Straight stem and threaded cup in patients under 60 years of age: 28.8-30.2 years of follow-up.

PURPOSE: The aim of this retrospective observational study of one cohort was to evaluate the long-term outcome in patients younger than 60 years after total hip arthroplasty using a straight uncemented stem and an uncemented threaded cup. METHODS: Between 1986 and 1987, 75 hips of 75 patients (mean age, 53.35 ± 6.17 years) were consecutively implanted with an Alloclassic Zweymüller/Alloclassic SL stem and an Alloclassic CSF cup. Forty-four patients had died over the last 30 years. The remaining 31 patients (mean age, 82.9 ± 6.4 years) were reinvited for follow-up examinations. Clinical and radiographic evaluations were carried out. RESULTS: At a mean follow-up of 29.5 (28.8-30.2), 4 patients (5.3%) were lost to follow-up. For the endpoint aseptic loosening (defined as the removal of stem or the cup for 2 cases), the overall survival rate is 97.3%. For the endpoint revision for any reason (22 patients), the survival rate is 70.6%. Eleven patients needed an exchange of head and liner, caused by wear. The average time from implantation until change of head and liner was 21.44 years (SD 5.92). Other reasons for revision surgery were septic loosening (3 cases), aseptic loosening of stem and cup (1 case), aseptic loosening of stem (1 case), periprosthetic calcification (2 cases), implant fracture (1 case), periprosthetic fracture (1 case), intraoperative fissure of stem (1 case), and total wear of liner including cup (1 case). CONCLUSION: The combination of a straight stem (Alloclassic) and a screw cup (CSF) shows excellent results in young patients under the age of 60 at ultra-long-term follow-up at 30 years. Revisions due to wear of the polyethylene liner are more likely than in the older patients.

[The European Arthroplasty Register (EAR), development and rationale for supranational cooperation of arthroplasty registers]. / Das European Arthroplasty Register (EAR), die Entwicklung und Sinnhaftigkeit übernationaler Zusammenarbeit von Endoprothesenregistern.

In Scandinavia national arthroplasty registers are accepted instruments in the assessment of joint implants. They have contributed essentially to the rapid detection of inferior products and, by encouraging a continuous process of quality improvement through feedback, have helped to avoid revision operations. However, national registers have a limited significance with regard to other countries and rarely used implants. In recent years, a great number of registers have been founded. The European Arthroplasty Register (EAR), an EFORT project, aims at supporting these projects, enhancing cooperation within a network, realising further benefit through registers, and fostering scientific activities. The registers have been conceived according to the successful Scandinavian model. It is, however, necessary to adapt the concept to the individual national circumstances. In order to increase the value of register publications for other countries, it makes sense to achieve a minimum of stardardisation in datasets, definitions, product designations, as well as in evaluation and publication methods. Since the datasets of national registers implicitly reflect the prevailing national circumstances, they are always more valuable for use in the respective country than evaluations from aggregated, supranational and therefore larger datasets. Supranational evaluations may yield additional findings, but they cannot replace a national register. Therefore, EAR has been conceived as a network of independent national registers considering itself as a supplement and by no means as a competitor of the established national registers.

Comparison of the information in arthroplasty registers from different countries.

This article considers some of the problems of the interpretation of information from other national arthroplasty registers when setting up a new register. In order for the most useful information to be available from registers much international co-operation is required between all those responsible for the design of registers as well as those who gather, assess and publish the data.

The minimal invasive surgery anterior approach with supine patient positioning: a step-wise introduction of technique.

The purpose of the review is to report the modified Smith-Peterson technique for use with minimal invasive total hip arthroplasty (MIS THA) with supine patient positioning. The modified Smith-Peterson technique allows for direct visualisation of the acetabulum and is an internerval approach. The MIS anterior approach with supine patient positioning offers a complete intermuscular and internervous access to the hip joint. The use of this technique yields a reduction of muscular trauma, intraoperative bloodloss, and postoperative rehabilitation. The reduction of soft tissue trauma may lead to minimal postoperative pain. While cosmesis is never a reason for using MIS, it does yield great patient satisfaction. The MIS anterior approach with supine patient positioning is a safe and reproducible method, offering an alternative option in MIS THA.

