Clinical outcomes of absorbable plates (hydroxyapatite-poly-l-lactide composites) for phalangeal fractures - case reports.

We report two cases of the basal phalanx fractures of the thumb treated with absorbable mesh plates. In both cases, the mesh plates specifically tailored for each fracture were effective in obtaining bone union and healing. We conclude that absorbable mesh plates could be a practical option for phalangeal fractures, especially where proprietary pre-molded metallic plates do not neatly fit the reduced fracture area.

DIFFUSION OF INJECTED COLLAGENASE CLOSTRIDIUM HISTOLYTICUM FOR DUPUYTREN´S DISEASE: AN IN-VIVO STUDY.

INTRODUCTION: While injecting Clostridium Histolyticum as a non-surgical tratment for Dupuytrens disease on the palmar side of the hand the recommended depth of the needle should be “around 2 to 3 mm in depth”. The diffusion of CCH inside the soft tissues around the cord might explain the occurrence of common adverse events reported in the literature such as oedema, injection site swelling, blood blisters, skin laceration, and pain in extremity. We hypothesized that the injected Collagenase Clostridium Histolyticum does not only concentrate inside the cord but also dissipates both along the cord and into the adjacent tissues. This study investigated our hypothesis by visual intraoperative findings after injecting Povidone iodine into the cord. MATERIAL AND METHODS: Povidone iodine  (PI)was injected into the cord on six patients with Dupuytrens contracture before an open surgical operation (partial fasciectomy). We marked three hypothetical Collagenase Clostridium Histolyticum injection points at 2 mm intervals on the skin above the cord around the metacarpo-phalangeal joint and the depth of the injection (distance from the skin surface to the middle of the cord) was measured by ultrasonography. After dispensing 0.25 ml of Povidone iodine into the three points at the measured depths, we performed careful dissection and investigated the extent of diffusion of Povidone iodine visually. RESULTS: The injection depth averaged 2.6 mm. In all cases, the cord was homogenously stained about 10 mm along its extent centrally to the injected sites and infiltration of Povidone iodine into the subcutaneous structure and fat tissue occurred. Three cases showed diffusion into the neurovascular bundles and two cases showed infiltration underneath the cord structure. CONCLUSIONS: This study simulated the likely diffusion outcomes of injected Collagenase Clostridium Histolyticum around the cord. This implies that even if Collagenase Clostridium Histolyticum is injected into the centre of the cord, it does not concentrate inside the cord only but also dissipates along the cord and infiltrates into the adjacent tissues with potential secondary damages.

OPTIMAL INJECTION DEPTH FOR COLLAGENASE CLOSTRIDIUM HISTOLYTICUM DETERMINED BY ULTRASONOGRAPHY IN THE TREATMENT OF DUPUYTREN´S DISEASE.

INTRODUCTION: A non-surgical procedure for the treatment of Dupuytrens disease is a palmar injection of Collagenase Clostridium Histolyticum to the recommended depth of “around 2-3 mm”. However, there is little supporting evidence from the literature to substantiate this. The aim of this study was to evaluate the “optimal depth” for injection of Collagenase Clostridium Histolyticum by ultrasonography for the treatment of Dupuytrens disease. MATERIAL AND METHODS: A total of 43 patients were enrolled in this study. We marked the collagenase injection point on the skin above the cord before injection. We then measured the distance from the surface of the skin to the middle of the cord by ultrasonography long axis imaging and defined this as the “optimal depth”. RESULTS: The average depth from the skin to the centre of the cord was 2.4 mm. The average distance from the surface of the skin to the proximal surface of the cord was 1.0 mm and the average thickness of the cord was 2.7 mm. CONCLUSION: By precise measurement of individual cases utilising ultrasonography we were able to confirm that the recommendations for injection depth as provided by the supplier of Collagenase Clostridium Histolyticum (2-3 mm) were in agreement with our findings. However no objective guide was supplied as with regards to interindividual variability between patients and we suggest that the use of preliminary ultrasonography will likely provide improved outcomes.

Donor leukocytes combine with immunosuppressive drug therapy to prolong limb allograft survival.

