Transarterial embolization for the management of hemarthrosis of the knee.

BACKGROUND: The purpose of this retrospective study was to evaluate transarterial catheter embolization (TAE) for the management of hemarthrosis of the knee in 35 patients treated at two different hospitals. METHODS: From June 1998 through January 2011, 35 patients (22 men and 13 women, mean age 57 years) underwent TAE for hemarthrosis of the knee using polyvinyl alcohol particles (PVA particles), multi-curled 0.018 in. microcoils or a combination of both. In one patient a detachable microcoil was used. Hemarthrosis developed after arthroscopy in 9, after trauma in 3, after arthroplasty in 18 and after sepsis in 2 patients. 2 patients had severe gonarthrosis and in one patient hemarthrosis was due to Marfan's syndrome. Angiographies showed abnormal and increased vasculature in 23 patients, one or more pseudoaneurysms in 8 and arterio-venous fistula in 2 patients. One patient showed both, pseudoaneurysm and hypervascularization and another one pseudoaneurysm and arterio-venous fistula. RESULTS: Technical success was achieved in 100%. None of the patients developed procedure-related complications such as periarticular skin- or tissue necrosis, including a patient who underwent TAE of two different bleeding sources in two consecutive sessions. Clinical success was 93.4%. Two patients showed recurrent swelling of the knee, 377 and 824 days after TAE respectively. However, only one of them required secondary TAE because of abnormal and increased vasculature. CONCLUSIONS: In our view, TAE is the treatment of choice for the management of hemarthrosis of the knee. It is an effective and minimally invasive technique with very low complication rates.

[Dorsolateral dislocation of the proximal interphalangeal joint: closed reduction and early active motion versus static splinting]. / Dorsolaterale Dislokation des proximalen Interphalangealgelenkes: Geschlossene Reposition und frühe aktive Mobilisation oder Gipsruhigstellung.

In this follow-up examination, the outcome of two conservative treatment regimens (immobilisation versus early active motion) were evaluated in 50 patients with dorsolateral dislocation of the proximal interphalangeal joint after a mean follow-up time of 7.9 years. The aim of this study was to prove whether early mobilisation results in better clinical outcome compared to prolonged immobilisation. In group A, 25 patients were treated by static splinting in a cast for four weeks. At follow-up, 21 patients were free of pain, three patients complained of pain following maximum loading and one patient experienced permanent pain. The mean range of motion was 89.4 degrees, the mean lack of extension was 12.7 degrees and the mean joint circumference was 3.4 mm thicker than the uninjured side. Pinch power was reduced to 78 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in five patients. In group B, 25 patients were treated by dorsal block splinting of the interphalangeal joint. The patients were allowed to extend their finger and to perform daily active exercises of the injured joint. At follow-up, eighteen patients were pain free, five experienced pain after maximum loading and two patients complained of permanent pain. The mean range of motion was 96.6 degrees, the mean limitation of extension was 5.3 degrees and the mean joint circumference was 4.1 mm thicker than on the uninjured side. Pinch power was reduced to 85 % of the uninjured side. All joints were clinically stable. Degenerative arthritis was seen in six patients. Early active motion following dorsolateral dislocation of the proximal interphalangeal joint leads to significantly superior results regarding the active range of motion and pinch power.

Interleukin-1 and tumor necrosis factor alpha inhibit repair of the porcine meniscus in vitro.

OBJECTIVE: Injury or removal of the knee meniscus leads to progressive joint degeneration, and current surgical therapies for meniscal tears seek to maximally preserve meniscal structure and function. However, the factors that influence intrinsic repair of the meniscus are not well understood. The goal of this study was to investigate the capacity of meniscus tissue to repair a simulated defect in vitro and to examine the effect of pro-inflammatory cytokines on this process. METHODS: Cylindrical explants were harvested from the outer one-third of medial porcine menisci. To simulate a full-thickness defect, a central core was removed and reinserted immediately into the defect. Explants were cultured for 2, 4, or 6 weeks in serum-containing media in the presence or absence of interleukin-1 (IL-1) or tumor necrosis factor alpha (TNF-alpha), and meniscal repair was investigated using mechanical testing and fluorescence confocal microscopy. RESULTS: Meniscal lesions in untreated samples showed a significant capacity for intrinsic repair in vitro, with increasing cell accumulation and repair strength over time in culture. In the presence of IL-1 or TNF-alpha, no repair was observed despite the presence of abundant viable cells. CONCLUSIONS: This study demonstrates that the meniscus exhibits an intrinsic repair response in vitro. However, the presence of pro-inflammatory cytokines completely inhibited repair. These findings suggest that increased levels of pro-inflammatory cytokines post-injury or under arthritic conditions may inhibit meniscal repair. Therefore, inhibition of these cytokines may provide a means of accelerating repair of damaged or injured menisci in vivo.

