Standards of perioperative management in total knee and hip arthroplasty procedures. A survey-based study. Part I: Preoperative management.

INTRODUCTION: Recent years have seen an increasing number of elective total knee (TKA) and hip arthroplasty (THA) procedures. Since a wide variety of methods and procedures are used in perioperative management, a survey-based study was carried out to identify the patterns of practice in Polish hospitals. MATERIAL AND METHODS: With the help of the LimeSurvey application, questionnaires for anaesthesio-logists and orthopaedists were prepared to gain insight into the preparation of patients for TKA and THA procedures and perioperative care. Questionnaires included both single and multiple-choice questions concerning among other things type of laboratory tests, additional examinations and consultations performed on a routine basis before elective TKA and THA procedures. RESULTS: A total of 162 medical centres took part in the study. Questionnaire responses were obtained from 93 (57%) orthopaedics teams and 112 (69%) anaesthesiology teams. A mean (standard deviation, SD) of 7.2 (3.5) laboratory tests are routinely ordered before surgery. For example, 47% of orthopaedists and 20% of anaesthesiologists order urinalysis, while 53% of orthopaedists and 26% of anaesthesiologists order a CRP test. Seventy-nine per cent of orthopaedists refer patients for at least one specialist consultation before the procedure. Dental consultation is requested by 40%, gynaecological consultation by 27%. Patient preoperative education is provided by 85% of orthopaedists and preoperative rehabilitation is prescribed by 46% of them. A total of 56% surveyed anaesthesiologists perform pre-anaesthetic evaluation upon patients' hospital admission. CONCLUSIONS: The study found that the number of examinations and specialist consultations conducted in Polish hospitals exceeded the scope of recommendations of scientific societies. Furthermore, the authors identified a need to standardise perioperative management in the form of Polish guidelines or recommendations, with the intention to improve patient safety and optimize health care expenses.

Effectiveness of Early Rehabilitation with Exergaming in Virtual Reality on Gait in Patients after Total Knee Replacement.

Total knee replacement (TKR) is the treatment of choice for advanced stages of osteoarthritis but it requires good postoperative rehabilitation. This study aimed to assess the effectiveness of exercises using virtual reality to improve gait parameters in patients after TKR. Fifty-nine patients 7−14 days after TKR surgery were divided into a study group (VRG, n = 38) and a control group (CG, n = 21). Both groups underwent the same 4-week rehabilitation protocol. The VRG group had 12 additional nonimmersive virtual reality game sessions on the Virtual Balance Clinic prototype system at 30 min each, focusing on gait and balance improvement. Spatiotemporal, force and foot plantar pressure parameters were collected on an instrumented treadmill during a 30 s walk. The most significant improvement was in the symmetry indices of forefoot force, maximum forefoot force, loading response time, and preswing time (p < 0.05) in both groups. Gait speed increased by 31.25% and 44% in the VRG and CG groups, respectively (p < 0.005). However, the extra exergaming sessions did not significantly improve rehabilitation outcomes. Therefore, additional VR training does not improve gait better than standard rehabilitation alone, but the improvement of gait, especially its symmetry, is significant within the first six weeks after surgery.

Nonlinear and Linear Measures in the Differentiation of Postural Control in Patients after Total Hip or Knee Replacement and Healthy Controls.

Primary osteoarthritis treatments such as a total hip (THR) or knee (TKR) replacement lead to postural control changes reinforced by age. Balance tests such as standing with eyes open (EO) or closed (EC) give a possibility to calculate both linear and nonlinear indicators. This study aimed to find the group of linear and/or nonlinear measures that can differentiate healthy people and patients with TKR or THR from each other. This study enrolled 49 THR patients, 53 TKR patients, and 16 healthy controls. The center of pressure (CoP) path length, sample entropy (SampEn), fractal dimension (FD), and the largest Lyapunov exponent (LyE) were calculated separately for AP and ML directions from standing with EO/EC. Cluster analysis did not result in correct allocation to the groups according to all variables. The discriminant model included LyE (ML-EO, ML-EC, AP-EC), FD (AP-EO, ML-EC, AP-EC), CoP-path AP-EC, and SampEn AP-EC. Regression analysis showed that all nonlinear variables depend on the group. The CoP path length is different only in THR patients. It was concluded that standing with EC is a better way to assess the amount of regularity of CoP movement and attention paid to maintain balance. Nonlinear measures better differentiate TKR and THR patients from healthy controls.

