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The Papers Presented at the Annual Meetings of the Knee Society Symposium includes selected papers read at the 2007 Annual Interim Meeting of the Knee Society held in Sienna, Italy in September 2007, and the 2008 Open Scientific Meeting of the Knee Society, held in San Francisco in March 2008. The wide range and high quality of the scientific material presented here is a credit to the excellent work of the Knee Society education committee and particularly to its Program Chair, Gil Scuderi, MD. Each of these papers is focused, concise and highly readable, which is a credit to the outstanding work of the staff at CORR in providing clear and consistent guidelines for each of the authors whose work was accepted for publication. The 2008 Ranawat Award was authored by Dr. Patricia Franklin and colleagues for their work on patient-specific attributes that affect the functional outcome after total knee replacement. While considerable interest in patient outcomes research has been present for some time now, we are still uncovering the hidden power, and the hidden pitfalls, of such evaluation tools in orthopaedics. Dr. Franklin and colleagues effectively demonstrate the substantial influence of specific patient characteristics in determining the ultimate functional outcome after knee replacement. These data are useful for surgeons and patients alike as part of the preoperative discussion so that expectations can be managed more appropriately. Further, this paper provides some insight into additional strategies that might be employed prior to knee replacement to affect some patient attributes that adversely impact outcome. The 2008 Coventry Award paper was authored by D’Lima, Colwell, and colleagues from the Scripps Clinic for their innovative report that directly measured the in vivo forces that the knee experiences after total knee arthroplasty. In an outstanding collaboration between basic science researchers, engineers, and clinicians, Dr. Colwell’s group designed and implanted in three patients an instrumented tibial component that allowed the direct measurement of both knee forces and moments in vivo. These results begin to give us a true glimpse of the forces that are seen by total knee bearing surfaces and fixation interfaces thus providing us with a more scientific approach to what have otherwise been empiric recommendations regarding physical activities after total knee arthroplasty. The 2008 John Insall Award paper was authored by Dr. Steven MacDonald and colleagues from London, Ontario and addressed the specific impact of gender on the clinical outcome after total knee arthroplasty. The introduction into the marketplace of so-called gender-specific total knee components has been met with a competing mix of interest and skepticism among surgeons, while among patients curiosity might be the most appropriate descriptor. This scientific work again highlights the powerful relationship between preoperative variables and postoperative outcomes. These authors rightly highlight the importance of focusing on the change or improvement in preoperative to postoperative outcomes measures and balance that against the absolute scores. Female gender was associated with lower preoperative scores with these outcomes tools so perhaps it is not surprising some of the postoperative scores remain lower than those observed in males. The change or improvement from preoperative to postoperative, however, appears to be similar between males and females after total knee arthroplasty. The remaining papers in this symposium are grouped to include new information regarding total knee surgical technique, gender-related issues in technique and outcome, computer navigation, patellar resurfacing, total knee materials and design issues and revision total knee concerns. As surgeons we have specific interest in improving our intraoperative skills. In this symposium there is information on a method to determine rotational position of total knee components, data on the impact of a ligament balancing technique on the rate of lateral retinacular release, and the introduction of an extramedullary femoral referencing system to facilitate less invasive surgery. Gender-related issues are addressed in a series of papers that look at both documenting physical measurement differences in knee anatomy and then measuring outcomes differences. While little doubt exists that gender-associated differences can be measured, what remains to be determined is the clinical importance of such findings, and in that area we collectively still have work to do. While it appears that the initial wave of enthusiasm for computer navigation in total knee arthroplasty has crested, we are now at a point where more definitive scientific data are emerging regarding the benefits and drawbacks to this particular technology. Two of the implicit promises of computer navigation have been that it may make the occasional knee surgeon more like the expert surgeon, and that a navigation system can be the eye that facilitates accurate minimally invasive surgery. In this symposium there are scientific data that cast some doubt on promise number two, and all of us in the scientific community continue to look for evidence that navigation is reproducibly accurate when used by the occasional knee surgeon. The added costs of this technology is an issue yet to be addressed. Revision TKA is an area of ascending importance as the demographics of our population point to a growing need in this area. In this Symposium there are useful data on the outcomes differences between primary and revision TKA, comparative data on in-hospital complications between primary and revision TKA, isolated patellar revision, patellar bone loss problems and the use of stems in conjunction with constrained condylar knee designs. The Knee Society remains committed to advancing scientific knowledge and educating clinicians worldwide regarding surgery of the knee. We hope that our readers find this Symposium to be intellectually rigorous and clinically useful.

