Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: a prospective randomised double-blind placebo-controlled multicentre trial.

The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm(2), 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant-Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.

Shoulder injuries in tennis players.

The mechanism of the overhead action in throwing sports has been studied extensively. This motion is unnatural and highly dynamic, often exceeding the physiological limits of the joint. Owing to overload of various anatomical structures, the shoulder is susceptible to injury. Optimal shoulder function requires good kinetic chain function, optimal stability, and coordination of the scapula in the overhead action. A well balanced action of the rotator cuff muscles and capsular structures is necessary to obtain a stable centre of rotation during the overhead action. This review concerns shoulder injuries, related to the overhead motion in tennis players, which can be explained by the same mechanism as thrower's shoulder.

Broken Delta interference screw after ACL reconstruction: a report of two cases.

We report two cases of an intra-articular dislocation of the proximal part of a broken biodegradable interference screw (Delta screw) used for tibial fixation of a semitendinosis gracilis graft in an unstable knee.

Repetitive nerve stimulation: effects of recording site and the nature of 'pseudofacilitation'.

OBJECTIVES: To describe changes in the waveform of the compound muscle action potential (CMAP) during repetitive nerve stimulation for various recording sites. METHODS: Responses to trains of 10 stimuli given at 0.1, 1, 3, 5, 10 and 30 Hz to the ulnar nerve were recorded simultaneously from 8 hand sites in 15 healthy subjects. Percentile changes of amplitude, duration and area of both negative and positive phases were analyzed. RESULTS: Duration consistently decreased during the trains. At 30 Hz, the mean amplitude of the negative phase increased on 5 sites but decreased on 3. Area consistently decreased, but least for hypothenar sites. Repeated stimulation causes an alteration in the waveform of the CMAP that consists of 4 elements: (1) shorter duration; (2) changed amplitude of the negative phase (up or down); (3) merging of bifid peaks; (4) changes were more pronounced for positive than negative phases. CONCLUSIONS: As the term 'pseudofacilitation' implies an increase in amplitude, it is often not appropriate. Increased muscle fiber conduction velocity can explain most of the waveform alterations. Movement and shortening of muscles may play additional roles. Consequences for diagnostic yield await a comparison with disease groups.

The influence of sulfate-reducing bacteria colonization of 2 different bioresorbable barrier membranes for GTR. An 18-month case-controlled microbiologic and clinical study.

The purpose of the present microbiologic and case-controlled clinical study was to examine the colonization of 2 different resorbable barrier membranes by sulfate-reducing bacteria (SRB). The barrier membranes tested were Guidor matrix barrier and Resolut regenerative material. Ten patients exhibiting 3 Class II furcation defects and 7 intrabony defects were included in the study. The probing depth and the clinical attachment level at 4 surfaces per tooth were taken at the beginning of the study. Microbiologic samples were taken from the experimental sites and from the approximal sites of the adjacent teeth. Both types of resorbable membranes were positive for SRB colonization. The detection of SRB in 2 of 7 intrabony defects and in all defects with furcation involvement before the membrane placement indicated that these organisms are a common inhabitant of sites showing periodontal destruction and are associated with guided tissue regeneration (GTR). According to the clinical criteria for healing tendencies used in this study, the GTR procedures were less successful in the presence of SRB. There were no significant clinical effects of different resorbable membrane materials or membrane layout on attachment level changes for either the intrabony defect or furcation groups after 18 months. There were no statistical differences for sites that became exposed to SRB when compared to sites that remained unexposed after 18 months. The numeric significance of SRB in relation to the total microbial count needs to be determined to gain insight into the ecologic role of membrane resorption rates.

Instability of the distal radio-ulnar joint: stabilization by a Gore-Tex ligament.

