Different cardiorespiratory responses to hemorrhage and hyperoxia in normotensive (WKY) and spontaneously hypertensive (SHR) rats.

OBJECTIVE: To compare the cardiorespiratory responses underlying the beneficial effects of hyperoxia during blood loss between normotensive (WKY) and hypertensive (SHR) rats. METHODS: Experiments were carried out in anesthetized animals with both carotid bifurcations either innervated or denervated. The effects of breathing 60% O2 in N2 were studied either in combination with non-hypotensive hemorrhage or during hemorrhagic hypotension. RESULTS: In normoxia arterial pressure fell more in SHR than in WKY for a given blood loss. During hyperoxia, nerve-intact rats showed initial suppression of ventilation, but bifurcation-denervated rats a powerful enhancement. In all groups, hyperoxia increased the overall tone of venous capacitance vessels. CONCLUSIONS: The greater blood loss in SHR than in WKY when bleeding down to a given arterial pressure results from a stronger constriction of venous capacitance vessels. Hyperoxia improves the ability of the cardiorespiratory system to resist the effects of hemorrhage by increasing the overall venous tone, thus supporting cardiac filling, and in some cases also by increasing alveolar ventilation, probably secondary to improved cerebral oxygenation. The beneficial effects of hyperoxia were: (i) not prevented by carotid denervation, and thus were presumably direct tissue effects of oxygen, (ii) strikingly weaker in SHR than in normotensive (WKY) rats.

Hip pain related to femoral neck stress fracture in a 12-year-old boy performing intensive soccer playing activities--a case report.

We describe the rare case of a 12-year-old boy complaining of repetitive severe pain in the left thigh, during physical activity related to a femoral neck stress fracture. Even though stress fractures are common in the adult athletic population, they occur rarely in children, with the epiphyseal growth plates still open. Diagnosis is delayed as only unspecific changes are found when conventional radiography is performed. For adequate treatment, early diagnosis by MRT or bone scintigraphy is essential. Conservative treatment will be effective through prevention of overuse.

A rare case of Salmonella osteomyelitis in the humerus as a differential diagnosis to a malignant bone tumor.

Salmonella osteomyelitis without predisposing factors is seldom seen and thus difficult to diagnose. We report on a 14-year-old healthy boy with Salmonella osteomyelitis which occurred 2 years after trauma. Radical operative debridement is recommended. Intravenous ciprofloxacin has proved to be effective because of good tissue penetration and sensitivity towards Salmonella.

Osteopetrosis, femoral fracture, and chronic osteomyelitis caused by Staphylococcus aureus small colony variants (SCV) treated by girdlestone resection--6-year follow-up.

Chronic osteomyelitis caused by Staphylococcus aureus small colony variants in combination with osteopetrosis is a unique combination of disorders that confronted us with major challenges. The therapeutic approach included four serial debridements and antimicrobial therapy. The aggressive treatment led to an instability of the brittle and hard osteopetrotic bone, and after 11 weeks, a fracture of the femoral neck occurred. A salvage procedure of the femur was performed, and the cultures obtained during this intervention remained negative. At a 6-year follow-up, the girdlestone situation still showed an acceptable functional outcome without any recurrence of osteomyelitis.

[Is there a correlation between clinical results or quality of life and radiological findings after implantation of a total knee prosthesis?]. / Besteht eine Korrelation zwischen klinischen Ergebnissen oder der Lebensqualität und dem radiologischen Befund nach Implantation einer totalen Knieendoprothese?

AIM OF THE STUDY: To establish whether there is a clinical correlation between clinical outcome or quality of life and radiographic findings. MATERIAL AND METHODS: 17 patients (mean age 68.2 years) with total knee arthroplasty were examined after an average follow-up of 24.6 months. The examination included the HSS score for clinical parameters, and the SF-36 questionnaire quality of life. Radiographs were evaluated in accordance with Ewald and Lotke, and a schema of our own. RESULTS: The HSS score returned a mean of 81 points, and the SF-36 questionnaire showed significantly poorer results in comparison with age-matched healthy subjects. The Lotke evaluation of the X-rays showed a mean value of 76.3. Correlations between the radiographic findings and the HSS score were not seen. Correlations between X-ray parameters (Ewald and Lotke) and the SF-36 were found only for pain and vitality. CONCLUSIONS: This is the first study to investigate the correlation between clinical parameters (including quality of life) and X-ray findings. Neither the clinical score nor the quality of life score was found to correlate with the radiographic findings. Nor was more than minimal correlation found between quality of life and HSS score. These results show that the presence of radiolucent lines or deviations from the perfect prosthesis position must not necessarily be considered to be of importance for clinical outcome and quality of life.

