[Accuracy of an image-free cup navigation system--an anatomical study]. / Genauigkeit eines bildfreien Navigationssystemes für die Hüftpfannenimplantation--eine anatomische Studie.

The position of the acetabular cup is of decisive importance for the function of a total hip replacement (THR). Using the conventional surgical technique, correct placement of the cup often fails due to a lack of information about pelvic tilt. With CT-based and fluoroscopically-assisted navigation procedures the accuracy of implantation has been significantly improved. However, additional radiation exposure, high cost and the increased time requirement have hampered the acceptance of these techniques. The present anatomical study evaluates the accuracy of an alternative procedure--image-free navigation. This method requires little extra effort, does not substantially delay surgery, and needs no additional imaging. Press-fit cups were implanted in 10 human cadaveric hips with the help of the image-free navigation system, and the position of the cups was checked intraoperatively with a CT-based navigation system and postoperatively by computed tomography. All cups were implanted within the targeted safe zone with an average inclination of 44 degrees (range 40 degrees-48 degrees, SABW 2.7 degrees) and an average anteversion of 18 degrees (range 12-24 degrees, SABW 4.1 degrees). Analysis of accuracy of the image-free navigation software revealed only a small, clinically tolerable deviation in cup anteversion and cup inclination in comparison with the CT-based navigation system and the post operative CT scans. The evaluated image-free navigation system appears to be a practicable and reliable alternative to the computer-assisted implantation of acetabular cups in total hip arthroplasty.

Tunnel enlargement and changes in synovial fluid cytokine profile following anterior cruciate ligament reconstruction with patellar tendon and hamstring tendon autografts.

There is growing evidence that cytokines such as tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta, IL-6, bone morphogenetic proteins (BMP), and nitric oxide (NO) play an important role in the pathogenesis of bone tunnel enlargement following anterior cruciate ligament (ACL) reconstruction. Furthermore, the release of these mediators has been considered a possible reason for the higher incidence of bone tunnel enlargement following hamstring tendon (HST) than following patellar tendon (PT) ACL reconstruction observed in several studies. In this investigation synovial fluid samples from 13 patients were collected immediately before (24+/-7 days after ACL rupture) and 7 days after ACL surgery and values of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2 were analyzed. Furthermore, the incidence of bone tunnel enlargement was assessed using radiographs 38+/-7 weeks after surgery. Six patients underwent autologous HST ACL reconstruction, and in seven patients an PT autograft was used. In the overall patient population there were significantly higher synovial fluid concentrations of IL-6 and BMP-2 postoperatively than preoperatively; TNF-alpha showed a trend towards lower postoperative levels while IL-1beta and NO remained unchanged. The concentrations of NO, TNF-alpha, and IL-6 found in the present study were clearly higher than normal values given in the literature. Assessment of bone tunnel enlargement revealed an average increase in tibial tunnel width of 28.4+/-3.1% with comparable values for HST and PT ACL reconstructions. There was no significant correlation between bone tunnel enlargement and postoperative synovial fluid concentrations of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2. However, all patients with bone tunnel enlargement had higher postoperative concentrations of TNF-alpha, IL-6, and NO in the synovial fluid. There were no significant differences in concentrations between HST and PT groups. In conclusion, we observed an association between tibial bone tunnel enlargement and elevated synovial fluid concentrations of IL-6, TNF-alpha, and NO 7 days after ACL surgery indicating the potential involvement of these biological mediators in the pathogenesis of bone tunnel enlargement. However, there was no difference between HST and PT ACL reconstructions regarding synovial fluid contents of IL-6, TNF-alpha, IL-1beta, NO, and BMP-2, suggesting a comparable biological response between these autografts following their use in ACL reconstruction.

Irregular rotation and shift of computer-assisted femoral stem implantation in THA--an experimental study.

