Influence of avascular necrosis of the femoral head on hip prosthesis integration: a radiological analysis.

BACKGROUND: Avascular osteonecrosis of the femoral head (AVN) often results in total hip arthroplasty (THA). The cause for increased THA revision rates among patients with AVN is not yet fully understood. PURPOSE: To perform a comparative radiological analysis of implant integration between patients with AVN and osteoarthritis (OA). MATERIAL AND METHODS: After a matched pair analysis of 58 patients, 30 received THA due to OA, 28 due to AVN. X-ray images were evaluated after one week ("baseline") and on average 37.58 months postoperatively ("endline"). The prosthesis was grouped into 10 regions of interest (ROI): seven femoral and three acetabular. Incidence, width, and extent of "radiolucent lines" were measured within each zone. RESULTS: Between baseline and endline, width and extent progressed more noticeably in all femoral and acetabular zones among patients with AVN. In femoral ROI 1, the width increased in 40% of AVN cases compared to 6.7% of OA cases. For acetabular ROI 3, the width increased in 26.7% of AVN cases compared to no perceived changes in the OA group. No signs of prosthetic loosening were found in the AVN group. CONCLUSION: The increase of width and extent of radiolucent lines over time in patients with AVN could be a sign of lack of osteointegration. However, prosthetic loosening in absence of clinical symptoms cannot be deduced from radiological findings after medium-term postoperative follow-up. Further long-term studies are required to monitor how radiolucent lines develop in respect to long-term implant loosening. Dependent on bone quality, individually adapted reaming and broaching of the implant site are recommended.

Nonlinear Terahertz Polarizability of Electrons Solvated in a Polar Liquid.

The nonlinear polaronic response of electrons solvated in liquid 2-propanol is studied by two-dimensional terahertz spectroscopy. Solvated electrons with a concentration of c_{e}≈800 µM are generated by femtosecond photoionization of alcohol molecules. Electron relaxation to a localized ground state impulsively excites coherent polaron oscillations with a frequency of 3.9 THz. Off-resonant perturbation of the terahertz coherence by a pulse centered at 1.5 THz modifies the polaron oscillation phase. This nonlinear change of electron polarizability is reproduced by theoretical calculations.

Intraoperative control by Schanz-screws is inaccurate to achieve the exact amount of correction in de-rotational osteotomies.

PURPOSE: The accuracy of intraoperative control of correction commonly is achieved by K-wires or Schanz-screws in combination with goniometer in de-rotational osteotomies. The purpose of this study is to investigate the accuracy of intraoperative torsional control in de-rotational femoral and tibial osteotomies. It is hypothesized, that intraoperative control by Schanz-screws and goniometer in de-rotational osteotomies around the knee is a safe and well predictable method to control the surgical torsional correction intraoperatively. METHODS: 55 consecutive osteotomies around the knee joint were registered, 28 femoral and 27 tibial. The indication for osteotomy was femoral or tibial torsional deformity with the clinical occurrence of patellofemoral maltracking or PFI. Pre- and postoperative torsions were measured according to the method of Waidelich on computed tomography (CT) scan. The scheduled value of torsional correction was defined by the surgeon preoperatively. Intraoperative control of torsional correction was achieved by 5 mm-Schanz-screws and goniometer. The measured values of torsional CT scan were compared to the preoperative defined and intended values and deviation was calculated separately for femoral and tibial osteotomies. RESULTS: The surgeon's intraoperative measured mean value of correction in all osteotomies was 15.2° (SD 4.6; range 10-27), whereas the postoperatively measured mean value on CT scan was 15.6 (6.8; 5.0-28.5). Intraoperatively the femoral mean value measured 17.9° (4.9; 10-27) and 12.4° (1.9; 10-15) for the tibia. Postoperatively the mean value for femoral correction was 19.8 (5.5; 9.0-28.5) and 11.3 (5.0; 5.0-26.0) for tibial correction. When considering a deviation of plus or minus 3° to be acceptable femorally 15 osteotomies (53.6%) and tibially 14 osteotomies (51.9%) fell within these limits. Nine femoral cases (32.1.%) were overcorrected, four cases undercorrected (14.3%). Four tibial cases of overcorrection (14.8%) and 9 tibial cases of undercorrection (33.3%) were observed. However, the observed difference between femur and tibia regarding the distribution of cases between the three groups did not reach significance. Moreover, there was no correlation between the extent of correction and the deviation from the intended result. CONCLUSION: The use of Schanz-screws and goniometer in de-rotational osteotomies as an intraoperative control of correction is an inaccurate method. Every surgeon performing derotational osteotomies must consider this and include postoperative torsional measurement in his postoperative algorithm until new tools or devices are available to guarantee a better intraoperative accuracy of torsional correction. STUDY DESIGN: Observational study. LEVEL OF EVIDENCE: III.

