Periacetabular osteotomy restores the typically excessive range of motion in dysplastic hips with a spherical head

BACKGROUND Residual acetabular dysplasia is seen in combination with femoral pathomorphologies including an aspherical femoral head and valgus neck-shaft angle with high antetorsion. It is unclear how these femoral pathomorphologies affect range of motion (ROM) and impingement zones after periacetabular osteotomy. QUESTIONS/PURPOSES (1) Does periacetabular osteotomy (PAO) restore the typically excessive ROM in dysplastic hips compared with normal hips; (2) how do impingement locations differ in dysplastic hips before and after PAO compared with normal hips; (3) does a concomitant cam-type morphology adversely affect internal rotation; and (4) does a concomitant varus-derotation intertrochanteric osteotomy (IO) affect external rotation? METHODS Between January 1999 and March 2002, we performed 200 PAOs for dysplasia; of those, 27 hips (14%) met prespecified study inclusion criteria, including availability of a pre- and postoperative CT scan that included the hip and the distal femur. In general, we obtained those scans to evaluate the pre- and postoperative acetabular and femoral morphology, the degree of acetabular reorientation, and healing of the osteotomies. Three-dimensional surface models based on CT scans of 27 hips before and after PAO and 19 normal hips were created. Normal hips were obtained from a population of CT-based computer-assisted THAs using the contralateral hip after exclusion of symptomatic hips or hips with abnormal radiographic anatomy. Using validated and computerized methods, we then determined ROM (flexion/extension, internal- [IR]/external rotation [ER], adduction/abduction) and two motion patterns including the anterior (IR in flexion) and posterior (ER in extension) impingement tests. The computed impingement locations were assigned to anatomical locations of the pelvis and the femur. ROM was calculated separately for hips with (n = 13) and without (n = 14) a cam-type morphology and PAOs with (n = 9) and without (n = 18) a concomitant IO. A post hoc power analysis based on the primary research question with an alpha of 0.05 and a beta error of 0.20 revealed a minimal detectable difference of 4.6° of flexion. RESULTS After PAO, flexion, IR, and adduction/abduction did not differ from the nondysplastic control hips with the numbers available (p ranging from 0.061 to 0.867). Extension was decreased (19° ± 15°; range, -18° to 30° versus 28° ± 3°; range, 19°-30°; p = 0.017) and ER in 0° flexion was increased (25° ± 18°; range, -10° to 41° versus 38° ± 7°; range, 17°-41°; p = 0.002). Dysplastic hips had a higher prevalence of extraarticular impingement at the anteroinferior iliac spine compared with normal hips (48% [13 of 27 hips] versus 5% [one of 19 hips], p = 0.002). A PAO increased the prevalence of impingement for the femoral head from 30% (eight of 27 hips) preoperatively to 59% (16 of 27 hips) postoperatively (p = 0.027). IR in flexion was decreased in hips with a cam-type deformity compared with those with a spherical femoral head (p values from 0.002 to 0.047 for 95°-120° of flexion). A concomitant IO led to a normalization of ER in extension (eg, 37° ± 7° [range, 21°-41°] of ER in 0° of flexion in hips with concomitant IO compared with 38° ± 7° [range, 17°-41°] in nondysplastic control hips; p = 0.777). CONCLUSIONS Using computer simulation of hip ROM, we could show that the PAO has the potential to restore the typically excessive ROM in dysplastic hips. However, a PAO can increase the prevalence of secondary intraarticular impingement of the aspherical femoral head and extraarticular impingement of the anteroinferior iliac spines in flexion and internal rotation. A cam-type morphology can result in anterior impingement with restriction of IR. Additionally, a valgus hip with high antetorsion can result in posterior impingement with decreased ER in extension, which can be normalized with a varus derotation IO of the femur. However, indication of an additional IO needs to be weighed against its inherent morbidity and possible complications. The results are based on a limited number of hips with a pre- and postoperative CT scan after PAO. Future prospective studies are needed to verify the current results based on computer simulation and to test their clinical importance.