The purpose and focus of the Musculoskeletal Tumor Society is stated on the organization’s website. “The mission of the Musculoskeletal Tumor Society is to advance the science of orthopaedic oncology and to promote high standards of patient care. It does this through excellence in education and research” [1]. The 2008 MSTS meeting in Phoenix, AZ, November 6–8, 2008, and hence this symposium, follows part of the prescription, providing an excellent forum for education. The second portion of the mission statement encourages advancing orthopaedic oncology through research. The organization has enjoyed limited success in conducting or promoting research despite valiant efforts by the leaders of the Research Committee. Why? Answers come from the membership, the discipline, and the organization. The membership of the MSTS has changed dramatically over the years. The original “Piranha Club” had 18 domestic orthopaedic surgeons, of whom only one remains actively practicing surgical oncology. The roster has ballooned to over 220 members, including Candidate, Affiliate, and Emeritus Members. While this reflects successful maturation of orthopaedic oncology, it has a dilutive effect on research and possibly even clinical progress. Case volume is correlated with outcome in all other cancer systems studied to date, for disease of organs ranging from prostate to pancreas. Why shouldn’t it also be true for bone and soft tissue sarcomas? As knowledge and training disseminate, experience per surgeon inevitably declines. Smaller case loads prevent concentrated expertise. Paradoxically, the numerical expansion of our membership may have improved our ability to deliver more convenient, good quality care to more people, but it may prevent us from making substantive advances in the field. Single centers usually lack the volume to ask or answer important questions. Collaboration is essential to maintain patient numbers required to study rare diseases. Standardization of treatment protocols is essential if the cases from different centers may be combined. This requires strong-willed commitment on the part of musculoskeletal oncologists to suppress some of their individuality and cooperate. This is necessary to advance the discipline and improve patient care. Large cooperative groups (eg, Children’s Oncology Group or COG, the Southwest Oncology Group or SWOG) have failed due to their cumbersome structure and an inability to channel resources to orthopaedic problems. The greatest success has been in ad hoc collaborations such as that coordinated by the MSTS to review the outcome of patients treated by limb salvage or amputation for distal femoral osteosarcoma [2], or the Toronto Group’s prospective evaluation of prognostic genetic markers (p53 and RB) in osteosarcoma patients from six centers [3]. This symposium includes a variety of novel and informative clinical papers dealing with resection and reconstruction techniques. However, most are single center studies that should be viewed as hypothesis generating ideas. They require confirmation in larger trials involving other centers to show the results can be generalized. The levels of evidence are typically IV. There is also a deficiency in basic and translational research needed to advance the field. Clearly, more effort needs to be expended to improve the quality and generalizability of our research. Investigators and reviewers need to support cluster- and association-based comparative research efforts, clinical trials, and basic investigations. There are national initiatives in this direction. Responding to the challenge proposed by the American Academy of Orthopaedic Surgeons, the Musculoskeletal Tumor Society is trying to develop evidence-based assessments of practice. This symposium includes the Society’s first effort along those lines, summarizing the best available opinion regarding the biopsy of musculoskeletal tumors. More recently, the AAOS/ORS/NIH sponsored a workshop in Albuquerque to define the research agenda for prospective outcome studies in each orthopaedic subspecialty. Two tumor projects made the final cut of recommendations. The first was a prospective study of proximal femoral metastases, comparing internal fixation (rodding) with joint arthroplasty. The second was a long-term followup of reconstructions performed for patients randomized to receive, or not receive, muramyl tripeptide phosphoethanolamine (MTP-PE) in the national Intergroup-133 study. These projects should receive the support of the oncology community, and would be good topics on which the MSTS could focus and include in future CORR Symposia.

