Monitoring of plasma levels of activated protein C using a clinically applicable oligonucleotide-based enzyme capture assay.

BACKGROUND: Human-activated protein C (APC) is a serine protease with anticoagulant, anti-inflammatory and cytoprotective functions. This feature renders APC to be a promising vascular-inflammatory biomarker. OBJECTIVE: The aim of the present study was the development and validation of a technique that allows the measurement of APC plasma levels under practical laboratory conditions. METHODS/PATIENTS: Based on the APC-binding ssDNA aptamer HS02-52G we developed an oligonucleotide-based enzyme capture assay (OECA) that quantifies aptamer-captured APC through hydrolysis rates of a fluorogenic peptide substrate. After optimization of pre-analytical conditions, plasma APC levels were measured in healthy individuals and patients undergoing hip replacement surgery. RESULTS AND CONCLUSION: A combination of APC-OECA with an aprotinin-based quenching strategy allowed APC analysis with a limit of detection as low as 0.022 ± 0.005 ng mL(-1) (0.39 ± 0.10 pmol L(-1)) and a limit of quantification of 0.116 ± 0.055 ng mL(-1) (2.06 ± 0.98 pmol L(-1)). While APC plasma levels in healthy individuals fell below the quantifiable range of the APC-OECA platform, levels substantially increased in patients undergoing hip replacement surgery reaching peak values of up to 12 ng mL(-1) (214 pmol L(-1)). When normalized to the amount of thrombin generated, interindividual variabilities in the APC generating capacity were observed. In general, with a turn-around time from blood sampling to generation of test results of < 7 h, the APC-OECA platform allows sensitive and rapid determination of circulating APC levels under pathological conditions.

[Homo erectus haemophilus - the haemophilic arthropathy of the leg]. / Homo erectus haemophilus. Die hämophile Arthropahtie der unteren Extremität.

The haemophilic arthropathy of the hip, the knee and the ankle makes a painful loss of the degree of movement. Especially the muscles which bend these joints are contracted. This means a loss of posture and quality of life as well. This article demonstrates the possibilities of the conservative and operative treatment and represents an algorithm of the indication of operative measurements. Finally, there is a report about the straighten up and the re-socialisation of a patient with haemophilia by total hip and knee arthroplasty.

[Conservative treatment in haemophilia - Improving effectivity and establishing standards]. / Konservative Hämophiliebehandlung unter Berücksichtigung der Optimierung und Standardisierung.

Rehabilitation and physical therapy in the sense of functional health is based on the international classification of function. It takes in two considerations: function and structure of the body and their influence on personal and social activity. The integrative concept of joint function translates the basic concept of body function and structure on to the motion of the locomotive system. Stability needs motoric control. Motoric control and the integrated neural components are to be influenced through regulation of muscle tonus (massage, manual therapy, medical training therapy, electrotherapy and thermotherapy). The stability of the joint is controlled by the passive components. Passive structures are optimised through passive therapies like joint mobilisation. Active components of joint function are optimised through activation (medical training therapy, stabilisation, mono or multisegmental levels). Emotional and neuronal components can be triggered through kinesthetic exercises like PNF, Jacobsen relaxation, biofeedback training, mental training. Exact examination of the locomotive system will help finding all symptoms. This is how we individualise the therapy of symptoms and structures. The motion pattern generator shows us how to use the possibilities of functional influence on the motion pattern. We have a lot of afferent signals that need individualised functional therapy. This is why we need functional measurements like motion analysis on the basis of ultrasound. An other tool is the kinetic superficial EMG measurement of muscle function. We can use it to determine the status of the joint and it will lead to therapeutical decisions. All functional measurements will help to improve quality control of the physical therapy process. Even if the haemophilic patient is healthy he is not fit at all. Measurements of fitness will help us to improve special skills and establish the human being as a subject in society and environment. The main skill to be improved in haemophiliacs is coordination, strength of the stomach muscles and the vastus medialis and the flexibility of the hamstrings.

[Algorithm for the treatment of the haemophilic arthropathia of the upper ankle joint]. / Behandlungsalgorithmus der hämophilen Arthropathie des oberen Sprunggelenkes.

