Mature Cystitic Teratoma of the Bladder Masquerading as a Distal Ureteral Stone

A 27-year woman presented with irritative lower urinary tract symptoms and alleged small right distal ureteric stone that had been diagnosed with KUB and non-contrast spiral CT.

Patient was scheduled for ureteroscopic lithotripsy, revealing absence of the presumed stone, while cystoscopy showed unexpected 2 cm pedunculated grayish white lesion, situated on the right lateral wall of the bladder with sparse hairs covering it.

An incomplete TURBT was done; the histological findings correlated with the gross picture seen on cystoscopy.

Following CT urography, the patient went an open partial cystectomy and right oophorectomy; the histopathology was consistent with mature bladder teratoma.

Impact of universal access to hepatitis C therapy on HIV-infected patients: implementation of the Spanish national hepatitis C strategy

In April 2015, the Spanish National Health System (SNHS) developed a national strategic plan for the diagnosis, treatment, and management of hepatitis C virus (HCV). Our aim was to analyze the impact of this on human immunodeficiency virus (HIV)-infected patients included in the HERACLES cohort during the first 6 months of its implementation. The HERACLES cohort (NCT02511496) was set up in March 2015 to evaluate the status and follow-up of chronic HCV infection in patients co-infected with HIV in the south of Spain. In September 2015, the data were analyzed to identify clinical events (death, liver decompensation, and liver fibrosis progression) and rate of treatment implementation in this population. The study population comprised a total of 3474 HIV/HCV co-infected patients. The distribution according to liver fibrosis stage was: 1152 F0-F1 (33.2 %); 513 F2 (14.4 %); 641 F3 (18.2 %); 761 F4 (21.9 %); and 407 whose liver fibrosis was not measured (12.3 %). During follow-up, 248 patients progressed by at least one fibrosis stage [7.1 %; 95 % confidence interval (CI): 6.3-8 %]. Among cirrhotic patients, 52 (6.8 %; 95 % CI: 5.2-8.9 %) developed hepatic decompensation. In the overall population, 50 patients died (1.4 %; 95 % CI: 1.1-1.9 %). Eight hundred and nineteen patients (23.56 %) initiated interferon (IFN)-free treatment during follow-up, of which 47.8 % were cirrhotic. In our study, during 6 months of follow-up, 23.56 % of HIV/HCV co-infected patients included in our cohort received HCV treatment. However, we observed a high incidence of negative short-term outcomes in our population.

A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing

OBJECTIVE

Negative pressure wound therapy (NPWT) has become an established treatment of traumatic and infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a further development that combines the conventional NPWT with instillation of different fluids which continuously administer therapeutic reagents to the wound. The aim of this study was to compare the impact of additional saline instillation in NPWTi to NPWT alone.

METHOD

Between January and July 2014, consecutive patients with acute wounds of the lower limb were treated with NPWTi with saline instillation. The number of revision surgeries, length of hospital stay, and duration of treatment until final healing were recorded and compared with matched patients undergoing NPWT without instillation.

RESULTS

There were 10 patients recruited with 10 matched controls examined restrospectivley. Patients who received NPWTi were found to have decreased time of hospitalisation (21.5 versus 26.5 days, p=0.43), and accelerated wound healing (9.0 versus 12.5 days, p=0.36) than patients who received NPWT. However, the difference in the outcomes of the patients who received NPWTi and patients who received NPWT was not found to be statisticallly significant.

CONCLUSION

NPWTi with instillation of saline is a promising method and its effectiveness needs to be tested in a randomised controlled trial compared with NPWT alone.

DECLARATION OF INTEREST

This study obtained support by KCI (Wiebsaden, Germany) for the surgical material.

Transcriptome-Wide High-Density Microarray Analysis Reveals Differential Gene Transcription in Periprosthetic Tissue From Hips With Chronic Periprosthetic Joint Infection vs Aseptic Loosening

BACKGROUND

Differentiating between periprosthetic hip infection and aseptic hip prosthesis loosening can be challenging, especially in patients with chronic infections. This study used whole-genome microarray analysis to investigate the transcriptomes of periprosthetic hip tissues to identify genes that are differentially transcripted between chronic periprosthetic hip infection and aseptic hip prosthesis loosening.

METHODS

In this pilot study, a total of 24 patients with either chronic periprosthetic hip infection (n = 12) or aseptic hip prosthesis loosening (n = 12) were analyzed. Periprosthetic hip infection was diagnosed based on modified criteria of the Musculoskeletal Infection Society. To evaluate differences in gene transcription, whole-genome microarray analysis was performed on the mRNA of periprosthetic tissue.

RESULTS

Microarray analysis revealed differential gene transcription in periprosthetic hip tissue affected by chronic hip infection vs aseptic hip prosthesis loosening. A total of 39 genes had area under the curve values greater than 0.9 for diagnosing chronic periprosthetic hip infection; 5 genes had annotations relevant to infection and metabolism. The 39 genes also included 7 genes that were differentially transcribed but that have no apparent connection to immune response processes plus 27 genes with unknown function.

CONCLUSION

Differences in gene transcription profiles might represent novel diagnostic targets that can be used to differentiate between chronic periprosthetic hip infections and aseptic hip prosthesis loosening. Secondary metabolites of differentially transcripted genes might serve as easily accessible markers for detecting chronic periprosthetic joint infection in future.

Liver stiffness predicts the response to direct-acting antiviral-based therapy against chronic hepatitis C in cirrhotic patients

The purpose of this investigation was to evaluate the impact of liver stiffness (LS) on the response to direct-acting antiviral (DAA)-based therapy against hepatitis C virus (HCV) infection in cirrhotic patients. Those patients included in two Spanish prospective cohorts of patients receiving therapy based on at least one DAA, who showed a baseline LS ≥ 12.5 kPa and who had reached the scheduled time point for sustained virological response evaluation 12 weeks after completing therapy (SVR12) were analysed. Pegylated interferon/ribavirin-based therapy plus an HCV NS3/4A protease inhibitor (PR-PI group) was administered to 198 subjects, while 146 received interferon-free regimens (IFN-free group). The numbers of patients with SVR12 according to an LS < 21 kPa versus ≥21 kPa were 59/99 (59.6%) versus 46/99 (46.5%) in the PR-PI group (p = 0.064) and 41/43 (95.3%) versus 90/103 (87.4%) in the IFN-free group (p = 0.232). Corresponding figures for the relapse rates in those who presented end-of-treatment response (ETR) were 3/62 (4.8%) versus 10/56 (17.9%, p = 0.024) and 1/42 (2.4%) versus 8/98 (8.2%, p = 0.278), respectively. In a multivariate analysis adjusted for age, sex and use of interferon, a baseline LS ≥ 21 kPa was identified as an independent predictor of relapse [adjusted odds ratio, AOR (95% confidence interval, CI): 4.228 (1.344-13.306); p = 0.014] in those patients with ETR. LS above 21 kPa is associated with higher rates of relapse to DAA-based therapy in HCV-infected patients with cirrhosis in clinical practice. LS could help us to tailor the duration and composition of DAA-based combinations in cirrhotic subjects, in order to minimise the likelihood of relapse.