INTRODUCTION: The two available computer-assisted surgery robotic systems consist of a preoperative planning computer workstation and an industrial robot with a high speed milling device. During the computed tomography (CT) scan of the hip and the ipsilateral knee for planning the hip arthroplasty, the patient's movements are registered by a bar that is fixed at the patient's leg along its axis. Despite the companies' claim that a high accuracy of implant position can be achieved by this method, misplacements of implants are reported in the literature. MATERIALS AND METHODS: In an experimental study, a cadaver femoral bone was rotated during the CT scan strictly around this bar to simulate a rotational movement of the patient. Using the CT data, the planning of the hip stem and the following preparation of the femur by the robot was possible without detection of the patient's movements by the system. According to the system manual, the computer should stop the planning or give a warning in case of patient movement during the CT scan. RESULTS: The postoperative CT scan of the cadaver femoral bone revealed a rotary deviation and a shift of the stem compared with the original planning, caused by the rotation during the CT scan. CONCLUSION: We propose using a second bar during the CT scan to detect these movements and thus avoiding misplacement of the implant.

Diffusion-weighted imaging of tumor recurrencies and posttherapeutical soft-tissue changes in humans.

The aim of this study was to examine soft tissue tumor recurrences and posttherapeutic soft tissue changes in humans with a diffusion-weighted steady-state free precession (SSFP) sequence. Twenty-four patients with 29 pathologies of the pelvis or the extremities were examined. The lesions were classified as follows: group 1, recurrent viable tumors (n = 10); group 2, postoperative hygromas (n = 7); and group 3, posttherapeutic reactive inflammatory muscle changes (n = 12). The sequence protocol in these patients consisted of short tau inversion recovery images, T2-weighted spin-echo (SE), pre- and postcontrast T1-weighted SE images and the diffusion-weighted SSFP sequence. The signal loss on diffusion-weighting was evaluated visually on a four-grade scale and quantitatively. The signal intensities were measured in regions of interest and a regression analysis was performed. Statistical analyses was performed utilizing the Student's t-test. The signal loss was significantly higher for hygromas and edematous muscle changes than for recurrent tumors (p < 0.001) indicating higher diffusion of water protons. The regression coefficient was -0.11 (mean) for tumors. Hygromas had a significantly higher signal loss than inflammatory edematous muscle changes (p < 0.01). The regression coefficients were -0.29 (mean) for hygromas and -0.22 (mean) for edematous muscle changes. The SSFP sequence seems to be a suitable method for diffusion-weighted imaging of the musculoskeletal system in humans. These preliminary results suggest that the signal loss and the regression coefficients can be used to characterize different types of tissue.

The value of desoxypyridinoline in the diagnostics of loosened arthroplasty.

According to several reports in the last few years, desoxypyridinoline (Dpd) in urine increases significantly in cases of loosened arthroplasty. Therefore, this marker was suggested as useful in the diagnostics of implant loosening. In this study, the level of Dpd was determined in 69 patients with arthroplasty of the hip or the knee joint. Thirty-four of these patients received revision surgery following implant loosening. In 35 of these 69 patients, there were no clinical or radiological signs of loosening (control group). The mean age of the patients with loosened implants (22 women, 13 men) was 67.9 years and of the control group (22 women, 12 men) 66.9 years. In the group with arthroplastic loosening, as well as in the control group, 14 patients had increased levels of Dpd. There were 20 patients in the group with loosened arthroplasty and 19 patients in the control group that had normal levels of Dpd. The female patients had a mean Dpd level of 8.6 nmol/mmol creatinine (4.3-24 nmol/mmol creatinine) in the urine in cases of loosening and 10.1 nmol/mmol creatinine (2-33 nmol/mmol creatinine) in the control group. The male patients had a mean Dpd level of 7.8 nmol/mmol creatinine (3.2-19.2 nmol/mmol creatinine) in the urine in cases of loosening and 5.8 nmol/mmol creatinine (0.3-11.7 nmol/mmol creatinine) in the control group. In conclusion there was no significant increase in Dpd in patients with implant loosening compared with the control group. Furthermore, older patients often suffer from diseases causing increased bone resorption that may falsify the test results. We cannot confirm that Dpd is helpful in the diagnostics and screening of implant loosening.

Diagnostic value of increased diffusion weighting of a steady-state free precession sequence for differentiating acute benign osteoporotic fractures from pathologic vertebral compression fractures.

