Late cardiac effect of anthracycline therapy in physically active breast cancer survivors - a prospective study.

The late-onset cardiotoxic effect of anthracycline is known, however the early detection and prevention of subclinical myocardial damage has not been fully understood yet. Besides medical therapy regular physical activities may also play a role in the prevention and reduction of side effects of chemotherapy. The aim of our present study was to detect the effect of regular physical activities on the diastolic function and on the symptoms of late heart failure in case of anthracycline chemotherapy. The prospective study included 55 female patients (age 31-65 year, average 49.5 years) with breast cancer and no cardiovascular risk factors. Proper cardiologic checkup included physical examination (blood pressure, pulse, etc.), ECG, standard echocardiography parameters (EF, LV dimensions etc.) and specific tissue Doppler (TDI) measurements. Symptoms of heart failure were also recorded. After five years of follow-up, symptoms of heart failure were evaluated again. Patients were assigned into two groups depending on their physical activity: 36 patients did perform regular physical activities (mean age 49.2 years) and 19 patients did not (average age 50.1 years). There was no significant difference between the two groups in basic physiological or standard echocardiography parameters neither at the baseline nor at the later time points. Diastolic dysfunction (decreased E/A) was detected 6 months after the beginning of the treatment (T2 time point) in both groups. In the inactive group this value fell below one however there was no significant difference (1.1±0.25 vs. 0.95±0.22). One year after the beginning of the treatment (T3) a significant difference could be detected between the two groups (1.05±0.28 vs. 0.86±0.25. P=0.038). Consistent change in diastolic function (Ea/Aa) could be detected with the more sensitive TDI (Tissue Doppler Imaging) measurements after treatments in both groups, especially in the septal segment (in the non active group the Ea/Aa decreased markedly but not significantly at T2 - 1.1±0.55 vs. 0.81±0.44, and this difference became significant at T3 and 2 years after treatment (T4), p=0.007 and p=0.065). The filling pressure (E/Ea) rose above 10 (p=0.09) in the non active group at T2; and it kept rising in both groups and became significant at T3 (p=0.012). Five years after the onset of the treatment symptoms of heart failure were less frequently reported in the physically active group than in the inactive one (19.45% vs. 68.42%). The data of our study show that the diastolic dysfunction of the left ventricle related to the anthracycline therapy became evident in the physically active group later and the symptoms of heart failure were less frequent than in the non active group after five years period. Enrollment in sport activities could be a good means for partial prevention in this group of patients. Cardiologic checkup at proper intervals plays a pivotal role in detection of possible cardiotoxicity. This is a strong indication for changes in the lifestyle of the patient and the treatment protocol alike.

Pitfalls during biomechanical testing - Evaluation of different fixation methods for measuring tendons endurance properties.

The goal of the study was to find a proper technique to fix tendon grafts into an INSTRON loading machine. From 8 human cadavers, 40 grafts were collected. We removed the bone-patella tendon-bone grafts, the semitendinosus and gracilis tendons, the quadriceps tendon-bone grafts, the Achilles tendons, and the peroneus longus tendons from each lower extremity. We tested the tendon grafts with five different types of fixation devices: surgical thread (Premicron 3), general mounting clamp, wire mesh, cement fixation, and a modified clamp for an INSTRON loading machine. The mean failure load in case of surgical thread fixation was (381N ± 26N). The results with the general clamp were (527N ± 45N). The wire meshes were more promising (750N ± 21N), but did not reach the outcomes we desired. Easy slippages of the ends of the tendons from the cement encasements were observed (253N ± 18N). We then began to use Shi's clamp that could produce 977N ± 416N peak force. We combined Shi's clamp with freezing of the graft and the rupture of the tendon itself demonstrated an average force of 2198 N ± 773N. We determined that our modified frozen clamp fixed the specimens against high tensile forces.

Mosaicplasty for the treatment of articular defects of the knee and ankle.

