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By C. Hanson. Eastern College.

However kytril 2mg low cost, scientiﬁc attention has only recently been focused on the causes and treat- ment of dandruff (1) buy 2 mg kytril with amex. The scalp, like the rest of the skin, is a stratiﬁed squa- mous epithelium continually shedding dead microscopically sized corneocytes from the sur- face. It is estimated that each person sheds about 4 kg of corneocyte squames per year (2). While bloodhounds may detect these shed ﬂakes from normal scalps, we are generally only aware of them when they are large enough to see clumped on the scalp, adherent to the hairs, and visible on clothing. Seborrheic dermatitis of the scalp includes both visible ﬂaking and inﬂammation with erythema and, generally, pruritus. Now that more is known about the pathophysiology of both conditions, it is reasonable to consider that most dandruff is seborrheic dermatitis with a range of inﬂamma- tory severity from inapparent to severe (1). At more severe grades, the ﬂakes are present over more of the scalp, are larger, and accumulate in clumps (Figs. At its most severe, dandruff ﬂaking can form a dense mat over the entire scalp surface. With clinically evident seborrheic dermatitis, the ﬂaking may occur in patches with associ- ated erythema and serous oozing. Seborrheic dermatitis also typically affects other hair-bearing or oily areas such as the eyebrows, sideburns, beard, moustache, alar and nasolabial creases, postauricular creases, glabellar crease, and sternum (Fig. Even the axillae and intertriginous folds in adults and the diaper area of infants may be involved. Patients with seborrheic dermatitis commonly report a positive family history of similar problems, suggesting a genetic predisposition. The tendency to develop seborrheic dermatitis persists life-long but ﬂuctuates in activity. It may appear as “cradle cap” (thick oily ﬂaking at the vertex of the scalp) in infancy, remit during childhood, return during adolescence, and appear episodically thereafter (3). Seborrheic dermatitis may produce hypopigmentation or post-inﬂammatory hyper- pigmentation, especially noticeable on pigmented skin. The primary symptom is pruritus, although the degree of itching does not necessarily correlate directly with the degree of ﬂaking. The Scalpdex and other quality-of-life measurement tools are available to assess these effects (6) There is often a discrepancy between the scalp condition severity and the patient’s aware- ness of it. In studies where subjects are asked to assess their scalp state prior to examination by a trained scalp grader, there is wide variation in the self-reported versus directly observed degree of scalp scale. This may be explained in part by a culturally learned reluctance to admit to “dandruff. In the past, it has been estimated that approximately 50% of the population have dandruff at some point in life, with 2–5% having inﬂammatory seborrheic dermatitis (7). The prevalence of scalp scale is higher in African American subjects, especially women, related in part to the decreased average shampoo frequency common to African American hairstyles. This was conﬁrmed in population screening of 1408 Caucasian, African American, and Chinese adults and teenagers studied in Minnesota, Georgia, and China. The prevalence of noticeable ﬂaking was 81–95% in African Americans, 66–82% in Caucasians, and 30–42% in the Chinese. The Chinese subjects, although they had a lower shampoo frequency, had a much higher prevalence of routine antidandruff shampoo use (10–20% in the United States vs 40–52% in the Chinese) which correlated with their overall lower level of ﬂaking (7,8). Thus, there will usually be increased scale where the scalp creases, under hat bands and eyeglass frames, and under areas where the hair is gathered into a ponytail or twist. Temporary changes in hair care can affect dandruff, such as illness, stroke, or injury to the arm or hand impeding shampooing. There is even a subtle decrease in scale on the side of the dominant hand, presumably because of more effective mechanical scale removal during shampooing and brushing. Systemic Disease Associations Worsening seborrheic dermatitis is an early and prominent sign in Parkinson’s disease and related neurological conditions (9,10). The reason for this association is not clear, though pooling of sweat where the facial muscles are inactive, inability to remove sweat and sebum, or changes in sebum are postulated (11,12). Seborrheic dermatitis in this population has been reported to be more severe, more extensive, and more erythematous and papular than usual in immunocompetent individuals. Diagnosis is facilitated by observation of psoriatic plaques elsewhere on the body or typical nail disease. The therapeutic measures used for dandruff and seborrheic dermatitis are also the ﬁrst line therapy for scalp psoriasis. Irritant dermatitis of the scalp presents with thin, dry, crackling scale plus symptoms of stinging, burning, or itching. It is most often produced by barrier disruption from strong sur- factants in shampoos or chemical treatments for hair styling. Patients with atopic dermatitis are particularly susceptible to such barrier damage.