Importance of decreased intracellular phosphate and magnesium concentrations and reduced ATPase activities in spontaneously hypertensive rats.

A decrease in total magnesium content is not a direct proof of a decreased magnesium ion concentration. It could reflect a phosphate alteration or an ATP metabolism disorder. Plasma phosphate levels are lower in spontaneously hypertensive rats (SHRs) than in Wistar-Kyoto (WKY) rats, and defects in membrane regulation or mitochondrial ATP synthase occur. Only sparse data exist concerning cellular magnesium and phosphate concentrations in hypertensive cells. In aortic smooth muscle cells from 10 SHRs of the Münster strain and 10 age-matched normotensive WKY rats, the intracellular phosphate and magnesium content was measured by electron probe X-ray microanalysis (Camscan CS 24 apparatus, Cambridge, U.K.). The Mg++ content was 0.90+/-0.15 g/kg dry weight in SHRs versus 1.15+/-0.10 g/kg dry weight in WKY rats (p<0.05). Vascular smooth muscle phosphate content was 23.6+/-0.79 g/kg dry weight in WKY rats versus 15.81+/-1.22 g/kg dryweight in SHRs (p<0.01). In seven animals, erythrocytic ATP content was 180.2+/-102 in SHRs vs. 432+/-72 micromol/L cells in WKY rats (p< 0.01). The Na+/K+-ATPase activity was significantly decreased in hypertensive animals as compared to controls (6.49+/-2.3 vs. 12.64+/-2.9 nmol inorganic phosphate/mg protein/min (p< 0.01)). Aortic smooth muscle cells from SHRs are characterized by markedly lowered cellular phosphate and magnesium concentrations and an altered ATP metabolism, possibly due to a membrane defect or a magnesium deficit in hypertensive cells.

Quality issues in tissue banking: quality management systems - a review.

The situation in tissue banking changed radically and fundamentally at the beginning of the 1990s. The essential causes are on the one hand, the continually increasing demand for human cells and tissue and other biological material for clinical use and research, and on the other hand, the rapid progress in the medical, technical and natural sciences. Biotechnology in particular, has profited from this. Modern tissue banks could no longer be imagined without its methods.A consequence of these developments and a prerequisite for the fulfilment of the derived requirements is the necessity for national and international cooperation as well as the harmonisation of ethical principles and quality assurance standards and regulations (von Versen (1999) Ann Chir Gynaecol 88: 215-220). The introduction of an all-encompassing Quality Management System (QMS) is a suitable instrument for this purpose.After the presentation of explanations and definitions of quality terminology, this article describes the use of the international standard ISO 9000 as a general QMS, which embraces both the specific methodology as well as the general aspects of Quality Management (research and development, design control, education and training, documentation, traceability, management control, corrective action, etc.) in tissue banking. The individual elements of this system are explained and selected examples are described. The authors look upon this QMS as an indispensable instrument for harmonisation and international cooperation in tissue banking.Finally, the use of such a standard would be a positive sign to the regulatory authorities and the public that tissue banking is making a visible effort to introduce a world-class QMS in its operations.

Reconstructive treatment of sclerosing osteomyelitis of the entire femur of 30 years' duration with avoidance of segmental resection.

We describe the successful operative treatment of a patient with chronic sclerosing osteomyelitis of the femur in which en bloc resection was avoided. Therapy consisted of combined endoscopic, computed tomography and bone scan-guided fenestration and intramedullary reaming, with removal of all sclerotic zones and normalization of the cortical thickness. An adequate supply of oxygen to the area was ensured by improved vascularisation and the application of hydrogen peroxide. At the medium term follow-up no recurrence was seen, and hip and knee function was normal.

Primary biomechanical influence of different sterilization methods on a freeze-dried bone-ligament transplant.

