Prospektive Studie zur Vermeidung heterotoper Ossifikationen nach Hüftgelenksersatz

Purpose

Two prospective trials were undertaken to assess the comparative efficacy of early postoperative irradiation with different radiation doses versus the postoperative use of nonsteroidal antiinflammatory drugs (NSAID) for prevention of heterotopic ossification (HO) following prothetic total hip replacement (THP).

Patients and Method

Between 1992 and 1994 585 patients received THP. These patients were randomwed in two longitudinal studies each with 3 treatment arms comparing postoperative irradiation with 4×3 Gy (101 patients), 1×5 Gy (93 patients), 1×7 Gy (95 patients) and the postoperative use of the NSAID indometacin for 7 days (113 patients) respectively for 14 days (90 patients) und acetyl salicyl acid (ASS) for 14 days (93 patients). Heterotopic ossification was scored according to the Brooker grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analysed and defined as historical control group.

Results

Incidence of heterotopic ossification was 5% in the 4×3 Gy group (Brooker grade I 5%, grade II 0%, grade III 0%), 30,5% in the 1×5 Gy group (Brooker grade I 24,7%, grade II 4,1%, grade III 1.0%) and 10,5% in the 1×7 Gy group (Brooker grade I 10.5%, grade II 0%, grade III 0%). 15.9% of the indometacin-7 days-group developed heterotopic ossification (Brooker grade I 8%, grade II 6.2%, grade III 1.7%, grade IV 0%), 12.2% of the indometacin-14 days-group (Brooker grade I 8.9%, grade II 2.2%, grade III 1.1%) and 37.5% of the ASS-group (Brooker grade I 27.9%, grade II 4.3%, grade III 5.3%). The lowest incidence of heterotopic ossification was found for the 4××3 Gy and the 1×7 Gy group, but no significant difference between these two different treatments was observed.

Conclusion

Prophylactic irradiation of the operative site after hip replacement is more effective than the use of NSAID. Because no significant difference between the fractionated ingle dose irradiation was found and the latter is more comfortable for patients and more economical, irradiation with single 7 Gy fraction should be prefered.     

Preoperative Irradiation for Prevention of Heterotopic Ossification Following Prosthetic Total Hip Replacement

BACKGROUND: The effectiveness of pre- or postoperative radiotherapy for prevention of heterotopic ossification (HO) following total hip replacement (THR) has already been demonstrated in the past. Thereby, in most studies using preoperative radiotherapy patients were irradiated < 6 h before surgery. The purpose of this prospective study was to analyze the effectiveness of preoperative irradiation on the evening before surgery and to identify risk factors for HO in a homogeneous collective of patients. PATIENTS AND METHODS: From July 1997 to July 2001, 416 patients (462 hips; 235 males, 227 females) received preoperative radiotherapy of the hip on the evening before surgery with a 7-Gy single fraction. The patients' median age was 67.1 years. The most frequent indication for radiotherapy was hypertrophic osteoarthritis (383 hips, 82.9%). Treatment results were assessed by comparison of pre- and postoperative hip X-rays (immediately and 6 months after surgery). The analysis of radiographs was performed according to the Brooker score. RESULTS: The overall incidence of HO was 18.1% (n = 84), Brooker score 1 12.3% (n = 57), score 2 3.9% (n = 18), score 3 1.5% (n = 7), and score 4 0.4% (n = 2). Sex, body height, hypertrophic osteoarthritis of higher degree, size of the femoral component of the prosthesis, previous ipsi- or contralateral HO, and short course of nonsteroidal anti-inflammatory drug (diclofenac) therapy significantly influenced the HO rate in univariate analysis. In multivariate analysis, an interdependence of prosthesis size, sex and patient's height was found. From these three variables, only prosthesis size was statistically significant in multivariate analysis. The cumulative dose of diclofenac (< or = 300 mg or > 300 mg) within the first 7 postoperative days and previous ipsi- or contralateral HO influenced the incidence of HO in multivariate analysis. CONCLUSION: Preoperative radiotherapy on the evening before surgery is an effective treatment modality to reduce overall (Brooker 1-4) and clinically relevant, severe HOs (Brooker 3-4), and includes several advantages compared to postoperative irradiation. Previous ipsi- and contralateral HOs were identified as high risk factors for HO in this study. In patients with these risk factors, the incidence of HO increased.     

