[Rotator cuff tear : Indications and pathology-specific reconstructive procedures]. / Rotatorenmanschettenruptur : Indikationen und pathologiespezifische rekonstruktive Verfahren.

Rotator cuff (RC) tears comprise a broad spectrum of lesions ranging from partial to full thickness tears of a single tendon and massive cuff tears. Both glenohumeral trauma as well as degenerative processes can result in tearing of the RC. Treatment therefore requires a meticulous diagnosis as well as a differentiated approach by careful consideration of morphological and patient-specific factors. The pathogenesis, tear morphology, clinical symptoms and functional demands of the patient determine the therapeutic approach. Despite pathological and individual patient-related factors, early surgical repair is generally recommended for traumatic RC tears in young patients and in patients with high functional demands due to the high risk of tear progression. The results of RC repair are negatively correlated with the size of the lesion, the number of tendons involved, the degree of tendon retraction, muscular alteration and patient age. This article provides an overview of the various pathogenesis, indications and surgical repair of RC tears with respect to modern pathology-specific reconstructive procedures.

The assessment of the stability of the tibial component of a novel knee arthroplasty system using radiostereometric analysis.

AIMS: The introduction of a novel design of total knee arthroplasty (TKA) must achieve outcomes at least as good as existing designs. A novel design of TKA with a reducing radius of the femoral component and a modified cam-post articulation has been released and requires assessment of the fixation to bone. Radiostereometric analysis (RSA) of the components within the first two postoperative years has been shown to be predictive of medium- to long-term fixation. The aim of this study was to assess the stability of the tibial component of this system during this period of time using RSA. PATIENTS AND METHODS: A cohort of 30 patients underwent primary, cemented TKA using the novel posterior stabilized fixed-bearing (ATTUNE) design. There was an even distribution of men and women (15:15). The mean age of the patients was 64 years (sd 8) at the time of surgery; their mean body mass index (BMI) was 35.4 kg/m 2 (sd 7.9). RSA was used to assess the stability of the tibial component at 6, 12, and 24 months compared with a six-week baseline examination. Patient-reported outcome measures were also assessed. RESULTS: The mean maximum total point motion (MTPM) of the tibial component between 12 and 24 months postoperatively was 0.08 mm (sd 0.08), which is well below the published threshold of 0.2 mm (p < 0.001). Patient-reported outcome measures consistently improved. CONCLUSION: The tibial component of this novel design of TKA showed stability between assessment 12 and 24 months postoperatively, suggesting an acceptably low risk of medium- to long-term failure due to aseptic loosening.

The effect of multimorbidity on changes in health-related quality of life following hip and knee arthroplasty.

Aims: The aim of this study was to assess the effect of multimorbidity on improvements in health-related quality of life (HRQoL) following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients and Methods: Using data from a regional joint registry for 14 573 patients, HRQoL was measured prior and one year following surgery using the Oxford Hip Score (OHS) and Oxford Knee Score (OKS), and the 12-Item Short-Form Health Survey Physical and Mental Component Summary scores (PCS and MCS, respectively). Multimorbidity was defined as the concurrence of two or more self-reported chronic conditions. A linear mixed-effects model was used to test the effects of multimorbidity and the number of chronic conditions on improvements in HRQoL. Results: Almost two-thirds of patients had multimorbidity, which adversely effected improvements in HRQoL. For THA, mean improvements in HRQoL scores were reduced by 2.21 points in OHS, 1.62 in PCS, and 4.14 in MCS; for TKA, the mean improvements were reduced by 1.71 points in OKS, 1.92 in PCS, and 3.55 in MCS (all p < 0.0001). An increase in the number of chronic conditions was associated with increasing reductions in HRQoL improvements. Conclusion: Multimorbidity adversely effects improvements in HRQoL following THA and TKA. Our findings are relevant to healthcare providers focused on the management of patients with chronic conditions and for administrators reporting and monitoring the outcomes of THA and TKA. Cite this article: Bone Joint J 2018;100-B:1168-74.

How do patients trade-off surgeon choice and waiting times for total joint replacement: a discrete choice experiment.

