Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia.

PURPOSE: Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia. METHODS: Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H0), after removal of the gland (Hdrop), 6 h (H6) and one day (D1) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times. RESULTS: The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H6, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant. CONCLUSION: The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

[Elastic stable intramedullary nailing in Ilizarov bone lengthening]. / Embrochage centro-médullaire dans les allongements osseux selon Ilizarov.

PURPOSE OF THE STUDY: Bone lengthening with the Ilizarov technique gives good results but certain disadvantages are common: possible axial deviation during lengthening, long time to bone union, risk of fracture after removal of the external fixator. Associating the Ilizarov technique with elastic stable intramedullary nailing (ESIN) commonly used in traumatology has to be evaluated. We conducted an experimental study and report results of the first clinical application. MATERIAL AND METHODS: Eleven lengthenings of the tibia were conducted in dogs aged 1 to 4 years using an Ilizarov external fixator associated with ESIN. Lengthening started on day 1 and continued for 28 days. X-rays were obtained every week during lengthening, then at 15 and 30 days during the fixation period and 30 days after removal of the fixator. In two cases, arteriography was performed. In a pilot clinical trial, fourteen patients (8 males, 6 females) were treated with this method (1 humerus, 1 forearm, 7 femurs, 5 tibias). Mean patient age was 14 years. RESULTS: In the experimental study, the x-rays showed rapid ossification of the regenerate which led to increased tibia length in 7 cases from 1.25 to 2 mm/day. Total bone union was observed in four dogs during the lengthening period. At day 15 of the fixation period, all tibia had fused with a good quality cortical bone and healing of the growth part of the regenerate. In three dogs, the external fixator was removed at day 15 of fixation and weight-bearing was total with the ESIN in place. No axial deviation and no skin problems were observed. The medullary artery was seen on the two arteriograms. In the clinical trial, bone union of the regenerate appeared earlier than in the Ilizarov series. The regenerate always displayed good density on the x-rays, proving intense bone activity. In three patients, the lengthening rate was increased to avoid premature bone fusion. The endosteal bone regenerate was obvious. Mean healing index was 18.6 days/cm (SD=6.2). Weight-bearing was allowed at six weeks. The desired correction was achieved in all patients and no complications were related to ESIN. DISCUSSION: Bone lengthening may be obtained with an intramedullary locking nail which avoids the use of an external fixator but also destroys the endomedullary circulation. Our experimental and clinical study shows that use of an ESIN does not inhibit the endosteal regenerate and seems to improve new bone formation. In many patients, the lengthening rate had to be increased to avoid premature bone fusion. When used in optimal conditions, ESIN can stimulate new endosteal and periosteal bone formation. In addition, ESIN increases shaft stability avoiding the risk of axial deviation. ESIN plays an additional role of stabilization after early removal of the external fixation.

[Reduction of the period of treatment for leg lengthening. Technique and advantages]. / Réduction de la durée du traitement dans les allongements osseux progressifs. Technique et advantage.

PURPOSE OF THE STUDY: We assessed an adaptation of the Ilizarov method aimed at a considerable reduction in the period of treatment for leg lengthening in order to limit complications related to the duration of the external fixation. This technique associates multiple segment lengthening, automatic high-frequency lengthening, and stimulation of bone regeneration by extemporaneous compression at the end of traction. MATERIAL AND METHODS: We analyzed 78 cases of automatic fémur lengthening in 40 patients and simultaneous fémur and tibia lengthening in 38 patients. There were 51 men and 27 women, mean age 13.2 years (6 - 43 years). Mean length deficiency was 4.3 cm for the fémur and 3.5 cm for the tibia. Femoral and/or tibial deformations were observed in 32 patients. Minimal follow-up was 1.5 years. The automatic traction device was composed of the conventional Ilizarov fixator and complementary elements. Different assemblies were used depending on the associated deformations allowing their progressive correction. For 17 patients, radioimmunoassay of thyrocalcitonin and parathormone was performed to compare the time courses. RESULTS: Mean femoral lengthening achieved was 49 mm (8.5 to 20%). Mean tibial lengthening was 42 mm (7.2 to 18.8%). The consolidation index was 18.1 to 21.3 days/cm for single-segment lengthenings and 11.5 days/cm (mean) for two-segment lengthenings (taking into account both the femoral and tibial gain in length). The ideal moment of compression was 5.6 N/cm(2). Acceleration of the bone repairing process was evidenced by activation of the osteotrop hormone system. According to the SOFCOT classification of complications (1990), 60 patients (76.9%) were in category I, 15 (19.3%) in category II, and 3 (3.8%) in category III. DISCUSSION: Improvement of lengthening procedures with external fixators remains an important issue. Treatment periods are often long with consolidation indices for the femur ranging from 39.6 d/cm to 45 d/cm, which can lead to many types of complications. Use of a high-frequency progressive lengthening procedure based on the Ilizarov method considerably reduces the rate of complications compared with progressive lengthening methods and has allowed achieving more satisfactory results in a shorter treatment period. CONCLUSION: Multiple-segment lengthening using an automatic lengthening procedure set at 1 mm per day in four times provides an important reduction in the treatment delays since distraction is performed more rapidly and fewer steps are needed. Automatic high-frequency lengthening with the Ilizarov method provides optimal conditions for tissue regeneration: Treatment periods are shorter and anatomic and functional outcome is very satisfactory. Stimulation by extemporaneous compression of the regeneration zone allows a significant reduction in the duration of consolidation. Shorter delays to consolidation help avoid device-related complications.