The upper ankle joint is one of the target-joints of the haemophilic patient. Therefore, the secondary arthritis of the upper ankle joint is one of the most frequent forms of haemophilic arthropathy. It is a secondary form of arthritis not only because of chronic synovitis and cartilage injury resulting from chronic recurrent intraarticular bleeds, but also due to the misalignment of the joint and abnormal joint stress. The consequences are manifest even in young patients and finally lead to upper ankle joint arthritis. In such clinical situations, the upper ankle joint-arthroplasty is a viable alternative to arthrodesis. After several years of bleeding of the upper ankle joint many patients with haemophilia suffer from symptomatic arthritis. Open joint cleansing considerably improves mobility in the upper ankle joint and alleviates the pain in the talonavicular joint. However, the recovered mobility of the arthritic upper ankle joint also activates arthritis, associated with severe pain. With no contraindication to upper ankle joint replacement, a cement-free prosthesis can be implanted. Three months after surgery, the patients are mobile, with good foot rolling properties without orthopaedic aids and without pain in the upper joint ankle. Concludion: In terms of biomechanics the upper ankle joint-arthroplasty is a superior alternative to arthrodesis in haemophilia patients. In order to minimize the complication rate, their treatment should be restricted to specially equipped interdisciplinary centers with adequately trained and experienced surgeons as well as haemostaseologists.

[Haemophilia and knee function: are there differences between haemophilic and healthy children?]. / Hämophilie und Kniefunktion - Gibt es Unterschiede zwischen hämophilen und gesunden Kinder?

With early prophylactic treatment our haemophilic children grow up in good health. Nevertheless, we cannot prevent every bleeding. Those bleedings may be just subclinical but they could lead to overloading of the knee and more and more of the ankle joint in the long term. Motion analysis can help to understand this process and prevent it. A comparison of the gait function of haemophilic and healthy children of the age 3-18 years showed distinct functional differences especially in the youngest age group (3-6 years). Apparently, the coordination skill gait rhythm was significantly worse in the heamophilic group. All measured functional deficits can be treated with physiotherapy. Possible reasons for these early functional differences are overprotection and/or early subclinical bleedings.

[Upper ankle joint prostheses in haemophilia patients]. / OSG-Prothesen bei hämophilien Patienten.

UNLABELLED: Secondary arthrosis of the upper ankle joint (talocalcanean joint) is one of the most frequent forms of haemophilic arthropathy. It is a secondary form of arthrosis not only because of chronic synovitis and cartilage injury resulting from chronic recurrent intraarticular bleeds, but also due to the misalignment of the joint and abnormal joint stress. The consequences are manifest even in young patients and finally lead to subtalar joint ankylosis with the biomechanical disorder of foot drop (talipes equinus). In such clinical situations, implantation of a subtalar joint endoprosthesis is a viable alternative to arthrodesis. CASE REPORT: A man (age: 52 years), suffering from severe haemophilia A (residual FVIII activity < 1 %), no inhibitor formation. The patient has a history of several years of painful ankylosis of the right ankle joint and minor talipes equinus, and suffers from symptomatic talonavicular arthrosis. Open joint cleansing considerably improved mobility in the upper ankle joint and alleviated the pain in the talonavicular joint. However, the recovered mobility of the arthrotic upper ankle joint also activated the patient's arthrosis, associated with severe pain. As there was no contraindication to upper ankle joint replacement, a cement-free prosthesis was implanted. Three months after surgery, the patient was mobile, with good foot rolling properties without orthopedic aids, and without pain in his upper joint ankle. CONCLUSION: In terms of biomechanics an upper ankle joint endoprosthesis is a superior alternative to arthrodesis in haemophilia patients. In order to minimize the complication rate, the treatment of haemophilia patients should be restricted to specially equipped interdisciplinary treatment centers with adequately trained and experienced surgeons as well as haemostaseologists.

[Pseudo tumours in haemophilia patients]. / Pseudotumoren bei hämophilien Patienten.

UNLABELLED: Pseudo tumours are amongst the rare yet pathognomonic complications of haemophilia. They are old, encapsulated haematomas which due to their sometimes enormous size can cause massive complaints. These haematomas are surrounded by a thick fibrous capsule. They are attributed to persistent bleedings. The pathophysiology of pseudo tumors is not conclusively established yet. Some believe that they originate from bone material or the periosteum, while others suggest their development from soft tissue. They spread aggressively, displace the surrounding tissue, and cause secondary periosteal erosion of the bone. This results in bone resorption and destruction of surrounding muscular and soft tissue. Pseudo tumours develop slowly over many years. They occur primarily in adults and are largely unresponsive to conservative treatment. CASE: A 48-year-old man with moderate hemophiliaA (FVIII:C 2%) and no FVIII inhibitor. Due to recurrent bleeding into the muscle of the right thigh diagnosis of two pseudo tumours (psoas, adductor magnus). In 2004 tumour extirpation with subsequent relapse; because of high local bleeding tendency (despite permanent prophylaxis with FVIII concentrate and adjusted lifestyle) surgical revision in 02/2008. Postoperatively, no recurrent bleeding; the patient is fully fit for work three months later. CONCLUSION: In order to reduce the complication rate when a pseudo tumor is suspected, patients should be treated in a specially equipped interdisciplinary center with adequately trained and experienced surgeons and haemostaseologists.

