The Levels of Inflammatory Markers in the Treatment of Stroke study (LIMITS): inflammatory biomarkers as risk predictors after lacunar stroke

BACKGROUND

Inflammation is increasingly recognised as playing a central role in atherosclerosis, and peripheral blood markers of inflammation have been associated with incident and recurrent cardiac events. The relationship of these potentially modifiable risk markers to prognosis after ischaemic stroke is less clear. The Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) study will address hypotheses related to the role of inflammatory markers in secondary stroke prevention in an efficient manner using the well-established framework of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (NCT00059306).

METHODS

SPS3 is an ongoing Phase III multicentre secondary prevention trial focused on preventing recurrent stroke in patients with small vessel ischaemic stroke, or lacunes. In SPS3, patients are assigned in a factorial design to aspirin vs. aspirin plus clopidogrel, and to usual vs. aggressive blood pressure targets. The purpose of LIMITS is to determine whether serum levels of inflammatory markers - including high-sensitivity C-reactive protein, serum amyloid A, CD40 ligand, and monocyte chemoattractant protein-1 - predict recurrent stroke and other vascular events among lacunar stroke patients. The project will also determine whether these markers predict which people will respond best to dual antiplatelet therapy with clopidogrel and aspirin, as well the relationship to cognitive function.

ANALYSIS

plan Multivariable Cox proportional hazard regression modeling will be used to estimate hazard ratios for the effect of marker levels on risk of recurrent stroke and other outcomes after adjusting for additional potential risk factors, including age, gender, ethnicity, treatment arm, and traditional stroke risk factors. Interactions between marker levels and treatment assignment for both arms of the SPS3 study will be assessed. Observations will be censored at the time of last follow-up visit.

CONCLUSIONS

LIMITS represents an efficient approach to the identification of novel inflammatory biomarkers for use in risk prediction and treatment selection in patients with small vessel disease.

[Hamstring versus quadriceps tendon graft in double-bundle anterior cruciate ligament reconstruction]

PURPOSE OF THE STUDY

The aim of this prospective study was to evaluate functional outcomes and knee joint stability after double-bundle anterior cruciate ligament reconstruction using three-tunnel quadriceps tendon-bone graft and four-tunnel hamstring graft (semi-tendinosus and gracilis muscles).

MATERIAL

Group 1 included 20 patients undergoing reconstruction with quadriceps tendon- bone graft group; 2 comprised of 20 patients treated by hamstring graft. There were 26 men and 14 women, with an average age of 27 (range, 16 to 44) years. The minimum follow-up period was one year.

METHODS

In group 1 patients, semi-anatomic anterior cruciate ligament reconstruction was performed by a three-tunnel technique (two tunnels in the femur and one in the tibia) using quadriceps femoris muscle graft. Group 2 patients were treated by anatomic four-tunnel reconstruction (two tunnels in the femur and two in the tibia) with the use of hamstring graft. Functional outcomes were evaluated on the basis of Lysholm and IKDC scores. Antero-posterior stability was measured with aKT-1000 arthrometer and rotational stability was assessed by the pivot-shift test. For statistical evaluation, the level of significance (p) was set at < 0.05.

RESULTS

The final evaluation showed an average Lysholm score of 88.9 ± 12 (76-100) points for group 1, and 87.9 ± 11 (62-100) points for group 2; there was no statistically significant difference. The rounded average result of the functional IKDC score after surgery was the same in the two groups (80 ± 10). The joints treated by the three-tunnel technique had on average better antero-posterior stability, but this was not statistically significant. The pivot-shift phenomenon was not seen in either of the groups. Operative times in both groups were comparable. An intra-operative fracture of the patella occurred in two patients of group 1.

DISCUSSION

No similar prospective study comparing the outcomes of the methods reported here has been found in the internatio- nal literature. The studies so far published have not included any such comparison or they compared other techniques, such as single- versus double-bundle reconstructions.