An Increased Iliocapsularis-to-rectus-femoris Ratio Is Suggestive for Instability in Borderline Hips

BACKGROUND The iliocapsularis muscle is an anterior hip structure that appears to function as a stabilizer in normal hips. Previous studies have shown that the iliocapsularis is hypertrophied in developmental dysplasia of the hip (DDH). An easy MR-based measurement of the ratio of the size of the iliocapsularis to that of adjacent anatomical structures such as the rectus femoris muscle might be helpful in everyday clinical use. QUESTIONS/PURPOSES We asked (1) whether the iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference is increased in DDH when compared with hips with acetabular overcoverage or normal hips; and (2) what is the diagnostic performance of these ratios to distinguish dysplastic from pincer hips? METHODS We retrospectively compared the anatomy of the iliocapsularis muscle between two study groups with symptomatic hips with different acetabular coverage and a control group with asymptomatic hips. The study groups were selected from a series of patients seen at the outpatient clinic for DDH or femoroacetabular impingement. The allocation to a study group was based on conventional radiographs: the dysplasia group was defined by a lateral center-edge (LCE) angle of < 25° with a minimal acetabular index of 14° and consisted of 45 patients (45 hips); the pincer group was defined by an LCE angle exceeding 39° and consisted of 37 patients (40 hips). The control group consisted of 30 asymptomatic hips (26 patients) with MRIs performed for nonorthopaedic reasons. The anatomy of the iliocapsularis and rectus femoris muscle was evaluated using MR arthrography of the hip and the following parameters: cross-sectional area, thickness, width, and circumference. The iliocapsularis-to-rectus-femoris ratio of these four anatomical parameters was then compared between the two study groups and the control group. The diagnostic performance of these ratios to distinguish dysplasia from protrusio was evaluated by calculating receiver operating characteristic (ROC) curves and the positive predictive value (PPV) for a ratio > 1. Presence and absence of DDH (ground truth) were determined on plain radiographs using the previously mentioned radiographic parameters. Evaluation of radiographs and MRIs was performed in a blinded fashion. The PPV was chosen because it indicates how likely a hip is dysplastic if the iliocapsularis-to-rectus-femoris ratio was > 1. RESULTS The iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference was increased in hips with radiographic evidence of DDH (ratios ranging from 1.31 to 1.35) compared with pincer (ratios ranging from 0.71 to 0.90; p < 0.001) and compared with the control group, the ratio of cross-sectional area, thickness, width, and circumference was increased (ratios ranging from 1.10 to 1.15; p ranging from 0.002 to 0.039). The area under the ROC curve ranged from 0.781 to 0.852. For a one-to-one iliocapsularis-to-rectus-femoris ratio, the PPV was 89% (95% confidence interval [CI], 73%-96%) for cross-sectional area, 77% (95% CI, 61%-88%) for thickness, 83% (95% CI, 67%-92%) for width, and 82% (95% CI, 67%-91%) for circumference. CONCLUSIONS The iliocapsularis-to-rectus-femoris ratio seems to be a valuable secondary sign of DDH. This parameter can be used as an adjunct for clinical decision-making in hips with borderline hip dysplasia and a concomitant cam-type deformity to identify the predominant pathology. Future studies will need to prove this finding can help clinicians determine whether the borderline dysplasia accounts for the hip symptoms with which the patient presents. LEVEL OF EVIDENCE Level III, prognostic study.

Impact of platelet rich plasma and adipose stem cells on lymphangiogenesis in a murine tail lymphedema model.