Avascular necrosis of the femoral head: three-dimensional measurement of drilling precision reveals high accuracy and no difference between fluoroscopically controlled core decompression and cancellous bone grafting.

INTRODUCTION: Avascular osteonecrosis of the femoral head (AVN) is a widespread disease affecting mostly young and active people, often exacerbating in progressive stages, ending in joint replacement. The most common joint preserving operative therapy for early stages is core decompression (CD), optional with cancellous bone grafting (CBG). For success it is vital that the necrotic area is hit and the sclerotic rim is broken by drilling into the defect zone to relieve intraosseous pressure. The aim of this study was to investigate if both techniques are precise enough to hit the center of the necrosis and if there is a difference in precision between drilling with small pins (CD) and the trephine (CBG). PATIENTS AND METHODS: 10 patients underwent CD, 12 patients CBG with conventional C-arm imaging. Postoperatively 3D MRI reconstructions of the necrotic area and the drilling channels were compared. The deviation of the drilling channel from the center of the necrotic area was measured. PROMs (HHS, HOOS, EQ-5D, SF-36) were evaluated to compare the clinical success of these procedures. RESULTS: Neither with CD nor with CBG the defect zone was missed. The drilling precision of both procedures did not differ significantly: distance to center 3.58 mm for CD (range 0.0-14.06, SD 4.2) versus 3.91 mm for CBG (range 0.0-15.27, SD 4.7). PROMs showed no significant difference. CONCLUSION: Concerning the most important difference between the two procedures-the surgical higher demanding technique of CBG-we suggest applying the less invasive technique of CD alone.

Phonon-Induced Relocation of Valence Charge in Boron Nitride Observed by Ultrafast X-Ray Diffraction.

The impact of coherent phonon excitations on the valence charge distribution in cubic boron nitride is mapped by femtosecond x-ray powder diffraction. Zone-edge transverse acoustic (TA) two-phonon excitations generated by an impulsive Raman process induce a steplike increase of diffracted x-ray intensity. Charge density maps derived from transient diffraction patterns reveal a spatial transfer of valence charge from the interstitial region onto boron and nitrogen atoms. This transfer is modulated with a frequency of 250 GHz due to a coherent superposition of TA phonons related to the ^{10}B and ^{11}B isotopes. Nuclear and electronic degrees of freedom couple through many-body Coulomb interactions.

Compact high-flux hard X-ray source driven by femtosecond mid-infrared pulses at a 1 kHz repetition rate.

A novel, to the best of our knowledge, table-top hard X-ray source driven by femtosecond mid-infrared pulses provides 8 keV pulses at a 1 kHz repetition rate with an unprecedented flux of up to 1.5×1012 X-ray photons/s. Sub-100 fs pulses at a center wavelength of 5 µm and multi-millijoule energy are generated in a four-stage optical parametric chirped-pulse amplifier and focused onto a thin Cu tape target. Electrons are extracted from the target and accelerated in a vacuum up to 100 keV kinetic energy during the optical cycle; the electrons generate a highly stable K α photon flux from the target in a transmission geometry.