The authors present a case of a spondylolisthesis with obvious foraminal stenosis on both sides as shown on the preoperative MRI. A proper operative technique in this case would include a restoration of disc height and the (partial) reduction of the slip. This technique would widen both foramina and no complication like opposite nerve root compression would occur. If reduction or disc height restoration cannot be achieved, decompression of both foramina should be performed. In mild cases a simple posterior distraction may be enough. In their paper the authors agree to this point as they write “decompression of the opposite side has not been judged necessary in the past as it has been commonly assumed that the TLIF spacer increases the disc space height and the foraminal height in the opposite foramen of the TLIF approach.” However, it seems that in the current case the authors failed to achieve restoration of disc height. Figure 7 shows differences between the preoperative and the postoperative CT scan of 1 mm (4 vs. 5 mm) and 1.5 mm (6.5 vs. 8 mm), respectively. The same is true for the “decrease” of foraminal height of 2 mm. I think that these measurements are not reliable since there is no calibration and no matching between the slices. Hence no obvious increase in disc height or decrease in foraminal height can be measured accurately. Anyway, the clinical significance of 1 or 2 mm of reduced foraminal height, if really present, seems to be questionable.

The work, "Ricardo M. The effect of ultrasound on the healing of muscle-pediculated bone graft in scaphoid non-union. Int Orthop. 2006 Apr;30(2):123–127", published by the prestigious journal International Orthopaedics, contains some misprints. In the paper it is reported that the ultrasound intensity emitted by the equipment employed in the study, a Theramed 101B, was 30 mW/cm2. Actually, the reported intensity should have been 50mW/cm2. The error could have come about since initially in the Department of Orthopedics and Traumatology of the Manuel Fajardo Teaching Hospital, a preliminary study was conducted for the stimulation of bone repair that indeed used 30mW/cm2. The first results of this preliminary study were published in the following reference, "O. Rodriguez, R. Monreal. Acceleration of Osseous Fracture Repair by Low-intensity Pulsed Ultrasound Therapy: A Preliminary Study", Proceedings of the II Latin-American Congress on Biomedical Engineering (ISBN 959-7132-57-5), Havana, Cuba, Cod. 265, (2001). Nevertheless after that preliminary study and since the beginning of 2000, the Theramed 101B equipment was modified for an emmision of 50 mW/cm2. Therefore, the year for the beginning of the study described by author should be 2000 and not 1999, and the reported intensity must be 50 mW/cm2, and not 30 mW/cm2. Sincerely yours, Orlando R. Rodriguez Rua (MD), Researcher of the “Instituto de Cibernetica, Matematica y Fisica”, La Habana Cuba. Chief of the project PRI/1/1 of the “Agencia Cubana de Energia Nuclear y Tecnologias de Avanzadas” under which the Theramed 101B was Developer with the collaboration of the “Departamento de Ingenieria Electrica y Electronica, Instituto Tecnologico y de Estudios Superiores de Monterrey, Campus Estado de Mexico, Mexico” and the “Seccion de Bioelectronica, Departamento de Ingenieria Electrica, Centro de Investigacion y de Estudios Avanzados del Instituto Politecnico Nacional, Mexico DF, Mexico”.

Background Hypermobility of the first carpometacarpal joint is mostly surgically treated with a volar approached stabilization by Eaton, but recent studies indicate the importance of the dorsoradial and intermetacarpal ligaments (DRL and IML) for carpometacarpal joint stability. The aim of this study was to compare a dorsal and volar technique for primary carpometacarpal hypermobility regarding pain and functional outcome. Methods Patients with non-degenerative, painful carpometacarpal hypermobility were included and were randomly assigned to either the volar technique using the FCR, or a dorsal technique using the ECRL. After premature termination of the trial, we followed all patients treated with the volar approach. Pain, strength, and ADL function using DASH and Michigan Hand Questionnaires (MHQ) were measured at baseline and 3 and 12 months after surgery. Results After including 16 patients, the randomized trial comparing the volar and dorsal technique was terminated because of significant increased pain in the dorsal group. Although none of the other outcome measures were significant in the underpowered comparison, in line with the pain scores, all variables showed a trend towards a worse outcome in the dorsal group. Between 2009 and 2012, 57 thumbs were surgically stabilized. We found significant better pain and MHQ scores, and after 1 year improved grip and key pinch strength. Patients returned to work within 8 (±7) weeks, of which 85 % in their original job. Conclusions Surgical stabilization of the thumb is an effective method for patients suffering from hypermobility regarding pain, daily function, and strength. We recommend a volar approach. Level of Evidence: Level I, therapeutic study

