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1.  Other aspects of Ambroise Paré’s life 
International Orthopaedics  2013;37(7):1405-1412.
doi:10.1007/s00264-013-1909-2
PMCID: PMC3685679  PMID: 23736967
2.  Refractory osteitis condensans ilii: Outcome of a novel mini-invasive surgical approach 
International Orthopaedics  2013;37(7):1251-1256.
Purpose
Osteitis condensans Ilii (OCI) is an orthopaedic mystery until now and the refractory type poses a great challenge in its management. Surgical resection and sacroiliac arthrodesis are major procedures with no guarantee of success for an unknown disease entity with a normal sacroiliac joint. The aim of this retrospective study was to evaluate results of a novel mini-invasive surgical approach for the refractory type after failure of conservative management.
Materials and Methods
Fourteen females were included with an average age 35.5 ± 5.8 years. Nine cases were multiparous and five were nulliparous. The pathology was bilateral in all cases; however, seven cases suffered bilateral symptoms, while seven cases had only unilateral complaints. Preoperative computed tomography was mandatory. All cases had three to five percutaneous iliac core decompressions through a cannulated drill bit. The Bath ankylosing spondylitis functional index (BASFI) was used for functional outcome evaluation.
Results
The mean follow up was 23.3 ± 4.1 months. The mean BASFI improved from 3.7 ± 0.6 preoperatively to 1.3 ± 0.2 during follow up (P = <0.001). There was a significant improvement with the four drillings over five decompression drillings (P = 0.011). Sacral side sclerosis was associated significantly (P = 0.009) with less improvement. No relapse or substantial complications were encountered.
Conclusions
This novel approach can be of great benefit for refractory OCI cases with almost no added morbidity or complications. It has advantages of the mini-invasive techniques in addition to sparing the physiological functions of the affected sacroiliac joints.
doi:10.1007/s00264-013-1901-x
PMCID: PMC3685678  PMID: 23645082
3.  Direct subcutaneous injection of polyethylene particles over the murine calvaria results in dramatic osteolysis 
International Orthopaedics  2013;37(7):1393-1398.
Purpose
The murine calvarial model has been widely employed for the in vivo study of particle-induced osteolysis, the most frequent cause of aseptic loosening of total joint replacements. Classically, this model uses an open surgical technique in which polyethylene (PE) particles are directly spread over the calvarium for the induction of osteolysis. We evaluated a minimally invasive modification of the calvarial model by using a direct subcutaneous injection of PE particles.
Methods
Polyethylene (PE) particles were injected subcutaneously over the calvaria of C57BL6J ten-week-old mice (“injection” group) or were implanted after surgical exposure of the calvaria (“open” group) (n = 5/group). For each group, five additional mice received no particles and served as controls. Particle-induced osteolysis was evaluated two weeks after the procedure using high-definition microCT imaging.
Results
Polyethylene particle injection over the calvaria resulted in a 40 % ± 1.8 % decrease in the bone volume fraction (BVF), compared to controls. Using the “open surgical technique”, the BVF decreased by 16 % ± 3.8 % as compared to controls (p < 0.0001).
Conclusions
Direct subcutaneous injection of PE particles over the murine calvaria produced more profound resorption of bone. Polyethylene particle implantation by injection is less invasive and reliably induces osteolysis to a greater degree than the open technique. This subcutaneous injection method will prove useful for repetitive injections of particles, and the assessment of potential local or systemic therapies.
doi:10.1007/s00264-013-1887-4
PMCID: PMC3685680  PMID: 23604215
4.  Pre-operative arthritis severity as a predictor for total knee arthroplasty patients’ satisfaction 
International Orthopaedics  2013;37(7):1257-1261.
Purpose
Studies have shown that up to 25 % of TKA patients are dissatisfied with the implanted knee, even if registry data shows ten-year revision rates below 5 %. It has been the question of our study, if it would be possible to identify those patients at risk for dissatisfaction pre-operatively.
Methods
The data of 1,121 consecutive TKA patients with a follow-up between one and six years have been analysed retrospectively. Demographic, radiologic and perioperative variables have been recorded and all patients were asked by questionnaire for satisfaction with the implanted knee. Logistic regression models have been used to identify significant risk factors.
