Long-term follow-up of 1217 consecutive short-stem total hip arthroplasty (THA): a retrospective single-center experience

BACKGROUND

An arthroplasty registry in Germany has been recently established but long-term results for most short-stem innovations are missing. Short-stem hip arthroplasty is usually indicated in young active patients. Our indication was extended to older age groups, femoral neck fractures (FNF), and dysplasia. We evaluated all total hip arthroplasties (THAs) in this population with a collum femoris preserving stem (CFP) performed from 2003 to 2013.

METHODS

A consecutive cohort of 1217 CFP THAs with a mean age of 68.7 years was followed retrospectively for a median of 4.8 years (patient follow-up interquartile range from 3.0 to 6.9 years). A questionnaire, which we used in two previous studies, was answered by 89.15% of patients and included information regarding complaints, grade of satisfaction, re-operations, and dislocation. Of the 1217 patients, 77 had died. Survival of the stem and the cup was assessed using a competing risks approach according to an Aalen-Johanson estimator with revision for septic or aseptic loosening or death as a competing endpoint.

RESULTS

Of the patients who answered the questionnaire, 92.5% had no complaints related to the procedures. In all 1217 patients, there were 43 revisions (4.2%) as follows: stem and cup revisions due to aseptic loosening of the stem (n = 10), infections (n = 6), pain (n = 4), or trauma (n = 3); cup revisions due to aseptic loosening (n = 3), dislocation (n = 5), and offset revisions (n = 12). Survivorship was 96% for the stem and 99% for the cup 9 years postoperatively. Statistical analysis confirmed a higher risk for revision in patients with a younger age (p = 0.033), male sex (p = 0.040), dysplasia (p = 0.032), and undersized or extra-large stems for stem revisions (p = 0.001) and female sex (p = 0.036) for cup revisions. FNF (p > 0.20) and age ≥ 80 years (p = 0.114) had no higher risk for loosening of the stem. Our data is also compared with the current literature, especially with the available CFP studies.

CONCLUSION

The survival rate of the CFP stem was as high as 96% after 9 years of followup which compares well-to-previously published long-term survival rates. There is no higher risk for revision in patients 80 years old or older and in cases with femoral neck fractures. The CFP preserves also allowed using standard stems in the rare cases of revision.

[Wound infections in abdominal surgery: aetiology, risk factors, antibiotic prophylaxis]

Nosocomial infections are the major cause for morbidity and mortality in hospital. In Germany 3.5 % of patients developed nosocomial infections, 15 % of these are wound infections post surgery. Asepsis, proper surgical technique and identifying patients at risk of infections and antibiotic prophylaxis are the most effective measures to reduce postoperative wound infection rate. To identify patients at risk by traditional wound classification system alone seems to be insufficient. Risk factors others than the suspected contamination rate at the end of the operation have to be detected. Indication, choice of the antibiotic agent and timing of antibiotic prophylaxis will be discussed.

Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial

INTRODUCTION

The increasing number of enterococcal infections in hospitals and reports about the development of resistance of these bacteria make it necessary to review their importance as co-pathogens in secondary peritonitis.

MATERIALS AND METHODS

A prospective randomized controlled trial on primary therapy of secondary peritonitis was carried out in six centers comparing cephalosporin-based antibiotic therapy to acylaminopenicillin-based therapy.

RESULTS

Enterococci were only cultured in 6 of 110 cases from the abdomen and were found in only 5 cases of postoperative complications. No differences were found between penicillin-based vs. cephalosporin-based therapy.

CONCLUSION

The study supports the view that these bacteria continue to play a minor role in secondary peritonitis. The point has to be emphasized, however, that the patients under study were in relatively good condition (APACHE II median 9 for cephalosporins and 10 for penicillins) and that postoperative cases of peritonitis were excluded.

Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group

INTRODUCTION AND METHODS

A prospective observational multicenter study with 18 hospitals was performed to assess preoperative risk, therapeutic management and outcome of patients with peritonitis. Data collection was carried out according to standardized and recommended definitions. Included in the study were 355 patients with macroscopically confirmed peritonitis.

