[Influence of the x-ray technique on evaluation of cup anteversion after total hip arthroplasty]

AIM

Total hip arthroplasty (THA) is a standard procedure in orthopaedic surgery. Planar radiography of the implant is routinely performed to ensure that the operation has achieved the desired result. This study investigates the influence of varying the X-ray beam on the analysis of the radiograph.

METHOD

Twenty-three patients were analysed after implantation of a total hip replacement. Besides a CT scan of the pelvis, symphysis- and hip-centred radiographs were available. The cup anteversion was calculated using two published algorithms. The CT-based data were the gold standard.

RESULTS

Our study revealed a significant major error in the analysis of the symphysis-centred radiographs when compared with the hip-centered radiographs. Widmer's algorithm showed a significant superiority over Pradhan's formula.

CONCLUSION

The best approximation of the anteversion angle was achieved using Widmer's technique by centering the X-ray beam onto the hip.

Validity of HoNOS in identifying frequently hospitalized patients with ICD-10 mental disorders

OBJECTIVE

To identify frequently hospitalized patients by using the outcome and severity measure Health of the Nation Outcome Scales (HoNOS) in combination with the International Classification of Diseases (ICD)-10 in patients consecutively admitted to a psychiatric hospital.

METHOD

All full-time in-patients and all day-hospital patients were considered. Frequently hospitalized patients were defined as those with 10 or more hospitalizations.

RESULTS

The total HoNOS score at admission was found valid to discriminate between frequently and non-frequently hospitalized patients as well as in ranking the ICD-10 diagnosis by severity of symptoms and social problems. Frequently hospitalized patients were predominantly found within the diagnoses of schizophrenia and bipolar affective disorders. In these groups, high HoNOS scores were significantly associated with a longer stay in hospital. Improvement during hospitalization as measured by the HoNOS was significantly better for bipolar than for schizophrenic patients.

CONCLUSION

HoNOS was found to be a clinically relevant supplement to ICD-10 in identifying frequently hospitalized patients.

Synovial osteochondromatosis in a 9-year-old girl: clinical and histopathological appearance

This article reports the clinical and histopathological appearance of synovial osteochondromatosis in the right knee joint of a 9-year-old girl. Initial symptoms such as monoarticular joint swelling led to further diagnostic procedures with the aid of different imaging techniques including X-ray examination and MRI. The definitive diagnosis was based on histopathological findings after performing arthroscopy of the affected joint and the intraoperative appearance of the synovial lesions. Besides antiphlogistical drug-therapy, the treatment of choice is synovectomy.

[Surgical anatomy of the lumbar spine]

The success and risks of spinal surgery depend on a correct diagnosis and detailed knowledge of anatomy. This report provides information on relevant structures of the lumbar spine and possible surgical complications. Anatomical topography and different surgical approaches are described step by step.

Medizinische und ökonomische Effizienz des Eigenblutverfahrens bei Endoprothesenimplantation des Hüft- oder Kniegelenkes

AIM

Preoperative autologous blood donation before joint replacement has become standard practice. However, this procedure is discussed controversially regarding medical benefit and cost-effectiveness.

METHOD

In a retrospective study the data of 994 patients scheduled for hip (THR) or knee arthroplasty (TKR) between 1/2000 and 9/2002 were analysed.

RESULTS

Altogether 612 patients donated autologous blood (61.6 %). 50.2 % of the patients got blood transfusions during surgery or in the course of their hospitalisation. Donors received blood units more often than non-donors (55.2 vs. 41.9 %). On average 1.4 +/- 1.7 blood units were given during or after THR and 0.8 +/- 1.1 units during or after TKR. Clear predispositions for an increased use of blood transfusions were cemented endoprosthesis, old age (> 70 years) as well as exclusive general anaesthesia. Since 57.8 % of the blood units were wasted, the additional expenses (only laboratory and material costs were calculated) for each retransfused autologous blood unit were calculated to be 28.76.

CONCLUSION

Besides saving homologous blood, autologous blood donation causes mainly an increased probability of giving transfusions and higher costs. Therefore autologous blood donation should be indicated more critically, especially in younger patients and knee replacements.