Fractionated and Single-Dose Radiotherapy for Heterotopic Bone Formation in Patients with Spinal Cord Injury A Phase-I/II Study

BACKGROUND: Heterotopic ossifications occur in about 20% of patients with spinal cord injury and may seriously compromise the rehabilitation process. Aim of the present study was to evaluate if radiotherapy administered early in the course of the disease prevents the manifestation of heterotopic ossification and if in patients whose bone formations have been resected recurrence can be avoided. PATIENTS AND METHODS: 52 patients (44 males, eight females, median age 33 years) and 75 joints were irradiated between December 1989 and March 2000. 49 patients (70 joints, 65 hips, three knees, one shoulder, one elbow) were evaluable. Median follow-up was 11 months. In 58 joints radiotherapy was performed as a primary treatment in the inflammatory phase of soft tissue swelling that precedes manifestation of heterotopic ossifications. Twelve joints were treated after resection of manifest heterotopic bone, two patients had primary and postoperative irradiation in different joints. The dose was 10 Gy in single fractions of 2-2.5 Gy in 34 joints and 7.5-20 Gy in six joints. From July 1996 on, 30 joints received single-dose irradiation with 8 Gy. RESULTS: 50/70 joints (71%) remained free from progression. This was the case for 47/65 (72%) hips, whereas in 18 hips (27%) the Brooker score increased for 1-2 grades and caused a moderate decrease of mobility in five joints. Out of the other five joints, two knees developed progression. No relevant side effects occurred. CONCLUSION: The present results suggest that radiotherapy is an effective local treatment option for spinal cord injured patients with heterotopic ossifications.     

The Influence of Heterotopic Ossification on Functional Status of Hip Joint Following Total Hip Arthroplasty

Purpose: The functional failure induced by heterotopic ossification (HO) following total hip arthroplasty (THA) was analyzed and correlated to the radiologic failure.Patients and Methods: From July 1997 to July 2001, 315 patients (345 hips) received THA indicated by a hypertrophic osteoarthritis of higher degree (Kellgren grade III, IV). All patients were irradiated prophylactically for prevention of HO on the evening before surgery with a 7-Gy single fraction. The patients’ median age was 66.3 years. Radiologic failure was assessed by comparison of pre- and postoperative hip X-rays (immediately and 6 months after surgery). Analysis of radiographs was performed according to the Brooker Score. Clinical failure was appraised by measurement of passive range of motion (ROM) of the hip joint with a standard goniometer. The t-test was used for statistical analysis.Results: 281 patients (81.5%) did not develop HO. HO of Brooker grade I or II was found in 58 patients (16.8%). Six patients (1.7%) developed HO Brooker grade III or IV. There was a significant negative correlation between the degree of radiologic and clinical failure. ROM differed significantly between patients with HO Brooker grade 0, I, II and patients with HO Brooker grade III, IV. Comparing the pre- and postoperative ROM, all patients with Brooker grade 0, I and II showed a significant improvement of flexion, internal and external rotation, abduction and adduction movement. Patients with HO Brooker grade III and IV showed no improvement of ROM in the postoperative follow-up.Conclusion: The development of HO following THA influences the physical function of the hip joint dependent on the degree of ossification. HO of lower degree (Brooker I, II) does not influence the clinical outcome, whereas HO of higher degree (Brooker III, IV) reduces the function of hip arthroplasty. Therefore, the purpose of a prophylactic therapy must be to reduce HO of higher degree.     

Fractionated and Single-Dose Radiotherapy for Heterotopic Bone Formation in Patients with Spinal Cord Injury A Phase-I/II Study