RESULTS

In the univariate analysis, the following factors influenced both the mortality and the incidence of postoperative complications: age, presence of certain concomitant disease, site of origin of peritonitis, type of admission and the ability of the surgeon to eliminate the source of infection. In addition, postoperative infective complications were related to the etiology of peritonitis and the exudate. In the multivariate analysis, APACHE II (P<0.001), successful operation (P<0.001), age (P<0.001), liver disease (P<0.03), malignant disease (P<0.04) and renal disease (P<0.05) turned out to be significant with respect to death. Escherichia coli was the predominant organism (51%), following by enterococci (30%) and bacteroides (25%). There was a significantly higher postoperative infection rate in patients with no adequate treatment of enterococci than patients with adequate treatment or no enterococci (P<0.05).

CONCLUSION

The study demonstrated the important role of the physiological reserve of the patient and of the surgeon, which is not adequately reflected in existing scoring systems. Further investigations are needed to study the impact of enterococci on the outcome.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

Prognostic modelling in peritonitis. Peritonitis Study Group of the Surgical Infection Society Europe

OBJECTIVE

To develop and to evaluate a new score to aid management in peritonitis.

DESIGN

Prospective, multicentre study.

SETTING

18 departments of surgery in Germany. Austria, and Switzerland.

SUBJECTS

355 patients with peritonitis confirmed at laparotomy.

INTERVENTIONS

Computation of four different prognostic systems: APACHE II; APACHE II and successful operation; APACHE II, successful operation and Goris score on the first postoperative day: and multivariate analysis. Predictions were evaluated according to the following criteria: specificity with a fixed sensitivity at 80%, receiver operating characteristic (ROC-) curve, and predictive value.

MAIN OUTCOME MEASURE

The ability to predict hospital death and infective complications.

RESULTS

Multivariate analysis was superior to APACHE II: APACHE II and successful operation: and APACHE II, successful operation, and Goris score. From the analysis a new prognostic model was derived from which it was possible to identify patients early in the postoperative period who are at high risk of developing further complications (prognostic peritonitis model: PPM).

CONCLUSIONS

None of the existing scores was of particular use for therapeutic decision making in peritonitis. The new prognostic model should be the focus of further trials in the management of peritonitis.

Planned relaparotomy vs relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe

OBJECTIVE

To define the role of planned relaparotomy (PR) in the treatment of intraperitoneal infection, compared with that of relaparotomy on demand (RD).

DESIGN

Case-control study on the basis of a prospective multicenter cohort analytic study. Statistical evaluation was done by the McNemar test for qualitative data and the Wilcoxon matched-pairs signed rank test for qualitative data.

SETTING

Eighteen hospitals of different care levels in Austria, Germany, and Switzerland.

PATIENTS

Thirty-eight of 42 patients with intra-abdominal infections who underwent PR were matched for APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, cause of infection, site of origin of peritonitis, and the ability of the surgeon to securely eliminate the source of infection with 38 patients taken from a cohort of 278 undergoing RD.

INTERVENTIONS

Planned relaparotomy was defined as at least one relaparotomy decided on at the time of the first surgical intervention; RD, relaparotomy indicated by clinical findings.

MAIN OUTCOME MEASURES

Mortality and incidence of postoperative multiple organ failure and infectious complications.

RESULTS

There was no significant difference in mortality between patients treated with PR (21%) or RD (13%). Postoperative multiple organ failure as defined by a Goris score of more than 5 was more frequent in the group of patients undergoing PR (50%), compared with the group undergoing RD (24%) (P = .01), as were infectious complications (68% vs 39% [P = .01]). Infectious complications were due to more frequent suture leaks (16% vs 0% [P = .05]), recurrent intra-abdominal sepsis (16% vs 0% [P = .05]), and septecemia (45% vs 18% [P = .05]) in the PR vs the RD groups. The incidence of other complications was not different in the two groups.