[In vitro effects of diclofenac and selective cyclooxygenase-2 inhibitors on prostaglandin release from inflamed bursa subacromialis tissue in patients with subacromial syndrome]

BACKGROUND

To compare the in vitro effects of selective COX-2 inhibitors (L-745,337, NS-398 and DFU) and of COX-unspecific diclofenac on release of PGE(2 )and 6-keto-PGF(1alpha) from inflamed bursa subacromialis tissue (IBST) obtained from a total of 35 patients with shoulder impingement syndrome (SIS).

PATIENTS AND METHODS

Bursal specimens were incubated in the presence of drugs (0.01-1000 microM) for 20 min and 16 h.

RESULTS

After 20 min 10 microM diclofenac significantly inhibited formation of PGE(2) and 6-keto-PGF(1alpha), whereas L-745,337 and NS-398 (10-1000 microM) induced significant inhibition only at concentrations > or =100 microM. In contrast to equimolar diclofenac, DFU (0.01-10 microM) induced no inhibition of bursal PGE(2) release but a dose-dependent, although statistically not significant inhibition after 16 h. The inhibitory potency of diclofenac (0.01-10 microM) was even more increased during long-term incubation showing greater inhibition than DFU at all concentrations studied.

CONCLUSION

The data suggest that in IBST in SIS in vitro the majority of PG is generated via the COX-1 pathway.

[Cup placement in hip replacement surgery -- A comparison of free-hand and computer assisted cup placement in total hip arthroplasty -- a multi-center study]

AIM

The purpose of the current study was to determine the accuracy of free hand and computer-assisted (CAS) cup placement.

MATERIAL AND METHODS

Between June 1985 and August 2001, 105 free-hand and from March to November 1999 80 total hip arthroplasties under computer assistance were implanted in the above mentioned centers. To determine the accuracy of the cups, the inclination and anteversion angles were measured. In all cases the cup position was measured with a CT-investigation of the pelvis. Statistical analysis was performed with the F-test.

RESULTS

With regard to the inclination and anteversion angles the variability of the cup position was significantly higher in the group of free hand implanted cups. In the CAS group we could not find any "extreme" positions.

CONCLUSION

Using computer-assisted surgery a significantly higher reproducible cup position can be obtained. Long time survey may present a lowering of the rate of early and late complications caused by better prostheses alignment in the follow up.

The accuracy of free-hand cup positioning--a CT based measurement of cup placement in 105 total hip arthroplasties

We studied 105 patients who received a total hip arthroplasty between June 1985 and August 2001 using freehand positioning of the acetabular cup. Using pelvic CT scan and the hip-plan module of SurgiGATE-System (Medivision, Oberdorf, Switzerland), we measured the angles of inclination and anteversion of the cup. Mean inclination angle was 45.8 degrees +/-10.1 degrees (range: 23.0-71.5 degrees ) and mean anteversion angle was 27.3 degrees +/-15.0 degrees (range: -23.5 degrees to 59.0 degrees ). We compared the results to the "safe" position as defined by Lewinnek et al. and found that only 27/105 cups were implanted within the limits of the safe position. We conclude that a safe position as defined by Lewinnek et al. [13] was only achieved in a minority of the cups that were implanted freehand.

[Mid-term clinical results of in-patient conservative treatment of cervicobrachialgia syndromes]

AIM

The aim of this study was to evaluate the mid-term results of an in-patient conservative therapy regimen for discogenic cervicobrachialgia.

METHODS

A retrospective follow-up of 100 patients after an average of 4.01 years with clinical examination and a questionnaire was performed.

RESULTS

The subjective outcome rating for pain on a scale from 0 (pain-free) to 10 (maximum imaginable pain) was reduced from 7.91 at beginning of the therapy to 3.19 at the end of the therapy and to 1.5 at follow-up (p < 0.005). Duration of pain, reductions of motion and palsy improved significantly. The patients' appraisal of required surgical therapy could be reduced from 26 % at beginning to 2 % at the end of the therapy.

CONCLUSION

The intensive conservative in-patient treatment for discogenic cervicobrachialgia shows a high satisfaction of the treated patients even after a follow-up of four years. The natural course of the disease shows a rapid and stable remission after wearing off the acute or subacute complaints.

