with the levels in the rest of the groups. The hyperresponsiveness noted among children with ARF was found to be at a quantitative level and was not due to recognition of more epitopes, as determined by Western blotting (immunoblotting). The profile of immune responsiveness in children with ARF to the streptococcal extracellular mitogens is discussed in relation to the pathogenesis of disease.

The dynamic responses of a railway bridge members due to vehicle‐track‐bridge interaction were investigated for the effects of vertical and lateral track irregularities, approach track quality, and bridge damping. In each case, a train consisting of three vehicles moving at constant speed was simulated traveling on the bridge. It was found that: (1) Greater approach irregularities produce higher impact factors and dynamic forces in bridge members; (2) impact factors in members with low static stress are high, but the dynamic stresses produced are low; (3) in general, impact factors reduce slightly due to bridge damping; and (4) the dynamic forces in lower lateral bracing members are small as compared to their allowable values.

Over a period of 3 years, 192 children with familial Mediterranean fever were prospectively studied. Of these, 106 (55%) were girls and 86 (45%) were boys. The prevalence was 1∶2600 children with a gene frequency of 1∶50. The age at onset ranged between 4 months and 16 years. Of these patients 24% started their illness below the age of 2 years and 88% were symptomatic before the age of 10 years: 82% had recurrent abdominal pain, 43% had pleurisy, 37% had arthritis, 15% had cutaneous manifestations, 12% had splenomegaly and 4% had hepatomegaly. The presenting symptoms were abdominal pain in 51%, unilateral chest pain in 23% and arthritis in 26%. The family history was positive in 62%. Of 12 affected families 19 members had/have renal failure and amyloidosis was confirmed in 7 patients.

A total of 1041 asymptomatic "normal" schoolchildren in Kuwait, aged 6-16 years, were investigated over six months from November 1978 through April 1979 for hemolytic streptococcal throat carriage and for streptococcal immune response. A high carrier rate of beta-hemolytic streptococci (47%) with an unusually high prevalence of group C (32%) was found. Group A was isolated in 10%, group B in 2%, and group G in 3% of the children. Comparison of the prevalence of the different serogroups of beta-hemolytic streptococci in our study with that of similar studies reported from temperate, subtropical, and tropical zones showed a high prevalence of groups C and G and a lower prevalence of group A in subtropical and tropical countries in contrast to a high prevalence of group A and lower prevalence of groups C and G in countries with temperate climate. The geometric mean titer of antistreptolysin O in group A carriers in our study was 270 Todd units and significantly higher than that in group C carriers (p less than 0.001), while the geometric mean titer of antihyaluronidase in group A carriers was 240 units and significantly higher than that in groups B, C, and G carriers (p less than 0.0005). The high magnitude of the streptococcal immune response probably reflects a high frequency of streptococcal infections in schoolchildren in Kuwait and possibly indicates a high attack rate of rheumatic fever in the country.

Clinical and epidemiological research of juvenile rheumatoid arthritis (JRA) has been facilitated by the use of the American Rheumatism Association (ARA) Criteria (1, 2), and the various modifications in Europe (3, 4). Recently, the course of the disease was shown to be as important for the long-term prognosis as is the onset type (4, 5). Reports on JRA from developing countries are scarce. We herein report our experience with the disease over a 10-year period in Kuwait, a small Arab country, where Arab expatriates constitute 50% of the populatation.

SummaryRecurrent hyperbilirubinaemia was described as a feature of familial Mediterranean fever in the 1950s and early 1960s. However, over the last 33 years only one case has been published. We present a 12-year-old Arab boy who developed recurrent hyperbilirubinaemia in the course of familial Mediterranean fever. His response to colchicine was excellent. Review of the literature reveals that hyperbilirubinaemia of familial Mediterranean fever has a distinct clinical picture characterized by concurrent peritonitis, minimal jaundice and short duration. Factors contributing to the paucity of reports in recent literature are discussed.

In a six-year study of 46 children with familial Mediterranean fever (recurrent hereditary polyserositis), 20 children (43 per cent) developed cutaneous manifestations. Ten children had 18 episodes of erysipelas-like erythema which proved to be specific for the disease. Twelve children (26 per cent) had 31 episodes of non-specific purpuric rash and six children (13 per cent) had nine episodes of Henoch-Schönlein purpura. Other manifestations included diffuse erythema of the face, and/or trunk, angioneurotic oedema, diffuse erythema of the palms and soles followed by mild desquamation of the skin, Raynaud's phenomenon and a subcutaneous nodule. The mean frequency of the cutaneous lesions was 1.6/patient/year before colchicine therapy and 0.4/patient/year after colchicine therapy (p=0.0005). The high incidence of cutaneous manifestations and their response to colchicine strongly suggest that skin involvement is an integral part familial Mediterranean fever.

The presence of antibodies to muramyl dipeptide (MOP), an adjuvant structure of streptococcal peptidoglycan, was investigated in patients with acute rheumatic fever (ARF). The detection of these antibodies was done by an enzyme-linked immunosorbent assay with a synthetic multivalent MOP conjugate as an antigen. Sera from 33 of 54 children with ARF had detectable levels of antibodies to MOP at the time of diagnosis. Such antibodies could only be detected in sera from two of 52 healthy children and one of 21 children with acute poststreptococcal glomerulonephritis. The specificity of the antibodies to MOP was demonstrated by inhibition, with free MOP, of binding of the sera to the MOP conjugate. The possible use of these antibodies in the diagnosis of ARF and in screening for safe synthetic muramyl peptides in immunization of humans is discussed.

Recurrent hereditary polyserositis (RHP) or familial Mediterranean fever (FMF) is a chronic inherited illness of obscure aetiology. The disease is characterised by paroxysmal attacks of fever, peritonitis, pleuritis or arthritis, and predominantly affects Sephardic Jews, Arabs, Turks and Armenians. In this study, we report our 11-year experience of 175 Arab patients with this disease. As with other ethnic groups, the most common manifestation (93.7 per cent) was peritonitis. Arthritis (33.7 per cent) and pleurisy (32 per cent) were next in frequency. Adult patients in this series unlike those in other ethnic groups, rarely presented with arthritis. Similarly rare were amyloidosis, rashes, splenomegaly, hepatomegaly or lymphadenopathy. The aetiology of this disease is not clear but we suspect that abnormalities in catecholamine metabolism may be a factor in the pathogenesis.