[Influence of local anesthesia and energy level on the clinical outcome of extracorporeal shock wave-treatment of chronic plantar fasciitis]. / Einfluss von Lokalanästhesie und Energieflussdichte bei niederenergetischer Extrakorporaler Stosswellentherapie der chronischen Plantaren Fasziitis -- Eine prospektiv-randomisierte klinische Studie.

BACKGROUND: The efficacy of low energy extracorporeal shock wave treatment (ESWT) for chronic plantar fasciitis is discussed controversially. It is unclear whether the simultaneous application of local anesthesia (LA) interferes with clinical outcome. METHODS: 60 patients with a chronic plantar fasciitis were enrolled in a triple-arm (20 patients per group), prospective randomized and observer-blinded pilot trial. The patients were randomly assigned to receive either active ESWT without LA (;3 x 1 500 shocks, total energy flux density [EFD] per shock 0.09 mJ/mm(2) [Group A]), ESWT with LA (3 x 1 500 shocks, EFD 0.18 mJ/mm(2) per shock [Group B]) or ESWT with LA (3 x 1 500 shocks, EFD 0.09 mJ/mm(2) [Group C]). Main outcome measures were: pain during first stepps in the morning (measured on a 0-10 point visual analogue scale) and number of patients with > 50 % reduction of pain and no further therapy needed, measured at 6 weeks after the last ESWT. RESULTS: Group A improved in the VAS from 6.4 (SD: 1.7) to 2.2 (SD: 2.6) points, group B from 6.7 (SD: 1.5) to 4.1 (SD: 2.4) points, group C from 6.2 (SD: 1.6) to 3.8 (SD: 2.5) points. A reduction of pain of at least 50 % was achieved in 60 % of group A, in 36 % of group B and in 30 % of group C. Group A without LA showed a significantly higher improvement in the VAS and subjective evaluation than groups B (p = 0.007) and C (p = 0.016). CONCLUSION: At 6 weeks success rates after low-energy ESWT with local anesthesia were significantly lower than after identical low-energy ESWT without local anesthesia. Higher energy levels could not balance the disadvantage of this effect. LA significantly influenced the clinical results after low energy ESWT in a negative way. Blinding patients by LA in ESWT studies must therefore be considered a systematic error in study design.

[Radiological appearance of the cementless ALLOCLASSIC SL-stem implanted in very old patients with primary hip osteoarthritis]. / Radiologisches Erscheinungsbild des zementfreien ALLOCLASSIC SL-Schaftes bei sehr alten Patienten mit primärer Coxarthrose.

AIM: The radiological appearance of the cementless ALLOCLASSIC SL-stem, implanted in patients with primary osteoarthritis of the hip and aged at least 80 years at time of surgery, was investigated. METHOD: 66 hips in 58 patients were analysed. 17 patients (19 hips) died in the interim, 5 patients (5 hips) were not available for follow-up because of health reasons (4) or lack of co-operation (1). 1 stem had to be explanted after a periprosthetic fracture of the femur. Finally, 41 total hip arthroplasties in 35 patients could be analysed after an average of 67.9 months (39.2-93.4). RESULTS: Bone atrophy - especially in the proximal Gruen zones - was frequently found. In contrast, radiolucent lines and osteolyses were rare occurrences. The Harris Hip score was preoperatively on average 33.0 points, at time of follow-up 81.7 points. The survival rate (endpoint aseptic loosening) was 100 % after a mean follow-up of 5.7 years. CONCLUSION: Also in very old patients the implantation of a cementless stem is possible and provides very good results.

Cementless total hip arthroplasty in patients older than 80 years of age.

We reviewed 80 patients (87 hips) who were older than 80 years of age at the time of cementless total hip arthroplasty. An Alloclassic SL stem had been implanted in all patients. A variety of cementless acetabular components was used. After a mean follow-up of 69.3 months (39.2 to 94.1) 48 hips in 43 patients were analysed clinically and radiologically. One patient had sustained a traumatic periprosthetic fracture of the femur with subsequent exchange of the stem 73 months after operation. Thirty-two patients (34 hips) had died and five patients (five hips) were unavailable for follow-up because of health reasons (four patients) or lack of co-operation (one patient). If the endpoint is defined as removal of the prosthesis because of aseptic loosening, the survival rate was 100% for the cup and stem after 78 months. The mean Harris hip score was 81.9 points. Radiolucent lines and osteolysis were seldom found.