Results
The data of 996 patients (89 %) were complete, 849 (85.2 %) reported satisfaction and 147 (14.8 %) dissatisfaction. Patients’ satisfaction was independent of the time after operation (p = 0.285). The only factor which influenced patients’ satisfaction was the osteoarthritic severity. In comparison to severe arthritis Kellgren Lawrence IV°, the risk for dissatisfaction was 2.556-fold elevated for arthritis grade III° (p < 0.001) and 2.956-fold higher for grade II° (p = 0.001).
Conclusions
Patients suffering from mild or moderate osteoarthritis are at risk for dissatisfaction after TKA. The TKA indication in those patients should therefore be critically proven. Furthermore, to adjust patients’ expectations, the elevated dissatisfaction risk in case of mild or moderate osteoarthritis should be included into patients’ pre-operative information.
doi:10.1007/s00264-013-1862-0
PMCID: PMC3685681  PMID: 23525526
6.  Newly modified Stoppa approach for acetabular fractures 
International Orthopaedics  2013;37(7):1347-1353.
Purpose
We present our experience of using a newly modified Stoppa approach combined with a lateral approach to the iliac crest in patients with acetabular fractures in reference to fracture reduction and fixation, technical aspects, and the incidence of complications.
Methods
We used a consecutive group of 29 adult patients with acetabular fractures treated operatively with a newly modified Stoppa approach between 2009 and 2011. The newly modified Stoppa approach was performed to fix the acetabular fractures with main anterior displacement and the anterior and lateral parts of the pelvis. This approach was combined with a lateral approach on the iliac crest for fractures of the iliac wing.
Results
All the patients were followed up for at least 1.5 years. Of the 29 patients, ten anterior column, two associated both column, seven anterior column with posterior hemi-transverse, four transverse, and six T-type fractures. The average blood loss was 950 mL, and average operative time was 155 minutes. Anatomic or satisfactory reduction was achieved in 96 % of the acetabular fractures. Two patients had mild symptoms of the lateral femoral cutaneous nerve and improved within three months.
Conclusions
The newly modified Stoppa approach provides excellent visualization to the anterior column, quadrilateral surface and permits good postoperative results for treatment of acetabular fractures. We considered this technique as a viable alternative for the ilioinguinal approach when exposure of the anterior acetabulum is needed.
doi:10.1007/s00264-013-1920-7
PMCID: PMC3685676  PMID: 23681609
7.  Improvement of research quality in the fields of orthopaedics and trauma—a global perspective 
International Orthopaedics  2013;37(7):1205-1212.
The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon’s knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today’s “Cross Check Era”, too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.
doi:10.1007/s00264-013-1897-2
PMCID: PMC3685675  PMID: 23689761
8.  Dexamethasone induces osteogenesis via regulation of hedgehog signalling molecules in rat mesenchymal stem cells 
International Orthopaedics  2013;37(7):1399-1404.
Purpose
Hedgehog signalling plays an important role during the development of tissues and organs, including bone and limb. Dexamethasone (DEX), a synthetic and widely used glucocorticoid, affects osteogenesis of bone marrow mesenchymal stem cells (MSCs), while the signalling pathway by which DEX affects osteoblast differentiation remains obscure. This study aimed to investigate expressions of hedgehog signalling molecules Shh, Ihh and Gli1 during DEX-induced osteogenesis of rat MSCs in vitro.
Methods
DEX promoted osteoblast differentiation of MSCs at 10−8 mol/L from seven days to 21 days, demonstrated by enhancing alkaline phosphatase (ALP) activity and osteoblast-associated marker type I collagen expression during osteoblastic differentiation. Gene and protein expressions of hedgehog signalling molecules, Shh, Ihh and Gli1 were tested by RT-PCR and western blot analysis during osteoblast differentiation.
Results
Shh expression was increased compared to the control while Ihh and Gli1 expressions were decreased on both mRNA and protein level during DEX-induced osteoblast differentiation of MSCs from seven days to 21 days. Altogether, these data demonstrate that DEX can enhance Shh expression via a Gli1-independent mechanism during osteoblast differentiation of MSCs.