Donor leukocytes administered at the time of transplantation may prolong organ allograft survival. This study examined the effectiveness of donor leukocyte injection combined with immunosuppression for limb transplantation across the strong histocompatibility barrier of a Brown Norway donor to a Lewis recipient. Eight animals received 6 x 10(7) donor leukocytes injected on the day of transplantation. From day 1, FK506 (2 mg/kg/d), mycophenolate mofetil (MMF) (15 mg/kg/d), and prednisone (0.5 mg/kg/d) were administered for 2 weeks. After week 2, prednisone and MMF were both tapered by 20% of the initial dosage per week. After week 7, the animals received only FK506 (2 mg/kg/d). From week 8, FK506 was tapered to the maintenance dose of 0.8 mg/kg/d at week 10 and was stopped on week 24. A control group of 8 animals underwent identical treatment except that the leukocyte injection was omitted. Rejection was observed in both groups during FK506 monotherapy; however, the onset of early rejection episodes was significantly later, the period for reversal of the first rejection was significantly shorter, and the dosage of FK506 at the time of rejection was significantly lower among leukocyte-treated recipients. After completion of immunosuppression, survival was modestly prolonged in the leukocyte-treated group. One animal is surviving without immunosuppression on day 234. This trial of donor leukocyte injection combined with immunosuppression in limb transplantation showed a modest, but significant, improvement in outcome.

Donor leukocytes combined with delayed immunosupressive drug therapy prolong limb allograft survival.

Donor leukocytes administered at the time of transplantation may prolong organ allograft survival. Delayed administration of calcineurin inhibitors, such as FK506 or cyclosporine, may enhance their efficacy. Herein the effectiveness of this strategy to promote limb transplant survival was investigated in the strong histocompatibility barrier of Brown-Norway donor to Lewis recipients. Donor leukocytes (6 x 10(7) intravenously) were injected on the day of transplantation followed on day 1 to 14 with mycophenolate mofetil (MMF; 15 mg/kg/d) and prednisone, (0.5 mg/kg/d) which were then tapered by 20% each week and stopped at week 7. Administration of of FK506 (2 mg/kg/d) was started on day 4 and continued for 8 weeks, then tapered for 4 weeks to a maintenance dose of 0.8 mg/kg/d, which was continued for 12 weeks (group A; n = 8). A control group (n = 8) underwent identical treatment save for donor leukocyte injection but rather commencement of FK506 on day 1. Rejection was common during FK506 tapering in both groups. However group A showed a significantly later onset, a shorter period for reversal of the first rejection, and a significantly lower dosage of FK506 at the time of rejection. After the completion of immunosuppression, rejection occurred significantly later in group A than the control group with one animal surviving without immunosuppression on day 344. This is the first trial of a donor leukocyte injection combined with delayed FK506 administration in limb transplantation, which suggested that it could produce a modest but significant improvement in outcome.

Experimental limb transplantation, part III: induction of tolerance in the rigorous strain combination of Brown Norway donor to Lewis recipient.

The complete withdrawal of immunosuppressive therapy after hind-limb transplantation across a strong histocompatibility barrier (Brown-Norway to Lewis) included a low-dose combination of FK506, mycophenolate mofetil (MMF), and prednisone. MMF and prednisone were tapered and withdrawn between weeks 2 and 7. From weeks 8 to 24, Group 1 animals (n=23) had FK506 tapered; for those in Group 2 (n=11) the dose of FK506 was not changed. At week 24, FK506 was stopped. The six limb grafts in Group 1 (26%) that achieved the 1-year end-point uneventfully showed chimerism by bone marrow and skin grafting supporting the presence of donor-specific tolerance. Rejection, which was common during tapering of FK506, was reversed by salvage therapy. All limbs were rejected postwithdrawal in Group 2. This study showed that tapering of FK506 combined with salvage therapy may allow long-term survival of some transplanted limbs after complete withdrawal of immunosuppressive therapy despite a complete MHC barrier.

Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption.

