[A 51-year-old woman with upper abdominal pain]. / Een 51-jarige vrouw met pijn in de bovenbuik.

A 51-year-old woman presented to the emergency room with upper abdominal pain and elevated infection parameters. No abnormalities were found during gastroscopy. A CT scan demonstrated perigastricappendagitis. Perigastricappendagitis is a rare infarction of a fatty appendix of the perigastric ligaments. It is a benign and self-limiting disease.

Displaced femoral neck fractures in patients 60 years of age or younger: results of internal fixation with the dynamic locking blade plate.

Aims: The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons. Patients and Methods: We present a multicentre prospective case series with a follow-up of one year. All patients aged ≤ 60 years with a displaced FNF treated with the DLBP between 1st August 2010 and December 2014 were included. Patients with pathological fractures, concomitant fractures of the lower limb, symptomatic arthritis, local infection or inflammation, inadequate local tissue coverage, or any mental or neuromuscular disorder were excluded. Primary outcome measure was failure in fracture healing due to nonunion, avascular necrosis, or implant failure requiring revision surgery. Results: In total, 106 consecutive patients (mean age 52 years, range 23 to 60; 46% (49/106) female) were included. The failure rate was 14 of 106 patients (13.2%, 95% confidence interval (CI) 7.1 to 19.9). Avascular necrosis occurred in 11 patients (10.4%), nonunion in six (5.6%), and loss of fixation in two (1.9%). Conclusion: The rate of fracture healing after DLBP fixation of displaced femoral neck fracture in young patients is promising and warrants further investigation by a randomized trial to compare the performance against other contemporary methods of fixation. Cite this article: Bone Joint J 2018;100-B:443-9.

Low failure rate by means of DLBP fixation of undisplaced femoral neck fractures.

BACKGROUND: This study evaluated the clinical results of a new implant in the internal fixation of undisplaced femoral neck fractures. METHOD: Irrespective of their age, 149 patients with undisplaced (Garden I and II) femoral neck fractures were included in a prospective multicentre clinical cohort study and were treated by internal fixation by means of the Dynamic Locking Blade Plate (DLBP). The mean age was 69 years and the follow-up at least one year. RESULTS: The DLBP fixation resulted in 6 out of 149 failures caused by AVN (2x), non-union (2x), loss of fixation (3x) or combination of these. CONCLUSION: The fixation of undisplaced femoral neck fractures by the DLBP resulted in a low failure rate of 4 %.

Patient-specific distal radius locking plate for fixation and accurate 3D positioning in corrective osteotomy.

Preoperative three-dimensional planning methods have been described extensively. However, transferring the virtual plan to the patient is often challenging. In this report, we describe the management of a severely malunited distal radius fracture using a patient-specific plate for accurate spatial positioning and fixation. Twenty months postoperatively the patient shows almost painless reconstruction and a nearly normal range of motion.

Geometrical adaptation in ulna and radius of cerebral palsy patients: measures and consequences.

BACKGROUND: The presence of significant forearm bone torsion might affect planning and evaluating treatment regimes in cerebral palsy patients. We aimed to evaluate the influence of longstanding wrist flexion, ulnar deviation, and forearm pronation due to spasticity on the bone geometries of radius and ulna. Furthermore, we aimed to model the hypothetical influence of these deformities on potential maximal moment balance for forearm rotation. METHODS: Geometrical measures were determined in hemiplegic cerebral palsy patients (n=5) and healthy controls (n=5). Bilateral differences between the spastic arm and the unaffected side were compared to bilateral differences between the dominant and non-dominant side in the healthy controls. Hypothetical effects of bone torsion on potential maximal forearm rotation moment were calculated using an existing anatomical muscle model. FINDINGS: Patients showed significantly smaller (radius: 41.6%; ulna: 32.9%) and shorter (radius: 9.1%; ulna: 8.4%) forearm bones in the non-dominant arm than in the dominant arm compared to controls (radius: 2.4%; ulna 2.5% and radius: 1.5%; ulna: 1.0% respectively). Furthermore, patients showed a significantly higher torsion angle difference (radius: 24.1°; ulna: 26.2°) in both forearm bones between arms than controls (radius: 2.0°; ulna 1.0°). The model predicted an approximate decrease of 30% of potential maximal supination moment as a consequence of bone torsion. INTERPRETATION: Torsion in the bones of the spastic forearm is likely to influence potential maximal moment balance and thus forearm rotation function. In clinical practice, bone torsion should be considered when evaluating movement limitations especially in children with longstanding spasticity of the upper extremity.

Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment?