Phylodynamic and Phylogeographic Profiles of Subtype B HIV-1 Epidemics in South Spain

BACKGROUND

Since 1982, HIV-1 epidemics have evolved to different scenarios in terms of transmission routes, subtype distribution and characteristics of transmission clusters. We investigated the evolutionary history of HIV-1 subtype B in south Spain.

PATIENTS & METHODS

We studied all newly diagnosed HIV-1 subtype B patients in East Andalusia during the 2005-2012 period. For the analysis, we used the reverse transcriptase and protease sequences from baseline resistance, and the Trugene® HIV Genotyping kit (Siemens, Barcelona, Spain). Subtyping was done with REGA v3.0. The maximum likelihood trees constructed with RAxML were used to study HIV-1 clustering. Phylogeographic and phylodynamic profiles were studied by Bayesian inference methods with BEAST v1.7.5 and SPREAD v1.0.6.

RESULTS

Of the 493 patients infected with HIV-1 subtype B, 234 grouped into 55 clusters, most of which were small (44 clusters ≤ 5 patients, 31 with 2 patients, 13 with 3). The rest (133/234) were grouped into 11 clusters with ≥ 5 patients, and most (82%, 109/133) were men who have sex with men (MSM) grouped into 8 clusters. The association with clusters was more frequent in Spanish (p = 0.02) men (p< 0.001), MSM (p<0.001) younger than 35 years (p = 0.001) and with a CD4+ T-cell count above 350 cells/ul (p<0.001). We estimated the date of HIV-1 subtype B regional epidemic diversification around 1970 (95% CI: 1965-1987), with an evolutionary rate of 2.4 (95%CI: 1.7-3.1) x 10-3 substitutions/site/year. Most clusters originated in the 1990s in MSMs. We observed exponential subtype B HIV-1 growth in 1980-1990 and 2005-2008. The most significant migration routes for subtype B went from inland cities to seaside locations.

CONCLUSIONS

We provide the first data on the phylodynamic and phylogeographic profiles of HIV-1 subtype B in south Spain. Our findings of transmission clustering among MSMs should alert healthcare managers to enhance preventive measures in this risk group in order to prevent future outbreaks.

Management of upper ureteral stones exceeding 15 mm in diameter: Shock wave lithotripsy versus semirigid ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy

Objectives:

We conducted a retrospective study to evaluate the efficacy and outcome of shock wave lithotripsy versus semirigid ureteroscopy in the management of the proximal ureteral stones of diameter exceeding 15 mm.

Methods:

During the 2009−2014 study period, 147 patients presenting with the proximal ureteral stones exceeding 15 mm in diameter were treated. Both shock wave lithotripsy and ureteroscopy with laser lithotripsy were offered for our patients. A 6/8.9 Fr semirigid ureteroscope was used in conjunction with a holmium:yttrium–aluminum–garnet laser. The stone-free rate was assessed at 2 weeks and 3 months post-treatment. All patients were evaluated for stone-free status, operation time, hospital stay, perioperative complications, and auxiliary procedures.

Results:

Of the 147 patients who took part in this study, 66 (45%) had undergone shock wave lithotripsy and 81 (55%) underwent ureteroscopy. At the 3-month follow-up, the overall stone-free rate in the shock wave lithotripsy group was 39/66 (59%) compared to 70/81 (86.4%) in the ureteroscopic laser lithotripsy group. Ureteroscopic laser lithotripsy achieved a highly significant stone-free rate (p = 0.0002), and the mean operative time, auxiliary procedures, and postoperative complication rates were comparable between the two groups.

Conclusion:

In terms of the management of proximal ureteral stones exceeding 15 mm in diameter, ureteroscopy achieved a greater stone-free rate and is considered the first-line of management. Shock wave lithotripsy achieved lower stone-free rate, and it could be used in selected cases.

Biomechanical comparison of fixation techniques for medial collateral ligament anatomical augmented repair

PURPOSE

Although the majority of medial collateral ligament (MCL) ruptures can be treated conservatively with good results, some injuries require operative treatment. Besides MCL reconstruction, anatomical augmented repair may be considered. This study was to assess biomechanical properties of different fixation techniques regarding elongation and ultimate load to failure.

METHODS

MCL anatomical augmented repair was simulated by fixation of porcine superficial digital flexor tendon grafts at porcine tibiae. Ten different fixation techniques were assessed. Fixation of the tendon graft was performed using 4.0-mm cancellous screws and either (1) 13.5-mm spiked polyether ketone (PEEK) washers; (2) 14-mm spiked washers; (3) 14-mm suture washers; (4) 14-mm customized washers; (5-8) combination of washers and No. 2 polyester sutures (FiberWire©); or using (9) single or (10) double 5.5-mm titanium suture anchors with No. 2 polyethylene sutures (Ultrabraid^®). Biomechanical analysis included pretensioning of the constructs at 20 N for 30 s following cyclic loading of 250 cycles between 20 and 100 N at 1 Hz for measurement of elongation. Additionally, ultimate failure load and failure mode analysis were performed.

RESULTS

Spiked PEEK washers secured with polyester sutures (5) yielded best biomechanical properties at time zero for both, elongation during cyclic loading (2.9 ± 0.7 mm) and ultimate failure load (469.8 ± 64.3 N).

CONCLUSIONS

These results suggest that spiked PEEK washers secured with polyester sutures are the most appropriate fixation technique for MCL anatomical augmented repair, thus providing best requirements to allow early knee mobilization and prevent secondary knee laxity.

The lasso-loop, lasso-mattress and simple-cinch stitch for arthroscopic rotator cuff repair: are there biomechanical differences?

PURPOSE

Various stitching techniques have been described to facilitate arthroscopic repair of rotator cuff tears. The aim of the present study was to compare the biomechanical properties of the lasso-loop, lasso-mattress and simple-cinch stitch for rotator cuff repair.

METHODS

Twelve infraspinatus tendons were harvested from sheep and split in half. The tendons were randomized into three different stitch configuration groups for biomechanical testing: lasso-loop, lasso-mattress and simple-cinch stitch. Each specimen was first cyclically loaded on a universal materials testing machine under force control from 5 to 30 N at 0.25 Hz for twenty cycles. Then, each specimen was loaded to failure under displacement control at a rate of 1 mm/s. Cyclic elongation, peak-to-peak displacement and ultimate tensile load were reported as mean ± standard error and compared using one way analysis of variance. The type of failure was recorded.

RESULTS

No differences in cyclic elongation (1.31 ± 0.09 mm for the simple-cinch vs. 1.49 ± 0.07 mm for the lasso-mattress vs. 1.61 ± 0.09 mm for the lasso-loop stitch, p = 0.063) or peak-to-peak displacement (0.58 ± 0.04 mm for the simple-cinch, 0.50 ± 0.03 mm for the lasso-mattress and 0.62 ± 0.06 mm for the lasso-loop stitch, p = 0.141) were seen between all tested stitch configurations. In the load-to-failure test, the simple cinch stitch (149.38 ± 11.89 N) and the lasso-mattress (149.38 ± 10.33 N) stitch demonstrated significantly higher ultimate load than the lasso-loop stitch (65.88 ± 4.75 N, p < 0.001). All stitch configurations failed with suture pull out.