Background: Heterotopic ossifications occur in about 20% of patients with spinal cord injury and may seriously compromise the rehabilitation process. Aim of the present study was to evaluate if radiotherapy administered early in the course of the disease prevents the manifestation of heterotopic ossification and if in patients whose bone formations have been resected recurrence can be avoided. Patients and Methods: 52 patients (44 males, eight females, median age 33 years) and 75 joints were irradiated between December 1989 and March 2000. 49 patients (70 joints, 65 hips, three knees, one shoulder, one elbow) were evaluable). Median follow-up was 11 months. In 58 joints radiotherapy was performed as a primary treatment in the inflammatory phase of soft tissue swelling that precedes manifestation of heterotopic ossifications. Twelve joints were treated after resection of manifest heterotopic bone, two patients had primary and postoperative irradiation in different joints. The dose was 10 Gy in single fractions of 2-2.5 Gy in 34 joints and 7.5-20 Gy in six joints. From July 1996 on, 30 joints received single-dose irradiation with 8 Gy. Results: 50/70 joints (71%) remained free from progression. This was the case for 47/65 (72%) hips, whereas in 18 hips (27%) the Brooker score increased for 1-2 grades and caused a moderate decrease of mobility in five joints. Out of the other five joints, two knees developed progression. No relevant side effects occurred. Conclusion: The present results suggest that radiotherapy is an effective local treatment option for spinal cord injured patients with heterotopic ossifications. Hintergrund: Heterotope Ossifikationen treten bei bis zu 20% von Patienten mit verletzungsbedingter Querschnittslähmung auf und können die Rehabilitation erheblich erschweren. Ziel der vorliegenden Studie war zu evaluieren, ob durch eine primär im Anfangsstadium der Erkrankung eingesetzte Strahlentherapie die Manifestation heterotoper Ossifikationen verhindert oder durch eine postoperative Bestrahlung ein Rezidiv vermieden werden kann. Patienten und Methode: Zwischen Dezember 1989 und März 2000 wurden 52 Patienten mit Querschnittslähmung (acht Frauen, 44 Männer, medianes Alter 33 Jahre) and 75 Gelenken bestrahlt; 49 Patienten und 70 Gelenke (65 Hüften, drei Knie, eine Schulter, ein Ellenbogen) waren auswertbar. Die mediane Nachbeobachtungszeit betrug 11 Monate. Bei 58 Gelenken erfolgte die Bestrahlung als primäre Therapie im Stadium der entzündlichen Weichteilschwellung, die der Manifestation heteroper Ossifikationen vorausgeht. Bei zwölf Gelenken wurde postoperativ nach Resektion manifester Ossifikationen bestrahlt. Die Dosis betrug bei 34 Gelenken 10 Gy (à 2-2.5 Gy), bei sechs Gelenken zwischen 7,5 und 20 Gy und seit Juli 1996 bei 30 Gelenken einmal 8 Gy. Die Therapie wurde auf der Basis von CT-Schnitten geplant und erfolgte am Linearbeschleuniger meist über opponierende Felder mit 6-8-MV-Photonen. Resultate: 50/70 Gelenke (71%) zeigten im weiteren Verlauf keine Progression, dies galt für 47/65 Hüftgelenke (72%), bei 18 Hüften (27%) nahm der Brooker-Score um ein bis zwei Grade zu. Bei den sonstigen füf Gelenken zeigte sich bei zwei Knien eine Progression. Relevante Nebenwirkungen traten nicht auf. Schlussfolgerung: Die Strahlentherapie scheint eine effektive Maßnahme zur primären Behandlung und eine wirksame Rezidivprophylaxe nach Resektion von heterotopen Ossifikationen bei Querschnittsgelähmten zu sein.     

Radiation-Induced Reduction of BMP-Induced Proteoglycan Synthesis in an Embryonal Mesenchymal Tissue Equivalent Using the Chicken “Limb Bud” Test

PURPOSE: Heterotopic ossification (HO) is a common complication following total hip replacement. Clinical studies showed the effectiveness of irradiation for prevention of heterotopic ossification. The mechanism of radiotherapy responsible for the reduction of heterotopic ossification is unclear. The purpose of this study was to find a suitable cell system, which can reproduce in-vitro data resulting from clinical in-vivo studies. The establishment of such a cell model allows detailed analyses of the mechanism of radiotherapy. METHOD: The chicken limb bud test was used as an in-vitro model. The cells acquired by the limb bud test were irradiated with different doses (0 Gy, 3 Gy, 7 Gy, 10 Gy, 20 Gy). Irradiation was set either 1 hour before, or 1 or 3 days after BMP-2 incubation. The synthesis of proteoglycans (PGS) upon treatment with bone morphogenetic protein (BMP)-2 was measured in cells incubated with BMP-2 for 4 days followed by 35SO4(2-) labeling for 6 hours. Labeled proteoglycans were precipitated using Alcian blue and measured in a raytest radio-TLC analyzer. The incubation with BMP-2 was defined to correlate the in-vivo stimulus meaning the operation. RESULTS: The proteoglycan synthesis was significantly reduced by irradiation 1 hour before or 1 day after BMP-2 incubation, if the dosage was at least 7 Gy. Higher doses than 7 Gy did not lead to lower proteoglycan levels. There was only a trend for a reduction of proteoglycan synthesis by 3 Gy irradiation, but no significant difference compared to the non-irradiated control. An irradiation 3 days after BMP-2 incubation had no effect on proteoglycan. CONCLUSION: A dose and time dependent effect of radiation on BMP-2-induced proteoglycan synthesis was observed. Therefore the results of clinical in-vivo studies were reproduced exactly by the limb bud test. We established an in-vitro cell model to analyze the mechanism of the prevention of heterotopic ossification by radiotherapy on cellular or sub-cellular level.     