Terahertz Polaron Oscillations of Electrons Solvated in Liquid Water.

The terahertz (THz) response of solvated electrons in liquid water is studied in nonlinear ultrafast pump-probe experiments. Free electrons with concentrations from c_{e}=4 to 140×10^{-6} moles/liter are generated by high-field THz or near-infrared multiphoton excitation. The time-resolved change of the dielectric function as mapped by broadband THz pulses exhibits pronounced oscillations persisting up to 30 ps. Their frequency increases with electron concentration from 0.2 to 1.5 THz. The oscillatory response is assigned to impulsively excited coherent polarons involving coupled electron and water shell motions with a frequency set by the local electric field.

Two-dimensional terahertz spectroscopy of condensed-phase molecular systems.

Nonlinear terahertz (THz) spectroscopy relies on the interaction of matter with few-cycle THz pulses of electric field amplitudes up to megavolts/centimeter (MV/cm). In condensed-phase molecular systems, both resonant interactions with elementary excitations at low frequencies such as intra- and intermolecular vibrations and nonresonant field-driven processes are relevant. Two-dimensional THz (2D-THz) spectroscopy is a key method for following nonequilibrium processes and dynamics of excitations to decipher the underlying interactions and molecular couplings. This article addresses the state of the art in 2D-THz spectroscopy by discussing the main concepts and illustrating them with recent results. The latter include the response of vibrational excitations in molecular crystals up to the nonperturbative regime of light-matter interaction and field-driven ionization processes and electron transport in liquid water.

Two-color two-dimensional terahertz spectroscopy: A new approach for exploring even-order nonlinearities in the nonperturbative regime.

Nonlinear two-dimensional terahertz (2D-THz) spectroscopy at frequencies of the emitted THz signal different from the driving frequencies allows for exploring the regime of (off-)resonant even-order nonlinearities in condensed matter. To demonstrate the potential of this method, we study two phenomena in the nonlinear THz response of bulk GaAs: (i) The nonlinear THz response to a pair of femtosecond near-infrared pulses unravels novel fourth- and sixth-order contributions involving interband shift currents, Raman-like excitations of transverse-optical phonon and intervalence-band coherences. (ii) Transient interband tunneling of electrons driven by ultrashort mid-infrared pulses can be effectively controlled by a low-frequency THz field with amplitudes below 50 kV/cm. The THz field controls the electron-hole separation modifying decoherence and the irreversibility of carrier generation.

Spatial distribution of electric-field enhancement across the gap of terahertz bow-tie antennas.

The electric-field enhancement in terahertz (THz) antennas designed for nonlinear THz spectroscopy of soft matter is characterized by spatially resolved electrooptic sampling. To mimic the relevant interaction geometry, metallic, resonant bow-tie antennas are deposited on a thin zinc telluride crystal of 10 µm thickness. The THz electric field transmitted through the antenna gap is recorded by electrooptic sampling. By focusing the 800 nm, sub-20 fs sampling pulses, we achieve a spatial resolution of some 3 µm, which is 1/3 to 1/8 of the antenna-gap width. The THz field in the gap displays an enhancement by a factor of up to 4.5 with a pronounced spectral variation, depending sensitively on the antenna-arm length and the gap width. By scanning the 800 nm probe spot laterally through the antenna gap, the spatial variation of the enhancement is determined, reaching the highest values at the edges of the gap. The results are in agreement with simulations of the electric-field distributions by finite-element calculations.

Frequency Upshift of the Transverse Optical Phonon Resonance in GaAs by Femtosecond Electron-Hole Excitation.

The impact of transient electric currents on the transverse optical (TO) phonon resonance is studied after excitation by two femtosecond near-infrared pulses via the fourth-order nonlinear terahertz emission. Nonlinear signals due to interband shift currents and heavy-hole-light-hole polarizations are separated from Raman-induced TO phonon coherences. The latter display a frequency upshift by some 100 GHz upon interband excitation of an electron-hole plasma. The frequency shift is caused by transverse electronic shift currents, which modify the dielectric function. A local-field model based on microscopic current densities reproduces the observed frequency upshift.

