Efficacy of local infiltration analgesia on recovery after total hip arthroplasty using direct anterior approach under spinal anaesthesia: a randomized, double-blind, placebo-controlled trial.

The utilization of local infiltration analgesia (LIA) is a common practice in total hip arthroplasty (THA) procedures to mitigate postoperative pain and diminish the necessity for opioids. However, contemporary literature reports conflicting results. Our working hypothesis was that LIA renders better postoperative VAS-scores and reduces the need for oral analgetics. We performed a randomized, double-blind, placebo-controlled trial aimed at examining the effectiveness of LIA in THA. A total of 90 patients were included for statistical analysis. Our primary endpoint was the Visual Analogue Scale, VAS, (0: no pain, 10: unbearable pain) preoperatively, at the 1st, 2nd, 3rd, 4th and 12th hour postoperative intervals and at discharge. Our secondary endpoints included the postoperative opioid consumption, as well as patient satisfaction at 2 and 6 weeks postoperatively, measured using the Numeric Rating Scale, NRS. LIA has a tendency for superior results regarding VAS- Scores at 3 and 4 hours postoperatively. There were no notable statistical distinctions observed in terms of patients necessitating rescue opioid consumption. Patient satisfaction using the NRS at both the 2-week and 6-week postoperatively did not differ significantly between both groups. The administration of LIA could offer advantages during the initial stages of postoperative recovery, which could be particularly valuable in rapid recovery programs.

Functional orientation of the acetabular component in ceramic-on-ceramic total hip arthroplasty and its relevance to squeaking.

AIMS: Long-term clinical outcomes for ceramic-on-ceramic (CoC) bearings are encouraging. However, there is a risk of squeaking. Guidelines for the orientation of the acetabular component are defined from static imaging, but the position of the pelvis and thus the acetabular component during activities associated with edge-loading are likely to be very different from those measured when the patient is supine. We assessed the functional orientation of the acetabular component. PATIENTS AND METHODS: A total of 18 patients with reproducible squeaking in their CoC hips during deep flexion were investigated with a control group of 36 non-squeaking CoC hips. The two groups were matched for the type of implant, the orientation of the acetabular component when supine, the size of the femoral head, ligament laxity, maximum hip flexion and body mass index. RESULTS: The mean functional anteversion of the acetabular component at the point when patients initiated rising from a seated position was significantly less in the squeaking group than in the control group, 8.1° (-10.5° to 36.0°) and 21.1° (-1.9° to 38.4°) respectively (p = 0.002). CONCLUSION: The functional orientation of the acetabular component during activities associated with posterior edge-loading are different from those measured when supine due to patient-specific pelvic kinematics. Individuals with a large anterior pelvic tilt during deep flexion might be more susceptible to posterior edge-loading and squeaking as a consequence of a significant decrease in the functional anteversion of the acetabular component. Cite this article: Bone Joint J 2016;98-B:910-16.

Mean tensile strength of the PCL in TKA depends on the preservation of the tibial insertion site.

PURPOSE: The tibial insertion of the posterior cruciate ligament (PCL) frequently becomes damaged when performing a tibial cut in a PCL-retaining total knee replacement (TKA). The aim of this study was to quantify the functional effect of this structural damage on the tensile strength and failure load. METHODS: Six paired knees from fresh-frozen cadaver specimens were used. All soft tissues but the PCL were removed. In the left-sided specimens, a classic tibial cut at a depth of 9 mm with 3° of posterior slope was made, while in the right-sided specimens, a bone block was left in front of the tibial PCL insertion. After cementing a tibial tray, the specimens were mounted in a loading frame in 60° of flexion. The femur was translated anteriorly at a constant velocity rate of 0.5 mm/s. Tensions in the PCL were measured continuously until failure occurred. RESULTS: In one specimen, the tibial PCL insertion was completely removed by the tibial cut. In the other five paired specimens, the mean tensile strength of the PCL was 380.6 ± 154.7 N in the left-sided knees. In the right-sided knees, the mean tensile strength was 738.4 ± 166.7. The average right-to-left ratio was 2.2 ± 0.7 (p = 0.006). CONCLUSION: The results of this study indicate that the conventional technique for tibial preparation in cruciate-retaining total knee arthroplasty can result in a significant decrease in tensile strength of the PCL, rendering it susceptible to failure and subsequent midflexion instability. Therefore, we recommend leaving the posterior tibial cortex anterior to the PCL insertion intact when performing a cruciate-retaining TKA.

