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.

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.

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.

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.

[Healing of the sacral wound cavity after abdomino-perineal extirpation of the rectum. A prospective randomized study using metronidazole]. / Die Heilung der sacralen Wundhöhle nach abdomino-perinealer Rectumexstirpation. Eine prospektiv randomisierte Studie mit Metronidazol.

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.

[Mediastinal metastases of extrathoracic tumors--important findings in mediastinoscopy]. / Mediastinale Metastasen extrathorakaler Tumoren--wichtige Befunde bei der Mediastinoskopie.

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.

[Synovial hemangioma of the knee joint--a rare cause of recurrent hemarthrosis]. / Das Synovialhämangiom des Kniegelenks--seltene Ursache eines rezidivierenden Hämarthros.

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.

[Accidental finding: the small, differentiated thyroid carcinoma. Report of 46 thyroid carcinomas of up to 15 mm diameter]. / Zufallsbefund: Das kleine, differenzierte Schilddrüsencarcinom. Bericht über 46 Schilddrüsencarcinome bis 15 mm Durchmesser.

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.

[The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis]. / Der Mannheimer Peritonitis-Index. Ein Instrument zur intraoperativen Prognose der 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.

[Interwoven wire suture with fascia lata-plasty in the treatment of subcutaneous rupture of the Achilles tendon--an obsolete method?]. / Die Drahtdurchflechtungsnaht mit Fascia-lata-Plastik zur Behandlung der subkutanen Achillessehnenruptur--eine veraltete Methode?

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.

[Wound infections in abdominal surgery: aetiology, risk factors, antibiotic prophylaxis]. / Wundinfektionen in der Viszeralchirurgie - Atiologie, Risikofaktoren, Antibiotikaprophylaxe.

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.

[Postoperative mechanical ileus]. / Postoperativer mechanischer 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.

[Calculi of the bile ducts--a problem for the elderly? Observations from the surgical viewpoint]. / Steinerkrankungen der Gallenwege--ein Problem des alten Menschen? Eine Betrachtung aus chirurgischer Sicht.

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.

[Drug therapy in surgical biliary diseases. A microbiological and animal experiment study]. / Chemotherapie bei chirurgischen Gallenwegserkrankungen. Eine mikrobiologische und tierexperimentelle Studie.

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.

[The asymptomatic gallstone]. / Der symptomlose Gallenstein.

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.

[Symptomless gallstone disease--when to treat surgically?]. / Symptomloses Gallensteinleiden--Wann chirurgisch behandeln?

The cholecystolithiasis is the symptom of a disease. Recent radiological procedures, above all sonography, can be helpful not only in more frequent detection of gallstones, but they can also provide information, even without clinical symptoms, on pathological changes to gallbladder and biliary tracts. However, early diagnosis of carcinoma of the gallbladder still is rare. Mortality of gallbladder carcinoma has remained unchanged in the Federal Republic of Germany over the past ten years, whereas mortality following cholecystolithiasis has been lowered due to progress in medicine. The surgical risk rises along with age and is low up before 60 years. Indication for cholecystectomy continues to be a highly individual decision which should be considered with particular caution in cases of "asymptomatic" gallstones.

[Antibiotic concentrations of the gallbladder following cystic duct stenosis. Clinical studies and animal experiments]. / Antibioticakonzentrationen der Gallenblase nach Cysticusverschluss. Klinische und tierexperimentelle Untersuchung.

Serum and bile kinetics are measured after experimental cystic duct ligation in 24 rabbits and after acute stone obstruction in 24 clinical cases. Tissue, bile, and serum levels are compared. The results clearly demonstrate that pharmacologic data alone do not give sufficient indications for antibiotic therapy in biliary tract infection. Expected pathologic bacteria and their actual resistance are considered to be of great importance in the indication of antibiotic therapy.

[Value of sputum cytology in preoperative diagnosis of bronchial carcinoma]. / Wert der Sputumzytologie in der präoperativen Diagnostik des Bronchialkarzinoms.

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.

[Current resistence situation in a surgical and urological department]. / Zur aktuellen Resistenzsituation an einer Chirurgischen und einer Urologischen Klinik

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.