Design und erste klinische Ergebnisse mit dem ZMR-Taper-Revisionsschaft

AIM

The purpose of this study was to survey and to evaluate the first clinical and radiological results with the cementless ZMR taper hip prosthesis.

METHOD

The modular distal-tapered stem was designed with a roughened titanium surface and sharp splines to achieve secure distal fixation and rotational stability. 90 ZMR taper hip prostheses were implanted between October 1999 and July 2002. Out of these, 4 interventions were primary and 86 were revision procedures. In 43 cases a complete hip prosthesis revision and in 43 cases a stem revision was necessary. The mean age of the 90 patients (42 males, 48 females) was 67.1 years. The mean follow-up period was 7.6 months (3 to 25 months).

RESULTS

The stem displayed an excellent distal fixation. The mean subsidence could be measured with 4.3 mm. Furthermore, most cases showed a particularly favourable remodelling of the proximal femoral bone stock. Complications associated with revision included intraoperatively 4 femur fractures, 3 femur fissures, 5 femur perforations, 2 trochanter fractures and postoperatively 19 dislocations, 5 superficial wound infections, 2 transient palsies, 1 pulmonary embolism, 1 stem rotation and 4 wound healing failures. Considering these complications 15 re-revisions were necessary and the ZMR taper hip prosthesis had to be exchanged in 3 cases.

CONCLUSION

On the one hand the ZMR taper hip prosthesis proved its value, particularly with regard to the stem modularity, the excellent distal fixation in conjunction with the possibility of partial body weight bearing and the rapid bone remodelling of the femur. On the other hand an increased number of postoperative complications and re-revisions occurred. Further long-term studies seem to be essential.

[Extracorporeal shockwave therapy (ESWT) in epicondylitis humeri radialis. A review of the literature]

This review article evaluates therapeutic procedures and clinical findings of extracorporeal shock wave therapy (ESWT) when used for lateral epicondylitis (LE) based on systematic research of the literature. A total of 20 studies were identified, 2 of which had been carried out as prospective, randomized, and controlled studies; the biometric quality of the remaining is clearly inferior. The inclusion and exclusion criteria used in the studies tallied well. In the more recent literature, important ESWT parameters such as energy used, number of impulses and treatment sessions, and locating methods also tallied in part. The studies reported only occasional side effects that could be evaluated as harmless. When evaluating the clinical success of ESWT, it was stated that about 40-80% of the patients achieved a good or very good result at follow-up examinations after 3-12 months. However, in the single placebo-controlled and blinded study with an independent observer, the same therapy results were achieved in the control group where a local anesthetic was used as in the ESWT group. For this reason, it has been concluded that up to now no clinically relevant efficacy has been proven for the use of ESWT for LE. It should no longer be applied clinically as a matter of course, but only as part of high-quality studies with an adequate control group and blinding of patients and follow-up examiners. Due to the pain incurred when applying ESWT and the risk of uncovering the masking, the blinding of the patients must be checked in each further controlled ESWT study.

[Extracorporeal shockwave therapy (ESWT) as therapeutic option in supraspinatus tendon syndrome? One year results of a placebo controlled study]

Extracorporeal shock wave therapy (ESWT) is seen as a therapeutic option in the treatment of chronic supraspinatus tendinitis by some authors. To test whether ESWT comprising 3 x 2000 pulses with the positive energy flux density ED+ of 0.33 mJ/mm2 is clinically superior to a sham ESWT treatment, a prospective, randomized, single-blinded, placebo-controlled study with an independent observer was performed. Forty patients were treated either by verum ESWT or sham ESWT under local anesthesia. Target criteria were the age-corrected Constant score, pain at rest and during activity on a visual analogue scale, and subjective improvement. Patients who reported no subjective improvement after 12 weeks were deblinded and received verum ESWT if they had belonged to the placebo group (partial crossover). The results of the verum group lie within the range of results for ESWT published by other authors. Patients in the placebo group with local anesthetic showed equally good results. At 12 weeks, and 1 year after intervention, no difference could be found between the verum and placebo groups regarding Constant score, pain, shoulder function, or subjective improvement. The nonresponders to the placebo ESWT continued to show no improvement after receiving verum ESWT. This contradicts a specific ESWT effect. Based on the results of this placebo-controlled study, ESWT appears to have no clinically relevant effect on supraspinatus tendinitis. The study underlines the importance of a control group in evaluating new treatment methods for diseases with unknown natural history.

[Continuous stroke volume monitoring as "hemodynamic online monitoring" in polytrauma intensive care patients: technically possible--clinically necessary?]

PURPOSE

Is the measurement of continuous cardiac output useful for the management of polytrauma patients?

METHODS

In a prospective non randomized study (ethic commission file 43/96) we evaluated the diagnostic and therapeutic impact of the CCO (continuous cardiac output measurement) for polytrauma patients on the ICU. The Baxter Vigilance System was used for measuring the continuous cardiac output. The CCO values were controlled once a day by the conventional "cold" thermodilution technique.

RESULTS

All values are given as mean +/- standard deviation. The Patients were scored on the first day for ISS (injury severity score) (47 +/- 17) and APACHE II (15 +/- 5). The CCO was used no later than 12 hours after the initial treatment in 20 polytrauma patients. As clinical outcome parameters were chosen: days on ventilation (23 +/- 23 days), days on the ICU (31 +/- 26 days) and mortality (20%). The treating ICU physicians were asked in a standardized questionnaire, whether or not there was an impact of the CCO measurement on their therapy. Seven different surgeons were working with the system.

CONCLUSION

The unique opinion was that the CCO device had an impact on their decision making in the fluid and drug management of the study patients. Our first experience, however, suggests that this device may become an important improvement in the management of haemodynamics in the early trauma phases. Before a wide-spread application of this method on the ICU an evidence based prospective randomized trial should be performed.