Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms

Purpose: The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. Methods: In this case–control study, n=36 patients with a preoperative mechanical tibiofemoral angle (mTFA)≥15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA<15°) of n=60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). Results: The degree of correcting the mTFA by TKA signifcantly correlated with the postoperative FFI (R=0.95, p<0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-of value of 16.5° [AUC 0.912 (0.85–0.975 95% CI), sensitivity=0.8, specifcity=0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10–127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong sig nifcant correlation with the FFI (R=0.74, p<0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. Conclusions: In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stif subtalar joint. Level of evidence III

Limitations of the MELD score in predicting mortality or need for removal from waiting list in patients awaiting liver transplantation

<p>Abstract</p> <p>Background</p> <p>Decompensated cirrhosis is associated with a poor prognosis and liver transplantation provides the only curative treatment option with excellent long-term results. The relative shortage of organ donors renders the allocation algorithms of organs essential. The optimal strategy based on scoring systems and/or waiting time is still under debate.</p> <p>Methods</p> <p>Data sets of 268 consecutive patients listed for single-organ liver transplantation for nonfulminant liver disease between 2003 and 2005 were included into the study. The Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores of all patients at the time of listing were used for calculation. The predictive ability not only for mortality on the waiting list but also for the need for withdrawal from the waiting list was calculated for both scores. The Mann-Whitney-U Test was used for the univariate analysis and the AUC-Model for discrimination of the scores.</p> <p>Results</p> <p>In the univariate analysis comparing patients who are still on the waiting list and patients who died or were removed from the waiting list due to poor conditions, the serum albumin, bilirubin INR, and CTP and MELD scores as well as the presence of ascites and encephalopathy were significantly different between the groups (p < 0.05), whereas serum creatinine and urea showed no difference.</p> <p>Comparing the predictive abilities of CTP and MELD scores, the best discrimination between patients still alive on the waiting list and patients who died on or were removed from the waiting list was achieved at a CTP score of ≥9 and a MELD score of ≥14.4. The sensitivity and specificity to identify mortality or severe deterioration for CTP was 69.0% and 70.5%, respectively; for MELD, it was 62.1% and 72.7%, respectively. This result was supported by the AUC analysis showing a strong trend for superiority of CTP over MELD scores (AUROC 0.73 and 0.68, resp.; p = 0.091).</p> <p>Conclusion</p> <p>The long term prediction of mortality or removal from waiting list in patients awaiting liver transplantation might be better assessed by the CTP score than the MELD score. This might have implications for the development of new improved scoring systems.</p

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Reduced seizure susceptibility of chronic epileptic tissue

