Total hip replacement in developmental dysplasia using an oval-shaped cementless press-fit cup

Purpose

Acetabular roof deficiency due to subluxation of the femoral head (Hartofilakidis type II) increases the complexity of total hip arthroplasty. In these cases some form of support is usually required, to reach stable fixation of the acetabular component. Pursuing this aim, the oval-shaped cementless cranial socket could be an alternative to conventional treatment options.

Methods

Between 1998 and 2008, 37 patients (40 hips) underwent primary total hip arthroplasty using the cranial socket (mean follow-up 5.6 years, range 26 to 133 months). In a retrospective study we compared these clinical and radiological results with the results of a matched control group consisting of 35 patients (40 hips) treated with a standard cementless hemispherical cup in combination with bulk femoral autografting (mean follow-up 6.9 years, range 30 to 151 months).

Results

There were no statistically significant differences in the HHS (p = 0.205) or the SF-36 (p = 0.26) between both groups. There was no prosthesis failure due to septic or aseptic loosening. Time of surgery was significantly shorter in the cranial socket group (p < 0.001). The acetabular component could be placed in the ideal rotational hip centre in 24 (60%) hips in the cranial socket group and 32 (80%) hips in the control group, respectively.

Conclusions

Our study indicates, that the cranial socket can be an alternative treatment option for the reconstruction of acetabular deficiency in osteoarthritis secondary to developmental dysplasia.     

Proximaler Tibiaersatz und alloplastische Rekonstruktion des Streckapparats nach Resektion kniegelenksnaher Tumoren

Objective

The goal of the operation is limb-sparing resection of tumors arising from the proximal tibia with adequate surgical margins and local tumor control. Implantation of a constrained tumor prosthesis with an alloplastic reconstruction of the extensor mechanism to restore painless joint function and loading capacity of the extremity.

Indications

Primary bone and soft tissue sarcomas. Benign or semimalignant aggressive lesions. Metastatic disease (radiation resistance and/or good prognosis).

Contraindications

Poor physical status. Extensive metastatic disease with life expectancy <6?months. Tumor penetration through the skin. Local infection or recalcitrant osteomyelitis. Poor therapeutic compliance. Large popliteal extraosseous tumor masses with infiltration of neurovascular structures.

Surgical technique

A single incision is made from the anteromedial aspect of the distal femur to the distal one third of the medial lower leg. Preparation of large medial and lateral fasciocutaneous flaps. The popliteal vessels are explored through a medial approach by releasing the pes anserinus and semimembranosus tendon, mobilizing the medial gastrocnemius muscle and detaching the soleus muscle from the tibial margo medialis. The anterior tibial artery and vein are ligated. If the knee joint is free of tumor, circumferential dissection of the knee capsule is performed and the patellar ligament is dissected. An osteotomy of the tibia shaft is performed with safety margins according to preoperative planning. In order to obtain adequate surgical margins, in some cases an en?bloc resection of the tibiofibular joint becomes necessary. Therefore, the peroneal nerve is exposed. Parts of the M. tibialis anterior, a portion of the M. soleus and the entire M. popliteus are left on the resected tibial bone. After implantation of the prosthesis and coupling of the femoral and tibial component, the extensor mechanism is reconstructed using an alloplastic cord. It is passed transversely through the distal end of the quadriceps tendon looping the proximal margin of the patella. Both ends are passed distally through a subsynovial tunnel and are fixed under adequate pretension in a metal block of the tibial component. The detached hamstrings and remaining ligaments can be fixed on preformed eyes of the prosthesis. A medial gastrocnemius muscle flap is used to provide soft tissue coverage of the tibial component.

Postoperative management

Immobilization and elevation of the extremity for 5?days, then flap conditioning. Mobilization in a hinged knee brace locked in extension for 6?weeks without weight bearing. During this time active flexion with a stepwise progress, isometric quadriceps training. Then beginning of straight leg raising exercises, stepwise unlocking of the brace with 30° every 2?weeks. Weight-bearing is increased by 10?kg/week. Thrombosis prophylaxis until full weight-bearing. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination and radiographic studies.