Purification and Characterization of Phosphoribosylpyrophosphate Synthetase from Rubber Tree Latex.

Phosphoribosylpyrophosphate synthetase (PRS; EC 2.7.6.1) from Hevea brasiliensis Mull. Arg. latex was located in the cytosol. After purification, its apparent molecular weight under nondenaturing conditions was estimated at 200,000 [plus or minus] 10,000; a single band at 57,000 [plus or minus] 3,000 was detected after sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The enzyme seemed to be a homotetramer. Its affinity constants were estimated at 200 [plus or minus] 30 [mu]M for adenosine triphosphate and 40 [plus or minus] 2 [mu]M for ribose-5-phosphate. The purified enzyme proved to be functional in a paraphysiological medium (cytosol deproteinized by ultrafiltration). Optimum pH was 7.5 in buffer and 6.5 in a paraphysiological medium. No PRS activity was detected in the absence of the Mg2+ ion. Of the numerous compounds tested, only Mn2+, phosphoribosylpyrophosphate, and inorganic phosphate affected the enzymatic reaction. Mn2+ (inhibitor constant = 20 [mu]M) and phosphoribosylpyrophosphate (inhibitor constant = 30 [mu]M) were inhibitors. PRS responded allosterically (Hill's coefficient = 2.3) to ribulose-5-phosphate in the presence of a physiological concentration of inorganic phosphate (10 mM). These results are set in the physiological context of laticifers.

Fractures of the radial head and associated elbow injuries in children.

Fractures of the radial head are frequently associated with elbow injuries in children. Thirty-seven patients with this association treated at the Nancy Children's Hospital were analyzed to ascertain the mechanism and the unfavorable factors of prognosis. The mechanism responsible was a valgus strain on the elbow at the moment of impact, associated with forces of compression and distraction. At an average follow-up of 2 years, 76% excellent and good results were obtained. Conservative treatment was always effective in minimally displaced fractures. With surgical reduction by closed intramedullary pinning (CIMP), there were only three failures in severely displaced fractures. With open reduction, results were always poor; 88% patients with fair and poor results had an associated fracture of the olecranon. The unfavorable prognostic factors were the severity of the initial tilting and displacement, the presence of associated elbow injuries, the inadequacy of reduction, and the open reduction procedure.

Treatment of Langerhans-cell histiocytosis in children. Experience at the Children's Hospital of Nancy.

Forty children who had Langerhans-cell histiocytosis were followed for an average of six years (range, excluding patients who died of the disease, two to fifteen years). The patients were divided into two diagnostic groups: those who had localized disease (involving one bone or more only) and those who had multifocal disease (an osseous lesion and a soft-tissue mass, a skin rash, diabetes insipidus, or generalized disease). Methods of treatment included curettage, bone-grafting, chemotherapy, local or systemic corticosteroids, and radiotherapy. Nineteen of the thirty patients who had localized disease had a complete response to the therapy, four had a partial response, and seven had no response. Twenty-one of these thirty patients had not had a recurrence by the time of the latest follow-up examination; nine had a local recurrence within four years after the initial therapy but had no additional recurrences after treatment of the local recurrence. No recurrence occurred more than four years after the time that the initial diagnosis had been made. Five of the ten patients who had multifocal disease had a complete response to the therapy, two had a partial response, and three had no response. Six patients had a recurrence; four did not. Two patients died of the disease. As a result of this study, we recommend the avoidance of intensive measures of treatment, if possible, and we advise long-term follow-up of these patients.

Treatment of sternocostal wall malformations of the child. A series of 210 surgical corrections since 1975.

