Novel biomarkers to detect infection in revision hip and knee arthroplasties.

BACKGROUND: A periprosthetic joint infection is one of the most challenging complications associated with THA and TKA. In the diagnostic process for detecting a periprosthetic joint infection, one of the most important steps is analysis of laboratory infection biomarkers. QUESTIONS/PURPOSES: We investigated the sensitivity and specificity of the biomarkers procalcitonin, interleukin 6 (IL-6), and interferon α (IFN-α) as compared with conventional biomarkers (C-reactive protein [CRP], leukocyte level) for a periprosthetic joint infection associated with revision arthroplasties. METHODS: We prospectively included and analyzed 84 patients (124 revision arthroplasties). The blood parameters of interest were procalcitonin, IL-6, IFN-α, leukocyte level, and CRP. Samples were taken preoperatively and on the first, third, and seventh postoperative days. The sensitivity and specificity of these biomarkers then were calculated. RESULTS: Considering the preoperative values of 84 patients (124 operations), procalcitonin, IL-6, CRP, and leukocyte level correlated with periprosthetic joint infection, whereas IFN-α did not. A procalcitonin cut-off level of 0.35 ng/mL revealed a sensitivity of 80% and specificity of 37%. An IL-6 cut-off level of 2.55 pg/mL had a sensitivity of 92% and specificity of 59%. CONCLUSIONS: In this study procalcitonin and IL-6 were helpful for detecting periprosthetic joint infections in revision arthroplasties, although CRP generally was superior. Procalcitonin and IL-6 may be considered adjuvant tests when the diagnosis of a periprosthetic joint infection is in doubt. This study showed, in addition to conventional biomarkers such as CRP and leukocyte level, procalcitonin and IL-6 were helpful for detecting infections associated with revision arthroplasties.

Surgery for liver metastases originating from sarcoma-case series.

INTRODUCTION: Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper. PATIENTS AND METHODS: The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm). RESULTS: Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042). CONCLUSION: Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: a prospective study of observer variability.

BACKGROUND: An acromiohumeral interval narrower than 6 mm has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study assessed interobserver and intraobserver variability in the radiographic measurement of the acromiohumeral interval. MATERIAL AND METHODS: Five board-certified orthopedic surgeons independently reviewed 58 blinded, standardized anteroposterior shoulder radiographs. The acromiohumeral interval was measured in millimeters. The 5 investigators classified each image a second time in random order. RESULTS: After the same 58 radiographs had been evaluated by the 5 investigators at both examination time points, no significant differences were noted in the interobserver and intraobserver measurements (P < .05). The respective maximum interobserver and intraobserver differences were 4 and 3 mm (range, 0-4 mm). CONCLUSION: The assessment of the acromiohumeral interval using standardized anteroposterior radiographs is a reliable and reproducible method of measurement. LEVEL OF EVIDENCE: Level 1; Investigating a diagnostic test.

A new fine-needle aspiration system.

BACKGROUND: The main reasons for fine needle aspiration (FNA) failure are insufficient number of cells in the sample, nonrepresentative samples, and contamination of samples. The aim of this study was to measure the number of cells harvested by a new needle system with an aeration aperture (Thyrosampler) in comparison with a conventional FNA system (C-FNA). METHODS: Under a double-blind setting, 30 aspirations, 15 with each system (C-FNA, Thyrosampler), were done in randomized order and recorded. RESULTS: The median total number of cells was 59 680 cells/mL with C-FNA and 396 400 cells/mL with Thyrosampler. The needle system with the aeration aperture led to a significantly higher cell amount (564% more cells than the conventional system; P < .005) in needle aspiration biopsy. CONCLUSION: The new system with the vacuum release feature leads to a significantly higher cell amount in needle aspiration biopsy, which is a well-defined benefit.

Correlation between thigh pain and radiological findings with a proximally porous-coated stem.

Thigh pain has been consistently reported with cementless hip arthroplasty. The correlation between thigh pain and radiological findings and the clinical significance of thigh pain have not been studied in any detail. We carried out a retrospective study to analyse the performance of a proximally porous-coated cementless femoral component. Ninety-eight total hip arthroplasties were followed up clinically and radiologically for an average of 33 months (range: 12 to 64) after operation. The clinical results were good or excellent in 85 cases (87%). Thirteen patients (13%) reported thigh pain at latest follow-up. Subsidence of the stem was recorded in 10 cases, cortical thickening occurred in 14 hips (14%), and 17 hips (17%) presented proximal osteopenia. Proximally, radiolucent lines were observed in 11 cases. Thigh pain correlated with radiolucent lines, femoral thickening, fibrous fixation and stem migration. Bone remodelling was noted to continue even five years after implantation. Our observations demonstrated bone ingrowth in the majority of the cases and a low incidence of thigh pain. The correlation between radiological changes and thigh pain suggests implant micromotion and migration in some hips. Patients with thigh pain, changes in the proximal femur and progressive subsidence need further clinical and radiological follow-up.