CONCLUSIONS

Based on Lysholm and IKDC score evaluation and antero-posterior and rotational stability assessment, it can be concluded that both the three- and the four-tunnel technique of anterior cruciate ligament reconstruction gave similar results, with no significant differences, at one-year follow-up. However, these are only short-term results and only a long-term follow-up can prove or disprove the validity of this conclusion.

[Latissimus dorsi transfer for the treatment of irreparable craniodorsal tears of the rotator cuff]

PURPOSE OF THE STUDY

Latissimus dorsi transfer is a relatively complicated procedure subsequently requiring an active, long-term physical therapy. The surgeon's performance and a patient's effort are therefore of worth consideration. However, sutures of massive rotator cuff tears do not always produce good results. The aim of the study is to evaluate the role of latissimus dorsi transfer in the treatment of these shoulder pathologies.

MATERIAL

A total of 21 patients were evaluated. Their age at the time of surgery ranged from 48 to 63 years, with an average of 54.8 years. A minimum follow-up was three years, the average was 47 months (70-36 months). The indication for surgery included a massive rotator cuff tear, without symptoms of arthropathy and with normal subscapularis muscle function, which had been resistant to conservative treatment for 6 months at least. In 13 patients, transfer was performed after previous surgery on the rotator cuff.

METHODS

The procedure was carried out in a lateral position. The latissimus dorsi tendon was cut off just at its attachment to the humerus, the muscle was mobilised and the musculo-tendinous flap was released to reach the proximal operative wound and to cover the greater tuberosity of the proximal humerus. A shoulder abduction splint was used to immobilise the upper extremity for 6 weeks. Active and supervised individual physical therapy followed.

RESULTS

Subjective evaluation was excellent in 10, good in 9, and poor in 2 patients. The average Constant-Murley score improved by 32.25 points as compared before surgery (from 38.50 to 70.75). The evaluation of active arm elevation in the frontal plane showed improvement in 16 patients (77 %) by 40 degrees on average, no change in five patients (23%), and no deterioration in any of the patients. Active external rotation with the arm held at the body side improved by 14 degrees on average. Progression of radiographic changes indicating arthropathy was recorded in five patients.Post-operative haematoma, developed three patients it was treated by needle aspiration in one, and drainage in two patients.

DISCUSSION

The results presented here are in agreement with those reported in the international literature.The method of latissimus dorsi transfer shows poorer outcomes after previous attempts to suture of massive rotator cuff tears. In patients with a restricted range of motion before surgery, the post-operative shoulder motion achieved at the final evaluation is also lower.

CONCLUSIONS

When based on a correct indication, latissimus dorsi transfer with an uncomplicated post-operative therapy will result in improvement of shoulder function and pain relief, and it is therefore justified. One of the prerequisites for good results is the initial patient's consent with a supervised, active and long-term post-operative physical therapy. The transfer itself is a demanding surgical procedure associated with several risks and it should therefore be performed by an experienced and competent surgeon with a deep knowledge of shoulder girdle anatomy.

[Modified Latarjet procedure for recurrent shoulder dislocation in elderly patients]

PURPOSE OF THE STUDY

The aim of this prospective study was to report on an open approach to a bony defect of the glenoid associated with anterior shoulder instability, using a modified Latarjet procedure, in elderly patients.

MATERIAL

From 2003 to 2005, 11 patients older than 50 years underwent an open Latarjet procedure performed by two senior surgeons. The mean age of the patients was 65 years (range, 51 to 79 years). All of them were available for follow-up examination. There were seven women and four men. The study inclusion criteria were a bony defect of the anterior glenoid confirmed by a CT scan, age over 50 years, and three or more previous dislocations.The mean pre-operative forward elevation was 121.2 degrees+/-16.6 degrees (range, 40 degrees-180 degrees) and external rotation was 43.3 degrees+/-13.1 degrees (range, 5 degrees-80 degrees). The mean number of dis- locations before surgery was 4.8 (range, 3-8).

METHODS

The Latarjet operation makes use of a large coracoid bone graft to extend the glenoid articular surface by means of a lengthened bone platform, and a sling effect of the conjoined tendon passing through the subscapularis muscle. The Constant-Murley score was used to evaluate the results.

