Measurement Techniques for Leg Length Discrepancy in Total Hip Arthroplasty: A Systematic Review of Reliability and Validity.

BACKGROUND: Total hip arthroplasty (THA) carries a substantial litigative burden. THA may introduce leg length discrepancy (LLD), necessitating a valid and reliable technique for LLD measurement. This study investigates the reliability and validity of techniques quantitively measuring LLD in both pre- and post-THA. METHODS: Embase and MEDLINE databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles assessing either the validity or reliability of LLD measurement techniques. Data was pooled using random effects meta-analysis to derive reliability estimates. Study quality was assessed using the Brink and Louw checklist. RESULTS: Forty-two articles with 2059 participants were included. Thirty-three investigated reliability and 25 validity. Reliability displayed high heterogeneity. Poor to excellent intra-rater reliability was reported for antero-posterior pelvis radiographs, moderate to excellent for computed tomography scanograms, and good to excellent for clinical methods and teleradiography, and excellent for bi-planar radiography (BPR). Poor to excellent inter-rater reliability was reported for antero-posterior pelvis radiographs and clinical methods, moderate to excellent for teleradiography, good to excellent for computed tomography scanogram and excellent for BPR. The tape measure method is a valid clinical measure of LLD whilst markerless motion analysis and the block method are not. Imaging techniques are appropriately cross-validated with the exception of BPR. CONCLUSION: The reported intra- and inter-rater reliability for most measurement techniques vary widely. The tape measure method is a valid clinical measurement of LLD. Imaging techniques have been appropriately cross-validated, with the exception of BPR, although they lack validation against a common reference technique.

Radiation exposure during scoliosis surgery: a prospective study.

BACKGROUND CONTEXT: The present literature on the cancer risks related to radiation exposure in patients and surgeons during scoliosis surgery is sparse. PURPOSE: To assess the radiation exposure in patients and surgeons during scoliosis surgery and estimate the increased cancer risk of both groups. STUDY DESIGN: Over a 6-month period, we conducted a prospective study to monitor the intraoperative radiation dose received by both patients and surgeons during scoliosis cases. PATIENT SAMPLE: It included 30 consecutive patients undergoing scoliosis surgery by a team of two surgeons (S1 and S2). OUTCOME MEASURES: We measured the radiation exposure to the eyes, thyroid, and hands for each surgeon; measured the difference of radiation exposure between the two surgeons; the difference in radiation exposure with respect to the proximity of the surgeon to the X-ray tube, and the radiation exposure for each patient. METHODS: An electronic dosimeter was attached over the thyroid guard and a thermoluminescent dosimeter ring on both hands of each surgeon. The patients were monitored using the dose area product (DAP) measurements from the image intensifier, and their radiation exposure was calculated with the Monte Carlo calculation. RESULTS: The mean eye dose per procedure for the two surgeons S1 and S2 was 0.8 µSv and 1.3 µSv, respectively. The mean thyroid dose for S2 and S1 was 1.2 µSv and 1.4 µSv, respectively. The dose recorded by the surgeon on the same side of the patient as the X-ray tube was significantly higher than for the surgeon on the far side (p<.05). Mean DAP per procedure was 91.3 cGycm(2) and the mean radiation dose for patients was 252.9 µSv. The increase in cancer risk for patients and surgeons was 0.001% and 0.0005%, respectively, for each year of exposure. CONCLUSIONS: A significantly higher dose of radiation during scoliosis surgery was received by the surgeon standing on the same side as the X-ray tube. However, both surgeons received a total radiation dose of less than 1% of the recommended dose limit per year and, therefore, the total radiation exposure in both surgeons and patients was well within the recommended safe limits.

Effects of FTY720 and rapamycin on inflammation in taurocholate-induced acute pancreatitis in the rat.

