Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey).

INTRODUCTION: Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results. MATERIALS AND METHODS: All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier. RESULTS: The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%). CONCLUSIONS: Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.

Reduction of blood loss with the use of a new combined intra-operative and post-operative autologous blood transfusion system compared with no drainage in primary total hip replacement.

Autologous retransfusion and no-drainage are both blood-saving measures in total hip replacement (THR). A new combined intra- and post-operative autotransfusion filter system has been developed especially for primary THR, and we conducted a randomised controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood transfusion (ABT) (n = 102) or no-drainage (n = 102). In the ABT group, a mean of 488 ml (sd 252) of blood was retransfused. The mean lowest post-operative haemoglobin level during the hospital stay was higher in the autotransfusion group (10.6 g/dl (7.8 to 13.9) vs 10.2 g/dl (7.5 to 13.3); p = 0.01). The mean haemoglobin levels for the ABT and no-drainage groups were not significantly different on the first day (11.3 g/dl (7.8 to 13.9) vs 11.0 g/dl (8.1 to 13.4); p = 0.07), the second day (11.1 g/dl (8.2 to 13.8) vs 10.8 g/dl (7.5 to 13.3); p = 0.09) or the third day (10.8 g/dl (8.0 to 13.0) vs 10.6 g/dl (7.5 to 14.1); p = 0.15). The mean total peri-operative net blood loss was 1464 ml (sd 505) in the ABT group and 1654 ml (sd 553) in the no-drainage group (p = 0.01). Homologous blood transfusions were needed in four patients (3.9%) in the ABT group and nine (8.8%) in the no-drainage group (p = 0.15). No statistically significant difference in adverse events was found between the groups. The use of a new intra- and post-operative autologous blood transfusion filter system results in less total blood loss and a smaller maximum decrease in haemoglobin levels than no-drainage following primary THR.

Poor accuracy of freehand cup positioning during total hip arthroplasty.

Several studies have demonstrated a correlation between the acetabular cup position and the risk of dislocation, wear and range of motion after total hip arthroplasty. The present study was designed to evaluate the accuracy of the surgeon's estimated position of the cup after freehand placement in total hip replacement. Peroperative estimated abduction and anteversion of 200 acetabular components (placed by three orthopaedic surgeons and nine residents) were compared with measured outcomes (according to Pradhan) on postoperative radiographs. Cups were placed in 49.7 degrees (SD 6.7) of abduction and 16.0 degrees (SD 8.1) of anteversion. Estimation of placement was 46.3 degrees (SD 4.3) of abduction and 14.6 degrees (SD 5.9) of anteversion. Of more interest is the fact that for the orthopaedic surgeons the mean inaccuracy of estimation was 4.1 degrees (SD 3.9) for abduction and 5.2 degrees (SD 4.5) for anteversion and for their residents this was respectively, 6.3 degrees (SD 4.6) and 5.7 degrees (SD 5.0). Significant differences were found between orthopaedic surgeons and residents for inaccuracy of estimation for abduction, not for anteversion. Body mass index, sex, (un)cemented fixation and surgical approach (anterolateral or posterolateral) were not significant factors. Based upon the inaccuracy of estimation, the group's chance on future cup placement within Lewinnek's safe zone (5-25 degrees anteversion and 30-50 degrees abduction) is 82.7 and 85.2% for anteversion and abduction separately. When both parameters are combined, the chance of accurate placement is only 70.5%. The chance of placement of the acetabular component within 5 degrees of an intended position, for both abduction and anteversion is 21.5% this percentage decreases to just 2.9% when the tolerated error is 1 degrees . There is a tendency to underestimate both abduction and anteversion. Orthopaedic surgeons are superior to their residents in estimating abduction of the acetabular component. The results of this study indicate that freehand placement of the acetabular component is not a reliable method.

Failure of the uncoated titanium ProxiLock femoral hip prosthesis.

