First long-term analysis of survival and clinical outcome in patient-specific instrumentation for total knee arthroplasty: follow-up of a prospective cohort study.

Patient-specific instrumentation (PSI) was introduced to improve post-operative alignment, and consequently the revision rate and clinical results after total knee arthroplasty (TKA). Short- to mid-term data are conflicting regarding these theoretical advantages of PSI. The purpose of this retrospective analysis was to evaluate the survival rate and clinical outcome in PSI TKA 8.4 years after initial surgery. To our knowledge, no other study investigated long-term follow-up of TKA procedures using PSI. From a total cohort of 184 consecutive patients (200 TKA) 136 patients (144 TKA, 72%) were prospectively analysed at a mean follow-up of 8.4 years (±0.4). A survival analysis with all-cause revision of TKA as endpoint was performed. Patient-reported outcome measures (PROMs) were obtained preoperatively and after 1-, 2-, 5-, and 8.4-years of follow-up. Differences between these moments of follow-up were analysed. At final follow-up, 4 TKAs (2%) had undergone revision, all between 2-4 years after primary surgery. Reasons for revision were late infection, aseptic loosening, instability and polyethylene insert breakage. The median score of certain PROMs (WOMAC, VAS, EQ-index, EQ-VAS) decreased compared to previous follow-up scores but were significantly higher than preoperative scores. After 8.4 years of follow-up, no additional revision surgery was performed compared to 5-years postoperatively. Certain PROMs at 8.4-year follow-up decreased compared to earlier moments of follow-up, but all PROMs improved compared to preoperative PROMs.

A short-term radiological and clinical comparison between the bi-cruciate and cruciate retaining total knee arthroplasty A retrospective case controlled study.

PURPOSE: The aim of this study was to provide a short term comparison in radiological and clinical outcome between Bi-Cruciate Retaining (BCR)- and Cruciate Retaining (CR) Total Knee Arthroplasty (TKA). METHODS: The cohort consists of 122 patients undergoing a TKA with PSI, equally distributed over the BCR- and CR-TKA group. Perioperative conditions were observed and radiological images were analysed pre-, 6-weeks, and 1-year postoperative to quantify alignment differences between BCR- and CR-TKA. Preoperatively predicted templates were compared with the implanted size to determine predictive value. In addition mean range of motion and revision rates were determined in both groups. RESULTS: No significant difference was observed in amount of outliers in component alignment between BCR- and CR-TKA. Outliers of the Hip-Knee-Ankle-Axis (HKA-axis) occurred significantly more frequent (P = 0.009) in the BCR-group (37.7%) compared to CR-TKA (18.0%). No clinically relevant differences regarding the predictive sizing of implant components was obtained. No significant differences were observed in revision rates (P = 1.000) and ROM (p = 0.425) between the BCR-groep and CR-group at 2-years FU. CONCLUSION: This study illustrates that although the HKA-axis was not fully restored, bi-cruciate retaining surgical technique for BCR-TKA is safe and effective with comparable radiological and clinical outcome as CR TKA. Randomized controlled trials with longer follow up on the HKA-axis alignment and clinical parameters are needed to confirm the presented results and should focus on possible cut off values concerning leg axis in order to define in what patients a BCR-TKA can safely be used. LEVEL OF EVIDENCE IV: Retrospective Case Controlled Study.

[Determination of Hypercapnic Ventilatory Response in COPD Patients]. / Bestimmung der hyperkapnischen Atemantwort bei Patienten mit COPD.

Previous studies showed a reduced hypercapnic ventilatory response (HCVR) in patients with COPD. However, the association between HCVR and COPD GOLD stages is unknown. The measurement of the HCVR is a methodological option to test the function of the breathing feedback cycle. The aim of this feasibility study was to present a new automatic and standardized device (MATAM) to measure and interpret the HCVR. This device determines if exposure to CO2 leads to an adequate increase in breathing frequency and tidal volume. Recordings are performed in a closed system that allows selective changes of each gas component. The minute ventilation (AMV) under hypercapnic stimulation is plotted against the end-tidal CO2 (ETCO2). The HCVR is defined as the linear regression line.28 patients (18 male; 10 female) with COPD GOLD stages 0 to IV were studied. The patients had a mean age of 57 ±â€Š14 (standard deviation) years and a mean BMI of 32 ±â€Š9 kg/m(2). We could show that the HCVR measurement in patients with COPD using MATAM was feasible. Patients with more severe COPD stages had a significantly more reduced HCVR. This could be an indication of reduced chemosensitivity due to a worsening of blood values (pH and pCO2) which affect the central chemoreceptors in the long term. Further studies will be needed to validate the MATAM device for healthy individuals and other patient groups, and for the investigation of standard values.