Analysis of hepatic resection of metastasis originating from gastric adenocarcinoma.

Few patients with metastatic gastric cancer have disease that is amenable to curative surgery. Thus far, little is known about liver surgery for metastases arising from gastric adenocarcinoma and prognostic factors. Of 73 patients operated on between 1980 and 1999 for noncolorectal, non-neuroendocrine hepatic metastases, 15 underwent liver resection for gastric adenocarcinoma metastasis. Ten patients underwent synchronous hepatic resection and five underwent metachronous hepatic surgery after a median disease-free interval of 10 months (range 6.1 to 47.3 months). None of the patients died within the first 30 days after surgery, and the in-hospital mortality rate was 6.7%. Among patients in the synchronous group, 26.7% experienced major complications mainly associated with gastric surgery. Overall median survival was 8.8 months (range 4 to 51 months); two patients survived more than 3 years. Univariate analysis revealed that the appearance of liver metastasis (synchronous vs. metachronous), the distribution of liver metastases (unilobar vs. bilobar), and the primary tumor site (proximal vs. distal) were marginally significant predictive factors regarding overall survival. Because of its high morbidity, synchronous liver resection for metastases originating from gastric adenocarcinoma is rarely followed by survival longer than 2 years. Primary tumor localization within the proximal third of the stomach and bilobar liver involvement appear to be predictive of poor outcome. On the other hand, curative resection of metachronous liver metastases may allow long-term survival in selected patients.

Common gene variants in RAD51, XRCC2 and XPD are not associated with clinical outcome in soft-tissue sarcoma patients.

BACKGROUND: DNA repair mechanisms play a major role in cancer risk and progression. Germline variants in DNA repair genes may result in altered gene function and/or activity, thereby causing inter-individual differences in a patient's tumor recurrence capacity. In genes of the DNA repair pathway the gene variants RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C have been previously related to genetic predisposition and prognosis of various cancer entities. In this study we investigated the association between these polymorphisms and time to recurrence (TTR) and overall survival (OS) in soft-tissue sarcoma (STS) patients after curative surgery. METHODS: Two hundred sixty STS patients were included in this retrospective study. Germline DNA was genotyped by 5'-exonuclease (TaqMan) technology. Kaplan Meier curves and multivariate Cox proportional models were calculated for TTR and OS. RESULTS: A statistically significant association was observed between tumor grade and adjuvant radiotherapy and TTR and between tumor grade and OS. No association was found between RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C and TTR and OS in univariate and multivariate analysis. CONCLUSION: Our results underline a prognostic effect of tumor grade and adjuvant radiotherapy in STS patients but indicate no association between RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C and clinical outcome in STS patients after curative surgery.

Influence of prereferral surgery in soft tissue sarcoma: 10 years' experience in a single institution.

Soft tissue sarcomas are a group of rare mesenchymal neoplasms comprising 0.8% of all malignant tumors. Workup should include medical history, physical examination, magnetic resonance imaging, biopsy, and thoracoabdominal computed tomography scan, in that order. Centralized multimodality treatment in a cross-disciplinary setting is mandatory. Treatment not according to current clinical practice guidelines is a common problem before referral to a specialized institution. The purpose of this 10-year, single-institution review was to investigate the influence of curative surgery on outcome, with a special emphasis on surgery before referral. A cohort of 266 patients who underwent curative surgery for soft tissue sarcoma between 1998 and 2008 was analyzed. One hundred thirty-one (49%) patients underwent surgery contrary to current clinical guidelines before referral, most (73%) at primary care units. One hundred thirteen (86%) of these patients underwent surgery without previous biopsy with a higher rate of intralesional margins (P<.001), a smaller mean diameter of primary lesion (P<.001), a higher rate of subcutaneous situs (P<.001), a lower mean American Joint Committee on Cancer score (P=.008), a higher rate of additional plastic surgery after re-resection (eg, flap surgery) (P<.001), and a longer period before referral (P<.001). No influence on survival, local recurrence, or metastasis existed. Prereferral surgery necessitating re-resection has no influence on survival but leads to an unfavorable clinical course. More effort should be made to improve awareness and referral modalities for general practitioners and physicians at community hospitals.