UNLABELLED: New prostheses should be evaluated for stability and clinical performance. In a prospective randomized clinical trial, we implanted 22 titanium (Ti) and 20 hydroxyapatite-coated (HA) ProxiLock femoral hip prostheses during total hip arthroplasty in 42 patients. The patients were followed for 24 months with clinical, radiographic and radiostereometric analysis. Full weightbearing was allowed immediately postoperatively. One patient with a titanium stem was lost to followup. During the first two months, 34 of the 41 stems subsided and/or rotated towards retroversion, regardless of stem type. At the 24-month followup 35 of the 41 prostheses were either fully stabilized (16 HA and 11 Ti stems) or had clinical irrelevant migration (four HA and four Ti stems). Six Ti prostheses showed continuous migrations with maximums of 4.7 mm translation and 12.2 degrees retroversion; four of these were revised, the other two had no clinical complaints. CLINICAL RELEVANCE: The migration pattern we found indicates insufficient primary fixation of the ProxiLock stem in an immediate full weightbearing protocol. The HA coating improves the secondary stability of the prosthesis compared to the uncoated stem. Early migration is associated with an increased risk of possible future loosening and revision, and therefore we discontinued the use of this prosthesis. LEVEL OF EVIDENCE: Therapeutic Level I. See Guidelines for Authors for a complete description of levels of evidence.

Cyclotron production of 64Cu by deuteron irradiation of 64Zn.

The short-lived (12.7h half-life) (64)Cu radioisotope is both a beta(+) and a beta(-) emitter. This property makes (64)Cu a promising candidate for novel medical applications, since it can be used simultaneously for therapeutic application of radiolabelled biomolecules and for diagnosis with PET. Following previous work on (64)Cu production by deuteron irradiation of natural zinc, we report here the production of this radioisotope by deuteron irradiation of enriched (64)Zn. In addition, yields of other radioisotopes such as (61)Cu, (67)Cu, (65)Zn, (69m)Zn, (66)Ga and (67)Ga, which were co-produced in this process, were also measured. The evaporation code ALICE-91 and the transport code SRIM 2003 were used to determine the excitation functions and the stopping power, respectively. All the nuclear reactions yielding the above-mentioned radioisotopes were taken into account in the calculations both for the natural and enriched Zn targets. The experimental and calculated yields were shown to be in reasonable agreement. The work was carried out at the Scanditronix MC-40 Cyclotron of the Institute for Health and Consumer Protection of the Joint Research Centre of the European Commission (Ispra site, Italy). The irradiations were carried out with 19.5 MeV deuterons, the maximum deuteron energy obtainable with the MC-40 cyclotron.

An injectable calcium phosphate cement as a bone-graft substitute in the treatment of displaced lateral tibial plateau fractures.

In the treatment of displaced tibial plateau fractures, filling the resultant metaphyseal defect is essential for maintaining reduction. This study reports on 14 patients with an average age of 53 (range 34-63) years who sustained such a fracture and whose tibial defect was augmented with an injectable calcium phosphate cement under arthroscopic and fluoroscopic control. Eight fractures were treated with subcortical percutaneous screw fixation, plates were used in four cases and two fractures were treated with bone cement only. Full weight-bearing was allowed after 6-12 weeks. At the last follow-up which averaged 28 (range 18-47) months, the reduction achieved at the index operation was not altered in any of the patients except one. Most patients recorded little or no pain with an average VAS score of 1.2 (0-3.4). Ten patients had no limitation of their walking distance. Patient satisfaction was good or excellent in 12 cases. Flexion averaged 140 degrees (range 130-150 degrees ) and extension was unlimited in 13 patients. The Lysholm knee score averaged 80 and the Knee Society score 180 (range 127-195). In our opinion the injectable calcium phosphate cement used here is a promising alternative for filling metaphyseal defects in the treatment of displaced tibial plateau fractures.

Synaptic interactions increase optic flow specificity.

Representations of optic flow are encoded in fly tangential neurons by pooling the signals of many retinotopically organized local motion-sensitive inputs as well as of other tangential cells originating in the ipsi- and contralateral half of the brain. In the so called HSE cell, a neuron involved in optomotor course control, two contralateral input elements, the H1 and H2 cells, mediate distinct EPSPs. These EPSPs frequently elicit spike-like depolarizations in the HSE cell. The synaptic transmission between the H2 and the HSE cell is analysed in detail and shown to be very reliable with respect to the amplitude and time-course of the postsynaptic potential. As a consequence of its synaptic input, the HSE cell responds best to wide-field motion, such as that generated on the eyes when the animal turns about its vertical body axis. It is shown that the specificity of the HSE cell for this type of optic flow is much enhanced if rapid membrane depolarizations, such as large-amplitude EPSPs or spike-like depolarizations, are taken into account rather than the average membrane potential.