Chronisch epileptisches Gewebe zeigt oftmals eine verringerte Empfindlichkeit gegenüber konvulsiven Substanzen. Ich habe nach Ursachen für diese erhöhte Krampfschwelle gesucht. Der neuronale Zellverlust in der Schicht III des medialen entorhinalen Cortex (MEC) wurde im Kainat - Modell für die mesiale Temporallappenepilepsie reproduziert. Nach Stimulation konnten in den oberflächlichen Schichten des MEC hochfrequente Potentiale registriert werden; diese Entladungen wurden durch Unterbrechung der glutamatergen Transmission blockiert. Im Gegensatz zu Kontrollgewebe hatte Bicucullin im Gewebe der epileptischen Tiere eine verringerte Wirkung auf die stimulationsinduzierten Feldpotentiale. Eine in situ Hybridisierung von GAD 65/67 zeigte eine konstante Zahl an Interneuronen in den Schichten II und III des MEC. 4-Aminopyridin (4-AP) induzierte im entorhinalen und perirhinalen Cortex im Gewebe der Kontrolltiere seizure like events (SLEs). Im Gegensatz hierzu konnten durch 4-AP in Gewebe chronisch epileptischer Tiere keine SLEs hervorgerufen werden. Real time PCR zeigte keine signifikante Herunterregulation der für 4-AP hochaffinen Kanäle im Subiculum, entorhinalen und perirhinalen Cortex von chronisch epileptischen Ratten. Die Expression der Kv3.4-Untereinheiten, welche erst im millimolaren Bereich durch 4-AP beeinflußt werden, war in diesen Regionen reduziert. Die Ergebnisse konnten durch immunzytochemische Antikörperfärbungen bestätigt werden. Elektrophysiologische in vitro Experimente mit Hirngewebe werden normalerweise in artefizieller zerebrospinaler Flüssigkeit durchgeführt, welche keine Aminosäuren enthält. Nach Substitution von Glutamin wurde im MEC chronisch epileptischer Ratten epileptiforme Aktivität beobachtet. In Präparaten von Kontrolltieren konnten diese Entladungen nicht registriert werden. Die Potentiale waren auf den MEC beschränkt, wurden durch einen AMPA / Kainat - Rezeptor Antagonisten attenuiert und durch Inhibition der neuronalen Glutaminaufnahme unterdrückt. Bicucullinmethiodid verstärkte die Entladungen. Die Übererregbarkeit der Neurone in Schicht II des MEC ist nicht durch einen Verlust der GABAergen Interneurone bedingt und resultiert möglicherweise in Alterationen der synaptischen Konnektivität innerhalb der oberflächlichen Schichten des MEC. Die Beobachtungen suggerieren Reorganisationsvorgänge im entorhinalen Cortex und Veränderungen der homeostatischen Plastizität, welche antikonvulsive Effekte aufweisen.Electrographically recorded spontaneous interictal and ictal activity are characteristic signs of epilepsy in humans and animals. Spontaneous epileptiform discharges have been observed rarely in combined entorhinal cortex hippocampal slices from chronic epileptic animals, although hyperexcitability of superficial layer neurons in the entorhinal cortex (EC) has been demonstrated. We could demonstrate that hyperexcitability in superficial medial EC (MEC) neurons is not due to loss of GABAergic interneurons and probably results from alterations in synaptic connectivity within superficial MEC. We investigated the potential of 4-AP (50–100 μM) to induce seizure like events (SLEs). 4-AP failed to induce SLEs in slices from chronic epileptic kainate treted rats except for one slice from one rat. This animal displayed only minor cell loss in layer III of the entorhinal cortex, in contrast to the other epileptic rats for which layer III neuronal loss was extensive. 4-AP at 50–100 μM likely affects potassium channels containing Kv1.4, Kv1.5, Kv3.1 or Kv3.2 subunits. The expression of Kv3.4 – an A-tpe current, responding to 4-AP in mM range - was significantly reduced. Using sub-unit-specific antibodies, the real-time PCR findings were confirmed by immunocytochemistry. We suggest that after chronic epilepsy, reorganization in the entorhinal cortex is accompanied by adaptations in homeostatic plasticity with anticonvulsant consequences. Electrophysiological Experiments are usually performed in artificial cerebrospinal fluid (aCSF) kept free of amino acids. Therefore, the role of glutamine (GLN), remains unclear. We evaluate whether combined entorhinal cortex hippocampal slices from pilocarpine-treated epileptic rats recover the ability to generate recurrent epileptiform discharges when perfused with aCSF containing GLN. In combined entorhinal hippocampal slices from chronic epileptic animals, GLN induces glutamatergic recurrent epileptiform discharges via neuronal uptake in superficial layers of the MEC where inhibitory function seemed to be partially preserved

Influence of spino-pelvic interactions on the functional anatomy of the lower limb

In dieser Habilitationsschrift wurde die klinische Relevanz spino-pelviner Interaktionen und der funktionellen Anatomie der unteren Extremität erörtert. Erstmals konnte gezeigt werden, dass spezifische degenerative Veränderungen der Wirbelsäule mit der anatomischen Beckenform assoziiert sind. Die postoperative individuelle spino-pelvine Kinematik ist von der operativen Rekonstruktion der lumbalen Lordose abhängig. Die Beckenkippung beeinflusst die azetabuläre Orientierung und kompensiert eine erhöhte azetabuläre Anteversion. Eine korrekte individuelle azetabuläre Orientierung ist nur unter Berücksichtigung der Beckenkippung und spino-pelvinen Kinematik möglich. Die mechanische Beinachse wird durch die physikalische Krafteinwirkung beeinflusst und kann nur unter physiologischer Belastung reliabel erfasst werden. Innerhalb der gesamten Dimension des medizinischen Fortschrittes kann die Evaluation der klinischen Relevanz funktioneller anatomischer Interaktionen die Optimierung existierender und Konzeption neuer Behandlungsstrategien von Pathologien des Bewegungsapparats ermöglichen

