Accuracy of digital templating of uncemented total hip arthroplasty at a certified arthroplasty center: a retrospective comparative study.

INTRODUCTION: To investigate the accuracy of preoperative digital templating for total hip arthroplasty (THA) at a certified arthroplasty center (EndoCert EPZmax). MATERIALS AND METHODS: In a retrospective study design, we analysed 620 uncemented primary THAs for templating accuracy by comparing the preoperatively planned THA component size and the implanted size as documented by the surgeon. Templating was determined to be a) exact if the planned and the implanted component were the same size and b) accurate if they were exact ± one size. Moreover, we investigated factors that potentially influence templating accuracy: overweight and obesity (WHO criteria), sex, implant design, surgeon experience, preoperative diagnosis. Digital templating was done with MediCAD software. The Mann-Whitney U test and the Kruskal-Wallis test were used for statistical analysis. RESULTS: Templating was exact in 52% of stems and 51% of cups and was accurate in 90% of the stems and 85% of the cups. Regarding the factors potentially influencing templating accuracy, the type of cup implant had a significant influence (p = 0.016). Moreover, greater accuracy of stem templating was achieved in female patients (p = 0.004). No such effect was determined for the other factors investigated. CONCLUSIONS: We conclude that preoperative 2D templating is accurate in 90% of the stems and 85% of the cups. Greater accuracy may be achieved in female patients. In addition to gender, the type of implant used may influence planning accuracy as well. Surgeon experience, BMI and preoperative diagnosis did not influence templating accuracy. LEVEL OF EVIDENCE: Level III (retrospective comparative study with prospective cohort).

Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial.

BACKGROUND: Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation. METHODS: A prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation. The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up. Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples. DISCUSSION: Although several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient's anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella. TRIAL REGISTRATION: The study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov .

Different wear in two highly cross-linked polyethylene liners in THA: wear analysis with EBRA.

INTRODUCTION: The purpose of this study was (1) to compare early wear rates in bedding-in periods of two highly cross-linked polyethylene liners frequently used in THA and (2) to evaluate risk factors indicating a possible higher wear rate. MATERIALS AND METHODS: 1120 patients who received a Crossfire or a Marathon highly cross-linked (HXLPE) ultra-high-molecular-weight polyethylene liner in primary THA at our Department between 2004 and 2018 were retrospectively reviewed. Patients with (1) only alumina heads on HXLPE acetabular bearings, (2) a minimum of four radiographs per patient for EBRA analysis, (3) no osteolysis around the acetabular cup and (4) no dislocations that occurred during the study period were included. RESULTS: A total of 328 patients (female: 183; male: 145; Marathon: 179; Crossfire: 149) fulfilled the inclusion criteria. Mean follow-up was 24 (range 7-51) months. With 0.22 (SD 0.27) mm mean total wear for the Marathon was three times greater than for the Crossfire, namely 0.07 (SD 0.14) mm. Mean cup migration during the investigated follow-up period was 0.7 (SD 0.8) mm for the Pinnacle and 0.5 mm (SD 0.7) for the Trident PSL cups. CONCLUSION: Initial early wear of highly cross-linked polyethylene in combination with alumina heads differs strongly between products. Long-term survivorship of these liners should be observed to determine whether early wear has an impact on aseptic loosening. LEVEL OF EVIDENCE: Level III (retrospective comparative study with prospective cohort).

[Wound treatment in diabetes patients and diabetic foot ulcers]. / Wundbehandlung bei Diabetes und diabetischem Fußulkus.

Diabetes mellitus (DM) is a paramount and rising medical challenge in both industrial and emerging nations. For Germany, 6.9 million out of 64.9 million insured persons in 2010 were reported to suffer from DM and approximately 5.8 million suffered from type 2 DM. The prevalence of diabetic foot ulcer (DFU) or diabetic foot syndrome (DFS) is 2-10% and the incidence is 2-6%. In addition, patients with DM present associated skin disorders with chronic wound healing, e.g., pyoderma gangrenosum or lecrobiosis lipoidica. Knowledge of the pathogenesis and skills for treatment of chronic wounds in diabetic patients are important for dermatologists. Patients with diabetes and wound healing disorders and accompanied unspecific skin disorders like eczema, cellulitis or contact dermatitis are often primarily or secondarily treated by dermatologists. In this article, practical hints for the treatment of DFS and other chronic wound in patients with DM are presented.