Observations on para-articular uptake of radiophosphate after hip replacement

A correlation was made between the incidence and intensity of 99mTc-methylene diphosphonate (MDP) concentration and the radiographic incidence and volume of heterotopic calcium deposition in 44 patients with hip arthroplasties, as well as with the duration of the hip implants. The incidence of soft tissue para-articular MDP concentration was 95% compared to a 68% incidence of radiographically visible heterotopic calcium, bone or both. The concentration of MDP did not decrease on average with the age of the implant, which ranged from 6 months to 15 years, even though radiographs showed evidence of mature ossification in many of them. The cause of these sustained high uptakes is open to speculation, but the findings indicate that radiophosphate imaging is not a reliable means of assessing maturation of heterotopic bone associated with hip arthroplasty.     

Methods of the physical medicine therapy in prevention of heterotopic ossification after total hip arthroplasty

BACKGROUND/AIM: In the prevention of periarticular heterotopic ossification (HO), a common complication after total hip arthroplasty (THA), nonsteroidal antiinflammatory drugs (NSAID) and irradiation are used. Some theories presume that local hypoxia of the soft tissue causes HO. The aim of this study was to investigate if the early use of pulsed electromagnetic fields (PEMF) could prevent this ossification since it accelerates the circulation and oxigenation of soft tissue. METHODS: The study included three groups of the patients with primary THA. The group C consisted of 66 patients/79 hips who had only kinesitherapy in postoperative rehabilitation. The group B consisted of 117 patients/131 hips who had PEMF and interferential current (IC) which, on average, started on the 14th day after the surgery combined with the standard kinesitherapy. The group A consisted of 117 patients/131 hips who had PEMF from the third postoperative day and IC from, on average, the 14th postoperative day with the standard kinesitherapy. The classification of HO was done on a standard AP roentgenograms of the hips, taken at least one year after the surgery. RESULTS: The overall HO was seen in 50.63% of the group C patients, in 43.51% of the B group and in 16.67% of the group A. Severe HO (III and IV class according to Brooker) was seen in 26.58% of the group C patients and in 6.10% of the group B, but none in the group A. CONCLUSION: According to the obtained results an early treatment with PEMF could prevent severe HO and reduce the overall HO.     

Observations on para-articular uptake of radiophosphate after hip replacement

A correlation was made between the incidence and intensity of ^99mTc-methylene diphosphonate (MDP) concentration and the rediographic incidence and volume of heterotopic calcium deposition in 44 patients with hip arthroplasties, as well as with the duration of the hip implants. The incidence of soft tissue para-articular MDP concentration was 95% compared to a 68% incidence of radiographically visible heterotopic calcium, bone or both. The concentration of MDP did not decrease on average with the age of the implant, which ranged from 6 months to 15 years, even though radiographs showed evidence of mature ossification in many of them. The cause of these sustained high uptakes is open to speculation, but the findings indicate that radiophosphate imaging is not a reliable means of assessing maturation of heterotopic bone associated with hip arthroplasty.     

Endometrial carcinoma in patients aged 75 years or older: outcome and complications after postoperative radiotherapy or radiotherapy alone.

A retrospective analysis is reported of 89 patients at least 75 years old (median age 79 years) treated with irradiation for endometrial carcinoma between 1972 and 1989, the median follow-up being 39 months. In 66 patients radiotherapy was given postoperatively and in one case preoperatively, 22 patients were treated with radiotherapy alone: intravaginal insertions exclusively in 22 patients (median dose 60 Gy to the mucosa) and combined with external radiotherapy in 53 patients (median external target dose 45 Gy; three or four fields, all treated daily, 1.8 to 2.0 Gy per fraction, five fractions per week; 30 Gy to the vaginal mucosa with low-dose rate). A few patients were treated with external radiotherapy or intrauterine insertions only. 65% of the patients treated with radiotherapy alone and 34% of the patients receiving postoperative radiotherapy had FIGO stage II or III disease. Five-year actuarial overall survival and disease-free survival for all patients with adenocarcinomas treated with curative intent was 47.5% and 57.2%, respectively. In 48 patients with surgical stages I and II, treated with postoperative adjuvant radiotherapy, overall actuarial survival is 58.2% and disease-free survived 65.5% at five years. After postoperative vaginal insertions only, no vaginal recurrence occurred. With combined external and intravaginal radiotherapy in surgical stage I and II, 4/36 patients (11%) showed a recurrence in the vagina only, the abdominal and pelvic recurrence rate being 8.3%. Grade 3 to 4 late toxicity was observed in 6/53 patients (11.3%) treated with external and intravaginal radiotherapy. However, in patients receiving external radiotherapy less than 45 Gy and intravaginal radiotherapy 30 to 40 Gy, as is standard postoperative adjuvant treatment today, only one grade 3 late toxicity was observed in 17 patients (5.9%). We conclude, that treatment of elderly patients with adenocarcinoma of the uterus should follow the same pattern as in younger patients, the acute side-effects and late toxicity of radiotherapy being similar.     