Terahertz Driven Amplification of Coherent Optical Phonons in GaAs Coupled to a Metasurface.

We demonstrate amplification of longitudinal optical (LO) phonons by polar-optical interaction with an electron plasma in a GaAs structure coupled to a metallic metasurface using two-color two-dimensional spectroscopy. In a novel scheme, the metamaterial resonator enhances broadband terahertz fields, which generate coherent LO phonons and drive free electrons in the conduction band of GaAs. The time evolution of the LO phonon amplitude is monitored with midinfrared pulses via the LO-phonon-induced Kerr nonlinearity of the sample, showing an amplification of the LO phonon amplitude by up to a factor of 10, in agreement with a theoretical estimate.

Recent advances in ultrafast X-ray sources.

Over more than a century, X-rays have transformed our understanding of the fundamental structure of matter and have been an indispensable tool for chemistry, physics, biology, materials science and related fields. Recent advances in ultrafast X-ray sources operating in the femtosecond to attosecond regimes have opened an important new frontier in X-ray science. These advances now enable: (i) sensitive probing of structural dynamics in matter on the fundamental timescales of atomic motion, (ii) element-specific probing of electronic structure and charge dynamics on fundamental timescales of electronic motion, and (iii) powerful new approaches for unravelling the coupling between electronic and atomic structural dynamics that underpin the properties and function of matter. Most notable is the recent realization of X-ray free-electron lasers (XFELs) with numerous new XFEL facilities in operation or under development worldwide. Advances in XFELs are complemented by advances in synchrotron-based and table-top laser-plasma X-ray sources now operating in the femtosecond regime, and laser-based high-order harmonic XUV sources operating in the attosecond regime. This article is part of the theme issue 'Measurement of ultrafast electronic and structural dynamics with X-rays'.

Resonant Second-Order Nonlinear Terahertz Response of Gallium Arsenide.

The second-order nonlinear response of bulk GaAs in the terahertz (THz) range is mapped via the THz field emitted after near-infrared interband excitation. Phase-resolved THz detection reveals three nonlinear processes occurring in parallel, the Raman excitation of transverse optical phonons, the creation of coherent polarizations on heavy-hole-light-hole transitions, and the generation of displacive shift currents with a THz spectrum controlled by the near-infrared optical phase. Theoretical calculations reproduce the data and demonstrate the interband character of shift currents.

Predictors of Outcome After Primary Total Joint Replacement.

BACKGROUND: Total hip and knee replacements are frequently performed curative treatment options in end-stage arthritis. In this study, we analyzed clinical outcome, complications, and predictors of outcome in modern joint replacement. METHODS: In a retrospective analysis of over 2000 primary total hip and knee replacements from our institutional joint registry, responder rates for positive outcome as defined by the OMERACT-OARSI criteria, postoperative complication rates, and patient-reported outcome measures (EQ-5D, WOMAC) within the first year were compared between hip and knee replacements. Furthermore, preoperative risk factors associated with nonresponder rate were evaluated. RESULTS: Positive responder rate was higher for hip replacements with 92.8% (1145/1234) than for knee replacements with 86.1% (839/975, P < .001). Infection rates were lower (P = .04), whereas intraoperative fracture occurred more frequently (P = .001) in hip than in knee replacements. Patient-reported outcome measures 1 year after surgery were higher in hip than in knee replacements with EQ-5D (0.88 ± 0.17 to 0.81 ± 0.19, P < .001) and WOMAC (84.58 ± 16.73 to 74.31 ± 18.94, P < .001). Besides the type of joint replacement (hazard ratio [HR] 2.0, P < .001), high preoperative outcome measures (HR 7.4, P < .001) and male gender (HR 1.4, P = .05) were independent risk factors of nonresponders after joint replacement. CONCLUSION: Both total hip and knee replacements are safe procedures with low complication rates. Still, postoperative outcome is higher in hip than in knee arthroplasty. High preoperative clinical scores are a risk factor for poor clinical improvement following total joint replacement and can be used in counseling patients in the office.