BACKGROUND Lymphedema is an underdiagnosed pathology which in industrialized countries mainly affects cancer patients that underwent lymph node dissection and/or radiation. Currently no effective therapy is available so that patients' life quality is compromised by swellings of the concerned body region. This unfortunate condition is associated with body imbalance and subsequent osteochondral deformations and impaired function as well as with an increased risk of potentially life threatening soft tissue infections. METHODS The effects of PRP and ASC on angiogenesis (anti-CD31 staining), microcirculation (Laser Doppler Imaging), lymphangiogenesis (anti-LYVE1 staining), microvascular architecture (corrosion casting) and wound healing (digital planimetry) are studied in a murine tail lymphedema model. RESULTS Wounds treated by PRP and ASC healed faster and showed a significantly increased epithelialization mainly from the proximal wound margin. The application of PRP induced a significantly increased lymphangiogenesis while the application of ASC did not induce any significant change in this regard. CONCLUSIONS PRP and ASC affect lymphangiogenesis and lymphedema development and might represent a promising approach to improve regeneration of lymphatic vessels, restore disrupted lymphatic circulation and treat or prevent lymphedema alone or in combination with currently available lymphedema therapies.

Local Heat Application for the Treatment of Buruli Ulcer: Results of a Phase II Open Label Single Center Non Comparative Clinical Trial.

BACKGROUND Buruli ulcer (BU) is a necrotizing skin disease most prevalent among West African children. The causative organism, Mycobacterium ulcerans, is sensitive to temperatures above 37°C. We investigated the safety and efficacy of a local heat application device based on phase change material. METHODS In a phase II open label single center noncomparative clinical trial (ISRCTN 72102977) under GCP standards in Cameroon, laboratory confirmed BU patients received up to 8 weeks of heat treatment. We assessed efficacy based on the endpoints 'absence of clinical BU specific features' or 'wound closure' within 6 months ("primary cure"), and 'absence of clinical recurrence within 24 month' ("definite cure"). RESULTS Of 53 patients 51 (96%) had ulcerative disease. 62% were classified as World Health Organization category II, 19% each as category I and III. The average lesion size was 45 cm(2). Within 6 months after completion of heat treatment 92.4% (49 of 53, 95% confidence interval [CI], 81.8% to 98.0%) achieved cure of their primary lesion. At 24 months follow-up 83.7% (41 of 49, 95% CI, 70.3% to 92.7%) of patients with primary cure remained free of recurrence. Heat treatment was well tolerated; adverse effects were occasional mild local skin reactions. CONCLUSIONS Local thermotherapy is a highly effective, simple, cheap and safe treatment for M. ulcerans disease. It has in particular potential as home-based remedy for BU suspicious lesions at community level where laboratory confirmation is not available. CLINICAL TRIALS REGISTRATION ISRCT 72102977.

Evaluation of the Morphological Characteristics of Laser-Irradiated Dentin

OBJECTIVE The aim of this study was to investigate the effect of different energy settings of Er:YAG laser irradiation on dentin surface morphology with respect to the number of opened dentinal tubules. BACKGROUND DATA An ideally prepared dentin surface with opened dentinal tubules is a prerequisite for adhesive fixation. No study, however, has yet compared the numbers of opened dentinal tubules with regard to statistical differences. METHODS Conventional preparations using a bur with or without additional acid etching acted as control groups. Dentin specimens were prepared from human third molars and randomly divided into eight groups according to the energy settings of the laser (1, 1.5, 4, 6, 7.5, and 8 W) and two controls (bur and bur plus acid etching). After surface preparation, dentin surfaces were analyzed with a scanning electron microscope, and the number of opened dentinal tubules in a defined area was counted. RESULTS The control groups showed smooth surfaces with (bur plus acid etching) and without opened dentinal tubules (bur), whereas all laser-irradiated surfaces showed rough surfaces. Using the energy setting of 4 W resulted in significantly more opened dentinal tubules than the conventional preparation technique using the bur with additional acid etching. In contrast, the energy setting of 8 W showed significantly fewer opened dentinal tubules, and also exhibited signs of thermal damage. CONCLUSIONS The Er:YAG laser with an energy setting of 4 W generates a dentin surface with opened dentinal tubules, a prerequisite for adhesive fixation.

Preußisch-deutsche Einigkeits-Hymne: Mel.: Was ist des Deutschen Vaterland? Wann kam der Feind in's Deutsche Land? Wann traf uns Schmach? wann traf uns Schand'? ...