The transmission of bacteria and viruses in ligament transplants should be prevented by sterilization. In this study, the influence of two different methods on the mechanical properties of a freeze-dried medial collateral ligament was analyzed in sheep. Group I (n = 10) was treated with irradiation (26 kGy) and group II (n = 10) with ethyleneoxide. The mechanical properties changed in respect of the maximal load: group I (-29.9%; P < 0.05), group II (-7.7%), elongation: group I (-6.6%), group II (-0.3%), stress: group I (-20.1%), group II (-6.8%), strain: group I (-0.64%), group II (-0.3%), stiffness: group I (-10.2%), group II (-10.5%), energy: group I (-31.4%), group II (-6.9%) and elastic modulus: group I (-1.3%), group II (-5.0%). The irradiation dose significantly reduced the maximal load, whereas ethyleneoxide sterilization resulted only in minor changes. Because of the potential cancerogenity of ethyleneoxide, a close monitoring of aeration times and its residuals are very essential. Further studies with lower irradiation doses of between 15 and 26 kGy seem to be justified.

High incidence of pathogenic microorganisms in bone allografts explanted in the morgue.

We analyzed the influence of the environment on bacterial contamination in 431 bone allografts from 97 donors (68 multiorgan, grafts taken in the operation theater; 29 morgue donors). From each bone transplant we cultured two aerobic and two anaerobic tissue specimens. The overall contamination rate was 49% (theater 51%, morgue 40%). In grafts explanted in the morgue, we noted more pathogenic microorganisms (60%) than in multiorgan donors, explanted under aseptic surgical conditions (33%). We conclude that the harvesting environment constitutes the major source of pathogenic microorganisms.

Diagnosis and treatment of joint infections in elderly patients.

Clinical, laboratory and radiological data of 35 patients (> 60 years) with septic arthritis were retrospectively analyzed in 2 groups submitted to different treatment protocols based on the radiological stage of destruction. Group I: intraarticular gentamicin-PMMA beads (8 cases), group II: resection-arthroplasty with gentamicincement spacer (27 cases). The average diagnostic delay was 4.8 months. Diagnostic errors were: osteoarthrosis in 9 cases, periarthritis of the shoulder in 5, femoral head necrosis in 4 cases, sciatic pain in 3, osteoporosis in 1, and thrombosis in 1 case. The re-operation rate in group I was 1.4 (range 1-2 operations) and in group II 1.2 (range 0-3 operations). Fifteen patients were left with a resection-arthroplasty. The restriction of motion remained moderate in 6 and severe in 9 cases. Three patients had sepsis and died. The final results were poor after both treatment protocols. Early diagnosis seems to be the most determining factor concerning the final outcome of septic arthritis.

Time-dependent clinical and roentgenographical results of Coventry high tibial valgisation osteotomy.

We analyzed the time-dependent results after Coventry osteotomy in 118 patients (129 cases) with uni-compartmental osteoarthrosis of the knee. The median follow-up was 11.6 years (range 0.7-17 years). Data were noted according to the time since surgery. Group I (> 2 years) consisted of all 129 cases, group II (> 4 years) of 41 cases and group III (> 8 years) of 15 cases. The HSS knee score (max. 100 points) improved from 33.2 +/- 20.4 (range 17-60) to 68.3 +/- 25.3 (range 30-90) in group I, to 54.7 +/- 18.9 (range 29-90) in group II and to 43.7 +/- 20.9 (range 23-85) in group III. The improvement started 4.6 +/- 7.8 months (range 0-60 months) after the operation and persisted for 4 years +/- 37.4 months (range 0-125 months). The functional knee score (max. 100 points) changed from 61.7 +/- 14.1 (range 41-70) to 71.7 +/- 13.1 (range 53-87) in group I, to 70.0 +/- 11.8 (range 54-88) in group II and to 64.2 +/- 8.0 (range 42-90) in group III. The initial loss in knee flexion was 5.6 degrees (range 0 degree-20 degrees) and for extension 1.0 degree (range -5 degrees-25 degrees). Anteroposterior ligament stability (max. 10 points) decreased from 9.2 +/- 2.1 (range 2-10) to 5.6 +/- 1.7 (range 2-9) in group III. Lateral ligament stability (max. 15 points) was relatively constant, from 12.6 +/- 1.9 (range 4-15) to 9.7 +/- 1.9 (range 2-14). Complications included one tibia fracture, one infection, six peroneus pareses, four haematomas and one pseudarthrosis. The mechanical axis was corrected to an average knee valgu2 of 5.2 degrees +/- 7.4 degrees, which deteriorated over time. Radiographic evidence of arthrosis appeared independent of the operation.