[Intravertebral pressure during vertebroplasty - an in-vitro study]. / Intravertebrale Druckentwicklung bei der Vertebroplastie - Eine anatomische In-vitro-Untersuchung.

INTRODUCTION: Extravasation of bone cement into the vertebral venous system during cement injection has been reported to be a major complication of percutaneous vertebroplasty. Therefore, high injection pressures during cement application into the fractured vertebral body are considered as one possible cause of cement leakage or extravasation. The aim of the current study was to measure the increase in intravertebral pressure caused by cement injection during vertebroplasty compared to the baseline venous pressure for the ascending lumbar vene. MATERIAL AND METHODS: In context of a cadaver study of 19 unfixed lumbar cadaver spines (L2-L5) [9 female, 10 male, 72 +/- 4.1 years] 19 vertebroplasties have been performed under operative conditions through a transpedicular approach. A manometer was placed in the lateral corticalis of each vertebral body for dynamic pressure measurement during 4 cement application cycles. Average and maximal intravertebral pressures as well as the average intravertebral pressure over the time of cement application ["area under the curve" (AUC)] were calculated. RESULTS: Average intravertebral pressure (10.9 +/- 12.6 kPa [min.: - 15.2 +/- 24.7 kPa; max.: 56.1 +/- 70.1 kPa]) showed a 13.6-fold increase compared to the baseline venous pressure for the ascending lumbar vein and a 70-fold increase compared to maximal pressure. During the 4 cement application cycles a continuous increase of the average intravertebral pressure over the application cycle (AUC) occurred. CONCLUSION: The 13.6-fold increase in intravertebral body pressure caused by cement injection during percutaneous vertebroplasty in comparison to the baseline venous pressure for the ascending lumbar vein might be one possible cause of the high rate of extravasation of bone cement reported in the current literature.

[Muscular compartment syndrome of the forearm in a haemophilia inhibitor patient]. / Das muskuläre Kompartmentsyndrom am Unterarm bei Hemmkörperhämophilie.

UNLABELLED: Acute compartment syndrome is a complication in which microcirculation is impaired due to increased tissue pressure within a confined (osteo-fibrous) space and leads to neuromuscular dysfunction. A serious complication of haemophilia is the development of inhibitors. In this case the immune system produces antibodies to factor VIII or IX during substitution therapy of haemophilia A or B. These antibodies are directed against both, the substituted and the endogenous factors. CASE REPORT: A man (age: 81 years) with originally moderate haemophilia A who at the age of 63 developed an inhibitor during treatment of a bleeding event. Painful swelling in the left forearm occurred without any recollection of trauma, and failed to subside under factor substitution initially performed by the patient. This finding necessitated emergency fasciotomy of the forearm flexor compartment. CONCLUSION: In order to keep the complication rate as low as possible in the presence of hemophilia with inhibitors, the patients should only be treated in a specially equipped interdisciplinary treatment center.

[Backpain and haemophilia]. / Rückenschmerzen und Hämophilie.

A literature research for back pain in hemophilia (1990-2007) revealed only five papers! They all had lumbar or sciatic pain due to hematoma. All symptoms responded to factor VIII replacement. A similar research for a normal population showed hundreds of papers with a lifetime prevalence of 80% for back pain. A survey of 49 patient with hemophilia showed similar results. 70% had experienced back pain before. The reported pain of 40 to 70 on a visual analog scale was significant. 40% reported that the back pain would be more limiting than the pain associated with hemophilia. The hemophilic patient has learned to cope! The treatment of back pain will be of growing importance for hemophilia centers while the typical complaints of hemophilic symptoms will decrease due to better treatment protocols.

[Pelvic osseous infections: clinical outcome and surgical treatment]. / Die bakterielle und abakterielle Osteitis des Beckens: Manifestations- und Therapieformen.

