[Cement-in-cement hip revision with a long-stemmed femoral component]. / Zement-in-Zement-Hüftrevision mit einem zementierten langen Prothesenstiel.

Revision hip surgery often requires individualized techniques and implants. We report on a case of failed femoral revision in an extensively cemented femur with a concomitant proximal and dorsal femoral bone defect. We advocate the clinically effective revision procedure of antegrade drilling of the stable cement mantle and use of a cemented long-stemmed femoral component. This cement-in-cement revision technique is discussed along with the pertinent literature.

Decreased myometrial beta-adrenoceptors in women receiving beta 2-adrenergic tocolytic therapy: correlation with lymphocyte beta-adrenoceptors.

We have determined simultaneously the density of beta-adrenoceptors in human myometria (by (-)-[125I]iodopindolol binding) derived from 36 women undergoing cesarean section and in the corresponding circulating lymphocytes (by (-)-[125I]iodocyanopindolol binding). In myometrial membranes about 80% to 85% of the beta-adrenoceptors were of the beta 2-subtype. The density of myometrial and lymphocyte beta-adrenoceptors in women treated with the beta 2-adrenoceptor agonist hexoprenaline to prevent preterm labor was about 65% to 70% lower than that in nontreated women. Concomitantly, in hexoprenaline-treated women the 10 mumol/L isoproterenol-evoked increase in lymphocyte cyclic adenosine monophosphate content (as index for lymphocyte beta-adrenoceptor responsiveness) was diminished to a similar extent. Combining all data resulted in a significant positive correlation between myometrial and lymphocyte beta-adrenoceptor densities (r = 0.7303; n = 36; p less than 0.001). It is possible that determination of beta-adrenoceptor function in circulating lymphocytes may be a useful model to monitor myometrial beta-adrenoceptor changes during tocolytic therapy.

Selective regulation of beta 1- and beta 2-adrenoceptors in the human heart by chronic beta-adrenoceptor antagonist treatment.

1. In 44 patients undergoing coronary artery bypass grafting, the effect of chronic administration of the beta-adrenoceptor antagonists sotalol, propranolol, pindolol, metoprolol and atenolol on beta-adrenoceptor density in right atria (containing 70% beta 1- and 30% beta 2-adrenoceptors) and in lymphocytes (having only beta 2-adrenoceptors) was studied. 2. beta-Adrenoceptor density in right atrial membranes and in intact lymphocytes was assessed by (-)-[125I]-iodocyanopindolol (ICYP) binding; the relative amount of right atrial beta 1- and beta 2-adrenoceptors was determined by inhibition of ICYP binding by the selective beta 2-adrenoceptor antagonist ICI 118,551 and analysis of the resulting competition curves by the iterative curve fitting programme LIGAND. 3. With the exception of pindolol, all beta-adrenoceptor antagonists increased right atrial beta-adrenoceptor density compared to that observed in atria from patients not treated with beta-adrenoceptor antagonists. 4. All beta-adrenoceptor antagonists increased right atrial beta 1-adrenoceptor density; on the other hand, only sotalol and propranolol also increased right atrial beta 2-adrenoceptor density, whereas metoprolol and atenolol did not affect it and pindolol decreased it. 5. Similarly, in corresponding lymphocytes, only sotalol or propranolol increased beta 2-adrenoceptor density, while metoprolol and atenolol did not affect it and pindolol decreased it. 6. It is concluded that beta-adrenoceptor antagonists subtype-selectively regulate cardiac and lymphocyte beta-adrenoceptor subtypes. The selective increase in cardiac beta 1-adrenoceptor density evoked by metoprolol and atenolol may be one of the reasons for the beneficial effects observed in patients with end-stage congestive cardiomyopathy following intermittent treatment with low doses of selective beta 1-adrenoceptor antagonists.

Thrombophlebitis associated with intravenous injection anaesthetics: influence of arm positioning.