[ThorAKUSTIK - a computer-based method to determine the oronasal respiratory flow]. / Bestimmung der Atemstromstärke mithilfe des ThorAKUSTIK-Verfahrens bei Mund- und Nasenatmung.

BACKGROUND: Respiratory flow detection with the aim of detecting sleep-related breathing disorders plays a major role in polysomnography. Due to the fact that pneumotachographs are too bulky and not suitable for measurements during sleep, the ThorAKUSTIK system has been developed. By attaching a noise sensor right next to larynx, it determines the respiratory flow in an acoustic way. METHODS: The ThorAKUSTIK system as well as a pneumotachograph were applied simultaneously. The correlation between those two methods has been calculated. PATIENTS: We investigated twenty male subjects. All of them were non-smokers. RESULTS: The ThorAKUSTIK-System showed a highly positive correlation (r = 0.89 to 0.91; p < 0.01) and was able to measure the respiratory flow in a reliable way. CONCLUSIONS: The ThorAKUSTIK-System allows a long-term live monitoring and has the potential to be used in several clinical departments. Larger studies are necessary to verify the application in the clinical routine.

Predisposition of subtle endometriotic lesions predominantly on the left side assessed by transvaginal hydrolaparoscopy (THL).

OBJECTIVE: Endometriosis is one of the most frequent gynaecological disorders being associated with infertility. Hence, the early detection of endometriosis in infertility patients is of importance for the treatment modalities in infertility. Transvaginal hydrolaparoscopy (THL) offers an accurate, safe and quick diagnostic tool, not only for the evaluation of the fallopian tubes but also for the detection of very subtle endometriotic lesions in the early stages of endometriosis. STUDY DESIGN: Between January 2008 and January 2010, we conducted a study in order to evaluate the prevalence, extent and localisation of endometriosis via the new technique of THL in infertility patients. 239 patients with a mean age of 33.9 years underwent THL after having given informed consent. RESULTS: In 237 patients, access to the cul-de-sac was successfully achieved. Endometriosis was detected in 77 of 237 cases (32.5%). In 85.7% of cases, the endometriotic lesions were classified as very small (ASRM stage I°). Predominantly, the small lesions were found merely on the left side of the patient's peritoneal cavity: in 43 cases (55.8%), endometriosis was detected strictly on the left side, whereas the disease was detected on the right side in only 5 patients (6.5%). In 29 patients, endometriosis could be detected in both sides of the pelvis (37.7%). The differences in the side-dependent distribution were statistically highly significant (p<0.0001). In most of the cases, the subtle endometriotic lesions affected the ovarian surface superficially (53.5%) or the peritoneum of the lateral pelvic wall (25.6%). CONCLUSIONS: These data clearly indicate that there is a high prevalence of endometriosis in patients with infertility. THL is an accurate, safe and quick method for a thorough examination of the female pelvis besides the patency of the fallopian tubes. The high prevalence of left-sided subtle endometriotic lesions must be interpreted that during THL a very early process in the development of endometriosis can be observed. Even minimal to mild endometriosis might lead to a significant restriction in uterotubal transport capacity whose integrity is directly correlated to normal pregnancy rates. The extent of the accompanying adenomyosis is directly correlated to the loss of intact uterotubal transport capacity.

Extraction of testicular sperm from previously cryopreserved tissue in couples with or without transport of oocytes and testicular tissue.

OBJECTIVE: To evaluate results of IVF and intracytoplasmic sperm injection (ICSI) with extraction of sperm from frozen-thawed testicular tissue. DESIGN: Retrospective follow-up study. SETTING: Fertility center. PATIENT(S): Thirty-five couples with transport of testicular tissue from a transport clinic and 125 local couples. INTERVENTION(S): Extraction of testicular sperm by maceration and enzymatic digestion from frozen-thawed testicular tissue before ICSI. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (PR) and implantation rate in couples with obstructive or nonobstructive azoospermia, motile or immotile sperm, and differing male serum FSH values. RESULT(S): The clinical PR per ET and implantation rate per embryo in couples with transport of testicular tissue were 40% and 18%, respectively, in cases of obstructive azoospermia and 37% and 26%, respectively, in cases of nonobstructive azoospermia. In the local couples, these rates were 42% and 19%, respectively, in cases of obstructive azoospermia and 18% and 10%, respectively, in cases of nonobstructive azoospermia. The implantation rates for ICSI were 26% with motile sperm and 11% with immotile sperm in the transport group and 16% and 8%, respectively, in the local group. Male serum FSH level did not clearly correlate with implantation rate. CONCLUSION(S): Clinical PR and implantation rate are not affected by transport of testicular tissue but are significantly affected by nonobstructive azoospermia and the use of immotile sperm. No major increase in chromosomal aberration or congenital malformation was noted in the offspring of this limited group.