BACKGROUND: Pelvic osteomyelitis is a bacterial infection of the pelvine skeleton. Apart from rare haematogen diffusion, it can occur after pelvic trauma or operation. Furthermore, it exists a sterile osteitis pubis after repetitive periostial microtrauma. Chronic progressions are possible. Further problems are fistulas and abscesses. With involvement of symphysis or iliosacral joint, the development of septic pelvine instability is possible. Due to the anatomic complexity of the pelvis, this affection can be neglected or underdiagnosed. METHODS: We have analysed septic pelvic operations performed during 1997 to 2006. We excluded septic affections of the hip joint after joint replacement. In 15 cases we found both radiological and microbiological signs of osseous inclusion in terms of pelvic osteomyelitis. RESULTS AND CONCLUSION: 15 patients were operated after preoperatively performed bacterial asservation and conventional X-ray, fistula scanning and pelvic CT scans. In 3 cases we placed drainages into abscess formations under CT-guidance. In 14 cases osseous infected areas existed in the pelvic skeleton and we performed a local bony resection. In 3 patients we performed removal of bacterially contaminated metal implants. In 3 cases an additional pelvic instability due to involvement of the symphysis was present. Here we resected the infected joint and performed an arthrodesis to reestablish the pelvic ring stability. Due to the localisation of the infected pelvic bone, different regimes of therapy are necessary. Iliac osteomyelitis can be treated by resection or sequestrectomy, pubic osteomyelitis or sterile osteitis can be treated similarly. Septic iliosacral joint infections as well as septic symphysis joint infections can be treated by resection and can lead to a pelvic ring instability. Simple revision surgery of fistula without removement of the fistula's origin will fail, as 9 of our patients had already had several fistula revisions without any signs of healing.

[Osteochondral marker proteins in the quantitative evaluation of matrix-based autologous chondrocyte transplantation CaRes]. / Osteochondrale Molekülmarker als quantitative Verlaufsparameter nach matrixgekoppelter autologer Chondrozytentransplantation CaRes.

PURPOSE: In this study we attempt to evaluate whether or not osteochondral markers of the synovial fluid can be helpful in defining objectively the repair process following matrix-based autologous chondrocyte implantation (ACI) CaReS (Cartilage Regeneration System). METHODS: As a part of a clinical prospective pilot study, synovial fluid of 19 patients was examined before, as well as 6, 12, 26, and 52 weeks after matrix-based ACI. A synovial fluid analysis was performed and markers of bone and cartilage metabolism were evaluated. Molecular markers routinely examined included MMP-1, MMP-3, MMP-13, TIMP, hCOMP, PICP und MIA. The levels were referenced to the total protein concentration of the synovial fluid and compared with clinical parameters (IKDC) and magnetic resonance imaging (MRI). RESULTS: With the exception of MMP3 all markers showed a drop of the concentration below preoperative levels at 6 weeks. All marker levels returned to below the preoperative concentration at 26 as well as 52 weeks after surgery. The MIA, MMP-3, PICP, hCOMP and TIMP levels showed significant changes over the period of 52 weeks (p<0.01). Statistically significant correlations between the marker levels and the clinical scores could only be observed at several times of assessment. CONCLUSIONS: Under consideration of missing correlations to clinical parameters (IKDC/MRI) non-specific osteochondral marker proteins of the synovial fluid cannot be used without further scrutiny to document changes in cartilage and osseous metabolism following matrix-supported ACI over the time of 52 weeks objectively. The drop of the concentrations below preoperative levels at 6 weeks can possibly be explained by the reduced traumatization of the joint with the CaRes procedure compared to the classic ACI. Specific markers for cartilage metabolism should be defined to permit a direct and objective comparison of the various conservative and operative methods presently available for the treatment of chondral lesions of the knee joint.

Rehabilitation of synovitis in patients with haemophilia.

Monitoring the synovium is a central requirement in haemophilia. In cases of acute synovitis, a sufficiently high dosage of coagulation factor should be used immediately, and pain control and anti-inflammatory treatment are essential. Severe effusion should be aspirated and persistent inflammation should be treated with steroid injections. In relation to physical therapy, cryotherapy with CO(2), and CP current after Bernhard should be used, if appropriate in combination with ultrasound and phonophoresis with Voltaren [Voltarol] Emulgel. Early functional treatment is essential following a short individually variable period of immobilization, with the aim of restoring flexibility, coordination and strength (closed chain). If the treatment is insufficient and chronic synovitis develops, consideration must be given after 2-3 month of early synovectomy, by chemical, radio-active, arthroscopic techniques, or by arthrotomy. The physical therapy following operations of this sort should be regarded as the same as for acute synovitis. The rehabilitation of synovitis is independent of co-infections.