Temperature-dependence of neuronal performance in the motion pathway of the blowfly calliphora erythrocephala

Raising the head temperature within a behaviourally relevant range has strong effects on the performance of an identified neuron, the H1 neuron, in the visual motion pathway of blowflies. The effect is seen as an increase in the mean amplitude of the responses to motion under both transient and steady-state conditions, a considerable decrease in the response latency and an improvement in the reliability of the responses to motion. These temperature-dependent effects are independent of whether the animal is exposed to transient temperature changes or is maintained continuously at the same temperature for its entire life. The changes in the neuronal response properties with temperature may be of immediate functional significance for the animal under its normal operating conditions. In particular, the decrease in latency and the improvement in the reliability with increasing temperature may be relevant for the fly when executing its extremely virtuosic flight manoeuvres.

Lack of adhesion molecules in testicular diffuse centroblastic and immunoblastic B cell lymphomas as a contributory factor in malignant behaviour.

Diffuse large B-cell lymphoma of the testis is a rare tumour, often with disseminated disease. According to the Kiel Classification, these lymphomas are of centroblastic or immunoblastic type, corresponding in the Working Formulation to malignant lymphoma, large cell non-cleaved and large cell immunoblastic, respectively. Adhesive cell-cell and cell-matrix interactions are generally assumed to play an important part in the metastatic process, and to find clues to the highly malignant biological behaviour of this tumour we examined expression of integrins and other adhesion molecules on the tumour cells and the presence of matrix proteins. Few adhesion molecules appeared to be expressed. CD44 was expressed in 10/12 lymphomas, CD49f/VLA-6 was positive in 5/12 cases, and CD49d/VLA-4, CD54 and CD62L were detectable in a small number (2-3) of lymphomas. All other adhesion molecules were lacking. This expression pattern is suggestive of a high metastatic potential: the tumour cells seem to be poorly attached to the extracellular matrix, to each other and to other cells (CD54-, CD11a-, CD58-). The adhesion molecules expressed, CD44, CD49f/VLA-6 and CD49d/VLA-4, have been reported to play a part in dissemination, mediating intravasation (CD49f/VLA-6) and extravasation (CD44, CD49d/VLA-4). This profile of adhesion molecules may explain, at least in part, the specific biological behaviour of these lymphomas with early and rapid dissemination.

[Herpes simplex encephalitis in childhood]. / Herpes-simplex-Enzephalitis im Kindesalter.

This is a report on diagnostic and therapeutic experience in 6 patients aged 3 weeks to 6.3 years suffering from herpes simplex encephalitis. In 2 patients, a 3-week-old newborn and a 1.3-year-old boy, acyclovir-therapy started at days 8 and 17 respectively, following the demonstration of hemorrhagic necrosis in the brain by cranial CT-scan and IgM-specific HSV-antibodies in the blood. A 6.3-year-old girl was treated with acyclovir at day 10 of her illness, when cCT showed hemorrhagic necrosis in the brain. It was not before the 21st day, that diagnosis of HSE could be confirmed serologically. She suffered a relapse of encephalitis 5 weeks later. In a 3-month-old boy, treated with acyclovir at day 4 of his illness, IgM-specific HSV-antibodies were found already at day 4. His clinical course was complicated by subdural effusion. These 4 children survived with severe neurologic sequelae. Another 2 patients, a 5- and 7.5-month-old boy respectively, survived without apparent defect. In both cases vesicles upon the tongue appeared in the beginning of illness. Acyclovir-therapy started at day 7, diagnosis being confirmed serologically later. In our experience HSE should be suspected in children suffering from fever, drowsiness and focal or secondarily generalizing seizures. In these cases antiviral therapy should not depend on serologic findings.

[Tumor markers and endocrinologic aspects in intracranial germinoma]. / Tumormarker und endokrinologische Aspekte beim intrakraniellen Germinom.

