Retrospektive Analyse zum onkologischen Patientengut (1992 – 2001) der Hals-, Nasen-, Ohrenklinik im Kenyatta National Hospital, Nairobi, Kenia

Das Kenyatta National Hospital (KNH) ist das Gesundheitszentrum, zu dem die Kenianer und teilweise auch Kranke aus den benachbarten Ländern kommen, wenn den Ärzten in den so genannten District Hospitals die Möglichkeiten zur weiteren Diagnostik und Behandlung fehlen. Es gibt es enorme Probleme, die so große Anzahl von Patienten zu versorgen. Das liegt zum einen an organisatorischen Defiziten, zum anderen an mangelnden Personal-, Material- und Platzressourcen. Nicht selten sterben Patienten allerdings, bevor sie von einem Arzt aufgenommen werden können. Dies gilt auch für Patienten mit fortgeschrittener Krebserkrankung. Ziel der vorliegenden Dissertation war eine erstmalige Datenerhebung zum onkologischen Patientengut der Abteilung für Hals-, Nasen- und Ohrenheilkunde am KNH Nairobi, vorgenommen im Rahmen eines Kooperationsprojektes mit der Marburger Univ.-HNO-Klinik. In diesem Rahmen sollte zudem die Infrastruktur der HNO-Abteilung hinterfragt werden, die über 40 Betten verfügt und im KNH der Chirurgischen Klinik unterstellt ist. Für die vorliegende Arbeit wurden 443 Akten von Patienten mit malignen Tumorerkrankungen im HNO-Bereich aus den Jahren von 1992–2001 erfasst und die erhobenen Daten anhand eines eigens entworfenen Fragebogens verschlüsselt und ausgewertet. In dem untersuchten Patientengut waren 75,6 % Männer. Der Altersdurchschnitt aller Patienten lag bei 48 Jahren (Standardabweichung ± 18,4 Jahre). Die malignen Tumoren waren wie folgt lokalisiert: 44,7 % im Epipharynx, 25,1 % im Larynx, 7,5 % im Hypopharynx, 5,6 % im Oropharynx und 5,4 % im Ösophagus. Insgesamt 11,7 % der 443 Patienten waren an einem an anderer Stelle lokalisierten Malignom erkrankt. Zur TNM-Klassifikation ist anzumerken, dass die Erstdiagnose in 75 % der Fälle im fortgeschrittenen Stadium (T3 und T4) gestellt wurde. In 23,9 % der Fälle wurde die Tumorgröße mit T1 und T2 angegeben. Die Symptome bestanden im Mittel schon 26 Wochen vor dem ersten Arztbesuch. Die bis zur Diagnosestellung benötigte Zeit lag im KNH im Median bei 13 Tagen. Die maligne Tumorerkrankung wurde in 81,9 % der Fälle durch Biopsie und histopathologische Begutachtung verifiziert. In 11,1 % der Fälle wurde die Diagnose nur durch Inspektion und Palpation gestellt und in 3,8 % anhand spezieller Bildgebung. Die histopathologische Begutachtung wurde im einzigen öffentlichen Pathologischen Institut Kenias im KNH vorgenommen. 53 % der Patienten mit Biopsieergebnis wiesen ein Plattenepithelkarzinom auf, 39,5 % ein lymphoepitheliales Karzinom. Ein hoher Anteil von 27,1 % der 443 onkologischen Patienten wurde ohne Therapie wieder entlassen. Der häufigste Grund hierfür waren die finanziellen Nöte der Patienten. Der Staat übernahm die Kosten für die Behandlung erst nach erwiesener Zahlungsunfähigkeit der gesamten Großfamilie, ein Nachweis, die teilweise außerordentlich schwierig zu stellen ist. Um Kosten zu sparen, wurde die Versorgung der Patienten mit Lebensmitteln und frischer Wäsche meist von den Angehörigen übernommen. Von den verbleibenden 323 Patienten wurden 79,9 % einer Strahlentherapie zugeführt, 11,1 % wurden operiert, 4,6 % der Patienten erhielten eine Chemotherapie und bei 4,4 % der Patienten wurde eine kombinierte Radiochemotherapie vorgenommen. Nachsorgeuntersuchungen wurden im KNH wegen fehlender Kapazitäten, hoher Kosten für die Patienten und organisatorischer Probleme in nur 54,8 % der therapierten Fälle durchgeführt. Die mit der vorliegenden Arbeit erstmals vorgenommene Datenerfassung zum onkologischen Patientengut der HNO-Abteilung am KNH in Nairobi kann dazu beitragen, die gemeinsam mit der Marburger Universitäts-HNO-Klinik angestrebte weitere, auch interdisziplinär vorzunehmende Optimierung im Diagnostik- und Behandlungsablauf voranzutreiben. Während finanzielle Probleme auf diesem Wege kaum nachhaltig verbessert werden können, sind es zunächst organisatorische Abläufe, die es tiefergehend zu hinterfragen gilt. Eine Fortsetzung der Erfassung statistischer Daten ermöglicht zudem die erstmalige Erstellung prognostisch relevanter Überlebenskurven