Of 450 children examined for front chest wall malformations, 210 underwent a corrective operation: 190 funnel chests and 20 pigeon chests. A classification of the anatomic forms is presented which contains 6 groups: vertical cup-shaped (the most common), horizontal cup-shaped, vallecular, mixed, complex with sternal torsion or polymalformations. The operation has been programmed in 64% of the cases between 10 and 18 years, but 36% were operated under 6 years because of a severe functional disturbance. On the technical side, Ravitch's procedure is still used on young infants; for the other cases sternochondro-plasty is to be preferred. The fixation of the chest wall is realized with an original, light, solid elastic material taking little space, and easy to remove. This material is presented. The immediate results: 62% very good, 35% good and 3% mediocre, sometimes do present a pejorative evolution, so that after two years of follow-up we notice: 55% remained perfect, 35% very good, 10% moderate of which, 4% to be reoperated. This deterioration touches more particularly the older children operated between 16 and 18 years. Among the children between 3 and 6 years the results are usually very good and remain stable with growth.

Ethylene-Induced Increase in Glutamine Synthetase Activity and mRNA Levels in Hevea brasiliensis Latex Cells.

Ethylene, used as a stimulant of latex production in Hevea brasiliensis, significantly activates the regenerating metabolism within the laticiferous cells. In this context, attention was focused on glutamine synthetase (GS; EC 6.3.1.2), a key enzyme in nitrogen metabolism. A specific and significant activation of the cytosolic glutamine synthetase (GScyt) in the laticiferous cells after ethylene treatment parallels the increase of latex yield. A marked accumulation of the corresponding mRNA was found, but in contrast, a slight and variable increase of the polypeptide level is at the limit of detection by western blotting. The GS response to ethylene might be mediated by ammonia that increases in latex cytosol following ethylene treatment. The physiological significance for such a regulation by ethylene of the GScyt is discussed in terms of the nitrogen requirement for protein synthesis associated with latex regeneration.

[Congenital fibular hemimelia]. / Hémimélie péronière congénitale.

Among the congenital malformations of the lower limb, hemimelia of the fibula is particularly important because of its frequency and the large number of anatomic forms which have been observed. Attempts at various therapeutic approaches have ranged from external prostheses to amputations and finally major skeletal lengthening. Based on a statistical study of 17 patients, we examined the different steps in the treatment of such cases with the aim of preserving the limb. Modalities for lengthening procedures and complications were studied in a comparison with results obtained with classical treatments.

[Bilateral lengthening of short lower limbs. 26 cases treated with the Ilizarov method]. / Allongement bilatéral des membres inférieurs pour petite taille. 26 cas traités par la méthode d'Ilizarov.

Gradual distraction with the Ilizarov external fixator was used on 26 patients for short stature. 19 patients complete their program (G1, 64 fixators): average pain is 12 cm for an initial stature of 133 cm; 3 patients stopped their program before end for psychological problems. Surgical procedures included: section of tensor fascia lata (9 cases), lengthening of Achilleus tendon (16 cases), skin debridement around pins (3 cases), modification of apparatus under general anesthesia (53 cases), iterative corticotomy (4 cases in G1) or peroneus section (4 in G1). Healing index was 23 D/cm for femur and 29 D/cm for tibia. Events occurred during the program: 1) mechanicals: 1 pin rupture; 2) bony: 1 delayed healing needing graftng, 3 bone impactions and 11 fractures after fixator removal, 1 axial deviation needing callotasy at fixator removal; 3) nervous and musculary: 12 transitory peroneal nerve lesions, 3 compartment syndromes, 2 proximal sciatic lesion, recovered, and 2 motor palsies; 4) joint lesions: 1 knee stiffness needing an extensive quadriceps release; 5) vascular: 1 deep venous thrombosis; 6) infectious: 10 superficial infections around pins, 4 osteitis and 1 arthritis; 7) cutaneous: 7 scar removals. Lengthening of people with short stature concerns motivated people fully aware of events occurring during a lengthening program which will decrease the initial handicap.

[Villonodular synovitis of the wrist. Apropos of a case in an adolescent]. / Synovite villonodulaire du poignet. A propos d'un cas chez une adolescente.

Pigmented villonodular synovitis of the wrist is an uncommon disease. It is also very rare in childhood and adolescence. The authors report a case with good outcome after surgery and review the literature concerning this.

Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning.

Radial neck fractures in children are serious injuries with frequent sequelae when the tilt exceeds 60 degrees. Conservative treatment is often inadequate in such cases and open reduction may produce iatrogenic complications. We report our experience with an original technique. An intramedullary wire introduced from below and projected upward allows reduction of the displacement and maintenance of the correction without infringing the joint. The operative technique is described. This method was used in 31 fractures with between 30 degrees and 80 degrees of tilt and in 16 fractures with > 80 degrees of tilt. Excellent and good functional results were obtained in 30 cases in the first group and in 11 cases in the second group.

Detection of naturally occurring enteroviruses in waters by reverse transcription, polymerase chain reaction, and hybridization.