CONCLUSIONS

The lasso-mattress and the simple-cinch stitch showed similar biomechanical properties with significant higher tensile loads needed for failure than the lasso-loop stitch.

Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background:

Arthroscopic debridement represents a salvage procedure for irreparable rotator cuff tears. It is important to accurately diagnose the patient for irreparable rotator cuff tears. The diagnosis and the therapeutic options must be explained to the patient. It is mandatory that the patient understands the primary goal of the arthroscopic debridement being reduction of pain, not improving strength or function.

Methods:

The procedure consists of 7 distinct steps to debride the soft tissues and alleviate pain.

Results:

Even though there is a lack of evidence that this procedure is superior to other therapeutic options, it has shown good results in patients with the main complaint of pain.

Conclusion:

The results reported in some studies should, however, be interpreted with caution, taking into consideration the substantial structural damage in irreparable defects.

Management of equivocal (early) Fournier's gangrene

BACKGROUND

Fournier's gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG.

METHODS

This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011-2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients' demographics, vital signs, laboratory finding and clinical findings were reported.

RESULTS

A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2.

CONCLUSIONS

Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.

Efficacy and safety of liraglutide compared to sulphonylurea during Ramadan in patients with type 2 diabetes (LIRA-Ramadan): a randomized trial

AIMS

Compare effects of liraglutide 1.8 mg and sulphonylurea, both combined with metformin, on glycaemic control in patients with type 2 diabetes (T2D) fasting during Ramadan.

MATERIALS AND METHODS

In this up to 33-week, open-label, active-controlled, parallel-group trial, adults [glycated haemoglobin (HbA1c) 7%-10% (53-86 mmol/mol); body mass index ≥20 kg/m(2) ; intent to fast] were randomized (1:1) ≥10 weeks before Ramadan to either switch to once-daily liraglutide (final dose 1.8 mg) or continue pre-trial sulphonylurea at maximum tolerated dose, both with metformin.

PRIMARY ENDPOINT

change in fructosamine, a validated marker of short-term glycaemic control, during Ramadan.

RESULTS

Similar reductions in fructosamine levels were observed for both groups during Ramadan [liraglutide (-12.8 µmol/L); sulphonylurea (-16.4 µmol/L); estimated treatment difference (ETD) 3.51 µmol/L (95% CI: -5.26; 12.28); p = 0.43], despite lower fructosamine levels in the liraglutide group at start of Ramadan. Fewer documented symptomatic hypoglycaemic episodes were reported in liraglutide-treated (2%, three subjects) versus sulphonylurea-treated patients (11%, 18 subjects). No severe hypoglycaemic episodes were reported by either group. Body weight decreased more during Ramadan with liraglutide (ETD: -0.54 kg; 95% CI: -0.94;-0.14; p = 0.0091). The proportion of patients reporting adverse events was similar between groups. Liraglutide led to greater HbA1c reduction [ETD: -0.59% (-6.40 mmol/mol), 95% CI: -0.79; -0.38%; -8.63; -4.17 mmol/mol; p < 0.0001].

CONCLUSIONS

Despite lower fructosamine levels and body weight at the beginning of Ramadan, use of liraglutide showed similar glycaemic improvements, fewer hypoglycaemic episodes and greater body weight reduction compared with sulphonylurea. LIRA-Ramadan provides evidence for liraglutide being safe and efficacious for management of T2D during Ramadan fasting.

Road Traffic Related Injury Severity in Truck Drivers: A Prospective Medical and Technical Analysis of 582 Truck Crashes

BACKGROUND

While cyclists and pedestrians are known to be at significant risk for severe injuries when exposed to road traffic accidents (RTA) involving trucks, little is known about RTA injury risk for truck drivers.

OBJECTIVES

The aim of this study was to analyze the injury severity in truck drivers following RTAs.

PATIENTS AND METHODS

Our local accident research unit prospectively documented 43000 RTAs involving 582 trucks between 2000 and 2011. Injury severity, including the abbreviated injury scale (AIS) and the maximum abbreviated injury scale (MAIS) were analyzed. Technical parameters (e.g. delta-v, direction of impact), the location of accident, and its dependency on the road type were also taken into consideration.

RESULTS

Thirteen percent (77/582) of truck drivers were injured. Extremities were found to be at highest risk of injury with the lower extremities (36x) being injured most severely (10x: AIS 2 and 3). Death occurred only after collisions with other trucks, and severity of injuries increased with an increased speed limit. The maximum abbreviated injury scale was higher in the crash opponents (56x MAIS ≥ 3) compared to the truck drivers (8x MAIS ≥ 3). Overall, 82% of the crash opponents were injured.

CONCLUSIONS

The safety of truck drivers is assured by their vehicles, the consequence being that the risk of becoming injured is likely to be low. However, the legs especially are at high risk for severe injuries during RTAs. This probability increases in the instance of a collision with another truck. Nevertheless, in RTAs involving trucks and regular passenger vehicles, the other party is in higher risk of injury.

Connection of a hip prosthesis and an intramedullary nail as a special solution in a subtrochanteric femoral fracture with fibrous dysplasia

Treatment of fractures associated with fibrous dysplasia is difficult because of poor bone quality. In a brief report we present a case in which a hip prosthesis is connected with the distal part of a broken cannulated intramedullary femur nail. Postoperatively, the patient was mobilized with full weight bearing. Radiographs proved the correct position of the implant and a favorable clinical function could be achieved.

A comparison of clinical parameters at presentation, pathological outcomes and biochemical relapse between NHS and private patients undergoing radical prostatectomy at a single centre in the United Kingdom

Objective:

We studied our hypothesis that patients with private health insurance (PHI) with prostate cancer present with more favourable pathological outcomes.

Patients and methods:

Data were analysed from 554 patients undergoing radical prostatectomy from 2002 to 2010. A total of 328 patients under the NHS and 226 men had PHI. Two groups were compared for age, PSA, Gleason score, number of cores involved, maximum tumour length on biopsy core, socioeconomic status, imaging and pathological outcomes.

Results:

PHI presented at a younger age (63 vs 61, p = 0.008) and lower mean PSA (9.5 vs 8.04, p = 0.0005). Staging MRI showed a significant difference in usage (77% vs 45% p < 0.001). Importantly there was significant difference in the total tumour volume (4 cc vs 8 cc, p = 0.001). There were significantly more wealthy patients being seen privately ( p < 0.0001). However, on the final Cox regression model only grade, stage and insurance status were significant predictors of BCR.

Conclusions:

Patients with PHI were younger, had a lower presenting PSA and were wealthier. There is a significant difference in the social profile seen, but wealth itself is not protective yet health insurance is. Insurance status and not social status represents a factor in predicting final pathological outcomes after RRP.

Patient Preference for Management of an Asymptomatic 15 mm Renal Calculus-Avoid Risk or Maximize Success?

INTRODUCTION

We evaluate patient preferences and the underlying factors determining decision making in the management of the asymptomatic 15 mm renal stone.