Purpose To compare the efficacy and safety of TDR to that of the fusion for the treatment of lumbar degenerative disc disease (LDDD). Methods Randomized controlled trials comparing TDR with any other intervention for LDDD were acquired by a comprehensive search in PubMedCentral, MEDLINE, EMBASE, BIOSIS, ClinicalTrials.gov, and the FDA trials register. Methodologic quality was assessed and relevant data were retrieved, and appropriate meta-analysis was performed. Two review authors independently selected studies, extracted data, and assessed risk of bias. Results and upper bounds of confidence intervals were compared with predefined clinically relevant differences. Results Six relevant randomized controlled trials (RCTs) involving 1,603 patients were identified and reported two year follow-up results. Patients in TDR group compared with lumbar fusion group demonstrated significant improvements in ODI, VAS scores and complication rates at the two year follow-up. Meanwhile, except for operating time in anterior group, intra-operative blood loss, operating time in posterior group, and reoperation rate were without clinical significance between the two groups. In addition, the range of motion (ROM) was maintained within normal ranges after TDR. Conclusions The results showed the TDR has significant safety and efficacy comparable to lumbar fusion at two year follow-up. Although superiority compared to fusion could not be proved, by comparing clinical symptoms relieved, motion preserved, and the low reoperation rate during long-term follow-up on TDR, TDR was considered safe and effective. Therefore, the authors suggest adopting TDR on a large scale; with failure of TDR, interbody fusion would be performed.

Purpose The purpose of this study was to evaluate clinical and radiological outcomes of autologous osteochondral transfer (OATS) for femoral head osteonecrosis. Methods Twenty-one hips in 20 patients (one woman and 19 men), average patients' age at the time of surgery of 35.4 (range 20–56) years, were treated with OATS for osteonecrosis of the femoral head (ONFH). Seven patients at pre-collapse ARCO stages IIA and IIB were treated with OATS alone. Thirteen patients with large pre-collapse ARCO IIC and post-collapse ARCO III and IV were treated with OATS and morselised bone allografts (OATS/allograft). Harris hip score (HHS) was used for clinical evaluation of outcomes; X-rays were performed to examine the evolution of the disease. Kaplan-Meier survival curves were used to determine the failure of the procedures with conversion to THR defined as endpoint. Results Follow-up of patients treated with OATS alone was 46.14 (range 18–75) months with HHS improvement from a preoperative mean of 42 to 87.85 points at the latest follow-up examination. Only one patient in this group needed a revision operation with THR. The survival for this group of patients was 85.71 % at four years. Follow-up of patients treated with AOTS/allograft was 32.7 (range 7–84) months with HHS improvement from a preoperative mean of 35.2 to 65.7 points at the latest follow-up examination. One patient died six months after the surgery. There were five conversions to THR because of femoral head collapse in this group of patients with survival of 61.54 % at three years. Conclusion The use of osteochondral grafts offers the possibility of successful treatment for ONFH at small and medium pre-collapse stages. The outcomes of large pre-collapse and post-collapse stages were below our expectations. OATS is a time buying procedure for young patients as it may defer total hip replacement.

This study evaluated the perception of veterinarians in including the emerging metastrongyloid Angiostrongylus vasorum in the differential diagnosis for dogs referred with appropriate signs. Veterinarians at teaching hospitals, private practices or kennels collected faecal samples from 606 symptomatic dogs in six different areas of Italy. The samples were examined with the Baermann technique. Fourteen dogs scored positive for A. vasorum, all showing different clinical pictures, with the most common reason for inclusion in the study being a combination of respiratory signs along with general signs. The most reported sign was cough, followed by aspecific distresses. Other respiratory signs were dyspnoea, tachypnoea and breathing sounds, while bleeding diathesis occurred in one dog. Gastrointestinal disorders were diarrhoea and vomitus, while no neurological signs were detected. Four key cases are herein described, with a special focus on their clinical description, findings at the collateral diagnostic imaging and therapeutic options with moxidectin. This survey provides new data on distribution of A. vasorum in Europe and on the clinical impact of the disease. The results confirm that clinical angiostrongylosis overlaps a series of other conditions of dogs. Awareness among vet practitioners is discussed along with the importance of including A. vasorum on the list of differential diagnoses in canine clinical practice and of performing appropriate diagnostic methods.