[Intervertebral cages from a biomechanical point of view]. / Intervertebrale Cages aus biomechanischer Sicht.

BACKGROUND: If lumbar interbody fusion is indicated, there are several options for instrumentation of the affected motion segment. Intervertebral cages are implanted in the disc to restore disc height and to stabilize the motion segment by tensioning the ligamentous structures. METHODS: Based on a selective literature search with the focus on biomechanical aspects of intervertebral cages, experimental and clinical studies are shown, interpreted, and discussed. RESULTS: In the literature, biomechanical flexibility tests of "stand alone" cages without supplemental instrumentation showed a limited stabilizing effect, particularly in extension and axial rotation, as well as an increased load transfer through the ventral column. Applying supplemental dorsal instrumentation can return the ventral/dorsal load sharing to the range of an intact motion segment and causes a marked increase of stability in all motion planes. Compared to bilateral dorsal instrumentation, unilateral dorsal instrumentation showed a reduced primary stability and leads to an asymmetrical loading of the cage which can cause unilateral loss of reduction. Nonmetallic cages with a stiffness adapted to bone allow better radiological evaluation of the bony fusion of the motion segment and theoretically have a reduced tendency to migrate. CONCLUSION: In combination with bilateral dorsal instrumentation, cage geometry and material have only a minor influence on primary stability and the main stability is provided by the internal fixator.

Intraperitoneal cholelithiasis after laparoscopic cholecystectomy--behavior of 'lost' concrements and their role in abscess formation.

UNLABELLED: In two experimental studies we sought preliminary information about the behavior of concrements lost in the peritoneal cavity during laparoscopic cholecystectomy. MATERIALS AND METHODS: In study 1, human gallstones were analyzed using X-ray diffraction, classified in three groups and examined with an ultramicroscope; then they were implanted in the peritoneal cavity of rats. After 8 weeks or 6 months, the animals were sacrificed and the concrements analyzed again as before. The tissues surrounding the calculi were also examined histologically. In study 2, human gallstones were examined with regard to bacterial contamination on the surface or in the middle of the calculi. The cholesterol content was analyzed, and the stones were divided into three groups and implantated in the rats as in the first study. After 8 weeks, the animals were sacrificed and areas with identifiable tissue reactions were examined histologically and microbiologically. RESULTS: The concrements lost their crystalline formation without any relation to their former cholesterol content, as shown by X-ray diffraction as well as ultramicroscopy. Mineralogically, these changes are a certain sign of structural dissolution. Cholesterol stones only caused abscess formations in association with gram-negative bowel germs. Sterile pigment concrements often led to a mesenchymal reaction such as granulomas. Contaminated pigment stones also resulted in extensive abscess formations.

Isradipine increases vascular prostaglandin I2-formation while the thromboxane B2-synthesis is diminished.

PGI2- and TXA2-synthesis from vascular tissue samples derived from cultured (endothelial and smooth muscle) cells, rabbit aorta and human bypass surgery were determined using specific radioimmunoassays for the stable derivatives (6-oxo-PGF1a and TXB2, respectively) of these compounds. Cultured cells were incubated in presence of isradipine, rabbits were pretreated for 4 weeks receiving 0.3 mg isradipine/kg*day, while patients were on isradipine (5-10 mg total dose/day, per os twice daily) since 6-19 weeks. In presence of isradipine, cultured cells produced significantly (p < 0.01) more 6-oxo-PGF1a and significantly less TXB2 (p < 0.05). 6-oxo-PGF1a-formation in rabbit aorta was significantly (p < 0.01) higher in isradipine treated normocholesterolemic animals while no significant changes were seen in isradipine treated hypercholesterolemic animals. TXB2 was significantly (p < 0.01) depressed in the abdominal and the thoracic aortic segment of isradipine treated hypercholesterolemic animals and was not significantly influenced in isradipine treated normocholesterolemic animals. Similarly, PGI2-synthesis in human arterial specimen was significantly (p < 0.01) enhanced as compared to the untreated controls. These findings indicate a beneficial behaviour of isradipine on vascular wall eicosanoid profile, which may contribute to a variety of antiatherosclerotic actions at the vascular wall level and to an improvement in hemostatic balance already described.

Arterial wall rather than platelets is responsible for diminished thrombogenicity during isradipine therapy.