Radiation-Induced Reduction of BMP-Induced Proteoglycan Synthesis in an Embryonal Mesenchymal Tissue Equivalent Using the Chicken "Limb Bud" Test

Purpose: Heterotopic ossification (HO) is a common complication following total hip replacement. Clinical studies showed the effectiveness of irradiation for prevention of heterotopic ossification. The mechanism of radiotherapy responsible for the reduction of heterotopic ossification is unclear. The purpose of this study was to find a suitable cell system, which can reproduce in-vitro data resulting from clinical in-vivo studies. The establishment of such a cell model allows detailed analyses of the mechanism of radiotherapy. Method: The chicken limb bud test was used as an in-vitro model. The cells acquired by the limb bud test were irradiated with different doses (0 Gy, 3 Gy, 7 Gy, 10 Gy, 20 Gy). Irradiation was set either 1 hour before, or 1 or 3 days after BMP-2 incubation. The synthesis of proteoglycans (PGS) upon treatment with bone morphogenetic protein (BMP)-2 was measured in cells incubated with BMP-2 for 4 days followed by ³⁵SO₄^2m labeling for 6 hours. Labeled proteoglycans were precipitated using Alcian blue and measured in a raytest radio-TLC analyzer. The incubation with BMP-2 was defined to correlate the in-vivo stimulus meaning the operation. Results: The proteoglycan synthesis was significantly reduced by irradiation 1 hour before or 1 day after BMP-2 incubation, if the dosage was at least 7 Gy. Higher doses than 7 Gy did not lead to lower proteoglycan levels. There was only a trend for a reduction of proteoglycan synthesis by 3 Gy irradiation, but no significant difference compared to the non-irradiated control. An irradiation 3 days after BMP-2 incubation had no effect on proteoglycan. Conclusion: A dose and time dependent effect of radiation on BMP-2-induced proteoglycan synthesis was observed. Therefore the results of clinical in-vivo studies were reproduced exactly by the limb bud test. We established an in-vitro cell model to analyze the mechanism of the prevention of heterotopic ossification by radiotherapy on cellular or sub-cellular level. Hintergrund: Heterotope Ossifikationen stellen eine häufige postoperative Komplikation nach Hüftgelenksoperationen dar. In klinischen Studien konnte gezeigt werden, dass eine Bestrahlung des Operationsbereichs Ossifikationen verhindern kann. Dabei ist der genaue Wirkmechanismus der ionisierenden Strahlen unbekannt. Ziel dieser Untersuchung war es, ein geeignetes Zellsystem zu finden, welches die aus der klinischen Beobachtung gewonnenen Kenntnisse in vitro reproduzieren lässt, um damit ein Modell zu haben, den Wirkungsmechanismus der Bestrahlung analysieren zu können. Material and Methode: Als In-vitro-Organmodell wurde der Limb-Bud-Test gewählt. Die dabei gewonnenen embryonalen mesenchymalen Zellen wurden mit unterschiedlichen Bestrahlungsdosen (0 Gy, 3 Gy, 7 Gy, 10 Gy, 20 Gy) zu unterschiedlichen Zeitpunkten bestrahlt (1 Stunde vor, 1 und 3 Tage nach Zugabe von Bone Morphogenetic Protein [BMP]-2). Die Zellen wurden 4 Tage mit BMP-2 und anschließend für 6 Stunden mit ³⁵SO₄^2m inkubiert. Die so markierten Proteoglykane wurden mittels Alcian-Blau gefällt und in einem Raytest-Radio-TLC-Analyzer gemessen. Die Inkubation der Zellsuspension mit BMP-2 entsprach dabei der in vivo als Ossifikationsreiz geltenden Operation. Ergebnisse: Die 1 Stunde vor oder 1 Tag nach BMP-2-Zugabe bestrahlten Zellsuspensionen zeigten eine deutliche Abnahme der Proteoglykansyntheserate (PGS), sobald die Bestrahlungsdosis mindestens 7 Gy betrug. Eine Steigerung der Dosis bis zu 20 Gy führte nicht zu einem weiteren Abfall der Proteoglykansyntheserate. Für eine Dosis von 3 Gy fand sich lediglich ein Trend zu einer reduzierten Proteoglykansynthese, ohne dass der Unterschied zur unbestrahlten Kontrollgruppe signifikant gewesen wäre. Eine Bestrahlung 3 Tage nach BMP-2-Zugabe hatte keinen Einfluss auf die Proteoglykansyntheserate. Schlussfolgerung: Der Limb-Bud-Test erlaubt es, die Ergebnisse der klinischen Studien in vitro zu reproduzieren. Man hat damit ein Zellmodell zur Verfügung, das es erlaubt, auf zellulärer und subzellulärer Ebene den Wirkungsmechanismus der ionisierenden Strahlen bei der Verhinderung ektoper Ossifikationen zu untersuchen.     

