Periarticular injections with continuous perfusion of local anaesthetics provide better pain relief and better function compared to femoral and sciatic blocks after TKA: a randomized clinical trial.

PURPOSE: Combined femoral and sciatic nerve blocks for post-operative pain management following total knee arthroplasty (TKA) improve patient satisfaction, decrease narcotic consumption and improve pain. However, accompanying motoric weakness can cause falls and related complications. We wonder whether peri-capsular injections in combination with intra-articular perfusion of local anaesthetics would result in equal or less pain without the related complications of nerve blocks. The objective of the study was to verify these aspects in a prospective randomized trial comparing both treatments. METHODS: Fifty TKA patients randomly received either a femoral (continuous) and a sciatic (single-shot) nerve block (CFNB group, 25 knees) or periarticular infiltrations and a continuous post-operative intra-articular infusion (PIAC group, 25 knees). VAS for pain, pain medication consumption, functional assessment, straight leg raising as well as KSS were recorded post-operatively for 6 days. RESULTS: VAS (p < 0.001) and KSS (p = 0.05) were significantly better for PIAC. There was increased pain following CFNB compared to PIAC. Catheters stayed for 4 days, a pain 'rebound' occurred after removing in CFNB but not after PIAC. There was no difference in regard to knee function (n.s.), but straight leg raising was significant better following PIAC. There were two falls in patients with CFNB. CONCLUSION: Peri-capsular injections combined with an intra-articular catheter provide better pain control, no rebound pain with better function and might decrease the risk of complications related to motor weakness. LEVEL OF EVIDENCE: I.

Femoral rotation in total knee arthroplasty: a comparison of patient individualized jigs with gap balancing in relation to anatomic landmarks.

PURPOSE: The purpose of our study was to compare the accuracy of the rotational position of the femoral component in total knee arthroplasty aligned with patient individualized jigs (PSJ) to a gap balancing technique (GBT). METHODS: A consecutive series of 21 osteoarthritic patients were treated with 22 cruciate-retaining total knee prostheses. During surgery, the rotation of the femoral component pinholes was recorded for all knees using PSJ and GBT and transferred to computer tomograms (CT). The rotational differences between PSJ and GBT relative to the transepicondylar axis were analysed. RESULTS: The medium rotation of the femoral component pinholes was 1.3° ± 5.1° (min = -6.3°; max = 14.4°) for PSJ and 0.1 ± 1.4° (min = -1.6°; max = 3.4°) for GBT. Outliers of more than 3° were found more frequently with PSJ in 12 cases but only in one for GBT. CONCLUSION: Based on our study, we would not recommend relying intra-operatively solely on the CT-based PSJ without the option to adjust or control femoral rotation. LEVEL OF EVIDENCE: II.

No difference in accuracy between pinless and conventional computer-assisted surgery in total knee arthroplasty.

PURPOSE: Many studies have demonstrated higher precision and better radiological results in Total knee arthroplasty (TKA) with computer-assisted surgery (CAS). On the other hand, studies revealed a lengthening of operation time up to 20 min for this technique and demonstrated rare additional complications as fractures and neurovascular injuries caused by the array pins and any intraoperative array dislocation leads to abortion of CAS. To combine the advantages and eliminate the disadvantages of standard CAS, we evaluated the accuracy of a so-called pinless CT-free version of knee navigation (pinless CAS) abandoning the reference pins and reducing the necessary workflow to a minimum. METHOD: The present study compares the accuracy of the reference methods of two different CT-free knee navigation software versions (Brainlab Knee 2.1 and Brainlab Knee Express 2.5). Thirty patients received TKA assisted by standard CAS. Intraoperatively, the proposed bony resections of standard CAS were matched with the new pinless CAS. Postoperatively, the results were checked by evaluating the radiographs concerning leg axis, femoral flexion and tibial slope. RESULTS: All results concerning precise cuts (femoral as well as tibial coronal/varus-valgus alignment, femoral flexion alignment and tibial slope, resection height) were comparable between both groups (n.s.). In femoral, we found a mean deviation of coronal alignment of 0.3° (SD 0.7) and flexion of 0.2° (SD 0.8). In tibial, we found a mean deviation of coronal alignment of 0.2° (SD 0.5) and slope of 0.2° (SD 0.6). The mean additional operation time for the pinless CAS was below 2 min. The postoperative mechanical leg axis was within the threshold of 3° in all patients, tibial slope and femoral flexion matched with CAS values. CONCLUSION: In clinical routine, pinless CAS can comprise the advantages of CAS leaving the disadvantages aside. It reduces surgical time and avoids complications associated with the tracking pins of conventional CAS.

Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis.