We investigated whether the vessel wall or platelets are primarily responsible for the decreased thrombogenicity induced by the calcium channel blocker isradipine after endothelium removal. In a cross-perfusion model, rabbit aorta and iliac artery endothelium of receiver animals were removed by balloon catheter before being perfused with the blood of the blood donor rabbits. Donor and/or receiver animals were treated with 0.3 mg/kg isradipine intravenously (i.v.) daily for 1 week or with 10 mg acetylsalicylic acid (ASA) in addition. The other animals received vehicle only or ASA. The animals were divided into four groups (I-IV, total n = 24) consisting of four subgroups of 6 animals each. In all, 96 rabbits were examined. Immediately after the last administration of the respective drug, native blood from a donor rabbit was circulated (30 ml/min) through a deendothelialized segment of a receiver rabbit. The contract (C) and spread (S) platelets as well as the denuded surface covered with platelet aggregates (> 5 microns high) were quantified by morphometry. Deposition of [111In]oxine-labeled platelets was quantitatively determined per surface unit. In addition, prostaglandin I2 (PGI2) formation by the denuded aortic and iliac artery segment was determined. In group I, receiver rabbit pretreatment with isradipine exhibited decreased adhesion and aggregation of platelets, even when the donor rabbit was treated with solvent or ASA. In group II, concomitant treatment of donor animals with ASA and isradipine had no significant effect, whereas ASA isradipine treatment of receiver animals enhanced thrombogenicity.(ABSTRACT TRUNCATED AT 250 WORDS)

Isradipine decreases arterial thrombogenicity in rabbits. A morphometric and radioisotopic study.

The effect of isradipine, a calcium antagonist, on aortic and iliac wall thrombogenicity was examined in rabbits. After one week of dosing, the abdominal aortic and iliac artery endothelium was abraded using a Fogarthy catheter. One group of animals (n = 8) was dosed for one week with isradipine 0.3 mg/kg. A second group of animals received 10 mg acetylsalicylic acid (ASA)/kg daily in addition, while a third group received the vehicle only. Finally, a fourth group of animals (n = 8) was treated with ASA only. The percentage denuded surface covered with contact (unspread) platelets decreased significantly (p < 0.01) from 14.7 +/- 2.0 to 9.3 +/- 2.1 (6.2 +/- 0.8 to 3.7 +/- 0.4). The amount of contact and spread platelets was diminished from 84.9 +/- 5.6 to 71.4 +/- 4.4 (91.8 +/- 5.3 to 75.2 +/- 4.6). Platelet thrombi decreased from 7.4 +/- 0.9 to 4.6 +/- 1.4 (9.4 +/- 1.9 to 5.2 +/- 0.7) in the aortic and the iliac artery, respectively. In-platelet deposition decreased by 39.9 and 41.9%. Concomitant ASA therapy not only abolished the effect of isradipine but enhanced thrombogenicity, probably as a result of almost complete blockade of vascular PGI2-production.

Isradipine inhibits mitotic and proliferative activity in the arterial wall.

The anti-mitotic (3H-thymidine uptake quantified using autoradiography) and anti-proliferative (counting of activated smooth muscle cells on semithin sections) effects of the dihydropyridine calcium channel blocker isradipine (0.3 mg/kg) have been assessed in a rabbit arterial stress model. Isradipine caused a significant drop in both mitotic and proliferative activity. These effects were more pronounced by pretreatment (6 hours before lesion induction with desoxycorticosterone) with isradipine as compared to posttreatment (6 hours after experimental lesioning). The benefit induced by isradipine was abolished by aspirin treatment. In-vitro vascular prostacyclin formation and cholesterol content were not affected. These findings suggest that the anti-atherosclerotic action of isradipine on mitotic activity and cellular proliferation is mediated by a cyclooxygenase product, most likely via enhanced local vascular PGI2-synthesis.

[Laparoscopy-assisted reoperation after sigmoid resection and Hartman rectal occlusion]. / Die laparoskopisch assistierte Rückoperation nach Sigmaresektion und Rectumverschluss nach Hartmann.

The anastomosis between the descending colon an the rectal stump after sigma-resection and blind closure of the rectum according to Hartmann could be performed as well via an open laparotomy approach as via a laparoscopic procedure. By means of a first group of five laparoscopically reoperated patients the authors are demonstrating the good practicability of their laparoscopic method. Extended adhesions in the pelvic area could be detached in all cases. The advantages of this laparoscopic operation are obvious and in the authors opinion laparoscopic assisted reconnection between colon and rectal stump seems to be a serious alternative to open surgery by laparotomy.