A characteristic of rotifers is their mastax proven kytril 1mg, which is a jaw-like device that grinds food as it enters the stomach buy discount kytril 2mg line. Indicator: Euchlanis is commonly found in activated sludge when effluent quality is good. It requires a continual supply of dissolved oxygen, evidence that aerobic conditions have been sustained. Waterborne Diseases ©6/1/2018 52 (866) 557-1746 Protozoan Diseases Protozoan pathogens are larger than bacteria and viruses but still microscopic. Some parasites enter the environment in a dormant form, with a protective cell wall, called a “cyst. Effective filtration treatment is therefore critical to removing these organisms from water sources. It has also been referred to as “backpacker’s disease” and “beaver fever” because of the many cases reported among hikers and others who consume untreated surface water. Symptoms include chronic diarrhea, abdominal cramps, bloating, frequent loose and pale greasy stools, fatigue and weight loss. Waterborne outbreaks in the United States occur most often in communities receiving their drinking water from streams or rivers without adequate disinfection or a filtration system. The organism, Giardia lamblia, has been responsible for more community-wide outbreaks of disease in the U. Cryptosporidiosis Cryptosporidiosis is an example of a protozoan disease that is common worldwide, but was only recently recognized as causing human disease. Cryptosporidium organisms have been identified in human fecal specimens from more than 50 countries on six continents. The mode of transmission is fecal-oral, either by person-to-person or animal-to-person. All of these diseases, with the exception of hepatitis A, have one symptom in common: diarrhea. They also have the same mode of transmission, fecal-oral, whether through person-to-person or animal-to-person contact, and the same routes of transmission, being either foodborne or waterborne. Although most pathogens cause mild, self-limiting disease, on occasion, they can cause serious, even life threatening illness. By understanding the nature of waterborne diseases, the importance of properly constructed, operated and maintained public water systems becomes obvious. While water treatment cannot achieve sterile water (no microorganisms), the goal of treatment must clearly be to produce drinking water that is as pathogen-free as possible at all times. For those who operate water systems with inadequate source protection or treatment facilities, the potential risk of a waterborne disease outbreak is real. For those operating systems that currently provide adequate source protection and treatment, operating and maintaining the system at a high level on a continuing basis is critical to prevent disease. Waterborne Diseases ©6/1/2018 53 (866) 557-1746 Summary of Common Waterborne Diseases Name Causative organism Source of organism Disease Viral gastroenteritis Rotavirus mostly in young children; Human feces; Diarrhea or vomiting. Norwalk-like viruses Human feces; also, shellfish; lives in polluted waters; Diarrhea and vomiting. Human feces; Symptoms vary with type caused; gastroenteritis Typhoid Salmonella typhi (bacterium) Human feces, urine Inflamed intestine, enlarged spleen, high temperature— sometimes fatal. Cholera Vibrio cholerae (bacterium) Human feces; also, shellfish; lives in many coastal waters; Vomiting, severe diarrhea, rapid dehydration, mineral loss —high mortality. Hepatitis A virus Human feces; shellfish grown in polluted waters; Yellowed skin, enlarged liver, fever, vomiting, weight loss, abdominal pain — low mortality, lasts up to four months. Amebiasis Entamoeba histolytica Human feces; Mild diarrhea, dysentery, (protozoan) extra intestinal infection. Giardiasis Giardia lamblia (protozoan) Animal or human feces; Diarrhea, cramps, nausea, and general weakness — lasts one week to months. Cryptosporidiosis Cryptosporidium parvum (protozoan) Animal or human feces Diarrhea, stomach pain — lasts days to weeks. The Best Method to kill most of these Bugs Disinfection is usually synonymous with chlorination. That is because chlorine addition is by far the most common form of disinfection used today. Disinfection is the process of killing microorganisms in water that might cause disease (pathogens). Disinfection, however, should not be confused with sterilization, which is the destruction of all microorganisms. Cryptosporidium parvum and Giardia lamblia will require proper water treatment techniques. An illustrated guide to the species used as biological indicators in freshwater biology. Pollution related structural and functional changes in aquatic communities with emphasis on freshwater algae and protozoa. Soil protozoa: fundamental problems, ecological significance, adaptations in ciliates and testaceans, bioindicators, and guide to the literature. Respiratory energy losses related to cell weight and temperature in ciliated protozoa.