Influence of Dynamization of Trochanteric Fracture Osteosynthesis on Bone Union.

BACKGROUND: Ineffectively treated trochanteric fractures lead to disability and thus constitute a significant social problem. The aim of the study was to analyze the effect of dynamization of the fixation of trochanteric fractures on bone union. MATERIAL AND METHODS: We conducted a retrospective study involving 149 patients operated on for trochan-teric fractures in 2015-2017. The fractures were anastomosed with a DHS extramedullary device or a Gamma 3 intramedullary nail. RESULTS: Bone union was achieved at an average of 11 weeks after the surgery (8-20 weeks). In the extra-me-dullary stabilization (DHS) group, union was achieved after 12 weeks (8 to 16 weeks) (N = 47). In in-tramedullary stabilization, union was achieved after 10 weeks (8 to 20 weeks) (N = 96). The intramedullary nails were locked statically or dynamically. The time to union in static stabilization was 12.3 weeks (8 to 20 weeks) (N = 31), while in dynamic stabilization it was 9.4 weeks (8 to 16 weeks) (N = 64). CONCLUSIONS: 1. This study revealed a measurable biologically beneficial effect of dynamization of the fixation of trochanteric fractures on the time of bone union. 2. Conventional radiographs and CT imaging according to indications significantly facilitate the classification of fractures and selection of the method of stabilization with dynamization. 3. Due to the considerable comminution of the trochanteric massif, double dynamization (cervical-trochanteric and femoral-trochanteric) of fracture fragments is essential, ensuring reduction of fracture gaps and self-reduction of inter-fracture resorptive gaps, which is a prerequisite for optimal union. 4. Allowing early, full weight-bearing of the operated limb within the painless range is an important element of effective dynamization.

A prospective randomized study, use of closed suction drainage after revision hip arthroplasty may lead to excessive blood loss.

Suction drainage after primary total hip arthroplasties (THA) offers no benefits. Revision hip arthroplasties (RHA) are more demanding procedures and associated with greater blood loss compared to primary cases. There is still a lack of literature regarding the application of drainage in RHA. A total of 40 patients who underwent RHA were included in this prospective study. Simple randomization with an allocation ratio 1:1 was performed. Primary outcomes: total blood loss, hemoglobin drop, joint hematoma size in USG, infection. Secondary outcomes: blood transfusion rate, soft tissue hematomas, C-reactive protein levels, Visual Analogue Scale before and on 3rd day after surgery, Harris Hip Score before and 6 weeks after surgery. An intention to treat analysis was performed, with a 2-year follow up. Statistically significant differences between groups was in blood loss: drainage 1559.78 ml, non-drainage 1058.27 ml, (p = 0.029) and hemoglobin level on 1st day after surgery: drainage 10.58 g/dl, non-drainage 11.61 g/dl (p = 0.0496). In terms of the other analyzed parameters, statistical differences were not found. Our study revealed that the use of suction drainage may lead to higher blood loss in the early postoperative period. Further studies are needed to evaluate our results.

Literature Analysis Regarding the Combination of Substances: Glucosamine + Chondroitin in the Treatment of Osteoarthritis.