The influence of personality traits on the subjective outcome of operative hallux valgus correction.

We studied prospectively the influence of personality traits on the subjective outcome of a chevron osteotomy in 42 patients with hallux valgus. The mean age of patients was 48.3 (20-70) years. Personality traits were evaluated by the means of the Freiburg Personality Inventory (FPI-R). Three months postoperatively 37 patients were satisfied, and five patients not satisfied with the operative procedure. The preoperative AOFAS Score improved from an average of 48.7 (30-65) points to 87.9 (50-100) points. A comparison of satisfied and dissatisfied patients revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angle was 12.2+/-7.8 degrees and 13.4+/-8.3 degrees (p=0.74) among satisfied and not satisfied patients, respectively, and the intermetatarsal angle (I-II) was 7.4+/-2.5 degrees and 7.6+/-4 degrees (p=0.89), respectively. The results suggest that the patient's subjective result after the operative correction may be influenced by some individual, personality profiles.

Accuracy of multiphasic helical computed tomography and intraoperative sonography in patients undergoing orthotopic liver transplantation for hepatoma: what is the truth?

OBJECTIVE: To determine the real value of liver imaging in cirrhosis by macro- and histomorphologic examination of the entire organ after orthotopic liver transplantation for hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: In comparative studies, a virtual sensitivity of up to 94% is described for helical computed tomography in HCC staging. The tumor detection rate of intraoperative ultrasonography (IOUS) is reported to be almost 100%. METHODS: This prospective observational study comprised 23 patients with HCC in cirrhosis admitted for orthotopic liver transplantation. Results of preoperative triphasic helical computed tomography (HCT) and IOUS were correlated with histopathologic results after 3-mm-slicing of the explanted liver. RESULTS: Overall, 179 liver segments were examined by HCT, IOUS, and MHM. Fifty-two malignant lesions and 10 dysplastic nodules were revealed by MHM. Using HCT, 13 HCCs could not be identified in 8 patients and 15 results were falsely positive in 10 patients. The detection rate of dysplastic nodes was 40% for HCT and 60% for IOUS. IOUS missed four HCCs in four patients and had six false-positive results in six patients. In a segment-based analysis, the overall accuracy of IOUS was significantly higher for IOUS (95.5%) versus HCT (89.9%). In the lesion-by-lesion analysis, the sensitivity was 92.3% for IOUS and 75.0% for HCT, with a significant difference. CONCLUSIONS: Correlation of explanted liver pathologic results offers precise evaluation of imaging modalities. The data of this histopathologically based study confirm that IOUS is significantly superior in staging HCC in cirrhosis versus CT, even after technical refinements through enhanced multiphasic high-velocity helical scanning.

Current value of intraoperative sonography during surgery for hepatic neoplasms.

Noninvasive liver imaging has developed rapidly resulting in increased accuracy for detecting primary and secondary hepatic tumors. Intraoperative ultrasonography (IOUS) was commonly considered to be the gold standard for liver staging, but the current value of IOUS is unknown in view of more sophisticated radiologic tools. The purpose of this prospective study was to evaluate the impact of IOUS on the treatment of 149 patients undergoing liver surgery for malignant disease (colorectal metastasis, 61 patients; hepatoma, 52 patients; other hepatic malignant tumors, 36 patients). The sensitivities of computed tomography (CT), helical CT, magnetic resonance imaging, and IOUS in patients with colorectal metastases were 69.2%, 82.5%, 84.9%, and 95.2% in a segment-by-segment analysis; in patients with hepatoma their sensitivities were 76.9%, 90.9%, 93.0%, and 99.3%; and in patients with other hepatic malignancies they were 66.7%, 89.6%, 93.3%, and 98.9%, respectively. Additional malignant lesions (AMLs) were first detected by inspection and palpation in 20 patients (13.4%). In another 18 patients (12.1%) IOUS revealed at least one AML. Overall, the findings obtained only by IOUS changed the surgical strategy in 34 cases (22.8%). It was concluded that IOUS, having undergone some refinement as well, still has immense diagnostic value in hepatectomy candidates. Frequently avoiding palliative liver resection and occasionally disproving unresectability as assessed by preoperative imaging, IOUS still has a significant impact on surgical decision making and should still be considered the gold standard.