Results

Between 1988 and 2009, endoprosthetic replacement and alloplastic reconstruction of the extensor mechanism after resection of tibial bone tumors was performed in 17?consecutive patients (9?females and 8?males) with a mean age of 31.1?years (range 11?C65?years). There were no local recurrences. Until now, 5?patients have died of tumor disease. One or more operative revisions were necessary in 53.9% of the patients. According to Kaplan?CMeier survival analysis, the implant survival at 5?years was 53.6% and 35.7% at 10?years, respectively. In 2?cases, a distal transfemoral amputation had to be performed due to deep infection. There were 3?cases of tibial stem revision due to implant failure and aseptic loosening, respectively. In 3?patients, the hinge of the prosthesis had to be revised. Impaired wound healing occurred in 2?cases. Peroneal nerve palsy was observed in 3?patients with recovery in only one. The mean Oxford knee score for 9?of the 12?living patients was 30.7?±?7.5 (24?C36). No patient had a clinically relevant extension lag. The mean range of motion at the last follow-up was 90.2°?±?26.7 (range 35?C130°). All patients were well satisfied with their postoperative outcomes.     

Gelenkerhaltende Hüftchirurgie im Erwachsenenalter

Deformity and malposition of the acetabulum can occur during the development of the hip. Developmental hip dysplasia and acetabular retroversion are possible causes of osteoarthritis in the young adult. Surgical management with reorientation of the acetabulum allows causal therapy of the deformity and preservation of the native hip joint. Established techniques are the Bernese periacetabular osteotomy (PAO) and the T?nnis and Kalchschmidt triple osteotomy of the pelvis. Both techniques permit three-dimensional correction of the position of the acetabulum. Advantages and disadvantages of each technique must be considered and are summarized in the present paper. If performed early (osteoarthritis grade T?nnis 0 and 1) with correct indication and proper technique, good results can be expected.     

Arthrodese nach Knietotalendoprothetik am Beispiel der septischen Lockerung

Up to 100,000 total knee arthroplasties are performed annually in Germany resulting in an increasing number of revision operations. Different underlying causes might preclude the reimplantation of an endoprosthesis, and knee arthrodesis represents the alternative of first choice to above-knee amputation. The most common indications for arthrodesis are the infected knee arthroplasty with defects of the extensor mechanism, soft tissue and bone defects, and persisting infection. Several procedures of arthrodesis have been introduced and should be well adapted to the individual situation of the patient. The results – especially related to quality of life – are encouraging and should facilitate the demanding decision if a total joint reimplantation is not reasonable.     

Extracorporeal Shock Wave Therapy for Chronic Painful Heel Syndrome: A Prospective, Double Blind, Randomized Trial Assessing the Efficacy of a New Electromagnetic Shock Wave Device

Published data describing the efficacy of extracorporeal shock wave therapy for the treatment of plantar heel pain provide conflicting results, and optimal treatment guidelines are yet to be determined. To assess the efficacy and safety of extracorporeal shockwave therapy compared with placebo in the treatment of chronic painful heel syndrome with a new electromagnetic device, we undertook a prospective, double-blind, randomized, placebo-controlled trial conducted among 40 participants who were randomly allocated to either active, focused extracorporeal shockwave therapy (0.25 mJ/mm(2)) or sham shockwave therapy. Both groups received 3 applications of 2000 shockwave impulses, each session 1 week apart. The primary outcome was the change in composite heel pain (morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter) as quantified using a visual analog pain scale at 12 weeks after completion of the interventions compared with baseline. Secondary endpoints included changes in morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter, as measured on a visual analog pain scale, as well as the change in the Roles and Maudsley score, at 12 weeks after the baseline measurement. Active extracorporeal shockwave therapy resulted in a 73.2% reduction in composite heel pain, and this was a 32.7% greater reduction than that achieved with placebo. The difference was not statistically significant (1-tailed Wilcoxon Mann-Whitney U test, P =.0302), but reached clinical relevance (Mann-Whitney effect size = 0.6737). In regard to the secondary outcomes, active extracorporeal shockwave therapy displayed relative superiority in comparison with the sham intervention. No relevant adverse events occurred in either intervention group. The results of the present study support the use of electromagnetically generated extracorporeal shockwave therapy for the treatment of refractory plantar heel pain.     

If-Then Plans Benefit Delay of Gratification Performance in Children With and Without ADHD

Children with impulse control deficits (i.e., children with ADHD) are known to have special problems with delaying gratifications. As making if-then plans (i.e., forming implementation intentions) has been found to benefit self-control even in individuals whose action control is chronically hampered (e.g., critical samples such as patients with frontal lobe damage, the elderly), we analyzed whether delay of gratification is facilitated in children with and without ADHD who have formed respective implementation intentions. In Study 1, forty-five inpatient children with ADHD (M _age = 10.7 years) increased delay of gratification performance after having formed respective implementation intentions. Study 2 replicated this finding in an outpatient sample of children with ADHD (n = 47, M _age = 10.3 years) and also in a comparison group of children without ADHD (n = 40, M _age = 11.3 years). Results are discussed with respect to their implications for action control in children with ADHD as well as research on implementation intentions and delay of gratification.     