An essential component of joint quality is cartilage. Therefore, the protection of this is a prerequisite for maintaining the condition of each joint. The assessment of the presence of articular cartilage is shown by X-ray of both joints in the standing position. Cartilage protection is possible for 1, 2 and 3 degree of cartilage damage according to the Kellgren and Lawrence scale.The challenge for the physician is to identify the cause of OA in accordance with the principles of Evidence Based Orthopedics/Traumatology, and not merely treat symptomatically, which is usually ineffective.In order to objectively present treatment methods, indications and the period of their implementation, it is biologically reasonable to refer to the needs of cartilage tissue resulting from the analysis of the causes of its damage and indications for justified methods of its protection.Biomechanical and biological elements are important in the process of implementing articular cartilage protection.The biomechanical elements are: limb axis disorders, differences in length, distortions at the level of the support quadrilateral, pelvic triangle and shoulder triangle, as well as balance disorders resulting from disturbances in the segmental proportion of the Fi number according to Leonardo da Vinci.There are many biological elements of the discussed disorder and they concern: the state of articular cartilage structure, matrix structure, matrix biophysical elements, molecular sponge mechanism, chondrocytes, cartilage nutrition and the severity of osteoarthritis (OA).The improvement of the conditions of the biological elements of damaged articular cartilage is considered fundamental and concerns the positive impact on numerous cartilage matrix proteins by chondroprotection. This element of treatment consists in the use of chondroitin sulphate and glucosamine as a drug, administered together in the appropriate dose and for a long time depending on the degree of degradation of the articular cartilage, usually from several to several months. The combination of chondroitin sulfate with glucosamine causes the activation of a much larger number of matrix proteins than each of the preparations separately.The pharmacokinetics of chondroitin sulfate and glucosamine are positive and favor their chondroprotective effect.The pharmacoproteomics of chondroitin sulfate and glucosamine administered together result from the activation of as many joint cartilage matrix proteins as possible. The development of proteomic techniques creates completely new therapeutic possibilities and is used to study the action of individual molecules.A clinically significant fact is that both chondroitin and glucosamine are natural, endogenous components of bone tissue and articular cartilage, so the use of both drugs is biologically compatible and results in numerous elements of cartilage protection.

Comparative study of suction drainage placement in cementless hip replacement among patients undergoing extended thromboprophylaxis: a prospective randomized study.

BACKGROUND: The use of drains reportedly does not improve surgical outcomes after hip replacement. There is still a lack of strict recommendations for drain placement after primary hip replacement. This study aimed to assess the safety of not using suction drainage after primary hip replacement in a population of patients undergoing extended thromboprophylaxis. METHODS: In this prospective randomized study, all patients were qualified for primary hip replacement and were divided into two groups: with and without drainage. The inclusion criterion was idiopathic hip osteoarthritis. The exclusion criteria were secondary coxarthrosis, autoimmune disease, coagulopathy, venous/arterial thrombosis, hepatic/renal insufficiency, cement, or hybrid endoprostheses. We performed an intention-to-treat analysis. Clinical, laboratory, and radiographic parameters were measured for the first three days after surgery. Hematoma collection, due to extended thromboprophylaxis, in the joint and soft tissues was evaluated precisely. The patients underwent follow-up for 30 days. RESULTS: The final analysis included a total of 100 patients. We did not find any significant statistical differences between groups in terms of hip fluid collection (9.76 vs. 10.33 mm, with and without drainage, respectively; mean difference, 0.6 mm; 95 % confidence interval [CI] -2.8 to 3.9; p = 0.653), estimated blood loss (1126 vs. 1224 ml; mean difference, 97.1 ml; 95 % CI -84.1 to 278.2; p = 0.59), and hemoglobin levels on postoperative day 3 (11.05 vs. 10.85 g/dl; mean difference, 0.2; 95 % CI -2.1 to 2.5; p = 0.53). In addition, the other parameters did not show significant differences between groups. Notably, two cases of early infections were observed in the no-drainage group, whereas there were no such complications in the drainage group. CONCLUSIONS: We conclude that the use of closed suction drainage after primary hip replacement is a safe procedure in patients undergoing extended thromboprophylaxis. Further research is warranted to validate these findings. TRIAL REGISTRATION: The study was successfully registered retrospectively at Clinicaltrial.gov with the identification number NCT04333264  03 April 2020.

Assessment of the Effectiveness of Rehabilitation after Total Knee Replacement Surgery Using Sample Entropy and Classical Measures of Body Balance.

