[Acetabular revision surgery with the oblong revision cup : clinical and radiological results of 217 cases]. / Azetabuläre Revisionsoperationen mit der längsovalen Revisionspfanne : Klinische und radiologische Ergebnisse von 217 Fällen.

BACKGROUND: Deficiencies of the acetabular bone stock are an increasing and challenging problem in revision hip surgery. The LOR oblong revision cup is a valuable option in revision hip surgery. The purpose of this study was to assess outcomes with the LOR revision cup in hips with acetabular bone deficiency, analyze the complications, and identify predictors of survival rate. PATIENTS AND METHODS: From 1996 to 2002, 217 revision surgeries were performed with LOR cups. The mean patient age at operation was 67.5 years (range 29-87 years). The mean postoperative follow-up was 4 years (range 4-100 months). The patients were evaluated clinically and with the Harris hip score (HHS), UCLA score, and WOMAC index. A continuous radiographic assessment was done to detect heterotopic ossifications and radiolucencies or loosening on the basis of the Mayo hip score. Predictors of survival rate were estimated using Kaplan-Meier survivorship analysis. RESULTS: Twenty-four patients (7.4%) died during the study period. Seven patients (3.1%) had revisions because of aseptic loosening and two patients (0.9%) because of infection. Clinical assessment at follow-up showed a significantly improved mean HHS from 45 points preoperatively to 78 points postoperatively. At the most recent follow-up, patients with a body mass index below 30 or those classified as Charnley A had a significantly better HHS. Because of migration on the latest radiographs, revision was indicated in 4.8% of the cases. The survival rate of all LOR implants based on implant removal was 96% after 40 months and 87% after 80 months. Based on radiographic evidence of loosened implants, the survival rate was 94% after 40 months and 79% after 80 months. Patients with more than two revisions had reduced implant survivorship compared with those having one or two revisions. The factors "age at operation", "gender", "obesity", "ASA score", "Charnley score", and "activity according to the UCLA score" did not influence the survival rate. CONCLUSION: We recommend this component in revision surgery on the basis of satisfactory clinical and radiological results at a mean of 48 months of follow-up. We identified the number of revisions as a predictor of survival rate.

[Revision surgery of hip resurfacing]. / Revisionschirurgie des Oberflächenersatzes.

Early results of contemporary hip resurfacing are encouraging and consequently an increasing number of this procedure has been performed worldwide. A theoretical advantage of hip resurfacing is that failed components can be revised safely and successfully revised to a conventional total hip arthroplasty. As the number of systematically analyzed failures is still limited, however, current data from the literature cannot substantially support this assumption. Our personal results indicate that the conversion of a failed femoral cup (i.e., due to neck fracture or aseptic loosening) to a conventional stem is a relatively simple and safe procedure. If and how potential wear of a firmly integrated acetabular component might have any impact on this type of revision, warrants further investigations. The conversion of acetabular components is influenced by the quality of the remaining pelvic bone stock and can therefore be compared to conventional revision surgery. However, as most providers of hip resurfacings systems only offer one-piece acetabular shells, the possibility of an isolated modular insert exchange is rare. In conclusion, the argument of easy revision surgery after hip resurfacing should be used with care.

[Clinical pathways. A useful steering instrument or a limitation for medical treatment?]. / Klinische Pfade. Sinnvolles Steuerungsinstrument oder Beschränkung ärztlicher Handlungsfreiheit?

Clinical pathways can be used to organize the optimal sequence for medical procedures. This process is patient centered and developed through the collaborative work of the participating medical specialties. The goals of clinical pathways are facilitation of outcomes, reduction of variance in patient care and cost containment. Clinical pathways can be used for patient information, internal and external transparency and in total quality management. The management of medical organisations can be supported by introducing the data from clinical pathways into prospective clinical and financial control.

[Results for endoprosthetic care in patients younger than 50 years]. / Ergebnisse endoprothetischer Versorgung bei Patienten vor dem 50. Lebensjahr.

Arthroplasty has become the most successful surgical procedure in developed countries. Replacement of severely damaged joints results in a substantial relief of pain, as the main symptom of osteoarthritis, in the majority of treated patients. With improved results in endoprosthetic surgery over the last decades, however, patients are increasingly undergoing the procedure to enhance their functional capacity and physical mobility. Especially younger patients, who cannot accept a restriction in their professional or sports activity, have become demanding candidates for surgery. This review summarizes the published results on shoulder, hip, knee, ankle and first metatarsophalangeal joint replacement in patients who are younger than 50 years of age. Mid- and long-term follow-up studies in this age group are evaluated in terms of prosthesis survival as well as functional improvement.

