Accuracy of navigation-assisted acetabular component positioning studied by computed tomography measurements: methods and results.

The postoperative position of the acetabular component is key for the outcome of total hip arthroplasty. Various aids have been developed to support the surgeon during implant placement. In a prospective study involving 4 centers, the computer-recorded cup alignment of 37 hip systems at the end of navigation-assisted surgery was compared with the cup angles measured on postoperative computerized tomograms. This comparison showed an average difference of 3.5 degrees (SD, 4.4 degrees ) for inclination and 6.5 degrees (SD, 7.3 degrees ) for anteversion angles. The differences in inclination correlated with the thickness of the soft tissue overlying the anterior superior iliac spine (r = 0.44; P = .007), whereas the differences in anteversion showed a correlation with the thickness of the soft tissue overlying the pubic tubercles (r = 0.52; P = .001). In centers experienced in the use of navigational tools, deviations were smaller than in units with little experience in their use.

Clinical outcome of salmon calcitonin nasal spray treatment in postmenopausal women after total hip arthroplasty.

OBJECTIVE: The increasing rate of hip fractures is giving rise to a number of socio-economic problems for the aging community. In addition to being unable to resume their previous living habits, many patients fail to achieve full functional recovery after the fractures. Total hip arthroplasty (THA) is a successful operation for the majority of patients with all forms of hip fractures, being performed increasingly often throughout the world. Revision rates for THA range up to 20% per year. Aseptic loosening is the reason for 75% of the revisions. An additional problem post-THA is the rate of heterotopic soft tissue calcification after THA, resulting in severely impaired function, pain, and a reduced range of hip movement. SUBJECTS: In an open study, 37 women who had undergone cementless THA after accidental hip fractures were treated twice daily with 200 IU of salmon calcitonin nasal spray for 12 months. Simultaneously the patients received one bag of 1,000 mg calcium plus 880 IU vitamin D daily throughout the treatment period of 1 year. A parallel group of 38 women with a similar clinical status in terms of hip fractures and cementless THA were treated with only one bag of 1,000 mg calcium plus 880 IU vitamin D daily through the treatment period. RESULTS: The results of this 12-month clinical trial show that 200 IU of salmon calcitonin nasal spray per day significantly improves the clinical outcome of postmenopausal elderly women following THA. Treatment with a salmon calcitonin nasal spray significantly reduces bone turnover, loss of bone density, and pain. The functional status of the patients was improved and the risk of falling reduced by rehabilitation during the observation period of 12 months. Additionally, calcitonin promoted the repair of hip fractures and was associated with a significantly lesser rate of refractures as well as periprosthetic ossifications. CONCLUSION: The increasing revision rate for THA during the first year and the patient's problem of resuming their previous living habits are the main foci of our study. Calcitonin nasal spray seems to cause few side effects. The additive treatment appears to improve the clinical outcome of THA in elderly postmenopausal women.

Akinetic mutism caused by bilateral infiltration of the fornix in a patient with astrocytoma.

In a 59-year-old female patient, a World Health Organization (WHO) grade II astrocytoma had been diagnosed 16 years ago, which finally progressed into WHO grade III. Several right frontal neurosurgical resections, local radiation and a local radioimplant had been applied. Despite this long record, she was reported alert with a Karnofsky index of 90% until admission. Within a few weeks she rapidly developed akinetic mutism. Upon admission, computed tomography (CT) scan showed a large cystic right frontal defect and a suggested small tumor recurrence. White matter of the frontal lobe appeared to be translucent and compatible with previous radiation. The severe mental changes were initially attributed to a delayed radiation encephalopathy. Neuropathologically, the white matter of the frontal lobe showed mild elevated cell density consistent with gliosis; however, a tumor recurrence invading the tip of the corpus callosum and invading the entire length both fornices appeared. From the neuropathological findings of massive local tumor recurrence in both fornices, together with the acute clinical onset, it seems unlikely that the sequel of radiotherapy caused akinetic mutism, but the symmetric and severe involvement of the limbic system. We conclude that the rapid progression from a state of alertness to a full clinical picture of akinetic mutism was because of infiltration of both fornices.