RESULTS

Shoulder stability and function were restored in all 11 patients at a minimum follow-up of 4 years (range, 49-69 months). There was no recurrence of instability. The range of motion was minimally reduced; the mean loss of elevation was 18.8 degrees and the mean loss of external rotation was 4.0 degrees. The mean Constant-Murley score increased from 56.4+/-13.3 points preoperatively to 81.8+/-11.3 points post-operatively (p<0.05). No significant post-operative complications were observed.

DISCUSSION

It is necessary to differentiate between the Latarjet procedure and its modification popularised by Helfet as the Bristow or the Bristow-Latarjet operation. The Bristow procedure transfers only the tip of the coracoid, along with the attached con- joined tendon, to the anterior side of the neck. This procedure does not treat the bony defect and provides a mere soft-tis- sue constraint. Only a few reports of the original Latarjet procedure can be found in the international literature.

CONCLUSIONS

The open Latarjet reconstruction can successfully restore shoulder stability in joints with a significant bony defect of the glenoid even in elderly patients. It is effective in situations in which soft-tissue reconstruction is not a reasonable option.

The relationship between maternal and umbilical cord androgen levels and polycystic ovary syndrome in adolescence: a prospective cohort study

CONTEXT

The prenatal antecedents of polycystic ovary syndrome (PCOS) are not known, but prenatal androgen exposure is thought to contribute. This has not previously been investigated in large prospective studies of normal human pregnancy.

OBJECTIVE

The aim of the study was to establish the prospective relationship between early life androgen exposure and PCOS in adolescence.

DESIGN AND SETTING

A prospective cohort study was conducted in the general community.

PATIENTS OR OTHER PARTICIPANTS

A total of 2900 pregnant women were recruited at 18 wk gestation. Prenatal androgen exposure was measured from maternal blood samples (at 18 and 34-36 wk) and umbilical cord blood. Timed (d 2-5 menstrual cycle) blood samples were collected, clinical hyperandrogenism was assessed, and transabdominal ultrasound examination of ovarian morphology was performed in 244 unselected girls from the Raine cohort aged 14-17 yr.

MAIN OUTCOME MEASURE(S)

We examined the relationship between early life androgen exposure and PCOS in adolescence.

RESULTS

We did not observe a statistically significant relationship between early life androgen exposure and PCOS in adolescence.

CONCLUSIONS

This is the first prospective study to evaluate the relationship between prenatal androgen exposure and PCOS in adolescence in normal pregnancy. Our findings do not support the hypothesis that maternal androgens, within the normal range for pregnancy, directly program PCOS in the offspring.

A systematic review of oral treatments for fungal infections of the skin of the feet

OBJECTIVE

To synthesize the evidence for the effectiveness and cost-effectiveness of oral treatments for fungal infections of the skin of the feet.

DESIGN

Systematic review.

INTERVENTIONS

Oral treatments for fungal infections.

METHODS

Ten electronic databases, four journals and the bibliographies of all review papers identified were searched. The authors also wrote to international pharmaceutical companies and all podiatry schools in the UK. The studies selected were randomized trials of clinically diagnosed fungal skin infections of the foot that confirmed cure by culture and microscopy. Two reviewers independently selected trials and abstracted data using a structured tool including 12 recognized quality criteria.

RESULTS

Of 26 trials identified, 12 met the inclusion criteria and evaluated five different treatments. Single placebo-controlled trials showed that terbinafine and itraconazole were both effective. Two trials showed that terbinafine cures 50% more patients than griseofulvin. Four trials compared terbinafine with itraconazole, one showed that terbinafine given for 2 weeks had a better cure rate than 2 weeks of itraconazole, but the other three showed that it was no better than 4 weeks of itraconazole.

CONCLUSIONS

There is significant evidence that terbinafine is more effective than griseofulvin, though more costly. There is weak evidence that terbinafine may be more cost-effective than itraconazole. Firm recommendations about the choice between terbinafine and the azoles need further research.