Conclusions
These results indicate that different patterns of hedgehog signalling are involved in DEX-induced osteogenesis and these findings provide insights into the mechanistic link between glucocorticoid-induced osteogenesis and hedgehog signalling pathway.
doi:10.1007/s00264-013-1902-9
PMCID: PMC3685673  PMID: 23645083
9.  The risk of dislocation after total hip arthroplasty for fractures is decreased with retentive cups 
International Orthopaedics  2013;37(7):1219-1223.
Purpose
Total hip arthroplasty (THA) has been efficacious for treating hip fractures in healthy older patients. However, in those patients with fractures a widely variable prevalence of dislocation has been reported, partly because of varying durations of follow up for this specific end-point. The purpose of the present study was to determine the cumulative risk of dislocation in these patients with fractures and to investigate if retentive cups decrease the risk of dislocation.
Methods
Between 2000 and 2005, 325 patients with neck fracture underwent primary THA using a retentive (325 hips) cup. The results of these 325 acetabular cups were compared to 180 THA without retentive cups performed for neck fractures in the same hospital between 1995 and 2000 by the same surgical team. The mean age of the 505 patients was 75 years (range 65–85). All patients were followed for a minimum of five years for radiographic evidence of implant failure. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation and recurrent dislocation was calculated with use of the Kaplan–Meier method.
Results
For patients without retentive cups, the cumulative risk of a first-time dislocation was 5 % at one month and 12 % at one year and then rose at a constant rate of approximately 1 % every year to 16 % at five years. For patients with retentive cups, the cumulative risk of a first-time dislocation was 1 % at one month, 2 % at one year and then did not changed at five years. There were no differences in the mortality rates or in loosening rates among the treatment groups. The rate of secondary surgery was highest in the group without retentive (10 % for recurrent dislocation) compared with 1 % in the group treated with retentive cups. In absence of retentive cups, multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were 80 years old or more (as compared with those who were less than 80 years old) was 1.5. Two underlying diagnoses occurring during follow up—cognitively impaired patients or neurologic disease—were also associated with a significantly greater risk of dislocation in absence of retentive cup. For these patients the risk was also decreased with a retentive cup.
Conclusion
With standard cups the incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are old female patients and those with a diagnosis of neurologic disease. Retentive cups in these patients are an effective technique to prevent post-operative hip dislocation.
doi:10.1007/s00264-013-1911-8
PMCID: PMC3685674  PMID: 23665654
11.  Constraint choice in revision knee arthroplasty 
International Orthopaedics  2013;37(7):1279-1284.
Purpose
Along with the increase in primary total knee arthroplasty, there has been an increase in the number of revisions. The aim of this study was to propose a selection algorithm for the knee revision constraint according to the state of ligaments and to the bone defects Anderson Orthopaedic Research Institute Classification [AORI] classification. The hypothesis was that this algorithm would facilitate the appropriate choice of prosthesis constraint, thus providing stable components and a good long-term survivorship of the knee revisions.
Methods
Sixty consecutive revision knee arthroplasties in 57 patients were prospectively evaluated. Prostheses implanted at revision included postero-stabilised, condylar constrained and rotating hinged, relative to the state of the ligaments and of the bone loss around the knee. The median follow-up was nine years (range, 4–12).
Results
The median IKS knee and function scores and HSS score were 41 (15–62), 21.5 (12–43) and 34 (23–65) points, respectively, before the operation, and 81 (48–97), 79 (56–92) and 83.5 (62–98) points (p < 0.001) at the latest follow-up evaluation. The median ROM increased from 74° (29–110°) preoperatively to 121° (98–132°) (p < 0.01) at the final follow-up. Re-revision was necessary in five (8.3 %) patients.
Conclusions
A selection algorithm for the revision implant constraint based on the state of ligaments and the bone loss AORI classification could provide stable knee reconstructions and long-term success of knee revisions.
doi:10.1007/s00264-013-1929-y
PMCID: PMC3685670  PMID: 23700251
12.  A national survey of United Kingdom trauma units on the use of pelvic binders 
International Orthopaedics  2013;37(7):1335-1339.
Purpose
Major pelvic injuries resulting from high-energy trauma require emergency hospital treatment, and part of the initial management includes mechanical stabilisation of the pelvis. Controversies include binder position, use in lateral compression injuries and application during radiological assessment. We present the results of a survey of both emergency department and orthopaedic specialties.