13,14-Dihydro-prostaglandin E1 decreases low-density lipoprotein influx into rabbit aorta.

The effect of 4-week daily administration of 13,14-dihydro-prostaglandin E1 (13,14-DH-PGE1; 2 micrograms/kg) on LDL influx into the rabbit aortic wall was examined versus the effect of the same dose of PGE1 and sham-treatment in 108 male animals fed an 1% cholesterol supplemented diet. Treatment was started after de-endothelialization of the abdominal aorta with a Fogarty catheter. After the 1-month treatment period the animals were injected with 10 microCi 125I-low-density lipoprotein (LDL; 0.5 mg protein/ml). Uptake of the radiolabelled LDL was measured in morphologically verified endothelialized, re-endothelialized and de-endothelialized abdominal aortic segments. The LDL influx into the aorta was significantly (P less than 0.001) lower in 13,14-DH-PGE1- and PGE1-treated rabbits than in the controls. This reduction was most pronounced in re- and de-endothelialized segments. No significant difference between effect of PGE1 and of its biologically active derivative, 13,14-DH-PGE1, on arterial LDL entry was found. These data demonstrate a comparable beneficial effect of 13,14-DH-PGE1 and PGE1 on vascular wall lipid metabolism by decreasing LDL entry into the aortic wall in vivo.

The diminished extracellular matrix production induced by isradipine, a calcium channel blocker, is completely abolished by cyclooxygenase inhibition.

Collagen and glycosaminoglycan synthesis are well known to be enhanced during early atherogenesis. In this experimental study the synthesis of collagen was determined using 14C proline incorporation, the glycosaminoglycan production by means of 35S-sulphate incorporation and subsequent quantification by means of autoradiography. Isradipine, a new calcium channel blocker of the dihydropyridine family at a dose of 0.3 mg/kg significantly (p less than 0.01) decreased the incorporation of both the radioactive precursors. This effect was abolished by a concomitant aspirin treatment, while aspirin alone did not exert any significant effect on the precursor incorporation. These data suggest that isradipine, which is known to stimulate PGI2 synthesis, may exert this antiatherosclerotic inhibitory action on extracellular matrix production via the endogenous liberation of PGI2.

Aspirin abolishes the decreased low-density lipoprotein (LDL) entry into the rabbit arterial wall induced by the calcium channel blocker isradipine.

After deendothelialization and experimentally induced hypercholesterolemia in rabbits, an increased LDL entry into the vascular wall can be monitored using radiolabelled LDL. In male rabbits aged 6 months the abdominal aortic endothelium was removed by a Fogarty catheter. The animals fed a 1% cholesterol supplemented diet were treated either with isradipine (0.3 mg/kg/daily) (n = 36) alone or in combination with aspirin (5 mg/kg/daily) (n = 36) for four weeks. Thirty-six animals served as controls. 1, 3, 6, 12, 24 and 48 hours prior to sacrificing, 10 microCi 125I-LDL was administered intravenously to six rabbits in each group. The LDL entry was quantified in the abdominal aorta according to morphologically assessed type of surface lining. Aortic cholesterol content was assessed by Sudan-III staining and quantitative determination. Endothelialized segments exhibited a significantly (p less than 0.05 - p less than 0.001) lower LDL uptake as compared to re- or deendothelialized segments. The LDL entry was significantly lower with isradipine treatment than in controls. In parallel the cholesterol content decreased and the Sudan-III-positive areas were smaller in size. This beneficial effect as well as that on aortic lipid content was abolished by a pretreatment with aspirin. While in the isradipine-treated animals PGI2 synthesis was significantly (p less than 0.01) enhanced, it was almost completely blocked by aspirin. These findings indicate that the benefit of reduced LDL entry caused by isradipine may be mediated by an increased endogenous PGI2 synthesis.

Concomitant aspirin treatment abolishes the antiatherosclerotic effects of the calcium channel blocker isradipine mediated by PGI2.

