Treatment of femoral neck fractures using actis stem: complication rate in 188 uncemented hemiarthroplasties.

INTRODUCTION: Cemented hemiarthroplasty (HA) is preferred in treating dislocated femoral neck fractures in elderly, osteoporotic patients, since uncemented HA was associated with mechanical complications more frequently. Cementation can conversely cause cardiopulmonary complications, leading to demand on safe, uncemented implants addressing osteoporosis. This study is set up as a retrospective feasibility study on the use of an uncemented, collared wedge implant (Actis®, DePuy Synthes, Warsaw, IN), for HA in elderly patients, focusing on complication rate. MATERIALS AND METHODS: From 1,194 patients, treated with HA in two study centers between 2017-2022, 188 received Actis® uncemented stem with bipolar head. Complete follow-up were retrospectively collected in all patients. RESULTS: In 188 patients (f: 64.9%; age: 83.1 ± 7.7a) included, no case of intra-operative mortality was recorded. 2 day mortality was 1.1%, 30 day mortality was 7.4% and 1 year mortality was 28.2%. 2 (1.1%) intra-operative fractures did not receive surgical revision, 3 (1.6%) post-operative periprosthetic fractures caused separate admission and revision. 2 cases (1.1%) of early infection required surgical revision. CONCLUSION: Our data provide proof of concept, that Actis® Stem allows an alternative, uncemented treatment option for displaced femoral neck fractures with HA. In case of preoperative or intraoperative medial cortical bone defects, stability of this implant is deteriorated.

Author Correction: Fibrinogen - A Practical and Cost Efficient Biomarker for Detecting Periprosthetic Joint Infection.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Combined serum biomarker analysis shows no benefit in the diagnosis of periprosthetic joint infection.

PURPOSE: In many cases, the diagnosis of a periprosthetic joint infection (PJI) consisting of the clinical appearance, laboratory tests, and other diagnostic tools remains a difficult task. Single serum biomarkers are easy to collect, are suitable for periodical assessment, and are a crucial tool in PJI diagnosis, but limited sensitivity or specificity is reported in literature. The aim of this study was to combine the best-performing single serum biomarkers into a multi-biomarker model aiming to improve the diagnostic properties. METHODS: Within a 27-month period, 124 surgical procedures (aseptic or septic revision total knee arthroplasty (TKA) or total hip arthroplasty (THA)) were prospectively included. The serum leukocyte count, C-reactive protein (CRP), interleukin-6, procalcitonin, interferon alpha, and fibrinogen were assessed 1 day prior to surgery. Logistic regression with lasso-regularization was used for the biomarkers and all their ratios. After randomly splitting the data into a training (75%) and a test set (25%), the multi-biomarker model was calculated and validated in a cross-validation approach. RESULTS: CRP (AUC 0.91, specificity 0.67, sensitivity 0.90, p value 0.03) and fibrinogen (AUC 0.93, specificity 0.73, sensitivity 0.94, p value 0.02) had the best single-biomarker performances. The multi-biomarker model including fibrinogen, CRP, the ratio of fibrinogen to CRP, and the ratio of serum thrombocytes to CRP showed a similar performance (AUC 0.95, specificity 0.91, sensitivity 0.72, p value 0.01). CONCLUSION: In this study, multiple biomarkers were tested for their diagnostic performance, with CRP and fibrinogen showing the best results regarding the AUC, accuracy, sensitivity, and specificity. It was not possible to further increase the diagnostic accuracy by combining multiple biomarkers using sophisticated statistical methods.

Radiation Exposure of Patient and Operating Room Personnel by Fluoroscopy and Navigation during Spinal Surgery.