This report outlines the endocrine abnormalities associated with intracranial germinoma in childhood. The presence of special tumoral markers as alpha 1-fetoprotein and beta-HCG could be of diagnostic value and is important in respect to therapy control. However the reported case shows that despite known radiosensitivity and appropriate radiotherapy localized tumor relapse may arise soon after treatment.

[Postmortem evaluation of barbiturate poisonings]. / Untersuchungen zur postmortalen Bewertung von Barbituratintoxikationen.

The evaluation of barbiturate intoxication as the cause of death is often difficult when the concentration in body fluids and organs is not extremely high. The problem arises because of the great capacity of barbiturates to produce tolerance after chronic use, a property that is often unknown. Therefore, the most abused barbiturates were studied to assess whether chronic intake causes morphological liver changes or not. It was found that the chronic abuse of drugs containing seco-, cyclo-, brallo-, and/or pentobarbital produces hypertrophy of the smooth endoplasmic reticulum of hepatocytes corresponding to that of phenobarbital. Neither acute barbiturate overdose (without a history of abuse) nor chronic abuse of opiates causes similar liver changes. In conclusion, barbiturate tolerance can be evaluated postmortem by light microscopic examination of the liver.

Two cases of ring chromosome 13. Chromosome banding patterns and mosaic configuration.

Two ring chromosomes 13 were studied by means of various cytogenetic techniques in two psychomotorically retarded male infants. Common features of our patients include microcephalia, hypertelorism, wide and prominent nose bridge, and cryptorchism. Various configurations of the aberrant chromosomes could be identified in cultured skin fibroblasts and peripheral lymphocytes from both patients. Chromosome heteromorphisms and analysis of silver stained nucleolus organizer regions (Ag-NOR) substantiated the parental origin of the ring chromosomes. The more severely affected patient showed a break point at band 13q32 in the long arm of the ring, whereas in the less severely affected the loss of material during ring formation was restricted to the telomere. This provides further evidence for a clinical relevance of the detected mosaic configurations of the rings.

Tandem duplication dup(X)(q13q22) in a male proband inherited from the mother showing mosaicism of X-inactivation.

An aberrant X chromosome containing extra material in the long arm was observed in a psychomotoric retarded boy and his healthy, short-statured mother. The proband showed generalized muscular hypotony, growth retardation, and somatic anomalies including hypoplastic genitalia and cryptorchism. Chromosomal banding techniques suggested a tandem duplication of the segment Xq13 leads to Xq22. In the mother the vast majority of lymphocytes showed late replication of the aberrant X chromosome. Some of her cells, however, contained an apparently active aberrant X. Both the early- and late-replicating aberrant X exhibited late replication patterns very similar to those described for normal X chromosomes in lymphocytes. Asynchrony of DNA replication among the two segments Xq13 leads to Xq22 in the dup(X) was never observed. We consider that the clinical picture of the proband is caused by an excess of active X material.

[Results of radiotherapy of bronchial carcinoma (author's transl)]. / Ergebnisse der Strahlenbehandlung des Bronchialkarzinoms

In a joint retrospective study by 17 radiotherapy clinics in German-speaking countries the results of treatment of bronchial carcinoma after radiotherapy were analysed in 7503 cases. The age peak was between the 60th and 70th year. Squamous-cell carcinoma was the most frequent histological type, followed by anaplastic carcinoma, with adenocarcinoma being rare. There was a high proportion of histologically not clearly identified cases (27% in central and 35% in peripheral carcinomas). Survival rate at one year was 31% for central (3662 patients) and peripheral (961 patients) tumours, but only 2% at five years. Prognostically there was no difference between histological types and kind of radiotherapy or technique, but total dose affected survival rate. At a total dose of less than 5000 rd the survival rate at five years was minimal. The prognosis of combined surgical and radiotherapeutic measures was slightly better than with a radiotherapy alone, but results were unpredictable for the individual case. It is concluded that radiotherapy aiming at cure should be used in imoperable bronchial carcinoma if the tumour state and general condition of the patient appear to make a cure possible. But if this is not the case, radiotherapy should be used only palliatively, i.e. only to ameliorate symptoms.