Efficacious treatment of full-thickness cartilage defects of the weightbearing surfaces is a multi-faceted challenge for the orthopaedic surgeon. Autologous osteochondral transplantation represents one solution: to bring about a hyaline or hyalinelike repair of the defected area. The current authors discuss the experimental background and their 8 years of clinical experience with the autologous osteochondral mosaicplasty. Several series of animal studies and subsequent clinical practice have confirmed the survival of the transplanted hyaline cartilage. Hyaline cartilage and fibrocartilage fill the donor sites located on the nonweightbearing surfaces and surfaces that bear less weight. Clinical scores, imaging techniques, control arthroscopies, histologic examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage. According to these investigations, femoral condylar implantations have shown good to excellent results in 92%, tibial resurfacing in 88%, patellar and/or trochlear mosaicplasties in 81%, and talar procedures in 94% of patients. The Bandi score showed long-term donor site disturbances in 3% of patients. Fifty-eight of the 68 control arthroscopies had good gliding surfaces, histologically-proven survival of the transplanted hyaline cartilage, and fibrocartilage covering of the donor sites. In the entire series, there were four deep infections and 34 painful hemarthroses after surgery. A multicentric, comparative, prospective evaluation of 413 arthroscopic resurfacing procedures (mosaicplasty, Pridie drilling, abrasion arthroplasty, and microfracture cases in homogenized subgroups) showed that mosaicplasty gave a more favorable clinical outcome in the long-term followup, than the other three techniques. Intermediate-term evaluation of the femoral condylar implantations (3-6-years followup) and talar mosaicplasties (3-7-years followup) confirmed the durability of the early results. From these encouraging results from an increasingly large series and similar results from other centers, it seems that autologous osteochondral mosaicplasty may be a viable alternative treatment of localized full-thickness cartilage damage of the weightbearing surfaces of the knee and other weightbearing synovial joints.

Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients.

An osteochondral defect (OCD) is known as a symptomatic lesion causing pain, recurrent synovitis, and altered joint mechanics most commonly in a weight-bearing joint. Loose bodies may develop, which may then cause joint destruction and/or locking. The damage to the articular surface is most likely a precursor of ankle osteoarthritis. With the recent advances in diagnostic imaging, such as MRI, as well as the development of ankle arthroscopy, the identification and classification of these lesions has become much more precise. This allows more accurate staging and improves treatment recommendations. The assessment of a particular treatment is also improved. A variety of treatment alternatives are now available. These include arthroscopic procedures including debridement, retrograde drilling, and bone grafting. Compared to open treatment, arthroscopic procedures may be particularly advantageous in the treatment of small defects and stable OCD lesions. Until recently, however, favorable results have been less predictable for large or unstable osteochondral defects. We treat these more difficult lesions with a mosaic autogenous osteochondral transplantation. In our hands, this appears to provide an optimal treatment result. The present report evaluates the clinical outcome of 36 patients followed for two to seven years after a mosaicplasty autogenous osteochondral transplantation from a non or less weight bearing portion of the knee to the ipsilateral talus. Ankle function was measured by the Hannover scoring system and showed good to excellent results in 34 cases (94%) with no long term donor site morbidity. The encouraging clinical results are supplemented with radiographs and histology, which support the premise of lasting relief of symptoms and prevention of ankle arthrosis.

The surgical technique and the age of the horse both influence the outcome of mosaicplasty in a cadaver equine stifle model.

Six pieces of grafts, 6.5 mm in diameter, 20 mm in length, were taken from each of 170 cadaver hindlimbs, using the cranial surface of the medial femoral trochlea for harvesting. The age of the horses varied between 4 months and 23 years. 30 limbs under the age of 12 years were selected for transplantation. Three of six grafts were transplanted into the medial femoral condyle using different combinations of tunnel depth and dilation. With ageing, a significant decline in transplantability was detected. In general, mosaicplasty cannot be recommended in horses above 11 years. Based on a previous clinical case (Bodó et al., 2000), a good surface alignment was indeed achieved with a combination of graft length drilling and dilation in most cases. However, the occasional entrapment of cartilage debris under the graft prevented perfect alignment in the present cadaver study in 27% of the grafts transplanted in this manner. Since the protrusion of grafts never exceeded 1.5 mm, we conclude that drilling 3-5 mm deeper than graft length with graft length deep dilation can avoid disadvantageous protrusion of the transplanted hyaline cartilage caps, achieving bone decompression at the same time.

Arthroscopic autologous osteochondral mosaicplasty for the treatment of subchondral cystic lesion in the medial femoral condyle in a horse.