[Intermittent compression devices for swelling reduction and thrombosis prophylaxis--a pilot study after total hip replacement. Is the 2 hour daily minimum application sufficient?]. / Die intermittierende Impulskompression zur Abschwellung und Thromboseprophylaxe--Pilotstudie nach Hüft-TEP. Ist die Minimalanwendungsdauer von 2 h täglich ausreichend?

BACKGROUND: The use of intermittent compression devices for thrombosis prophylaxis and the reduction of postoperative swelling are widely accepted. The recommended minimum application of 2 h daily has never been statistically verified. Without evidence based data, the benefit of this costly equipment cannot be maximized. PATIENTS AND METHODS: A randomized clinical trial on 41 patients after total hip replacement was performed. The A-V Impulse System was applied for 2 h a day during the first 5 postoperative days to observe whether this time was sufficiently effective. RESULTS: In the control group, two deep vein thromboses occurred postoperatively, but there were none in the treatment group. Even though two patients from the treatment group had to be excluded from the study because of severe pain, all other parameters including visual analogue pain scale results and limb circumferences were comparable in both groups. CONCLUSION: These preliminary results suggest that pump systems can prevent deep venous thrombosis after hip surgery even when applied for only short intervals over a short period of time. However, large scale confirmatory studies are needed.

Migration of two different cementless hip arthroplasty stems in combination with two different heads: a biomechanical in vitro study.

The aim of the present in vitro study was to evaluate migrational characteristics of cementless primary hip arthroplasty stems in combination with a diameter 50 mm head (hemiarthroplasty) and a diameter 28 mm head in and with a polyethylene cup (total hip arthroplasty) in fresh-frozen human specimens. Two different types (Endo SL, FMT) were implanted into seven pairs of fresh-frozen human femoral specimens. The implanted stems were combined with a diameter 50 mm head (hemiarthroplasty) on one side and with a polyethylene cup and a 28 mm head (total hip arthroplasty) on the other side. Dynamic mechanical loading was applied for 50,000 cycles while recording relative motions between stem and bone stock using a 3-D motion analysis system. The Endo SL stem showed a significantly higher amplitude of relative motion in all translational and rotational components regardless of the head used. In both stem types a strong tendency for higher axial migration with the diameter 50 mm head in comparison to the THA head was found. The lowest axial migration was found in the FMTstem in combination with the small head and a PE cup. The highest axial migration was found in the Endo SL stem combined with the diameter 50 mm head. Our results indicate that the head might play an important role for axial migration of cementless stems.

Lateral arm flap: analysis of its anatomy and modification using a vascularized fragment of the distal humerus.

Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged treatment with repeated interventions. Frequently, a free flap is applied as a first step and bone grafting is carried out in a second procedure. Ideally, these two procedures are combined in one operation, utilizing a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such an osteoseptocutaneous flap and has been utilized clinically with success; however, the vascular anatomy of the flap, especially the humeral fragment, has not been described in detail previously, and there is broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the humerus were also documented. The lateral arm flap has a consistent arterial supply from three septocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm. Knowledge of the consistent vascular anatomy of the lateral humerus and soft tissue of the donor site allows an osteoseptocutaneous flap to be raised safely with an appropriate technique. We recommend use of the lateral arm flap with a humeral fragment for the treatment of combined soft tissue and bone defects when a single step surgical solution is indicated.

Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints.

The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.