Intraoperative radiography imaging is essential for accurate spinal implant placement. Hazards caused by ionizing radiation raised concern on personnel's work life long exposure in the operating room (OR). To particularize a cumulative risk estimation of radiation of personnel and patient, depending on used methods (C-arm fluoroscopy, O-arm navigation) and patient characteristics during spinal surgery, detailed investigation of radiation exposure in a clinical setting is required. Lumbosacral dorsal spinal fusion was performed in 37 patients (19 navigated, 18 fluoroscopy) during this prospective study. Radiation exposure was measured on several body regions with thermoluminescent dosimeters on patient and OR personnel (surgeon, assistant, sterile nurse, radiology technologist). Comparison between patient characteristics and radiation exposure was included. The highest patients values were measured in the surgery field and gonads area during navigation (43.2 ± 19.4 mSv; fluoroscopy: 27.7 ± 31.3 mSv; p = 0.02), followed by the thoracic region during fluoroscopy (7.7 ± 14.8 mSv; navigation: 1.1 ± 1.0 mSv; p = 0.06), other measured regions can be considered marginal in comparison. Amongst OR personnel exposure of the surgeon was significant higher during fluoroscopy (right hand: 566 ± 560 µSv and thoracic region: 275 ± 147 µSv; followed by thyroid and forehead) compared to navigation (right finger: 49 ± 19 µSv; similar levels for all regions; p < 0.001 in all regions). When compared to the surgeon, other OR personnel had significantly lower radiation doses on all body regions using fluoroscopy, and similar dose during navigation. The highest eye's lens region value was measured during fluoroscopy for the patient (185 ± 165 µSv; navigation: 205 ± 60 µSv; p = 0.57) and the surgeon (164 ± 74 µSv; navigation: 92 ± 41 µSv; p < 0.001). There was a significant correlation between patient BMI and radiation exposure to the surgery field during fluoroscopy. To our knowledge, these data present the first real life, detailed comparison of radiation exposure on OR personnel and patients between clinical use of navigation and fluoroscopy. Although patient's radiation dose is approximately 3-fold during navigation compared to the fluoroscopy, we found that a spinal surgeon could perform up to 10-fold number of surgeries (10.000 versus 883) until maximum permissible annual effective radiation dose would be reached. Especially for a spinal surgeon, who is mainly exposed amongst OR personnel, radiation prevention and protection must remain a main issue.

Navigation versus experience: providing training in accurate lumbar pedicle screw positioning.

PURPOSE: Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. METHODS: Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. RESULTS: Significant improvement of trainee's PS placement accuracy (Sclafani score 8.2-8.83; p = 0.006) and time (13.3-6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2-4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3-0.0%) and trainee (5.1-2.6%) during the whole study, no postoperative complications occurred. CONCLUSION: Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.

[Clinical administration of platelet-rich plasma and growth factors to the musculoskeletal system]. / Klinische Anwendung von Platelet-rich plasma und Wachstumsfaktoren am Bewegungsapparat.

Platelet-rich plasma (PRP) and growth factors have been increasing in popularity for the orthopedic treatment of degenerative and traumatic diseases. The treatment concept is based on the substitution of growth-inducing substances in tissues with low or absent regeneration capacity (cartilage, tendons) as well as for the induction or further acceleration of growth and regeneration (bone, muscle). This review article provides an overview on the clinical feasibility of usage and a summary of the current study situation.

Risk of extrapelvine vascular injuries in osteosynthesis with gliding hip screws.

BACKGROUND: Dynamic hip screw (DHS) osteosynthesis represents one of the most frequently performed fixation methods in orthopedic practice. The purpose of this study was to determine the potential risk of vascular damage by DHS side-plate screws (PS) and plunging instruments for individual femoral vessels and screw positions. METHODS: In ten hemipelvic/leg specimens mounted with a large femur distractor, a DHS system with a four-hole side-plate was inserted. PS were inserted in 3 consecutive courses with different inclinations in the frontal plane of 0° (group 1), - 30° posterior (group 2) and + 30° anterior (group 3) in relation to the side-plate's surface, resulting in 120 PS positions. After screw tightening, the soft tissues on the medial side of the femur were dissected and investigated for vascular compromise; in each course, the effect of overshot instruments within a range of 50 mm beyond the side-plate's surface was also tested. RESULTS: Totally, 37/120 screw positions (31%) revealed potential vascular compromise which comprised of 15/120 (13%) direct hits by screw tips and 22/120 (18%) potential impacts by plunging instruments. The deep femoral artery system (DFA) was significantly (p = 0.007) most often affected but no significant differences for individual vascular structures were seen. Direct vascular impacts occurred significantly more often (p = 0.0047) in screws with 0° inclination compared to + 30° inclination (p = 0.017). Significant differences among individual screw positions were only found in group - 30° with direct vessel contacts (p = 0.038). CONCLUSIONS: The DFA system is significantly more at risk while significant preference of a certain vessel is missing. Our data indicate that more than 30% of 120 screw positions in DHS osteosynthesis revealed a potential danger of vascular compromise, when surgical principles are denied in hip fracture fixation. CLINICAL RELEVANCE: Though vascular complications are infrequently encountered in DHS osteosynthesis they have to be considered as a potential complication when surgical principles are not followed in this anatomic area.