CONCLUSIONS

Until larger prospective studies are available, the indication for PR should be evaluated with caution.

[Synovial hemangioma of the knee joint--a rare cause of recurrent hemarthrosis]

In the differential diagnosis of bloody knee joint effusions synovial haemangioma as a rare cause has to be considered. Especially suspicious are long durations of disease with recurrent atraumatic blood-stained joint effusions and repeated episodes of painful limitation of motion, laboratory and radiographic findings often being normal. On the one hand arthroscopy can prove the diagnosis by obtaining an ample biopsy specimen, on the other hand it facilitates the healing of the lesion at the same time by radical removal of the tumour.

Prospective evaluation of prognostic scoring systems in peritonitis. Peritonitis Study Group

OBJECTIVE

To assess the accuracy of the APACHE II score, the Mannheim Peritonitis Index (MPI), and the Peritonitis Index Altona (PIA) II in the prediction of outcome of patients with peritonitis.

DESIGN

Prospective, multicentre study.

SETTING

12 Departments of Surgery in Europe.

SUBJECTS

271 Patients with peritonitis confirmed at laparatomy.

INTERVENTIONS

Computation of the three scores on one set of data for each patient.

MAIN OUTCOME MEASURES

The ability to predict death or survival within 30 days of operation with each of the three scores. The prediction were evaluated according to the following criteria: discriminatory ability (areas under the receiver-operator characteristic (ROC) curves relating sensitivity to specificity); sharpness (level of confidence that was associated with a prediction); and reliability (agreement between predicted and observed mortality within equidistant intervals on the scale).

RESULTS

APACHE II was superior to both the MPI and PIA II in its discriminatory ability and reliability, but the MPI and PIA II made more "sharp" predictions.

CONCLUSIONS

None of the three scores is of any use for predicting the outcome for individual patients. APACHE II is the current standard for assessing the severity of peritonitis.

[Calculi of the bile ducts--a problem for the elderly? Observations from the surgical viewpoint]

Age alone does not increase the risk in biliary surgery. However, cholelithiasis in the elderly is often associated with an increased frequency of acute cholecystitis and cholangitis due to stone obstruction. The proportion of elderly people in the world is still growing, therefore, we can expect to see increasingly more complications of gallstones. Elective surgery for gallstone disease in all age groups is to be preferred to a policy of waiting for stone complications with the resultant risk of higher mortality and postoperative morbidity of emergency surgery.

[Postoperative mechanical ileus]

Postoperative GI obstruction is the third most common postoperative complication, after peritonitis and bleeding, leading to laparotomy. The mortality has declined in the last decade from around 20%-35% to 10%-20%. This is probably caused by better intra-operative surgical techniques and better understanding of the pathophysiology of gastrointestinal motility. The problem most frequently lies in the proximal small bowel particularly after operations on the colon, especially in the presence of inflammation or peritonitis. Differentiation between postoperative paralysis and mechanical obstructions is very difficult. Modern diagnostic techniques have not changed this fact. For assessment of the abdomen, repeated surgical investigations is still of more value than laboratory data alone.

Concentration of ciprofloxacin in bone tissue after single parenteral administration to patients older than 70 years

The concentrations of ciprofloxacin produced in bone, cartilage and menisci after a single administration of 200 mg were determined at different intervals in a group of patients with an average age of 80 years. Concentrations of 0.11 to 0.94 mg/kg bone tissue were measured after 0.5 to 5 hours. In the cartilage a concentration of active substance was measureable only once (4.18 mg/kg). In the presence of marked circulatory disorders the active substance concentrations reached in the bone were above those found in the seriously damaged muscle. Although the concentrations reached in the bone are effective, no risk should be taken in osteomyelitis. Ciprofloxacin should therefore be used at high dosage and possibly be combined with another substance. Given for therapeutic purposes, a single dose of ciprofloxacin is naturally not effective enough, and given for prophylactic purposes, not safe enough to prevent a post-traumatic osteitis.

Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intraabdominal infection. Joint Working Party of SIS North America and Europe

Analysis of the experience with scientific studies on patients with secondary intraabdominal infection has revealed that problems of interpretation and comparability between studies exist as they relate to variable diagnostic criteria, unmeasured severity of disease, and unclear outcome measures. A consistent system of definitions has been developed to address these deficiencies. Intraabdominal infection is defined as clinical peritonitis requiring both operative and microbiological confirmation for proof of infection. The APACHE II system is proposed for grading the severity of the infection and for stratification of patient risk of mortality. Mortality and time until death, on one hand, and recovery and time until recovery, on the other, are proposed as the main outcome measures, both being independently and positively defined. It is anticipated that this system of minimum rules will produce studies that can be compared, hence, accelerating knowledge and understanding about intraabdominal infection and its best treatment.

[The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis]

Based on the experience with 1243 patients suffering from purulent peritonitis 255 patients of two surgical departments were studied prospectively in a cohort study. Lethality was 24%. For intraabdominal infection an index is established that allows for the first time to predict lethal outcome of the disease in the individual patient. For each index-score the expected mortality is given by a modern mathematical calculation. The 'Mannheim Peritonitis Index' includes only clinical risk-factors that are routinely documented pre- and intraoperatively. Methods of evaluation, validation and the comparison with other prognostic indices are presented.

[The asymptomatic gallstone]

There are several sound arguments to operate on "silent" gallstones: The operative mortality following simple cholecystectomy in patients under 40 is zero. 50% of all patients with silent gallstones will be operated upon or develop symptoms within 10-20 years after the initial diagnosis. Carcinoma of the gallbladder is very rarely diagnosed in time and in most cases is incurable at the time of operation. The number of deaths in the FRG due to a carcinoma of the gallbladder has been consistently high in the last decade. Risk factors for cholecystectomy increase with the patients age. Therefore early cholecystectomy is recommended. Nevertheless indication for cholecystectomy is an individual decision.

[Interwoven wire suture with fascia lata-plasty in the treatment of subcutaneous rupture of the Achilles tendon--an obsolete method?]

Lately there has been an increased incidence of rupture of the Achilles tendon following the general increase in mass sports. Surgery is the treatment of choice, and various methods are being described. We have been using the wire suture method with fascia lata plasty for more then twenty years. The rate of infection is 3.8% and that of rerupture 1.2%, figures that correspond to those stated for other surgical methods. Moreover, 87% of the patients were very satisfied with the result of the operation; they are fit for work without any restriction, and some of them even practise their sports activities as before. For this reason we consider that wire suturing with fascia lata plasty is by no means obsolete in the treatment of rupture of the Achilles tendon.

[Mediastinal metastases of extrathoracic tumors--important findings in mediastinoscopy]

From 700 mediastinoscopies performed between 1976 and 1985, 11 revealed metastases from extrathoracic malignancies. Primary tumours were eventually located in the gastrointestinal tract (5), the breasts (2), the kidneys (2) and the thyroid gland (1). All lymphatics join within the mediastinum. Therefore mediastinal secondaries from tumours of all body regions may be encountered. Mediastinoscopy facilitates safe biopsy and histological diagnosis. It is essential for adequate therapy.

[Healing of the sacral wound cavity after abdomino-perineal extirpation of the rectum. A prospective randomized study using metronidazole]

In a prospective, controlled randomised study of 100 patients the healing of the sacral wound after abdomino-perineal exstirpation of the rectum with and without metronidazole parenterally was compared. A significant reduction in hospital stay and in postoperative time of drainage of the sacral wound was found. The primary wound healing, defined as healing without complications within 14 days, was registered in 84% in the treated group and in 56% in the controls. No influence was seen in the number of urinary tract infection by this treatment.

