Total and unicondylar knee arthroplasty are equivalent treatment options in end-stage spontaneous osteonecrosis of the knee, and the size of the lesion has no influence on the results.

PURPOSE: The purpose of the present study was to compare total (TKA) and unicondylar (UKA) knee arthroplasty for spontaneous osteonecrosis of the knee (SONK), and to investigate potential correlations to radiographic parameters. METHODS: All consecutive patients with a magnetic resonance imaging (MRI) proven SONK treated with either TKA or UKA between 2002 and 2018 were analysed. The primary outcomes were postoperative complications and failure rates. Functional assessment included Knee Society Score (KSS), WOMAC Score, and range of motion. A novel three-dimensional measurement method was established to determine the size of the osteonecrotic lesion. All outcome parameters were correlated to the size of the necrotic lesion using Spearman's rank correlation. RESULTS: The two treatment groups (34 TKAs, 37 UKAs) did not differ regarding age, body mass index, and ratio of the volume of the necrotic lesion to the volume of the femoral condyle (n.s.). At a mean follow-up of 6.6 years, patients with UKA had better functional outcomes compared to patients with a TKA (WOMAC Score 1.0 vs. 1.6, p = 0.04; KSS pain 86 vs. 83, n.s), with a similar complication rate. No correlation was found between necrotic lesion size and failure rate (n.s.). CONCLUSION: UKA is a valuable treatment option for SONK leading to good functional results and a low failure rate. In case of a surgeon's concern regarding implant anchorage, TKA represents an equivalent solution. The MR-tomographic size of the osteonecrotic lesions seems to have no influence on the results. LEVEL OF EVIDENCE: III.

Synovial C-reactive protein features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI).

OBJECTIVES: Synovial fluid C-reactive protein (syCRP) has been recently described as a new biomarker in preoperative diagnostics to identify periprosthetic joint infections (PJI). The aim of this study was to evaluate syCRP in a large cohort of patients with suspected PJI and to calculate the optimal cut-off to diagnose PJI. METHODS: Between September 2015 and June 2017, we prospectively included patients with suspected PJI, in which syCRP was additionally measured along with routine preoperative diagnostic serum and synovial biomarkers. We analysed the sensitivity and specificity of syCRP using receiver operating characteristic curves. RESULTS: We included 192 cases (hip n = 80, knee n = 91, shoulder n = 21) with a final diagnosis of PJI in 26 cases (14.0%). Combined for all joints, the syCRP values were significantly higher in the PJI group than in the no PJI group (median: 13.8 vs. 0 mg/l; p < 0.001). The optimal cut-off (Youden Index: 0.71) for the PJI diagnosis combined for all joints was at a syCRP value of 2.9 mg/l with a sensitivity of 88%, a specificity of 82%, and a negative predictive value of 98%. CONCLUSIONS: SyCRP features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI).

Treatment of osteochondral lesions in the elbow: results after autologous osteochondral transplantation.

BACKGROUND: Osteochondral lesions in the elbow still remain a challenging field of surgery. In recent years promising clinical results were described for the osteochondral transplantation technique. The aim of this retrospective study was to evaluate the clinical and radiological outcome in the mid-term follow-up of a large cohort of patients following osteochondral transplantation in the elbow. METHODS: 18 patients with advanced osteochondral lesions of the elbow treated by autologous osteochondral autograft cylinders and a minimum follow-up of 36 months were included in the study. The Broberg-Morrey score (BMS) and the American Shoulder and Elbow score (ASES) were used to assess elbow function and pain, respectively. The joint status was analyzed using plain radiographs and MRI scans taken from all patients at recent follow-up. In addition, the ipsilateral knee joint was examined for donor-site morbidity using the Lysholm knee score. RESULTS: 14 patients were evaluated with a mean follow-up of 7 years (range 3-14 years). The mean BMS was 95.1 (range 72-100) points. The ASES score also showed promising results: pain at worst 1.5 (range 0-5) points, pain at rest 0.4 (range 0-5) points, pain lifting loads 2.8 (range 0-8) points, repetitive movement pain 1.5 (range 0-8) points. The range of motion of the injured elbow was free and equal to the contralateral side. Signs of osteoarthritis could be found on plain radiographs in three patients. The MRIs at follow-up showed graft viability in all patients. However, a slight incongruency of the chondral surface could be detected in two patients. The average Lysholm score was 90.9 (range 0-70) points. CONCLUSIONS: Osteochondral transplantation in the elbow leads to both clinical and radiographic good-to-excellent mid-term results and therefore represents a reasonable treatment option for advanced osteochondral lesions in the elbow. LEVEL OF EVIDENCE: Retrospective study; Therapeutic Level IV.

Cyclic flow variations after coronary angioplasty in humans: clinical and angiographic characteristics and elimination with 7E3 monoclonal antiplatelet antibody.