Methods
A telephone survey of all 144 trauma units in the UK accepting adult pelvic trauma patients was carried out in July 2012. The duty registrar for the emergency and orthopaedic departments was contacted and asked to complete a questionnaire.
Results
A response rate of 100 % was achieved. Pelvic binders were available for use in approximately three quarters of the trauma units surveyed. Eight-five emergency department (59 %) and 79 orthopaedic (54.9 %) registrars had been given training on pelvic binder application. Fifty-six emergency department (38.9 %) and 114 orthopaedic (79.1 %) registrars identified the level of the greater trochanters as the most suitable position for the binder. Forty-five emergency department (31.3 %) and 58 orthopaedic (40.3 %) registrars used pelvic binders in suspected lateral compression injuries. One hundred and twenty-six emergency department (87.5 %) and 113 orthopaedic (78.5 %) registrars would not release the binder during radiological assessment of the pelvis in a haemodynamically stable patient.
Conclusion
There is great variability in practice amongst trauma units in the UK. Training must be formalised and provided as a mandatory part of departmental induction. The use of standardised treatment algorithms in trauma units and the Advanced Trauma and Life Support (ATLS) framework may help decision making and improve patient survival rates.
doi:10.1007/s00264-013-1828-2
PMCID: PMC3685669  PMID: 23420325
14.  Results of a French multicentre retrospective experience with four hundred and eighteen failed unicondylar knee arthroplasties 
International Orthopaedics  2013;37(7):1273-1278.
Purpose
By means of a multicentre retrospective study based on the failure of 418 aseptic unicondylar knee arthroplasties (UKA) our aims were to present the different types of revision procedure used in failed UKAs, to establish a clear operative strategy for each type of revision and to better define the indications for each type of revision.
Methods
Aseptic loosening was the principal cause of failure (n = 184, 44 %) of which 99 cases were isolated tibial loosening (23.5 % of the whole series and 54 % of all loosening), 25 were isolated femoral loosening (six and 13.6 %) and 60 were both femoral and tibial loosening (14.3 and 32.6 %). The next most common causes of failure were progression of arthritis (n = 56, 13.4 %), polyethylene wear (n = 53, 12.7 %), implant positioning errors (n = 26), technical difficulties (n = six) and implant failure (n = 16, 3.8 % of cases). Data collection was performed online using OrthoWave™ software (Aria, Bruay Labuissiere, France), which allows collection of all details of the primary and revision surgery to be recorded.
Results
A total of 426 revisions were performed; 371 patients underwent revision to a total knee arthroplasty (TKA) (87 %), 33 patients (7.7 %) were revised to an ipsilateral UKA, 11 (2.6 %) patients underwent contralateral UKA (ten) or patellofemoral arthroplasty (one) and 11 patients (2.6 %) underwent revision without any change in implants.
Conclusions
Before considering a revision procedure it is important to establish a definite cause of failure in order to select the most appropriate revision strategy. Revision to a TKA is by far the most common strategy for revision of failed UKA but by no means the only available option. Partial revisions either to an alternative ipsilateral UKA or contralateral UKA are viable less invasive techniques, which in carefully selected patients and in experienced hands warrant consideration.
doi:10.1007/s00264-013-1915-4
PMCID: PMC3685668  PMID: 23715952
15.  Hypertrophy of the ligamentum flavum in lumbar spinal canal stenosis is associated with increased bFGF expression 
International Orthopaedics  2013;37(7):1387-1392.
Purpose
A prospective study was undertaken to investigate basic fibroblast growth factor (bFGF) expression in hypertrophic ligamentum flavum (LF) from patients with lumbar spinal canal stenosis (LSCS) and to determine whether there was a correlation of bFGF expression with LF thickness.
Methods
Twenty patients with lumbar spinal canal stenosis were enrolled in this study. bFGF mRNA and protein expressions in LF were analyzed using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR), immunohistochemistry, and enzyme-linked immunosorbent assay (ELISA), respectively. The thickness of LF was measured by axial T1-weighted magnetic resonance imaging.