STUDY DESIGN: Herniated lumbar disc specimens were cocultured with peripheral blood mononuclear cells, and cells isolated from extruded disc were cultured to study the production of matrix metalloproteinases. OBJECTIVE: To investigate the role of peripheral blood mononuclear cells infiltrating extruded discs and disc-derived cells in the production of matrix metalloproteinases. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging analysis of herniated disc patients revealed a progressive decrease in the size of herniated discs. Spontaneous regression of herniated disc is associated with infiltrating macrophages, and matrix metalloproteinases have been implicated in this phenomenon. However, the correlation between infiltrating macrophages and the production of matrix metalloproteinases has received little research attention. METHODS: Each disc specimen was incubated with homologous peripheral blood mononuclear cells. The numbers of peripheral blood mononuclear cells attached to the surfaces of herniated discs were counted and the culture media was assayed for MMP-3. The cells isolated from herniated discs were incubated with cytokines and the production of matrix metalloproteinases was measured. Total RNA was extracted from herniated discs and RT-PCR was carried out. RESULTS: Significantly larger numbers of peripheral blood mononuclear cells were attached to the surfaces of extruded discs, and higher amounts of MMP-3 were detected than those of control discs. The culture medium of extruded discs showed higher MMP-1 and MMP-3 production than those from controls. Significant enhancement of MMP-1 and MMP-3 mRNA expression was observed in the disc-derived cells stimulated with cytokines. CONCLUSION: These results suggest that peripheral blood mononuclear cells infiltrating extruded discs may secrete a variety of biologic materials capable of further recruiting monocytes into herniated discs in an autocrine fashion. Disc cells stimulated with cytokines showed enhanced production of matrix metalloproteinases, which might play an important role in spontaneous regression of disc materials.

Immunohistologic study of the ruptured intervertebral disc of the lumbar spine.

STUDY DESIGN: This study analyzed immunohistological features of the extruded or sequestrated intervertebral disc of the lumbar spine. To clarify the pathogenesis of neovascularization, cells isolated from herniated disc were cultured and examined biologically. OBJECTIVES: The objectives of this study were to characterize the histologic features of extruded or sequestrated discs and inflammatory cells that infiltrate along the margins of the disc tissue and to clarify the pathogenesis of neovascularization observed at the edge of the disc tissue. SUMMARY OF BACKGROUND DATA: When some of the contents of the disc extrudes into the epidural space and is considered "foreign," an autoimmune response develops, which can lead to a chronic inflammatory response. However, the pathogenesis of inflammatory cell infiltrations and neovascularization are not clearly defined. METHODS: The herniated discs were obtained during surgery and were stained with anti-interleukin-1, intercellular adhesion molecule-1, lymphocyte function-associated antigen, and basic fibroblast growth factor antibodies by using an indirect immunoperoxidase method. Cells isolated from herniated disc were cocultured with human endothelial cells and basic fibroblast growth factor contained by cultured disc cells were measured by radioimmunoassay. RESULTS: The ingrowth of granulation tissue with vascularization, occurring at the edge of fibrocartilage fragment, was present at 11 of 16 of extruded and 3 of 5 of sequestrated discs. Anti-interleukin-1, intracellular adhesion molecule-1, lymphocyte function-associated antigen, and basic fibroblast growth factor were expressed on most of mononuclear cells infiltrating into the extruded or sequestrated disc. Cells from the extruded or sequestrated disc demonstrated significantly greater levels of basic fibroblast growth factor than those from the protruded disc, and they enhanced the proliferation of endothelial cells. CONCLUSIONS: This study showed that mononuclear cells infiltrating along the margins of extruded discs expressed inflammatory mediators and might induce neovascularization and persistence of inflammation.

Effects of glycolytic metabolites on preservation of high energy phosphate level and synaptic transmission in the granule cells of guinea pig hippocampal slices.

The present study was undertaken to investigate whether neural activity of hippocampal slices can be preserved after replacing D-glucose with glycolytic intermediate metabolites such as lactate, pyruvate and citrate or with other sugars such as fructose, mannose, maltose, glucosamine, sucrose and galactose. As an index of neural activity, population spikes (PS) were recorded in the granule cell layers after electrical stimulation to the perforant path of guinea pig hippocampal slices. In addition, we determined the levels of ATP and creatine phosphate (CrP) in each slice after the replacement of D-glucose with these substrates, and correlated it with the neural activity. Substrates other than D-glucose could not maintain the PS for even 20 min although the slices perfused with medium containing lactate, pyruvate, galactose, fructose and maltose maintained similar levels of ATP and CrP as in slices incubated in the D-glucose-containing medium. These results indicate that D-glucose is essential for the preservation of synaptic activity in addition to its main role as the substrate for energy production to maintain the levels of high energy phosphates.