Proximal interphalangeal joint replacement with an unconstrained pyrocarbon prosthesis (Ascension(R)): a long-term follow-up

There have been limited publications that report long-term outcomes of pyrocarbon implants. This report describes both clinical and radiographic long-term results for patients who have been treated with pyrocarbon proximal interphalangeal implants. Thirteen implants in ten patients are reported for an average follow-up of 8.3 years (range 6.2–9.3). All patients were suffering from degenerative joint disease. Five of the 13 digits were free of pain, the remaining eight digits had mild to moderate pain (visual analogue scale 2–5). The average active range of motion was 58° (SD 19°) at latest examination. X-ray results were unremarkable in six digits with an acceptable position of the prosthesis. However, in seven patients significant radiolucent lines (≥ 1 mm) were observed. Three prostheses demonstrated a migration of the proximal component, and one a subsidence of the distal component. Our study does not support the use of this implant for treatment of osteoarthritis of the finger joint owing to high complication rates and limited range of motion

Native femoral anteversion should not be used as reference in cementless total hip arthroplasty with a straight, tapered stem: a retrospective clinical study

Backround: Improper femoral and acetabular component positioning can be associated with instability, impingement, component wear and finally patient dissatisfaction in total hip arthroplasty (THA). The concept of "femur first"/" combined anteversion", incorporates various aspects of performing a functional optimization of the prosthetic stem and cup position of the stem relative to the cup intraoperatively. In the present study we asked two questions: (1) Do native femoral anteversion and anteversion of the implant correlate? (2) Do anteversion of the final broach and implant anteversion correlate? Methods: In a secondary analysis of a prospective controlled trial, a subgroup of 55 patients, who underwent computer-assisted, cementless THA with a straight, tapered stem through an anterolateral, minimally invasive (MIS) approach in a lateral decubitus position were examined retrospectivly. Intraoperative fluoroscopy was used to verify a "best-fit" position of the final broach. An image-free navigation system was used for measurement of the native femoral version, version of the final broach and the final implant. Femoral neck resection height was measured in postoperative CT-scans. This investigation was approved by the local Ethics Commission (No. 10-121-0263) and is a secondary analysis of a larger project (DRKS00000739, German Clinical Trials Register May-02-2011). Results: The mean difference between native femoral version and final implant was 1.9 degrees (+/-9.5), with a range from -20.7 degrees to 21.5 degrees and a Spearman's correlation coefficient of 0.39 (p < 0.003). In contrast, we observed a mean difference between final broach and implant version of -1.9 degrees (+/-3.5), with a range from -12.7 degrees to 8.7 degrees and a Spearman's correlation coefficient of 0.89 (p < 0.001). In 83.6 % (46/55) final stem version was outside the normal range as defined by Tonnis (15-20 degrees). The mean femoral neck resection height was 7.3 mm (+/-5.6). There was no correlation between resection height and version of the implant (Spearman's correlation coefficient 0.14). Conclusion: Native femoral version significantly differs from the final anteversion of a cementless, straight, tapered stem and therefore is not a reliable reference in cementless THA. Measuring anteversion of the final "fit and fill" broach is a feasible assistance in order to predict final stem anteversion intraoperatively. There is no correlation between femoral neck resection height and version of the implant

Efficacy of antibiotic treatment of implant-associated Staphylococcus aureus infections with moxifloxacin, flucloxacillin, rifampin, and combination therapy: an animal study

The efficacy of antibiotic monotherapy and combination therapy in the treatment of implant-associated infection by Staphylococcus aureus was evaluated in an animal study. The femoral medullary cavity of 66 male Wistar rats was contaminated with S. aureus (ATCC 29213) and a metal device was implanted, of which 61 could be evaluated. Six treatment groups were studied: flucloxacillin, flucloxacillin in combination with rifampin, moxifloxacin, moxifloxacin in combination with rifampin, rifampin, and a control group with aqua. The treatment was applied for 14 days. After euthanasia, the bacterial counts in the periprosthetic bone, the soft tissue, and the implant-associated biofilm were measured. Both antibiotic combination treatments (moxifloxacin plus rifampin and flucloxacillin plus rifampin) achieved a highly significant decrease in microbial counts in the bone and soft tissue and in the biofilm. Mono-antibiotic treatments with either moxifloxacin or flucloxacillin were unable to achieve a significant decrease in microbial counts in bone and soft tissue or the biofilm, whilst rifampin was able to reduce the counts significantly only in the biofilm. Antibiotic resistance was measured in 1/3 of the cases in the rifampin group, whereas no resistance was measured in all other groups. The results show that combinations of both moxifloxacin and flucloxacillin plus rifampin are adequate for the treatment of periprosthetic infections due to infections with S. aureus, whereas monotherapies are not effective or not applicable due to the rapid development of antibiotic resistance. Therefore, moxifloxacin is an effective alternative in combination with rifampin for the treatment of implant-associated infections

Development and evaluation of an image-free computer-assisted impingement detection technique for total hip arthroplasty