全髋关节置换术与内固定术治疗糖尿病股骨颈骨折患者的疗效对比分析

目的分析全髋关节置换术与内固定术治疗糖尿病股骨颈骨折患者的疗效。方法回顾性分析2013年1月—2015年12月在复旦大学附属华东医院骨科治疗的60例二型糖尿病股骨颈骨折患者,其中男性30例,女性30例;年龄43~62岁,平均51.1岁;致伤原因均为高处坠落伤。根据手术方案不同分为研究组(n=30)和对照组(n=30)。研究组患者采用全髋关节置换术进行治疗,对照组患者采用空心钉内固定治疗。观察并记录两组患者的手术时间、出血量、输血量、住院时间、髋关节功能有效率、术后并发症发生率及X线片诊断结果,并对结果进行分析比较。结果术后随访时间1年。研究组患者的手术时间、出血量、输血量、住院时间分别为(99.3±17.9)min、(334.6±24.8)mL、(298.4±30.4)mL、(12.2±3.8)d,明显高于对照组[(86.3±17.8)min、(197.2±23.5)mL、(194.5±31.0)mL、(9.9±2.2)d],差异有统计学意义(P0.05);研究组患者的术后活动时间[(5.3±2.3)d]明显短于对照组[(9.7±5.2)d],差异有统计学意义(P0.05);治疗后,研究组患者的髋关节功能有效率(93.4%)明显高于对照组(73.3%),差异有统计学意义(χ~2=4.3200,P0.04);研究组患者出现异位骨化病2例,假体远端骨折3例;对照组出现股骨头塌陷1例,股骨不愈合3例,股骨头坏死2例,异位骨化病1例;研究组患者术后并发症包括深静脉血栓1例,尿路感染1例,对照组包括深静脉血栓2例,尿路感染1例,肺炎1例,两组比较差异无统计学意义(P0.05);研究组患者中死亡2例,病死率为6.6%,对照组患者中死亡1例,病死率为3.3%,两组比较差异无统计学意义(P0.05)。结论内固定法治疗操作简单,出血少,住院时间短;全髋关节置换治疗术后活动时间较早,治疗优良率高,临床应根据患者的具体情况选择合适的手术方式。     

Clinical and radiographic "reankylosis" following hip surgery in ankylosing spondylitis.

Eleven patients with ankylosing spondylitis underwent reconstructive hip surgery (21 hips). In 10 of these hips multiple surgical procedures had been performed. The final procedure included total hip arthroplasties (16 hips), femoral cup arthroplasties (four hips) and an Austin-Moore prosthetic replacement (one hip). A clinical and radiographic evaluation in the postoperative period revealed a high incidence of decreased joint motion and heterotopic ossification. Clinically moderate to severe restriction of motion was noted in 12 hips, and in six of these "reankylosis" was present. Radiographically moderate to severe new bone formation was seen in 11 hips, and in nine of these "reankylosis" was suggested. An association of excessive ossification and multiple surgical procedures was evident. It would appear that when the prime indication for hip surgery in patients with ankylosing spondylitis is restricted motion, the operation may not be beneficial.     

虚拟手术设计结合3D打印在复杂髋臼骨折治疗中的应用

目的 探讨虚拟手术设计结合3D打印在复杂髋臼骨折治疗中的应用.方法 回顾性分析连云港市第一人民医院急诊外科2017年2月—2020年2月收治的复杂髋臼骨折患者80例,男性47例,女性33例;年龄27～62岁,平均44.0岁.按照手术方法不同分为3D组(36例)和常规组(44例),常规组行传统方法切开复位钢板内固定;3D...     

Acute Toxicity of Adjuvant Radiotherapy in Locally Advanced Differentiated Thyroid Carcinoma