BACKGROUND: Patient-related outcomes have become the focus of increased attention when assessing knee arthroplasty. METHODS: We retrieved questionnaires from 485 (584 knees) patients at a minimum of 3years after undergoing primary knee arthroplasty. We excluded bilateral knee arthroplasty, leaving 141 UKA and 245 TKA who rated their satisfaction and expectation regarding pain, range of motion (ROM), daily living function (DLF), return to recreational activity (RRA) and ability to kneel (ATK) on a scale of 0 (worst) to 10 (best). We further collected data on pain level and the modified Cincinnati rating scale. Range of motion was documented pre- and postoperatively at a minimum of six months. The cohort was subdivided into three age groups and compared with each other (Group 1: <55, n=113; Group 2: 55-64, n=117; Group 3: 65+, n=155). RESULTS: Average satisfaction with pain, ROM and ATK for patients under 55 was higher for UKA than for TKA. Patients>65 with TKA were on average more satisfied than patients with UKA in these three items. However, patients under 55 with UKA were up to 2.9 times more likely to have their expectations met when compared to patients receiving TKA. Patients with UKA under 55 rated their joint as good/excellent in 96.0% versus patients in the same age group with TKA in 81.0%. CONCLUSIONS: We found that overall, younger patients who were treated with UKA demonstrated higher satisfaction scores in most subsets when compared with the patients of the same age group who received TKA.

Basic symptoms and their contribution to the differential typology of acute schizophrenic and schizoaffective disorders.

One hundred and fifty male inpatients - 128 patients with DSM-IV schizophrenia and 22 patients with DSM-IV schizoaffective disorder - were investigated, over the course of their acute psychosis, on whether there were differences in the extent of basic symptoms (measured by the Bonn Scale for the Assessment of Basic Symptoms) according to their diagnostic subtype. Another aim was to find out if the diagnostic subtypes could be discriminated by means of basic symptoms and if clusters gained from basic symptoms were in accordance with the diagnostic subtypes. Differences in basic symptoms were found between the subtypes, but a clear discrimination of diagnostic subtypes by means of basic symptoms could not be achieved. There was indication that patients with prominent delusions or auditory hallucinations reported more basic symptoms than patients with exclusively prominent disorganization.

[Short-term results of interposition arthroplasty with autologous femur head graft combined with cement-free threaded cups for treatment of dysplastic coxarthrosis]. / Kurzfristige Ergebnisse der Interpositionsarthroplastik mittels autologem Femurkopfresektat in Kombination mit zementfreien Schraubpfannen zur Behandlung der Dysplasiecoxarthrose.

INTRODUCTION: The operative treatment of arthritis in congenital dysplastic hips (CDH) with an autologous femoral head graft is a well established technique in total joint arthroplasty. This prospective study introduces a new operative technique in which the fixation of the autologous bone graft is achieved through the threaded Zweymueller cup solely. Early results are presented. METHOD: 34 patients, (average age of 53.2 years, 24 to 74 years) with CDH had a total joint arthroplasty in combination with a femoral head autograft between 1995 and 1997 (32 patients in study). The fixation of the bone graft was achieved with screws or with a press-fit technique through the threaded cup. The results are described with an average of 2 years. RESULTS: The patients were followed prospectively for an average of 2 years. The Harris hip score increased from 32 preoperatively (range 14-61) to 82 (range 54 to 91) postoperatively. 30 hips had excellent and good results, one satisfactory and one had an unsatisfactory result. Radiographic evaluation demonstrated no osteolysis, one radiolucency was seen in Zone III of the acetabulum and heterotopic bone formation was observed in 11 of 31 radiographically evaluated hips (Brooker type I: 7, type II: 3 and type III: 1). All bone grafts achieved union, all grafts survived, and all acetabular components survived, but one. There were no complications such as dislocation, infection, nerve palsy, or a thrombo-embolic event observed. CONCLUSION: Fixation of the femoral head autograft in CDH with a threaded cup solely showed no disadvantages over the established fixation technique with screws over a short-term follow-up. A solid stable fixation of the graft with a threaded Zweymueller cup was achieved and resulted in full graft integration without the use of screws.

X-ray crystallographic determination of the structure of the influenza C virus haemagglutinin-esterase-fusion glycoprotein.