Accuracy of tibial positioning in the frontal plane: a prospective study comparing conventional and innovative techniques in total knee arthroplasty

Background: Coronal alignment of the tibial component determines functional outcome and survival in total knee arthroplasty (TKA). Innovative techniques for tibial instrumentation have been developed to improve accuracy and reduce the rate of outliers. Methods In a prospective study, 300 patients were allocated to four different groups using a randomization process (two innovative and two conventional) techniques of tibial instrumentation (conventional: extramedullary, intramedullary; innovative: navigation and patient-specific instrumentation (PSI); n = 75 for each group). The aims were to reconstruct the medial proximal tibial angle (MPTA) to 90° and the mechanical tibio-femoral axis (mTFA) to 0°. Both angles were evaluated and compared between all groups three months after the surgery. Patients who presented with a postoperative mTFA > 3° were classified as outliers. Results: The navigation and intramedullary technique both demonstrated that they were significantly more precise in reconstructing a neutral mTFA and MPTA compared to the other two techniques. The odd’s ratio (OR) for producing outliers was highest for the PSI method (PSI OR = 5.5, p  0.05; intramedullary positioning OR = 1.7, p > 0.05; navigation OR = 0.04, p < 0.05). We could only observe significant differences between pre- and postoperative MPTA in the navigation and intramedullary group. The MPTA showed a significant negative correlation with the mTFA in all groups preoperatively and in the extramedullary, intramedullary and PSI postoperatively. Conclusion: The navigation and intramedullary instrumentation provided the precise positioning of the tibial component. Outliers were most common within the PSI and extramedullary technique. Optimal alignment is dependent on the technique of tibial instrumentation and tibial component positioning determines the accuracy in TKA since mTFA correlated with MPTA pre- and postoperatively

Transversus Abdominis Plane Block Reduces Intraoperative Opioid Consumption in Patients Undergoing Periacetabular Osteotomy

Background: Administering intraoperative analgesia in patients undergoing periacetabular osteotomy (PAO) is challenging due to both the relevant surgical approach and osteotomies, which are associated with pain. The aim of this study was to assess the effect of the transversus abdominis plane block (TAPb) on intraoperative opioid consumption and circulation parameters in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial involving 42 consecutive patients undergoing PAO for symptomatic developmental dysplasia of the hip (DDH) in our department. Patients assigned to the study group received an ultrasound-guided TAPb with 0.75% ropivacaine before the beginning of the surgery and after general anesthesia induction. Patients assigned to the control group did not receive a TAPb. General anesthesia was conducted according to a defined study protocol. The primary endpoint of the study was the intraoperative opioid consumption, measured in morphine equivalent dose (MED). Secondary endpoints were the assessment of intraoperative heart rate, mean arterial pressure (MAP), need for hypotension treatment, and length of hospital stay (LOHS). A total of 41 patients (n = 21 TAPb group, n = 20 control group) completed the study; of these, 33 were women (88.5%) and 8 were men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All operations were performed by a single high-volume surgeon and all TAPb procedures were performed by a single experienced senior anesthesiologist. Results: We observed a significantly lower intraoperative opioid consumption in the TAPb group compared to the control group (930 vs. 1186 MED per kg bodyweight; p = 0.016). No significant differences were observed in the secondary outcome parameters. We observed no perioperative complications. Conclusion: Ultrasound-guided TAPb significantly reduces intraoperative opioid consumption in patients undergoing PAO

Abnormal functional architecture of amygdala-centered networks in adolescent posttraumatic stress disorder

New methods for child psychiatric diagnosis and treatment outcome evaluatio