Diagnosis and treatment of problems caused by instability of the distal radio-ulnar joint are complex. In this retrospective study, the results of a uniform procedure by using a Gore-Tex ligament for stabilization of the distal radio-ulnar joint are presented. In eight patients, nine wrists were operated on. The mean age of the patients was 35 years. The dominant side was involved in six patients. The mean follow-up was 3.4 years. Three of nine wrist problems were of spontaneous onset. In these wrists, the final results were excellent. The other six wrists were operated on for problems after trauma: four patients after soft-tissue injury, one patient after distal radius fracture, and one patient after forearm fracture. Among these cases, one result was excellent, four were good, and another one was fair.

Inability of intact cells of Treponema denticola to degrade human serum proteins IgA, IgG and albumin.

Treponema denticola has been shown to be associated with periodontitis in man and animals. The organism ferments amino acids and thrives on the proteins in the periodontal pocket. Accordingly, T. denticola possesses various proteolytic enzymes, including a chymotrypsin-like protease, capable of hydrolyzing a whole range of proteins, including immunoglobulins. Yet, it is not clear whether the intact cells of T. denticola can degrade immunoglobulins and albumin. The purpose of this study was to clarify this point. Three strains of T. denticola were cultured in liquid medium, and cells were harvested by centrifugation. Protein degradation in cell suspensions was assayed by capillary electrophoresis and immunonephelometry. None of the T. denticola strains appeared to be able to degrade IgA, IgG, or albumin, while a strain of P. gingivalis completely hydrolyzed these proteins. The findings suggest that, in the periodontal pocket, T. denticola depends on proteinases from other bacteria for utilization of the available serum proteins. This is in accordance with clinical data showing a close relationship between T. denticola and strongly proteolytic bacteria, such as Porphyromonas gingivalis and Bacteroides forsythus.

Musculoskeletal disorders in juvenile onset mixed connective tissue disease.

OBJECTIVE: We studied the occurrence of musculoskeletal involvement in patients with juvenile onset mixed connective tissue disease (MCTD) and their functional ability. METHODS: Thirteen patients who fulfilled the Kasukawa criteria of MCTD, were subjected to a general orthopedic assessment, as well as to a specific examination of tenderness and swelling of joints, muscle strength, joint motion and alignment, radiographical evaluation, and on disability and discomfort. RESULTS: Low indices were found on the modified Ritchie Articular Index (RI) (0.07) and the Fuchs Swelling Index (0.13). Mild to moderate indices were measured on the Joint Alignment and Motion Scale (JAM) (0.52) and on the Larsen Radiographic Evaluation Scales for the wrist, metacarpal, proximal and distal interphalangeal joints (L-RES) (1.40, 0.62, 0.31, 0.31). The mean pulp-thickness ratio was 22%, which is an indication for sclerodermic changes in the hands. Proximal muscle weakness was found in 10/13 patients (mainly in the upper extremity), distal muscle weakness was found in 12/13 patients. On the pediatric version of the Stanford Health Assessment Questionnaire (C-HAQ), pain and discomfort scored 0.04, disability scored 0.46; those scores were considered to below. Between L-RES and JAM a significant correlation was found (0.74, 0.74 and 0.73; p < 0.01). Another significant correlation was found between the RI and the disability score of the HAQ (0.58; p < 0.05). CONCLUSION: Sclerodermic changes as well as arthritic changes are of a benign character in our population of patients with juvenile onset MCTD.

[Satisfactory results of surgical reconstruction of rotator cuff ruptures, 1984-1990]. / Bevredigende resultaten van operatieve reconstructie van 'rotator cuff'-rupturen, 1984-1990.

OBJECTIVE: Evaluation of the middle-long term results of open surgical treatment of rotator cuff tears and identification of pre- and peroperative parameters with predictive value for the final result. DESIGN: Retrospective study (1984-1990). SETTING: Department of orthopaedics of the Sint Antonius Hospital, Nieuwegein, the Netherlands. METHOD: All patients were asked to cooperate on an extensive standard anamnesis and physical examination. Re-evaluation of the X-rays, arthrograms and operation reports took place. There were three stragglers. RESULTS: The follow-up concerned 41 shoulders in 40 patients (21 women, 19 men). The average age was 61 years (37-77). The average postoperative period was 5 years (2.5-9.2). The subjective final result was satisfactory in 80% as judged by persistent complaints and function of the operated shoulder. Young and active patients were less satisfied with the final result than older, female patients. More persistent complaints were seen in larger and longer existing cuff tears. CONCLUSIONS: Open surgical treatment of rotator cuff tears gave a satisfying result, as described in literature. Sex, age, level of activity and size of the tear appeared to be predictive parameters for the subjective final result.