BACKGROUND AND PURPOSE: The indication for adjuvant postoperative radiotherapy in patients with differentiated thyroid carcinoma (DTC) extending beyond the thyroid capsule has been an issue of controversy during the past 2 decades. No randomized studies evaluating the benefit of radiotherapy have been published so far. In the Multicenter Study Differentiated Thyroid Carcinoma (MSDS), a randomization has been performed concerning external-beam radiotherapy in patients with DTC extending beyond the thyroid capsule (pT4 pN0/1/x cM0, TNM classification, 5th edition, 1997) following surgery and radioiodine therapy. Radiation-associated toxicity has been prospectively evaluated. PATIENTS AND METHODS: Radiotherapy was performed with 50.4 Gy (pN0) or 54.0 Gy (pN1/x) to the cervical, supraclavicular and upper mediastinal lymph nodes. A total dose of 59.4 Gy (R0 resection) or 66.6 Gy (R1) was used to treat the tumor bed. Conventional fractionation was used with 1.8 Gy/d. At the time of the analysis, 36 patients were randomized or allocated to treatment arm A (with external-beam radiotherapy). Of these, 22 were treated with radiotherapy, and documentation of acute toxicity was available. Toxicity was evaluated prospectively according to the RTOG/EORTC criteria. RESULTS: The maximal acute toxicity observed during radiotherapy was grade I in four patients, grade II in 16 patients, and grade III in two patients (9.1%; 95% confidence interval [95% CI] 1.1-29.2%). Toxicity was mainly observed at the pharynx, larynx, and skin. In 19 patients, residual toxicity within 100 days following radiotherapy was evaluated. No residual toxicity was observed in two patients. Maximal residual toxicity was grade I in 13 patients and grade II in four. No further grade III toxicity could be observed. CONCLUSION: The majority of patients experience mild to moderate side effects from adjuvant external-beam radiotherapy. At the first follow-up examination, most side effects have subsided. Acute toxicity is tolerable in these patients.     

Radiotherapy for the prophylaxis of heterotopic ossification after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trails

Heterotopic ossification (HO) refers to the formation of lamellar bone in soft tissues and is a significant complication after total hip arthroplasty (THA). Radiotherapy has been proven as an effective prophylaxis especially for those patients with high risk of HO after THA. However the dose, timing, and frequency of radiation have yet to be determined. To compare HO progressions with different radiotherapy strategies and explore an optimal radiation option. We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trails (through December 1, 2019; no language restrictions) collecting patients who accepted prophylaxis radiation for whom HO progression outcomes were reported. Of 87 identified studies, 10 randomized controlled trails including 1203 patients and 1268 hips were taken to this analysis. Compared with the low biologically effective radiation dose group (biologically effective dose [BED] < 20 Gy), the medium biologically effective radiation dose group (20 Gy ≤ BED ≤ 24 Gy) had statistically significant difference on the prophylaxis of HO (p = 0.003). But for overall incidence of HO, there was no statistically significant difference between low BED group and high BED group (BED > 24, p = 0.21). There was statistically significant reduction in the prophylaxis of HO progression with multiple fractions as opposed to single fraction radiotherapy (p = 0.04). Hips with preoperative radiation were no more likely to observe HO progression than those with postoperative radiotherapy (p = 0.43). Radiotherapy with medium dose (20 Gy ≤ BED ≤ 24 Gy) after THA is an effective dose for preventing HO. In the prophylaxis of HO, multiple fractions seem to be more effective than single fraction radiation. Preoperative radiotherapy could prevent HO progression with the same efficacy postoperative.     

Curative Radiotherapy in Elderly Patients with Endometrial Cancer Patterns of Relapse, Toxicity and Quality of Life

PURPOSE: To assess survival, disease-specific survival, acute and late toxicity and quality of life in patients with curable endometrial carcinoma treated with adjuvant or primary radiotherapy at the age > or = 75 years. PATIENTS AND METHODS: In a prospective study, outcome was regularly assessed in 49 patients treated between 1991 and 1995 at a median age of 78.4 years. Radiotherapy was applied using the same concept as in younger patients. Thirty-eight patients received postoperative adjuvant radiotherapy (vaginal insertions only: n = 18; external and vaginal insertions: n = 17; external radiotherapy only: n = 3), 8 patients were treated for a vaginal recurrence. Three patients received primary radiotherapy. Median pelvic dose was 39.6 Gy (ICRU) with 1.8 Gy per fraction (4 fields). Vaginal HDR radiotherapy consisted of 5 times 5 Gy at 0.5 cm depth in cases with no external radiotherapy, and of 3 times 5 Gy in addition to pelvic radiotherapy, respectively. Median follow-up was 3.2 years. The EORTC QLQ-C30 was used for self-assessment of quality of life. RESULTS: Survival and disease-specific survival at 5 years was 64% and 84%, respectively. There was no pelvic or vaginal recurrence in patients with Stage IA to IIB. Patients with positive adnexa and those treated for vaginal recurrence relapsed in 50%. Two patients (4%) did not complete radiotherapy because of severe diarrhea. Grade 4 late complications were observed in 1/38 patients following adjuvant radiotherapy and in 2/8 patients treated for a recurrence. The actuarial rate of Grade 3 to 4 complications was 7% at 3 years. Quality of life was good in most cases and remained constant over time. CONCLUSIONS: Elderly patients with endometrial cancer may be treated following the same guidelines as younger patients. Radiotherapy for a vaginal recurrence is less effective and more toxic.     