[Necrosis of the femoral head in late pregnancy. Necessity of early diagnosis]. / Die peripartale Femurkopfnekrose. Notwendigkeit zur Frühdiagnostik.

Limping and groin pain can issue diagnostic problems during late pregnancy. Differential diagnosis of two idiopathic syndromes, transient osteoporosis and osteonecrosis of the femoral head, is made possible by MRI in the early stages. This case is reported to demonstrate the need to distinguish between those syndromes early so as to prevent further joint damage.

[Resurfacing arthroplasty of the hip]. / Oberflächenersatz am Hüftgelenk.

Currently, an increase in resurfacing arthroplasty in the treatment of hip osteoarthritis--especially in young adults--can be observed. New bearing technologies (mainly metal-on-metal surfaces) show better tribologic results than historical designs (e.g. the Wagner cup). At present, it is unclear whether these modifications and a definitively low dislocation rate--due to the large head diameter--can be supported by further good clinical results. The quantity as well as the quality of the available investigations prevents a definite opinion at the moment. Appropriate clinical studies with documented radiographic follow-up are necessary to compare the outcome of these new implants with standard techniques.

[Hip resurfacing arthroplasty]. / Hüftgelenk-Oberflächenersatzendoprothesen.

In comparison to stemmed total hip replacements, hip resurfacing offers advantages especially in joint stability and amount of femoral bone resection. After the poor results achieved with this concept that were mainly caused by failure of the materials used, reintroduction of the metal-on-metal bearing initiated a renaissance. This bearing, the cementless cup, and the improved surgical technique led to better short- to medium-term results. Revision and complication rates are now comparable to conventional total hip replacements. The functional capacity of the method is higher. Because long-term results are not available, however, questions remain, for instance, the consequences of the higher metal ion serum concentrations or the impossibility of changing the inlay when femoral revision becomes necessary.

[Functional results after surface replacement of the hip: comparison between dysplasia and idiopathic osteoarthritis]. / Funktionelle Behandlungsergebnisse nach Oberflächenersatz am Hüftgelenk: Vergleich zwischen Dysplasie- und idiopathischer Koxarthrosen.

AIM: To determine if there are differences in function after resurfacing arthroplasty of the hip in patients with primary osteoarthritis compared to patients with secondary osteoarthritis due to developmental dysplasia of the hip. METHOD: In a controlled prospective study of Birmingham Hip Resurfacing (BHR) we included all patients with primary osteoarthritis (n = 54, average age 48.4 years) and osteoarthritis due to high grade dysplasia (Eftekhar B, n = 34, average age 55.8 years). Standardized clinical (Harris hip score) and radiographic examinations were performed 6 weeks, 3 months and 6 months and then every year after the operation. RESULTS: All patients could be followed up to 1.5 years (1-4 years) after surgery. The average Harris hip score improved to 82-95 points in both groups 3 months postoperatively. Statistically significant differences could be found in the subscales "function" and "limp", where patients with dysplastic hips showed somewhat lower results after 6 (function) to 12 weeks (limp) postoperatively. This is probably attributable to extended non-weight-bearing after acetabular reconstruction in these cases, as the difference disappeared with full weight-bearing. Radiographically determined neck-shaft angles are slightly higher in dysplastic hips (142 degrees versus 135 degrees ), but we did not recognize any significant differences in implant positioning. CONCLUSION: The short- to mid-term results showed no clinically relevant functional differences after surface replacement in patients with primary osteoarthritis of the hip and patients with secondary osteoarthritis due to higher grade dysplasia. Long-term observation is necessary, however, to determine if these positive functional results are reflected by appropriate radiographic survival.

[Urinary concentration of collagen metabolites in endoprosthesis loosening]. / Harnkonzentrationen von Kollagenabbauprodukten bei Endoprothesenlockerungen.

Aseptic loosening is the most common long-term complication in arthroplasty. Loosening is in every case associated with bone resorption at the interface that leads to bone defects and complicates the revision. The diagnosis of aseptic loosening is based on clinical and radiological evaluation. Especially in clinically asymptomatic cases an early diagnosis with these methods is difficult. In our study we wanted to evaluate the diagnostic value of biochemical markers of the bone resorption in aseptic loosening. We compared 58 patients with proven implant loosening during surgery with 67 patients without clinical or radiological signs of loosening. We measured the crosslinks pyridinoline and hydroxypyridinoline in urine samples. In contrast to Schneider et al. [increased urinary crosslink levels in aseptic loosening of total hip arthroplasty, J. Arthroplasty 1995; 13 (6): 687-692] we found no significant differences between loose and asymptomatic hip or knee prosthesis. Also no correlation between the size of the acetabular defects of loose hip implants and the urinary crosslink excretion was measurable. Our results show no or only little diagnostic value of the urinary crosslinks pyridinoline and deoxypyridinoline in aseptic loosening of total hip and knee arthroplasty.