108 male rabbits, aged 6 months, with experimental hypercholesterolemia and experimental abdominal aortic lesioning received different regimen of antiatherosclerotic treatment; 36 of them were treated with isradipine, a dihydropyridine calcium antagonist (0.3 mg/kg/daily), 36 with isradipine in combination with aspirin whereas 36 animals received placebo. The entry of 125I-radiolabelled LDL into the aorta was demonstrated to be significantly diminished in isradipine-treated rabbits as well as positive Sudan-III-staining and aortic cholesterol content were in comparison to placebo. This benefit was almost completely abolished by concomitant aspirin-treatment. The notable increase in vascular prostacyclin (PGI2) is supposed to mediate the strong antiatherosclerotic effect of isradipine resulting in an inhibition of LDL-entry and vascular cholesterol accumulation. Aspirin almost totally blocked the raise in PGI2-synthesis by the inhibition of cyclooxygenase detected in isradipine-treated animals. It can be concluded, that aspirin-treatment may minimize the antiatherosclerotic actions of calcium antagonists which are mediated by the PG-system.

[The cystic duct stump after laparoscopic cholecystectomy]. / Der Zystikusstumpf nach laparoskopischer Cholezystektomie.

The aim of this study was to evaluate the length of cystic-duct stumps after laparoscopic cholecystectomy. 113 patients underwent intravenous cholangiography 2 to 3 months postoperatively, whereby a cystic-duct remnant of up to 1 cm was found in 34.5% (n = 39) and between 1 and 2 cm in 36.3% (n = 41). In 24.8% (n = 28) a stump measuring 2 to 3 cm was registered and in 4.4% (n = 5) the cystic-duct remnant was more than 3 cm. Possible consequences with regard to the development of the postcholecystectomy syndrome are discussed. In our experience laparoscopic cholangiography seems to be a useful procedure to detect cysticolithiasis and as preliminary measure to undertaking the correct therapeutic steps. Adherence of this strategy might avoid possible later complications by elimination of their principal cause.

[Laparoscopic cholecystectomy--current status]. / Die laparoskopische Cholezystektomie--aktuelle Situation.

Laparoscopic cholecystectomy (LCHE) is a safe and effective way to treat gall stones. The procedure was carried out for the first time in France in 1987 and since then it has spread rapidly all over the world, in view of the excellent results achieved. The major benefits are the low morbidity, the very short hospitalization, the early return to daily life and work and its excellent cosmetic results. LCHE is indicated in symptomatic non-complicated gall-bladder disease. The operative technique is standardized, the complication rate is low. Compared with other treatments such as litholysis, extracorporeal shock wave therapy and standard cholecystectomy it is a superior, definitive alternative, which is prognosed to become the therapy of choice in gallbladder disease.

[Experimental bile duct replacement using deep seromuscular stomach wall grafts]. / Experimenteller Gallengangsersatz mittels gestieltem sero-muskulärem Magenwandtransplantat.

Numerous materials and experimental designs were tested hitherto concerning their usefulness as a substitute of the ductus choledochus. However, an ideal substitute to discover failed. We had tested a serous muscular stomach wall patch, flapped at the gastroepiploic vasa, in 6 pigs. Choledochus epithelium did not grow in every case. A scarred shrinking with following stenosis of the transplant resulted in all cases with a longer observation period. We concluded from that a serous muscularly flapped stomach wall transplant does not suit as a bile duct substitute.

[Intralobar pulmonary sequestration]. / Intralobäre Lungensequester.

14 cases of intralobar sequestration of the lung are reviewed. There are 3 different patterns of clinical and radiological symptoms. Angiography is of great value in establishing the diagnosis and defining the anatomic details of the anomalous blood supply, allowing careful planning of the surgical procedure, which was a lower lobectomy in 12 cases. Segmental resections were feasible in 2 cases. No significant complications were observed.

[Carcino-embryonic antigen as screening protein in the follow-up of patients with surgically-treated gastrointestinal cancer (author's transl)]. / Das karzinoembryonale Antigen als Screeningprotein in der Nachkontrolle chirurgisch behandelter Patienten mit gastrointestinalem Karzinom.

Carcino-embryonic antigen (CEA) was determined in 206 patients with gastrointestinal cancer (131 colonic and 75 stomach) at the 2nd Department of Surgery of the University of Vienna. The value of CEA in predicting tumour recurrence and/or metastatic spread has been assessed within the framework of regular follow-up control examinations after surgery. A postoperative rise in CEA titre corresponded with cancer recurrence or metastasis both in patients with stomach (91%), as well as colonic cancer (86%), whilst low postoperative CEA values correlated with a negative clinical report only in patients with carcinome of the colon to any degree of accuracy (91%). The correspondence was much lower in patients with stomach cancer (67%).