Chromosomal aberrations in couples undergoing intracytoplasmic sperm injection: influence on implantation and ongoing pregnancy rates.

OBJECTIVE: To determine the incidence of chromosomal aberrations in couples undergoing intracytoplasmic sperm injection (ICSI) and their influence on subsequent implantation and ongoing pregnancy rates. DESIGN: Prospective study. SETTING: Fertility center. PATIENT(S): Candidates for ICSI. INTERVENTION(S): Chromosomes were trypsin-banded in 2,280 patients. In all cases, 10 metaphases were karyotyped. Sex chromosome analysis was performed in 10 additional metaphases. When apparent chromosomal aberrations were detected, 100 metaphases were analyzed. MAIN OUTCOME MEASURE(S): Implantation and ongoing pregnancy rates in couples with a chromosomal disorder. RESULTS: A chromosomal abnormality was demonstrated in 7.2% of all couples. Among the male partners, 4.48% had aberrations. Autosomal aberrations were present in 2.96%, and numerical or structural sex chromosome abnormalities were found in 1.52%. Among the female partners, numerical or structural abnormalities were documented in 9.79%. Only 2.32% of the female partners had autosomal structural abnormalities. Numerical or structural anomalies involving sex chromosomes were found in 7.47%. Implantation rates of 9.4% and 16.3% per embryo were observed in female partners with sex chromosome mosaicism and autosomal aberrations, respectively. In male partners, the respective rates were 3.8% and 23.1%. CONCLUSION(S): The incidence of chromosomal disorders in couples seeking ICSI treatment is considerable, especially minor mosaicism (<10%) of sex chromosomes in the female partners. Preliminary data indicate a low implantation rate in couples with minor mosaicism of sex chromosomes.

Blastocyst transfer in day-5 embryo transfer depends primarily on the number of oocytes retrieved and not on age.

OBJECTIVE: To analyze the effects of patient age and treatment cycle number on the occurrence of blastocyst transfer and subsequent implantation. DESIGN: Prospective study. SETTING: Department of endocrinology and reproduction. PATIENT(S): All 1,099 women had day-5 transfers after IVF or intracytoplasmic sperm injection treatment. INTERVENTION(S): All patients were checked for embryo development in vitro in consecutive day-5 transfer cycles. Two blastocysts or three lesser-developed embryos were transferred. MAIN OUTCOME MEASURE(S): Blastocyst formation rate or clinical pregnancy/implantation rate. RESULT(S): Of 929 patients in the first cycle, 545 (59%) had at least one blastocyst available for ET. Among 151 patients with a blastocyst in cycle 1, 77 developed one or more blastocysts in cycle 2 (51%). Fifty of 143 patients without a blastocyst in cycle 1 had at least one blastocyst in cycle 2 (35%). After subdivision of all day-5 ETs according to the first four cycles, the following implantation rates per embryo were found for ET with one or more blastocysts: cycle 1 (n = 545), 23%; cycle 2 (n = 264), 23%; cycle 3 (n = 110), 14%; and cycle 4 (n = 27), 12%, and with noncavitating embryos, respectively: (n = 384) 6%, (n = 193) 6%, (n = 94) 2%, and (n = 35) 3%. The negative correlation of the age of the woman on blastulation depended primarily on the number of oocytes retrieved. CONCLUSION(S): The blastocyst implantation rate decreased after cycle 2. Biologic ovarian age, rather than chronologic age, determines the frequency of blastocyst transfer or pregnancy rate.

A prospective, randomized study of embryo transfer results after 3 or 5 days of embryo culture in in vitro fertilization.