Fibrinogen - A Practical and Cost Efficient Biomarker for Detecting Periprosthetic Joint Infection.

The early and accurate diagnosis of periprosthetic joint infection (PJI) can be challenging. Fibrinogen plays an important role in mediating inflammation of bacterial infections and therefore could be a valuable biomarker for PJI. The purpose of this study was to investigate the sensitivity and specificity of serum levels of fibrinogen in detecting PJI, and to compare the results with the established PJI biomarkers C-reactive protein (CRP) and leukocyte count. Eighty-four patients (124 surgeries) were prospectively included. The preoperatively analyzed parameters were fibrinogen, CRP and leukocyte count. The sensitivity and specificity of the biomarkers were calculated and compared. Fibrinogen (p < 0.001), CRP (p < 0.001) and leukocyte count (p < 0.001) had a statistically significant correlation with the criteria defining the presence of PJI. For fibrinogen, the value of 519 mg/dl had a sensitivity of 0.90 and a specificity of 0.34. The CRP cut-off point of 11.00 mg/dl had a sensitivity of 0.90 and a specificity of 0.74. The leukocyte count of 5.68 G/l had a sensitivity of 0.90 and a specificity of 0.39. Our results indicated that fibrinogen is a significant biomarker for detecting a bacterial PJI. It has shown to be a cost-efficient diagnostic support with high sensitivity and specificity.

Passage of an Anterior Odontoid Screw through Gastrointestinal Tract.

Purpose. Anterior screw fixation has become a popular surgical treatment method for instable odontoid fractures. Screw loosening and migration are a rare, severe complication following anterior odontoid fixation, which can lead to esophagus perforation and requires revision operation. Methods. We report a case of screw loosening and migration after anterior odontoid fixation, which perforated the esophagus and was excreted without complications in a 78-year-old male patient. Results. A ventral dislocated anterior screw perforated through the esophagus after eight years after implantation and was excreted through the gastrointestinal (GI) tract. At a 6-month follow-up after the event the patient was asymptomatic. Conclusion. Extrusion via the GI tract is not safe enough to be considered as a treatment option for loosened screws. Some improvements could be implemented to prevent such an incident. Furthermore, this case is a fine example that recent preoperative imaging is mandatory before revision surgery for screw loosening.

Identification of matrix metalloproteinase-12 as a candidate molecule for prevention and treatment of cardiometabolic disease.

Obesity is strongly associated with metabolic syndrome, a combination of risk factors that predispose to the development of the cardiometabolic diseases: atherosclerotic cardiovascular disease and type 2 diabetes mellitus. Prevention of metabolic syndrome requires novel interventions to address this health challenge. The objective of this study was the identification of candidate molecules for the prevention and treatment of insulin resistance and atherosclerosis, conditions that underlie type 2 diabetes mellitus and cardiovascular disease, respectively. We used an unbiased bioinformatics approach to identify molecules that are upregulated in both conditions by combining murine and human data from a microarray experiment and meta-analyses. We obtained a pool of eight genes that were upregulated in all the databases analysed. This included well known and novel molecules involved in the pathophysiology of type 2 diabetes mellitus and cardiovascular disease. Notably, matrix metalloproteinase 12 (MMP12) was highly ranked in all analyses and was therefore chosen for further investigation. Analyses of visceral and subcutaneous white adipose tissue from obese compared to lean mice and humans convincingly confirmed the up-regulation of MMP12 in obesity at mRNA, protein and activity levels. In conclusion, using this unbiased approach an interesting pool of candidate molecules was identified, all of which have potential as targets in the treatment and prevention of cardiometabolic diseases.

Vascular complications in plating of the proximal femur: review.

