Kálmán Szepesi

Thrombotic and fibrinolytic alterations in the aseptic necrosis of femoral head

&NA; Recent reports seem to support the role of the thrombophilia and decreased fibrinolysis in the aetiopathogenesis of aseptic necrosis of bone. In the present study, haemostatic disturbances were analysed in adults (n = 49) and patients in childhood (Perthes disease) (n = 47) with aseptic necrosis of the femoral head. Fibrinolytic parameters (in vitro clot lysis, plasminogen, plasmatic plasminogen activator inhibitor‐1 activity, D‐dimer) along with lipoprotein (a) [Lp(a)] and fibrinogen were measured. von Willebrand factor, platelet activation and some thrombophilic factors (activated protein C resistance and factor V Leiden mutation, protein C, protein S activity) were also determined. Impaired fibrinolysis, an increased Lp(a) level along with slow clot lysis and increased platelet activation were found in adult cases. We detected five cases of factor V Leiden mutations (one heterozygotic and four homozygotic) among patients with Perthes disease. The clinical course of the heterozygous case was similar to the usual form of Perthes disease. The most severe form of Perthes disease has been observed in homozygous factor V Leiden mutation cases. The mutation of factor V Leiden per se probably does not induce the development of aseptic necrosis of bone tissue in childhood, but it does play a role in its acceleration. Homozygous factor V Leiden mutation definitely runs a more severe course. On the other hand, in adult cases, the disturbances of haemostasis, impaired fibrinolysis, elevated Lp(a) level, increased platelet activation and slight elevation of fibrinogen might have clinical relevance. Further studies should focus on proving the role of the haemostatic alterations in the pathogenesis of severe forms of aseptic bone necrosis. The use of antithrombotic drugs in order to slow the process of aseptic necrosis also has to be addressed in future surveys. Blood Coagul Fibrinolysis 14:243‐248

Pemberton's pericapsular osteotomy for the treatment of acetabular dysplasia.

We present the results of 80 Pemberton procedures carried out between 1977 and 1990. The patient age at the time of operation ranged between 2 and 12 years, and follow-up was between 1 and 15 years. Before Pembertons operation, conservative treatment, closed and open reduction, and derotation femoral osteotomy were used. Pembertons operation was combined with intertrochanteric femoral osteotomy in 30 cases. The mean values of the acetabular and center edge angle of Wiberg showed postoperative improvement of 19 and 17 degrees, respectively; whereas at follow-up, improvement was 20 and 23 degrees, respectively. Radiologically, 79% of the cases met Severins classification grade I-II criteria. Clinically, 81% were classified as excellent and good. The results were closely correlated with ischemic necrosis due to preoperative treatment. Only patients belonging to groups II-IV of Kalamchi and MacEwen, plus one patient operated on at relatively old age (12 years), were found radiologically to be in Severins groups III and IV. The results among patients operated on before age 7 were more favorable than those of patients operated on at an older age.

Assessment of thrombotic risk factors predisposing to thromboembolic complications in prosthetic orthopedic surgery

BackgroundCongenital thrombophilia is responsible for thromboembolic complications despite prolonged low-molecular-weight heparin (LMWH) prophylaxis following hip and knee endoprosthesis surgery.MethodsA series of 86 patients with hip or knee endoprosthesis surgery were assessed 1 year after operation. Antithrombin III, protein C, and protein S were determined, and the activated protein C sensitivity ratio was measured. We screened for the presence of lupus anticoagulant, factor V Leiden mutation, and polymorphism of prothrombin G20210A. The lower limb venous circulation was monitored by color Doppler ultrasonography. Pulmonary embolism (PE) was diagnosed using ventilation and perfusion scintigraphy.ResultsIn all, 33 patients had thromboembolic complications, 18 with thrombophilia (7 with combined form). Of the 53 patients without complications 12 had thrombophilia (2 with combined form). The differences were statistically significant. The risk score, the prevalence of FV Leiden and prothrombin G20210A mutations, and lupus anticoagulant were also significantly higher in the symptomatic group. Deep vein thrombosis (DVT) developed preoperatively in 15 patients; DVT and PE in 4 patients; thrombophilia was diagnosed in 53% and 75% of these cases. In all, 17 patients had postoperative thromboembolic complications: DVT developed in nine and PE in one patient (all with thrombophilia); DVT + PE developed in seven patients (all but one had thrombophilia).ConclusionsSignificant differences were found in the incidence (P ≤ 0.01) of thrombophilia and the risk score (P ≤ 0.02) between symptomatic and asymptomatic patients. We recommend preoperative thrombophilia screening for patients with a history or familial prevalence of thromboembolism and/or with a high risk score (≥15). In cases of thrombophilia, the form and duration of anticoagulant treatment must be decided individually.

Long-term follow-up of DDH patients who underwent open reduction without a postoperative cast

We present the results – assessed after bony maturation – of an early anterior approach open reduction performed using our modified technique on 49 hips at 6–24 months of age. We start postoperative functional treatment using a Pavlik harness and an abduction splint, abandoning plaster cast. Secondary surgeries were performed in 11 hips (22.4%) at 3–7 years of age. Our results were ‘satisfactory’ (Severin Grade I, II) in 96% of the cases. According to the joints’ Severin Grade, the total hip replacement probability at an early age is 8.16% in our series. Our principles and practice, introduced in 1980 in terms of secondary surgeries, are in total harmony with the recent literature.