Intramedullary, antibiotic-loaded cemented, massive allografts for skeletal reconstruction. 26 cases compared with 19 uncemented allografts.

We compared the outcomes of 26 intramedullary cemented massive allografts with 19 allografts without cementation; all allografts were used for reconstruction after excision of bone sarcomas. In the cementation group, 12 allografts were used as osteochondral grafts (proximal humerus 4, proximal tibia 4, and distal femur 4), 7 as intercalary diaphyseal allografts of the femur, and 7 for a knee arthrodesis. In the uncemented allografts, 3 allografts were used as osteochondral grafts (proximal humerus 2, proximal tibia 1), 2 as intercalary diaphyseal allograft of the femur, and 14 for a knee arthrodesis. The average length of follow-up was 40 (25-60) months. 14 of 26 cemented allografts had an excellent (osteotomy line: not visible) or good (fusion > or = 75% of the cortical thickness) healing of the junction site. Infection developed in 1 allograft. Fracture occurred in 4 of 12 cemented osteochondral allografts due to a subchondral collapse (all in the proximal tibia). Fractures at the junction site in the lower extremity developed in 4 of 22 cemented allografts. In 19 allografts without cementation, 11 had excellent or good healing of the junction. Late infection developed in 4 allografts, fracture of the allograft in 3 cases, and junction fracture in 3 of 17 patients with reconstruction of the lower extremity. Intramedullary graft cementation seems to reduce the fracture and infection rates.

[The German Society of Orthopedics and Traumatology classification of bone defects in total hip endoprostheses revision operations]. / Die DGOT-Klassifikation von Knochendefekten bei Hüft-Totalendoprothesen-Revisionsoperationen.

PROBLEM: In revision alloarthroplasty the need for bone allografts increased. The documentation of the defects is not done routinely. METHOD: For better documentation the German Society for Orthopedics and Traumatology (DGOT) developed a new and practical defect classification system. It was tested clinically in the last 6 years. RESULTS: In the acetabulum and femoral shaft seven defect types were distinguished and presented in figures. For the acetabulum: 1 cavitary holes, 2-4 unisegmental, 5 bisegmental, 6 trisegmental, 7 pelvic instability. For the femur: 1 intramedullary 2 trochanter 3 calcar 4 med. shaft 5 lat. shaft 6 part. diaphysis 7 total diaphysis. CONCLUSION: With this classification system we could better compared different reconstruction approaches in endoprosthetic surgery.

High complication rates with pelvic allografts. Experience of 22 sarcoma resections.

We performed 22 reconstructions by allografts in patients with pelvic sarcoma: 14 Ewing's sarcomas, 7 chondrosarcomas, and 1 osteosarcoma. All patients with Ewing's sarcoma and osteosarcoma received chemotherapy. No patients with chondrosarcoma had adjuvant treatment. 12 reconstructions were iliosacral arthrodesis after resection of an ilium tumor, 1 was iliofemoral arthrodesis and 9 were pelvic reconstructions with total hip prosthesis after resection of an acetabulum tumor. In the surviving patients, the mean length of follow-up was 4 (2-6) years. 2 allografts fractured and 8 allografts developed an infection. The infection was commoner in patients who had chondrosarcomas, large tumors, and a long operation time. Neither chemotherapy nor radiotherapy increased the infection rate. All infected allografts had to be removed.

Congenital ball-and-socket anomaly of the ankle.

We present the clinical and radiographic appearance of 11 patients with a ball-and-socket ankle joint with an average follow-up of 13.7 years. Ten patients demonstrated parallel symptoms of the femur-fibula-ulna syndrome (FFU) associated with a mean leg-length discrepancy of 4.3 cm (range, 2-20). In six patients, an annual follow-up of talar development was possible. Radiographically the patients showed an additional tarsal coalition at a mean age of 4.8 years (range, 3.2-5.9). This earlier fusion could be detected by an arthrographic examination. All patients had no clinical complaints except a slight reduction of hindfoot mobility. The ball-and-socket ankle joint is presumably not congenital itself but secondary to congenital conditions in the peritalar region.

Alterations in erythrocyte plasma membrane ATPase activity and adenine nucleotide content in a spontaneously diabetic subline of the Chinese hamster.