METHODS

A survey was randomly distributed to 106 patients at our multidisciplinary stone clinic. Patients were given a hypothetical scenario of a 15 mm renal stone, and were asked to choose among the 3 treatment options of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. The success rate, risk and morbidity associated with each treatment were provided to patients. Statistical analysis involved the Fisher exact and Wilcoxon signed rank tests. Analysis was performed using standard computer software with p <0.05 considered statistically significant.

RESULTS

A total of 103 patients completed our survey, and 58 (56%) chose ureteroscopy, 26 (25%) chose percutaneous nephrolithotomy and 19 (19%) preferred shock wave lithotripsy as the treatment option. Patients who selected shock wave lithotripsy were increasingly concerned with risk rather than success rate (74% vs 16%, respectively). In contrast, patients who selected percutaneous nephrolithotomy were more concerned with the success rate rather than risk (81% vs 7.5%, respectively). Rates of success and risk were given approximately equal importance by patients selecting ureteroscopy (40% vs 48%, respectively).

CONCLUSIONS

Patients who choose percutaneous nephrolithotomy are primarily motivated by a desire to maximize success while the choice of shock wave lithotripsy is primarily motivated by a desire to minimize risks. The majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. Understanding the factors driving patient decision making would allow urologists to more effectively manage expectations and provide counseling.

Injury severity of pedestrians, bicyclists and motorcyclists resulting from crashes with reversing cars

OBJECTIVE

Pedestrians, bicyclists and motorcyclists can suffer serious injury in road traffic crashes. To date, no studies examine the injury severity within this vulnerable cohort following collisions with reversing cars.

MATERIAL AND METHODS

Our institution prospectively maintains a database including medical and technical information regarding traffic accidents in our area, including urban and suburban regions. In a retrospective review of this database, the authors describe the injury severity of pedestrians, bicyclists and motorcyclists following traffic crashes involving reversing cars. Injury severity was described using the abbreviated injury scale (AIS) as well as the maximum abbreviated injury scale (MAIS).

RESULTS

This study included 234 crashes occurring between 1999 and 2012. The lower extremity was injured most often while also suffering more severe injuries with a median AIS of 1 compared to 0 in all other documented body regions. The upper extremity was injured second most often. AIS ranging from 4 to 6 were infrequent. AIS 3 however, was documented for the legs in 4.3% of patients. MAIS 0, 1, 2, 3, 5 and 9 were found in 1, 164, 46, 14, 1, and 8 patients in the study cohort, respectively. Pedestrians and motorcyclists were seriously injured in 9.1% and 9.6% of cases, respectively. In contrast, no bicyclists suffered serious injuries. As to the zone of impact, most collisions occurred at the rear center of the vehicle (35%) followed by rear left (26%), rear right (20%), side rear (11%), side center (4%) and side front (3%). 204 (87.2%) collisions occurred during the day, 19 (8.1%) at night and 11 (4.7%) at twilight. Speed was similar in crashes involving pedestrians, bicyclists and motorcyclists, being as high as 7.0±3.6, 7.0±4.0 and 7.9±4.2km/h respectively.

CONCLUSIONS

This is the first study that analyzes injury severity among these vulnerable road users following collisions with reversing vehicles. The majority of collisions occur at low impact speed during the day. Most injuries resulting from these collisions are not serious, however pedestrians are at greatest risk of severe injury to any body region. The lower extremities suffer the most serious and frequent injuries within this cohort.

Non-Operative Management of Rotator Cuff Tears

Background:

The role of nonoperative management for rotator cuff tears remains a matter of debate. Clinical results reported in the literature mainly consist of level IV studies, oftentimes combining a mixed bag of tear sizes and configurations, and are contradictory to some extent.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Most studies show an overall success rate of around 75% for nonoperative treatment. However, the majority of studies also present a progression of tear size and fatty muscle infiltration over time, with however debatable clinical relevance for the patient. Suggested factors associated with progression of a rotator cuff tear are an age of 60 years or older, full-thickness tears, and fatty infiltration of the rotator cuff muscles at the time of initial diagnosis.

Conclusion:

Non-operative management is indicated for patients with lower functional demands and moderate symptoms, and/or of course for those refusing to have surgery. Close routinely monitoring regarding development of tear size should be performed, especially in patients that remain symptomatic during nonoperative treatment. To ensure judicious patient counseling, it has to be taken into account that 1) tears that are initially graded as reparable may become irreparable over time, and 2) results after secondary surgical therapy after failed nonoperative treatment are usually reported to be inferior to those who underwent primary tendon repair.

Diagnostic performance of swab PCR as an alternative to tissue culture methods for diagnosing infections associated with fracture fixation devices

BACKGROUND

Molecular procedures could potentially improve diagnoses of orthopaedic implant-related infections, but are not yet clinically implemented. Analysis of sonication fluid shows the highest sensitivity for diagnosing implant infections in cases of revision surgery with implant removal. However, there remains controversy regarding the best method for obtaining specimens in cases of revision surgery with implant retention. Tissue culture is the most common diagnostic method for pathogen identification in such cases. Here we aimed to assess the diagnostic performance of swab PCR analysis compared to tissue culture from patients undergoing revision surgery of fracture fixation devices.

METHODS

We prospectively investigated 62 consecutive subjects who underwent revision surgery of fracture fixation devices during a two-year period. Tissue samples were collected for cultures, and swabs from the implant surface were obtained for 16S rRNA PCR analysis. Subjects were classified as having an implant-related infection if (1) they presented with a sinus tract or open wound in communication with the implant; or (2) purulence was encountered intraoperatively; or (3) two out of three tissue cultures tested positive for the presence of the same pathogen. Tissue culture and swab PCR results from the subjects were used to calculate the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the ROC curve (AUC) for identifying an orthopaedic implant-related infection.

RESULTS

Orthopaedic implant-related infections were detected in 51 subjects. Tissue culture identified infections in 47 cases, and swab PCR in 35 cases. Among the 11 aseptic cases, tissue culture was positive in 2 cases and swab PCR in 4 cases. Tissue culture showed a significantly higher area under the ROC curve for diagnosing infection (AUC=0.89; 95% CI, 0.67-0.96) compared to swab PCR (AUC=0.66; 95% CI, 0.46-0.80) (p=0.033).

CONCLUSIONS

Compared to swab PCR, tissue culture showed better performance for diagnosing orthopaedic implant-related infection. Although molecular methods are expected to yield higher diagnostic accuracy than cultures, it appears that the method of obtaining specimens plays an important role. Improved methods of specimen collection are required before swab PCR can become a reliable alternative to tissue-consumptive methods.

LEADER-4: blood pressure control in patients with type 2 diabetes and high cardiovascular risk: baseline data from the LEADER randomized trial

OBJECTIVE

As glucagon-like peptide-1 receptor agonists lower blood pressure (BP) in type 2 diabetes mellitus (T2DM), we examined BP control in relation to targets set by international bodies prior to randomization in the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial.