BACKGROUND: Thrombophlebitis (TP) is a frequent complication of the intravenous application of injection anaesthetics. We investigated the influence of different arm positions on the incidence of such a complication in patients undergoing shoulder arthroscopy. PATIENTS AND METHODS: This prospective, randomised study was done in 86 consecutive major shoulder arthroscopies. In order to evaluate the influence of different arm positions, the arm not operated on was positioned either cranial (n = 31) or caudal (n = 55) to the level of the right atrium. The number of TP in the 5 days following the arthroscopy was detected clinically and proven by ultrasound studies. RESULTS: 8 TP occurred in the group of patients with caudal arm positioning and none in the other group. Statistically, the incidence of TP was not associated with the weight or the height of the patients nor with the duration of the anaesthesia or the doses of anaesthetics used in each patient (p < 0.05). CONCLUSION: An elevated position of the arm used for anaesthesia during shoulder arthroscopy is suggested in order to prevent TP.

Surgical excision of pseudotumorous pretibial myxedema.

Pretibial myxedema is a well-known clinical feature of autoimmune thyroid malfunction and is classically associated with Graves' disease. Its clinical course is frequently not related to the clinical control of the underlying thyroid disease. Treatment is primarily medical, consisting of oral and topical corticosteroids. We present a case of successful local excision of a pseudotumorous manifestation at the dorsum of the foot recalcitrant to multimodal medical and dermatological therapy.

[A novel device for active shoulder rehabilitation with glenohumeral traction or compression]. / Ein neuartiges Gerät zur aktiven Schulterrehabilitation unter glenohumeraler Traktion oder Kompression.

The equipment available for rehabilitation of patients with joint conditions still lacks a device that, in common with usual physiotherapeutic measures (manipulation, proprioceptive neuromuscular facilitation, Bobath therapy), is based on traction and/or compression or oscillating forms. The novel "Shoulder Rotator" is such a simple device for the variable treatment of shoulder disorders in all three spatial dimensions. After individual instruction, the patient performs rotating glenohumeral exercises with simultaneous glenohumeral joint traction, compression, or oscillations against static or dynamic resistance. The "Shoulder Rotator" is similar to the established continuous passive motion device for the shoulder and is mounted on a mobile chair. The electronic device control is computerised and permits a wide variety of treatment options, individual regimes, and documentation. The oscillating, compression/distraction mode of operation provides an analgesic effect. The isolated compression mode along the rotatory axis enables conditioning of joint proprioception. The distraction mode along the rotatory axis facilitates muscular relaxation. Resistive rotatory exercises strengthen the rotatory glenohumeral muscles and help centre the humeral head in the glenoid. In addition to the advantage of adding documentation of treatment progress as required for evidence-based medicine, this novel device may bring about a cost-effective, genuine quality improvement in shoulder rehabilitation.

[Rotating platform spinout in LCS knee arthroplasty]. / Spinout der rotierenden Plattform bei der LCS-Knieendoprothese.

In knee arthroplasty, a lax flexion gap may cause flexion instability. Subsequently, the operated knee may subluxate or dislocate. We report on a case of recurrent subluxations with malrotation of the rotating platform (spinout) after primary LCS total knee arthroplasty. Potential causes for spinout, therapy procedures, and consequences for the primary surgical technique are discussed. In the LCS rotating platform knee arthroplasty, the flexion gap must not be laxer than the extension gap. In such an instance, we recommend a higher rotating platform and a more proximal distal transverse femoral osteotomy.

Surgical treatment of enchondroma in long tubular bones. Preservation of function versus extensive excision in the humerus.

Insufficient criteria to distinguish enchondroma from low-grade chondrosarcoma occasionally lead to uncertainty concerning the optimal extent of surgery. For either tumor the clinical outcome is mainly compromised by local recurrence. Reviewing our medical records, we retrospectively identified a female patient who was diagnosed as suffering from a large enchondroma of the left humerus in childhood and could be followed up for almost two decades. Following local excision of the tumor at the age of 14 years, clinical follow-up was uneventful for 20 years. A potential primary extensive excision or amputation would have substantially compromised this young woman's quality of life. The complete preservation of function here following a local excision has stimulated a critical discussion of radical surgical treatment.