Changes in B-mode ultrasound echo intensity following injection of bupivacaine hydrochloride to rat hind limb muscles in relation to histologic changes

This study tested the hypothesis that infiltration of inflammatory cells in muscle fibers would increase echo intensity (image brightness) of B-mode ultrasound images. Bupivacaine hydrochloride (BPVC) or saline solution (SAL) was injected to the tibialis anterior (TA) muscles of 14- to 23-wk-old male Wistar rats. Ultrasound images were taken from the muscles before and at 0, 2, 4, 6, 9, 12, 24, 48, 72, 120, 168 and 336 h after the injection and analyzed for the echo intensity (echogenicity) expressed as the mean value of image pixel value of a region-of-interest. Changes in the echo intensity were compared between BPVC-injected and control or SAL-injected muscles. In the subsequent study, rats (n = 2 per time point) were sacrificed after taking ultrasound image at 0, 2, 6, 12, 24, 48 and 168 h after BPVC injection to the right TA and SAL injection to the left TA to observe histologic changes under a light microscope and the relationship between echo intensity and inflammatory cells was assessed. No significant changes in echo intensity were observed for the control, but BPVC induced significant (p < 0.05) increases in the echo intensity peaking 0 to 24 h postinjection. SAL also increased echo intensity immediately after injection but returned to the baseline by 24 h postinjection. The time course of changes in the echo intensity did not match with the time course of increases in inflammatory cells in the muscle. It is concluded that infiltration of inflammatory cells is not a direct cause of the increased echo intensity.

A re-appraisal of the morphological changes within the endometrium during menstruation: a hysteroscopic, histological and scanning electron microscopic study

BACKGROUND

The morphological changes occurring during the dynamic process of menstruation have previously been described only in terms of data derived from static sources, including histological and electron microscopic studies. Recent advances in pressure-controlled, continuous flow hysteroscopy permit dynamic images to complement the traditional modalities.

METHODS

A prospective observational study of 15 women (age range 22-52 years) during various phases of active menstrual shedding and repair using the novel hysteroscopic plus histological and scanning electron microscopic approaches. The women had not taken hormonal therapy in the previous 2 months and all had regular menstrual cycles of 27-30 days.

RESULTS

For the first time, the hysteroscopic appearance of the endometrium during menstruation has been documented. This technique indicates that endometrial loss and regeneration are piecemeal processes that occur simultaneously in different areas of the uterine cavity. The exposed basalis endometrium is rapidly covered with a fibrinous mesh, upon and within which new surface epithelial cells develop. New epithelial cells appeared to arise from the underlying stromal cells rather than as epithelial outgrowths from the residual gland stumps as had previously been thought.

CONCLUSIONS

Endometrial surface epithelial regeneration is a rapid, localized and piecemeal process that appears to occur as a consequence of cellular differentiation from stromal cells within the residual basalis.

PCOS and infertility

Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women of a reproductive age, occurring in approximately one in seven women. Of these women approximately two-thirds will not ovulate on a regular basis and consequently may therefore seek treatment for ovulation induction. After exclusion of other significant causes of sub-fertility the pragmatic approach to ovulation induction is to commence with clomiphene citrate. The goal of ovulation induction is the development of a single ovulatory follicle and the avoidance of a multiple gestation. Second line therapies consist of gonadotrophin therapy and laparoscopic ovarian drilling, the place of metformin therapy is believed to lie in the management of woman with impaired glucose tolerance. It is imperative that all ovulation induction is performed with access to rapid serum estradiol monitoring and ultrasound facilities. The benefit of the use of aromatase inhibitors has not yet been proven in large studies. Women with PCOS undergoing in vitro fertilization (IVF) are at a substantial risk of ovarian hyperstimulation syndrome and this approach should be avoided if at all possible. If it is required these women may be suitable candidates for in vitro maturation of oocytes (IVM) so avoiding ovarian hyperstimulation. Women with PCOS are potentially at an increased risk of miscarriage and in pregnancy of they are at an increased risk of developing gestational diabetes, pregnancy-induced hypertension and pre-eclampsia. Furthermore the neonate has a significantly higher risk of admission to a neonatal intensive care unit and a higher perinatal mortality.