Comparison in virus-seeded mineral water of three detection methods for enteroviruses, direct hybridization, cell culture, and reverse transcription into cDNA followed by polymerase chain reaction and hybridization, showed that the last procedure was 10 to 1,000 times more sensitive than detection by cell culture and 10(5) to 10(7) times more sensitive than direct hybridization. The presence of naturally occurring enteroviruses was also demonstrated in activated sludge and in concentrated and non-concentrated surface water samples by reverse transcription-polymerase chain reaction-hybridization. However, in activated sludge and in concentrated surface waters, enzymatic amplification was sometimes inhibited by contaminants.

[Toe transfers in traumatic mutilations of the hand in children. Solutions, techniques and results]. / Transferts d'orteils dans les mutilations traumatiques de la main chez l'enfant. Solutions, techniques et résultats.

Severe mutilating injuries of the hand are rarely encountered in children. Among the reconstruction techniques, partial and total toe transfers are to be considered because these techniques fulfill the growth requirements and because good sensory results can be expected in children. A clinical series of partial or total toe transfers, performed for correction of post traumatic mutilations is presented. Clinical results and technical refinements are discussed.

[The ECMES [Centro-Medullary Elastic Stabilising Wiring) osteosynthesis method in limb fractures in children. Principle, application on the femur. Apropos of 250 fractures followed-up since 1979]. / L'ECMES comme procédé d'ostéosynthèse des fractures des membres chez l'enfant. Principe, application sur le fémur. A propos de 250 fractures suivies depuis 1979.

The theoretical basis of this new technique were recalled: a closed operation respecting the conjugation cartilages. The material, composed of flexible wires of adequate diameter are bent and stabilised forming a non traumatic fixation which is inserted into the medullary canal of the fractured bone under fluoroscopic surveillance. The second part of this paper deals with the results of 250 fractures of the femur followed up since 1979. Late outcome in terms of complications and stimulation of the post-trauma growth, which is a problem in all forms of fractures in the child, especially of the femur, is presented.

[Conservative surgery of the pancreas in complete traumatic sections of the Wirsung duct in children. Apropos of 2 cases]. / Chirurgie conservatrice du pancréas dans les sections traumatiques complètes du canal de Wirsung chez l'enfant. A propos de 2 observations.

A unanimous consensus has been achieved indicating the requirement of left pancreatectomy after complete ruptures of the body of the pancreas in the child. Nevertheless, exeresis of the entire left part of the pancreas has severe long-term consequences, especially if a small part of the gland is not left in place after the rupture. We report two cases of complete rupture of the isthma of the pancreas in two children who were treated by suture of the Wirsung and of the pancreas, followed by drainage. The drain dropped off early in both cases but did not hinder cicatrisation. Follow-up examinations were completely normal after a 12-year follow up in the first case and after 10 months in the second.

Treatment of congenital pseudoarthrosis of the tibia using the Ilizarov technique.

The principle of treatment of congenital pseudoarthrosis of the tibia (CPT) with the Ilizarov method corrects all angular deformity and maximizes the cross-sectional area of union of the pseudoarthrosis. Fifteen patients with a total of 16 CPT were treated using the Ilizarov apparatus. Various forces were used to treat the pseudoarthrosis site including compression, distraction, open reduction, resection and shortening, resection and bone transport, and invagination of one end in the other. Lengthening was performed in 12 of the 16. Deformity was corrected in all cases. The union rate was 94% with one treatment and 100% with two treatments. There were five refractures, three early and two late. Previous pin sites, residual angular deformity, and natural history were considered predisposing factors for refractures. One patient refractured twice but remained ununited. Fifteen remained united, with a mean follow-up period of four years (range, two to seven). There were two residual deformities, one in the regenerate and one at the level of the CPT.

[Localizations of histiocytosis X in bone]. / Les localisations osseuses de l'histiocytose X.

Histiocytosis X is still of unknown origin. Its clinical patterns are various and it is above all a bone disease of children, mostly boys. It is a tumoral condition basically benign but with a strong tendency toward dissemination and destruction. Its natural history is unpredictable. The authors have reviewed 37 cases after a 44 months mean follow-up for bringing up a better understanding of the role of orthopedic surgery. The diagnosis was always based on biopsies looking for at least two basic signs out of four possible ones. Scintigraphy was used to detect other locations. MRI was used to evaluate the effect of treatment. In single eosinophilic granuloma, curettage was associated with biopsy. Local injections of corticoids may help in spinal locations. In disseminated forms, surgical treatment should be little aggressive, limited to a biopsy of the most superficial lesion. These forms should be treated by radiotherapy corticotherapy and chemotherapy, as well as the aggressive lesions, the extensive ones, the threatening ones and those which are not accessible.