[Flexion contracture in haemophilic knee arthropathy--10-year follow-up after hamstring release and dorsal capsulotomy]. / Flexionskontraktur bei hämophiler Kniearthropathie--10-Jahres-Follow-up nach Hamstring-Release und dorsaler Kapsulotomie.

INTRODUCTION: The aim of this study was to evaluate the long term results of joint preserving surgery with hamstring release and dorsal capsulotomy for the treatment of therapy resistant knee flexion contracture in patients with severe haemophilia. METHODS: 16 patients having undergone hamstring release and dorsal capsulotomy were prospectively observed and clinically evaluated over a period of at least 10 years. Follow-up was on average 16.6 (10-26) years. The average age at the time of surgery was 29.4 (15-40) years and at the last follow-up 43.0 (29-65) years. Clinical assessment of the patients was performed at least twice per year and outcome was evaluated by using the Score of the Orthopaedic Advisory Committee of the World Federation of Haemophilia (WFH). RESULTS: The preoperative extension deficit of 21.1+/-1.82 degrees (10-40 degrees) was improved to 16+/-3.6 degrees (5-30 degrees; p=0.54) at the last follow-up. In the first 4 years after surgery there was a noticeable and continuous improvement of the preoperative extension deficit. The clinical score improved from 7.6+/-0.4 preoperatively to 3.8+/-0.4 one year after surgery. 14 years after surgery a significant difference to preoperative values was no longer evident for the remaining 10 patients. The first 4 years after surgery average range of movement (ROM) improved, yet these differences were not statistically significant. Based on the clinical outcomes as described by Rodriguez-Merchan, last follow-up showed one patient with a good, 11 patients with a moderate and 4 patients with a poor postoperative result. The Petterson score showed a marked and significant deterioration from 7 (5-10) to 9 (7-12) points at final follow-up. DISCUSSION: The joint preserving method of hamstring release and dorsal capsulotomy for the treatment of therapy resistant knee flexion contracture in patients with severe hemophilia does not prevent the progression of haemophilic arthropathy. Despite this, improvement of the flexion contracture leads to a better joint function over a number of years postoperatively. Especially for the younger patient suffering from manifest haemarthropathic changes of the knee joint, this management option is a feasible alternative to at least postpone joint replacement.

[Nation-wide registration of limb deficiencies in Germany]. / Register zur bundesweiten Erfassung angeborener Gliedmassenfehlbildungen.

AIM: A detailed registration of the frequency and the aetiology of limb deficiencies has been established for the first time in Germany. METHOD: According to the ESPED model (Documentation of rare paediatric diseases in Germany) we send out at an interval of three months a questionnaire for registration of live births, still births and their limb deficiencies to 1 073 gynaecological hospitals. In case of a positive response for a limb deficiency a second questionnaire is sent for details about pregnancy, birth and family. The limb defects are registered according to the ICD-10 classification and statistically analysed. RESULTS: Current acquisition period: 48 months (April 2000-April 2004). Total number of registered births: 1 070 541. Number of live births with limb deficiencies: 1 534 (0.14 %). Number of still births with limb deficiencies: 55 (1.7 %). Minor limb deficiencies such as polydactyly (22.4 %) are more frequent than major deficiencies of the tibia (1.0 %) or of the fibula (1.6 %). A familiar disposition is found in 9.7 %. A correlation to the profession of parents or their age (mother: 29, father: 33), or nicotine abuse could not be detected. The numbers of special features during pregnancy (amniocentesis in 3.3 %, oligohydramnion in 0.5 %, polyhydramnion in 0.3 %, etc.) and during delivery (relation between normal delivery and caesarean section = 59.5 %/29 %, etc.) were similar to the frequencies in the normal population. CONCLUSIONS: Our register represents the largest study world-wide in respect to the birth rate and the most accurate record of limb deficiencies. In the current acquisition period no correlation of the registered limb deficiencies to environmental effects, individual misbehaviour, exposed professional group and peculiarities during pregnancy and parturition could be found. The continuation of our register is essential for further detection of the incidence and aetiology of limb defects.