OBJECTIVES: To compare the implantation rate of embryos after 3 and 5 days of IVF culture. DESIGN: Prospective randomization of ET depending on the weekday of ovum pick-up (OPU). SETTING: University Department of Endocrinology and Reproduction. PATIENTS: All women entering an outclinic IVF program. INTERVENTIONS: Two hundred thirty-three ETs performed on day 3 after OPU and 410 performed on day 5 were analyzed. When blastocysts with a clear inner cell mass were available, a maximum of two were replaced. RESULTS: On day 3 after OPU, 60 pregnancies per 233 ET (26%) and on day 5, 102 pregnancies per 410 ET (25%) were induced. The average implantation rate per embryo was 13% and 12%, respectively. After subdivision according to embryo morphology, pregnancy rate per ET (n = 59) and implantation rate per embryo on day 3 with exclusively unfragmented embryos were 32% and 18%, respectively, not significantly different from ET (n = 73) exclusively with embryos containing > 0% and < 20% fragments: 27% and 12%. After transfer on day 5, when one or more cavitating embryos were available (n = 227), pregnancy and implantation rates were 40% and 23%, statistically different from ET on day 3. On day 5, ET exclusively with morula stages showing signs of starting blastulation (n = 26), pregnancy rate and implantation rate were 12% and 11%, respectively, from ET (n = 157) with embryos not reaching the latter stage: 6% and 3%. CONCLUSIONS: Overall ET results after 3 and 5 days are comparable. After 5 days of culture, one to two embryos can be replaced with an average implantation rate of > 23% per embryo, minimizing the incidence of triplets.

A randomized study of transcervical intrafallopian transfer of pronucleate embryos controlled by ultrasound versus intrauterine transfer of four- to eight-cell embryos.

OBJECTIVE: To establish the value of transcervical intrafallopian transfer of zygotes and the accuracy of fallopian cannulation. DESIGN: A prospective randomized study, comparing ultrasonically controlled transcervical intrafallopian transfer of zygotes with intrauterine transfer of cleaved embryos. SETTING: Department of IVF of the Rotterdam Academic Hospital. PATIENTS: One hundred forty-five patients with patent tubes entered the IVF program. MAIN OUTCOME MEASURE: Pregnancy rates in both groups and ultrasound (US) assessment during fallopian cannulation and ET. RESULTS: Transvaginal cannulation of the tube appears not to be sufficiently accurate when performed without US guidance. Catheter damage occurred in many cases. The previously reported superior implantation rate after intrafallopian transfer in comparison with intrauterine transfer could not be confirmed. CONCLUSIONS: Intrauterine transfer of cleaved embryos remains the method of choice in IVF.

Determination of cyclophosphamide in urine by gas chromatography-mass spectrometry.

A sensitive gas chromatographic method for the determination of cyclophosphamide in urine is presented. After liquid-liquid extraction with diethyl ether and derivatization with trifluoroacetic anhydride, cyclophosphamide was identified and quantified with mass spectrometry. The method is suitable for the determination of cyclophosphamide at concentrations of more than 0.25 ng/ml, which enables the uptake of cyclophosphamide during occupational activities, such as the preparation and administration of antineoplastic agents in hospitals, to be measured. Simple preparation makes the method appropriate for routine analysis.

Vaginal disinfection with povidon iodine and the outcome of in-vitro fertilization.

In a prospective randomized study, the influence was assessed of vaginal disinfection with a 1% solution of povidon iodine (Betadine), before performing a transvaginal ultrasound-guided oocyte retrieval, on fertilization, cleavage rate and pregnancy rate. The outcome of 334 oocyte retrievals was studied. In 160 cases, Betadine was used and in the remaining 174 cases, normal saline was used. No differences in the fertilization and cleavage rates were found (fertilization 45.5% versus 47.8%, cleavage 49.8% versus 52.1% in the Betadine and normal saline groups respectively). However the pregnancy rate was significantly higher in the normal saline group (17.2% versus 30.3% clinical pregnancies per embryo transfer). No increase in infection risk occurred in the saline group.

Transcervical intrafallopian transfer of zygotes.

Reportedly, gamete intrafallopian transfer and zygote intrafallopian transfer are successful methods in assisted conception. This pilot study describes the experiences and results of a recently developed technique of vaginal transcervical intrafallopian transfer. In a group of 38 women with unexplained infertility, oocytes were retrieved. In 25 patients, pronucleate embryos were transferred to the fallopian tubes. A positive pregnancy test was reported in 8 cases. Considerations pertaining to this method and technical implications are discussed.

Uterine and ovarian flow velocity waveforms in the normal menstrual cycle: a transvaginal Doppler study.

A combined transvaginal 2D real-time and pulsed Doppler method was used for recording flow velocity waveforms in the uterine and ovarian arteries from 16 healthy women during the follicular and luteal phase of the normal menstrual cycle. Continuous forward end-diastolic flow velocities were documented in 74% of the ovarian artery and 96.5% of the uterine artery flow velocity waveforms. Comparison of the pulsatility index from the left and right ovarian artery revealed a significantly lower pulsatility index on the side of the ovary bearing the developing corpus luteum, suggesting reduced down-stream impedance or increased blood flow. The pulsatility index from the uterine artery only seems to be marginally involved in the observed impedance changes during the luteal phase of the menstrual cycle.