Activated Protein C Resistance Does Not Increase Risk for Recurrent Stroke or Death in Stroke Patients.

BACKGROUND: Activated protein C (APC) resistance is the most common inherited prothrombotic disorder. The role of APC resistance in ischemic stroke is controversially discussed. OBJECTIVES: The aim of this single center follow up study was to investigate the effect of APC resistance on stroke recurrence and survival in stroke patients. PATIENTS/METHODS: We retrospectively identified 966 patients who had had an ischemic stroke or transitory ischemic attack (TIA) and in whom laboratory tests for APC resistance had been conducted. These patients were contacted to determine the primary outcomes of recurrent ischemic stroke or death. RESULTS: A total of 858 patients with an average follow up time of 8.48 years were included. APC resistance did not influence cumulative incidence functions for stroke free and total survival. In multivariate analyses, crude and adjusted hazard ratios for recurrent stroke as well as for death where not significantly increased in patients with APC resistance. This also applies to the subgroups of young patients, patients with cryptogenic stroke and patients with atrial fibrillation. CONCLUSION: APC-resistance is not a risk factor for subsequent stroke or death in patients with a first ischemic stroke or TIA. Testing for APC-resistance in stroke patients therefore cannot be routinely recommended.

Watching soccer is not associated with an increase in cardiac events.

BACKGROUND: It remains controversial, whether spectators of soccer matches are exposed to an increased risk of cardiac events. In 2006, the Soccer World Cup (SWC) took place in Germany and provided an excellent opportunity to assess the effects of emotional stress on cardiac events in a large cohort of soccer enthusiasts in the region of Bavaria. METHODS: We analyzed data from the Bavarian Council for Statistics and Data Management for the period of SWC (June 9-July 9, 2006) and reference periods (SWCRef; May 1-July 31, 2005; May 1-June 8, 2006 and July 10-31, 2006) for the following diagnoses: myocardial infarction; myocardial re-infarction; cardiac arrest; paroxysmal tachycardia; atrial fibrillation, atrial flutter; all remaining tachyarrhythmias. Data were compared to the seven days during the tournament, on which the German team played (SWCGerman), the rest of the SWC period (i.e. the days the German team did not play, 24 days, SWCRest) and SWCRef (61 days). RESULTS: There was neither a significant increase (p>0.433) in total cardiac events in Bavaria per day during SWCGerman (161.1 ± 46.7) or SWCRest (170.5 ± 52.3) as compared to the SWCRef (176.2 ± 51.8), nor in any investigated diagnosis. After controlling for age, gender, loss of a match, outside temperature and nitric-dioxide air pollution levels the results remained essentially unchanged. CONCLUSION: Watching soccer was not associated with an increased incidence of cardiac events, regardless of whether the home team played or not. These data further support the hypothesis that spectators of sporting events are not exposed to an increased risk of cardiac events.

Intra-articular versus periarticular acromioclavicular joint injection: a multicenter, prospective, randomized, controlled trial.

PURPOSE: The purpose of this randomized study was to compare the clinical efficacy of intra-articular versus periarticular acromioclavicular joint injections. METHODS: In this multicenter, prospective, randomized, controlled trial, 101 patients (106 shoulders) with symptomatic acromioclavicular joints were treated with an injection and were randomly assigned to either the intra-articular group or the periarticular group. To ensure accurate needle placement either intra-articularly or in a periarticular manner, the needle was placed under ultrasound guidance. Baseline values including the Constant-Murley score, pain assessment with a visual analog scale for pain under local pressure and pain at night, and the crossover arm test were investigated in 7 different centers immediately before treatment. Follow-up examinations were scheduled after 1 hour, 1 week, and 3 weeks. RESULTS: All patients completed the study. Overall, a highly significant clinical improvement in all tested variables and in both groups was observed over time (P < .0001) beginning with 1 hour after treatment and lasting for the entire follow-up period of 3 weeks. The difference between the 2 groups was not significant except regarding the crossover arm test (P < .016). CONCLUSIONS: With both injection techniques, a highly significant clinical advantage for the patient can be achieved. The difference between the 2 treatments was not significant except for more pain reduction according to the crossover arm test after intra-articular injection at 3 weeks' follow-up. LEVEL OF EVIDENCE: Level II, multicenter, randomized, prospective, controlled trial.

Mismatch between heart failure patients in clinical trials and the real world.