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Patients with conﬁrmed intestinal perforation need intensive care as well as surgical intervention kytril 2 mg fast delivery. Early intervention is crucial as morbidity rates increase with delayed surgery after perforation purchase kytril 2 mg line. Epidemic measures: 1) Search intensively for the case/carrier who is the source of infection and for the vehicle (water or food) through which infection was transmitted. Pasteurize or boil milk, or exclude milk supplies and other foods suspected on epidemiological evidence, until safety is en- sured. Disaster implications: With disruption of usual water supply and sewage disposal, and of controls on food and water, trans- mission of typhoid fever may occur if there are active cases or carriers in a displaced population. Efforts are advised to restore safe drinking-water supplies and excreta disposal facilities. Selec- tive immunization of stabilized groups such as school children, prisoners and utility, municipal or hospital personnel may be helpful. International measures: 1) For typhoid fever: Immunization is advised for international travellers to endemic areas, especially if travel is likely to involve exposure to unsafe food and water, or close contact in rural areas to indigenous populations. Identiﬁcation—A rickettsial disease with variable onset; often sudden and marked by headache, chills, prostration, fever and general pains. A macular eruption appears on the 5th to 6th day, initially on the upper trunk, followed by spread to the entire body, but usually not to the face, palms or soles. Toxaemia is usually pronounced, and the disease terminates by rapid defervescence after about 2 weeks of fever. The case-fatality rate increases with age and varies from 10% to 40% in the absence of speciﬁc treatment. Mild infections may occur without eruption, especially in children and people partially protected by prior immunization. Blood can be collected on ﬁlter paper that are forwarded to a reference laboratory. Occurrence—In colder areas where people may live under unhy- gienic conditions and are infested with lice; explosive epidemics may occur during war and famine. Endemic foci exist in the mountainous regions of Mexico, in Central and South America, in central and eastern Africa and numerous countries of Asia. Reservoir—Humans are the reservoir and are responsible for maintaining the infection during interepidemic periods. Although not a major source of human disease, sporadic cases may be associated with ﬂying squirrels. Mode of transmission—The body louse, Pediculus humanus corporis, is infected by feeding on the blood of a patient with acute typhus fever. Patients with Brill-Zinsser disease can infect lice and may serve as foci for new outbreaks in louse-infested communities. Infected lice excrete rickettsiae in their feces and usually defecate at the time of feeding. People are infected by rubbing feces or crushed lice into the bite or into superﬁcial abrasions. Transmission from the ﬂying squirrel is presumed to be through the bite of the squirrel ﬂea, but this has not been documented. Period of communicability—The disease is not directly transmit- ted from person to person. Patients are infective for lice during the febrile illness and possibly for 2–3 days after the temperature returns to normal. Infected lice pass rickettsiae in their feces within 2–6 days after the blood-meal; they are infective earlier if crushed. The louse invariably dies within 2 weeks after infection; rickettsiae may remain viable in the dead louse for weeks. Preventive measures: 1) Apply an effective residual insecticide powder at appropriate intervals by hand or power blower to clothes and persons of populations living under conditions favoring louse infesta- tion. Lice tend to leave abnormally hot or cold bodies in search of a normothermic clothed body. When faced with a seriously ill patient with possible typhus, suitable treatment should be started without waiting for laboratory conﬁrmation. Epidemic measures: The best measure for rapid control of typhus is application of an insecticide with residual effect to all contacts. Where louse infestation is known to be widespread, systematic application of residual insecticide to all people in the community is indicated. In epidemics, individuals may protect themselves by wearing silk or plastic clothing tightly fastened around wrists, ankles and neck, and impregnating clothes with repellents or permethrin. Disaster implications: Typhus can be expected to be a signiﬁcant problem in louse-infested populations in endemic areas if social upheavals and crowding occur.