[Determination of therapy management in rectal carcinoma by staging with 18-FDG-PET]. / Bestimmung des Therapiemanagements beim Rectumcarcinom durch Staging mittels 18-FDG-PET.

The curative treatment of carcinoma of the rectum in the early stage of the disease is radical local surgery. If there is a solitary liver metastasis, resection is also a curative treatment. This report describes a female patient with rectal carcinoma, in whom a solitary liver metastasis in the left lobe was diagnosed only by FDG-PET and verified at surgery. This case report demonstrates the potential role of FDG-PET even for primary staging in detecting occult hepatic and extrahepatic metastases, thus significantly influencing the therapeutic management and prognosis of these patients.

Serum crosslaps in comparison to serum osteocalcin and urinary bone resorption markers.

In this study we evaluated the routine practice and clinical application of serum crosslaps to urinary-crosslaps, -N-telopeptide-related fraction of type 1 collagen, -deoxpyridinoline, -totalpyridinoline and serum osteocalcin. The utility of both the serum and urine immunoassays for bone formation and resorption marker were tested in a cohort of 593 female and male patients from our outpatient clinic for osteology and rheumatology and compared to important osteoporosis risk factors like age, gender, E2 deficiency, bone density and chronic renal failure. The biochemical maker of bone formation, serum osteocalcin exhibit significant correlations to all five tested serum and urinary markers of bone resorption (p < 0.0001) crosswise to all different groups of patients. The group of chronic renal failure patients showed no significant correlation between the tested bone turnover parameters and the serum creatinine level except a significant increase and correlation for serum crosslaps and for the ratio of serum and urinary crosslaps. Associations between the age of the patients and the markers of bone turnover were rather poor. We found a significant, negative association between serum and urinary bone turnover markers and bone density and were interested, whether in patients with bone density < 2.5 SD an enhanced bone turnover could be detected in the same way as for E2 deficiency. Applying a discriminant analysis it was possible to discriminate between the patient with BD < 2.5 SD and those with BD > 1.0 SD with a sensitivity of 70% and a specificity of 65% using serum crosslaps. In case of urinary crosslaps the discriminatory power was slightly lower (sensitivity: 65.6%, specificity: 67.5%) and for serum osteocalcin the discriminatory power was negligible higher (sensitivity: 79%, specificity: 56%). The highly significant correlation between the urinary and serum crosslinked peptides by ELISA and serum osteocalcin supports the concept that these respective indices of bone formation and resorption both in urine and serum reflect a coupled process in vivo with sensitivity and specificity to pathological bone density, estrogen deficiency and chronic renal failure.

Serum osteocalcin and urinary crosslaps are suitable markers of bone turnover in response to short-term hormone replacement therapy.

In this study we evaluated the effect of short-term hormone replacement therapy (HRT) on bone formation (serum osteocalcin) and resorption markers (urinary type I collagen peptides (crosslaps), urinary total free pyridinoline (TPYRI) and urinary free deoxypyridinoline (DPYRI)) as well as female sex hormones (serum estradiol, follicle stimulating hormone (FSH) and luteinizing hormone (LH)) in a group of early postmenopausal women with severe estrogen deficiency. The 46 healthy postmenopausal women with serum estradiol levels < 10 ng/l were subsequently divided into two groups, according to their compliance with HRT. In the group taking HRT significant changes from baseline values could be observed in estradiol, FSH, urinary crosslaps and serum osteocalcin levels after 6 months, whereas no changes could be observed in LH, TPYRI and DPYRI from baseline values. In the group which refused HRT all values were increased relative to baseline values, indicating increased bone turnover. Serum osteocalcin and urinary crosslaps were significantly decreased in women taking HRT in comparison to the group refusing HRT. After 6 months the treated patients showed a decrease in urinary crosslaps of 42% (SD 12%) and in serum osteocalcin of 24% (SD 6%) in comparison with baseline values. In patients who refused HRT, urinary crosslaps were increased by 43% (SD 20%) and serum osteocalcin levels decreased by 2% (SD 9%) compared to baseline values. In postmenopausal women suffering from severe estrogen deficiency (estradiol < 10 ng/l) serum osteocalcin and urinary crosslaps are significantly increased, indicating a clear correlation between estrogen deficiency and an increase in bone resorption as well as bone formation. The recommended HRT dose was sufficient to reduce the rate of bone turnover to premenopausal values. Serum osteocalcin and urinary crosslaps are suitable candidates not only for the assessment of a high postmenopausal bone turnover, but also for monitoring the response to and for verifying the actual intake of HRT or other antiresorptive treatment.