The aim of this health economic analysis was to compare the cost-effectiveness of ticagrelor versus clopidogrel within the German health care system. A two-part decision model was adapted to compare treatment with ticagrelor or clopidogrel in a low-dose acetylsalicylic acid (ASA) cohort (≤150 mg) for all ACS patients and subtypes NSTEMI/IA and STEMI. A decision-tree approach was chosen for the first year after initial hospitalization based on trial observations from a subgroup of the PLATO study. Subsequent years were estimated by a Markov model. Following a macro-costing approach, costs were based on official tariffs and published literature. Extensive sensitivity analyses were performed to test the robustness of the model. One-year treatment with ticagrelor is associated with an estimated 0.1796 life-years gained (LYG) and gained 0.1570 quality-adjusted life-years (QALY), respectively, over the lifetime horizon. Overall average cost with ticagrelor is estimated to be EUR 11,815 vs. EUR 11,387 with generic clopidogrel over a lifetime horizon. The incremental cost-effectiveness ratio (ICER) was EUR 2,385 per LYG (EUR 2,728 per QALY). Comparing ticagrelor with Plavix® or the lowest priced generic clopidogrel, ICER ranges from dominant to EUR 3,118 per LYG (EUR 3,567 per QALY). These findings are robust under various additional sensitivity analyses. Hence, 12 months of ACS treatment using ticagrelor/ASA instead of clopidogrel/ASA may offer a cost-effective therapeutic option, even when the generic price for clopidogrel is employed. Electronic supplementary material The online version of this article (doi:10.1007/s00392-013-0552-7) contains supplementary material, which is available to authorized users.

Purpose The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA). Methods We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices. Results In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications. Conclusions Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.

Purpose Recurrences and deaths are known to occur, even if less frequently, in small, node-negative breast cancer patients, and decision on adjuvant treatments remains controversial. In the present analysis, we evaluate recurrence risk in patients with pT1 a, b, c, node-negative, breast cancer, accordingly with some prognostic biological factors. Methods We retrospectively evaluated 900 node-negative patients (pT1a, b, c) surgery treated between 2000 and 2009 in four Italian oncologic centers. We defined 3 different cohorts: ER positive (ER+); Her-2 positive (Her-2+); and triple negative (TN). Results pT1a was seen in 7.6% of patients, 37.7 % pT1b, 54.8 % pT1c. Concerning the 3 different cohorts, 58.2 % were ER+; 10.8 % were Her-2+; 8.2 % were TN. Overall, chemotherapy was given to 3.0 %, 27.2 %, 69.8 % of pT1a, b, c, respectively, and to 22.7 %, 58.8 %, 68.9 % of ER+, Her-2+, TN subgroups. At a median follow-up of 67 months, 5-year DFS was 96.3 %, 89.2 %, 89.4 % in pT1a, b, c, respectively (100 %, 93.6 %, 89.8 % in ER+; 100 %, 78.7 %, 85.0 % in Her-2+; 100 %, 76.8 %, 85.2 % in TN) (p = ns). At multivariate analysis, histologic grade and Ki-67 resulted independent prognostic factors. Overall, 5-year OS was 98 %, without differences among pT1a, b, c, or among the 3 cohorts. Conclusions Overall, 5-year DFS was very favorable in this series of small, node-negative breast cancers, but Her-2+ and TN cohorts have a higher recurrence rate than ER+ cohort (p

The aim of this study was to evaluate the clinical effectiveness of covered Niti-S stent placement under multidetector CT and fluoroscopy guidance for the palliation of dysphagia in patients with cervical esophageal cancer. Under radiological imaging guidance using axial and sagittal CT scans, and fluoroscopy, Niti-S esophageal stents were placed in ten consecutive patients with complete obstruction caused by cervical esophageal cancer (9 men and 1 woman; age range = 54–79 years; mean age = 68.1 years) between February 2010 and December 2011. The procedure time and technical success rate were evaluated. Swallowing improvement was assessed by the following items: ability to eat and/or swallow (graded as follows: 3 = ability to eat normal diet, 2 = ability to eat semisolids, 1 = ability to swallow liquids, 0 = complete obstruction). Procedural and post-procedural complications were also evaluated. Survival (mean ± SD) was examined. The mean (±SD) procedure time was 40 ± 19 min (range = 21–69 min). Stent placement was technically successful in all patients; inadequate stent deployment did not occur in any case. Ability to eat and/or swallow was improved and scored 2.4 (score 3 in 5 cases, score 2 in 4 cases, score 1 in 1 case, and score 0 in no case) after stent placement. No major or post-procedural complications were encountered. The mean survival time was 131 ± 77 days (range = 31–259 days). Niti-S stents appeared to be a safe and effective device for the palliation of dysphagia caused by advanced cervical esophageal cancer. Multidetector CT and fluoroscopy image guidance helped the operators accurately place the stents in the cervical esophagus.