The structure of the haemagglutinin-esterase-fusion (HEF) glycoprotein from influenza C virus has been determined to 3.2 A resolution by X-ray crystallography. A synthetic mercury-containing esterase inhibitor and receptor analogue, 9-acetamidosialic acid alpha-thiomethylmercuryglycoside, was designed as the single isomorphous heavy-atom derivative. The asymmetric unit of one crystal form (form I; P4322, a = b = 155.4, c = 414.4 A) contained an HEF trimer. Six mercury sites identifying the three haemagglutination and three esterase sites were located by difference Patterson map analysis of a 6.5 A resolution derivative data set. These positions defined the molecular threefold-symmetry axis of the HEF trimer. A molecular envelope was defined by averaging a 7.0 A resolution electron-density map, phased by single isomorphous replacement (SIR), about the non-crystallographic threefold-symmetry axis. Iterative non-crystallographic symmetry averaging in real space, solvent flattening and histogram matching were used to extend the phases to 3.5 A resolution. Molecular replacement of the model into a second crystal form (form II; P43212, a = b = 217.4, c = 421.4 A) containing two HEF trimers per asymmetric unit permitted iterative ninefold averaging of the electron density. The 3.5 A electron-density map allowed an unambiguous tracing of the polypeptide chain and identification of N-linked carbohydrates. The model has been refined by least squares to 3.2 A resolution (Rfree = 26.7%).

Structure of the haemagglutinin-esterase-fusion glycoprotein of influenza C virus.

The spike glycoproteins of the lipid-enveloped orthomyxoviruses and paramyxoviruses have three functions: to recognize the receptor on the cell surface, to mediate viral fusion with the cell membrane, and to destroy the receptor. In influenza C virus, a single glycoprotein, the haemagglutinin-esterase-fusion (HEF) protein, possesses all three functions. In influenza A and B, the first two activities are mediated by haemagglutinin and the third by a second glycoprotein, neuraminidase. Here we report the crystal structure of the HEF envelope glycoprotein of influenza C virus. We have identified the receptor-binding site and the receptor-destroying enzyme (9-O-acetylesterase) sites, by using receptor analogues. The receptor-binding domain is structurally similar to the sialic acid-binding domain of influenza A haemagglutinin, but binds 9-O-acetylsialic acid. The esterase domain has a structure similar to the esterase from Streptomyces scabies and a brain acetylhydrolase. The receptor domain is inserted into a surface loop of the esterase domain and the esterase domain is inserted into a surface loop of the stem. The stem domain is similar to that of influenza A haemagglutinin, except that the triple-stranded, alpha-helical bundle diverges at both of its ends, and the amino terminus of HEF2, the fusion peptide, is partially exposed. The segregation of HEF's three functions into structurally distinct domains suggests that the entire stem region, including sequences at the amino and carboxy termini of HEF1 which precede the post-translational cleavage site between HEF1 and HEF2, forms an independent fusion domain which is probably derived from an ancestral membrane fusion protein.

Synthesis and inhibitory properties of a thiomethylmercuric sialic acid with application to the X-ray structure determination of 9-O-acetylsialic acid esterase from influenza C virus.

2-alpha-Thiomethylmercuryl 9-acetamido-9-deoxy-sialoside was prepared and found to inhibit the 9-O-acetylsialic acid esterase from influenza C virus in a competitive manner with a Ki of 4.2 +/- 0.5 mM. The inhibitor is being used in the X-ray determination of the crystal structure of the esterase.

First lumbrical latency and amplitude. Control values and findings in carpal tunnel syndrome.

It has been suggested that the nerve fibers to the first and second lumbrical muscles are relatively spared in patients with carpal tunnel syndrome compared with the fibers to the abductor pollicis brevis. Latencies and amplitudes of the first lumbrical and the abductor pollicis brevis (APB) muscles were compared with both wrist stimulation and midpalmar stimulation. The lumbrical latency at 12 cm and the APB at 8 cm were found to be similar at less than 4.3 ms. Amplitudes to the lumbrical were 0.6-8 mV compared with 4-13.6 mV for the APB. Three patients who had an abnormal sensory study, yet normal motor values to the APB, were found to have abnormal lumbrical latencies. This is an additional technique that could be useful for individuals suspected of carpal tunnel syndrome who have normal latencies and amplitudes to the APB.

[The piriformis syndrome]. / Das Piriformis-Syndrom.

A rare mentioned and therefore and often overlooked cause of low back pain with sciatica. The piriformis muscle arises from the anterior surface of the sacrum and inserts on the superior border of the greater trochanter. Functionally, the piriformis muscle is an external rotator and abductor of the thigh. Muscle spasm or on inflammatory process set into motion by the spasm cause an epineurial irritation of the sciatic nerve. The symptoms present almost identically to lumbar disk syndrome, except for the consistent absence of true neurologic findings. Diagnosis is accomplished by rectal palpation of myofascial trigger points within the piriformis muscle, also pain and weakness on resistant abduction-external rotation of the thigh. The essential therapy is the injection of local anesthetic and a small dose of corticoid into the precise focal point of hyperirritability deep in the belly of the muscle. Recurrences are uncommon.