Biochemical Response after 3-D Conformal Radiotherapy of Localized Prostate Cancer to a Total Dose of 66 Gy

BACKGROUND: Since the introduction of 3-D conformal radiotherapy (CRT) doses of /= 70 Gy should be considered. As a consequence of our earlier analysis a prospective multicenter treatment optimization protocol has been initiated in 1999. The protocol includes a risk-adapted dose increase from 70 Gy in low-risk patients to 74 Gy in high-risk patients including short-term androgen ablation.     

Herpes Zoster in Breast Cancer Patients after Radiotherapy

PURPOSE: We have studied the incidence of herpes zoster in patients with adjuvant radiotherapy for breast cancer with special emphasis on possible correlations with other prognostic factors or survival. PATIENTS AND METHODS: From 1/1985 through 12/1993, 1,155 breast cancer patients received postoperative radiotherapy with curative intent in our department. After mastectomy 961 patients were irradiated and after breast-preserving treatment 194 patients. The age ranged from 34 to 79 years, the median follow-up was 3.1 years (range: 0.3 to 12.4 years). There were 443 women (38%) pre- and 712 (62%) postmenopausal. 21% had T3- to T4-tumors, 55% had axillary lymph node involvement, and 65% received additional systemic hormonal and/or cytotoxic therapy. In case of postmastectomy radiotherapy, the lateral chest wall and lymphatics (axilla, parasternal and supraclavicular nodes) were irradiated with an anterior photon field to 50 Gy (axilla 44 Gy) and most of the chest wall with an electron field to 44 Gy in 2-Gy fractions. After breast-preservation, the breast was irradiated via tangential fields with 6- to 8-MV photons up to 50 Gy plus 8 Gy electron boost to the tumor bed. Most of the patients were followed routinely in the department for 2 to 5 years. The frequency of zoster was determined retrospectively by reviewing the patients' records. RESULTS: A zoster after radiotherapy occurred in 41/1,155 patients (3.7%), mostly within the first 2 years after completion of radiotherapy. All infections remained localized and there was no evidence for systemic infections. Type of treatment (mastectomy vs breast-preservation) had no impact on the frequency of herpes zoster (36/961 patients after mastectomy and 5/194 patients after breast-preservation). There was also no correlation with other prognostic factors such as age, menopausal status, stage of disease or the use of adjuvant chemotherapy, nor was the occurrence of zoster linked to the degree of acute skin reaction in the radiation field. Moreover, patients with zoster had the same prognosis as compared to patients without zoster with regard to local control and survival. CONCLUSIONS: The observed frequency of zoster (about 4% of patients after postoperative radiotherapy) in this retrospective study suggests that the risk of developing zoster in this patient group may be 3- to 5-fold higher as compared to the incidence in the general population. However, the occurrence of zoster was not linked to prognosis and treatment response.     

Feasibility and preliminary outcome of salvage combined HDR brachytherapy and external beam radiotherapy (EBRT) for local recurrences after radical prostatectomy

PURPOSE: Feasibility of combined fractionated intensity modulated brachytherapy (IMBT) and external beam radiotherapy (EBRT) as well as the effect of local dose escalation was investigated in a non-randomized retrospective observation trial for histologically-proven macroscopic local recurrences of prostate cancer after radical prostatectomy. METHODS AND MATERIALS: Thirty-five patients with transrectal ultrasound (TRUS) detectable tumors were treated. Applied dose per IMBT fraction was 15 Gy, prescribed on the target (TRUS visible tumor) surface. For the first 21 patients, two fractions of IMBT were delivered in 2 weeks interval, complementary to 30 Gy EBRT to the small pelvis. Further, as second step of dose escalation, 14 patients were treated with 2 x 15 Gy IMBT combined with 40 Gy EBRT. The total treatment time was 4 and 5 weeks, respectively. RESULTS: PSA was decreased in 34 out of 35 patients post-therapeutically. After a mean follow-up of 27 months, 32 out of 35 patients are alive. However, in 67% of the patients, we observed postimplant PSA elevation with or without detectable local and/or systemic progress. The mean duration of biochemical non-evidence of disease (bNED) after radiation was 12 months for all patients (31% in the 30 Gy group and 42% in the 40 Gy group). No RTOG/EORTC grade III or IV side effects were registered during/after radiotherapy. CONCLUSION: Combined EBRT and IMBT-boost of TRUS detectable recurrences of prostate cancer after radical prostatectomy seems to be a feasible method of salvage treatment. These early results need to be confirmed by further prospective randomized trials and by longer follow-up in all dose groups.