Mid-infrared beam splitter for ultrashort pulses.

A design is presented for a beam splitter suitable for ultrashort pulses in the mid-infrared and terahertz spectral range consisting of a structured metal layer on a diamond substrate. Both the theory and experiment show that this beam splitter does not distort the temporal pulse shape.

Strong Local-Field Enhancement of the Nonlinear Soft-Mode Response in a Molecular Crystal.

The nonlinear response of soft-mode excitations in polycrystalline acetylsalicylic acid (aspirin) is studied with two-dimensional terahertz spectroscopy. We demonstrate that the correlation of CH_{3} rotational modes with collective oscillations of π electrons drives the system into the nonperturbative regime of light-matter interaction, even for a moderate strength of the THz driving field on the order of 50 kV/cm. Nonlinear absorption around 1.1 THz leads to a blueshifted coherent emission at 1.7 THz, revealing the dynamic breakup of the strong electron-phonon correlations. The observed behavior is reproduced by theoretical calculations including dynamic local-field correlations.

Navigation is Equal to Estimation by Eye and Palpation in Preventing Psoas Impingement in THA.

BACKGROUND: Iliopsoas tendon impingement is one possible reason for persistent groin pain and diminished functional outcome after THA. So far, estimation by eye and palpation is the standard procedure to intraoperatively assess the distance of the cup to the anterior rim. However, novel technologies such as imageless navigation enable intraoperative measurements of the cup in relation to the psoas tendon and bony landmarks. QUESTIONS/PURPOSES: We asked whether psoas impingement (1) can be reduced using imageless navigation compared with the standard technique and (2) is associated with specific patient characteristics. Furthermore, we investigated (3) if anterior cup protrusion (overhang) is associated with lower outcome scores for pain and function. METHODS: The current study is a reanalysis of data from a randomized controlled trial evaluating navigation for THA; 135 patients were randomized for surgery with or without the use of imageless navigation. The risk for anterior protrusion of the cup above the acetabular rim and thus potential psoas impingement, defined as an overhang of the cup above the anterior acetabular rim as measured on postoperative CT, was either controlled with the help of navigation or standard control by eye and palpation intraoperatively. Postoperatively, the anterior protrusion of the cup above the acetabular rim was measured on three-dimensional (3-D) CT by a blinded, external institute. In addition to patient-related outcome measures, the Harris hip score, Hip disability and Osteoarthritis Outcome Score, and EuroQol were obtained 1 year postoperatively. Altogether 123 data sets were available for primary analysis and 115 were available for 1-year followup. RESULTS: There was no difference, with the numbers available, between the navigated and the control groups in terms of the mean distance of the cup below the anterosuperior acetabular rim (3.9 mm; -5.3 to 12.6 mm versus 4.4 mm; -7.9 to 13.7 mm; p = 0.72) or the anteroinferior acetabular rim (4.7 mm; -6.2 to 14.8 mm versus 4.2 mm; -7.1 to 16.3 mm; p = 0.29). There was no difference, with the numbers available, in terms of the proportion of cups with anterior overhang (7%, four of 57 versus, 15%, 10 of 66; p = 0.16), respectively. After controlling for potential confounding variables such as cup inclination, cup size, patient age, BMI, stage of arthritis, and length of skin incision, we found cup anteversion (hazard ratio [HR], 0.87; 95% CI, 0.81-0.93; p < 0.001) and female sex (HR, 3.88; 95% CI, 1.01-14.93; p = 0.049) were associated with a propensity to potential psoas impingement. With the numbers available, there were no differences observed in clinical scores between groups with and without anterior cup protrusion. CONCLUSIONS: We found no differences between imageless navigation and estimation by eye and palpation in preventing potential psoas impingement. Despite the comparable clinical outcome for patients with and without cup protrusion, the orthopaedic surgeon should be especially aware of propensity for psoas impingement in women. LEVEL OF EVIDENCE: Level II, therapeutic study.