Exercises in virtual reality (VR) have recently become a popular form of rehabilitation and are reported to be more effective than a standard rehabilitation protocol alone. The aim of this study was to assess the efficacy of adjunct VR training in improving postural control in patients after total knee replacement surgery (TKR). Forty-two patients within 7-14 days of TKR were enrolled and divided into a VR group and a control group (C). The C group underwent standard postoperative rehabilitation. The VR group additionally attended twelve 30-min exercise sessions using the Virtual Balance Clinic prototype system. Balance was assessed on the AMTI plate in bipedal standing with and without visual feedback before and after the four-week rehabilitation. Linear measures and sample entropy of CoP data were analyzed. After four weeks of rehabilitation, a significant reduction in parameters in the sagittal plane and ellipse area was noted while the eyes remained open. Regression analysis showed that sample entropy depended on sex, body weight, visual feedback and age. Based on the sample entropy results, it was concluded that the complexity of the body reaction had not improved. The standing-with-eyes-closed test activates automatic balance mechanisms and offers better possibilities as a diagnostic tool.

Two-stage revision arthroplasty in the treatment of periprosthetic hip infections with severe bone loss: Results from 182 cases.

The optimum treatment for periprosthetic joint infection (PJI) of the hip with substantial bone defects remains controversial. A retrospective assessment was performed for 182 patients treated for PJI with a two-stage protocol from 2005 to 2015. Implant removal and debridement were followed by Girdlestone arthroplasty or spacer implantation. The results of the Girdlestone and spacer groups were compared. There were 71 cases that received spacers, and 111 Girdlestone procedures were performed. After the first stage, 26.37% of cultures were negative, and among patients with a detected pathogen, methicillin-sensitive Staphylococcus aureus was the most common organism (41.79%). Acetabular and femoral bone defects, according to the Paprosky classification, were more severe in the Girdlestone group (P<0.05). During the follow-up (mean, 5.95 years), the overall incidence of complications was 21.42%. The mean Harris hip score was significantly lower in the Girdlestone group (68.39 vs 77.79; P<0.0001). The infection recurrence rate reached 8.79%. Despite satisfactory infection control, the number of complications and poor functional outcomes associated with resection arthroplasty indicate the necessity for development of different approaches for patients with advanced bone loss.

Usefulness of ultrasonography in the diagnosis of hematoma after primary hip arthroplasty.

INTRODUCTION: To date, suction drainage has been routinely used after hip joint replacement. Currently, the validity of this practice is questioned in the literature. Hematoma is a risk factor of periprosthetic infection. Post-operative ultrasonography enables precise assessment of hip joint hematoma. AIM: The aim of the study was to evaluate the usefulness of hip joint ultrasonography with respect to the validity of using suction drainage after primary hip arthroplasty. MATERIAL: Inclusion criteria: coxarthrosis. Exclusion criteria: primary and secondary coagulopathy, renal or hepatic failure and history of venous or arterial thrombosis. In total, 90 patients were enrolled. METHODS: The study was prospective. The patients were assigned into groups in accordance with simple randomization. On the third day postsurgery, an ultrasound examination was conducted in all patients. RESULTS: Deep infection was found in two patients with suction drainage. Hematoma was almost twice bigger in the drainage group. There were no statistically significant differences in the Harris Hip Score between the groups. No statistically significant differences were found between the groups in: complete blood count parameters and C-reactive protein values in the first and third day after surgery, the amount of transfused packed red blood cells, duration of hospital stay, cost of hospital stay and the relationship between osteophyte removal and hematoma size. CONCLUSIONS: Ultrasonography performed after hip replacement surgeries is useful in the assessment of hematoma. The randomized study did not reveal statistically significant differences between the group with and without drainage, thus suggesting that this practice can be abandoned, except for selected cases. Due to a short hospital stay, it is recommended to conduct an ultrasound scan in addition to routine radiography and laboratory tests in order to reduce the risk of complications.

Results of the Treatment of Infected Nonunions of the Lower Limbs Using the Ilizarov Method.