Erythromycin-induced torsades de pointes and ventricular fibrillation in a patient with Legionella pneumonia.

Several case reports of erythromycin-induced torsades de pointes (TDP) arrhythmia have been reported in the literature. However, this potentially lethal side-effect of a frequently prescribed drug is not generally known. We report a patient who developed TDP followed by ventricular fibrillation during rapid infusion of erythromycin lactobionate. Although the patient used diuretics, probably predisposing her to arrhythmias due to hypokalaemia, several ECG abnormalities predisposing to TDP, all related to erythromycin infusion, occurred during observation in the ICU, establishing the precipitating role of erythromycin. The diagnosis was made only after QT prolongation, TDP and ventricular fibrillation were observed during rapid intravenous infusion of erythromycin lactobionate, one of the reasons no doubt being the assumed lack of serious side-effects of this frequently prescribed drug.

Atrial natriuretic peptide improves pulmonary gas exchange in subjects exposed to hypoxia.

Atrial Natriuretic Peptide (ANP) is secreted in response to hypoxia and pulmonary vasoconstriction. The hormone modulates pulmonary vascular tone in vivo and decreases pulmonary edema in isolated lungs exposed to several toxic agents. In addition, ANP improves the barrier function of endothelial cell monolayers in vitro. The plasma levels of ANP are elevated in patients with high-altitude pulmonary edema. We hypothesized that under these circumstances, ANP improves pulmonary gas exchange by attenuating the transvascular permeation of plasma (water). Therefore, we studied the effect of low-dose ANP in 11 healthy mountaineers exposed to hypoxia in a single-blind, placebo-controlled, cross-over design. During four 1-h periods, the subjects were stepwise exposed to decreasing barometric pressure, with a minimum of 456 mm Hg (simulated altitude, 4,115 m). Infusion of 5 ng/kg/min human-ANP increased the plasma ANP concentrations approximately twofold. The plasma concentrations of cyclic GMP, which is the second messenger of ANP, rose approximately threefold. Infusion of ANP did not affect the hemodynamic or ventilatory response to hypoxia. The hemoglobin concentration, however, rose from 9.0 +/- 0.1 to 9.4 +/- 0.1 mmol/L (p < 0.01) during ANP infusion but not during placebo infusion. The change in plasma volume calculated from this hemoconcentration indicated that approximately 10% of the plasma volume had permeated into the interstitium. Despite the observed whole-body hemoconcentration, oxygen saturation was significantly higher during ANP infusion than during placebo infusion (84.7 +/- 1.7 versus 79.6 +/- 1.8%, p < 0.05), and the alveolar-arterial oxygen difference was significantly lower (3.5 +/- 0.7 versus 7.3 +/- 0.8 mm Hg, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Preventive aspects of root caries.

Several factors are responsible for an increasing number of exposed root surfaces, resulting in a higher root caries risk. Assuming that the pathogenesis of root and enamel caries have strong similarities, the same preventive methods could be applied for root caries and for enamel caries. However, due to a higher critical pH for dentine/cement, the prevention for root caries should be more intensive. Several studies indicate that fluoride is the cornerstone of root caries prevention. In addition, antimicrobials, in particular chlorhexidine, can be helpful in inhibiting root caries development. This paper proposes the use of three different risk categories for root caries to help adjust the intensity of preventive measures to the needs of the individual patient.

[3 adolescents with hip pain caused by idiopathic chondrolysis]. / Drie adolescenten met pijn in de heup door idiopathische chondrolyse.