INTRODUCTION: Plating of the proximal femur represents a standard fixation method in orthopedic and trauma surgery. Vascular lesions are uncommon but potentially life-threatening. With the increasing number of hip surgery also more of these complications have to be anticipated. The purpose of this study was to evaluate the most common types and locations of vascular lesions after plating of the proximal femur as well as the most important causes. MATERIALS AND METHODS: A literature research was undertaken of the English and german literature on vascular complications after plating of the proximal femur following a structured search protocol. RESULTS: 62 cases with vascular compromise after plating of the proximal femur revealed significantly more iatrogenic origin (n = 41/62) was observed than lesions caused by fracture fragments (n = 11/62) (p = 0.0001); most iatrogenic reasons (n = 28/62) were related to the insertion of plate screws (PS). Lesions were significantly more often located (57/62) in the deep femoral artery (DFA) system than in other vascular systems (n = 5/62) (p = 0.0001). Vascular damages represented significantly more often pseudoaneurysms (PA) (42/62) than major lesions in the vessel wall with acute bleeding (17/62) or vascular occlusions (3/62); (p = 0.0001). PA cases also revealed a significantly longer diagnostic delay than other lesions (36 days vs. 2 days, p = 0.0064). Among clinical symptoms swelling of the thigh (57/62), local pains (42/62) and anemia (26/62) were most often observed. Swelling and pains were significantly more often reported in PAs (p = 0.0338; p = 0.0003). Most patients achieved full functional recovery (n = 41/62), but over-all complication rate was quite high (n = 18/62). CONCLUSIONS: Vascular compromise in plate osteosynthesis of the proximal femur affects significantly more often the DFA system and represents most often PA. As the majority of cases revealed iatrogenic origin, a thorough surgical technique and awareness can help to avoid these complications.

Failure of mass antibiotic prophylaxis to control a prolonged outbreak of meningococcal disease in an Israeli village.

In January 1994 mass antibiotic prophylaxis was undertaken in the contiguous villages of Deir el-Asad and B'ine in northern Israel (combined population of 11600) in response to a prolonged outbreak of serogroup B meningococcal infection with an overall annual rate of 37.4 cases of infection per 100000 residents. The average case fatality rate in the villages was 23% compared with 11% in Israel during the same period. Neisseria meningitidis group B was identified in 9 of 13 (69%) cases. Seven of these were subtype P1.7,16. The persistence of the outbreak with its accompanying public reaction prompted the establishment of an intervention programme that included antibiotic prophylaxis for the whole community with monitoring for pharyngeal carriage of meningococci in a stratified sample of the population. The objectives were to achieve a reduction of carriage of the outbreak strain and to reduce morbidity and mortality. A total of 1036 pharyngeal swabs were taken 1 day before and 6 weeks after treatment. Antibiotic prophylaxis was administered in one dose: children under 5-years-old received ceftriaxone i.m.; all others received oral ciprofloxacin. Overall, 96% of the population received treatment. The carriage rate was 8.3% prior to treatment (three serogroup B:14:P1.7,16), and 1.3% afterwards (one serogroup B:14:P1.7,16). The intervention failed to eradicate carriage of the putative outbreak strain, or to reduce the incidence and fatality rates in the villages. The outbreak finally terminated in late 1996. Public health professionals should bear this experience in mind when faced with prolonged, localized, nonexplosive outbreaks of meningococcal disease associated with low carriage rates of the outbreak strain.

[Spontaneous regression of a small cell bronchial carcinoma]. / Spontanregression eines kleinzelligen Bronchuskarzinoms.

A circular focus of 1 cm diameter was discovered by chance on a thoracic x-ray of a female patient of 66 years of age suffering from chronic interstitial nephritis due to analgesics. Bronchoscopic suction revealed histologically a small-cell carcinoma of the lung but there was no indication of formation of metastases. The patient refused any tumor-specific treatment. In the further course of the disease the focus showed up radiologically for seven months and was then no longer visible throughout the following 14 months. The patient finally died subsequent to an extensive posterior myocardial infarction. Postmortem examination excluded the presence of a primary tumor of the lung or metastases. Our case suggests the rare occurrence of a spontaneous regression of a small-cell bronchial carcinoma. Although spontaneous regression of malignant diseases is ascribed to immunological factors, such regression can also occur if the immunological system is impaired, as had been the case in this particular patient with chronic renal insufficiency.