OBJECTIVE: Patients face significant waiting times for hip and knee total joint replacement (TJR) in publicly funded healthcare systems. We aimed to assess how surgeon selection and reputation affect patients' willingness to wait for TJR. DESIGN: We assessed patient preferences using a discrete choice experiment questionnaire with 12 choice scenarios administered to patients referred for TJR. Based on qualitative research, pre- and pilot-testing, we characterized each scenario by five attributes: surgeon reputation, surgeon selection, waiting time to surgeon visit (initial consultation), waiting time to surgery, and travel time to hospital. Preferences were assessed using hierarchical Bayes (HB) analysis and evaluated for goodness-of-fit. We conducted simulation analyses to understand how patients value surgeon reputation and surgeon selection in terms of willingness to wait for surgeon visit and surgery. RESULTS: Of 422 participants, 68% were referred for knee TJR. The most important attribute was surgeon reputation followed by waiting times, surgeon selection process and travel time. Patients appear willing to wait 10 months for a visit with an excellent reputation surgeon before switching to a good reputation surgeon. Patients in the highest pain category were willing to wait 7.3 months before accepting the next available surgeon, compared to 12 months for patients experiencing the least pain. CONCLUSIONS: Our findings confirm that patients value surgeon reputation in the context of wait times and surgeon selection. We suggest opportunities to reduce wait times by explicitly offering the next available surgeon to increase patient choice, and by reporting surgeon performance to reduce potential misinformation about reputation.

Bone-mediated anteroinferior glenohumeral instability : Current concepts.

Recurrent anterior shoulder instability is commonly associated with defects of the anterior glenoid rim. Substantial osseous defects significantly diminish the glenohumeral stability and require a bony augmentation, either by a coracoid transfer or free bone grafting procedure. Both reconstructive techniques have been applied for a long time and evaluated biomechanically and clinically. Although neither treatment option has been recognized as clearly superior, both comprise certain advantages and disadvantages. The Latarjet technique enables a biomechanically superior stabilization through the additional sling effect at time zero, but constitutes an extra-anatomical procedure with a broad spectrum and relatively high incidence of complications. Free bone grafting techniques enable an anatomical reconstruction of the glenoid concavity, offer the advantage of an unlimited graft size and show generally less severe and more easily manageable complications. The indications need to be carefully considered depending on the specific defect type, the glenoid track concept in cases of bipolar lesions as well as the individual patient characteristics. For both reconstructive procedures, open and arthroscopic approaches have been described with very good results, allowing a selection based on individual surgical skills and experience levels.

[Initial management of traumatic ventral shoulder dislocation]. / Initiales Management der traumatischen ventralen Schultererstluxation.

BACKGROUND: In the current literature a consensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, a variety of factors need to be considered for the planning of further treatment. OBJECTIVE: This article aims at giving an overview of the essential aspects of the initial management in the rescue center, clinical and radiological diagnostic procedures and the subsequent treatment options. MATERIAL AND METHODS: The content of this article is based on our own clinical experiences in combination with a systematic literature search for relevant clinical and baseline studies. RESULTS: Besides a detailed anamnesis and clinical examination, X­rays in two planes are important for the diagnosis. Potential nerve injuries or fractures need to be borne in mind before and after reduction of the joint and documented accordingly. The Matsen's maneuver can be recommended as it enables a careful repositioning. In rare cases of an irreducible shoulder dislocation due to soft tissue or bony articular interpositions, an open reduction might be necessary. Further therapeutic concepts should be adapted to patient age, activity level and accompanying pathologies, which determine the risk of a recurrent dislocation. A surgical approach for stabilization of the shoulder is highly recommended in cases of concomitant bony defects as well as in young and physically active patients. CONCLUSION: A well-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. A generally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.

Assessing the comparability of hip arthroplasty registries in order to improve the recording and monitoring of outcome.

AIMS: We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery. MATERIALS AND METHODS: We conducted a review of registries that are full members of the International Society of Arthroplasty Registries with publicly available annual reports in English. Of the six registries which were included, we compared the reporting of: mean age, definitions for revision and re-operation, reasons for revision, the approach to analysing revisions, and patient-reported outcome measures (PROMs) for primary and revision total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA). RESULTS: Outcomes were infrequently reported for HRA compared with THA and all hip arthroplasties. Revisions were consistently defined, though re-operation was defined by one registry. Implant survival was most commonly reported as the cumulative incidence of revision using Kaplan-Meier survival analysis. Three registries reported patient reported outcome measures. CONCLUSION: More consistency in the reporting of outcomes for specific types of procedures is needed to improve the interpretation of joint registry data and accurately monitor safety trends. As collecting additional details of surgical and patient-reported outcomes becomes increasingly important, the experience of established registries will be valuable in establishing consistency among registries while maintaining the quality of data. TAKE HOME MESSAGE: As the volume of joint replacements performed each year continues to increase, greater consistency in the reporting of surgical and patient-reported outcomes among joint replacement registries would improve the interpretation and comparability of these data to monitor outcomes accurately.

