Long-term follow-up of 1217 consecutive short-stem total hip arthroplasty (THA): a retrospective single-center experience.

BACKGROUND: An arthroplasty registry in Germany has been recently established but long-term results for most short-stem innovations are missing. Short-stem hip arthroplasty is usually indicated in young active patients. Our indication was extended to older age groups, femoral neck fractures (FNF), and dysplasia. We evaluated all total hip arthroplasties (THAs) in this population with a collum femoris preserving stem (CFP) performed from 2003 to 2013. METHODS: A consecutive cohort of 1217 CFP THAs with a mean age of 68.7 years was followed retrospectively for a median of 4.8 years (patient follow-up interquartile range from 3.0 to 6.9 years). A questionnaire, which we used in two previous studies, was answered by 89.15% of patients and included information regarding complaints, grade of satisfaction, re-operations, and dislocation. Of the 1217 patients, 77 had died. Survival of the stem and the cup was assessed using a competing risks approach according to an Aalen-Johanson estimator with revision for septic or aseptic loosening or death as a competing endpoint. RESULTS: Of the patients who answered the questionnaire, 92.5% had no complaints related to the procedures. In all 1217 patients, there were 43 revisions (4.2%) as follows: stem and cup revisions due to aseptic loosening of the stem (n = 10), infections (n = 6), pain (n = 4), or trauma (n = 3); cup revisions due to aseptic loosening (n = 3), dislocation (n = 5), and offset revisions (n = 12). Survivorship was 96% for the stem and 99% for the cup 9 years postoperatively. Statistical analysis confirmed a higher risk for revision in patients with a younger age (p = 0.033), male sex (p = 0.040), dysplasia (p = 0.032), and undersized or extra-large stems for stem revisions (p = 0.001) and female sex (p = 0.036) for cup revisions. FNF (p > 0.20) and age ≥ 80 years (p = 0.114) had no higher risk for loosening of the stem. Our data is also compared with the current literature, especially with the available CFP studies. CONCLUSION: The survival rate of the CFP stem was as high as 96% after 9 years of followup which compares well-to-previously published long-term survival rates. There is no higher risk for revision in patients 80 years old or older and in cases with femoral neck fractures. The CFP preserves also allowed using standard stems in the rare cases of revision.

[Wound infections in abdominal surgery: aetiology, risk factors, antibiotic prophylaxis]. / Wundinfektionen in der Viszeralchirurgie - Atiologie, Risikofaktoren, Antibiotikaprophylaxe.

Nosocomial infections are the major cause for morbidity and mortality in hospital. In Germany 3.5 % of patients developed nosocomial infections, 15 % of these are wound infections post surgery. Asepsis, proper surgical technique and identifying patients at risk of infections and antibiotic prophylaxis are the most effective measures to reduce postoperative wound infection rate. To identify patients at risk by traditional wound classification system alone seems to be insufficient. Risk factors others than the suspected contamination rate at the end of the operation have to be detected. Indication, choice of the antibiotic agent and timing of antibiotic prophylaxis will be discussed.

Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial.

INTRODUCTION: The increasing number of enterococcal infections in hospitals and reports about the development of resistance of these bacteria make it necessary to review their importance as co-pathogens in secondary peritonitis. MATERIALS AND METHODS: A prospective randomized controlled trial on primary therapy of secondary peritonitis was carried out in six centers comparing cephalosporin-based antibiotic therapy to acylaminopenicillin-based therapy. RESULTS: Enterococci were only cultured in 6 of 110 cases from the abdomen and were found in only 5 cases of postoperative complications. No differences were found between penicillin-based vs. cephalosporin-based therapy. CONCLUSION: The study supports the view that these bacteria continue to play a minor role in secondary peritonitis. The point has to be emphasized, however, that the patients under study were in relatively good condition (APACHE II median 9 for cephalosporins and 10 for penicillins) and that postoperative cases of peritonitis were excluded.

Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group.