The relation between cubital tunnel syndrome and the elbow alignment.

The authors reviewed forty-three surgically managed cases of cubital tunnel syndrome treated during the past twelve years. Surgery had been performed on thirty-one men and twelve women. Their average age was 46.8 years old. The etiology of cubital tunnel syndrome had been determined as follows: There were twenty-three cases of osteoarthritis of the elbow joint. There were four cases of isolated cubitus valgus deformity. There were three cases of isolated cubitus varus deformity. There were three cases of rheumatoid arthritis. One patient had sustained trauma to the cubital tunnel. In nine other patients there were various causes but no joint malalignment. The selection of the surgical technique for the correction of cubital tunnel syndrome was a function of the etiology of the condition. Cubital tunnel syndrome from osteoarthritis was surgically managed with a modified King technique. Ulnar neuropathy with a cubitus valgus deformity was managed with an ulnar nerve anterior transposition. Ulnar neuropathy with a cubitus varus deformity was managed with a neurolysis. The surgical outcome for cubital tunnel syndrome in patients with an angular deformity at the elbow frequently was not optimum. However, although some patients remained symptomatic, the majority of postoperative patients did obtain improved motor strength and conduction velocities. This confirmed the efficacy of surgical management regardless of the cubital tunnel syndrome etiology.

An indirect immunofluorescence method for detection of Mycoplasma hominis in vaginal smears.

We developed a novel method for the detection of Mycoplasma hominis from vaginal swabs using an indirect immunofluorescence technique. It is a rapid and simple method that can be finished in only 5 hr and is more sensitive than the usual culture isolation method. The indirect immunofluorescence method was applied to vaginal smears from 193 healthy women and 33.7% gave a positive test. This value was much higher than that (11.4%) obtained from the same specimens by the culture method. When vaginal smears were subjected to Papanicolaou staining after the indirect immunofluorescence method, the specific immunofluorescence of the epithelial cells was located exactly at the sites of granular aggregates stained with Papanicolaou stain. A histological examination by Papanicolaou staining showed that the incidence of inflammation seems to be slightly higher in M. hominis-carriers than in non-carriers.

Generation of cytotoxic T lymphocytes from thymocyte precursors to trinitrophenyl-modified self antigens. II. Establishment of a T cell hybrid clone constitutively producing killer-helper factor(s) (KHF) and functional analysis of released KHF.

T cell hybridoma lines were constructed by fusion of Mycobacterium tuberculosis-primed and boosted BALB/c T cells with the AKR-derived T lymphoma cell line BW5147. Certain of the hybridomas prepared in this manner secreted constitutively into their culture supernatants biologically active molecules that displayed precursors of cytotoxic T cell activating properties characteristic of killer-helper factor (KHF). Cell surface analysis revealed that the hybridomas were indeed somatic cell hybrids between the two respective partner cells used for fusion. KHF properties of these hybridoma supernatants were verified by their capacity to stimulate peanut agglutinin-binding (PNA+) C3H/He thymocytes to respond in vitro to 2,4,6-trinitrophenyl(TNP)-modified syngeneic stimulator cells in conjunction with suboptimal doses (10 U/ml) of interleukin 2 (IL 2) for the generation of H-2-restricted, TNP-reactive cytotoxic T cells. The biologically active molecules secreted by a T cell hybrid clone (2Y4) were, like conventional KHF, distinct from IL 1, IL 2, or immune interferon (IFN-gamma). The partially purified KHF derived from 2Y4 cells shows activity at apparent m.w. range of 34,000 to 60,000 on gel permeation, and is relatively homogeneous with respect to isoelectric point, which was approximately 4.5 to 4.7. The partially purified 2Y4-KHF is able to augment proliferation of as well as the expression of IL 2 receptors on PNA+ thymocytes in conjunction with IL 2. Finally, addition of 2Y4-KHF on day 0, followed by the addition of IL 2 on day 2 for 7 days of culture was effective in generating potent CTL responses, whereas addition of IL 2 on day 0, followed by the addition of 2Y4-KHF on day 2 to the culture was ineffective.