Vincent’s Hospital cheap kytril 2 mg free shipping, Melbourne purchase 2mg kytril amex, Victoria, Australia Zoe Diana Draelos Dermatology Consulting Services, High Point, North Carolina, U. Dy Department of Dermatology, Rush University Medical Center, Chicago, Illinois, U. Goldberg Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, U. John Gray Gray’s Medical Practice, Gosbury Hill Health Center, Chessington and Proctor and Gamble Beauty, Surrey, U. Hordinsky Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, U. Christine Jaworsky Department of Dermatology, Case Western Reserve University, Cleveland, Ohio, U. Kerchner Department of Dermatology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U. McMichael Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U. Paradi Mirmirani Department of Dermatology, Case Western Reserve University, Cleveland, Ohio, and University of California, San Francisco, California, U. David Resch Division of Medicine/Psychiatry, Southern Illinois University School of Medicine, Springﬁeld, Illinois, U. Roseborough Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U. Lydia Sahara Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, U. Vincent’s Hospital and Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia Erin M. Whiting Department of Dermatology and Pediatrics, University of Texas Southwestern Medical Center, Baylor Hair Research and Treatment Center, Dallas, Texas, U. Brian Zelickson Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, U. Selection for shorter and ﬁner body hair has resulted in only head hair remaining in any quantity. This however is capable of growing to greater lengths than that of any other mammal (Fig. Since the human head bears some 100,000–150,000 hair follicles, an individual adult with 30 months continuous, unstyled growth, will carry some 30 kilometers of hair. It is worth mentioning some of the salient features that relate to the human hair shaft. The cross section of the hair shaft has three major components: the cuticle, the cortex, and the medulla (Fig. The main constitu- ents of hair are sulphur-rich protein, lipids, water, melanin, and trace elements (2). The cortex, the main bulk of a fully keratinized hair shaft, contributes almost all the mechanical properties of the hair, including strength and elasticity (2). The cuticle consists of six to eight layers of ﬂattened overlapping cells with their free edges directed upward to the tip of the hair shaft (2). Innermost is the endocuticle, derived from the developing cell cytoplasm contents. The exocu- ticle lies closer to the external surface and comprises three parts: the b-layer, the a-layer, and the epicuticle. The epicuticle is a hydrophobic lipid layer of 18-methyleicosanoic acid on the surface of the ﬁber, or the f-layer. The normal cuticle has a smooth appearance, allowing light reﬂection and limiting fric- tion between the hair shafts. The cuticle may be damaged by frictional forces (brushing, combing or blow-drying) as chemical removal of the f-layer, particularly by oxidation, eliminates the ﬁrst hydrophobic defense and leaves the hair more porous and vulnerable. Cuticle disruption with alkaline chemicals is the ﬁrst step in permanent hair styling (3). If the cuticle is damaged there is little change in the tensile proper- ties of hair. The cortex consists of closely packed spindle-shaped cortical cells rich in keratin ﬁlaments that are oriented parallel to the longitudinal axis of the hair shaft (2), and an amorphous matrix of high sulphur proteins. The intermediate ﬁlament hair keratins (40–60 kDa), comprising 400 to 500 amino acid residues in heptad sequence repeats, form hard keratin polypeptide chains that pair together to form protoﬁlaments, which make up a keratin chain. Cysteine residues in adjacent keratin ﬁlaments form covalent disulphide bonds, which create a strong crosslink between adjacent keratin chains (6). Other weaker bonds link the keratin polypeptide chains together, such as Van der Waal interactions, hydrogen bonds, and coulombic interactions known as salt links (6).