BACKGROUND: Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly. MATERIALS AND METHODS: In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations. RESULTS: Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction). CONCLUSION: This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older. LEVEL OF EVIDENCE: According to OCEBM Working Group,Level IV.

Corrective distal radius osteotomy: including bilateral differences in 3-D planning.

After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. Recent studies report computer-assisted 3-D planning techniques in which the mirrored contralateral unaffected radius serves as reference for planning the position of the distal radius before corrective osteotomy surgery. Bilateral asymmetry, however, may introduce length errors into this type of preoperative planning that can be compensated for by taking into account the concomitant ulnae asymmetry. This article investigates a method for planning a correction osteotomy of the distal radius, while compensating for bilateral length differences using a linear regression model that describes the relationship between radii and ulnae asymmetry. The method is evaluated quantitatively using CT scans of 20 healthy individuals, and qualitatively using CT scans of patients suffering from a malunion of the distal radius. The improved planning method reduces absolute length deviations by a factor of two and markedly reduces positioning variation, from 2.9 ± 2.1 to 1.5 ± 0.6 mm. We expect the method to be of great value for future 3-D planning of a corrective distal radius osteotomy.

Patient-tailored plate for bone fixation and accurate 3D positioning in corrective osteotomy.

A bone fracture may lead to malunion of bone segments, which gives discomfort to the patient and may lead to chronic pain, reduced function and finally to early osteoarthritis. Corrective osteotomy is a treatment option to realign the bone segments. In this procedure, the surgeon tries to improve alignment by cutting the bone at, or near, the fracture location and fixates the bone segments in an improved position, using a plate and screws. Three-dimensional positioning is very complex and difficult to plan, perform and evaluate using standard 2D fluoroscopy imaging. This study introduces a new technique that uses preoperative 3D imaging to plan positioning and design a patient-tailored fixation plate that only fits in one way and realigns the bone segments as planned. The method is evaluated using artificial bones and renders realignment highly accurate and very reproducible (d(err) < 1.2 ± 0.8 mm and φ(err) < 1.8° ± 2.1°). Application of a patient-tailored plate is expected to be of great value for future corrective osteotomy surgeries.

Three-dimensional assessment of bilateral symmetry of the radius and ulna for planning corrective surgeries.

PURPOSE: The contralateral unaffected side is often used as a reference in planning a corrective osteotomy of a malunited distal radius. Two-dimensional radiographs have proven unreliable in assessing bilateral symmetry, so we assessed 3-dimensional configurations to assess bilateral symmetry. METHODS: We investigated bilateral symmetry using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography of both forearms. The left radius and ulna were segmented to create virtual 3-dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored computed tomographic image of the contralateral side. This allowed us to calculate the relative displacements (Δx, Δy, Δz) and rotations (Δφx, Δφy, Δφz) for aligning the left bone with the right bone segments. We investigated the relation between longitudinal length differences in radiuses and ulnas. RESULTS: Relative differences of the radiuses were (Δx, Δy, Δz): -0.81 ± 1.22 mm, -0.01 ± 0.64 mm, and 2.63 ± 2.03 mm; and (Δφx, Δφy, Δφz): 0.13° ± 1.00°, -0.60° ± 1.35°, and 0.53° ± 5.00°. The same parameters for the ulna were (Δx, Δy, Δz): -0.22 ± 0.82 mm, 0.52 ± 0.99 mm, 2.08 ± 2.33 mm; and (Δφx, Δφy, Δφz): -0.56° ± 0.96°, -0.71° ± 1.51°, and -2.61° ± 5.58°. There is a strong relation between absolute length differences (Δz) between the radiuses and ulnas of individuals. CONCLUSIONS: We observed substantial length and rotational differences around the longitudinal bone axis in healthy individuals. Surgical planning using the unaffected side as a reference may not be as useful as previously assumed. However, including the length difference of the adjacent forearm bones can be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies and in other reconstructive surgery procedures. CLINICAL RELEVANCE: Bilateral symmetry is important in reconstructive surgery procedures where the contralateral unaffected side is often used as a reference for planning and evaluation.

Computer-assisted planning and navigation for corrective distal radius osteotomy, based on pre- and intraoperative imaging.