Measurements of the neutron spectrum in transit to Mars on the Mars Science Laboratory.

The Mars Science Laboratory spacecraft, containing the Curiosity rover, was launched to Mars on 26 November 2011. Although designed for measuring the radiation on the surface of Mars, the Radiation Assessment Detector (RAD) measured the radiation environment inside the spacecraft during most of the 253-day, 560-million-kilometer cruise to Mars. An important factor for determining the biological impact of the radiation environment inside the spacecraft is the specific contribution of neutrons with their high biological effectiveness. We apply an inversion method (based on a maximum-likelihood estimation) to calculate the neutron and gamma spectra from the RAD neutral particle measurements. The measured neutron spectrum (12-436 MeV) translates into a radiation dose rate of 3.8±1.2 µGy/day and a dose equivalent of 19±5 µSv/day. Extrapolating the measured spectrum (0.1-1000 MeV), we find that the total neutron-induced dose rate is 6±2 µGy/day and the dose equivalent rate is 30±10 µSv/day. For a 360 day round-trip from Earth to Mars with comparable shielding, this translates into a neutron induced dose equivalent of about 11±4 mSv.

Strong and deep Atlantic meridional overturning circulation during the last glacial cycle.

Extreme, abrupt Northern Hemisphere climate oscillations during the last glacial cycle (140,000 years ago to present) were modulated by changes in ocean circulation and atmospheric forcing. However, the variability of the Atlantic meridional overturning circulation (AMOC), which has a role in controlling heat transport from low to high latitudes and in ocean CO2 storage, is still poorly constrained beyond the Last Glacial Maximum. Here we show that a deep and vigorous overturning circulation mode has persisted for most of the last glacial cycle, dominating ocean circulation in the Atlantic, whereas a shallower glacial mode with southern-sourced waters filling the deep western North Atlantic prevailed during glacial maxima. Our results are based on a reconstruction of both the strength and the direction of the AMOC during the last glacial cycle from a highly resolved marine sedimentary record in the deep western North Atlantic. Parallel measurements of two independent chemical water tracers (the isotope ratios of (231)Pa/(230)Th and (143)Nd/(144)Nd), which are not directly affected by changes in the global cycle, reveal consistent responses of the AMOC during the last two glacial terminations. Any significant deviations from this configuration, resulting in slowdowns of the AMOC, were restricted to centennial-scale excursions during catastrophic iceberg discharges of the Heinrich stadials. Severe and multicentennial weakening of North Atlantic Deep Water formation occurred only during Heinrich stadials close to glacial maxima with increased ice coverage, probably as a result of increased fresh-water input. In contrast, the AMOC was relatively insensitive to submillennial meltwater pulses during warmer climate states, and an active AMOC prevailed during Dansgaard-Oeschger interstadials (Greenland warm periods).

Wear testing of crosslinked polyethylene: wear rate variability and microbial contamination.

The wear performance of two types of crosslinked polyethylene (Marathon™ and XLK™, DePuy Synthes Inc., Warsaw, IN) was evaluated in a pin-on-disc wear tester, a hip wear simulator, and a knee wear simulator. Sodium azide was used as the microbial inhibitor in the calf serum-based lubricant. In the pin-on-disc wear tester, the Marathon wear rate of 5.33±0.54mm(3)/Mc was significantly lower (p=0.002) than the wear rate of 6.43±0.60mm(3)/Mc for XLK. Inversely, the Marathon wear rate of 15.07±1.03mm(3)/Mc from the hip wear simulator was 2.2-times greater than the XLK wear rate of 6.71±1.03mm(3)/Mc from the knee wear simulator. Differences in implant design, conformity, GUR type, and kinematic test conditions were suggested to account for the difference between the wear rates generated in the different types of wear testing apparati. In all wear tests, sodium azide was ineffective at inhibiting microbial growth in the lubricant. Eight different organisms were identified in the lubricant samples from the wear tests, which suggested the necessity of using an alternative, more effective microbial inhibitor. Careful sample preparation and thorough cleaning has shown to improve the consistency of the wear results. The wear rates generated in the hip and knee wear simulators closely reflected the wear behaviour of Marathon and XLK reported in published data that were tested under similar conditions.