[Minimally invasive medial unicompartmental knee replacement]. / Der minimal-invasive mediale Halbschlitten. Möglichkeiten und Grenzen.

Medial unicompartmental knee replacements have been used for more than 40 years. Due to increased experience in determining the indication for use and improvements in design of the prosthesis and tribology, the long-term results have now reached a high level. The advantages of these systems are less bone loss and better proprioception. The disadvantage is the risk of panarthrosis, which might be reduced by accurate indications for operations. Good indications are patients older than 60 years with normal weight and normal sports activity. Well-functioning collateral and cruciate ligaments are mandatory. Due to the fact that during implantation eversion of the patella is not necessary, a minimally invasive approach might be used. Overcorrection of the mechanical axis of the leg should be avoided. By observing these principles, very good long-term results can be achieved with medial unicompartmental arthroplasty. Better proprioception and better mobility of the knee are advantages of these implants compared to total knee arthroplasty. In the case of revision with a bicondylar implant, the situation is less complex compared to revisions after osteotomies or bicondylar replacements. Remobilization in this situation is shorter with better results compared to a revision with a bicondylar prosthesis.

[Blood transfusion in total hip endoprosthesis operations in relation to Redon drainage and pressure bandages. An innovation in surgical method]. / Blutverbrauch bei Hüfttotalendoprothesenoperationen in Abhängigkeit von Redondrainage und Druckverband. Eine Innovation im operativen Vorgehen.

PROBLEM: There is a difference in the use of redon drainage following hip arthroplasty worldwide. The aim of the study was to find the best version. METHOD: In a prospective randomized study including 158 patients with coxarthrosis we implanted cementless Alloclassic hip-endoprostheses and registered consumption of blood, blood loss, hemoglobin level, subcutaneuos hematoma, swelling of the proximal thigh, bleeding and exsudation of the wound in four groups supplied with three, two (subcutaneously and subfascial) and one (subcutaneously or subfascial) drainage with compression bandage and one group with two redons (subcutaneously and subfascial) without compression bandage. For prophylaxis of deep vein thrombosis we used low dose heparin. RESULT: We could demonstrate, that the application of two redons one subcutaneously and one subfascial gave the best result. Compared to the conventional procedure with three redons we achieved a reduction of 47% of blood units, a significant reduction of exsudation and bleeding out of the wound, subcutaneous hematomas and a reduced swelling of the proximal leg in addition to better clinical conditions of the patients. The reason is a more accelerated stop of the bleeding out of the spongy bone. The application of one drain subcutaneously or subfascial showed no further reduction of blood loss, but an increase of wound exsudation and bleeding out the wound and an increase of subcutaneous hematomas. Sufficient external compression of the area of operation by a compression bandage is very important. Disadvantages as a result of changing the way of drainage have not been detected. CONCLUSION: The use of two Redons one subcutaneously and one subfascial showed an obvious benefit without any clinical disadvantage compared to 3 redons or no drainage.

Metal/metal articulating interfaces.

Polyethylene wear can be shown as a problem in long-term joint replacement. Metal-on-metal bearing is solving this problem, as long-term clinical and experimental investigations demonstrate. To avoid the problem of high friction found in old series, a new Metasul called technique with a smaller diameter was invented. Intermediate results of Weber and our own data show promising outlook for a solution to the wear-induced problem in hip replacement.

[Therapy and prevention in children with inflammatory rheumatic diseases]. / Therapie und Prävention bei Kindern mit entzündlich rheumatischen Krankheiten.

Since 1981, annual four-week holidays have been arranged for children with juvenile rheumatic arthritis, during which the children are cared for by a team of pediatricians, orthopedists, ergotherapists, physiotherapists and assistants trained in psychology. With systematic splint therapy, physiotherapy, and by enhancing drug awareness during these therapeutic holidays significant improvements in joint mobility and subjective wellbeing were achieved. Of the 103 children treated (209 places were available), the majority spent several holidays, with a resulting improvement in joint mobility lasting several years. Through systematic training, adaptation to splints, and physiotherapy acceptance was also enhanced, with a preventive effect for the rest of the year. The success of these measures has encouraged the authors to continue the project.