A new surgical approach in 8 cases of polygonal triple pelvic osteotomy

We have undertaken 12 polygonal osteotomies, using an improved approach in 8. The operation was successful in correction of acetabular dysplasia after ossification of the triradiate cartilage. It was also useful in early arthrosis with slight deformity of the femoral head.

Increased platelet activation and decreased fibrinolysis in the pathogenesis of aseptic necrosis of the femoral head.

Thrombotic events, increased tendency toward intravascular thrombosis and decreased fibrinolysis seem to be possible pathologic causes for aseptic necrosis of the femoral head (ANFH) in adults. This project was to study whether either increased platelet activation or decreased fibrinolytic activity and/or any other thrombogenic factor may be implicated in the evolvement of ANFH. The speed of the in vitro lysis was significantly lower in patients (both in primary and in secondary cases) compared with healthy controls. The platelet activation (measuring with beta TG) proved to be significantly higher in the primary group as well as in the secondary group compared with healthy controls. Lp(a) levels were elevated in primary and secondary cases. This alteration was more characteristic in the primary cases. Fibrinogen levels were also elevated in the primary group, but the difference was not significant. The data shown here may further support that hypofibrinolysis and increased thrombogenesis are major causes of ANFH. Early diagnosis of ANFH increases the chances of modifying the course of this disabling disease.

A complementary thoracic implant for the surgical correction of the scoliotic curve. A preliminary report

SummaryThe results of the surgical correction of scoliosis through posterior approach have significantly improved by the introduction of new implants during the past decades. Even with these improvements the available implants only allow limited correction especially regarding axial rotation, and also their application is rather complicated. We developed a new implant which simultaneously grasps and exerts forces on both transverse processes of the vertebrae, to achieve a more efficient and safer correction with a simple surgical technique. In our paper we report on the concept of the new implant, its most important features, its mechanical tests, cadaver experimentations, and biomechanical assessments.

Capsular neuronal elements and their relation to pain reduction and functional improvement following total hip replacement

We studied changes of pain intensity and functional impairment in 22 patients with osteoarthrosis undergoing total hip replacement. Using a visual analogue scale, the mean scores for pain and disability before surgery were 71.7 and 70.9 respectively. Both scores showed gradual improvement during a 1-year follow-up period, with more than 90% of the total improvement occurring within the first 3 months. After 1 year, the scores for pain and disability were 11.9 and 4.1 respectively. The hip joint capsule was studied using immunohistochemistry to detect neurofilaments. Neurofilament immunoreactivity was observed in 16/22 cases and was correlated with pain and disability scores. However, there were no correlations between pre- and postoperative pain scores, the score changes, and the quantity of capsular neurofilaments. Thus, other factors than capsular neurofilaments influence the scores of pain and disability in osteoarthritis.RésuméNous avons étudié les changements d’intensité de la douleur et les modifications fonctionnelles chez 22 malades ayant subit une prothèse totale de la hanche pour arthrose. Avec une échelle analogue visuelle, les scores moyens pour la douleur et l’invalidité avant la chirurgie étaient de 71.7 et 70.9 respectivement. Les deux scores ont montré l’amélioration graduelle pendant une année après l’opération, avec plus de 90% de l’amélioration totale dans les trois premiers mois. Après une année les scores pour douleur et invalidité étaient de 11.9 et 4.1 respectivement. La capsule articulaire a été étudiée par immunohistochimie pour détecter les neurofilaments. L’immunoréactivité des neurofilaments a été observé dans 16/22 cas et était corrèlée avec la douleur et le score de l’invalidité. Cependant, il n’y avait pas de corrélations entre les scores de la douleur pré- et postopératoire, la modification du score fonctionnel et la quantité de neurofilaments capsulaires. Il y a donc d’autres facteurs que les neurofilaments capsulaires qui influencent la douleur et l’invalidité dans l’arthrose.

Multilevel callus distraction: a novel idea to shorten the lengthening time

Lower extremity inequality is a common problem in everyday orthopaedic practice. The leg discrepancy can lead to variety of other problems, i.e., spinal problems. Surgical intervention is very demanding and requires patient compliance. Wagners and Ilizarovs elongation technique are most commonly used worldwide, but it gives satisfactory results only in a long period of time and as we know there could be several inconvenient outcomes. Our idea aims at shortening this time period, and avoiding some of the inconvenient outcomes. Unfortunately we do not have the opportunity to go further in our investigations, but we hope that someone interested in this field will have an idea which would make continuation possible.

THE EFFECT OF EARLY ANTERIOR APPROACH OPEN REDUCTION WITH FUNCTIONAL POSTOPERATIVE TREATMENT ON THE EARLY DEVELOPMENT OF THE ACETABULUM IN CDH

Between 1980 and 1983, 30 anterior approach open reductions were performed on congenitally dislocated hips of 29 patients after unsuccessful conservative treatment; patients were between 6 and 18 months old. After the removal of the obstruction from the acetabulum, the reduction was performed with preservation of the limbus. Some part of the capsule was removed to constrict and tighten it and to prevent redislocation. This capsuloplasty demonstrates the success of a Pavlik harness and abduction splint postoperatively, without plaster fixation. The accelerated development of the acetabulum could be observed on radiograph by this functional treatment, compared to the control group treated with the usual hip spica postoperatively. The development of the acetabulum on the operated side almost equals the sound side within a year. If the operation was performed earlier, joint development would be quicker.