Measurements of energetic particle radiation in transit to Mars on the Mars Science Laboratory.

The Mars Science Laboratory spacecraft, containing the Curiosity rover, was launched to Mars on 26 November 2011, and for most of the 253-day, 560-million-kilometer cruise to Mars, the Radiation Assessment Detector made detailed measurements of the energetic particle radiation environment inside the spacecraft. These data provide insights into the radiation hazards that would be associated with a human mission to Mars. We report measurements of the radiation dose, dose equivalent, and linear energy transfer spectra. The dose equivalent for even the shortest round-trip with current propulsion systems and comparable shielding is found to be 0.66 ± 0.12 sievert.

Performance assessment of femoral knee components made from cobalt-chromium alloy and oxidized zirconium.

BACKGROUND: The surface characteristics of the femoral component affect polyethylene wear in modular total knee replacements. In the present retrieval study, the surface characteristics of cobalt-chromium (CoCr) alloy and oxidized zirconium (OxZr) femoral components were assessed and compared. METHODS: Twenty-six retrieved CoCr alloy femoral components were matched with twenty-six retrieved OxZr femoral components for implantation period, body-mass index, patient gender, implant type, and polyethylene insert thickness. The surface damage on the retrieved femoral components was evaluated using a semi-quantitative assessment method, scanning electron microscopy, and contact profilometry. RESULTS: The retrieved CoCr alloy femoral components showed less posterior surface gouging than OxZr femoral components; however, at a higher magnification, the grooving damage features on the retrieved CoCr alloy femoral components confirmed an abrasive wear mechanism. The surface roughness values Rp, Rpm, and Rpk for the retrieved CoCr alloy femoral components were found to be significantly higher than those of the retrieved OxZr femoral components (p≤0.031). The surface roughness values were higher on the medial condyles than on the lateral condyles of the retrieved CoCr alloy femoral components; such a difference was not observed on the retrieved OxZr femoral components. CONCLUSIONS: The surface roughness of CoCr alloy femoral components increased while the surface roughness of the OxZr femoral components remained unchanged after in vivo service. Therefore, the OxZr femoral components' resistance to abrasive wear may enable lower polyethylene wear and ensure long-term durability in vivo. LEVEL OF EVIDENCE: Level IV.

The operative management of osteoporotic fractures of the knee: to fix or replace?

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

[Visualized medicine. Macroscopy, molecular anatomy and medical art]. / Dargestellte Medizin. Von der Makroskopie zur molekularen Anatomie und medizinischen Kunst.

Quite frequently clinicians avail themselves of works of well known artists in order to illustrate certain diseases. In contrast, pathologists find it harder to use art to demonstrate morphology. My approach to compensate for this is twofold: on the one hand, with 8 mostly three dimensional wooden objects with either mirror or aluminium elements, on the other with 449 collages consisting of pictures exclusively with a medical background (histology, radiology, nuclear medicine) or showing a combination of histological or cytological photos with pictures of flowers, trees or landscapes. My experience is that this technique arouses interest in complex medical issues even with medically unqualified individuals.

The CD63 basophil activation test in Hymenoptera venom allergy: a prospective study.

BACKGROUND: The basophil activation test (BAT), which relies on flow cytometric quantitation of the allergen-induced up-regulation of the granule-associated marker CD63 in peripheral blood basophils, has been suggested to be a useful approach in detecting responsiveness to allergens. The purpose of this study was to establish the usefulness of the BAT with regard to the clinical history and current diagnostic tools in Hymenoptera venom allergy using a prospective study design. METHODS: Fifty-seven consecutive patients allergic to Hymenoptera venom as defined by a systemic reaction after an insect sting, and 30 age- and sex-matched control subjects with a negative history were included. The degree and nature of sensitization was confirmed by skin testing, specific immunoglobulin E (IgE), serum tryptase levels and BAT. In the nonallergic control group only analysis of specific IgE and BAT were performed. Correlation of BAT, skin test and specific IgE, respectively, with the clinical history in the allergic group was termed as sensitivity and in the control group as specificity. RESULTS: Twenty one of 23 (91.3%) bee venom allergic patients and 29 of 34 (85.3%) patients allergic to wasp and hornet venom tested positive in BAT. The overall sensitivity of BAT, specific IgE and skin tests were 87.7, 91.2 and 93.0%, respectively. The overall specificities were 86.7% for BAT and 66.7% for specific IgE. No correlation between the severity of clinical symptoms and the magnitude of basophil activation was observed. CONCLUSION: The BAT seems to be an appropriate method to identify patients allergic to bee or wasp venom with a comparable sensitivity to standard diagnostic regimens. The higher specificity of BAT as compared with specific IgE makes this test a useful tool in the diagnosis of Hymenoptera venom allergy.