Soft tissue restricts impingement-free mobility in total hip arthroplasty.

PURPOSE: Impingement is a major source for decreased range of motion (ROM) and dislocation in total hip arthroplasty (THA). In the current study we analyzed the impact of soft tissue impingement on ROM compared to bony and/or prosthetic impingement. METHODS: In the course of a prospective clinical trial 54 patients underwent cementless total hip arthroplasty in the lateral decubitus position using imageless navigation. The navigation device enabled intra-operative ROM measurements indicating soft tissue impingement. Post-operatively, all patients received postoperative 3D-CT. Absolute ROM without bony and/or prosthetic impingement was calculated with the help of a collision-detection-algorithm. RESULTS: Due to soft tissue impingement we found a reduced ROM of over 20° (p < 0.001) compared to bony and/or prosthetic impingement regarding flexion, extension, abduction and adduction and of over 10° regarding external rotation (p < 0.001). In contrast, soft tissue impingement showed less impact on internal rotation in 90° of flexion (p = 0.76). Multivariate analysis showed an association between BMI and flexion, whereas all other ROM directions were independent of BMI. CONCLUSIONS: Soft tissue has a major impact on impingement-free ROM after THA. For the majority of movements, soft tissue restrictions are more important than bony and prosthetic impingement. Future models of patient individual joint replacement including pre-operative (CT) planning and intra-operative navigation should include algorithms additionally accounting for soft tissue impingement.

Accuracy of measuring acetabular cup position after total hip arthroplasty: comparison between a radiographic planning software and three-dimensional computed tomography.

PURPOSE: Various methods are available for measuring acetabular cup position after total hip arthroplasty (THA) on standard anterior-posterior (AP) radiographs. We compared the accuracy of a commercial radiographic planning software program with that of three-dimensional computed tomography (3D-CT) scans. METHODS: We obtained plain AP radiographs and 3D-CTs from 65 patients after THA. In addition to calculating cup anteversion and inclination with 3D-CT, we determined the cup position using the radiographic planning software program mediCAD® 2.5 (Hectec, Niederviehbach, Germany). Furthermore, we compared the measurements using the inter-teardrop and bi-ischial lines as pelvic landmarks. RESULTS: The mean difference in anteversion between 3D-CT and mediCAD® software was 0.1° using the inter-teardrop line (standard deviation [SD], 8.8°; range, -21° to 23°; p = 0.97) and 0.4° using the bi-ischial line (SD, 8.8°; range, -23° to 21°; p = 0.72). Inclination showed a mean difference of 0.6° using the inter-teardrop line (SD, 4.4°; range, -9° to 21°; p = 0.24) and 0.5° using bi-ischial line (SD, 4.6°; range, -9° to 22°; p = 0.35). The means for absolute differences were 7.2° for anteversion and 3.1° for inclination. With regard to using the bi-ischial or inter-teardrop line, no significant difference was found between the two pelvic landmarks. The intra-class correlation coefficient (ICC) was analysed for anteversion and inclination using either the inter-teardrop line or the bi-ischial line as radiographic baseline. CONCLUSIONS: A radiographic planning software program (mediCAD®) is a helpful tool for measuring cup inclination on AP radiographs. With respect to anteversion, measurements are rather susceptible to mistakes with mean inaccuracies of over 7°. Thus, 3D-CT remains the "gold standard" if a lower tolerance limit (±3°) is required for more complex biomechanical evaluations. As a pelvic landmark, the interteardrop line is preferential to the bi-ischial line because of its lower impact on the position of the pelvis.