Diagnostic relevance of the detection of Legionella DNA in urine samples by the polymerase chain reaction.

Urine samples from 317 patients with pneumonia and from 242 patients without pneumonia were tested using a polymerase chain reaction (PCR) system for detection of the Legionella 5S rRNA gene. The results were compared with findings obtained using the established methods for diagnosis of legionellosis. Of the 317 patients with pneumonia, 58 had confirmed legionellosis, 35 had a presumptive Legionella infection, and 224 had no evidence of Legionella infection as determined by conventional methods using published criteria. The PCR was positive for 42 patients with confirmed infections, yielding a sensitivity of 72.4%. Furthermore, 16 (47%) patients with presumptive legionellosis and five (2.2%) patients without other evidence of Legionella infection had positive results. All samples from 242 patients without pneumonia were PCR-negative. When the results for all patients were considered, the specificity of the assay was > or =98.9%. The results demonstrate that the sensitivity and specificity values of urinary PCR are in the same range as those of established methods. The use of PCR in urine complements the repertoire of rapid diagnostic methods, especially for infections caused by legionellae not belonging to Legionella pneumophila serogroup 1, in which tests for detection of urinary antigen often fail.

Molecular characterization of a virulence-associated epitope on the lipopolysaccharide of Legionella pneumophila serogroup 1.

For identification of lipopolysaccharide (LPS)-associated epitopes of Legionella pneumophila serogroup 1, LPS of strain Philadelphia 1 was investigated using monoclonal antibodies (MAbs). The O-specific chain of LPS is a homopolymer of 5-acetamidino-7-acetamido-8-O-acetyl-3,5,7,9-tetradeoxy-D-glycero- L-galacto- nonulosonic acid. At least four immunoaccessible epitopes were recognized by different MAbs on the intact LPS. After O-deacetylation of LPS, the reactivity of one of the MAbs (MAb 3/1) was lost, indicating thus that the corresponding epitope is associated with the 8-O-acetyl group. Since the reactivity pattern of the MAb 3/1 is identical with those of the MAb 2 which was considered as a virulence marker for serogroup 1, this epitope may be involved in mediating virulence in L. pneumophila. Four MAbs specific to strains of serogroup 1 other than the monoclonal subtype Philadelphia recognized epitopes on the O-deacetylated LPS of strain Philadelphia 1 and, therefore, the virulence-associated epitope blocks recognition of the immunodeterminants that are accessible on the intact LPS of the strains lacking this epitope.

Monoclonal antibodies to Legionella Mip proteins recognize genus- and species-specific epitopes.

Monoclonal antibodies (MAbs) against the virulence-associated Mip protein of Legionella spp. were raised by immunizing BALB/c mice with (i) Legionella pneumophila, (ii) Legionella micdadei, and (iii) purified recombinant native Mip protein cloned from L. pneumophila Philadelphia 1. Following screening of seeded wells by immunoblot analysis with homologous antigens, eight Mip-specific MAbs were found. These MAbs were chosen to investigate the antigenic diversity of Mip proteins in the genus Legionella. Mip was detected in 82 Legionella strains representing all 34 species tested. One of these MAbs, obtained from immunization with L. micdadei, recognized an epitope common to all Legionella species tested by immunoblot analysis. Another MAb was discovered to be specific for the Mip protein of L. pneumophila. The remaining six MAbs recognized 18 to 79% of Legionella species included in this study. By making use of the MAbs introduced in this study, it could be shown that, based on Mip protein epitope expression, Legionella species can be divided into at least six antigenetically distinct groups. As demonstrated by 43 L. pneumophila strains representing all serogroups, no antigenic diversity of Mip proteins was found for this species. In addition, 18 non-Legionella species, including Chlamydia trachomatis, Neisseria meningitidis, Pseudomonas aeruginosa, and Saccharomyces cerevisiae, all of which are known to carry genes homologous to the Legionella mip genes, were reacted against all eight MAbs. No cross-reactivity was detectable in any of those strains.

Detection of Legionella DNA in human and guinea pig urine samples by the polymerase chain reaction.