The cases are described of three adolescents in whom hip pain was found to be due to chondrolysis. Arthroscopy revealed chronic synovitis in all three cases. It is stated that the synovitis is probably the cause of the articular damage and that the disorder should be regarded as juvenile chronic arthritis of the oligoarticular type. Treatment with intra-articular triamcinolone acetonide and in two patients with an anti-inflammatory agent as well resulted in almost complete recovery of hip function.

Body measurements, estrogen availability and the risk of human breast cancer: a case-control study.

Recent studies on lifestyle-related mechanisms involved in cardiovascular risk offer important clues for a better understanding of breast-cancer epidemiology. Central body-fat distribution promoted by an affluent dietary intake and a sedentary lifestyle over many years is related to elevated serum triglycerides and free fatty acids, with lower levels of sex-hormone-binding globulin (SHBG). The resulting greater availability of estradiol not bound to SHBG could help to explain the high breast-cancer incidence in Western industrialized countries. We conducted a case-control study comparing 225 women aged 38 to 75 years with operable (stage I or II) breast cancer and 441 women of the same age having no breast cancer who participated in a population-based breast-cancer screening program. Body fatness, as measured by body mass index (BMI), fat distribution as measured by waist-to-hip girth ratio (WHR), body height, serum lipids, SHBG and the available fraction of estradiol were analyzed in a conditional logistic regression, together with family history for breast cancer, reproductive history and smoking. Post-menopausal cases showed no difference in body fatness (BMI), but a significant preponderance of central adiposity (WHR). In contrast, pre-menopausal cases were significantly leaner, but had a similar body-fat distribution as compared with controls. In all women, WHR, and less strongly BMI, was positively correlated with serum levels of triglycerides and available estradiol fractions. An independent, positive linear correlation between body height and relative risk (RR) was observed. Moreover, a significant correlation between SHBG and menarcheal age was seen in cases, but not in controls. These data support our hypothesis that lifestyle relates to breast-cancer risk by metabolic-endocrine mechanisms which modulate the availability of individual sex-steroid concentrations in plasma. The findings of height as a risk factor and adult SHBG levels being correlated with menarcheal age suggest that lifestyle factors promoting breast-cancer development already act around puberty. The leanness of pre-menopausal cases awaits further explanation.

[Physiotherapy and orthopedic treatment of juvenile chronic arthritis]. / Fysiotherapeutische en orthopedische behandeling van juveniele chronische arthritis.

The management of juvenile chronic arthritis requires a multidisciplinary approach. Treatment is based on knowledge of the pathogenetic factors playing a role in the disintegration of joints due to the chronic synovitis and consist of non-operative and operative methods. These therapeutic modalities are used in close coherence with each other. Preservation of ambulation and hand function has a priority in the treatment program. Early intervention, in order to prevent joint destruction is one of the cornerstones in the treatment of juvenile chronic arthritis.

[Wrist disorders in juvenile chronic arthritis]. / Polsafwijkingen bij juveniele chronische artritis.

In Juvenile Chronic Arthritis the wrist often is involved. Synovitis of this joint gives rise to several types of disintegration, which can lead to serious deformities and loss of function. Therapeutical considerations should be based upon knowledge of these types of disintegration and the natural history.

Idiopathic chondrolysis of the hip. A distinct clinical entity?

We report 4 cases of idiopathic chondrolysis of the hip in children, a rare disease. In several aspects, there was a close resemblance to classical pauciarticular juvenile chronic arthritis. Hence, we question the clinical entity denoted as idiopathic chondrolysis of the hip.

Epidemiology of root surface caries in patients treated for periodontal diseases.

The prevalence of root surface caries was estimated in 83 patients surgically treated for periodontal disease and some relating factors were analyzed. The overall root caries index (RCI) was 6.28%. Anterior teeth in the mandible were significantly less affected than other groups of teeth. Root surfaces, divided into subgroups according to surgical treatment and length of exposure, showed no significant differences in RCI. No correlation was found between DFS-index and RCI. RCI increased with age. Concomitantly in older people more time had elapsed between the periodontal treatment and the present clinical examination. Salivary S. mutans counts and a combination of higher salivary S. mutans and lactobacilli counts were good indicators for the presence of root surface caries.