Background Drug-coated balloons (DCBs) have been developed for the percutaneous treatment of coronary artery disease. An initial focus has been the management of in-stent restenosis (ISR) but randomised controlled trials (RCTs) have been small and powered only for angiographic endpoints. Objective The aim of the work was to assess the clinical and angiographic outcomes of patients treated for ISR with DCB versus control (balloon angioplasty or drug-eluting stents) by a meta-analysis of RCTs. Methods A comprehensive search was performed of RCTs where patients with ISR were randomly assigned to either DCB or alternative coronary intervention. Outcome measurements were death, myocardial infarction (MI), target lesion revascularisation (TLR), binary definition of restenosis and in-lesion late luminal loss (LLL). Results Four studies were identified that fulfilled the inclusion criteria. Pooled odds ratios (ORs) were calculated for patients treated for ISR (n = 399). Mean follow-up duration was 14.5 months. DCBs were associated with lower rates of TLR [8.8 vs. 29.7 % OR (95 % confidence interval, CI) 0.20 (0.11–0.36), p

Purpose Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results. Method We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months. Results No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports. Conclusion After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.

Objective We tested whether bedside testing for H-FABP is, alone or integrated in combination models, useful for rapid risk stratification of non-high-risk PE. Methods We prospectively studied 136 normotensive patients with confirmed PE. H-FABP was determined using a qualitative bedside-test showing a positive result for plasma concentration >7 ng/ml. Results Overall, 11 patients (8.1 %) had an adverse 30-day outcome. Of 58 patients (42.6 %) with a positive H-FABP bedside-test, 9 (15.5 %) had an unfavourable course compared to 2 of 78 patients (2.6 %) with a negative test result (p = 0.009). Logistic regression analysis indicated a sevenfold increased risk for an adverse outcome (95 % CI, 1.45–33.67; p = 0.016) for patients with a positive H-FABP bedside-test. Additive prognostic information were obtained by a novel score including the H-FABP bedside-test (1.5 points), tachycardia (2 points), and syncope (1.5 points) (OR 11.57 [2.38–56.24]; p = 0.002 for ≥3 points). Increasing points were associated with a continuous exponential increase in the rate of an adverse 30-day outcome (0 % for patients with 0 points and 44.4 % for ≥5 points). Notably, this simple score provided similar prognostic value as the combination of the H-FABP bedside-test with echocardiographic signs of right ventricular dysfunction (OR 12.73 [2.51–64.43]; p = 0.002). Conclusions Bedside testing for H-FABP appears a useful tool for immediate risk stratification of non-high-risk patients with acute PE, who may be at increased risk of an adverse outcome, in particular if integrated in a novel score without the need of echocardiographic examination.

The principle of stretching wound margins for primary wound closure is commonly practiced and used for various skin defects, leading at times to excessive tension and complications during wound closure. Different surgical techniques, skin stretching devices and tissue expanders have been utilized to address this issue. Previously designed skin stretching devices resulted in considerable morbidity. They were invasive by nature and associated with relatively high localized tissue pressure, frequently leading to necrosis, damage and tearing of skin at the wound margins. To assess the clinical effectiveness and performance and, to determine the safety of TopClosure® for gradual, controlled, temporary, noninvasive and invasive applications for skin stretching and secure wound closing, the TopClosure® device was applied to 20 patients for preoperative skin lesion removal and to secure closure of a variety of wound sizes. TopClosure® was reinforced with adhesives, staples and/or surgical sutures, depending on the circumstances of the wound and the surgeon’s judgment. TopClosure® was used prior to, during and/or after surgery to reduce tension across wound edges. No significant complications or adverse events were associated with its use. TopClosure® was effectively used for preoperative skin expansion in preparation for dermal resection (e.g., congenital nevi). It aided closure of large wounds involving significant loss of skin and soft tissue by mobilizing skin and subcutaneous tissue, thus avoiding the need for skin grafts or flaps. Following surgery, it was used to secure closure of wounds under tension, thus improving wound aesthetics. A sample case study will be presented. We designed TopClosure®, an innovative device, to modify the currently practiced concept of wound closure by applying minimal stress to the skin, away from damaged wound edges, with flexible force vectors and versatile methods of attachment to the skin, in a noninvasive or invasive manner.