Cranioventral Subluxation of the Odontoid Process With Accompanying Neo(pseudo)arthrosis in Rheumatoid Arthritis.

Cervical spine involvement is a common feature in the course of long existing rheumatoid arthritis (RA).We describe a rare type of vertical subluxation with pronounced cranioventral disposition of the odontoid process and neo(pseudo)arthrosis between the skull and the tip of the odontoid processus. This 74-year-old women with RA for 40 years had progressive neck symptoms over the previous 5 years. She no longer had signs of active synovitis. Plain roentgenographs performed in a neutral position and full flexion and extension gave information about neither the osseous integrity nor the subluxation of the dens axis. Computed tomography and MR imaging techniques established the nature of the atlantoaxial and atlantooccipital joint involvement. During 2 years, this rare cranio-ventral subluxation with neo(pseudo)arthrosis seems to be rather solid, and follow up CT-images demonstrate no signs of progressive migration or suggestion of immediate fracture risk. Pronounced reduction of cervical spine mobility by long standing destructive cases of RA should always raise suspicions for cervical subluxation at the atlantoaxial level, irrespective of serological and clinical signs of rheumatoid arthritis. Vertical subluxation as seen in this patient may be missed on routine x-rays.

Iliac artery aneurysm causing isolated superior gluteal nerve lesion.

Lesions of the superior gluteal nerve (SGN) lead to weakness of hip abduction, manifesting itself as a gait abnormality, with contralateral tilting of the pelvis with each step. Causes are numerous and may occur at different anatomical locations before the nerve enters the suprapiriform foramen, in the foramen itself, or after the nerve has exited the foramen. This case report describes an SGN lesion by a large iliac artery aneurysm in a patient presenting with a gait disorder.

Increase of axial and appendicular trabecular and cortical bone density in established osteoporosis with intermittent nasal salmon calcitonin therapy.

The aim of this study was to examine the effect of intranasal administration of salmon calcitonin to a group of 24 postmenopausal women with severe, established osteoporosis (t score < -2.5 SD) and more than one vertebral fracture. The patients were treated with 200 IU of nasal salmon calcitonin daily for 2 months with a subsequent pause of 2 months (3 cycles) and 500 mg calcium daily over a total of 12 months in an open randomized study. The patients were compared with an age matched control group of 18 women of a similar clinical status who were treated with calcium and vitamin D only. In the nasal calcitonin treatment group an increase in the trabecular axial bone density of 2.8% was achieved, as well as increase in trabecular appendicular (forearm) bone density of 1.6%, together with a cortical bone density increase of 1.8% axial and 1% appendicular. Initially, elevated values of urinary deoxypyridinoline were found in 12 women in the nasal calcitonin treatment group; these levels returned to normal under salmon calcitonin nasal therapy and documented the inhibition of increased osteoclastic activity. Cyclic intermittent calcitonin nasal therapy led to a general increase in trabecular and cortical axial and appendicular bone density, marked alleviation of the subjective sensation of pain, and a reduction in the daily dose of accompanying nonsteroidal anti-inflammatory drugs by 50%.