An 11-year-old, Hungarian half-bred stallion was presented with a history of mixed left hindlimb lameness of 6 months duration. Subchondral bone cyst of the medial femoral condyle and injury of the medial meniscus were diagnosed. Osteochondral autograft transplantation (mosaic arthroplasty) was performed, taking grafts from the less weight-bearing medial border of the medial femoral trochlea of the affected limb, and transplanting them into the cyst during arthroscopy. The lameness was evaluated prior to and one year after the operation with a motion analysis system during treadmill exercise. Considerable improvement of the lameness and the clinical signs as well as successful transplantation of the grafts, and a new hard joint cartilage surface of the medial femoral condyle could be detected during follow-up arthroscopy. Osteochondral autograft transplantation seems to bee a possible alternative for treating subchondral cystic lesions of the medial femoral condyle in horses. A new technique for the surgical treatment of a subchondral cystic lesion of the medial femoral condyle in the horse is described.

Osteochondral mosaicplasty for the treatment of focal chondral and osteochondral lesions of the knee and talus in the athlete. Rationale, indications, techniques, and results.

New techniques for articular cartilage transplantation have become available recently for traumatic chondral injuries. Applications to the athlete have generated considerable interest in the sports medicine community. The autogenous osteochondral grafting mosaicplasty has been used to treat these injuries in the athlete population for the past six years. The rationale, indications, operative technique, results, and limitations of mosaicplasty in the athlete are presented and discussed.

[Repair of cartilage defects. Technical aspects]. / La réparation cartilagineuse. Aspects techniques.

Efficacious treatment of chondral and osteochondral defects of the weight bearing surfaces represents a real challenge for the orthopaedic surgeon. Treatment options for full thickness cartilage defects are discussed in this paper. Poor biomechanical characteristics of the reparative fibrocartilage promoted by "traditional resurfacing techniques" provide only moderate clinical outcome in the treatment of such lesions. During the last decade several new efforts have been expressed to provide a hyaline or hyaline-like gliding surface for a full thickness defected area on the weight bearing surface. Among several surgical procedures, autologous osteochondral transplantation methods, including osteochondral mosaicplasty, chondrocyte transplantation, periosteal and perichondrial resurfacement and allograft transplantation are the favoured "new methods". Experimental background, operative techniques and clinical results of these new procedures are detailed in this overview. According to the early and medium term experiences of these methods it seems that a hyaline or hyaline-like resurfacement of the defected area can provide a more durable gliding surface and a better clinical outcome than the so called "traditional resurfacing techniques". Autologous osteochondral mosaicplasty--as an easy, one-step procedure, providing a relatively quick rehabilitation--can be an alternative in the treatment of small and medium sized lesions. Excellent clinical outcome, low costs of the treatment and short rehabilitation time represent the main advantages of this method. Autologous chondrocyte transplantation seems to be a promising option in the treatment of larger full thickness defects but requires relatively expensive two-step procedure and longer rehabilitation period. Both of the above mentioned techniques have femoral, tibial, patellofemoral and talar applications as well. According to the present recommendations transplantation of osteochondral allografts can be indicated at massive osteochondral lesions. There are less experiences with the clinical use of periosteal and perichondrial resurfacing techniques and biomaterials. Beside the promising early and medium term results of these methods the authors express that a successful treatment of the full-thickness cartilage damages of the weight bearing surfaces depends not only the way of the cartilage repair but on the treatment of the underlying cause as well. According to this statement for an effective treatment of full thickness defects on the weight bearing surfaces requires careful patient selection, complex operative plan and well organized treatment course.

Mosaicplasty for the treatment of articular cartilage defects: application in clinical practice.

This article describes a one-step operative technique for the treatment of circumscript cartilage defects of weight-bearing surfaces of the knee. Since 1992, a total of 227 patients were treated using this technique for full-thickness lesions resulting from chondropathy, traumatic chondral defects, and osteochondritis dissecans; the procedure was evaluated in 57 patients who had > 3 years of follow-up. Magnetic resonance imaging, computed tomography arthrographies, ultrasound, and arthroscopy were used to evaluate the technique. Using the modified Hospital for Special Surgery (HSS) knee scoring system, 91% of the patients achieved a good or excellent result. The operative technique, clinical results, and complications are detailed.

Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique--a preliminary report.