Surgical hematoma evacuation of cortical intracerebral hemorrhage ≥10 ml reduces risk of subsequent epilepsy by more than 70%: A retrospective monocenter study

Aim

The aim of this study was to re-evaluate risk factors for post-ICH epilepsy (PICHE) and examine the impact of surgical hematoma evacuation on epilepsy development after ICH.

Background and purpose

Epilepsy is a common complication after intracerebral hemorrhage (ICH). Information on risk factors is still scarce and the role of ICH evacuation remains uncertain.

Methods

We retrospectively included patients with spontaneous ICH treated in our hospital in 2006–2019. Patients' medical records were analyzed. In addition, mailed questionnaires and telephone interviews were used to complete the dataset. Uni- and multivariable hazard ratios (HRs) were applied to investigate risk factors for PICHE and the impact of surgical ICH evacuation.

Results

Among 587 ICH patients available for analyses, 139 (23.7%) developed PICHE (mean follow-up 1795 ± 1378 days). The median time of epilepsy onset was 7 months after ICH (range 1–132 months). Risk factors associated with PICHE were cortical hemorrhage (multivariable HR 1.65 [95% CI 1.14–2.37]; p = 0.008), ICH volume > 10 ml (multivariable HR 1.91 [95% CI 1.33–2.73]; p < 0.001) and acute symptomatic seizures (multivariable HR 1.81 [95% CI 1.20–2.75]; p = 0.005). Patients with cortical ICH > 10 ml who underwent surgical hematoma evacuation were less likely to develop epilepsy than those with conservative treatment alone (multivariable HR 0.26 [95% CI 0.08–0.84]; p = 0.025).

Conclusions

Post-ICH epilepsy is frequent and predicted by large cortical ICH and acute symptomatic seizures. Hematoma evacuation reduced the risk of PICHE by more than 70% in patients with large cortical ICH. This finding could be considered in the clinical decision making on the acute treatment of ICH.     

Treatment of infected total knee arthroplasty. When does implant salvage make sense?

Infection of a total knee arthroplasty can be classified as acute, chronic and haematogenic with and without implant loosening. A differentiated treatment concept for all types of infection is necessary. Furthermore, specific treatment has to be initiated early, as any delay is associated with a worsening of the prognosis. Treatment of infection with implant salvage may be one therapeutic option if the implant is not loose. According to the current literature, therapy with retention of the prosthesis may be promising: (1) in the case of early infection (<3 weeks of ongoing symptoms), (2) with unconstrained implants, (3) in the case of infection with a single organism that is susceptible to antibiotic therapy, (4) if soft tissue coverage is not affected, and (5) if the immune system is not compromised. Chronic infections, (semi-)constrained implants and soft tissue defects have to be considered as contraindications and implants should be removed. Early and consequent therapy with operative débridement and specific long-term antibiotic therapy are necessary to achieve implant salvage. The additional application of antibiotics addressing bacterial biofilms have helped to improve the prognosis. Due to the fact that revision arthroplasty is often associated with limited function after infection of the total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.     

Limited fibrinogenolysis in stored whole blood and in fresh frozen plasma

Measurement of the F-CB3 related antigen of the fibrinogen alpha-chain shows a time dependent increase of fibrino(geno)lysis in whole blood during storage from 70.7 +/- 16.4 pmol/ml (day 2) to 356.3 +/- 110 pmol/ml (day 39). Simultaneously PMN-elastase increases from 95 +/- 44 micrograms/l (day 2) to 3492 +/- 954 micrograms/l (day 39). The significant correlation between PMN-elastase and F-CB3 values (n = 180, r = 0.73, p less than 0.001) may reflect a relationship between the liberation of granulocyte enzymes and the extent of fibrino(geno)lysis. The isolation and separation of fibrinogen material on SDS-PAGE indicates a limited degradation of the parent fibrinogen molecule (340 kD). During storage the fraction of slightly degraded fibrinogen (300 kD) and pre-X fragment (280 kD) increases. The separation of the reduced fibrinogen material demonstrates that the limited fibrinogenolysis mainly took place in the A alpha-chain. Additional studies on fresh frozen plasma show that PMN-elastase values (98.6 +/- 41.8 micrograms/l), F-CB3 values (84.8 +/- 31.2 pmol/ml) and the SDS-PAGE pattern of the fibrinogen material are similar to the results in whole blood stored for two days.