Comparative 5-year results of short hip total hip arthroplasty with Ti- or CoCr-neck adapters.

This prospective study investigated revision after modular short stem implantation. Results are presented for 2 different types of neck adapters (titanium and cobalt-chromium [CoCr]). Eighty-five patients with titanium adapters and 87 patients with CoCr adapters underwent follow-up examination after an average of 5.7 and 5.2 years, respectively. Mean patient age was 57 years in both groups. Indications were primary osteoarthritis (80%), cup dysplasia (14%), and other (6%). Mean Harris Hip Scores were 98 and 99 points (titanium and CoCr groups, respectively). Ninety percent and 96% of patients were very satisfied or satisfied (titanium and CoCr groups, respectively); 3% of patients in both groups were dissatisfied. Pain decreased from visual analog scale score 7 and 6 preoperatively to 0.37 and 0.15 postoperatively for the titanium and CoCr groups, respectively. No joint dislocation occurred. Six patients needed revision within the first year (2 for infection, 1 for via falsa position, and 2 for aseptic loosening in the titanium group, and 1 for aseptic loosening in the CoCr group). Nine revisions occurred due to neck adapter failure (titanium group). Primary standard stems were used in all revisions. Excluding material-related adapter failures in the titanium group, the 5-year survival rate was 94.8% (95% confidence interval [CI], 88.9-97.6 for titanium) and 99% (95% CI, 93.7-99.8 for CoCr). No radiographic signs of loosening were seen at last follow-up. Fine sclerotic lines were detected in Gruen zones 1 (17.2%) and 2 (14%), hypertrophies in zone 3 (4.3%), and periprosthetic cancellous bone compressions in zone 6 (75.8%). No adapter fractures occurred for CoCr components. The treatment and anchoring system of the short stem studied yielded good results and allowed revision using standard stems in all patients.

Five-year results of a cementless short-hip-stem prosthesis.

Hip prosthesis stems with a short stem length and proximal fixation geometry support a bone-preserving and muscle-sparing implantation and should also allow for revision surgery with a standard hip stem. We present 250 prospectively documented clinical and radiological results from the Metha Short Hip Stem prosthesis (B. Braun-Aesculap, Tuttlingen, Germany) after an average follow-up of 4.9 years. The average patient age at surgery was 60 years. Indication for total hip replacement was primary osteoarthrosis (OA) (78% of patients), OA based on developmental dysplasia of the hip (16%), and other indications (6%). At the last follow-up, the average Harris Hip Score was 97 points. 85% of patients were very satisfied and 14% were satisfied after surgery, whereas 1% were dissatisfied. Pain according to the Visual Analogue Scale improved from 7.4 (min 1.6, max 9.5) pre-operatively to 0.23 (min 0, max 6.6). No joint dislocations occurred when predominantly using 28 mm and 32 mm prosthesis heads. Nine short-stems were revised: three after bacterial infections, two after primary via valsa with penetration of the femoral cortex two and three months after surgery, and three after early aseptic cases of loosening within the first year. A further nine osseously consolidated short-stems had to be replaced due to breakage of the modular titanium cone adapter after an average of 3.1 years (min 1.9, max 4.4). All surgical revisions were performed using primary standard stems. Without taking the material-related adapter failures into account, a five year Kaplan-Meier survival rate of 96.7% (95% confidence interval 93.4-98.3) was determined for the short-stem prostheses. There were no radiological signs of loosening in any of the short-stem prostheses at the last examination. Fine sclerotic lines were detected in Gruen's AP zones 1 (19%) and 2 (10.5%), individual hypertrophies in zone 3 (3.5%), fine seams in zones 4 (5.5%) and 5 (4%), without pedestal formations in zone 4, clear cancellous bone compressions in zone 6 (97.5%), as well as single fine scleroses (1.5%) and atrophies (2.5%) in zone 7. The mid-term clinical results with periprosthetic bone remodeling and without radiological signs of loosening confirm this metaphyseal short-stem treatment and fixation concept and the possibility of revision surgery using standard hip stems. Long-term results must be further observed on a prospective basis as part of this collective study.