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Characteristically produce large valvular vegetations with a high rate of embolization and relapse 1mg kytril. Groups A order kytril 1mg mastercard, C, G streptococci More frequently seen in the elderly (nursing homes) and diabetics. Cases usually require the combination of ampicillin and gentamicin, with or without surgery, for cure. They are very invasive and abscess producing in both myocardium and valvular structures. Its mortality rate may be as high as 40% due to metastatic infection, severe valvular damage, and congestive heart failure. The silaic acid component of its capsule is a major virulence factor that inhibits the activation of the alternative complement pathway (14–16, 16a). Its connection with chronic liver disease has been more recently appreciated (21) Most isolates are quite sensitive to penicillin (22). The teichoic acid component of the cell wall facilitates its attachment to the nasal mucosa from which it may set up a “beachhead” on the skin of the patient. Any break in the dermis promotes the entry for the staphylococcus into the microcirculation. Most notable among these are fibronectin-binding proteins and various clumping factors. Staphylococci may remain dormant within the endothelial Infective Endocarditis and Its Mimics in Critical Care 221 cells but are eventually released back into the circulation. Once this pathogen is in the bloodstream, it makes effective use of its unique abilities to invade the endothelium and propagate the platelet fibrin thrombus (27–30). It resides on the skin of both the healthy and the ill as well as being colonizer of the nares. Among these are protein A; catalase; alpha, beta, and gamma toxins; leukocidins and its capsule. Upon the death of the white cell, the viable staphylococci are deposited into the surrounding tissue or return to the intravascular space. It also possesses a superb ability to infect prosthetic devices of all kinds including intravascular devices/catheters by means of its production of the glycocalix biofilm. This environment protects the organisms from the host’s defenses as well as from most antimicrobial agents (32). It is quite difficult for the clinical laboratory to differentiate them from other coagulase-negative organisms. Pseudomonas aeruginosa adheres to the endothelium the most effectively of any of the gram-negative rods. It elaborates several virulence factors, extracellular proteases, elastase alkaline proteases. These produce necrosis in a range of tissues especially in the elastic layer of the lamina propria of all caliber is the blood vessels. These toxins also disrupt the function of polymorphonuclear leukocytes, K- and T-cells, as well as the structure of complement and immunoglobulins. Exotoxin A disrupts protein synthesis and is the factor that is best correlated with systemic toxicity and mortality. Its polysaccharide capsule interferes with phagocytosis and the antibacterial effect of the aminoglycosides (35,36). These are genetically unrelated gram-negative bacilli/cocobacilli that share the oropharynx as the primary site of residence. They usually produce subacute disease that is notable for its massive arterial emboli (40). Most often, these infections are ventilator or intravascular catheter associated (43). What makes their treatment so difficult is the multiplicity of their defensive mechanisms that make them resistant to many classes of antibiotics. Risk factors for its development include exposure to broad-spectrum antibiotics and to cytotoxic agents (46). They enter the bloodstream from the injection site directly or from contamination of the drug paraphernalia (38). This rate may be higher in some areas in the world in which hard to grow organisms, such as Coxiella burnetti, are fairly common. The reason for so doing is well expressed by Friedland, “nosocomial endocarditis occurs in a definable subpopulation of hospitalized patients and is potentially preventable. It is defined as a valvular infection that presents either 48 hours after an individual has been hospitalized or one that is associated with a health-care facility procedure that has been performed within four weeks of the development of symptoms. The typical patient is older with a higher rate of underlying valvular abnormalities.