METHODS

We analyzed baseline data from LEADER (NCT01179048), an ongoing phase 3B, randomized, double-blind, placebo-controlled cardiovascular outcomes trial examining the cardiovascular safety of the glucagon-like peptide-1 receptor agonist liraglutide in 9340 people with T2DM from 32 countries [age (all mean ± SD) 64 ± 7.2 years, BMI 32.5 ± 6.3 kg/m, duration of diabetes 12.7 ± 8.0 years], all of whom were at high risk for cardiovascular disease (CVD).

RESULTS

A total of 81% (n = 7592) of participants had prior CVD and 90% (n = 8408) had a prior history of hypertension. Despite prescription of multiple antihypertensive agents at baseline, only 51% were treated to a target BP of less than 140/85 mmHg and only 26% to the recommended baseline BP target of less than 130/80 mmHg. In univariate analyses, those with prior CVD were prescribed more agents (P < 0.001) and had lower BP than those without (137 ± 18.8/78 ± 10.6 mmHg versus 140 ± 17.7/80 ± 9.9 mmHg; P < 0.001). In logistic regression analyses, residency in North America (64% treated to <140/85 mmHg; 38% treated to <130/80 mmHg) was the strongest predictor of BP control.

CONCLUSION

These contemporary data confirm that BP remains insufficiently controlled in a large proportion of individuals with T2DM at high cardiovascular risk, particularly outside North America. Longitudinal data from the LEADER trial may provide further insights into BP control in relation to cardiovascular outcomes in this condition.

Are porcine flexor digitorum profundus tendons suitable graft substitutes for human hamstring tendons in biomechanical in vitro-studies?

INTRODUCTION

Although a plenty of studies exist assessing the strength of ligamentous fixation techniques using porcine flexor digitorum profundus tendons as graft substitutes for human hamstring tendons, there is no biomechanical study comparing these two tendons. To interpret the results obtained with porcine flexor digitorum profundus tendons, knowledge of their biomechanical properties is essential. The purpose of this study was to compare the biomechanical properties of human hamstring tendons and porcine flexor digitorum profundus tendons.

MATERIALS AND METHODS

A total of six human hamstring tendons and six porcine flexor digitorum profundus tendons were analysed in this study. Quadruple-bundle human hamstring tendons and double-bundle porcine flexor digitorum profundus tendons with a diameter of 9 mm were used. Specimens were placed into a tensile loading fixation of a servohydraulic testing machine. Biomechanical analysis included pretensioning of the constructs at 50 N for 10 min following cyclic loading of 1500 cycles between 50 and 200 N at 0.5 Hz for measurement of elongation. Subsequently, ultimate failure load and failure mode analysis were performed with a ramp speed of 20 mm/min.

RESULTS

Human hamstring tendons showed significantly higher maximum load to failure values compared to porcine flexor digitorum profundus tendons (1597 ± 179.6 N vs. 1109 ± 101.9 N; p = 0.035). Human hamstring tendons yielded significantly lower initial elongation during preload, but not during cyclical loading.

CONCLUSIONS

When porcine flexor digitorum profundus tendons are used as graft substitutes for human hamstring tendons in biomechanical studies, maximum load to failure is underestimated while elongation is comparable to that of human hamstring tendons. Transferring results of biomechanical studies into clinical practice, the lower maximum load to failure of porcine flexor digitorum profundus tendons needs to be taken into consideration.

Rapid exclusion of bacterial arthritis using a glucometer

Bacterial arthritis is a medical emergency. However, prompt diagnosis and differentiation from non-infectious diseases are challenging. As bacterial metabolism leads to glucose reduction, measurement of synovial fluid glucose seems to be a promising diagnostic approach. The purpose of this study was to determine whether synovial fluid glucose levels could be accurately measured by using a glucometer and to evaluate its diagnostic accuracy in diagnosing bacterial arthritis compared to currently available markers. In a prospective diagnostic study, 102 consecutive patients with atraumatic joint effusion were included. Synovial fluid glucose concentrations were determined using both glucometer and automated analyzer respectively. Synovial fluid culture, crystal analysis, and synovial cell analysis were performed. Blood samples were taken for blood cultures, analyses of serum infection markers, and serum glucose. There was a high correlation between synovial fluid glucose measured by the glucometer and the automated analyzer (r ² = 0.92). According to the receiver operating characteristic curve, a threshold of 1.4 mmol/l had a sensitivity of 100 % (95 % CI 78.2-100 %), a specificity of 92.0 % (95 % CI 84.1-96.7 %), a positive predictive value of 68.2 % (95 % CI 45.1-86.1 %), and a negative predictive value of 100 % (95 % CI 95.5-100 %). These results suggest that synovial fluid glucose concentrations could be reliably measured using a glucometer. Due to its simplicity, this test has the potential to be an adjunct in the diagnostic cascade of bacterial arthritis.

Influence of biomechanical and biochemical stimulation on the proliferation and differentiation of bone marrow stromal cells seeded on polyurethane scaffolds

The aim of the present investigation was to compare the effects of cyclic compression, perfusion, dexamethasone (DEX) and bone morphogenetic protein-7 (BMP-7) on the proliferation and differentiation of human bone marrow stromal cells (hBMSCs) in polyurethane scaffolds in a perfusion bioreactor. Polyurethane scaffolds seeded with hBMSCs were cultured under six different conditions, as follows: 10% Cyclic compression at 0.5 and 5 Hz; 10 ml/min perfusion; 100 nM DEX; 100 ng/ml BMP-7; and 1 ml/min perfusion without mechanical and biochemical stimulation (control). On days 7 and 14, samples were tested for the following data: Cell proliferation; mRNA expression of Runx2, COL1A1 and osteocalcin; osteocalcin content; calcium deposition; and the equilibrium modulus of the tissue specimen. The results indicated that BMP-7 and 10 ml/min perfusion promoted cell proliferation, which was inhibited by 5 Hz cyclic compression and DEX. On day 7, the 5 Hz cyclic compression inhibited Runx2 expression, whereas the 0.5 Hz cyclic compression and BMP-7 upregulated the COL1A1 mRNA levels on day 7 and enhanced the osteocalcin expression on day 14. The DEX-treated hBMSCs exhibited downregulated osteocalcin expression. After 14 days, the BMP-7 group exhibited the highest calcium deposition, followed by the 0.5 Hz cyclic compression and the DEX groups. The equilibrium modulus of the engineered constructs significantly increased in the BMP-7, 0.5 Hz cyclic compression and DEX groups. In conclusion, the present results suggest that BMP-7 and perfusion enhance cell proliferation, whereas high frequency cyclic compression inhibits the proliferation and osteogenic differentiation of hBMSCs. Low frequency cyclic compression is more effective than DEX, but less effective compared with BMP-7 on the osteogenic differentiation of hBMSCs seeded on polyurethane scaffolds.