BACKGROUND: Infected nonunion is a complex complication of the treatment of long bone fractures. An in creased incidence of injuries, including high energy injuries (often open ones), contributes to a higher incidence of nonunion. These primarily infected injuries cause osteomyelitis, which prevents bone union, resulting in an infected nonunion. The Ilizarov method meets the biological and biomechanical treatment requirements, opti mising the process of inflammation healing and producing bone union. MATERIAL AND METHODS: A total of 54 patients were treated in 2000-2014 for nonunion in the lower limbs with the Ilizarov method, which was used after previous treatment had failed. The subjects underwent intra operative resection of the locus of infection, sequestrectomy and a Judet procedure, followed by the use of the Ilizarov apparatus and bone transport, depending on the defect. RESULTS: Inflammation healed in 52 patients (96%) and bone union was achieved in 46 patients (86%). Good outcomes with healed inflammation and bone union were reported in 76% of the cases, fair outcomes with tem porary elimination of the inflammation and without bone union in 16%, and poor outcomes without inflam ma tion healing and without bone union in 7%. CONCLUSIONS: Treatment of infected nonunion can only be effective after eliminating endogenous inflamma tory foci, covering skin defects, ensuring a good condition of the skin and soft tissues, restoring normal blood supply to the bone fragments, and good biomechanical fixation of the fragments with dynamisation or compression. The Ilizarov method is a method of choice in the treatment of cases of infected nonunion where other treatments have failed.

Management of bleeding or urgent interventions in patients treated with direct oral anticoagulants: 2017 recommendations for Poland.

Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban are mainly used in the prevention of thromboembolic complications in patients with atrial fibrillation (AF) and in the treatment of venous thromboembolism. As compared with vitamin K antagonists (VKAs), they are characterized by at least similar efficacy and better safety profiles, especially with respect to intracranial hemorrhages. Moreover, they are more convenient therapeutic agents. The 2016 European Society of Cardiology guidelines clearly favor DOACs over VKAs in patients with AF. However, DOAC therapy is also associated with the risk of bleeding complications. The aim of this review was to provide recommendations for the management of bleeding complications during DOAC therapy in the Polish setting. The recommendations were based on the most important documents concerning this issue and were developed by representatives of different medical specialties. Experience in managing cases of bleeding on DOAC therapy is still limited. Therefore, we hope that this publication will be helpful in everyday clinical practice and that it will be useful for developing in­hospital recommendations for the management of patients with DOAC­related bleeding.

Spinal tuberculosis with severe neurological symptoms as a complication of intravesical BCG therapy for carcinoma of the bladder.

INTRODUCTION: Non-invasive bladder cancer is effectively treated with intravesical BCG therapy. The administration of the BCG vaccine is to destroy the neoplastic lesion or prevent further recurrences. The activity of the vaccine involves boosting the immune system through the stimulation of the inflammation in the bladder. Adverse reactions after this immunotherapy are rare. The aim of the study was to present complications in the form of spinal tuberculosis and serious neurological symptoms that occurred during intravesical BCG immunotherapy for carcinoma of the bladder. The manuscript also describes a method for neurosurgical spinal cord decompression of the thoracic spine. MATERIAL AND METHODS: In the first patient, aged 66, after intravesical BCG therapy for bladder carcinoma, back pain and spastic paralysis of the lower limbs were observed. The MRI and CT revealed destruction of the intervertebral disc and vertebral endplates Th11-Th12. Mycobacterium tuberculosis complex bacilli were cultured from the material obtained by puncture aspiration. In the second patient, aged 35 years, during intravesical BCG immunotherapy for carcinoma of the bladder, girdle thoracic spine pain was observed. The MRI and CT of the spine showed visible lesions characteristic of tuberculosis. Immobilization in a plaster corset and implementation of antituberculous treatment resulted in quick relief of the pain and healing of the tuberculosis focus in the spine. CONCLUSION: The cases described in the work are the first documented reports in the Polish literature of spinal tuberculosis which occurred as a complication of intravesical administration of bacilli Calmette-Guérin. The diagnosis was based on the finding of BCG vaccine bacillus with molecular methods or PCR. Full antimycobacterial treatment was implemented.

Analysis of Risk Factors for Periprosthetic Joint Infection in Clinical Data.