Ikterus und schwere Leberfunktionsst�rung bei der hormonablativen Behandlung des Prostatakarzinoms

Flutamide is an antiandrogen and frequently used for the treatment of prostatic cancer. Severe hepatotoxicity occurs in few patients but may be fatal. We report on two patients with prostatic cancer who received a therapy with flutamide. They showed different degrees of liver damage. One patient recovered completely after withdrawal of Flutamide under medication with steroids. Clinical symptoms and laboratory findings returned to normal within four weeks. Despite immediate withdrawal of Flutamide, the other patient showed a severe course with progressive liver dysfunction and hepatorenal syndrome. He finally died under the clinical picture of fulminant hepatic coma. This case represents the first death associated with flutamide in Germany. The literature concerning the metabolism of flutamide and the published cases of hepatotoxicity of this drug are reviewed.

[Participatory mapping as a tool for public health decision-making in nomadic settings. A case study among Dazagada pastoralists of the Bahr-el-Ghazal region in Chad]

Integrating the strategies of the point of view of nomadic breeders of cattle into a geographic information system (GIS) highlights the complexity of the temporospatial context associated with point of view of nding health care seeking by nomadic pastoralists. The method used in this study was based on a combination of participatory mapping with group discussions and semi-structured interviews. The resulting data allowed georeferencing of the pastoral environment in the inner Lake Chad Basin according to the representation of Dazagada pastoralists of the Bahr-el-Ghazal region (Kanem, Tchad). By providing better insight into the day-to-day life of nomadic people determining their capacities to make use of primary health care, this holistic approach provides a tool to assist public health decision-makers in optimizing the use of health care facilities by nomadic communities.

[Health care centre attendance by Arab nomadic pastoralists. A case study in Kanem, Chad]

Attendence at a rural health centre in a nomadic setting was monitored over several months to gain insight into factors determining accessibility to permanent primary health facilities by nomadic people. Multiple interactions between favorable and unfavorable factors for health care seeking in a nomadic setting were identified for a health care center particularly appreciated by pastoral nomads.

[Occupational diseases of the spine]

Since 1993 occupational influences of the spine are included into the German workman's compensation law (Berufskrankheitenverordnung). Because it is difficult to differentiate degenerative from occupational disc diseases only 3 % of the proposals have been accepted in the last years. Unfortunately most of the epidemiologic studies only consider morphologic changes of the spine but not discogenic diseases. More efforts have to be made to prevent spine diseases in the working place by exercises and back training. Our results of medical opinions in 256 cases of occupational spine diseases are presented and analysed.

Early response gene expression during differentiation of cultured Leishmania donovani

The promastigote form of the unicellular parasite, Leishmania donovani, must differentiate into the amastigote form to establish an infection in a mammalian host. Identification of genes whose expression changes during differentiation could help reveal mechanisms of Leishmania gene regulation and identify targets for controlling the diseases caused by this human pathogen. Two genomic clones were isolated, P9 that is more highly expressed in promastigotes than in axenic amastigotes and A14 that is preferentially expressed in axenic amastigotes. Analysis of the DNA sequences revealed open reading frames that would encode 55.5 kDa and 100 kDa proteins, respectively, with no homology to known proteins. The mRNA level for these genes during 24 h time courses of parasite differentiation in culture was compared to two genes known to be differentially expressed, c-lpk2 and mkk. Changes in RNA level occurred within 2 h for each gene and continued in advance of morphological changes. The expression levels of these four genes in axenic amastigotes correlated with results from animal-derived parasites.

[Computer-assisted navigated cup placement of different cup types in hip arthroplasty--a randomised controlled trial]

AIM

The position of the acetabular implant has a great influence on the outcome of total hip arthroplasty. The acetabular implants differ in their characteristics during insertion. In order to control the influence of the implant in different axes, 80 implantations of acetabular component were performed under computer-assisted control by a surogate navigation system.

METHOD

Within a prospective randomised study, 70 total hip replacements were performed by one surgeon using two different uncemented implants (PPF screw cup/Hedrocel pressfit cup). The position of the cup was measured at different times during surgery and was compared to 10 cemented PE cup placements.