Welsch (Projektbearbeiter): Aufruf zur Einigkeit Gesamtdeutschlands und zur Überwindung partikularstaatlicher Egoismen: "Wir woll'n in Preußen Deutsche sein." In Umformung des von Gustav Reichardt vertonten Gedichtes 'Was ist des Teutschen Vaterland?' von Ernst Moritz Arndt

Protrusio acetabuli: joint loading with severe pincer impingement and its theoretical implications for surgical therapy

Severe pincer impingement (acetabular protrusio) is an established cause of hip pain and osteoarthritis. The proposed underlying pathomechanism is a dynamic pathological contact of the prominent acetabular rim with the femoral head-neck junction. However, this cannot explain the classically described medial osteoarthritis in these hips. We therefore asked: (1) Does an overload exist in the medial aspect of the protrusio joint? and (2) What is the influence of three contemporary joint-preserving procedures on load distribution in protrusio hips? In vivo force and motion data for walking and standing to sitting were applied to six 3D finite element models (normal, dysplasia, protrusio, acetabular rim trimming, acetabular reorientation, and combined reorientation/rim trimming). Compared with dysplasia, the protrusio joint resulted in opposite patterns of von Mises stress and contact pressure during walking. In protrusio hips, we found an overload at the medial margin of the lunate surface (54% higher than normal). Isolated rim trimming further increased the medial overload (up to 28% higher than protrusio), whereas acetabular reorientation with/without rim trimming reduced stresses by up to 25%. Our results can be used as an adjunct for surgical decision making in the treatment of acetabular protrusio.

Hemodynamics analyses in treated and untreated carotid arteries of the same patient: A preliminary study based on three patient cases

Carotid atherosclerotic disease is highly related to cerebrovascular events. Carotid endarterectomy is the common operation method to treat this disease. In this study, hemodynamics analyses are performed on the carotid arteries in three patients, whose right carotid artery had been treated by carotid endarterectomy and the left carotid artery remained untreated. Flow and loading conditions are compared between these treated and untreated carotid arteries and evaluation of the operative results is discussed. Patient-specific models are reconstructed from MDCT data. Intraoperative ultrasound flow measurements are performed on the treated carotid arteries and the obtained data are used as the boundary conditions of the models and the validations of the computational results. Finite volume method is employed to solve the transport equations and the flow and loading conditions of the models are reported. The results indicate that: (i) in two of the three patients, the internal-to-external flow rate ratio in the untreated carotid artery is larger than that in the treated one, and the average overall flow split ratio by summing up the data of both the left and right carotid arteries is about 2.15; (ii) in the carotid bulb, high wall shear stress occurs at the bifurcation near the external carotid artery in all of the cases without hard plaques; (iii) the operated arteries present low time-averaged wall shear stress at the carotid bulb, especially for the treated arteries with patch technique, indicating the possibility of the recurrence of stenosis; (iv) high temporal gradient of wall shear stress (>35 Pa/s) is shown in the narrowing regions along the vessels; and (v) in the carotid arteries without serious stenosis, the maximum velocity magnitude during mid-diastole is 32~37% of that at systolic peak, however, in the carotid artery with 50% stenosis by hard plaques, this value is nearly doubled (64%). The computational work quantifies flow and loading distributions in the treated and untreated carotid arteries of the same patient, contributing to evaluation of the operative results and indicating the recurrent sites of potential atheromatous plaques.

Der Doctrinair : Meine Herren! Ich gebe es Ihnen zu, es hat uns eine glückliche ... ; (56te Sitzung)

Welsch (Projektbearbeiter): Mann am Rednerpult. Karikatur, laut handschriftlichem Vermerk auf den Abgeordneten der Frankfurter Nationalversammlung Moriz Mohl [Veit, V.: Frankfurt a. M. u. d. Rev.; 1908, S. 538].