Set up a system of rinsing fingers (and fingernails) in 10% grain alcohol in the bathroom quality kytril 2 mg. A warm stomach full of food at a neutral pH is just the right culture condition for these bacteria generic kytril 2mg without prescription. If your body has the right conditions (like a low acid stomach) to let them grow you dare not swallow another one! Shigellas arrive with dairy foods, too, but prefer the lower intestine as their headquarters. Besides getting digestive improvement you get mental improvement, less depression, less dizziness, less irritability after clearing these up. Other Clues Digestion problems that remain after eliminating bacteria can be diagnosed in a rational way. Ask these questions: • Is the stool orangish-yellow, or very pale, instead of greenish brown? If so, it must be lighter than water and contain fat or a great deal of undigested material. If the stool floats or is orangish in color prepare your elderly person for a liver cleanse (page 552) to clear a bile duct of ob- struction. Do a kidney cleanse (page 549) first, using half a dose instead of the regular dose, for three to six weeks. Attend your loved one in person for the liver cleanse, have a commode at bedside, protect bedding from accident: use paper underwear if necessary. Share the joy of getting gallstones out painlessly with your loved one; let them see and count them if they wish before you flush them (use a flashlight). Use starch skin soother to dispense onto the wet paper towel, besides borax solution and alcohol. The starch skin softener gives the smoothness of soap, and prevents the pain of friction. Evidently the body absorbs all the magnesium so eagerly, none is left in the intestine to absorb water and create diarrhea. It is especially important though to rehydrate your elderly person after a diarrhea. As the stones from the far corners of the liver move forward, they compact into larger stones and plug the ducts again. Try to give a cleanse once a month until the dark color of the stool returns and it no longer floats. The benefits of a liver cleanse will last longer if valerian herb is taken the day after the cleanse and from then forward. If you try bran, you should add vitamin C and boil it, first, because it is very moldy. Poop Your Troubles Away Two bowel movements a day are the minimum necessary for good health. The morning cup of water, drunk at the bedside has the magical ability to move the bowels. Walking and liver cleansing are the most health-promoting activities you can do for your loved one. To overcome resistance, find a cheerful neighborhood person will- ing to do this task for pay. The need to respond to a new stranger energizes the elderly more than your persuasion can. If your loved one is already on a pill for beginning diabetes, take this as your challenge never to let it get worse. It is a destruction of the pancreas (specifically the islets) by the pancreatic fluke which is attracted to the pancreas by wood alcohol. Zap flukes and eliminate wood alcohol as described in the section on diabetes (page 173). Use no artificial sweetener and no beverages besides milk, water and the recipes given in this book. They are well motivated to pre- vent the need for giving themselves daily shots of insulin. Fried potatoes with 2 eggs (use only butter, olive oil or lard), 1 cup hot or cold milk. Cream of rice, with homemade “half n half” or whipping cream, cinnamon and vitamin C stirred in. Fruit cup, large bowl of peeled, chopped mixed fruit with whipping cream and 1 tbs. Green beans with potatoes, meat dish, cabbage apple salad, water with lemon juice and honey, 1 cup hot milk. Fresh green beans, especially fava beans contain a sub- stance that is described in old herbal literature to be espe- cially beneficial to diabetics.

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The most frequent causes of failure are loosening and of particles generic 2 mg kytril mastercard, which can cause loosening cheap kytril 2 mg on line, other articular particle disease. Up to 20% of both the acetabular cup and the femoral head made of patients will need revision surgery over 20 postoperative alumina ceramic. Good to excellent results are Main Types of Devices Used expected in 95% of appropriately selected patients. Hip Currently Used Materials Unipolar: Usually a femoral component only (or a mod- ular femoral component). Used mainly in older patients Metal following a femoral-neck fracture in whom the acetabu- lum is relatively normal. A number of combinations are in current use, designed to be long-wearing and inert biologically. The principle Bipolar arthroplasty: Comprising both a fixed femoral alloys used are cobalt-chrome-molybdenum, cobalt- component and an acetabular component that moves chrome-tungsten and titanium-aluminium-vanadium. Thus, motion should occur The prosthesis may be inserted with cement (to trans- between the native acetabulum and the acetabular com- fer stress from the prosthesis to bone) or have a sin- ponent and between the femoral component and the ac- tered irregular (“porous”) coating, allowing bone in- etabular