OBJECTIVES: This study aimed at T-cell inhibition by immunosuppressants to reduce cell damage and improve the course of severe acute pancreatitis (SAP). METHODS: A taurocholate-induced SAP was used and 5 groups were compared: (1) rapamycin + FTY720, (2) rapamycin, (3) FTY720, (4) cortisol, and (5) control: sodium chloride. Drugs were applied intravenously at SAP induction; 6 hours later, rats were killed. Interleukin (IL)-1, IL-6, IL-10, tumor necrosis factor α, platelet-activating factor, amylase, and lipase were measured in serum and myeloperoxidase tissue activity in pancreas, kidney, lung, liver, and spleen. Edema, inflammation, and necrosis were histologically determined in pancreas. CD4/CD8 immunohistochemistry was performed. RESULTS: Inflammation was ameliorated in all 4 treated groups. Necrosis development was suppressed by FTY720, FTY720 + rapamycin, and cortisol. IL-6 and IL-10 were significantly lower in these groups. Amylase was higher in all treatment groups compared to the controls except for the cortisol group. Tumor necrosis factor α, lipase, and myeloperoxidase activity were not affected by therapy. CD4+/CD8+ cells were significantly less in FTY720-treated pancreata. CONCLUSION: Rapamycin and FTY720 ameliorated the severity of SAP, which may be due to early suppression of helper T cells. FTY720 reduced the development of pancreatic necrosis. The combination of both immunosuppressants did not show advantage to treatment with FTY720 alone.

Good Clinical Outcome following Non-operative Treatment of Concomitant Fractures of Coracoid Process and Distal End of Clavicle: A Case Report.

INTRODUCTION: A coracoid fracture is a rare orthopaedic condition as it accounts for only 2 - 10 % of all scapular fractures and <0.1% of all fractures. In even rarer cases coracoid fractures are also associated with other bony injuries of the shoulder. There is currently no consensus on the treatment of such injuries. CASE REPORT: We present an unusually rare case of a simultaneous fracture of the coracoid process and the lateral end of clavicle. The patient was treated with shoulder arm sling for 6 weeks followed by physiotherapy. At 6 months follow up the patient was pain free with full range of motion at right shoulder. CONCLUSION: Concomitant fractures of lateral end clavicle and coracoid process are rare and may not be visible of plain radiographs. CT scan may be indicated if the clinical examination suspects additional injuries of shoulder girdle. We have treated this injury non operatively with a good clinical outcome.

Evaluation of a novel nanocrystalline hydroxyapatite paste Ostim in comparison to Alpha-BSM - more bone ingrowth inside the implanted material with Ostim compared to Alpha BSM.

BACKGROUND: The purpose of this study was to evaluate the performance a newly developed nanocrystalline hydroxyapatite, OSTIM following functional implantation in femoral sites in thirty-eight sheep for 1, 2 or 3 months. Ostim 35 was compared to an established calcium phosphate, Alpha BSM. METHODS: Biomechanical testing, micro-CT analysis, histological and histomorphological analyses were conducted to compare the treatments including evaluation of bone regeneration level, material degradation, implant biomechanical characteristics. RESULTS: The micro-computed tomography (microCT) analysis and macroscopic observations showed that Ostim seemed to diffuse easily particularly when the defects were created in a cancellous bone area. Alpha BSM remained in the defect.The performance of Ostim was good in terms of mechanical properties that were similar to Alpha BSM and the histological analysis showed that the bone regeneration was better with Ostim than with Alpha BSM. The histomorphometric analysis confirmed the qualitative analysis and showed more bone ingrowth inside the implanted material with Ostim when compared to Alpha BSM at all time points. CONCLUSIONS: The successful bone healing with osseous consolidation verifies the importance of the nanocrystalline hydroxyapatite in the treatment of metaphyseal osseous volume defects in the metaphyseal spongiosa.

Kyphoplasty for patients with multiple myeloma is a safe surgical procedure: results from a large patient cohort.

INTRODUCTION: Only in recent years has balloon kyphoplasty gained significance in the treatment of vertebral fractures as an adequate minimally invasive vertebral stabilization technique. Kyphoplasty has also increasingly been used to treat vertebral osteolyses caused by multiple myeloma (MM). PATIENTS AND METHODS: In our cohort of 76 patients with MM with a total of 190 vertebral fractures treated with kyphoplasty, we performed a 30-day postoperative analysis of cement leakage, neurologic symptoms, pulmonary embolism, and infections. RESULTS: Painful osteolytic or fractured vertebrae or even imminent vertebral instability caused by osteolyses were seen as indications for kyphoplasty. One case of pulmonary embolism was observed because of cement leakage as the only postoperative complication. CONCLUSION: By careful interdisciplinary indication setting and a standardized treatment model, kyphoplasty presents a very safe and effective procedure for the treatment of vertebral osteolyses and fractures caused by MM.