INTRODUCTION AND METHODS: A prospective observational multicenter study with 18 hospitals was performed to assess preoperative risk, therapeutic management and outcome of patients with peritonitis. Data collection was carried out according to standardized and recommended definitions. Included in the study were 355 patients with macroscopically confirmed peritonitis. RESULTS: In the univariate analysis, the following factors influenced both the mortality and the incidence of postoperative complications: age, presence of certain concomitant disease, site of origin of peritonitis, type of admission and the ability of the surgeon to eliminate the source of infection. In addition, postoperative infective complications were related to the etiology of peritonitis and the exudate. In the multivariate analysis, APACHE II (P<0.001), successful operation (P<0.001), age (P<0.001), liver disease (P<0.03), malignant disease (P<0.04) and renal disease (P<0.05) turned out to be significant with respect to death. Escherichia coli was the predominant organism (51%), following by enterococci (30%) and bacteroides (25%). There was a significantly higher postoperative infection rate in patients with no adequate treatment of enterococci than patients with adequate treatment or no enterococci (P<0.05). CONCLUSION: The study demonstrated the important role of the physiological reserve of the patient and of the surgeon, which is not adequately reflected in existing scoring systems. Further investigations are needed to study the impact of enterococci on the outcome.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study.

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

Prognostic modelling in peritonitis. Peritonitis Study Group of the Surgical Infection Society Europe.

OBJECTIVE: To develop and to evaluate a new score to aid management in peritonitis. DESIGN: Prospective, multicentre study. SETTING: 18 departments of surgery in Germany. Austria, and Switzerland. SUBJECTS: 355 patients with peritonitis confirmed at laparotomy. INTERVENTIONS: Computation of four different prognostic systems: APACHE II; APACHE II and successful operation; APACHE II, successful operation and Goris score on the first postoperative day: and multivariate analysis. Predictions were evaluated according to the following criteria: specificity with a fixed sensitivity at 80%, receiver operating characteristic (ROC-) curve, and predictive value. MAIN OUTCOME MEASURE: The ability to predict hospital death and infective complications. RESULTS: Multivariate analysis was superior to APACHE II: APACHE II and successful operation: and APACHE II, successful operation, and Goris score. From the analysis a new prognostic model was derived from which it was possible to identify patients early in the postoperative period who are at high risk of developing further complications (prognostic peritonitis model: PPM). CONCLUSIONS: None of the existing scores was of particular use for therapeutic decision making in peritonitis. The new prognostic model should be the focus of further trials in the management of peritonitis.

Planned relaparotomy vs relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe.

OBJECTIVE: To define the role of planned relaparotomy (PR) in the treatment of intraperitoneal infection, compared with that of relaparotomy on demand (RD). DESIGN: Case-control study on the basis of a prospective multicenter cohort analytic study. Statistical evaluation was done by the McNemar test for qualitative data and the Wilcoxon matched-pairs signed rank test for qualitative data. SETTING: Eighteen hospitals of different care levels in Austria, Germany, and Switzerland. PATIENTS: Thirty-eight of 42 patients with intra-abdominal infections who underwent PR were matched for APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, cause of infection, site of origin of peritonitis, and the ability of the surgeon to securely eliminate the source of infection with 38 patients taken from a cohort of 278 undergoing RD. INTERVENTIONS: Planned relaparotomy was defined as at least one relaparotomy decided on at the time of the first surgical intervention; RD, relaparotomy indicated by clinical findings. MAIN OUTCOME MEASURES: Mortality and incidence of postoperative multiple organ failure and infectious complications. RESULTS: There was no significant difference in mortality between patients treated with PR (21%) or RD (13%). Postoperative multiple organ failure as defined by a Goris score of more than 5 was more frequent in the group of patients undergoing PR (50%), compared with the group undergoing RD (24%) (P = .01), as were infectious complications (68% vs 39% [P = .01]). Infectious complications were due to more frequent suture leaks (16% vs 0% [P = .05]), recurrent intra-abdominal sepsis (16% vs 0% [P = .05]), and septecemia (45% vs 18% [P = .05]) in the PR vs the RD groups. The incidence of other complications was not different in the two groups. CONCLUSIONS: Until larger prospective studies are available, the indication for PR should be evaluated with caution.

[Synovial hemangioma of the knee joint--a rare cause of recurrent hemarthrosis]. / Das Synovialhämangiom des Kniegelenks--seltene Ursache eines rezidivierenden Hämarthros.