Is the length of the femoral component important in primary total hip replacement?

Many different lengths of stem are available for use in primary total hip replacement, and the morphology of the proximal femur varies greatly. The more recently developed shortened stems provide a distribution of stress which closely mimics that of the native femur. Shortening the femoral component potentially comes at the cost of decreased initial stability. Clinical studies on the performance of shortened cemented and cementless stems are promising, although long-term follow-up studies are lacking. We provide an overview of the current literature on the anatomical features of the proximal femur and the biomechanical aspects and clinical outcomes associated with the length of the femoral component in primary hip replacement, and suggest a classification system for the length of femoral stems.

Hematometra after radiotherapy for cervical carcinoma.

The development of a hematometra after radiotherapy for cervical carcinoma is often related to recurrent disease. We present two cases in which a hematometra developed during the use of estrogen replacement therapy. This development was related to regained endometrial activity in combination with fibrosis and obliteration of the upper vagina and/or cervix. In one patient a dilatation and curettage could be performed; in the other a hysterectomy was necessary in order to exclude recurrent disease. These two cases show once more that endometrium can regain its proliferative activity after radiotherapy for cervical cancer. Estrogen replacement therapy in these patients should include the use of a progestagen agent in order to avoid continuous unopposed endometrial stimulation. In the absence of progesterone withdrawal bleeding the uterine cavity should be routinely examined for the development of a hematometra.

[Immunoblastic lymphadenopathy--malignant neoplasia or hyperimmune reaction? (author's transl)]. / Immunoblastische Lymphadenopathie--maligne Neoplasie oder hyperimmunisatorische Reaktion

Six patients have been observed which exhibited the features of the so called immunoblastic lymphadenopathy. The histological and clinical findings allow to distinguish the disease from both the malignant lymphomas and other forms of benign pseudolymphomas. The most important clinical features are severe general symptoms, generalised lymphadenopathy, hepatosplenomegaly, skin rash and a variety of abnormal reactions in the B-cell system such as hypergammaglobulinaemia, a transient positive Coombs test and the appearance of plasma cells in the peripheral blood. Evidence for a neoplastic nature of the disease is lacking. Nevertheless, the course of the disease may be progressive and fatal, but spontaneous remissions and subsequent relapses have also been essential part of the therapeutic strategy. Immunosupressants such as corticosteroids may have a positive effect in cases with immunological complications.

[Studies on the influence of pentosanepolysulfate and a combination of pentosanepolysulfate, metamizol and paracetamol on inflammatory liability (author's transl)]. / Untersuchungen zur Beeinflussung der Entzündungsbereitschaft durch Pentosanpolysulfat und einer Kombination aus Pentosanpolysulfat, Metamizol und Paracetamol

The influence of pentosanepolysulfate (SP 54) and a combination of pentosanepolysulfate, metamizol and paracetamol (Probaphen) on the course of an experimentally induced erythema caused by intracutaneous injection of a lipopolysaccharide from Pseudomonas has been studied in man. The intramuscular injection of Probaphen as well as SP 54, separately given, showed a significant antiinflammatory effect. A similar effect was also achieved after administration of Probaphen suppositories. Probaphen shortened the inflammatory reaction more effectively than did SP 54 alone. The oral application of Probaphen, however, did not influence the course of inflammation.

[Studies on the influence of an artifically induced inflammatory reaction by creatinine, urea and guanidine injection (author's transl)]. / Untersuchungen zur Beeinflussung der Entzündungsbereitschaft durch harnpflichtige Substanzen

The influence of creatinine, urea and guanidine injection on the course of an artifically induced inflammatory reaction has been studied in rats. The formalin and bolus alba edema served as inflammatory models. It was shown that the inflammatory reaction was not significantly altered by urea. By creatinine, however, the inflammation was diminished. If urea and creatinine were given together the course of the inflammatory reaction was not altered significantly, suggesting an inhibitory interrelation between these two substances. Guanidines showed the strongest inhibiting effect on inflammation. It is discussed that guanidines influence energy availability by inhibition of oxydative phosphorylation.