Complications during and after surgery of the lower cervical spine by isolated anterior approach with CSLP implant

BACKGROUND

The merits of different operative approaches in the management of spinal injury is debated. The aim of this study was to assess, retrospectively, the outcome of treatment of injuries of the lower cervical spine by an anterior approach, in terms of fusion rate and complications.

MATERIALS AND METHODS

Between 1995 and 2004, 270 patients with an injury of the lower cervical spine were operated on by an anterior approach in our hospital. There were 67 females and 203 males. Using the Aebi and Nazarian classification, 22% of patients had a type A injury, 23% of patients had a type B injury and 55% of patients had a type C injury. All had an anterior approach with monocortical stabilisation using a cervical spine locking plate [Synthes].

RESULTS

Radiological evidence of fusion was found in all but one patient at 6 months. Complications occurred in a small proportion of the series. Recurrent laryngeal nerve injury was noted in seven patients, an abscess in the wound in one patient, a haematoma requiring re-operation for evacuation in two patients. The cervical locking plate broke in one patient and this patient went on to develop a pseudoarthrosis from failure to fuse. In another patient there was release of the plate osteosynthesis.

CONCLUSIONS

Treatment of the injured lower cervical spine by an anterior operation and plate fixation was successful in achieving bone fusion in almost every patient and was followed by a complication in only a small proportion of our series. Similar results in other reports indicate that this approach is a safe and effective procedure.

Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacks

BACKGROUND

Non-valvular atrial fibrillation (AF) carries an increased risk of stroke mediated by embolism of stasis-precipitated thrombi originating in the left atrial appendage. Both oral anticoagulants and antiplatelet agents have proven effective for stroke prevention in most patients at high risk for vascular events, but primary stroke prevention in patients with non-valvular AF potentially merits separate consideration because of the suspected cardio-embolic mechanism of most strokes in AF patients.

OBJECTIVES

To characterize the relative effect of long-term oral anticoagulant treatment compared with antiplatelet therapy on major vascular events in patients with non-valvular AF and no history of stroke or transient ischemic attack (TIA).

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (June 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2006) and EMBASE (1980 to June 2006). We contacted the Atrial Fibrillation Collaboration and experts working in the field to identify unpublished and ongoing trials.

SELECTION CRITERIA

All unconfounded, randomized trials in which long-term (more than four weeks) adjusted-dose oral anticoagulant treatment was compared with antiplatelet therapy in patients with chronic non-valvular AF.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed quality and extracted data. The Peto method was used for combining odds ratios after assessing for heterogeneity.

MAIN RESULTS

Eight randomized trials, including 9598 patients, tested adjusted-dose warfarin versus aspirin (in dosages ranging from 75 to 325 mg/day) in AF patients without prior stroke or TIA. The mean overall follow up was 1.9 years/participant. Oral anticoagulants were associated with lower risk of all stroke (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.54 to 0.85), ischemic stroke (OR 0.53, 95% CI 0.41 to 0.68) and systemic emboli (OR 0.48, 95% CI 0.25 to 0.90). All disabling or fatal strokes (OR 0.71, 95% CI 0.59 to 1.04) and myocardial infarction (OR 0.69, 95% CI 0.47 to 1.01) were substantially but not significantly reduced by oral anticoagulants. Vascular death (OR 0.93, 95% CI 0.75 to 1.15) and all cause mortality (OR 0.99, 95% CI 0.83 to 1.18), were similar with these treatments. Intracranial hemorrhages (OR 1.98, 95% CI 1.20 to 3.28) were increased by oral anticoagulant therapy.

AUTHORS' CONCLUSIONS

Adjusted-dose warfarin and related oral anticoagulants reduce stroke, disabling stroke and other major vascular events for those with non-valvular AF by about one third when compared with antiplatelet therapy.

Präzise computergestützte Beinachsenkorrektur mit öffnender valgisierender Tibiakopfosteotomie

AIM

This prospective study investigates open-wedge high tibial osteotomy performed with the aid of a kinematic computer-guided navigation system. After the X-ray control the osteotomy was stabilized by internal LCP fixation. The aim of the study was to demonstrate the accuracy of the navigation system and to prove the reliability of the LCP fixation.