Computer Assisted Diagnosis and Treatment Planning of Femoroacetabular Impingement (FAI)

Femoroacetabular impingement (FAI) is a dynamic conflict of the hip defined by a pathological, early abutment of the proximal femur onto the acetabulum or pelvis. In the past two decades, FAI has received increasing focus in both research and clinical practice as a cause of hip pain and prearthrotic deformity. Anatomical abnormalities such as an aspherical femoral head (cam-type FAI), a focal or general overgrowth of the acetabulum (pincer-type FAI), a high riding greater or lesser trochanter (extra-articular FAI), or abnormal torsion of the femur have been identified as underlying pathomorphologies. Open and arthroscopic treatment options are available to correct the deformity and to allow impingement-free range of motion. In routine practice, diagnosis and treatment planning of FAI is based on clinical examination and conventional imaging modalities such as standard radiography, magnetic resonance arthrography (MRA), and computed tomography (CT). Modern software tools allow three-dimensional analysis of the hip joint by extracting pelvic landmarks from two-dimensional antero-posterior pelvic radiographs. An object-oriented cross-platform program (Hip2Norm) has been developed and validated to standardize pelvic rotation and tilt on conventional AP pelvis radiographs. It has been shown that Hip2Norm is an accurate, consistent, reliable and reproducible tool for the correction of selected hip parameters on conventional radiographs. In contrast to conventional imaging modalities, which provide only static visualization, novel computer assisted tools have been developed to allow the dynamic analysis of FAI pathomechanics. In this context, a validated, CT-based software package (HipMotion) has been introduced. HipMotion is based on polygonal three-dimensional models of the patient’s pelvis and femur. The software includes simulation methods for range of motion, collision detection and accurate mapping of impingement areas. A preoperative treatment plan can be created by performing a virtual resection of any mapped impingement zones both on the femoral head-neck junction, as well as the acetabular rim using the same three-dimensional models. The following book chapter provides a summarized description of current computer-assisted tools for the diagnosis and treatment planning of FAI highlighting the possibility for both static and dynamic evaluation, reliability and reproducibility, and its applicability to routine clinical use.

Reimchronik des Pfaffen Maurizius

Boberach: Die Schwäche des deutschen Liberalismus und prominente Mitglieder der Nationalversammlung, vor allem Gagern, werden angegriffen. - Welsch (Projektbearbeiter): "... im heinesierenden Chronikenstil gehaltene satirische Fresken aus der Paulskirche" [Meyers Konv.-Lex., 6. Aufl.] des Dichters und Abgeordneten der Frankfurter Nationalversammlung Hartmann

Der Rabbiner Samuel Belassar in Regensburg und seine Sabbatstube

Moritz Stern

Zu den Wormser Dokumenten (Jahrgg. 3, S. 227)

Moritz Stern

Der Wormser Reichsrabbiner Anselm

Moritz Stern

Surgical Technique: Reverse Periacetabular Osteotomy

Acetabular retroversion is the result of an externally rotated hemipelvis rather than a focal overgrowth of the anterior wall and/or hypoplasia of the posterior wall. Acetabular retroversion is a cause of pincer impingement which, if left untreated, can lead to hip pain and osteoarthritis. The causal surgical treatment in hips with acetabular retroversion is acetabular reorientation with a reverse periacetabular osteotomy (PAO). Indication is based on a positive correlation among symptoms (typically groin pain), physical findings on examination (positive anterior impingement test and decreased flexion and internal rotation), and radiographic signs for acetabular retroversion. These include a positive crossover, posterior wall, and ischial spine sign. A reverse PAO is performed with four osteotomies and a controlled fracture. Unlike reorientation of the acetabular fragment in dysplastic hips, correction for acetabular retroversion is achieved by a combined extension and internal rotation of the acetabular fragment. Typically, a small supra-acetabular wedge resection is required to allow sufficient extension of the fragment. The quality of acetabular reorientation is evaluated by intraoperative AP pelvic radiographs. In addition, intraoperative testing of range of motion following acetabular reorientation is mandatory. An arthrotomy and offset correction of the femoral head-neck area is indicated in hips with decreased internal rotation following acetabular reorientation. In a 10-year follow-up study of reverse PAO, a favorable outcome with preservation of all native joints was found. Correct acetabular orientation and, if necessary, a concomitant offset correction were the keys of successful outcome.