[Indications for immunoscintigraphy in orthopedics and its interpretation]. / Indikationen zur Immunszintigraphie in der Orthopädie und deren Deutung.

In the view of an orthopedist the immunscintigraphy is a diagnostic and differential diagnostic enrichment. The MAK BW 250/183 is stored in a lyophiled shape. The MAK is marked with 99m Tc with little expense and in a short time. The advantage of the immunscintigraphy is the high sensitivity for places where granulocytes are gathered. The immunscintigraphy proved to be a very good proceed in recording acute inflammations.

[Kinetics and immunocytochemical staining of 99mTc-labeled monoclonal anti-CEA antibodies against granulocytes following intravenous administration]. / Kinetik und immunzytochemische Färbung monoklonaler 99mTc-markierter Anti-CEA-Antikörper gegen Granulozyten nach intravenöser Applikation.

Until now the clinical identification of the affinity of monoclonal 99mTc-anti-CEA antibodies (MAK BW 250/183) on granulocytes was made with tumor cells carrying the same epitope on NCA-95 and human granulocytes in vitro. As this antibody only binds human granulocytes, animal experiments are impossible. 3 patients had their blood withdrawn within 6 h after injection, another patient had his left hip-joint biopsied after 24 h, the samples undergoing subsequent immunocytochemical dyeing. Dyeing of granulocytes all over the smears was evident whereas lymphocytes, monocytes and erythrocytes did not show any reaction. After 6 h there seemed to be a large difference between a relatively high quantity of 86% unlabelled 99mTc-MAb and 75% of immunocytochemically stainable granulocytes in the blood through an excess of binding epitopes. Six h after injection 27% of the activity were, on average, detectable in whole blood. At this time the activity in blood was reduced to an extent that scintigraphic imaging was feasible.

Guidelines for Chiari's osteotomy in the immature skeleton developed from a canine model.

Three variations of Chiari's pelvic osteotomy were performed on 18 dysplastic hip joints in young, growing German shepherd dogs and rottweilers. The results of the operations and the reactions of the skeletal tissue were investigated radiologically and histologically after six and 12 months. By use of polyfluorochrome sequential labeling and microangiography, it was demonstrated that neither the formation of new bone nor the blood supply in the vicinity of the rim of the acetabulum (apophysis of the acetabular roof) was seriously impaired by the operation. Conversely, the operative technique was of decisive importance to the result of the operation. Only if the osteotomy was performed through the original acetabular rim, completely covering the femoral head, was the newly formed acetabular roof adequately biomechanically loaded, providing the conditions required for functionally adapted differentiation of skeletal tissue. Chiari's pelvic osteotomy can be performed on canine hips with good chances of success, provided one uses the proper operative technique. Apophyseal bone growth and the blood supply of the newly formed acetabular roof were apparently not disturbed by Chiari's operation.

[Human calcitonin in the treatment of symptomatic Paget's disease]. / Humanes Kalzitonin in der Behandlung des symptomatischen Morbus Paget.

We evaluated the effect of a 6 months trial with synthetic human calcitonin in 10 symptomatic patients with polyosseous Paget's disease of bone. All patients reported a distinct clinical improvement which correlated with a significant decrease of alkaline phosphatase in the plasma and hydroxyproline and calcium excretion in the urine. Though no changes in skeletal x-rays were observed, the bone lesions showed a significant decrease of activity in tho bone scintigrams. Histologically there was a marked decrease of bone turn-over calcitonin therapy. No patient revealed the formation of autoantibodies against exogenous calcitonin after treatment.

Evidence for negative correlation between quantitative histological studies and microradiography of iliac crest bone and forearm osteodensitometry in elderly women with osteoporosis.

Quantitative histomorphometric and microradiographic analysis of iliac crest bone biopsy specimens of 10 unselected and untreated postmenopausal women with osteoporosis was performed and the results were correlated with the values measured by osteodensitometry on the right forearm. No positive correlation between histomorphometry or microradiography and osteodensitometry was observed. Moreover, the data of various histomorphometric parameters and those of the bone mineral content measured by microradiography revealed a significant negative correlation when compared to the values obtained by osteodensitometry. Our results suggest, that evaluation of one skeletal site is not necessarily representative of the entire skeleton in patients with postmenopausal osteoporosis.