Periprosthetic or bony impingement in total hip arthroplasty (THA) has been correlated to dislocation, increased wear, reduced postoperative functionality with pain and/or decreased range of motion (ROM). We sought to study the accuracy and assess the reliability of measuring bony and periprosthetic impingement on a virtual bone model prior to the implantation of the acetabular cup with the help of image-free navigation technology in an experimental cadaver study. Impingement-free ROM measurements were recorded during minimally invasive, computer-assisted THA on 14 hips of 7 cadaveric donors. Preoperatively and postoperatively the donors were scanned using computed tomography (CT). Impingement-free ROM on three-dimensional CT-based models was then compared with corresponding, intraoperative navigation models. Bony/periprosthetic impingement can be detected with a mean accuracy limit of below 5° for motion angles, which should be reached after THA for activities of daily living with the help of image-free navigation technology

Reproducibility of navigation based kinematic analysis of the knee – A cadaveric investigation

Purpose: Several navigation-based kinematic studies of the knee have been published recently, but little information is available about reproducibility and reliability of the acquired data. The aim of the present study first is to determine reproducibility and reliability of kinematical measurements of healthy knees and knees after TKA (total knee arthroplasty) with regards to rotational and translational measurement parameters. Second the mathematical background, applicability, and limitations of investigating navigation-based kinematics should be compiled. Methods: Using cadavers fixed by the Thiel method, in ten knees reproducibility of obtained angular and translational kinematic parameters were investigated before and after total knee arthroplasty. For this reason agreement of obtained data of a first and a second movement cycle and the same after a surgical intervention was assessed using a commercially available navigational device. Results: For both angular and translational parameters in healthy knees and knees after total knee arthroplasty mean differences between measured parameters of the first and second movement cycle and after surgical intervention of less than 0.5 degrees or millimeters (standard deviation 1.3 or less) or a inter class correlation of 0.92 and more, respectively, was found. Discussion: Use of a commercial navigation system allows highly accurate investigations of knee kinematics in cadavers before and after TKA. This technique, which does not require any specific technical knowledge of the investigator, is in accordance with current accepted biomechanical methods. (C) 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved

Significant influence of rotational limb alignment parameters on patellar kinematics: an in vitro study

Component malrotation has a major impact on patellar kinematics in total knee arthroplasty. The influence of natural rotational limb alignment on patellar kinematics is unclear so far. Based on recent clinical investigations, we hypothesized that rotational limb alignment significantly influences patellar kinematics. Patellar kinematics of ten cadaveric knees was measured using computer navigation during passive motion. Data were correlated with different rotational limb alignment parameters of preoperative CT scans. Femoral antetorsion showed a significant influence on patellar rotation, while tibial tubercle-posterior cruciate ligament distance additionally displayed a significant influence on patellar mediolateral shift (p < 0.05). Femoral posterior condylar angle was sensitive to patellar epicondylar distance, rotation and tilt (p < 0.05). Patellar rotation was influenced by five out of eight rotational limb alignment parameters (p < 0.05). Rotational limb alignment should be paid more attention in terms of clinical evaluation of patellar tracking and future biomechanical and clinical investigations

Total Knee Arthroplasty Violates the Law of Burmester—A Biomechanical Investigation

Background: Kinematic patterns of knees after total knee arthroplasty (TKA) are different from those of healthy knees. We hypothesised that these changes cause a relevant shift in the medial and lateral epicondyles and, consequently, the insertion sites of the collateral ligaments. Any alterations, however, violate the law of Burmester, which states a close relation between the course of the collateral and cruciate ligaments, and the articular surfaces. Methods: Ten healthy knees of whole body cadavers were investigated. The positions of the medial and lateral epicondyles in relation to the tibia were compared before and after cruciate retaining fixed bearing TKA between 0 and 90° of flexion using a navigational device. Results: After TKA, the medial and lateral epicondyles significantly shifted laterally (~3–5mm) between 0° and 40° of flexion. Additionally, the lateral epicondyle was located significantly more dorsal (~3–5mm) during 0° and 20° of flexion and significantly shifted proximally (~2.5–3mm) between 0° and 30° of flexion. Conclusions: By changing the epicondylar positions relative to the articular surfaces, the law of Burmester is violated in the present study setting. This might explain the impairment in motion, instability, or mid-flexion instability and the persistent pain in the knees after TKA

Changes in sagittal component alignment alters patellar kinematics in TKA: an in vitro study

Patellar maltracking due to incorrect component alignment is considered as a main reason for anterior knee pain after total knee arthroplasty (TKA). In contrast to coronal and axial component placement, the influence of sagittal component alignment on patellar kinematics has not been investigated so far. In ten lower cadaveric limbs, TKAs were implanted using a commercial computer navigation system. In six knees, the femoral component was aligned in 5A degrees and in four knees in 0A degrees of flexion, respectively. Patellar kinematics were registered by means of a computer navigation system using an additional patella tracking array and correlated with femoral and tibial sagittal component alignment. Sagittal component alignment significantly altered patellar mediolateral shift (p < 0.05). In contrast, patellar epicondylar distance, rotation and tilt were not significantly influenced. Sagittal component alignment in TKA has a major impact on patellar kinematics and should therefore be considered while addressing tibiofemoral kinematics intraoperatively