Chest X-ray in collagen vascular diseases. A comparison of chest X-ray with bronchoalveolar lavage and transbronchial forceps biopsy.

The diagnostic value of chest X-ray following the ILO standards was compared with bronchoalveolar lavage (BAL) and the histology of transbronchial forceps biopsy in 83 patients with collagen vascular diseases. BAL in the middle lobe was considered abnormal in case of increased cell count per milliliter and/or lymphocytosis and/or neutrophil granulocytosis and this was found in 32 out of 42 cases (76.2%) with, and in 33 of out 41 cases (80.5%) without abnormal radiological finding. Pathological changes in the histology were found in 14 out of 20 cases (70.0%) with and in 40 out of 63 cases (63.5%) without abnormal chest X-ray in the upper lobe from which the transbronchial forceps biopsy specimens were obtained. In histological specimens obtained from transbronchial forceps biopsy, only fibrosis correlated with abnormal radiological findings in this region. Other inflammatory processes defied prediction by chest X-ray. This suggests that, regardless of chest X-ray findings, BAL should be performed together with transbronchial forceps biopsy for the histological examination of patients with collagen vascular diseases in which interstitial lung involvement is suspected.

[Effect of kidney occlusion on survival in renal cell carcinoma: a 10-year retrospective study]. / Einfluss der Nierenokklusion auf die Uberlebenszeit beim Nierenzellkarzinom: Eine retrospektive 10-Jahres-Studie.

84 out of 116 patients suffering from renal cancer with comparable tumor stages were nephrectomized. 39 out of these 84 patients have had an additional embolization preoperatively. The survival rate and the development of metastases did not show any significant difference between only nephrectomized and occluded plus nephrectomized patients.

[Complications of preoperative arterial vascular embolization in malignant kidney tumors]. / Komplikationen der präoperativen arteriellen Gefässembolisation bei malignem Nierentumor.

In 66 patients with renal tumours on 30 patients a preoperative transfemoral embolisation of the renal artery of the tumour-bearing kidney was performed. The complications were established and compared with the 36 patients without occlusion. On account of the considerable side effects a preoperative occlusion seems to be reasonable only in selected cases.

[Computed tomographic analysis of postoperative abdominal compartments. A comparative study of 100 patients with abdominal abscesses]. / Computertomographische Analyse postoperativer abdomineller Kompartments. Eine Vergleichsstudie an 100 Patienten mit abdominellen Abszessen.

100 patients with 140 abdominal abscesses were included in this study: 113 occurred intraperitoneal, 85% of these postoperatively, 15% spontaneously and in 11.5% the retroperitoneal space was affected concomitantly. In the postoperative group multilocular disease (= more than one typical compartment affected) was much more frequent when compared to spontaneous abscesses. Surgery with peritoneal barrier changes resulted in formation of new and "atypical" abdominal compartments which were the site of 39% of postoperative abscesses in this series. Communications of the lesser sac with the left subphrenic space were most frequently involved, followed by the fused right subphrenic and subhepatic space, when the coronary ligament was disconnected operatively. Knowledge of surgically induced changes of normal abdominal anatomy and its role for abscess formation and propagation may be very essential for correct CT-localization and CT-guided drainage.

[Percutaneous drainage of complicated abscesses and fluid collections]. / Perkutane Drainage komplizierter Abszesse und Flüssigkeitsansammlungen.

The original concept of percutaneous, radiological abscess drainage was confined to well circumscribed, solitary abscesses, that could be reached by a short access avoiding transgression of uninvolved organs or compartments. With increasing experience criteria for percutaneous abscess drainage have been expanded to radiological treatment of pancreatic, periappendiceal, diverticular, interloop and mediastinal abscesses and fluid collections. The authors present their experience with percutaneous treatment of such "complicated" abscesses in 140 patients.