RESUMEN
INTRODUCTION: Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. MATERIALS AND METHODS: The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm2 within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. RESULTS: A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. CONCLUSIONS: Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.
Asunto(s)
Placas Óseas , Tornillos Óseos , Trasplante Óseo/métodos , Tratamiento con Ondas de Choque Extracorpóreas/métodos , Fijación Interna de Fracturas , Fracturas no Consolidadas , Ilion/trasplante , Hueso Escafoides , Adulto , Femenino , Estudios de Seguimiento , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/métodos , Fracturas no Consolidadas/diagnóstico , Fracturas no Consolidadas/cirugía , Humanos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Dimensión del Dolor , Rango del Movimiento Articular , Estudios Retrospectivos , Hueso Escafoides/diagnóstico por imagen , Hueso Escafoides/lesiones , Hueso Escafoides/cirugía , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Extracorporeal shock waves are known to stimulate the differentiation of mesenchymal stem cells toward osteoprogenitors and induce the expression of osteogenic-related growth hormones. The aim of this study was to investigate if and how extracorporeal shock waves affected new bone formation, bone microarchitecture, and the mechanical properties of bone in a healthy rat model, in order to evaluate whether extracorporeal shock wave therapy might be a potential treatment for osteoporosis. METHODS: Thirteen rats received 1000 electrohydraulically generated unfocused extracorporeal shock waves to the right tibia. The contralateral, left tibia was not treated and served as a control. At two, seven, twenty-one, and forty-nine days after administration of the shock waves, in vivo single-photon-emission computed tomography (SPECT) scanning was performed to measure new bone formation on the basis of uptake of technetium-labeled methylene diphosphonate ((99m)Tc-MDP) (n = 6). Prior to and forty-nine days after the extracorporeal shock wave therapy, micro-computed tomography (micro-CT) scans were made to examine the architectural bone changes. In addition, mechanical testing, microcrack, and histological analyses were performed. RESULTS: Extracorporeal shock waves induced a strong increase in (99m)Tc-MDP uptake in the treated tibia compared with the uptake in the untreated, control tibia. Micro-CT analysis showed that extracorporeal shock waves stimulated increases in both trabecular and cortical volume, which resulted in higher bone stiffness compared with that of the control tibiae. Histological analysis showed intramedullary soft-tissue damage and de novo bone with active osteoblasts and osteoid in the bone marrow of the legs treated with extracorporeal shock waves. Microcrack analysis showed no differences between the treated and control legs. CONCLUSIONS: This study shows that a single treatment with extracorporeal shock waves induces anabolic effects in both cancellous and cortical bone, leading to improved biomechanical properties. Furthermore, treatment with extracorporeal shock waves results in transient damage to the bone marrow, which might be related to the anabolic effects. After further examination and optimization, unfocused extracorporeal shock waves might enable local treatment of skeletal sites susceptible to fracture.
Asunto(s)
Ondas de Choque de Alta Energía , Tibia/efectos de la radiación , Animales , Fenómenos Biomecánicos , Miembro Posterior , Imagenología Tridimensional , Masculino , Osteogénesis , Osteoporosis/radioterapia , Radiofármacos/farmacocinética , Ratas , Ratas Wistar , Estadísticas no Paramétricas , Medronato de Tecnecio Tc 99m/farmacocinética , Tibia/diagnóstico por imagen , Tibia/fisiología , Tomografía Computarizada de Emisión de Fotón Único , Microtomografía por Rayos XRESUMEN
We have recently demonstrated that extracorporeal shock-wave therapy (ESWT) is effective in promoting the healing of dermal wounds and in regenerating alveolar bone lost through periodontal disease. The objective of the present study was to determine any antibacterial effect of ESWT on oral bacteria. Monoculture suspensions of 6 bacterial species were treated with 100 to 500 pulses of ESWT at energy flux densities (EFD) of 0.12 mJ/mm(2), 0.22 mJ/mm(2), and 0.3 mJ/mm(2). Following treatment, aliquots were plated for viability determination and compared with untreated controls. ESWT showed a significant microbicidal effect for Streptococcus mutans and an unencapsulated strain of Porphyromonas gingivalis following as few as 100 pulses at 0.3 mJ/mm(2) (p
Asunto(s)
Porphyromonas gingivalis/efectos de la radiación , Radiación no Ionizante , Streptococcus mutans/efectos de la radiación , Actinomyces/efectos de la radiación , Análisis de Varianza , Adhesión Bacteriana/efectos de la radiación , Recuento de Colonia Microbiana , Fusobacterium nucleatum/efectos de la radiación , Viabilidad Microbiana/efectos de la radiación , Dosis de Radiación , Staphylococcus aureus/efectos de la radiación , Estadísticas no ParamétricasRESUMEN