BACKGROUND: Evidence-based medicine urges physicians to translate results from clinical trials to their patients. This, however, can only work, if real world patients are represented in clinical trials. METHODS: We searched the literature on chronic heart failure (1950-2/2011) for studies designed to detect effects on mortality (mortality studies, MS) and exercise training studies (ETS) as the leading non-pharmaceutical/non-surgical treatment option in order to compare their characteristics with European (Euro Heart Survey on Heart Failure, EHSHF) and North American (Framingham Heart Study, FHS) epidemiological studies. RESULTS: After an extensive literature search, we identified 207 ETS and 59 MS. Subjects enrolled in ETS were younger (ETS: 62.5 ± 6.6; MS: 63.9 ± 4.6; EHSHF: 71.0 ± 3.5; FHS: 78.0 years), more often male (ETS: 80.9%; MS: 77.3%; EHSHF: 53.0%; FHS: 49.6%; p<0.001), and had substantially less comorbidities such as diabetes mellitus (ETS: 13.6%; MS: 22.5%; EHSHF: 27.0%; FHS: 25.3%; p<0.001), or hypertension (ETS: 26.3%; MS: 39.1%; EHSHF: 53.0%; FHS: 46.9%; p<0.001). Angiotensin converting enzyme-inhibitors, beta-blockers, and angiotensin-receptor-blockers were more commonly used in ETS than in EHSHF (all p<0.001). Only 16 (10.6%) ETS and 20 (62.5%) MS reported ethnic background. CONCLUSION: Heart failure patients in exercise training studies and mortality studies do not represent real world patients. In order to extrapolate data to the general population future exercise training studies as well as mortality studies need to include representative patients. Otherwise, knowledge gained can only be translated to a minority of our patients.

Influence of surgical experience on the efficiency of discectomy in TLIF: a cadaveric testing in 40 levels.

STUDY DESIGN: Cadaveric study. OBJECTIVE: The purpose of this study was to assess the influence of surgical experience on the efficiency of lumbar discectomy in open transforaminal lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: There is limited knowledge about the efficiency of discectomy among surgeons. As a first study, we are evaluating the effect of surgical experience on it. METHODS: Manual and powered discectomies were randomized and performed by 3 attending spine surgeons and 2 clinical spine fellows. Each discectomy procedure was analyzed for the area of complete endplate preparation, total elapsed time, and number of instrument passes. The surface area of discectomy at each endplate was measured utilizing digital imaging and the appropriate software. For the purpose of the analysis, the superior and the inferior endplates were divided into ipsilateral and contralateral halves, and each half was further divided into ventral and dorsal quadrants. Each quadrant was analyzed in a blinded manner by 2 observers. RESULTS: A total of 40 discectomies were performed on 9 fresh-frozen cadaveric torsos between the levels T12 and S1. A powered discectomy device was used in levels 9 and 11 by the attendings. Manual discectomy was performed in 11 levels by the spine fellows and 9 by the spine attendings. No significant difference was observed between the spine fellows and spine attendings when the manual instruments were used (P = 0.924). However, the spine attending surgeon group had a significantly increased total area of discectomy compared with the fellows (P = 0.003). No significant difference was observed between the groups when instrument passes or the total elapsed time were compared either utilizing the manual or the powered technique. CONCLUSIONS: Our results demonstrate that a satisfactory discectomy may be performed by surgeons with relatively less surgical experience in the transforaminal approach using a powered discectomy device.

Management of Vancouver B2 and B3 femoral periprosthetic fractures using a modular cementless stem without allografting.

PURPOSE: We reviewed our experience with the management of B2 and B3 femoral periprosthetic fractures using a distally fixed modular femoral stem in 55 patients. METHODS: All periprosthetic fractures were managed immediately after injury without using allograft; 53 hips were available for a mean follow up of 67 months. RESULTS: All fractures united, and the mean Harris hip score at the last follow up was 72. Subsidence was noted in two patients (4%) within six months postoperatively and required revision surgery. One patient developed peroneal nerve palsy. Two hips dislocated and were managed by closed reduction. CONCLUSION: In these severe cases of periprosthetic fracture, the technique reviewed here proved to be reliable.

Femoral shortening and cementless arthroplasty in Crowe type 4 congenital dislocation of the hip.

PURPOSE: In reconstruction of congenital hip dislocation by total hip arthroplasty (THA), positioning of the acetabular component in the true acetabulum is sometimes accompanied by shortening of the femur. Shortening of the femur is of importance for minimising risk of damaging neurovascular structures due to excessive limb lengthening. Furthermore, reduction of the femoral head into the true acetabulum remains challenging without shortening of the femur. METHODS: We performed a consecutive case series of cementless THA with femoral shortening and Crowe type 4 congenital dislocation. All acetabular cups were placed in their original anatomical location. In all cases a proximal diaphyseal step-cut shortening osteotomy was performed and stabilised with two to three titanium cerclage bands. RESULTS: At an average of 60 months follow-up (range 36-96), 12 patients (13 THA) were scored clinically by the Merle D'Aubigne and Harris hip scores. In ten cases good to excellent outcome scores were observed. During the follow-up period no cases of aseptic loosening, nerve palsy, nonunions or dislocations were found. CONCLUSIONS: This technique seems to be an excellent treatment option in the case of Crowe type 4 hips presenting with endstage osteoarthritis.

Follow-up of thirty-three computed-tomography-guided percutaneous radiofrequency thermoablations of osteoid osteoma.