RESULTS

During the milling procedure the anteversion of the two uncemented cups differed significantly (p = 0.026). The standard deviation of anteversion during implantation different significantly relating to the cup type: press-fit cup 3.86 degrees, screw cup 2.1 degrees and cemented PE cups 0,84 degrees. The inclination was less susceptible.

CONCLUSION

The cup design of uncemented acetabular implants influences the outcome of surgery. In our trial a spherical press-fit cup showed a greater variability than the screw-cup. The CAS system can be used as a tool to minimise these effects.

Homologues of LMPK, a mitogen-activated protein kinase from Leishmania mexicana, in different Leishmania species

LMPK, a mitogen-activated protein (MAP) kinase homologue of Leishmania mexicana, is essential for the proliferation of the amastigote, the mammalian stage of the protozoan parasite. This has been demonstrated using deletion mutant promastigotes, the insect stage of the parasite: first, in vitro after differentiation to amastigotes, which subsequently lost their potential to proliferate; second, by infection of peritoneal macrophages, which were able to cope with the infection and cleared the parasites; third, by infection of BALB/c mice, which showed no lesion development. The lmpk deletion mutant promastigotes are a potential live vaccine because they infect macrophages, transform to amastigotes and deliver amastigote antigens to raise an immune response without causing the disease. In addition, inhibition of LMPK in a wild-type infection is likely to resolve the disease and as such, is an ideal target for drug development against leishmaniasis. Here we investigated the presence and copy number of lmpk homologues in Leishmania amazonensis, L. major, L. tropica, L. aethiopica, L. donovani, L. infantum, and L. braziliensis and discuss the results with regard to drug development and vaccination using kinase deletion mutants.

The inactivation of lipoxygenase-1 from soybeans by amidrazones

Several compounds containing an amidrazone moiety are known to be potent inhibitors of lipoxygenase-1 activity from soybeans (L-1) with IC(50)-values in the range of 10 microM to 38 nM. Recently it was proposed that phenylhydrazones act as irreversible mechanism-based inhibitors of lipoxygenases. Because of the structural similarities between both compounds it was assumed for the amidrazones to affect the lipoxygenase reaction in the same suicide manner. Cyclisation of the amidrazone moiety to the corresponding triazoline should yield compounds without substrate properties. However, they are still able to inactivate the enzyme. The inhibition of L-1 from soybeans by two representative compounds of a series of amidrazones and triazolines has been characterised as a slow, tight-binding interaction via a two-step mechanism. Dialysis experiments indicate the reversible nature of interaction of the amidrazone with the ferrous enzyme while the ferric enzyme was irreversibly inactivated. In contrast, the interaction of the triazoline with both the ferric and ferrous species of the enzyme was completely reversible which demonstrates the noncovalent and reversible mode of binding and inactivation. The triazoline was found not to be a substrate of the dioxygenase reaction of lipoxygenase whereas the amidrazone is only a very poor substrate of the enzymatic oxidation reaction. The presented results point out the inhibition of L-1 by amidrazones and triazolines to fall into the same kinetic classification. Therefore it is obvious that the inhibition of L-1 by these compounds cannot be attributed to a truly mechanism-based inactivation.

Lumbar micro disc surgery with and without autologous fat graft. A prospective randomized trial evaluated with reference to clinical and social factors

Epidural scarring is one of the possible complications after lumbar disc surgery. Perineural scar tissue has been considered responsible for recurrent neurological symptoms in patients operated on for disc herniation and leads to a high rate of unsatisfactory results. In addition, postoperative scars may increase the technical difficulty and risk of subsequent procedures. Various materials have been used in animal studies to try to affect the degree of epidural scar tissue with controversial results. In particular, free fat transplantation has been described to reduce the degree of intraspinal scar tissue. We therefore performed a prospective, double-blind, randomized study comparing clinical and social factors of patients being operated on for the first time for lumbar disc herniation. A total of 92 patients received an implantation of autologous fat graft, 94 did not. After a median of 24.2 months after their surgery, an objective examinator compared various clinical parameters and the social situation of patients in both groups without knowing the operation method used. We found no significant differences between the fat-graft group and the control group regarding either the clinical outcome or the social aspects.