A detection system for Legionella DNA in urine samples based on the polymerase chain reaction (PCR) was developed and tested on infected guinea pigs and patients suffering from pneumonia. Results were compared with standard methods for diagnosis of Legionnaires' disease. A primer system was selected which amplifies a 108 bp DNA fragment of the 5S rRNA gene. The sensitivity of the PCR system was one femtogram of extracted Legionella DNA. Three methods were tested for pretreatment of urine samples. Of these, the Geneclean II kit (Bio 101, USA) gave the best results for artificially contaminated urine samples as well as those from infected guinea pigs or patients. Thirty-seven urine samples from 15 guinea pigs intraperitoneally infected with either Legionella pneumophila serogroup 1, 3 and 6 or Legionella micdadei, 26 urine samples of 21 patients suffering from pneumonia, and 30 control samples of patients with urinary tract infection (UTI) were tested. Legionella DNA was detected in 29 of the guinea pig urine samples; whereas, urinary antigen detection using EIA was positive in only 20 of the samples. PCR was also positive in the samples of 11 patients with pneumonia, 9 of which were confirmed by other microbiological methods, such as culture, direct fluorescent antibody test, urinary antigen detection and antibody testing. However, of the 30 control samples from patients with UTI, three samples yielded positive results. The results demonstrate that Legionella DNA is excreted in the urine of infected individuals and that the PCR shows a higher degree of sensitivity than EIA to the detection of soluble Legionella antigen in urine.(ABSTRACT TRUNCATED AT 250 WORDS)

Serogroup-specific and serogroup-cross-reactive epitopes of Legionella pneumophila.

A panel of monoclonal antibodies was used to serotype 343 Legionella pneumophila isolates, using the indirect immunofluorescence test and ELISA. In addition, the isolates were typed by means of absorbed rabbit antisera to provide a reference procedure. As shown by a comparison of reaction patterns, serogroup-specific monoclonal antibodies were found for serogroups 1, 2, 3, 4, 6, 7, 8, and 10. Monoclonal subtypes were found to exist within serogroups 1, 2, 5, and 6. Using the monoclonal antibody panel introduced for serogroups 1 to 8 and 10, it was possible to serotype or subtype 92% of the isolates tested. The remaining isolates belonged to serogroups 9, 11 to 14 and to a monoclonal subtype of serogroup 5. 8 monoclonal antibodies recognized serogroup-cross-reactive epitopes. Except for serogroups 1, 7, and 11, all others shared a common antigenic determinant. Another common epitope was shared by strains of serogroups 2 and 3. Additional cross-reactivity was associated in particular with strains of serogroups 5, 8, and 10.

[Detection of intracellular multiplication of Legionella pneumophila in protozoa by antigen quantification using ELISA]. / Nachweis der intrazellulären Vermehrung von Legionella pneumophila in Protozoen durch Antigenquantifizierung mittels ELISA.

Legionellae and Acanthamoeba castellanii were co-cultivated (37 degrees C, 2 days) to study the intracellular multiplication of Legionella pneumophila strains (n = 37) derived from different sources. The quantification of intracellular growth was observed by both traditional counting of colony forming units and antigen detection by ELISA using polyclonal and monoclonal antibodies. There was a good correlation between the two methods. Depending on detection antibodies chosen, the correlation coefficient ranged from 0.86 to 0.91. Clinical and water isolates associated with legionellosis exhibited significant higher multiplication rates than water isolates without association with legionelloses. Utilization of antigen estimation by ELISA proved to have the following advantages: (1) Availability of results within a few hours after lysis of cells, and (2) simple handling of co-cultivation owing to omission of killing non-ingested bacteria and elutriate the antibiotic. Therefore, the procedure described is recommended for virulence screening, particularly for large number of colonies of Legionella-positive water samples or genetically manipulated legionellae.

[RoTrac capillary pore membranes for laboratory filtration. II. Bacteria-free filtration]. / RoTrac-Kapillarporenmembranen für die Laborfiltration. II. Mittielung: Bakterienfreie Filtration.

Because of their special characteristics Capillary pore membranes (CPM) are now applied in several branches of separation techniques and analytics. Besides applications in particle analytics and microfiltration of different media capillary pore membranes can be used in microorganism separation. It was shown that RoTrac CPM can be used for bacteria free (or so called sterile) filtration. Acceptable fluxes were reached in separation of Pseudomonas diminuta (test species ATCC 19146). Membranes with pore diameters of 0.2 micron and smaller always assure a bacteria free filtrate even for a very high bacteria count of about 10(7)-10(8) bacteria/ml. In filtration of Mycoplasma arginini no sterile filtrate was obtained for a pore diameter of 0.08 micron and a high bacteria count of 3 * 10(7) bacteria/ml. The bacteria rejection by a factor of 10(5) was however remarkable. Only for 0.05 and 0.08 micron with reduced bacteria load the filtrate was bacteria free.