METHOD

A total of 39 patients were operated between 2002 and 2003 following this method. The outcomes were evaluated at least 2 years after the surgery clinically and radiologically; 21 females (1 female underwent bilateral osteotomy) and 18 males were included in the study sample.

RESULTS

Prior to the osteotomy, the mean anatomic lateral tibiofemoral angle (aLTFA) was 181.1 degrees . The desired 4 degrees "overcorrection" of valgus (aLTFA 170 degrees) was found on X-rays postoperatively in all cases. The mean correction was 11.1 degrees. The correction achieved was stable during the 2-year follow-up period. The osteotomy healed in all cases after 4 months. The full range of motion remained after the surgery in all cases. All patients were satisfied with their results. The Lysholm score was 55 points before and 82 points after the osteotomy (27 points difference).

CONCLUSION

The computer-assisted open-wedge high tibial osteotomy with tricortical grafts stabilized by LCP fixation gives exact and reproducible results without loss of correction.

[Minimally invasive and navigated implantation for total knee arthroplasty: X-ray analysis and early clinical results]

Total knee arthroplasty (TKA) alignment is one of the most important factors in long-term prosthesis survival. Minimally invasive surgical (MIS) procedures are becoming more common. There may be an increased overall complication rate, especially component malpositioning, due to poor visualisation. The disadvantage of restricted visualisation in the less invasive technique can be compensated by a navigation system. This combined procedure is described in this paper. A total of 40 Search Evolution TKAs were implanted using OrthoPilot navigation in the standard manner, and 40 TKAs were implanted using MIS via a subvastus approach. Primary osteoarthritis of the third or fourth degree, without severe valgus deformity, was the indication. These patients were then selected at random as they came to the institution. The results were evaluated radiologically and clinically.Pain, range of motion, gait and function, and the entire clinical score 10 days after the operation were significantly better in the MIS-group. At 6 and 12 weeks postoperatively, these results were no longer statistically significant. Ideal radiological results were obtained in all cases. No differences in limb axis and component alignment were found after the operation between the navigated groups. MIS is technically very demanding. That is why it should be used only in carefully selected cases. Its advantages occur in the first weeks after the surgery. The long-term results must still be determined.

[Accurate placement of bone tunnels in reconstruction of the anterior cruciate ligament - a contribution of computer-assisted navigation]

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent injuries to the knee joint in the young. ACL repair is a major orthopedic procedure most often performed in the younger adult population. Early stabilization of the knee joint by ACL reconstruction also decreases the risk of injury to other important structures. At ACL reconstruction, the biggest problem is usually the exact placement of drilled tunnels. This significantly affects the outcome of surgery, i. e., range of motion, knee joint stability, reaction of the synovium in the knee, pain, impingement and potential graft failure with lesion development. However, 70 % of ACL reconstructions are carried out by orthopedic surgeons whose experience is limited to less than 20 ACL repair procedures in a year! Arthroscopy does not allow the surgeon to gain a complete 3D view of important anatomical structures, particularly in the anteroposterior direction. Computer-assisted navigation systems should aid in minimizing these problems. First reports on the use of computer-assisted navigation in ACL reconstruction, which have already been published in the international literature, have provided clear evidence that more exact bone tunnel placement can be achieved with navigation than with the use of conventional techniques. In addition, kinematic navigation enables us to measure anteroposterior and rotational knee stability, isometry, impingement and the angles of bone tunnel placement. It permits a choice from various types of graft. Last but not least, kinematic navigation provides a tool for recording surgery outcomes without a necessity to use further examination methods. Its drawbacks, namely, the learning curve, additional fixation of navigation probes to the femur and tibia and slightly longer operative time, should be considered in the context of presumed long-term benefits for the patient.