BACKGROUND: Progress in orthopaedics has now made it possible to improve the functional status of damaged hip joints with hip arthroplasty and eliminate the associated pain. The constantly growing number of hip replacement procedures is, however, associated with a proportional rise in the number of subsequent surgery-related complications. The most important complication is septic loosening of the implant. The treatment of septic complications is often ineffective and recovery becomes impossible. In that setting, an awareness of the risk factors of septic complications and an ability to prevent periprosthetic joint infection (PJI) are becoming necessary. AIM: The aim of the study was to analyse the risk factors of PJI as an essential element of the prophylaxis of septic complications. MATERIAL AND METHODS: We analysed the data of 142 patients treated for PJI at the Ward of Bone and Joint Infections, Department of Orthopaedics, Medical Centre of Postgraduate Education in Otwock, between 2008 and 2010. Their medical records were analysed retrospectively. The diagnosis was evidence-based, relying on case histories, physical examination and accessory investigations, including imaging studies and biochemical and microbiological testing. RESULTS: The analysis of clinical data served to identify factors that appeared repetitively in the patients with PJI treated at the Ward. Those elements constitute the combination of risk factors for PIJ. CONCLUSIONS: 1. An awareness of risk factors for septic complications and their early elimination are necessary in daily orthopaedic care. 2. The pre-surgery checklist is a very effective tool to eliminate the most common risk factors of PJI.

A Retrospective Analysis of Bacteriological Studies of Surgical Site Infections in a Monoprofile, Multidepartmental Orthopedic Hospital.

BACKGROUND: Despite improvements in surgical techniques, aseptics and prevention of infections, hospital surgical site infections (SSI) still remain one of the main reasons for failure in therapeutic musculoskeletal surgery. This study aimed to conduct a retrospective analysis of microbiological examinations and determine pathogen sensitivity to antibiotics as the basis for selecting methods for preventing and treating complicating infections. MATERIAL AND METHODS: The study is a retrospective analysis of bacteriological tests performed in the departments of the Public Clinical Hospital of the Medical Centre of Postgraduate Education in Otwock. Importantly, our monoprofile hospital specialising in musculoskeletal pathology is a reference centre, admitting patients from the entire country. Often these are patients transferred from Intensive Care Units at other hospitals with internally infected local emergencies (infections with local, complex, multidrug resistant bacterial flora). Bacteriological mapping of the hospital covered the period from 2009 to 2013 to indicate so called "strategic departments" demonstrating the most complex multidrug-resistant bacterial flora. Surgical site infections were managed by surgery with targeted antibiotic therapy. RESULTS: Analysis of patients' profiles revealed that SSIs detected across hospital departments in SPSK CMKP in Otwock mostly came from other medical centers where patients were initially hospitalized. The Osteomyelitis Department and the Department of Pelvic Pathology and Traumatology were identified as "strategic departments". CONCLUSIONS: 1. The analysis indicated that methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen responsible for complicating infections in our hospital. 2. The percentage of bacterial resistance to methicillin signifi -cantly increased in patients with multi-organ injuries who had previously been hospitalized at other centres. 3. Credible prevention and diagnosis of inflammatory risk factors in the preoperative period was of key importance in reducing the percentage of complicating infections.

Sonication as a diagnostic approach used to investigate the infectious etiology of prosthetic hip joint loosening.

The purpose of the study was to evaluate the usefulness of sonication for the diagnosis of prosthetic joint infections (PJIs) by its comparison with periprosthetic tissues (PTs) and synovial fluid (SV-F) cultures. The study groups included 54 patients undergoing exchange of total hip prostheses for so called "aseptic" loosening occurring without clinical manifestations of an accompanying PJI and 22 patients who developed a sinus tract communicating with the prosthesis which was indicative of an ongoing infectious process. Significant positive culture results were obtained among 10 (18.5%) patients with "aseptic" implant failure and in 18 (81.8%) patients who developed a sinus tract. Sonicate-fluid (S-F) yielded bacterial growth in all culture-positive patients with "aseptic" loosening vs. 15 patients with presumed PJIs. There was a concordance in terms of bacterial species isolated from S-F and conventional cultures from individual patients. Coagulase-negative staphylococci were isolated most frequently. Sensitivity of sonication (75%) exceeded that estimated for PTs (69%) and SV-F (45%) cultures. We conclude that identification of causative agents of PJIs which is critical to further therapeutic decisions is aided by the combination of sonication and conventional culture.

The 100 most cited psoriasis articles in clinical dermatologic journals, 1970 to 2012.