liner. Acetabular fixation is generally by This is the most commonly used device in patients with bone in-growth. Ultra-High-Molecular-Weight Polyethylene Hybrid total hip replacement: The acetabular compo- nent is fixed by bone in-growth while the femoral com- This hard, high-density material provides a low-friction ponent is cemented. Furthermore, it allows Customised: Following tumor resection or difficult revi- plastic deformity increasing congruity. The Radiology of Hip and Knee Joint Prostheses 107 Knee The joint-line height is drawn from the tibial tubercle to the superior surface of the tibial component (the infe- Unicompartmental: Used when only one compartment rior edge of the femoral component) on the lateral radi- needs replacement; both the femoral and tibial sides of ograph. A joint line 8 mm higher than in the preoperative ex- amination is associated with a poorer clinical outcome. Total knee replacement: Posterior-cruciate-sparing or [3] A low joint line causes a low patella and may result cruciate-substituting designs may be inserted. Unicompartmental arthroplasty: The femoral and tibial Mobile tibial polyethylene bearings: Rotating platform components should parallel each other, with no rotatory allows rotation, meniscal bearings allow rotation and an- element, and lie parallel to floor. Constrained: Reserved for revision surgery, severe bone loss or after tumor resection. These devices do not permit knee rotation and are subject to failure (loosening) in pa- Bone In-growth and Porous Coating tients whose activity level is high. Porous coating, while significantly adding to the cost of Patellofemoral: Either as part of a total knee replacement, joint replacement, may significantly improve implant when a polyethylene “button” is cemented into the articu- longevity. Beads of a similar alloy are sintered onto the lar surface of the patella, or as a specific patellofemoral metallic components, permitting bony in-growth to occur joint replacement when the major knee compartments are without the need for intervening cement. Clearly, this requires stability to allow in-growth to occur, with implications for the postoperative period. Normal Appearances Anticipated normal plain-film appearances include re- sorption of medial femoral cortex at the calcar femoris Hip Replacements (98%), reduced bone density where it is unloaded, the ab- sence of a thin lucent rim around the implant, although The following features on plain film suggest an ideal po- such a lucency with a sclerotic margin is common (79%) sition for a total hip replacement. It is also normal to see endosteal sclerosis at the Acetabular anteversion should measure 0–30° on a true tip of a prosthesis (36%), localized periosteal new bone lateral view. The femoral component should be coaxial and cortical thickening, representing altered stress loading with the femoral shaft. Acetabular screws, if used, should (12%) and a degree of prosthetic subsidence (7%). The lucent line has Complications of Joint Replacement a sclerotic margin and develops during the first 2 years after insertion. A metal- joints, including pain and other symptoms, for which no bone lucency may be present immediately after surgery cause may be found. In addition, not all abnormal joint replace- quential radiographs for cemented devices whereas slight ments are associated with symptoms. Overall, complica- subsidence is acceptable, and part of the design in unce- tions occur in 1-5% of total hip replacements annually. The major complications are described in the follow- ing: Knee Replacements Loosening With or Without Coexisting Infection Alignment: Obtain standing views to check alignment and compare with earlier radiographs. The infection rate is approximately 1% of total hip replacements, 2% of Total knee: The tibial articular surface should be par- total knee replacements and 3% of revision joints per an- allel to the floor in a weight-bearing position. Obviously, figures vary but at 10 years after inser- femoral component should lie in 5-7° of valgus. The tion as many as 50% of hips may appear radiographical- patellar button should be central and well embedded in ly loose, 30% requiring revision [5]. The progressive similarly to 3-phase bone scan but less well than conven- widening of an interface, especially if associated with bone tional radiographs [8]. The presence of a joint effusion (shown on plain X-ray or ultrasound) implies a Arthrography joint that is abnormal, although a small joint effusion is usual in total knee replacements. Additional signs include The major objective of arthrography is to obtain fluid for excessive component migration or subsidence of unce- culture and sensitivity and to document intra-articular mented components, subsidence of cemented components, needle position. It is important to remember to aspirate cement or fatigue fractures of metallic components, dis- material for both aerobic and anaerobic cultures. A periosteal reaction should always be re- riostatic, aspiration prior to local anesthetic or saline in- garded as suspicious of infection, as opposed to local cor- jection is preferred.