[Consequennce of nontreatment scapholunate instability of the wrist]

Authors evaluate the results of patients with acute rupture of the scapholunate (SL) ligament, demonstrated by arthroscopy, in this study. One group of patients was treated with reinsertion of SL ligament by the help of Mitek anchor. In the other group there were patients with diagnosed total rupture of SL ligament which rejected the reinsertion of the ligament. Authors evaluate results of both groups 24 months after the injury. On the basis of clinical and X-ray results, even after such short time, reasonably worse results for the group without performed reinsertion were determined. Even X-ray documented arthrotic changes of scapholunate advanced collapse (SLAC) type were present.

Mood state and psychological adjustment to pregnancy

The aim of this study was to investigate whether there is an association between antenatal mood state (depression and anxiety) and psychological adjustment to pregnancy. Participants were first-time, low obstetric risk mothers at a Sydney teaching hospital who completed self-report questionnaires measuring depression, anxiety, thoughts about motherhood and self as mother and relationship with the fetus. Higher symptom levels of antenatal anxiety were related to less optimal maternal-fetal quality of attachment, more negative attitudes towards motherhood and the self as mother. Similar trends were found for symptoms of depression, however depression was not significantly related to psychological adjustment to pregnancy variables. The significance of anxiety in the current study highlights the importance of considering anxiety in the psychological adjustment to pregnancy, as well as the in the context of perinatal mental health more generally. Implications of these findings for intervention are also briefly discussed.

[Defect of the femoral condyle in the knee after patellectomy. Long-term results of fresh massive osteochondral allografting]

The presence of a massive full-thickness osteochondral defect in the knee of young and active individuals is an unsolved problem in orthopedic surgery, especially in post-traumatic large bone defects. Fresh massive osteochondral allografts have been used for many years but mostly in oncology but not in post-traumatic cases. This case report describes a 20-year-old right leg-dominant woman, who, at age 19, sustained open Gustilo-Anderson type III comminuted fractures of the left patella and lateral femoral condyle in a motorbike accident. Initial treatment included immediate débridement and patellectomy with lavage. The large defect of the femoral condyle was reconstructed with a massive osteochondral allograft 1 year after the injury. The graft was obtained from our institutional tissue bank. The damaged bearing part of the condyle was resected to bleeding bone to create the nearly rectangular defect. The central condyle wall remained intact. The graft was trimmed to fit the defect and fixed with three cancellous 6.5-mm screws. The meniscus was not damaged. Partial weight bearing was permitted at 8 weeks and full weight bearing at 16 weeks after the surgery. At the last follow-up control 10 years after the surgery, no evidence of tibiofemoral arthrosis was present. The allograft-host interface was not visible. The radiodensity of the graft was nearly identical to the host bone. The Lysholm score and clinical findings were identical (100 points) to those 18 months after the surgery. The patient was extremely satisfied without complaints at 30 years of age.

[Our experience with an image guided navigation system for accurate alignment in total hip replacement by minimally invasive posterolateral surgery]

PURPOSE OF THE STUDY

The aim of the study was to compare a radiographic position of the acetabular component with a position guided by the navigation system in final acetabular cup alignment.

MATERIAL

Between May and October 2005, 15 patients underwent implantation of a cementless acetabular component from the posterolateral minimally invasive approach with the use of kinematic navigation.

METHODS

The final acetabular cup alignment was determined from the data saved in the navigation system. The radiographic measurement of acetabular cup inclination was made from an anteroposterior projection of both hips on one image, and anteversion was determined by the Ackland method.

RESULTS

The average values for inclination and anteversion shown on radiographs were 41.8 degrees (range, 35-51) and 19.8 degrees (range, 5-32), respectively. The average values of cup alignment recorded at implantation by the navigation system were 27.6 degrees (range, 22-35) for inclination and 24.3 degrees (range, 17-28) for anteversion.

DISCUSSION

The acetabular cup alignment is considered optimal when inclination is 45 degrees and anteversion 15 degrees. This is more difficult to achieve in minimally invasive surgery due to a limited view of the operating field. This disadvantage can be overcome by using various navigation systems the function of which depends on the accuracy of recorded data.

CONCLUSIONS

Because the data recorded by the system used in our study were not accurate, we do not consider the OrthoPilot navigation system to be an effective aid in minimally invasive posterolateral surgery.