Results
Expression of bFGF was substantially higher in the hypertrophic LF group than in the control group (P < 0.001) as quantified by quantitative real-time PCR. In immunohistochemical study, bFGF was positively stained on the fibroblasts within hypertrophic LF compared to nonpathologic LF of controls. Subsequent ELISA analysis revealed that bFGF concentration in the hypertrophic LF group was remarkably higher than that in the control group (P = 0.003). The thickness of LF in the hypertrophic LF was significantly greater than that in the control group (P < 0.001). LSCS patients with greater severity of LF hypertrophy had significantly higher bFGF levels in the LF tissues (P < 0.001). Furthermore, the bFGF concentration exhibited a positive correlation with the LF thickness (r = 0.974, P < 0.001).
Conclusions
These findings suggest that the increased expression of bFGF is associated with the hypertrophy of ligamentum flavum in patients with LSCS.
doi:10.1007/s00264-013-1864-y
PMCID: PMC3685665  PMID: 23519824
16.  How to prevent cut-out and cut-through in biaxial proximal femoral nails: is there anything beyond lag screw positioning and tip–apex distance? 
International Orthopaedics  2013;37(7):1363-1368.
Purpose
Hip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip–apex distance (TAD), we analysed the influence of anti-rotational pin length.
Methods
We compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.
Results
Hip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).
Conclusions
In biaxial nails anti-rotational element positioning is underestimated, however, crucial.
doi:10.1007/s00264-013-1898-1
PMCID: PMC3685663  PMID: 23649496
18.  Umbrella-shaped, memory alloy femoral head support device for treatment of avascular osteonecrosis of the femoral head 
International Orthopaedics  2013;37(7):1225-1232.
Purpose
Avascular necrosis (AVN) of the femoral head is a common orthopaedic disease that is difficult to treat. The purpose of this study was to explore the preliminary efficacy of a self-designed umbrella-shaped memory alloy femoral head support device in the treatment of adult patients with avascular osteonecrosis of the femoral head.
Methods
The minimally-invasive approach involved curettage of the necrotic tissue of the femoral head, and a self-designed umbrella-shaped, memory alloy femoral head support device was implanted into the collapsed necrotic area to support the collapsed femoral head. Autologous iliac bone and artificial bone were implanted into the support device for the treatment of adult patients with avascular osteonecrosis of the femoral head.
Results
The clinical device was used in ten patients and 18 hip joints. The support device failed in one hip joint, which subsequently underwent joint replacement surgery, and the remaining 17 implanted devices were followed up for four to 19 months. The 17 postoperative hip joints were evaluated using the percent-efficacy evaluation method for avascular osteonecrosis of the femoral head in adult patients, and the efficacy rate was 82.35 %.
Conclusion
The umbrella-shaped femoral head support device can be used in Ficat stage I, stage II, and stage III adult patients with avascular osteonecrosis of the femoral head.
doi:10.1007/s00264-013-1869-6
PMCID: PMC3685662  PMID: 23532589
19.  Excessive femoral offset does not affect the range of motion after total hip arthroplasty 
International Orthopaedics  2013;37(7):1233-1237.
Purpose
Implant dislocations are often caused by implant or bone impingement, and less impingement is critical to prevent dislocations. The aim of this study was to clarify the effect of the femoral offset in avoiding component or bony impingement after total hip arthroplasty (THA).
Methods
Seventy-eight patients underwent THA with a Pinnacle cup and Summit stem (DePuy). Intraoperative kinematic analysis was performed with a navigation system, which was used to obtain intraoperative range of motion (ROM) measurements during trial insertion of stems of two different offset lengths with the same head size. Further, ROM was also measured after actual component insertion.
Results
Maximal ROM was independent of the femoral offset of the stem in each patient. However, the range of external rotation was significantly greater in patients with a greater femoral offset.
Conclusions
The Summit stem has enough offset length to avoid implant/bone impingement, even when the standard offset stem is used. Nevertheless, selection of the offset stem should be performed carefully to prevent offset complications.
doi:10.1007/s00264-013-1881-x
PMCID: PMC3685658  PMID: 23553118
20.  Indications for and results of arthroscopy in the arthritic knee: a European survey 
International Orthopaedics  2013;37(7):1263-1271.
Purpose
The place of arthroscopic treatment in osteoarthritis of the knee has generated much controversy. A survey was initiated to collect the opinion of experienced surgeons.