Efficacy and safety of switching to abacavir/lamivudine (ABC/3TC) plus rilpivirine (RPV) in virologically suppressed HIV-infected patients on HAART

We analysed the efficacy and safety of switching from a regimen based on nonnucleoside reverse transcriptase inhibitors (NNRTI) or integrase inhibitors (INI) to ABC/3TC + RPV in virologically suppressed HIV-infected patients. This multicentre, retrospective study comprised asymptomatic HIV-infected patients who switched from 2 NRTI + NNRTI or 2 NRTI + INI to ABC/3TC + RPV between February 2013 and December 2013; all had undetectable HIV viral load prior to switching. Efficacy and safety, and changes in lipids and cardiovascular risk (CVR) were analysed at 48 weeks. Of 85 patients (74.1 % men, mean age 49.5 years), 83 (97.6 %) switched from a regimen based on NNRTI (EFV 74, RPV 5, ETV 2, NVP 2), and 45 (53 %) switched from TDF/FTC to ABC/3TC. The main reasons for switching were toxicity (58.8 %) and convenience (29.4 %). At 48 weeks, 78 (91.8 %) patients continued taking the same regimen; efficacy was 88 % by intention to treat, and 96 % by per protocol. Two patients were lost to follow-up and five ceased the new regimen (4 due to adverse effects and 1 virologic failure). Mean CD4 cell counts increased (744 vs. 885 cells/μL; p = 0.0001), and there were mean decreases in fasting total cholesterol (-15.9 mg/dL; p < 0.0001) and LDL-cholesterol (-11.0 mg/dL; p < 0.004), with no changes in HDL-cholesterol, triglycerides, total cholesterol:HDL-cholesterol ratio, and CVR. ABC/3TC + RPV is effective and safe in virologically-suppressed patients on antiretroviral therapy (ART). Forty-eight weeks after switching the lipid profile improved with decreases in total and LDL cholesterol.

Systemic Inflammatory Response Syndrome after Percutaneous Nephrolithotomy: A Randomized Single-Blind Clinical Trial Evaluating the Impact of Irrigation Pressure

PURPOSE

We evaluated the impact of intraoperative irrigation pressures on the risk of systemic inflammatory response after percutaneous nephrolithotomy.

MATERIALS AND METHODS

Between January 2014 and March 2015, 90 patients with renal stones planned for percutaneous nephrolithotomy were randomized between low (80 mm Hg) and high (200 mm Hg) irrigation pressure. Patient demographics, perioperative outcomes and systemic inflammatory response incidence rates were compared using the chi-square and Wilcoxon signed rank tests.

RESULTS

Mean patient age, gender, body mass index and other perioperative outcomes were similar in both arms. High pressure irrigation was associated with a higher risk of systemic inflammatory response syndrome (46%) compared to low pressure irrigation (11%, p=0.0002). On multivariate analysis only high irrigation pressure, paraplegia or neurogenic bladder and nonquinolone perioperative medication were predictive of postoperative systemic inflammatory response syndrome.

CONCLUSIONS

High pressure fluid irrigation fluid increases the risk of postoperative systemic inflammatory response syndrome after percutaneous nephrolithotomy.

[Negative Pressure Wound Therapy with Instillation in the Treatment of Critical Wounds]

BACKGROUND

In recent decades, negative pressure wound therapy (NPWT) has become the gold standard in the treatment of infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a new development, that combines conventional NPWT with instillation of fluids.

OBJECTIVES

The purpose of this study was to review the results of current literature on the clinical use of NPWTi in acute and chronic wounds.

MATERIAL AND METHODS

A literature search was performed using Pubmed and the Cochrane Library, including articles in English and German.

RESULTS

The data suggest that NPWTi is a promising therapeutic option in the treatment of wounds, and applicable in various fields.

CONCLUSIONS

NPWTi appears to be a useful adjunct in the treatment of critical wounds. However, data from prospective randomised trials to support the validity of the results are sparse.

[Sagittal Balance of the Spine--Clinical Importance and Radiographic Assessment]

Sagittal deformities of the spine frequently result in back pain, as patients have to expend much energy in compensation. The sagittal alignment of the spine is defined by its curvatures (lordosis and kyphosis) relative to the position of the pelvis. Diagnostic assessment is based on full spine a. p. and lateral X-rays. The sagittal balance is primarily described by different angles that can be measured, e.g. lumbar lordosis, pelvic incidence, pelvic tilt and thoracic kyphosis. The quality of life can best be estimated by subtracting lumbar lordosis from the pelvic incidence. However, initial evaluation of the sagittal balance can also be based on the sagittal vertical axis. The severity of imbalance can be described by the sagittal vertical axis and the pelvic tilt, but surgical therapy necessitates a more profound analysis, which can be based on the SRS-Schwab classification.

Chondrocyte survival in osteochondral transplant cylinders depends on the harvesting technique

PURPOSE

In autologous osteochondral transplantation, the edges of the harvested plug are particularly susceptible to mechanical or thermal damage to the chondrocytes. We hypothesised that the applied harvesting device has an impact on chondrocyte vitality.

METHODS

Both knees of five blackhead sheep (ten knees) underwent open osteochondral plug harvesting with three different circular harvesting devices (osteoarticular transfer system harvester [OATS; diameter 8 mm; Arthrex, Munich, Germany], diamond cutter [DC; diameter 8.35 mm; Karl Storz, Tuttlingen, Germany] and hollow reamer with cutting crown [HRCC; diameter 7 mm; Dannoritzer, Tuttlingen, Germany]) from distinctly assigned anatomical sites of the knee joint. The rotary cutters (DC and HRCC) were either used with (+) or without cooling (-). Surgical cuts of the cartilage with a scalpel blade were chosen as control method. After cryotomy cutting, chondrocyte vitality was assessed using fluorescence microscopy and a Live/Dead assay.

RESULTS

There were distinct patterns of chondrocyte vitality, with reproducible accumulations of dead chondrocytes along the harvesting edge. No statistical difference in chondrocyte survivorship was seen between the OATS technique and the control method, or between the HRCC+ technique and the control method (P > 0.05). The DC+, HRCC- and DC- techniques yielded significantly lower chondrocyte survival rates compared with the control method (P < 0.05).

CONCLUSIONS

Chondrocyte survival in osteochondral cylinders depends on the applied harvesting technique. The use of rotary cutters without cooling yielded worst results, while the traditional OATS punch and rotary cutters with cooling achieved comparable rates of chondrocyte vitality.

Management of anterior caliceal stones >15 mm

Anterior caliceal stones represent a challenge to endourologist to select the best modality of management with the least morbidity. To study different treatment modalities of management of anterior caliceal stones >15 mm. It is an observational prospective study of patients with anterior caliceal stones more than 15 mm. Inclusion criteria were patients with isolated anterior caliceal stones, or branched anterior caliceal stones with posterior caliceal extension. Patients were evaluated using non-contrast CT preoperatively. They were divided into three groups: group 1 underwent PCNL through posterior caliceal puncture in cases with wide anterior calyx infundibulum or obtuse infundibulopelvic pelvic, group 2 underwent PCNL through anterior caliceal access in cases with narrow infundibulum or acute infundibulopelvic angel and group 3 underwent flexible ureteroscopy and laser lithotripsy. Intraoperative and postoperative findings were recorded and compared. Eighty eight patients were included in this study, Group 1 (44 patients) group 2 (28 patients), and group 3 (16 patients). Operative time was not significantly different across the three groups (68 ± 11.5, 72 ± 9 and 74 ± 11 min in group 1, 2 and 3, respectively, P = 0.053). Fluoroscopy time was significantly shorter for group 3 (2 ± 0.5 m, P = 0.0001) compared to group 1 and 2 (5.6 ± 4.6 and 4.5 ± 1.4 min), respectively. There were no significant differences in stone-free rates after initial treatment between the three groups; 84, 82, and 69 %, in groups 1, 2 and 3, respectively (P = 0.4). Postoperative hemoglobin drop was noted to be highest for group 2 and lowest for group 3 which was significantly different (1.7 ± 0.8, 2.2 ± 1.1, and 0.3 ± 0.3 g/dl, for patients in groups 1, 2 and 3 respectively, P = 0.0001). Group 2 showed the highest post-operative complication rate (21 %) in comparison to group 1 (11 %) and group 3 (6 %), however, differences were not statistically significant (P = 0.3). PCNL through posterior or anterior caliceal puncture is an excellent modality to treat anterior caliceal stones with high stone clearance rate. Despite the higher chance of bleeding with anterior caliceal puncture, it is still inevitably needed in difficult anterior caliceal stones with unfavorable anatomy. RIRS is a good alternative to PCNL with the advantage of less radiation exposure and less bleeding.