Therapeutic use of the natriuretic peptide ularitide in acute renal failure.

BACKGROUND: Ularitide is a member of the natriuretic peptide family. This hormone exhibits an N-terminal extension by four amino acids compared with atrial natriuretic peptide. Ularitide was shown to exert strong diuretic and natriuretic effects when infused intravenously. Its main action sites are the glomerulum, inducing preglomerular vasodilation and postglomerular vasoconstriction and thereby elevating the glomerular filtration rate, and the tubular system inhibiting Na(+)-reabsorption. In initial uncontrolled clinical trials, this peptide was shown to have beneficial effects in patients suffering from oliguric acute renal failure. METHODS: We conducted a double-blind, placebo-controlled, multicenter, dose-finding trial recruiting 176 patients randomized into 4 different Ularitide doses groups (U5, U20, U40, and U80 ng/kg/min) and a placebo group (U0). Ularitide/placebo infusion was performed for 5 days with half the originally infused dose on day 5. The primary objective of the study was to test various doses of Ularitide in patients suffering from oliguric acute renal failure to avoid mechanical renal replacement therapy during the first 12 hours. FINDINGS: The results indicate that Ularitide does not reduce the incidence of mechanical renal replacement therapy compared with placebo-treated patients during the first 12 h of treatment (U0: 36 (20), U5: 35 (11), U20: 36 (9), U40: 28 (8), U80: 41 (12), (% (n) (p = 0.87)). Diuresis increased in the Ularitide-treated groups and the placebo group after onset of infusion and did not show any significant difference in the first 12 h collection period (U0: 576, U5: 514, U20: 500, U40: 360, U80: 158 ML/12h (Median), (p = 0.16)). INTERPRETATION: In summary, the incidence of mechanical renal replacement therapy in critically ill patients suffering from oliguric acute renal failure could not be altered positively by Ularitide administration according to our protocol. Further prospective clinical trials are needed to answer the question whether a different patient collective or a prophylactic administration of Ularitide are more promising approaches in the clinical setting of oliguric acute renal failure.

[Alveolar hemorrhagic syndrome in sarcoidosis]. / Alveoläres Hämorrhagiesyndrom bei Sarkoidose.

BACKGROUND: Alveolar hemorrhage is uncommon in sarcoidosis, even in the presence of severe alveolitis. PATIENT: A heavy smoker with bihilar adenopathy presented with severe alveolar hemorrhage in the absence of radiological signs of pulmonary involvement. Sarcoidosis was confirmed histologically by transbronchial and mediastinal lymph node biopsies. The bleeding stopped before the installation of anti-inflammatory medication and did not reoccur within 9 months of follow up, but BAL analysis demonstrated the persistence of alveolar siderophages. CONCLUSIONS: Sarcoidosis should be considered as a rare cause of diffuse alveolar hemorrhage.

[Differentiated metastasis of mature testicular teratoma as differential kidney and adrenal tumor diagnosis]. / Differenzierte Metastase eines reifen Hodenteratoms als Differentialdiagnose eines Nieren-bzw. Nebennierentumors.

We report on the eighth known case of a mature metastasis of a mature teratoma of the testis. In a 19-year-old patient who had undergone a pyeloplasty of the left renal pelvis 6 years before, a mature metastasis of an occult mature teratoma of the testis was found at the former operation site. This case--in addition to those published previously--emphasizes the fact that a mature teratoma of the testis has to be regarded as a malignant tumor in adults. It is supposed that the mature teratoma originates, as other testicular tumors, from carcinoma-in-situ-cells, which are responsible for metastasize and are not detected after lysis.