UNLABELLED: Periodontal inflammation with alveolar bone resorption is a hallmark of periodontitis. We hypothesized that extracorporeal shock wave therapy (ESWT) could promote the regeneration of alveolar bone following Porphyromonas gingivalis-induced periodontitis in rats. Rats were infected with P. gingivalis for 10 wks, which caused alveolar bone resorption. The rats were then treated with a single episode of 100, 300, or 1000 impulses of shock wave on both cheeks at energy levels 0.1 mJ/mm(2). Alveolar bone levels were determined at 0, 3, 6, and 12 wks following ESWT and compared with those in untreated controls. Infected rats treated with 300 and 1000 impulses demonstrated significantly improved alveolar bone levels at 3 wks compared with untreated controls, and the improved levels remained for at least 6 wks in most rats. The results demonstrated effective regeneration of alveolar bone by ESWT and suggested that ESWT should be evaluated as an adjunct in the regeneration of periodontal tissues following periodontal disease. ABBREVIATIONS: ESWT, extracorporeal shock wave therapy; PCR, polymerase chain-reaction.
Asunto(s)
Pérdida de Hueso Alveolar/radioterapia , Regeneración Ósea/efectos de la radiación , Resorción Ósea/radioterapia , Ondas de Choque de Alta Energía/uso terapéutico , Pérdida de Hueso Alveolar/etiología , Pérdida de Hueso Alveolar/microbiología , Animales , Infecciones por Bacteroidaceae/complicaciones , Resorción Ósea/etiología , Resorción Ósea/microbiología , Modelos Animales de Enfermedad , Femenino , Gingivitis/complicaciones , Gingivitis/microbiología , Porphyromonas gingivalis , Ratas , Ratas Sprague-DawleyRESUMEN
One hundred fifteen patients with nonunions or delayed fracture healing were treated with high-energy shock waves. After shock wave treatment, immobilization of the fracture also was done. The followup was at least 3 months and as long as 4 years. In 87 patients (75.7%), one treatment with shock waves resulted in bony consolidation with a simultaneous decrease in symptoms. Besides negligible local reactions (swelling, hematomas, petechial hemorrhages), no complications were observed. The treatment was noninvasive, and personnel and technical requirements were not problematic. The authors concluded that the application of extracorporeal shock wave therapy should be the first choice of treatment for patients with nonunions and delayed bone fracture healing.
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Fracturas no Consolidadas/terapia , Ondas de Choque de Alta Energía/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Ondas de Choque de Alta Energía/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
The objectives of the study were to assess the effects of moderate sodium restriction on blood pressure in insulin-dependent diabetic (IDDM) patients with nephropathy and high normal or mildly hypertensive blood pressure (primary objective), and to document possible associated changes of exchangeable body sodium, body volumes, components of the renin-angiotensin-aldosterone system, atrial natriuretic peptide, and catecholamines (secondary objective). Sixteen patients with untreated systolic blood pressure > or = 140 < 160 mmHg and/or diastolic blood pressure > or = 85 < 100 mmHg were included in a double-blind, randomized, placebo-controlled trial. After a 4-week run-in period on their usual diet and a 2-week dietary training period to reduce sodium intake to about 90 mmol/day, eight patients received 100 mmol/day sodium supplement (group 2) and eight patients a matching placebo (group 1) for 4 weeks while continuing on the reduced-sodium diet. Patients were examined at weekly intervals. Main response variables were mean values of supine and sitting systolic and diastolic blood pressure as measured in the clinic and by the patients at home. The differences in blood pressure between the beginning and the end of the blinded 4-week study period were calculated and the differences in changes between the two patient groups were regarded as the main outcome parameters. During the blinded 4-week study period, average urinary sodium excretion was 92 +/- 33 (mean +/- SD) mmol/day in group 1 and 199 +/- 52 mmol/day in group 2 (p = 0.0002). The differences in blood pressure changes between the two patient groups were 3.9(-1.2 to 9) mmHg [mean (95% confidence intervals)] for systolic home blood pressure, 0.9(-3.7 to 5.5) mmHg for diastolic home blood pressure, 4.9(-3.3 to 13.1) mmHg for clinic systolic blood pressure and 5.3(1 to 9.7 mmHg, p = 0.02) for clinic diastolic blood pressure. Combining all patients, there were relevant associations between changes of urinary sodium excretion and blood volume (Spearman correlation coefficient r = 0.57), blood pressure and angiotensin II (diastolic: r = -0.7; systolic: r = -0.48), and exchangeable body sodium and renin activity (r = -0.5). In conclusion, in this study of IDDM patients with nephropathy and high normal or mildly hypertensive blood pressure, a difference in sodium intake of about 100 mmol/day for a period of 4 weeks led to a slight reduction of clinic diastolic blood pressure. Studies including larger numbers of patients with various stages of nephropathy and hypertension are needed to definitely clarify the effects of sodium restriction in IDDM.