The relationship between pain, disability, quality of life and cognitive-behavioural factors in chronic back pain.

PURPOSE: This pilot study systematically examined the correlations between the outcome variables pain intensity, disability and health-related quality of life (HRQOL) and between these outcomes and known psychological risk factors for chronic low back pain (CLBP), such as depression, trait anxiety, avoidance- and endurance-related pain responses at two different assessment points. METHOD: Data from 52 CLBP inpatients treated in an orthopedic clinic were investigated at two points in time: during the first days after admission and 6 months after the termination of the inpatient treatment. Bivariate relationships between pain intensity, disability, HRQOL and psychological variables were examined with the help of Pearson product moment correlations. Furthermore, the differences that exist between correlations at baseline and follow-up were tested for significance. RESULTS: Significant and large differences were found between the correlations with low correlations at baseline and high correlations at the follow-up. Furthermore, HRQOL showed a positive correlation with endurance-related and a negative correlation with avoidance-related pain responses. CONCLUSIONS: Focusing on a systematic comparison of two significant assessment time points in CLBP with an acute exacerbation at baseline, the results of this study underlined the recurrent course of LBP. The results highlight that the assessment time points play an important role in CLBP. IMPLICATIONS FOR REHABILITATION: • Low back pain is a major public health problem with high direct and indirect back-pain-related costs. • Chronic low back pain is a disabling disease which restricts quality of life. • Psychological factors may have a larger impact on disability and quality of life than pain itself. • The recurrent course of low back pain highlights the importance of multidisciplinary pain management even during acute exacerbations of pain.

First-dose analgesic effect of the cyclo-oxygenase-2 selective inhibitor lumiracoxib in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled comparison with celecoxib [NCT00267215].

Cyclo-oxygenase-2 selective inhibitors are frequently used to manage osteoarthritis. We compared the analgesic efficacy of the novel cyclo-oxygenase-2 selective inhibitor lumiracoxib (Prexige) versus placebo and celecoxib in patients with knee osteoarthritis. This seven day, double-blind, placebo and active comparator controlled, parallel group study included 364 patients aged > or = 50 years with moderate-to-severe symptomatic knee osteoarthritis. Patients received lumiracoxib 400 mg/day (four times the recommended chronic dose in osteoarthritis; n = 144), placebo (n = 75), or celecoxib 200 mg twice daily (n = 145). The primary variable was actual pain intensity difference (100 mm visual-analogue scale) between baseline and the mean of three hour and five hour assessments after the first dose. Actual pain intensity difference, average and worst pain, pain relief and functional status (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were measured over seven days. Patients also completed a global evaluation of treatment effect at study end or premature discontinuation. For the primary variable, the superiority of lumiracoxib versus placebo, the noninferiority of lumiracoxib versus celecoxib, and the superiority of lumiracoxib versus celecoxib were assessed by closed test procedure adjusting for multiplicity, thereby maintaining the overall 5% significance level. In addition, celecoxib was assessed versus placebo in a predefined exploratory manner to assess trial sensitivity. Lumiracoxib provided better analgesia than placebo 3-5 hours after the first dose (P = 0.004) through to study end. The estimated difference between lumiracoxib and celecoxib 3-5 hours after the first dose was not significant (P = 0.185). Celecoxib was not significantly different from placebo in this analysis (P = 0.069). At study end 13.9% of lumiracoxib-treated patients reported complete pain relief versus 5.5% and 5.3% of celecoxib and placebo recipients, respectively. WOMAC total and subscales improved for both active treatments versus placebo except for difficulty in performing daily activities, for which celecoxib just failed to achieve significance (P = 0.056). In the patient's global evaluation of treatment effect, 58.1% of patients receiving lumiracoxib rated treatment as 'excellent' or 'good', versus 48.6% of celecoxib and 25.3% of placebo patients. Lumiracoxib was well tolerated. The overall incidence of adverse events was similar across treatment groups.