BACKGROUND: Citation analysis is an effective way to gauge the impact of an article on the scientific community. OBJECTIVE: The purpose of this study was to perform a citation analysis of 24 clinical dermatologic journals from 1970 to 2012, limited to the topic of psoriasis. METHODS: The authors conducted a search of "psoriasis" in the Science Citation Index from 1970 to 2012, including articles that have received 100 or more citations. The top 100 most cited articles were further analyzed for country, institution, and study type. RESULTS: Fifty of the top 100 most cited articles were from the United States and 81 of them were original articles. The majority of the top 100 classics were from dermatology programs in the United States, but institutions in the United Kingdom and Germany also made notable contributions. Citation classics in psoriasis were highly published from 1985 to 1989 and 2000 to 2004. LIMITATIONS: LIMITATIONS included potential neglect of a clinical dermatologic journal and the limited search term of "psoriasis." CONCLUSION: The great majority of citation classics were published in the premier dermatologic journals. The top-ranking dermatology programs in the United States produced the majority of the top 100 classics in psoriasis. The high number of citation classics from 1985 to 1989 correlates to the discovery of the immune-mediated pathogenesis of psoriasis at that time. The 21st century brought forth the monumental development of biologic agents in psoriasis therapy, reflected by the high number of citation classics from 2000 to 2004.

Stimulation of bone union with dynamic beams of Konzal's "R" external fixator.

BACKGROUND: Treatment of septic long bone non-union remains a complex therapeutic problem. External stabilisation with Konzal's "R" fixator has been used in the Orthopaedic Department of CPME for years and allows for rigid stabilisation of bone fragments and good mutual alignment. Tried and tested in the treatment of osteitis, the fixator, however, offers limited possibilities for dynamisation and interfragmental compression. The following article presents a modernised design of Konzal's "R" with dynamic beams. MATERIAL AND METHODS: The efficacy of dynamisation of the fixator with the modernised design was compared with that of the earlier technique of eccentric shifting of static beams by assessing the time of bone union, the average number of pin restabilisations required, and the percentage of "partial unions" in two groups treated with the different methods. RESULTS: In the dynamic beam group, mean time to bone union was shorter by 5.1 months on average. This group also recorded a significantly lower percentage of "partial unions" (<50% of diaphysial circumference) as well as a lower count of necessary pin restabilisations per patient. There was no correlation between time to bone union and the duration of active inflammation prior to the surgical treatment or the presence of an open fistula. CONCLUSIONS: 1. The modernised design allows for dynamic load bearing by the bone tissue between the fragments rather than by the fixator's static beams. 2. The biomechanical principle of the fixator provides for optimal bone healing and shortens the time to bone union.

Infectious prosthetic hip joint loosening: bacterial species involved in its aetiology and their antibiotic resistance profiles against antibiotics recommended for the therapy of implant-associated infections.

Reliable microbiological diagnosis along with surgery and prolonged antibiotic therapy are key elements in the management of prosthetic-joint infections (PJIs). The purpose of this study was to characterize antibiotic resistance profiles of bacteria involved in the aetiology of PJIs. A total of 33 bacterial isolates cultured from 31 patients undergoing exchange of total hip prostheses were analyzed. The diagnostic approach toward isolation of prosthesis- associated microorganisms included sonication of retrieved implants and conventional cultures of periprosthetic tissues and synovial fluid. The in vitro resistance profiles of bacterial isolates were determined in relation to antibiotics recommended for the therapy of PJIs using the disc diffusion method, E-tests(®) and broth microdilution system. Coagulase-negative staphylococci (CNS) were predominant microorganisms followed by Staphylococcus aureus, Enterobacter cloacae, Streptococcus mitis, and Propionibacterium acnes. Twenty out of 30 and 12 out of 30 staphylococcal isolates were methicillin- and multi-drug resistant, respectively. Only two isolates were rifampicinresistant. All staphylococci were susceptible to glycopeptides and linezolid. This paper stresses the pathogenic role of staphylococci in patients suffering from implant loosening and reports high methicillin- and multidrug-resistance rates in these bacteria. Hence, antimicrobial susceptibility tests of individual bacterial isolates must always be performed to guide selection of the optimal therapeutic option.