BACKGROUND AND PURPOSE: Differentiating acute benign from neoplastic vertebral compression fractures can pose a problem in differential diagnosis on routine MR sequences, as signal changes can be quite similar. Our purpose was to assess the value of increasing the diffusion weighting of a diffusion-weighted steady-state free precession (SSFP) sequence for differentiating these two types of vertebral compression fractures. METHODS: Twenty-nine patients with 32 acute vertebral compression fractures caused by osteoporosis (n = 15) or malignancy (n = 17) were examined with a diffusion-weighted SSFP sequence, a T1-weighted spin-echo sequence, and a short-inversion-time inversion recovery sequence. The SSFP sequence was performed with increased diffusion weighting (delta = 0.6, 3.0, 6.0, and 9.0 ms). The signal intensities of the fractured vertebral bodies were rated on a five-point scale from markedly hypointense to markedly hyperintense relative to normal adjacent vertebral bodies. Quantitative analysis was performed by region-of-interest measurements and by calculating the bone marrow contrast ratio. Statistical analysis was performed with the Mann Whitney U test and Student's t test. RESULTS: At delta = 3 ms, the osteoporotic fractures yielded hypointense signal in seven cases, isointense signal in six, and hyperintense signal in two. The fractures showed a progressive signal loss with increased diffusion weighting, so that hypointensity was reached in all but one case. All metastatic fractures had hyperintense signal with delta = 3 and 6.0 ms. With delta = 9.0 ms, four fractures became isointense. CONCLUSION: Increasing diffusion weighting can reduce false-positive hyperintense osteoporotic fractures or make hypointensity more obvious in cases of osteoporotic fractures.

Tripled semitendinosus anterior cruciate ligament reconstruction with Endobutton fixation: a 2-3-year follow-up study of 35 patients.

We evaluated the clinical outcome of tripled semitendinosus tendon ACL reconstruction with femoral Endobutton (Acufex, Smith&Nephew, Andover, MA) and tibial Suture Washer (Acufex, Smith&Nephew, Andover, MA) (n 29) or post screw fixation (n 6) in 35 patients on an average of 28 (20-37) months after surgery. On the basis of IKDC criteria, 22 patients showed a normal or nearly normal knee function and 25 patients had a KT 1000 maximal manual side-to-side difference of < or =5 mm at follow-up. Subjectively, 28 patients graded their knee function as normal or nearly normal. The average Lysholm score was 88 points, average OAK score 90 points and average modified HSS score 93 points. 19 patients reached their preinjury level of activity at follow-up. The postoperative Lachman test was < or =1+ in 24 patients and 24 patients also showed an absent pivot shift. Significant bone tunnel enlargement occurred in 26 patients on the femoral side and in 23 patients on the tibial side. We found no correlation between bone tunnel enlargement and clinical outcome. The clinical outcome of tripled semitendinosus tendon ACL reconstruction with Endobutton fixation on the femoral side was not entirely satisfactory. The procedure was associated with a high incidence of bone tunnel enlargement in this series.

Operative or conservative treatment of the acutely torn anterior cruciate ligament in middle-aged patients. A follow-up study of 133 patients between the ages of 40 and 59 years.

In all, 133 patients with an acute rupture of the anterior cruciate ligament (ACL) were reviewed (aged 40 to 59 years). Average follow-up was 29 +/- 10 months. Thirty-one patients underwent conservative therapy, 35 patients were treated by primary suture, while in 67 the primary suture was augmented with the semitendinosus tendon. The patients with primary repair and semitendinosus tendon augmentation showed significantly better results according to OAK and Lysholm scores, the Lachman test, pivot-shift testing, and KT-1000 arthrometer measurements than those treated conservatively or with primary suture. The physical activity level was significantly higher in the patients with augmented ACL repair than in the conservatively treated patients. There was no significant difference between the patients with augmented ACL repair and conservative treatment in the assessment of range of motion, while the patients with primary suture had a significantly greater loss of flexion than those in the other two treatment groups. Increasing age was not found to have a negative effect on either operative or conservative treatment. The results indicate that patients between the ages of 40 and 59 years can be treated successfully by ACL surgery.