PURPOSE: This study aimed to determine the mid- and long-term success and complication rates of radiofrequency ablation (RFA) in treatment of osteoid osteoma (OO). Furthermore we were interested in the value of bone biopsy when using a core-drill before the radiofrequency ablation. METHODS: We retrospectively analysed data of 33 patients (33 osteoid osteomas, 22 males, 11 females) who underwent computed-tomography (CT) guided radiofrequency ablation between 1998 and 2005. The patients had a mean age of 20 years (range, five to 50 years). They were monitored for a mean follow-up of 92 months (range, 60-121 months). RESULTS: Lesions were located as follows: 11 cases in the proximal femur, five in the femoral shaft, six in the tibia, one in the calcaneus, two in the metatarsals (second and fourth metatarsals), one in the os cuneiforme mediale, six in the humeral and one in the ulnar shaft. Within the presented time frame 32 of 33 patients were successfully treated and had no more complaints. In one of 33 patients relapse occurred after 28 months and RFA was repeated. There were no complications associated with the procedure. Biopsy obtained prior to thermocoagulation with the help of a core-drill was able to prove diagnosis in all patients (100%). CONCLUSIONS: These results indicate that the presented technique of CT guided RFA combined with the use of a core-drill for biopsy prior to RFA treatment is a highly effective, efficient, minimally invasive and safe method for the treatment of OO, yielding a success rate of 97% combined with a 100% histological verification of the diagnosis after a minimum follow-up period of five years.

Revision total hip arthroplasty using a cementless tapered revision stem in patients with a mean age of 82 years.

PURPOSE: A tapered straight cementless stem was used for revision in a group of old and very old patients. We wanted to know whether the use of this implant could achieve satisfactory results despite age and osteoporosis. METHODS: We retrospectively analysed data of 77 elderly patients (77 hips) who underwent revision in cemented and uncemented primary total hip arthroplasties (THA). The patients had a mean age of 82.2 years (range, 75-92 years) at revision surgery. They were monitored for a mean follow up of 7.1 years (range, 5.0-10.2 years). During the minimum follow-up period 11 patients died of unrelated causes, leaving 66 patients (66 hips) for evaluation. RESULTS: During the period of study three stems failed due to aseptic loosening, three hips dislocated and were successfully treated by closed reduction and bracing. No infection, osteolysis or significant stress shielding around the stems was observed. The survivorship at an average of 7.1-year follow-up was 95.5%. CONCLUSIONS: These results indicate that this stem is an excellent alternative in revision THA in patients of 75 years or older.

Synovial immunopathology in haemochromatosis arthropathy.

BACKGROUND: Hereditary haemochromatosis (HH) is a common autosomal recessive inherited disorder that frequently causes arthritis. The pathophysiology of musculoskeletal involvement is, however, unclear. OBJECTIVE: To analyse synovial tissue obtained at surgery from patients with HH arthropathy and compare it qualitatively and quantitatively with specimens from patients with rheumatoid arthritis (RA) and osteoarthritis (OA). METHODS: Synovial tissue from 15 patients with HH, 20 with RA and 39 with OA was obtained during surgery. A synovitis grading system was used to determine the severity of synovial inflammation. Using immunohistochemistry, synovial neovascularisation and infiltration of macrophages, neutrophils and lymphocytes were quantitatively assessed. RESULTS: Synovitis in HH arthropathy largely resembles OA with mild infiltration of mononuclear cells and lymphocytes, formation of synovial microvessels and a low degree of synovial hyperplasia. While many features of HH arthropathy are reminiscent of OA, macrophage and especially neutrophil invasion is clearly more prominent in HH arthropathy than in primary OA and mimics features of RA. This finding was observed particularly in synovial tissue of HH samples with marked haemosiderin deposition. DISCUSSION: The histological picture of the synovium in HH arthropathy largely resembles a process reminiscent of OA. Neutrophil invasion is, however, markedly increased in HH arthropathy, especially in joints with iron deposition. Accumulation of neutrophils may be crucial for the production of matrix enzymes, which enables cartilage degradation and more rapidly progressive articular damage.

Long-term results of a contemporary metal-on-metal total hip arthroplasty: a 10-year follow-up study.

The goal of the study was to evaluate the long-term results of a metal-on-metal articulation. We evaluated the results and histologic findings in patients who had undergone revision. One hundred total hip arthroplasties with a Lubrimet metal-on-metal articulation (Smith and Nephew, Rotkreuz, Switzerland) were implanted in 99 consecutive unselected patients in 1995 and 1996, and the results were prospectively analyzed up to a mean of 126 months postoperatively. Periprosthetic tissues of all 6 hips that had undergone revision because of aseptic loosening, mechanical failure, or periprosthetic fracture showed metallosis and extensive lymphocytic and plasma cell infiltration around the metal debris. With removal of the component because of aseptic loosening as the end point, survivorship was 98% for the stem and 96% for the cup.