Malunion after a distal radius fracture is very common and if symptomatic, is treated with a so-called corrective osteotomy. In a traditional distal radius osteotomy, the radius is cut at the fracture site and a wedge is inserted in the osteotomy gap to correct the distal radius pose. The standard procedure uses two orthogonal radiographs to estimate the two inclination angles and the dimensions of the wedge to be inserted into the osteotomy gap. However, optimal correction in 3-Dspace requires restoring three angles and three displacements. This paper introduces a new technique that uses preoperative planning based on 3-D images. Intraoperative 3-D imaging is also used after inserting pins with marker tools in the proximal and distal part of the radius and before the osteotomy. Positioning tools are developed to correct the distal radius pose in six degrees of freedom by navigating the pins. The method is accurate ( d 1.2 mm, ϕ 0.9°, m TRE = 1.7 mm), highly reproducible (SE (d) < 1.0 mm, SE (ϕ) ≤ 1.4°, SE (m) (TRE) = 0.7 mm), and allows intraoperative evaluation of the end result. Small incisions for pin placement and for the osteotomy render the method minimally invasive.

Biomechanical analysis of the Gamma nail and sliding hip screw.

Nine pairs of human cadaveric femora were used to study the biomechanical characteristics of the Gamma nail and a standard telescoping screw plate implant (Ambi) to determine whether there were any mechanical advantages of one system over the other. Parameters studied included structural stiffness, strain distribution, and failure modes for intertrochanteric and subtrochanteric fractures. There was no significant difference in structural stiffness for stable intertrochanteric and subtrochanteric fractures. The Gamma Nail composites, however, were stiffer than the Ambi for unstable subtrochanteric fractures. Both implants effectively unloaded the proximal medial cortex. In each instance, failure of the Gamma nail composite occurred through the distal locking screws. The Gamma nail does not appear to offer any distinct biomechanical advantage over the sliding hip screw system in the treatment of stable and unstable intertrochanteric fractures, but it may play a role in the treatment of unstable subtrochanteric fractures.

Intramedullary nailing of (impending) pathologic fractures.

Forty-one (impending) fractures were reviewed in 39 patients with metastatic bone disease. Thirty-one lesions were located in the femur, and the remaining ten lesions were located in the humerus. In 22 cases there were multiple lesions in the affected bone. All patients were treated with intramedullary nailing, 21 times because of a pathologic fracture and 20 times because of an impending pathologic fracture. There was no mortality related to the surgical procedures. In nine patients the postoperative course was complicated (four technical and five systemic complications). Pain relief was achieved in 29 patients. Ambulatory status was improved in 27 patients. A pathologic refracture in the same bone occurred in five cases, all located in the femoral neck. Intramedullary nailing is useful in the treatment of metastatic bone disease. This technique facilitates stabilization of the whole bone, which in our view, with respect to the presented data, is mandatory.

In situ preservation of kidneys from non-heart-beating donors--a proposal for a standardized protocol.

The growing success in renal transplantation has resulted in an increase in the need for donor organs. Procurement of kidneys from heart-beating (HB) donors is unlikely ever to meet this demand. Non-heart-beating (NHB) donors offer a yet untapped source of renal grafts. Cadaver kidneys from patients who have sustained cardiac standstill are often considered unsuitable for transplantation due to prolonged warm ischemia time. Using an emergency in situ perfusion technique it is possible to limit warm ischemic damage and to salvage these kidneys for transplantation. The procedure requires prompt action and cooperation of emergency service personnel. This report presents a protocol for the emergency in situ preservation procedure that can be practiced in most hospitals. At the University Hospital of Maastricht, The Netherlands, implementation of this procedure resulted in 20% more kidneys available for transplantation. Although NHB donor kidneys showed a higher rate of delayed function compared with a matched HB donor kidney population, there was no significant difference in long-term graft survival between the two groups.

Functional and morphological adaptations following four weeks of knee immobilization.

Immobilization of the knee as part of the treatment in bone or joint lesions leads to atrophy and consequently loss of functionally. In patients this atrophy and loss of functionality is difficult to quantify because of interfering symptoms and missing baseline data. In the present study structural and functional changes in thigh muscles were examined in eight healthy volunteers of whom one leg was immobilized in a cast for four weeks. Quadriceps cross-sectional area determined with computed tomography was 21% +/- 7% diminished after four weeks immobilization (p < 0.05). Muscle biopsies from the musculus vastus lateralis revealed an 16% decreased fiber diameter (p < 0.05) and no significant shift in fiber types. Isokinetic strength measurements of knee extensors and flexors demonstrated a fall in peak torque of 53% +/- 9% and 26% +/- 13% at an angular velocity of 60 deg.s-1 (p < 0.01). Aerobic power in one-leg-cycling exercise was not significantly affected, but isokinetic quadriceps endurance work decreased from 9.1 kJ to 5.6 kJ (p < 0.05). Despite the fall in quadriceps performance the subjects had only minor functional complaints for a few days. It is concluded that immobilization of the knee is an important factor in the development of thigh muscle atrophy in patients and should therefore be diminished as much as possible.