[RoTrac capillary pore membranes for laboratory filtration. I. Degermination filtration]. / RoTrac-Kapillarporenmembranen für die Laborfiltration. I. Mitteilung: Entkeimungsfiltration.

RoTrac capillary pore membranes (CPM) are produced by means of the nuclear track technology. Thus a defined and in wide ranges independent adjunction of the different membrane parameters (diameter, density, shape and inclination of pores) is possible. The wanted uniform separation diameter of the membrane can exactly be chosen according to the size of the microorganisms to be rejected. By dead end filtration experiments with E. coli and Serratia marcescens the suitability of RoTrac-CPM in bacteria removal filtration was proven. Blocking was very strong for membranes with pore diameters in size range of the microorganisms (approximately 0.45 micron). Though the filtrate had immense reduced bacteria counts (from 10(7)-10(8) to 10-100 bacteria/ml), it was generally not sterile. For membranes with a pore diameter of 0.2 micron and smaller blocking was essentially lesser. Here filtrate was always sterile. Flux (and thus the filterable volume) corresponds to values of competitive membranes. Compared with those the proven possibility of simple cleaning is an advantage, because rejection and blocking of symmetrical CPM occur directly on the membrane surface. This is promising for use of CPM in cross flow filtration.

Subtyping of Legionella pneumophila serogroup 1 strains isolated in Germany using monoclonal antibodies.

Legionella pneumophila serogroup 1 (Lp1) strains isolated from patients and hot water supplies in different locations of Germany were subtyped using seven monoclonal antibodies (mabs) in the indirect immunofluorescence test (IFA) and in part, using a dot blot assay. Four of these mabs were produced in Dresden. Three mabs (mab 33G3, mab 32A12 and mab 144c2) were kindly supplied by J. Joly, Quebec, Canada. Altogether, seven antigenic variants were found among Lp1 strains isolated in Germany. Patient strains belonged to the Philadelphia, Benidorm, Knoxville, France, Olda-Heysham and Bellingham subgroups, whereas environmental isolates reacted like the Bellingham, Oxford, Philadelphia, Knoxville and France strains. The majority of patient strains (15 out of 26, 58%) reacted with our mab 3/1 (corresponding to mab 2 of the standard panel), but only 26 out of 118 environmental strains (22%) isolated from 4 of 15 hot water supplies did so (p less than 0.05). The majority of water-borne Lp1 strains reacted with a mab specific of the Bellingham subgroup. Three water systems under study were associated with human legionellosis. Two of them contained Bellingham-like strains, one Philadelphia-like legionellae.

[A minor epidemic due to Legionella pneumophila serogroup 1]. / Kleinepidemie durch Legionella pneumophila Serogruppe 1.

Ten days after starting military service in a police barracks a 25-year-old man developed left middle and lower lobe pneumonia which did not respond to ampicillin (8 g daily) and gentamycin (120 mg daily). Parenteral administration of doxycycline (100 mg daily) was equally ineffective. However, the fever fell on administration of cefotiam (4 g daily). Antibody tests demonstrated Legionella pneumophila serogroup 1 as the causative organism. Because of the confined accommodation of the conscripts the source of the infection was thought to be the hot water system in the barracks. In two other policemen the demonstration of antibodies and of urine antigens confirmed Legionella infection as cause of an acute respiratory illness (Pontiac disease). Legionella pneumophila serogroup 1 subtype Philadelphia, 1-8 colony-forming units per ml, was isolated from six of 14 hot water samples in the barracks. This subtype possesses a virulence-associated antigen which is found in the majority of patient isolates of Legionella pneumophila serogroup 1.

[Determination of Legionella antigens using monoclonal antibodies]. / Bestimmung von Legionella-Antigenen mit Hilfe monoklonaler Antikörper.

The detection of antigens is the most important tool for rapid diagnosis of Legionellosis. 34 Legionella (L.) spp. with 51 serogroups have been identified from several sources. According to the antigenic diversity, it is necessary to select monoclonal antibodies (mab) adequate to diagnostic purposes. Mab with specificity to genus, species and serogroups were discussed. L. pneumophila accounts for 70 to 80% of all cases of Legionelloses. In this study self-made mab to L. pneumophila are presented that demonstrate these bacteria in clinical materials from respiratory tract using immunofluorescent tests and by detection of soluble antigens in pleura fluids and urine specimens using enzyme immunoassay.