In the differential diagnosis of bloody knee joint effusions synovial haemangioma as a rare cause has to be considered. Especially suspicious are long durations of disease with recurrent atraumatic blood-stained joint effusions and repeated episodes of painful limitation of motion, laboratory and radiographic findings often being normal. On the one hand arthroscopy can prove the diagnosis by obtaining an ample biopsy specimen, on the other hand it facilitates the healing of the lesion at the same time by radical removal of the tumour.

Prospective evaluation of prognostic scoring systems in peritonitis. Peritonitis Study Group.

OBJECTIVE: To assess the accuracy of the APACHE II score, the Mannheim Peritonitis Index (MPI), and the Peritonitis Index Altona (PIA) II in the prediction of outcome of patients with peritonitis. DESIGN: Prospective, multicentre study. SETTING: 12 Departments of Surgery in Europe. SUBJECTS: 271 Patients with peritonitis confirmed at laparatomy. INTERVENTIONS: Computation of the three scores on one set of data for each patient. MAIN OUTCOME MEASURES: The ability to predict death or survival within 30 days of operation with each of the three scores. The prediction were evaluated according to the following criteria: discriminatory ability (areas under the receiver-operator characteristic (ROC) curves relating sensitivity to specificity); sharpness (level of confidence that was associated with a prediction); and reliability (agreement between predicted and observed mortality within equidistant intervals on the scale). RESULTS: APACHE II was superior to both the MPI and PIA II in its discriminatory ability and reliability, but the MPI and PIA II made more "sharp" predictions. CONCLUSIONS: None of the three scores is of any use for predicting the outcome for individual patients. APACHE II is the current standard for assessing the severity of peritonitis.

[Calculi of the bile ducts--a problem for the elderly? Observations from the surgical viewpoint]. / Steinerkrankungen der Gallenwege--ein Problem des alten Menschen? Eine Betrachtung aus chirurgischer Sicht.

Age alone does not increase the risk in biliary surgery. However, cholelithiasis in the elderly is often associated with an increased frequency of acute cholecystitis and cholangitis due to stone obstruction. The proportion of elderly people in the world is still growing, therefore, we can expect to see increasingly more complications of gallstones. Elective surgery for gallstone disease in all age groups is to be preferred to a policy of waiting for stone complications with the resultant risk of higher mortality and postoperative morbidity of emergency surgery.

[Postoperative mechanical ileus]. / Postoperativer mechanischer Ileus.

Postoperative GI obstruction is the third most common postoperative complication, after peritonitis and bleeding, leading to laparotomy. The mortality has declined in the last decade from around 20%-35% to 10%-20%. This is probably caused by better intra-operative surgical techniques and better understanding of the pathophysiology of gastrointestinal motility. The problem most frequently lies in the proximal small bowel particularly after operations on the colon, especially in the presence of inflammation or peritonitis. Differentiation between postoperative paralysis and mechanical obstructions is very difficult. Modern diagnostic techniques have not changed this fact. For assessment of the abdomen, repeated surgical investigations is still of more value than laboratory data alone.

Concentration of ciprofloxacin in bone tissue after single parenteral administration to patients older than 70 years.

The concentrations of ciprofloxacin produced in bone, cartilage and menisci after a single administration of 200 mg were determined at different intervals in a group of patients with an average age of 80 years. Concentrations of 0.11 to 0.94 mg/kg bone tissue were measured after 0.5 to 5 hours. In the cartilage a concentration of active substance was measureable only once (4.18 mg/kg). In the presence of marked circulatory disorders the active substance concentrations reached in the bone were above those found in the seriously damaged muscle. Although the concentrations reached in the bone are effective, no risk should be taken in osteomyelitis. Ciprofloxacin should therefore be used at high dosage and possibly be combined with another substance. Given for therapeutic purposes, a single dose of ciprofloxacin is naturally not effective enough, and given for prophylactic purposes, not safe enough to prevent a post-traumatic osteitis.

Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intraabdominal infection. Joint Working Party of SIS North America and Europe.