Bilateral simultaneous rupture of the patellar tendon. Case report and review of the literature.

A case of bilateral simultaneous rupture of the patellar tendon due to apicitis patellae is presented. Clinical picture, diagnosis, pathogenesis and treatment are discussed. In addition, the literature on the subject is reviewed.

[Experimental possibilities of biological provocation of panic attacks]. / Experimentelle Möglichkeiten der biologischen Provokation von Panikattacken.

On the point of anxiety states, behavioural sciences have only recently been provided with sufficient operational definitions of clinical concepts to enable us to start working on the construction of valid models for the different disorders. Panic attacks are defined as attacks manifested by discrete periods of apprehension or fear, concomitant with at least four marked vegetative sensations, as described in the DSM-III. Several interventions have proved to be able to mimic experimentally such episodes in vulnerable patients, providing the researcher with valuable models for panic research such as the lactate infusion technique, the single CO2 inhalation model and, to a lesser extent, the hyperventilation provocationtest. The study of these models may be a major contribution to a better understanding of panic anxiety, both from a biological and behavioural point of view. Biological observations of those models point to pH changes and ionic shifts as a physiological concomitant in the genesis of experimentally induced panic, and suggests that hypersensitive chemoreceptive structures of the CNS may be implicated. As to the behavioural aspects of the models, there is strong evidence for the ancient phobophobia, or "fear of fear" idea, which may explain the invaldating recurrence of panic attacks.

The cytokinetic behavior of donor hepatocytes after syngenic hepatocyte transplantation into the spleen.

The cytokinetic behavior of isolated hepatocytes transplanted into the spleen of syngenic normal Wistar rats was studied. Hepatocyte transplantation (HTX) was performed by the intrasplenic injection of 10(7) isolated hepatocytes. The proliferation index (PI) of intrasplenic donor hepatocytes was assessed by immunocytochemical visualization of DNA-synthesizing cells after pulse-labeling with bromodeoxyuridine (BrdU), a thymidine analogue. A method for determination of intrasplenic liver mass based on tissue glutamate dehydrogenase content was developed. The spontaneous PI of donor hepatocytes at 12 and at 20 weeks post-HTX amounted to around 3%. A significant increase of intrasplenic liver mass was demonstrated between the 12th and 20th week post-HTX (from 8.1 +/- 0.8% to 10.8 +/- 0.8% of spleen weight, P less than 0.05). After partial hepatectomy (PH) at 12 weeks post-HTX, the PI of liver cells in the spleen showed a transient increase up to about 10%, which rapidly declined to the "spontaneous" level of 3%. However, PH did not cause an additional increase in intrasplenic liver mass. This study shows that continuous mitotic activity of intrasplenic hepatocytes results in an actual increase of liver mass in spleen. Although a short-lived increase of proliferative activity of ectopically grafted hepatocytes was shown to occur after PH in the HTX-treated rat, this procedure did not result in an additional increase of intrasplenic liver tissue.

Transplantation of isolated hepatocytes into the pancreas.

In previous research into hepatocyte transplantation (HTX) the spleen was the preferred acceptor organ for isolated donor hepatocytes. In this study the pancreas was tested as an acceptor organ for HTX. HTX into the pancreas or spleen was performed by injection of 10(7) isolated hepatocytes into the parenchyma of these organs. Intrapancreatic hepatocytes showed good viability 3 months after syngenic HTX as assessed by histological and immunocytochemical parameters. Definite proof of sustained metabolic activity of normal hepatocytes, 3 months after transplantation into the pancreas of congenitally jaundiced rats, was obtained by demonstration of bilirubin conjugates in bile of the recipients: 4.0% of total biliary bilirubin was conjugated. Intrasplenic HTX, however, was more effective and resulted in a conjugated fraction of 17.7% of total biliary bilirubin (p less than 0.001). Reduction of total plasma bilirubin was significant with both methods, but more pronounced in intra-splenic HTX. Bile drainage from the hepatocellular transplant via the pancreatic excretory system into the gut was not observed: conjugated bilirubins were not found in pancreatic juice of HTX-treated jaundiced rats. Intrapancreatic HTX did not adversely affect the host rat; evidence of pancreatitis or diabetes was not found. It is concluded that the pancreas is a suitable acceptor organ for HTX. However, intrapancreatic HTX appears to be less effective than intrasplenic HTX in the treatment of enzyme deficiency disease.