[Accidental finding: the small, differentiated thyroid carcinoma. Report of 46 thyroid carcinomas of up to 15 mm diameter]

Review of 190 cases of thyroid carcinoma between 1974 and 1981 showed an increasing rate of small papillary carcinoma. The study included 46 tumors which did not exceed 15 mm in diameter. Most of these lesions (3/4) were discovered incidentally at thyroid operations of various types. In spite of the early stage of carcinoma 6 tumors were already associated with cervical nodal metastasis, cases showed multiple lesions within the thyroid gland, homolateral and bilateral. With respect to these cases total thyroidectomy and subsequent radium therapy are generally suggested.

[Significance of clinical symptoms in the early diagnosis of bronchial cancer]

The lack of symptoms in lung cancer is the main reason for its late diagnosis and therapy. In the surgical clinic of Northwest Hospital, Frankfurt/Main, only 32,5% of 1494 bronchogenic carcinomas (1970-1980) were operable. 40% of these lung cancers were detected by routine examination, 45,7% of the operable carcinomas and 25% of the inoperable carcinomas. Peripherally located carcinomas showed very few symptoms; even at an early stage, centrally located carcinomas showed as many symptoms as inoperable carcinomas.

[Lung resections in bronchial carcinoma of patients older than 70 years (author's transl)]

In a retrospective study (1969--1979) of 530 resections performed because of bronchial carcinoma, there were 70 patients older than 70 years (13.2%). Two-thirds of their resections were carried out on T 1--2 N0M0 and one-third on T 1--2-N1M0. For 22 central and 48 peripheral carcinomas, 25 pneumonectomies, 40 lobectomies, and 5 bilobectomies were performed. The mortality was 14.2% (lung embolism, pneumonia, apoplexia, and one insufficiency of the bronchial resection stump). Postoperative complications were atelectasis (28.5%), pneumonia (4%), lung embolism (6%), and two pleura empyemas. Of the patients operated on from 1976 to 1978, 40% (T1N0M0) and 30% (T2N0M0) and 30% (T2N0M0) are alive after 2.5 years.

[Is surgical treatment of small cell bronchial carcinoma still indicated?]

Based on own results, general negation of operation in small cell carcinoma of the lung does not appear warranted. Surgical treatment is indicated when a non-metastasizing tumour is present. Small cell bronchial carcinoma operated in tumour stage I has a clearly better prognosis than a carcinoma of the same stage treated by chemo- or radiotherapy. A certain response of these carcinomas to cytostatic or radiotherapy has not been established. Should tumour metastases be demonstrable, i.e. lymph node metastases in the mediastinum or distant metastases, as is the case in the majority of these rapidly metastasizing carcinomas, chemo- or radiotherapy has been shown to be superior to operative treatment.

[Drug therapy in surgical biliary diseases. A microbiological and animal experiment study]

In this study type and occurrence of microorganisms in gallbladder and choledochal bile are compared to results of other authors. The value of antibiotic therapy in acute cystic duct obstruction in a clinical study and in animal experiments are discussed. Efficacy of different antibiotic substances (mezlocillin, cefazolin, cefotaxim, rolitetracyclin and aminoglycosides) are measured by means of the reduction in colony count in T-tube bile. Antibiotic effect was least when tetracyclines and aminoglycosides were given. Beta-lactam antibiotics caused marked reduction and even elimination of bacteria in choledochal bile. Antibiotic therapy for the treatment of bacterial infection of the bile is reasonable only after decompression of the biliary tract in the presence of obstructive jaundice. In case of cystic duct obstruction antibiotic therapy is uncertain.

[Value of sputum cytology in preoperative diagnosis of bronchial carcinoma]

Of 492 in patients with primary lung cancer, pathological proof of diagnosis after thoracotomy was obtained by sputum cytology in 53,87%. Better results were obtained in patients over the age of 70 years and even in peripheral lung tumors. The results were analyzed according to tumor size, localization and malignant cell type. The prognosis of patients with positive and negative cytological specimens are compared.

[Peritonitis after perforation of the gallbladder]

The high risk of peritonitis following a perforation of the gall bladder is discussed in a short review of the literature. In 15 years 9084 operations of the bile ducts were performed at Nord-West-Hospital, Franfurt/M., among these were 36 cases of free gall bladder perforation. Our experiences with abdominal drainage only, without perfusion of the abdomen following cholecystectomy and revision of the bile ducts with simultaneous systemic appliance of antibiotics are reported.