Generation of cytotoxic T lymphocytes from thymocyte precursors to trinitrophenyl-modified self antigens. I. Requirement of both killer-helper factor(s) and interleukin 2 for CTL generation from a subpopulation of thymocytes.

The requirement for signals in the induction of cytotoxic T lymphocytes (CTL) from thymocyte precursors has been investigated. Either unfractionated or peanut agglutinin-binding (PNA+) C3H/He thymocytes were stimulated with mitomycin C(MMC)-treated, 2,4,6-trinitrophenyl(TNP)-modified syngeneic spleen cells in the presence of a variety of lymphokine preparations. Cellfree supernatant (CFS) from purified protein derivatives(PPD-CFS) stimulated Mycobacterium tuberculosis (Tbc)-primed cells, or partially purified interleukin 2 (IL 2) mediated strong cytotoxic responses in unfractionated thymocytes, whereas only PPD-CFS at final concentrations beyond 30% was active for CTL generation in PNA+ thymocytes. Neither IL 2 at concentrations of below 60 U/ml nor a low concentration of PPD-CFS (at final below 10%) had such a capacity. The addition of monoclonal anti-IL 2 receptor antibody completely blocked CTL generation induced by PPD-CFS in PNA+ thymocytes. In contrast, anti-immune interferon (IFN-gamma) antibody showed a marginal effect. PPD-CFS (10%) and IL 2 (10 U/ml) could synergistically trigger PNA+ thymocytes to induce CTL generation. These results suggested that both IL 2 and "helper" factors other than IL 2 are required for CTL generation from PNA+ thymocytes. We refer to these kinds of helper factors as killer helper factors (KHF). Partially purified IL 2-free KHF show two peaks of activities at apparent m.w. 14,000 to 34,000 and 44,000 to 90,000, and are heterogeneous with respect to isoelectric point, which is between 4.5 and 5.1. Cultures that received TNP-modified syngeneic cells and KHF on day 0 and IL 2 on day 2 generated potent CTL responses, whereas the addition of IL 2 on day 0 followed by the addition of KHF on day 2 to the culture was ineffective, suggesting that KHF is required in the early phase of the culture to achieve optimal CTL responses.

Comparative studies on B cell reactivities in two X-linked immunodeficient mice to the B cell-stimulating factors.

Responsiveness of B cells from X-linked immunodeficient CBA/N and DBA/2Ha mice to the B cell growth factor-1 (BCGF-I or BSF-1) and B cell differentiation factors (B151-TRF1 and B151-TRF2) was comparatively studied. B cells from CBA/N mice did not respond to BSF-1 in the presence of soluble anti-mu antibody. However, the BSF-1-response of CBA/N B cells was detected when activated by the anti-mu antibody-coupled Sepharose-beads. In the B151-TRF1 assay, antigen-unprimed B cells from CBA/N mice failed to respond to B151-TRF1, whereas antigen-primed B cells became responsive to B151-TRF1. In the B151-TRF2 assay, CBA/N B cells were non-responder to B151-TRF2. In these assays, however, unprimed CBA/N B cells were able to absorb both B151-TRF1- and B151-TRF2-activities to the same extent as the non-defective strain B cells. These results indicate that B cell defect in CBA/N mice may be reflected by some abnormality in signal transmission at encounter to the B cell-stimulating factors but not by inability to bind these factors. These low responder properties of CBA/N B cells were all inherited in an X-linked recessive manner. In contrast, B cells from DBA/2Ha mice well responded to BSF-1 and B151-TRF2, whereas both antigen-unprimed and -primed DBA/2Ha B cells failed to respond to B151-TRF1. This selective B151-TRF1-unresponsiveness of DBA/2Ha B cells was also controlled by an X-linked recessive inheritance. Moreover, in contrast to CBA/N mice, selective unresponsiveness of B cells to B151-TRF1 in DBA/2Ha mice was reflected by the absence of B151-TRF1-receptor expression, as demonstrated by absorption experiment. The B cell populations found in these two distinct X-linked immunodeficient mice may provide an useful experimental model for analyzing B cell activation process mediated by various B cell stimulation factors.