Participation of cyclooxygenase-1 in prostaglandin E2 release from synovitis tissue in primary osteoarthritis in vitro.

OBJECTIVES: To investigate the relative contribution of the cyclooxygenase (COX) isoenzymes COX-1 and COX-2 to prostaglandin E2 (PGE2) release from inflamed synovial tissue in N=10 patients with primary osteoarthritis (OA) in vitro and to determine possible effects of COX inhibitors on the gene expression of synovial COX-1 and COX-2. DESIGN: The effects of a COX-unspecific nonsteroidal anti-inflammatory drug (NSAID; diclofenac), a selective COX-1 inhibitor (SC-560) and a selective COX-2 inhibitor (SC-58125) on PGE2 release from inflamed synovial tissue (0.1-10 microM, 3 and 6 h incubation time) were compared. Release of PGE2 into the incubation media was measured by means of the enzyme-linked immunosorbent assay. Expression of synovial COX-1/-2 was quantified by means of real-time reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: All agents inhibited synovial PGE2 release dose-dependently. Compared to short-term incubations, the inhibitory potency of diclofenac, SC-58125 and SC-560 was increased (0.1-10 microM) and decreased (0.1-1 microM), respectively, during 6 h: At 10 microM, SC-560 and SC-58125 had obviously lost their specificity for COX-1 and COX-2, respectively, indicated by a comparable inhibitory potency of the selective COX-1 inhibitor (86.6%) and the selective COX-2 inhibitor (96.6%) within identical tissue specimens. In contrast, at 1 microM, 83% and 62.8% inhibition was seen for diclofenac and SC-58125, respectively. SC-560 showed 30.6% inhibition (P<0.05). In contrast to synovial COX-1, RT-PCR revealed a significant induction of COX-2 through PGE2. CONCLUSIONS: With respect to the concentrations studied, the data suggest that in inflamed synovial tissue in OA, up to 30% of PGE2 might be generated via the COX-1 pathway. In therapy of OA, the relative contribution of COX-1 in synovial inflammation should be considered, weighing the potency of COX-unspecific NSAID against the assumed superior gastrointestinal safety profile of selective COX-2 inhibitors.

Noncontiguous unstable spine fractures.

STUDY DESIGN: Evaluation of 1054 patient charts and 100 random roentgenogram charts as well as clinical investigation of 39 patients. OBJECTIVES: Noncontiguous unstable spine fractures are rare, easy overlooked, and difficult to treat. The purpose of the study was to evaluate the delay in diagnosis and clinical and radiologic outcome of these fractures. SUMMARY OF BACKGROUND DATA: Noncontiguous spine fractures are reported in about 1.6-16.7% in the literature. In most of the studies stable fractures, which did not need any special treatment, were also included. Therefore, in this study only unstable fractures requiring treatment were reinvestigated. METHODS: A total of 1054 patients with fractures of the spine were treated over a period of 14 years in the spinal cord injury unit and retrospectively reviewed; 141 (13.4%) of the patients had multiple fractures, but only 39 (3.7%) had a noncontiguous spine fracture, most frequently from a fall or jump from a greater height, or traffic accidents. RESULTS: Thirty patients (76.9%) had all fractures diagnosed at the first examination. Nine patients (23.1%) had a delayed diagnosis of the secondary lesion, but this delay resulted in no neurologic deterioration. A total of 32 extraspinal injuries were diagnosed and treated 14 times surgically. Loss of correction was seen after surgical treatment (n = 21), and increasing deformity occurred after conservative treatment (n = 18). The neurologic deficit improved in 10 conservatively (4) and operatively (6) treated patients and deteriorated in one patient after surgery. CONCLUSION: A delayed diagnosis of the second fracture was frequently seen without clinical consequences, and neurologic improvement occurred after conservative and operative treatment. Surgical treatment resulted in significantly earlier mobilization and less kyphotic deformity.