Analysis of the experience with scientific studies on patients with secondary intraabdominal infection has revealed that problems of interpretation and comparability between studies exist as they relate to variable diagnostic criteria, unmeasured severity of disease, and unclear outcome measures. A consistent system of definitions has been developed to address these deficiencies. Intraabdominal infection is defined as clinical peritonitis requiring both operative and microbiological confirmation for proof of infection. The APACHE II system is proposed for grading the severity of the infection and for stratification of patient risk of mortality. Mortality and time until death, on one hand, and recovery and time until recovery, on the other, are proposed as the main outcome measures, both being independently and positively defined. It is anticipated that this system of minimum rules will produce studies that can be compared, hence, accelerating knowledge and understanding about intraabdominal infection and its best treatment.

[The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis]. / Der Mannheimer Peritonitis-Index. Ein Instrument zur intraoperativen Prognose der Peritonitis.

Based on the experience with 1243 patients suffering from purulent peritonitis 255 patients of two surgical departments were studied prospectively in a cohort study. Lethality was 24%. For intraabdominal infection an index is established that allows for the first time to predict lethal outcome of the disease in the individual patient. For each index-score the expected mortality is given by a modern mathematical calculation. The 'Mannheim Peritonitis Index' includes only clinical risk-factors that are routinely documented pre- and intraoperatively. Methods of evaluation, validation and the comparison with other prognostic indices are presented.

[Symptomless gallstone disease--when to treat surgically?]. / Symptomloses Gallensteinleiden--Wann chirurgisch behandeln?

The cholecystolithiasis is the symptom of a disease. Recent radiological procedures, above all sonography, can be helpful not only in more frequent detection of gallstones, but they can also provide information, even without clinical symptoms, on pathological changes to gallbladder and biliary tracts. However, early diagnosis of carcinoma of the gallbladder still is rare. Mortality of gallbladder carcinoma has remained unchanged in the Federal Republic of Germany over the past ten years, whereas mortality following cholecystolithiasis has been lowered due to progress in medicine. The surgical risk rises along with age and is low up before 60 years. Indication for cholecystectomy continues to be a highly individual decision which should be considered with particular caution in cases of "asymptomatic" gallstones.

[Interwoven wire suture with fascia lata-plasty in the treatment of subcutaneous rupture of the Achilles tendon--an obsolete method?]. / Die Drahtdurchflechtungsnaht mit Fascia-lata-Plastik zur Behandlung der subkutanen Achillessehnenruptur--eine veraltete Methode?

Lately there has been an increased incidence of rupture of the Achilles tendon following the general increase in mass sports. Surgery is the treatment of choice, and various methods are being described. We have been using the wire suture method with fascia lata plasty for more then twenty years. The rate of infection is 3.8% and that of rerupture 1.2%, figures that correspond to those stated for other surgical methods. Moreover, 87% of the patients were very satisfied with the result of the operation; they are fit for work without any restriction, and some of them even practise their sports activities as before. For this reason we consider that wire suturing with fascia lata plasty is by no means obsolete in the treatment of rupture of the Achilles tendon.

[Mediastinal metastases of extrathoracic tumors--important findings in mediastinoscopy]. / Mediastinale Metastasen extrathorakaler Tumoren--wichtige Befunde bei der Mediastinoskopie.

From 700 mediastinoscopies performed between 1976 and 1985, 11 revealed metastases from extrathoracic malignancies. Primary tumours were eventually located in the gastrointestinal tract (5), the breasts (2), the kidneys (2) and the thyroid gland (1). All lymphatics join within the mediastinum. Therefore mediastinal secondaries from tumours of all body regions may be encountered. Mediastinoscopy facilitates safe biopsy and histological diagnosis. It is essential for adequate therapy.

[The asymptomatic gallstone]. / Der symptomlose Gallenstein.

There are several sound arguments to operate on "silent" gallstones: The operative mortality following simple cholecystectomy in patients under 40 is zero. 50% of all patients with silent gallstones will be operated upon or develop symptoms within 10-20 years after the initial diagnosis. Carcinoma of the gallbladder is very rarely diagnosed in time and in most cases is incurable at the time of operation. The number of deaths in the FRG due to a carcinoma of the gallbladder has been consistently high in the last decade. Risk factors for cholecystectomy increase with the patients age. Therefore early cholecystectomy is recommended. Nevertheless indication for cholecystectomy is an individual decision.