Progression of liver stiffness predicts clinical events in HIV/HCV-coinfected patients with compensated cirrhosis

Background

Our objective was to assess the predictive value of the changes of liver stiffness (LS) for clinical outcome in HIV/HCV-coinfected patients with compensated liver cirrhosis and a LS value < 40 kPa.

Methods

Prospective cohort of 275 HIV/HCV-coinfected patients with cirrhosis, no previous liver decompensation (LD) and LS < 40 kPa. The time from diagnosis to LD and/or hepatocellular carcinoma (HCC) and the predictors of this outcome were evaluated. Significant progression of LS was defined as an increase ≥ 30 % over the baseline value at any time during the follow-up.

Results

After a median (Q1-Q3) follow-up of 32 (20–48) months, 19 (6.9 %, 95 % CI: 3.8 %–9.9 %) patients developed a first LD and/or HCC. At the end of the follow-up, 247 (90 %) patients had undergone a further LS examination. Of them, 77 (31 %) patients had a significant progression of LS. The mean (SD) survival time free of LD and/or HCC was 67 (3) and 77 (1) months in patients with or without significant progression of LS (p = 0.01). Significant progression of LS was an independent predictor of LD and/or HCC (Adjusted Hazard Ratio 4.63; 95 % confidence interval: 1.34–16.02; p = 0.015).

Conclusions

Significant progression of LS is associated with a higher risk of clinical events in HIV/HCV-coinfected patients with compensated cirrhosis and LS < 40 kPa.

Nail-medullary canal ratio affects mechanical axis deviation during femoral lengthening with an intramedullary distractor

INTRODUCTION

Callus distraction of the femur using an intramedullary distractor has several advantages over the use of external fixators. However, difficulty in controlling the mechanical axis during lengthening may cause deformities and knee osteoarthritis. Purpose of the study is to answer the following questions: (1) is lengthening with an intramedullary device associated with a medial or lateral shift of the mechanical axis? (2) Which factors are associated with varisation/valgisation of the mechanical axis during lengthening?

MATERIALS AND METHODS

We analysed pre-treatment and post-treatment radiographs from 20 patients who underwent unilateral femoral-lengthening procedures using intramedullary distractors. Patients with acute correction of pre-existing deformities or combined ipsilateral femoral and tibial lengthening were excluded. Mechanical axis deviations, osteotomy level, and nail-medullary canal ratio were recorded.

RESULTS

Compared to the preoperative axis, the mechanical axis shifted medially in 7 patients (varisation group) and laterally in 13 patients (valgisation group). The groups did not significantly differ regarding preoperative leg length discrepancy (LLD), mechanical axis alignment, LLD-cause and implants used. The nail-medullary canal ratio significantly differed between groups (p<0.001), being <85% in the varisation group and >85% in the valgisation group. The distance between the lesser trochanter and the osteotomy site was significantly longer in the valgisation group (58.9±16.3mm, middle third of the femur) compared to the varisation group (40.6±11.4mm, proximal third of the femur; p=0.02).

CONCLUSION

The nail-medullary canal ratio should be considered during preoperative planning. To avoid a varisation effect-for example, in cases with pre-existing varus alignment-it would be advisable to perform an osteotomy at the middle third of the femur with implantation of a nail that fully covers the medullary canal at the osteotomy site.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

A novel implant-free tibial pull-press-fixation for ACL reconstruction

INTRODUCTION

Extracortical fixation techniques in anterior cruciate ligament reconstruction bear the risk of tunnel enlargement, while close-to-aperture fixations often show lower failure loads. The purpose for this study was to investigate the biomechanical benefits of a novel implant-free combination of an extra-cortical and close-to-aperture fixation.

MATERIALS AND METHODS

Quadrupled human cadaveric semitendinosus tendons were fixed to 30 porcine tibiae with either a cannulated interference screw (I), an implant-free post-fixation (S), or a novel pull-press fixation (P). Specimens were cyclically loaded 20 times between 20 and 60 N followed by 500 cycles with 60-200 N, followed by a load-to-failure test with 1 mm/s.

RESULTS

The mean elongation of the tendons in the P-group during the 500 cycles between 60 and 200 N was significantly lower (5.69 ± 2.16 mm) compared to 9.20 ± 3.21 mm in S-group and 9.37 ± 3.1 mm in the I-group (p < 0.05). The mean maximum load-to-failure was significantly higher in the P-group (728.2 ± 76.4 N) compared to 476.4 ± 68.8 N in the S-group and 625.9 ± 82.5 N in the I-group (p < 0.05). Stiffness of the constructs in the P-group was significantly higher (121.7 ± 44.9 N/mm) compared to 46.2 ± 17.7 N/mm in the S- and 72.8 ± 29.8 N/mm in the I-group (p < 0.03).

CONCLUSIONS

This study indicates superior biomechanical properties of a novel implant-free tibial pull-press fixation to conventional implant-free and close-to-aperture interference screw fixations in terms of cyclic elongation and maximum load-to-failure.

LEVEL OF EVIDENCE

Not applicable, basic science study.

Ionoacoustic characterization of the proton Bragg peak with submillimeter accuracy

PURPOSE

Range verification in ion beam therapy relies to date on nuclear imaging techniques which require complex and costly detector systems. A different approach is the detection of thermoacoustic signals that are generated due to localized energy loss of ion beams in tissue (ionoacoustics). Aim of this work was to study experimentally the achievable position resolution of ionoacoustics under idealized conditions using high frequency ultrasonic transducers and a specifically selected probing beam.

METHODS

A water phantom was irradiated by a pulsed 20 MeV proton beam with varying pulse intensity and length. The acoustic signal of single proton pulses was measured by different PZT-based ultrasound detectors (3.5 and 10 MHz central frequencies). The proton dose distribution in water was calculated by Geant4 and used as input for simulation of the generated acoustic wave by the matlab toolbox k-WAVE.