Crush syndrome due to drug-induced compartment syndrome: a rare condition not to be overlooked.

PURPOSE: The crush syndrome caused by drug-induced compartment syndrome (DCS) is a challenge for surgeons because it is regularly associated with potentially fatal complications. Drug-induced compartment syndrome can often be distinguished from other forms of compartment syndrome by the presence of severe rhabdomyolysis with kidney crush and severe postoperative complications such as local and generalized infection, persistent nerve damage, coagulopathy, and multiorgan failure. METHODS: In the past 15 years, eight prospectively documented, operatively managed, DCS with subsequent crush syndrome cases were recorded. RESULTS: All of the patients required renal replacement therapy. The creatine kinase (CK) values in the context of rhabdomyolysis reached an average of 86 (range 47-144) kU/l. The renal function recovered in all surviving patients. The analysis showed that the diagnosis of a DCS is usually made after an average of 13 h. It then took an average of an additional 7 h before a fasciotomy was performed. Six operational revisions were necessary. In three out of eight patients the extremities had to be amputated. CONCLUSIONS: In DCS the decision to open the compartment should be made immediately upon the clinical diagnosis. A protracted intensive phase is expected. The benefit to patients is closely associated with surgical wound debridement along with rigorous intensive therapy.

1150 kyphoplasties over 7 years: indications, techniques, and intraoperative complications.

In our cohort of 555 patients with a total of 1150 vertebral fractures treated with kyphoplasty we performed a 30-day postoperative analysis of cement leakage, neurological symptoms, pulmonary embolism, and infections. In our department, 22% of kyphoplasties were performed with calcium phosphate cement and the remainder with polymethylmethacrylate. All patients were initially assessed by an interdisciplinary kyphoplasty colloquium, composed of consultants in traumatology, radiology, and endocrinology. Indications included fresh traumatic vertebral fractures; painful sintered osteoporotic vertebrae; osteolysis and painful vertebral body collapse caused by multiple myelomas; and lymphomas and pathological fractures due to metastases of malignant tumors (prostate cancer, breast cancer, ovarian cancer, and malignant melanoma) or benign vertebral tumors (hemangioma). Contraindications included patients with instability of the posterior wall and/or pedicles, an infection of the fractured vertebra, a severe hemorrhagic diathesis, known allergies to the cements, pregnancy, and ASA score of 4. The standard postoperative computed tomography scan of the kyphoplasty-treated vertebrae revealed a dorsal cement leakage in 38 vertebrae representing 3.3% of all levels. A permanent monoparesis of the left leg, 2 cases of temporary neurological deficits, 2 cases of hemorrhage, and 1 asymptomatic pulmonary embolism were observed as postoperative complications. We observed no complications relating to polymethylmethacrylate described in the literature. By careful interdisciplinary indication setting and a standardized treatment model, kyphoplasty presents a safe and effective procedure for the treatment of various vertebral fractures.

The effect of synacthen on acute necrotizing pancreatitis in rats.

OBJECTIVES: This study investigates the hypothesis that an adrenocorticotropic hormone-analog therapy may ameliorate relative adrenal insufficiency in the early phase of acute necrotizing pancreatitis (NP) by boosting endogenous glucocorticoid production. METHODS: Forty Wistar rats with taurocholate-induced NP were divided into 5 groups: the first group received low-dose Synacthen (0.5 mg/kg); the second, high-dose Synacthen (5mg/kg); the third,low-dose cortisol (10 mg/kg); the fourth, high-dose cortisol (100 mg/kg); and the fifth, the control group, received no treatment. All animals were killed after 6 hours: concentrations of plasma corticosterone, interleukin 1 (IL-1), IL-6, IL-10, tumor necrosis factor alpha, amylase, and lipase in ascites, myeloperoxidase activity in the pancreas, and a histological score were evaluated. RESULTS: Corticosterone increased neither in the low-dose nor in the high-dose Synacthen group. Synacthen did not improve the early course of NP in terms of laboratory and histological results. A reduction of pancreatic necrosis and inflammation was observed in the low-dose cortisol group. CONCLUSIONS: Endogenous glucocorticoid release seemed to be at its maximum during the early stage of NP and could not be further increased by Synacthen. Low-dose exogenous cortisol ameliorated the disease. These findings support the existence of relative adrenal insufficiency in the early phase of acute NP.