Purpose Whilst excellent long-term results with contemporary uncemented stems have been reported for total hip arthroplasty in young patients, the survival rates for the whole reconstruction are often compromised by high failure rates on the acetabular site due to peri-acetabular osteolysis and accelerated wear. Methods In patients 60 years old or younger, we retrospectively reviewed the results at a minimum of ten years of 89 consecutive uncemented total hip replacements in 88 patients using the press-fit Fitmore acetabular component in combination with the CLS Spotorno stem and a 28-mm Metasul metal-on-metal articulation or a 28-mm alumina ceramic on conventional polyethylene bearing. The mean age at the time of surgery was 49 years (range, 25–60). The mean clinical and radiological follow-up was 12 years (range, 10–15). Results Six patients (six hips) died and two patients (two hips) were lost to follow-up. Five hips were revised: one for deep infection, one for peri-prosthetic femoral fracture, and one for aseptic stem loosening. In two hips an isolated revision of the acetabular liner was performed (one for recurrent dislocation and one for unexplained pain). No revision was performed for accelerated wear, osteolysis or aseptic loosening of the acetabular shell. We could not detect peri-acetabular osteolysis visible on plain radiographs in those hips evaluated radiographically. The Kaplan-Meier survival with revision for any reason as the endpoint was 94% (95% confidence interval, 86–97) at 12 years. Conclusions The survival rates and the radiological outcomes with this implant combination in this young and active patient group are encouraging when compared to the results reported for other uncemented cups in this age group.

PURPOSE: There is renewed interest in the all-polyethylene tibial component in total knee arthroplasty (TKA). Long-term results of this prosthesis in rheumatoid arthritis (RA) patients, however, are limited. Therefore, we studied 104 primary cemented all-polyethylene tibial TKA in 80 consecutive RA patients for up to 25 years to determine the long-term survival of all-polyethylene tibial components in patients suffering from end stage RA. METHODS: We estimated revision rates according the revision rate per 100 observed component years used in national joint registries. Kaplan-Meier was used to estimate survival curves. RESULTS: During the 25-year follow-up, three revisions for tibial component loosening were performed. The mean revision rate of all-polyethylene tibial components with revision for aseptic loosening as the endpoint was 0.09 per 100 observed component years. This corresponds to a revision rate of 0.9% after ten years and 2.25% after 25 years. Survivorship according to Kaplan-Meier was 100% at ten years and 87.5% at 25 years [95% confidence interval (CI) 64.6-100)]. CONCLUSION: This study shows good long-term results of all-polyethylene tibial TKA in patients with RA. RA patients with multiple-joint inflammation may be less physically active than osteoarthritis patients, resulting in a lower demand on the prosthesis, and these patients may, indeed, be good candidates for all-polyethylene tibial TKA. Our results suggest that all-polyethylene tibial TKA could be a successful and cost-saving treatment for end-stage knee arthritis in RA patients.

Background Studies have demonstrated sex differences in femoral shape and quadriceps angle raising a question of whether implant design should be sex-specific. Much of this research has addressed shape differences within the Caucasian population and little is known about differences among ethnic groups. Questions/purposes We therefore asked: Do shape differences in the distal femur and proximal tibia exist among different ethnic groups and between the sexes in each ethnic population? And if ethnic differences exist, do they have a clinical impact on current TKA design? Subjects and Methods We analyzed 1000 normal adult knees (80 African American, 80 East Asian, and 860 Caucasian). Three-dimensional surface models were created for each bone and added to three-dimensional statistical bone atlases. Statistical shape analysis was conducted with a process combining principal components and multiple discriminate analyses. Eleven femoral and nine tibial measurements were calculated. Results We found differences in mean measurements between the sexes and ethnicities. Males had larger knees, with a mean 5-mm-larger anteroposterior dimension than females in all ethnicities. African American females had a 7.4-mm-deeper patellar groove, 2.3-mm-smaller tibial mediolateral dimension, and 2.5-mm-larger tibial anteroposterior dimension than Caucasian females. African American males had a 4.3-mm-larger femoral anteroposterior dimension, 10.1-mm-larger tibial mediolateral dimension, and 6-mm-larger tibial anteroposterior dimension than Asian males. Conclusions We identified differences in three-dimensional knee morphology among Caucasian, African American, and East Asian populations. Clinical studies will be required to determine whether these differences are important for implant design.