[Amniotic fluid embolism--a case report with positive outcome]. / Fruchtwasserembolie--Ein Fallbericht mit positivem Ausgang.

While inducing delivery, shock occurred in a 23-year old primipara (41 weeks and 5 days of gestation). She showed symptoms of cyanosis, unconsciousness and asystoly. During cardiopulmonary resuscitation an emergency Caesarean section was performed. The resuscitation had to be continued for 1.5 hours and was followed by severe haemorrhage. Hysterectomy had to be performed, because the substitution of packed red blood cells, whole blood, fresh frozen plasma and other blood derivatives could not stop bleeding. Although the prognosis seemed to be very poor, mother and child survived without any physical damage or neurological deficit until now. Because of the clinical pattern we diagnosed an AFE syndrome (amniotic fluid embolism).

Mechanoreceptors sensitive to flow at the gastroduodenal junction of the cat.

Vagal afferent activity was recorded from the cervical vagus simultaneously with intraluminal pressure and flow rate at the proximal duodenum, in cats anesthetized with pentobarbital sodium. Thirty-seven mechanoreceptors that adapted slowly to maintained pressure changes were found to be sensitive to the flow of saline through the pylorus. The passage of liquid was associated with an increase of pressure equal to one-tenth of that necessary to trigger a response of the receptors during the distension of a small balloon. The frequency of discharge was increased by the passage of liquid for positive back pressures < or = 1.5 kPa but not when back pressure was negative. The relationship between the discharge of the receptor and the flow rate was complex and showed an hysteresis. We conclude that there exist slowly adapting mechanoreceptors sensitive to distension of the duodenum that can also sense the passage of liquid.

Dopamine metabolism in the rabbit carotid body in vitro: effect of hypoxia and hypercapnia.

Dopamine (DA) and noradrenaline (NA) were measured in the rabbit carotid body (CB) in vitro bv HPLC-ED under the following experimental conditions: 1h superfusion in normoxic, hypoxic (10% O2 in N2) or hypercapnic (8% CO2, 20% O2, 72% N2) medium, 5h superfusion in normoxia or hypoxia. The contents of DA and NA were decreased by hypoxia and hypercapnia after 1 h and 5h indicating a possible DA and NA secretion. Under the same experimental conditions synthesis of DA and NA and catabolism of DA were studied with enzymatic inhibition of tyrosine hydroxylase and monoamine oxidase (MAO) respectively. In hypoxia (1 h and 5h) the rate constant of DA synthesis was the same as in normoxia; however NA synthesis was decreased after 1 h hypoxia. On the contrary, hypercapnia, appeared to be a very effective stimulus of DA and NA synthesis.

Organization scores of self and other on the repertory grid.

Traditional repertory grid studies of construct system organization have assumed that measures of organization derived from the construing of others are equivalent to measures derived from the construing of self. They also have assumed that constructs generated around the construing of others can be used to construe the self. Finally, they have assumed that the self is a unitary concept that does not vary across contexts. This study provides some empirical data on these assumptions by comparing the construction of self and others on repertory grids. Only moderate correlations between the organization of self and others were found on grid measures of construct independence and construct integration. Higher relationships were found on measures of construct system meaningfulness and the constructed use of categories. The implications of these data for repertory grid research are discussed.

[Meningococcal disease in western Galilee].

79 patients with meningococcal disease were evaluated retrospectively between 1972-1986. All the neisseria isolated were sensitive to penicillin but resistant to sulphonamides. Most of the infections (54%) were caused by serogroup B strains. Clinical features included fever (98%), vomiting (65%), and headache (60%). Purpura appeared in 95% and severe neurological features in 25%. Most patients (83%) were children less than 10 years old. The incidence was 1.4/100,000 in the non-Jewish population and 2.3/100,000 in the Jewish population. The overall mortality was 23%, but about 50% in the Jewish population (10 deaths in 18 cases). In kibbutzim the incidence (7.5/100,000) and mortality were especially high. The need for awareness of the disease and the importance of early diagnosis and aggressive treatment are emphasized.