Evaluation of a novel nanocrystalline hydroxyapatite paste and a solid hydroxyapatite ceramic for the treatment of critical size bone defects (CSD) in rabbits.

The purpose of our study was to test the effectiveness of Ostim nanocrystalline hydroxyapatite paste and Cerabone ceramic by treating a critical size bone defect (CSD) on the right foreleg of a white New Zealand rabbit. Evaluation was carried out by comparing four groups each with a different CSD filling: an only OSTIM bone filling, an only Cerabone filling, an OSTIM-Cerabone combination, and a control group with no filling of the CSD. The results of this study display a rapid and uniform bone ingrowth following the CSD filling with Ostim. The histological and histomorphometrical data have shown similarly excellent results for both the Ostim and Cerabone-Ostim groups. The control group faired poorly in comparison, as three cases of non-union were observed and none of the defects were totally refilled with fresh bone within 60 days. The successful bone healing with osseous consolidation verifies the importance of the nanocrystalline hydroxyapatite in the treatment of metaphyseal osseous volume defects in the metaphyseal spongiosa.

The use of nanocrystalline hydroxyapatite for the reconstruction of calcaneal fractures: Preliminary results.

The purpose of this investigation was to evaluate the feasibility of a nanocrystalline hydroxyapatite compound in the treatment of calcaneal fractures with osseous defects after reduction. The study included 21 patients, representing 24 closed intraarticular calcaneus fractures with large defects remaining after operative reduction. All cases were supplemented with the hydroxyapatite bone substitute and stabilized with a calcaneal honeycomb plate. Radiographs were taken at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively, with specific attention given to measurement of Gissane's angle, Böhler's angle, and calcaneal height. A postoperative subjective and objective evaluation of the fracture, using the Creighton Nebraska Health Foundation scale, was performed 1 year postoperatively. Böhler's angle improved from a mean 8.6 +/- 5.3 degrees preoperatively to an immediate postoperative mean result of 31.5 +/- 6.5 degrees and 27.7 +/- 8.6 1 year postoperatively. The mean Creighton-Nebraska functional score was 86 +/- 10 at the 1-year follow-up evaluation. These results suggest that open reduction with plate fixation combined with nanocrystalline hydroxyapatite augmentation presents a good and reliable surgical technique for treatment of calcaneus fractures.

Void filling of tibia compression fracture zones using a novel resorbable nanocrystalline hydroxyapatite paste in combination with a hydroxyapatite ceramic core: first clinical results.

INTRODUCTION: It is a generally accepted standard surgical practice to fill-in the metaphyseal defect zones resulting from the reduction of tibia compression fractures. The development of various innovative bone substitutes is also currently on the increase. MATERIALS AND METHODS: In our prospective study, we used Ostim, a novel resorbable nanocrystalline hydroxyapatite paste, together with Cerabone, a solid hydroxyapatite ceramic, in combination with angularly stable osteosynthesis to treat 24 tibia compression fractures. Types B2 and B3, as well as types C2 and C3 fractures, according to the AO classification, were included in the study. RESULTS: The mean total range of joint motion in terms of flexion and extension was improved from the immediate postoperative value of 79 +/- 14 degrees to 97 +/- 13 degrees at 6 weeks after surgery, to 109 +/- 16 degrees at 3 months, and finally to 118 +/- 17 degrees at 1 year. In three patients, a delayed wound healing was observed as a local complication. CONCLUSION: The use of the Ostim and Cerabone combination is an effective method in treating tibia compression fractures with large defect zones left after reduction.