[Process and outcome quality in giant cell tumor in relation to surgical management]. / Prozess- und Ergebnisqualität beim Riesenzelltumor in Abhängigkeit vom chirurgischen Management.

Giant-cell bone tumors display a locally aggressive growth pattern, frequently recur if no adjuvant treatment is given, and may potentially metastasize. By virtue of their biological behavior and typically juxta-articular localization, giant-cell bone tumors require specific surgical management. Thus, an intralesional tumor excision must be supplemented by adjuvant bone cementing, possibly combined with instillation of phenol or cryotherapy. These combined treatment modalities assure a high-quality procedure, defined as the actual way medical care is delivered, by promoting the quality of the outcome, defined as the effect of a medical procedure on the patient's state of health.

Cost analysis for total hip arthroplasty by measurement of time and material expenditure.

We prospectively determined the total cost of total hip arthroplasty in 26 consecutive cases by comprehensive measurement of time consumption and detailed data acquisition for material consumption including every single item. The average partial cost caused by complications was calculated through the average prolongation of hospitalization in 1550 cases. Expenses of 18,660 DM for a hospitalization period of 23 days and 2/3 cementless arthroplasties were just covered by the diagnosis-related reimbursement, even though quality improvement measures like optimized cementing techniques, jet lavage, intraoperative X-ray control, autologous blood collection, and retransfusion sets were employed.

Composition, constitution, and interaction of bone with hydroxyapatite coatings determined by FT Raman microscopy.

An optimized FT Raman microscope (inverted microscope with high throughput of radiation) was developed that allows minimal sample preparation and Raman spectroscopy without fluorescence. A quantitative determination of the mineralization of bone tissue and hydroxyapatite (HA) coatings of hip and knee prostheses was performed. The lateral resolution reached down to 10 microm. The distribution of the HA content in the coatings investigated was found to be similar all the time. This result was independent of the composition of the coatings and the history of the whole prosthesis. In the immediate vicinity of the prosthesis a large HA content could be observed that decreased to a minimum towards the periphery of the coating and increased at the site of the ongrown bone. For the interface between bone and HA coating a transitional zone was observed at a lateral distance of 30-40 microm to the implant.

[Complications after harvesting of autologous bone from the ventral and dorsal iliac crest - a prospective, controlled study]. / Komplikationen nach Entnahme autologen Knochens aus dem ventralen und dorsalen Beckenkamm - eine prospektive, kontrollierte Studie.

INTRODUCTION: In a prospective, controlled study, donor site morbidity after bone graft harvesting from the anterior and posterior iliac crest was documented. METHODS: In 113 patients, monocortical to tricortical bone grafts were taken from the anterior (n = 73) or dorsal (n = 40) iliac crest. Bone graft size (0.4 - 43 cm 3, median 9.7 cm 3), Operation time (12 - 65 minutes, median 28 minutes), and postoperative donor site were documented. RESULTS: Donor site morbidity was higher after harvesting from the ventral than from the dorsal iliac crest: total morbidity 48 vs. 32.5 %, large haematomas 9.6 vs. 7.5 %, moderate haematomas 34.3 vs. 15 %, wound dehiscence 2.7 vs. 0 %. One revision operation was necessary because of a large haematoma at the ventral crest. After harvesting from the ventral iliac crest, there was one fracture ofthe iliac wing and one avulsion fracture of the iliac crest. There were no infections, no injuries of arteries or of the lateral femoral cutaneous nerve and no hemiation. After harvesting from the dorsal iliac crest, there were no major complications. CONCLUSION: Bone graft harvesting from the posterior iliac crest should be preferred over harvesting from the anterior iliac crest beeause of the substantially reduced donor site morbidity. Harvesting from the ventral iliac crest should have a clear indication, synthetic bone substitutes should be taken into consideration.