A double mobility acetabular implant for primary hip arthroplasty in patients at high risk of dislocation

IntroductionDislocation following total hip replacement continues to be a problem for which no completely satisfactory solution has been found. Several methods have been proposed to reduce the incidence of hip dislocations with varying degrees of success, including elevated rim liners, constrained liners and large diameter bearings. We present our experience with the double mobility acetabular component in patients at high risk of instability.MethodsThis was a retrospective review of 65 primary total hip arthroplasties in 55 patients (15 men, 40 women), performed between October 2005 and November 2009. The majority (80%) of patients had at least two and 26% had at least three risk factors for instability. The mean age was 76 years (range: 44–92 years). The patients were followed up for a mean duration of 60 months (range: 36–85 months).ResultsFourteen patients died and one was lost to follow-up, leaving fifty hips for final assessment. Until the final follow-up appointment, no patients had dislocation and none required revision surgery. The mean Oxford hip score improved from 45.0 to 26.5 (p<0.0001). The mean Merle d’Aubigné pain score improved from 1.4 to 4.9 (p<0.0001), the walking score from 2.3 to 3.1 (p<0.07) and the absolute hip function score from 5.4 to 10.8 (p<0.0001). There were no clinical or radiographic signs of loosening.ConclusionsThe double mobility acetabular component was successful at preventing dislocation during early to medium-term follow-up. However, as data are still lacking with regard to polyethylene wear rates at the additional bearing surface, it would be prudent to restrict the use of this implant to selected patients at high risk of instability.     

Endometrial hyperplasia

Atypical and severe hyperplasia of the endometrium is often associated with a carcinoma and, on their own, present a malignant potential which requires a specific treatment, involving an extension of the indications for hysterectomy after the menopause.     

Pregnancy and childbirth in gypsies

The features of the gypsy population, including the conditions of their lifestyle, are very unusual and medical follow-up is very irregular, resulting in obstetric and neonatal pathology. On the basis of a series of 1571 pregnancies, the authors describe the disadvantages of these features which can only be improved by a reciprocal confidence between gypsies and the medical profession.     

Diagnosis and therapy of necrotizing fasciitis

Necrotizing fasciitis is a soft tissue infection with a lethality ranging up to 80%. Infection causes the activation of interleukin, tumor necrosis factor alpha, and gamma-interferon through a triggering mechanism. This results in a capillary thrombosis with necrosis of the fascia, cutis, and subcutis. The patient's history often reveals a triggering event in the form of a recent minimal trauma or operative procedure. In a fulminant necrotizing fasciitis, the development of sepsis with consecutive multiple-organ failure mainly determines the outcome of the disease. Diagnosis is made initially upon clinical findings with a rapid progression of the disease and confirmed later by histologic and microbiologic findings. Radical surgical debridement within the first 24 h with postoperative treatment in an intensive care unit represents the cornerstone of therapy. Between January 1992 and March 2001, we treated 15 patients with necrotizing fasciitis. Lethality was 33%. There was a significant correlation between risk factors (present in 86% of the patients) and morbidity. Diagnosis and therapy should be performed by an experienced surgeon. In this contribution, we discuss the most important criteria that lead to the diagnosis and the therapeutic consequences.     

Identification and use of biomarkers in Gaucher disease and other lysosomal storage diseases

The value of biomarkers in the clinical management of lysosomal storage diseases is best illustrated by the present use of plasma chitotriosidase levels in the diagnosis and monitoring of Gaucher disease. The enzyme chitotriosidase is specifically produced and secreted by the pathological storage macrophages (Gaucher cells). Plasma chitotriosidase levels are elevated on average 1000-fold in symptomatic patients with Gaucher disease and reflect the body burden on storage cells. Changes in plasma chitotriosidase reflect changes in clinical symptoms. Monitoring of plasma chitotriosidase levels is nowadays commonly used in decision making regarding initiation and optimization of costly therapeutic interventions (enzyme replacement therapy or substrate reduction therapy). A novel substrate has been developed that further facilitates the measurement of chitotriosidase in plasma samples. Moreover, an alternative Gaucher-cell marker, CCL18, has been very recently identified and can also be employed to monitor the disease, particularly in those patients lacking chitotriosidase due to a genetic mutation. There is a need for comparable surrogate markers for other lysosomal storage diseases and the search for such molecules is an area of intense investigation.
Conclusion: The use of biomarkers can provide valuable insight into the molecular pathogenesis of LSDs, such as Gaucher disease and Fabry disease.     

Activation of blood platelets in response to maximal isometric exercise of the dominant arm

Isometric exercise is a popular form of physical activity for many people. Only few studies exist on the effects of this type of exercise on the hemostatic system. Eleven male healthy subjects (21-42 years) of varying fitness levels were investigated before, immediately after and 10 min after strenuous isometric exercise of the dominant arm. Blood samples were drawn by repetitive puncture from both the exercising and the contralateral arm. The following variables were studied: Prothrombin time and partial thromboplastin time as group tests for the plasmatic coagulation system; platelet count as well as p-selectin expression for the platelet system; tissue plasminogen activator (t-PA) activity and antigen for the fibrinolytic system. The partial thromboplastin time was shortened immediately after maximal isometric exercise of the dominant arm, the prothrombin time remained unchanged. No change was found in the platelet count, but a marked p-selectin expression was observed immediately after maximal isometric exercise of the dominant arm (p < 0.05) and even in the resting contralateral arm. Values returned to baseline after 10 min. There was a slight increase of t-PA antigen concentration and white blood cell count at maximal isometric contraction which did not occur in the resting arm, although changes over the 3 time points were significant in both arms. Maximal isometric exercise leads to platelet activation in both arms, a slight aPTT decrease and t-PA antigen increase in local blood stream. As compensatory fibrinolytic changes do not occur, it is an open question whether isometric exercise increases the potential risk of thromboembolism.     

Evaluation of attempted prevention of unexpected infant death in very high-risk infants by planned health care

Three hundred and ninety-six babies born in Sheffield between 1982 and 1990 identified as being at "very high risk" of unexpected infant death by means of a scoring system, received an intensive programme of health care including a case discussion between a paediatrician, the GP and the health visitor held in the family doctor's surgery, weekly visits from the health visitor and informal hospital admission. Significantly fewer sudden unexpected infant deaths occurred in this group than were expected by logistic regression anlysis or occurred in the best available control group with comparable scores ( p = 0.024). Problems in evaluation include identification of an adequate control population, ethical difficulties in introducing a controlled study when the programme is already perceived as effective, and the calculation of "expected death rates". The results of this study indicate that very energetic programmes of intervention may prevent some deaths in vulnerable infants.