OBJECTIVES: We tested the hypothesis that cyclic alterations in coronary artery blood flow that occurred after coronary angioplasty could be attenuated or abolished by a monoclonal antibody to the platelet surface membrane GP IIb/IIIa receptor. BACKGROUND: Coronary artery cyclic flow variations may occur after coronary angioplasty in experimental animal models and humans. In animal models of coronary thrombosis, cyclic alterations in flow often have preceded thrombotic occlusion or reocclusion. Several agents that inhibit platelet function have been shown to attenuate or eliminate cyclic flow variations in these models. METHODS: We monitored coronary artery flow in 27 patients for 30 min after coronary angioplasty, using 0.018-in. (0.046 cm) coronary guide wires with pulsed wave Doppler ultrasound transducers on the distal tips. Clinical data were collected and quantitative analyses performed on coronary arteriograms made before and after the angioplasty procedures. We compared findings in patients with and without cyclic flow variations detected. RESULTS: There were 20 men and 7 women. Mean age was 58 years, and 63% had unstable angina. They received standard doses of nitrates, aspirin, heparin, calcium channel antagonists and other medications clinically indicated. Nevertheless, we detected cyclic flow variations in five patients (19%). Four of these patients had stable flow restored with intravenous injection of 0.25 mg/kg normal body weight of monoclonal antibody c7E3 Fab to the platelet GP IIb/IIIa receptor. In one patient, stable flow was restored by repeat dilation when an immediate angiogram revealed renarrowing. Patients developing cyclic alterations in flow had longer lesions (18.7 +/- 7.5 mm vs. 13.1 +/- 5.7 mm, p < 0.05) that had responded less well to angioplasty (stenosis postangioplasty 47 +/- 13% vs. 33 +/- 15%, p < 0.05). CONCLUSIONS: Cyclic alterations in coronary artery blood flow may occur in some patients after coronary angioplasty, despite the use of standard antiplatelet, antithrombotic and antivasospastic medications. We found that they could be eliminated by this monoclonal antibody that blocks the final common event of platelet aggregation.

Increased urinary leukotriene excretion in patients with cardiac ischemia. In vivo evidence for 5-lipoxygenase activation.

BACKGROUND: Experimental cardiac ischemia in some animal models results in the activation of the enzyme 5-lipoxygenase and the subsequent production of leukotrienes, potent proinflammatory lipid mediators, by the affected myocardium. Furthermore, prototype antileukotriene drugs can show some beneficial effects on infarct size and cardiac function in these models. Accordingly, urinary excretion of leukotriene E4 (LTE4), the major urinary metabolite of peptide leukotrienes in humans, was measured in patients admitted to the hospital with evidence of acute myocardial ischemia to assess in vivo release of 5-lipoxygenase products during and after the ischemic episode. METHODS AND RESULTS: Urinary leukotriene excretion was measured by reversed-phase high-performance liquid chromatography and specific radioimmunoassay on admission with acute chest pain and again on day 3 in the following patient groups: acute myocardial infarction (AMI), AMI and clinical evidence of early reperfusion after treatment with recombinant tissue-type plasminogen activator (rt-PA), diagnosis of unstable angina (UA) based on clinical history and coronary arteriography, controls with nonischemic chest pain who underwent coronary arteriography, and age-matched controls and normal hospital employees. In 16 patients with diagnosis of AMI, LTE4 excretion on admission (331 +/- 99 pg/mg creatinine sulfate; mean +/- SEM) was considerably higher than that measured on day 3 (195 +/- 59 pg/mg creatinine sulfate). In a subgroup of seven subjects treated with rt-PA resulting in early reperfusion, day 1 excretion was similar (215 +/- 50 pg/mg) but had significantly declined by day 3 (65 +/- 16 pg/mg; p less than 0.01). Urinary LTE4 excretion at admission for chest pain was also elevated in 14 patients having unstable angina (UA; 370 +/- 125 pg LTE4/mg creatinine sulfate). This had declined significantly (p less than 0.05) by day 3 (at which time chest pain had resolved) to 94 +/- 31 pg/mg creatinine sulfate, an excretion rate comparable with that measured in eight similarly aged subjects (64 +/- 12 pg/mg creatinine). CONCLUSIONS: This study suggests that peptide leukotrienes are released during episodes of myocardial ischemia and provides clinical evidence for involvement of their biosynthetic enzyme, 5-lipoxygenase, during and after acute myocardial infarction and unstable angina attacks. Thus, potent and specific orally active leukotriene biosynthesis inhibitors may have therapeutic potential in limiting myocardial damage and functional abnormalities after acute ischemia.

Plosive/fricative distinction: the voiceless case.

Using only three measures of the waveform, the zero-crossing rate, the logarithm of the root-mean-square (rms) energy, and the derivative of the log rms energy with respect to time [termed rate of rise (ROR)], voiceless plosives (including affricates) can be distinguished from voiceless fricatives in word-initial, medial, and final positions. Peaks in the ROR contour are considered for significance to the plosive/fricative distinction by examining the log rms energy and zero-crossing rate. Then, the magnitude of the first significant peak in the ROR contour is used as the primary classifier. The algorithm was tested on 1364 tokens (720 word-initial tokens produced by four female and four male speakers; 360 word-medial tokens produced by two males and two females; 320 word-final tokens produced by two males and two females). Data from two male and two female speakers (360 word-initial tokens) were used as a training set, and the remaining data were used as a test set. The overall rate of correct classification was 96.8%. Implications of this result are discussed.

[Conglutinatio orificii uteri externi as indication for cesarean section]. / Conglutinatio orificii uteri externi als Indikation zur Sectio caesarea

A case of conglutinatio orificii uteri externi is reported. Aetiology and pathogenesis of this rare complication of birth are discussed.