Bilateral total knee arthroplasty can be performed either as a staged or simultaneous procedure. We conducted a retrospective comparative study to compare the need for transfusion, the length of procedure, the length of stay, and complications of bilateral simultaneous knee arthroplasty with those of unilateral knee arthroplasty. Sixty-nine patients who underwent bilateral simultaneous knee arthroplasty procedures were compared with a matched control group of 69 patients who underwent unilateral knee arthroplasty. Receiver Operating Characteristic (ROC) curve was used to determine optimum cut-off values. Both groups of patients had a similar age and gender distribution, preoperative haemoglobin and ASA scores. Cumulative transfusion episodes were lower in the bilateral group than twice that of the unilateral group. In multivariate analysis the preoperative haemoglobin level and bilateral procedures were independent factors predicting the need for transfusion. The average length of procedure and length of hospital stay in the bilateral group was less than twice than that of the unilateral group. Advanced age and bilateral procedures were independent predictors of prolonged length of stay. A haemoglobin level of 12.5 g/dL and age of 70 were most suitable cut-off points to predict need for transfusion and occurrence of medical complications respectively. We conclude that bilateral simultaneous knee arthroplasties are safe and cost effective in appropriately selected patients. We recommend avoiding bilateral simultaneous procedures in patients over the age of 70 years and with significant comorbidities.

Fig 2 Three dimensional reconstruction reveals a transverse fracture just below the attachment of the first ribs to the manubrium. from the lying position, when the fracture happend. He had been performing body building exercises every second day for six months. He had trained the pectoralis muscle group each time, using four different sessions inclusive of bench press. He started body building, because he was in very poor condition. The causal mechanism in this case must be found in the muscle attahments and the direction of their forces on the manubrium and sternum. The attachment of the manubrium to the spine through the first and second ribs and the attachment to the shoulders through the clavicles are also part of the mechanism. The sternal head of the sternocleidomastoid and part of the pectoralis major are attached anteriorly to the manubrium and sternum. The sternohyoid and sternothyroid muscles are attached posteriorly to the manubrium, whereas the tranverse thoracis is attached to the posterior surface of the sternum. The very strong rectus abdominis is attached to the distal part of sternum. During sit up exercises hyperflexion of the spine presses the upper part of the manubrium anteriorly, and the contraction of the abdominal and thoracic muscles at the same time add to the fracture angulation.Computerised tomography scannning with three dimensional reconstruction revealed a transverse fracture just below the attachment of the first ribs to the manubrium (fig 2).Presumably, the repetitive strenuous training sessions in this formerly untrained patient led to a stress fracture in the manubrium, because the strength of the muscles build up faster than the strength of the bones. Fracturedislocation of the manubriosternal joint has been described as a complication of seizures,3 and the mechanism in our case may be somewhat similar. (BrJt Sports Med 1996;30:177-178)

No abstract

We reviewed 31 patients at a mean of five years after mallet deformity of the finger had been treated with a thermoplastic splint. Intra-articular fractures were present in 35% of patients. Osteoarthritic changes had developed in 48%, most in association with fracture, and 29% had a swan-neck deformity. There was a loss of extension greater than 10 degrees in 35%; the average deficit at the interphalangeal joint was 8.3 degrees and the average flexion arc was 48.5 degrees. Despite these findings, patient satisfaction was generally high, with little evidence of functional impairment.

We reviewed 31 patients at a mean of five years after mallet deformity of the finger had been treated with a thermoplastic splint. Intra-articular fractures were present in 35% of patients. Osteoarthritic changes had developed in 48%, most in association with fracture, and 29% had a swan-neck deformity. There was a loss of extension greater than 10° in 35%; the average deficit at the interphalangeal joint was 8.3° and the average flexion arc was 48.5°. Despite these findings, patient satisfaction was generally high, with little evidence of functional impairment.