A one-stage autogenous osteochondral grafting technique for the treatment of talar dome osteochondritis dissecans is described. Eleven patients with osteochondritis dissecans lesions, 10 mm or greater in diameter, were operated on using the mosaicplasty autogenous osteochondral transplantation technique. Osteochondral cylindrical grafts from the ipsilateral knee were delivered into the talar defect using specially designed tube chisels. These procedures were done by arthrotomy. With follow-up of 12 to 28 months (mean, 16 months), the patients returned to full activities and the results, using the Hannover scoring system, have been excellent.

Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects. A preliminary report.

An arthroscopic technique for the use of mosaicplasty osteochondral grafting in the treatment of femoral condylar articular defects is described. During the procedure, small cylindrical grafts are harvested from the nonweightbearing periphery of the patellofemoral joint and implanted in mosaiclike fashion into the focal cartilage defect of the weightbearing condylar surface. This report describes the arthroscopic technique using newly designed instruments and the early results of 44 patients treated by this method. Good to excellent results have been obtained based on follow-up ranging from 1 to 5 years. The modified HSS scores are compared with a control group consisting of patients treated by abrasion arthroplasty. Evaluation was done clinically and, in some cases, by ultrasound, magnetic resonance imaging, 3-dimensional computed tomography. The results of 10 control arthroscopies and the histological evaluations of 6 biopsies demonstrated the hyalinelike cartilage surface at the recipient area and the fibrocartilage formation at the surface of the donor holes.

[New possibilities in the management of severe circumscribed cartilage damage in the knee]. / Súlyos, körülírt térdízületi porckárosodás sebészi kezelésének új lehetösége.

Authors review the possibilities of the treatment of degenerative damage of the knee. Their new method of operation is described, used in cases of severe cartilage damage of the superficial articular surface of the patella and of the weight bearing surface of the knee. In the available literature one similar method was found, described by Japanese authors in 1993. Authors gain since 1992 from the non weight bearing articular surface of the femur cartilagineous-osreous cylinders for the supply of the defects of the weight bearing surface and the cartilagineous defects of the patella. By this a gliding surface, better than gained with the former method can be created. The method described after an early follow up of their first 14 operations.

[Experience with the "Oxford" type uni-condylar meniscus- and surface replacing knee prosthesis. Preliminary report]. / Az "Oxford" típusú unicondylaris meniscus- és felszínpótló térdprotézissel szerzett tapasztalataink. Elözetes jelentés.

Authors report on the first implantation of a new type of an unicondylar meniscus and surface replacing knee prosthesis in this country. After a brief literary review the prosthesis, the instruments developed for the implantation, the indications and the early favourable results of their two operations are described.

[Experience with the AGC-2000 type bicondylar surface-substituting knee prosthesis]. / Az AGC-2000 típusú bicondylaris felszínpótló térdprotézissel szerzett tapasztalataink.

Authors report on the first use of bicondylar surface substitution knee prosthesis of a new type. The prosthesis and the instruments developed for implantation are demonstrated. In the first five operations the appropriateness of the implantation instruments, the exactness of their handling, the assortment of the series of prosthesis have met the plus which, compared to the types known until now, can secure the exactness of the operation and improve the ratio of the lasting good results.

[Distal osteotomy of the metatarsal bones in the treatment of metatarsalgia]. / A lábközép csontok distalis osteotomiái a metatarsalgia kezelésében.

Authors review briefly the development of the principles of metatarsal osteotomies and the basic concepts that seem to be the most suitable in the choice of the type and execution of the operation. The effectiveness of the surgical treatment is stressed if the following viewpoints are considered: 1. Synchronous correction of the rays II, III, and IV. 2. Simultaneously achieved abbreviation and forming of the arch. 3. Instead of internal fixation transversal lifting bandage with early weight bearing. The finding, according which, beside the telescope osteotomy of Helal, Wolf's metatarsal osteotomy with axial deviation is also a valuable alternative, is supported by the follow-up of their own 2 years material.

[Management of recurrent patellar dislocation by semitendinous muscle transfer]. / Szokványos térdkalácsficam megoldása a semitendinosus in átültetésével.

After review of the pertinent literature authors report on a new tendon transfer technique not having been found in the available literature. The method has been considered suitable for the treatment of patellar dislocations due to erroneous stretching direction occurring before the end of growth. The semitendinous muscle was separated and transfosed in the tunnel drilled into the patella. By means of this technique the function of the muscle was used against the lateralization tendency of the patella. The paper presents the follow-up of 9 cases.