RESULTS

In measurements from this study, a clear signal of the Bragg peak was observed for an energy deposition as low as 10(12) eV. The signal amplitude showed a linear increase with particle number per pulse and thus, dose. Bragg peak position measurements were reproducible within ±30 μm and agreed with Geant4 simulations to better than 100 μm. The ionoacoustic signal pattern allowed for a detailed analysis of the Bragg peak and could be well reproduced by k-WAVE simulations.

CONCLUSIONS

The authors have studied the ionoacoustic signal of the Bragg peak in experiments using a 20 MeV proton beam with its correspondingly localized energy deposition, demonstrating submillimeter position resolution and providing a deep insight in the correlation between the acoustic signal and Bragg peak shape. These results, together with earlier experiments and new simulations (including the results in this study) at higher energies, suggest ionoacoustics as a technique for range verification in particle therapy at locations, where the tumor can be localized by ultrasound imaging. This acoustic range verification approach could offer the possibility of combining anatomical ultrasound and Bragg peak imaging, but further studies are required for translation of these findings to clinical application.

Total Hip Arthroplasty in Patients with Skeletal Dysplasia

127 patients with a height ≤ 150 cm (non metric ≤ 4 feet and 11 inches) who received hip arthroplasty surgery between July 1, 2006 and May 30, 2013 at our institution were enrolled. Retrospective data evaluation was performed for two different times of follow-up (1 year and 5 years respectively). 115 patients were evaluated for 1-year follow up. Out of these, 27 patients were available for 5-year follow up. The mean Harris Hip Score increased from 40 ± 13 on admission to 82 ± 20 (P<0.001) at 1-year follow-up and 79 ± 17 (P<0.001) at 5-year follow-up. Hip arthroplasty can be performed in patients with dwarfism with good clinical benefits. However, survival rates are worse compared to the general population.

Current Concepts for Patellar Dislocation

Context:

Patellar dislocation usually occurs to the lateral side, leading to ruptures of the Medial Patellofemoral Ligament (MPFL) in about 90% of the cases. Even though several prognostic factors are identified for patellofemoral instability after patellar dislocation so far, the appropriate therapy remains a controversial issue.

Evidence Acquisition:

Authors searched the Medline library for studies on both surgical and conservative treatment for patellar dislocation and patellofemoral instability. Additionally, the reference list of each article was searched for additional studies.

Results:

A thorough analysis of the anatomical risk factors with a particular focus on patella alta, increased Tibial Tuberosity-Trochlear Groove (TT-TG) distance, trochlear dysplasia as well as torsional abnormalities should be performed early after the first dislocation to allow adequate patient counseling. Summarizing the results of all published randomized clinical trials and comparing surgical and conservative treatment after the first-time patellar dislocation until today indicated no significant evident difference for children, adolescents, and adults. Therefore, nonoperative treatment was indicated after a first-time patellar dislocation in the vast majority of patients.

Conclusions:

Surgical treatment for patellar dislocation is indicated primarily in case of relevant concomitant injuries such as osteochondral fractures, and secondarily for recurrent dislocations.

Concepts and Potential Future Developments for Treatment of Periprosthetic Proximal Femoral Fractures

Periprosthetic proximal femoral fractures are a major challenge for the orthopaedic surgeon, with a continuously increasing incidence due to aging populations and concordantly increasing numbers of total hip replacements. Surgical decision-making mainly depends on the stability of the arthroplasty, and the quality of bone stock. As patients final outcomes mainly depend on early mobilization, a high primary stability of the construct is of particular relevance. Osteosynthetic procedures are usually applied for fractures with a stable arthroplasty, while fractures with a loosened endoprosthesis commonly require revision arthroplasty. Osteoporotic bone with insufficient anchoring substance for screws poses one major concern for cases with well-fixed arthroplasties. Complication rates and perioperative mortality have remained unacceptably high, emphasizing the need for new innovations in the treatment of periprosthetic fractures. Transprosthetic drilling of screws through the hip stem as the most solid and reliable part in the patient might represent a promising future approach, with auspicious results in recent biomechanical studies.

Iatrogenic hepatic subcapsular biloma following PCNL: Diagnosis and management

After the first description in 1976, percutaneous nephrolithotomy (PCNL) remains the treatment of choice for large renal stones. Adjacent organ injuries are rare complications, with pulmonary and colonic representing the most common, while hepatic represents one of the rarest. We describe our case of hepatic subcapsular biloma following a subcostal PCNL, conservatively managed by percutaneous drainage and endoscopic biliary stenting.

[New therapy approaches for giant cell tumors]

BACKGROUND

Giant cell bone tumors (GCT) are benign but partially locally aggressive osteolytic tumors which typically occur around the knee joint in the epiphysis and metaphysis of long bones after maturation of the skeleton is completed. Due to the locally aggressive growth behavior with destruction of the bone structure, the rare possibility of pulmonary metastases in recurrent cases and a very rare possibility of malignancy, GCTs were previously also described as semimalignant bone tumors.

THERAPY

The established therapy of these tumors at the typical locations consists of intralesional curettage, extension of resection margins using a high speed trephine and defect reconstruction with bone cement. The local recurrence rate is high (10-40 %) and lowest after using thermal extension of resection margins with a high speed trephine and defect reconstruction with bone cement. For uncommon localizations, such as the spinal column and the sacrum as well as in cases of recurrence, surgical treatment is more complicated.

HISTOLOGY

Histologically, GCTs consist of osteoclastic giant and oval-shaped stromal cells which show a high expression of receptor activator of nuclear factor-κB ligand (RANKL) and decisively contribute to the osteolytic activity of the tumor. Novel pharmaceutical therapy approaches with human monoclonal RANKL antibodies interfere in this osteodestructive process in an inhibitory manner and can represent alternative treatment options just as the osteosupportive therapy with bisphosphonates.

CONCLUSION

After unsatisfactory attempts at surgical treatment of GCT patients, the new treatment option with denosumab is a promising alternative due to its effect as a monoclonal RANKL inhibitor.

[Study of human immunodeficiency virus transmission chains in Andalusia: analysis from baseline antiretroviral resistance sequences]

INTRODUCTION AND OBJECTIVE

Protease and reverse transcriptase HIV-1 sequences provide useful information for patient clinical management, as well as information on resistance to antiretrovirals. The aim of this study is to evaluate transmission events, transmitted drug resistance, and to georeference subtypes among newly diagnosed patients referred to our center.

METHODS

A study was conducted on 693 patients diagnosed between 2005 and 2012 in Southern Spain. Protease and reverse transcriptase sequences were obtained for resistance to cART analysis with Trugene(®) HIV Genotyping Kit (Siemens, NAD). MEGA 5.2, Neighbor-Joining, ArcGIS and REGA were used for subsequent analysis.

RESULTS

The results showed 298 patients clustered into 77 different transmission events. Most of the clusters were formed by pairs (n=49), of men having sex with men (n=26), Spanish (n=37), and below 45 years of age (73.5%). Urban areas from Granada, and the coastal areas of Almeria and Granada showed the greatest subtype heterogeneity. Five clusters were formed by more than 10 patients, and 15 clusters had transmitted drug resistance.

CONCLUSIONS

The study data demonstrate how the phylogenetic characterization of transmission clusters is a powerful tool to monitor the spread of HIV, and may contribute to design correct preventive measures to minimize it.