Methods
Of the 211 surgeons interviewed, 170 (80.6 %) replied to the electronic questionnaire. Respondents had at least ten years of experience in arthroscopy and currently perform more than 100 arthroscopies per year. Various indications and treatment modalities for arthroscopy in osteoarthritis of the knee had to be evaluated on a scale from “excellent” to “no indication”.
Results
The respondents generally believe that an improvement is more likely in low-grade osteoarthritis (p < 0.001) and in neutral leg axis (p < 0.001). The outcome was rated better if symptoms had persisted for less than six months (p < 0.001) and for patients that were younger than 60 years (p < 0.001). Partial meniscectomy and notchplasty in cases of extension deficit were considered as successful treatment options. Debridement was an accepted indication, with an outcome mainly rated as fair. A majority saw no indication for joint lavage, arthroscopic treatment of arthrofibrosis and removal of osteophytes. The outcome appears to be poor if a bone edema is diagnosed on magnetic resonance imaging prior to arthroscopy. Only 55.9 % of respondents were comfortable with the current definition of osteoarthritis.
Conclusions
Experienced arthroscopic surgeons all over Europe believe arthroscopy in osteoarthritis is appropriate, under certain conditions. The major task for surgeons is to select the right patients who are likely to benefit from this intervention.
doi:10.1007/s00264-013-1896-3
PMCID: PMC3685659  PMID: 23685877
21.  Anterior internal fixator versus a femoral distractor and external fixation for sacroiliac joint compression and single stance gait testing: a mechanical study in synthetic bone 
International Orthopaedics  2013;37(7):1341-1346.
Purpose
The purpose of this study was to evaluate the biomechanical stability and compressive forces across the sacroiliac (SI) joint of an anterior internal fixator compared to the femoral distractor and external fixator for vertically unstable pelvic fractures.
Methods
Five composite pelvises with a simulated APC type III injury fixed with a femoral distractor, external fixator, or anterior internal fixator were tested. A pressure-sensitive film (Tekscan) was placed in the disrupted SI joint recording the magnitude of force. Then, in a single-leg stance model (Instron machine), a load was applied through the sacrum. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Peak load and displacement were measured, and axial stiffness was calculated. Values were compared using a Student’s t-test (p < 0.05).
Results
The SI joint was compressed significantly (p < 0.001) more using the anterior internal fixator (18.9 N) and femoral distractor (18.6 N) than the two-pin external fixator (2.5 N). There was no significant difference between the anterior internal fixator and the femoral distractor in displacement at the SI joint. The pubic symphysis displaced less with the femoral distractor than the anterior internal fixator (5.5 mm vs. 4.1 mm; p < 0.05).
Conclusions
The anterior pedicle screw internal fixator allows for indirect compression across the sacroiliac joint that is superior to two-pin external fixation and comparable to the femoral distractor. The anterior internal fixator may be an option for temporary anterior pelvic fixation in situations where external fixation or the femoral distractor have otherwise been used.
doi:10.1007/s00264-013-1890-9
PMCID: PMC3685661  PMID: 23645004
22.  Balloon treatment of posterior shoulder dislocation with reverse Hill–Sachs injury: description of a new technique 
International Orthopaedics  2013;37(7):1291-1295.
Purpose
Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as “reverse Hill-Sachs lesions” may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation.
Methods
From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior “reverse Hill-Sachs” impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up.
Results
At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation.
Conclusion
Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.
doi:10.1007/s00264-013-1877-6
PMCID: PMC3685657  PMID: 23568144
23.  The safety and efficacy of high-dose daptomycin combined with rifampicin for the treatment of Gram-positive osteoarticular infections 
International Orthopaedics  2013;37(7):1375-1380.
Purpose
Treatment of Gram-positive osteoarticular infections requires an adequate surgical approach combined with intensive antimicrobial therapy. The aim of this study was to evaluate the safety and efficacy of a combined regimen of high-dose daptomycin and rifampicin, in patients with various types of Gram-positive osteoarticular infections.
Methods
This single centre, non-comparative, prospective study evaluated the safety and efficacy of a combined regimen of intravenous daptomycin (8 mg/kg/day) and oral rifampicin (600 mg/day) in patients with Gram-positive osteoarticular infections, with a minimal follow-up of one year. Creatine phosphokinase, transaminases, bilirubinaemia, and serum creatinine, were measured at baseline and regular intervals.