[Pathogen elimination after surgical interventions on common bile duct (author's transl)]

Of 130 bile samples from the choledochus, 64% were positive for bacteria. Different antibiotics were administered according to the susceptibility tests. Colony counts were monitored daily. Beta-lactam antibiotics lead to a more rapid pathogen clearance than the tetracyclines. Antibiotic therapy is discussed especially in older patients and in patients with recurrent interventions on common bile duct. Bile cultures were positive in most of these patients.

[What position does primary scar carcinoma of the lung take in surgical treatment of lung cancer? (author's transl)]

The results of surgical treatment of 295 resected peripheral carcinomas of the lung were analysed by tumor staging and histology. 89 cases of scar cancer of the lung have been compared to 206 peripheral cancers. The overall 5-year survival rate was far less in the peripheral lung cancer group (24%). Best prognosis had patients with tumors without lymph node metastasis or adenocarcinoma in the scar (39--45%). These tumors tend to be slowly progressive and metastasize late. When early characteristic signs can be seen on x-ray examination, lung scars should be followed carefully.

[Pancoast's tumor. Symptoms, diagnosis and therapy]

Pancoast-tumor is a rare form of malignant tumor in the superior pulmonary sulcus. In our clinic out of 910 operated bronchial carcinomas 18 were Pancoast-tumors. The clinical findings with tumor of the apical lobe of the lung, shoulder-arm pain, Horner syndrome, rib destruction as well as neurological findings are discussed. The proper treatment consists of radical resection of the affected lobe, cranial thoracic wall and affected nerve tissue. The prognosis depends on the extension and lymph node metastases. Only early diagnosis, radical tumor-resection and postoperative radiation can improve prognosis and survival time.

[Chemodectoma in the carotid triangle region]

The only treatment of the extensive and infiltrative carotid body tumors is radical resection. Exact preoperative diagnosis in unknown tumors of the neck avoid hazardous complications during operative resection. This report contains diagnosis and definition of these rare tumors. Various operative procedures of tumor-resection are discussed. Carotid angiographies and operative photographs from three cases demonstrate the extent and close relation of the carotid artery.

[Current resistence situation in a surgical and urological department]

Spectrum and sensitivity of bacteria were studied at the Surgical (534 positive wound smears) and the Urological Clinics (7879 urine specimens). Krankenhaus Nordwest, Frankfurt/M., during the period of 1969-1971 and in 1973. The most common organisms identified in wound smears were E. coli, followed by Staph. areus, Aerobacter and Proteus species. E. coli were also predominant in urine, but followed by Enterococci, Proteus and Pseudomonas. E. coli, Proteus species and especially Pseudomonas increased in number whereas Enterococci decreased. There was no pronounced increase in resistance to 9 current antibiotics as well as to chemotherapeutics during the observation period which was particularly striking in the case of Ampicillin used on a large scale. The results of our study support the presently employed therapeutic method using bactericidal antibiotics of the penicillin group in strict indications.

[Surgical treatment of kinking of the internal carotid artery (author's transl)]

Report on 20 cases of non arteriosclerotic kinking of the internal carotid artery. Besides the more common resection-technique a myoplasty using the digastric muscle is performed. Regional cerebral blood flow by 133 Xenon and angiography pre- and postoperatively are compared.

[Concentration of antibiotics in the human lung. Clinical studies of Reverin distribution in various pulmonary lobes]

On 12 patients with bronchial carcinoma serum and lung-tissue concentration levels of tetracyclin were measured. The concentration levels of the antibiotic were twice as high in the lung tissue as in the serum. In the lower lobe of the lung significantly higher values were measured than in the upper lobe. The demonstrated tissue levels of Pyrrolidino-methyltetracyclin (Reverin) in human lung are high enough to be effective in pulmonary bacterial infection.