The CHIG/Han subline of the Chinese hamster develops noninsulin-dependent diabetes mellitus characterized by hyperinsulinemia and different degrees of glucose intolerance. To study whether these abnormalities could affect transmembrane cation transport activity, we determined membrane ATPase activity and ATP concentrations in red blood cells of diabetes-resistant CHIA and diabetes-susceptible CHIG sublines of the Chinese hamster. Mg(2+)-ATPase activity was increased in red blood cell membranes of diabetic hamsters compared with that of nondiabetic CHIG and the diabetes-resistant CHIA animals and correlated with plasma triglyceride and cholesterol levels. Ca(2+)-ATPase and Na+/K+ATPase activity were not significantly different between diabetic and nondiabetic hamsters, but for the Na+/K(+)-ATPase, Km was decreased and the Vmax value increased in membrane preparations from severely diabetic hamsters. Both ATP and ADP content were lower in erythrocytes from diabetic than nondiabetic hamsters. Independently of the levels of glycemia, AMP concentrations were higher in CHIG than in CHIA hamsters. While ATP/AMP ratios were found to be decreased in erythrocytes from diabetes-susceptible CHIG hamsters compared to the diabetes-resistant CHIA animals, they were significantly correlated with the levels of glycemia. Furthermore, the relationship between blood glucose levels and kidney weight in hamsters of the diabetes-susceptible CHIG subline was such, that severely hyperglycemic animals displayed the greatest increase in kidney wet weight. These results indicate that the progressive metabolic deterioration in the development of noninsulin-dependent diabetes is associated with significant changes in the activity and kinetic parameters of cellular ATPases which could probably indicate early membrane alterations which may eventually result in the late microangiopathic complications of diabetes.

[Long-term treatment outcome in ventral and combined ventrodorsal spondylodesis in the surgical therapy of scoliosis]. / Langfristige Behandlungsergebnisse ventraler und kombinierter ventrodorsaler Spondylodesen in der operativen Therapie der Skoliose.

We report on 48 patients with a mean postoperative follow-up of 7.7 years. 9 patients underwent simple anterior derotation spondylodesis (VDS), 31 patients were additionally fused with posterior Harrington spondylodesis. In 7 of 8 patients the Dwyer compression spondylodesis (DCS) was completed with the Harrington instrumentation. 2 of 3 scoliosis were idiopathic, the residual cases were mainly neuromuscular. The primary curve (preoperative mean: 69.9 degrees) was initially corrected by 62.8% and sustained a loss of correction of 7.6 degrees resp. 10.9% during long-term follow-up. The long-term loss of correction was maximal after DCS showing 10.4 degrees (14.4%), on the average, and minimal after combined VDS and Harrington spondylodesis showing 6.9 degrees (9.3%). After simple VDS the long-term progression of the curve was 7.0 degrees (12.9%). In this group the initial correction was above-average high showing 76.4%. The main loss of correction occurred during the first 2 years after surgery. The long-term correction stability did not show significant differences between simple VDS and combined antero-posterior instrumentation. After anterior instrumentation of the primary curve the secondary cranial nerve spontaneously straightened up by 30%, on the average, and remained stable in the long-term. The anterior instrumentation of the spine lead to a mean loss of lordosis of 13.6 degrees which in the long-term additionally increased by 6.4 degrees due to the anterior epiphyseodesis effect. In 17 patients (42.5%) 24 fractures of the 3 mm-threaded VDS-compression rod occurred. In case of single rod fractures no higher loss of correction or differences in incidence of pain were observed in comparison to intact implants.

[Ultrasonographic measurement of leg length and leg length differences]. / Die sonographische Beinlängen-und Beinlängendifferenzmessung.

A new diagnostic method for measuring the leg length and the leg length difference by means of ultrasound is presented. A special device for holding and moving the ultrasound transducer was constructed. The measuring points on the hip, knee and upper ankle can be visualised by means of a 5- or 7.5-MHz linear scanner. The measuring device gives the distance of the points in cm so that the difference correspond to the length of the leg, femur and tibia. Tests conducted on corpes and clinical examples show that ultrasound in combination with our special device is an ideal method for determining the exact lengths of the leg. The ultrasound measuring of the leg length offers a reliable, non invasive and easily performed method. Because ultrasound is not limited by radiation hazards, our technique can be used for clinical screening.