Results
The median daily doses of daptomycin and rifampicin, administered for a median duration of 21 (range, 10–122) days to 16 patients (median age, 63.5 years; 11 males, five females) presenting with staphylococcal (n = 15) or streptococcal (n = 1) osteoarticular infections, were 8.15 (range, 6.6–8.9) mg/kg/day and 600 (range, 600–900) mg/day, respectively. The combined regimen of daptomycin and rifampicin was well tolerated by all except one patient, without requiring treatment adjustment or discontinuation. One patient developed allergic responses probably due to rifampicin after 42 days. Fifteen (94 %) patients showed favourable clinical and microbiological outcomes.
Conclusions
The combined regimen of high-dose daptomycin and rifampicin was well tolerated and may provide a useful alternative to standard glycopeptide therapy for Gram-positive osteoarticular infections.
doi:10.1007/s00264-013-1856-y
PMCID: PMC3685655  PMID: 23519823
24.  Hip score and disease activity correlation in patients with rheumatoid arthritis after total hip arthroplasty 
International Orthopaedics  2013;37(7):1245-1250.
Purpose
The disease activity score including 28 joints (DAS28), the simplified disease activity index and the clinical disease activity index (CDAI) were developed in order to provide a quantifiable measure of rheumatoid arthritis (RA) activity. Although inflamed hip joints greatly impact activities of daily living (ADL) and walking ability, the hip joint was not included in the DAS28, SDAI or CDAI assessments. Although excellent clinical results have been reported for total hip arthroplasty (THA) in RA patients, correlations between disease activity and hip function in RA patients after THA remain unknown.
Methods
We analysed the effect of RA disease activity on a hip function score in an observational cohort of RA patients after THA. Twenty-five registered RA patients who had undergone THA (33 joints) were included. Hip function was recorded and RA disease activity was measured on the same day. The mean age of the patients was 65.17 years. They were followed up for a mean of 5.24 years after surgery. The mean duration of disease following RA diagnosis for this patient group was 19.47 years. The Japanese Orthopaedic Association (JOA) hip score was used as a clinical outcome measure for hip dysfunction. RA disease activity and health-related quality of life were measured using the DAS28, SDAI, CDAI and the modified health assessment questionnaire (MHAQ).
Results
The mean JOA score for hip function was 80.48 at the final follow-up. The mean DAS28-ESR, DAS28-CRP, SDAI, CDAI and MHAQ measuring RA disease activity levels were 3.38, 2.65, 9.59, 8.63 and 0.44, respectively, at the final follow-up. There was a significant negative correlation between the JOA hip score and all disease activity assessments observed after THA (DAS-ESR [P = 0.0067], DAS-CRP [P = 0.0008]), SDAI [P = 0.0034], CDAI [P = 0.0003]) and MHAQ [P = 0.0002]).
Conclusion
We found significant negative correlations between JOA hip scores and all disease activity assessments in RA patients treated with THA.
doi:10.1007/s00264-013-1900-y
PMCID: PMC3685656  PMID: 23640680
25.  Temperature control with internally applied cooling in solid material drilling: an experimental, biomechanical study 
International Orthopaedics  2013;37(7):1355-1361.
Purpose
The purpose of this study was to evaluate the different temperature levels while drilling solid materials and to compare different cooling solutions for possible temperature control. An additional purpose was to develop an internal cooling device which can be connected to routinely used manual drilling devices in trauma surgery.
Methods
Drilling was performed on a straight hip stem implanted in bovine femora without cooling, with externally applied cooling and with a newly developed internal cooling device. Temperature changes were measured by seven thermocouples arranged near the borehole. Additionally, thermographic scans were performed during drilling.
Results
Drilling without cooling leads to an immediate increase in temperature to levels of thermal osteonecrosis (over 200 °C). With externally applied cooling temperatures were decreased, but were still up to a tissue damaging 85 °C. Internally applied cooling led to a temperature decrease to tissue-preserving levels during the drilling procedure (24.7 °C).
Conclusion
Internal cooling with HPC-drillers lowered the measured temperatures to non-tissue damaging temperatures and should avoid structural tissue damage.
doi:10.1007/s00264-013-1850-4
PMCID: PMC3685654  PMID: 23512602

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