Asunto(s)
Presión Sanguínea/fisiología , Diabetes Mellitus Tipo 1/fisiopatología , Nefropatías Diabéticas/fisiopatología , Sodio en la Dieta/farmacología , Adolescente , Adulto , Aldosterona/sangre , Angiotensina II/sangre , Factor Natriurético Atrial/sangre , Presión Sanguínea/efectos de los fármacos , Volumen Sanguíneo , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/dietoterapia , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/dietoterapia , Diástole , Dieta Hiposódica , Ingestión de Energía , Epinefrina/sangre , Volumen de Eritrocitos , Hematócrito , Humanos , Persona de Mediana Edad , Norepinefrina/sangre , Educación del Paciente como Asunto , Peptidil-Dipeptidasa A/sangre , Placebos , Potasio/orina , Renina/sangre , Sistema Renina-Angiotensina/efectos de los fármacos , Sodio/orina , Estadísticas no Paramétricas , SístoleRESUMEN
To assess the effects of continuous positive (CPAP) or negative airway pressure (CNAP) breathing (+/- 10-12 cmH2O, duration 25 min) on blood content in the body's capacitance vasculature, regional distribution of labeled red blood cells was evaluated in seven spontaneously breathing supine volunteers. Counts were acquired by whole body scans and detectors overlying the liver, intestine, left ventricle, and lower arm, and arterial pressure, heart rate, calf blood flow and vascular resistance, hematocrit, vasopressin, and atrial natriuretic peptide plasma concentrations were also obtained. With CPAP, thoracic, cardiac, and left ventricular counts diminished significantly by 7-10%, were accompanied by significant increases in counts over both the gut and liver, and remained decreased during CPAP but reversed to baseline with zero airway pressure. Calf blood flow and vascular resistance significantly decreased and increased, respectively, whereas limb counts, arterial pressure, heart rate, and hormone concentrations remained unchanged. With CNAP, in contrast, regional counts and other variables did not change. Thus, moderate levels of CPAP deplete the intrathoracic vascular bed and heart, shifting blood toward the gut and liver but not toward the limbs. No short-term compensation increasing cardiac filling during CPAP was seen. In contrast, CNAP did not alter intrathoracic or organ blood content and, therefore, does not simply mirror the effects evoked by CPAP.
Asunto(s)
Respiración con Presión Positiva , Posición Supina/fisiología , Ventiladores de Presión Negativa , Adulto , Presión Sanguínea/fisiología , Volumen Sanguíneo/fisiología , Sistema Digestivo/irrigación sanguínea , Frecuencia Cardíaca/fisiología , Hematócrito , Hormonas/sangre , Humanos , Pierna/irrigación sanguínea , Circulación Hepática/fisiología , Masculino , Flujo Sanguíneo Regional/fisiología , Mecánica Respiratoria/fisiologíaRESUMEN
The authors evaluated in humans whether atrial natriuretic peptide (ANP) alters the regional distribution of blood in capacitance vessels. Eight healthy male volunteers (mean age: 30 years, range: 24-39) were studied twice. On different days and in a randomized, double blind fashion they received either alpha h-ANP (99-126), 25 micrograms intravenously followed by infusion of 0.1 microgram kg-1 min-1, or vehicle. Changes of regional blood content in heart, liver, and intestine were evaluated at 3-min intervals using autologous radioactively (99mTc) labeled red cells. Calf circumference (strain gauge), central venous pressure, and heart rate were recorded continuously while arterial pressure (oscillometry), hematocrit, ANP and cGMP plasma concentrations were determined intermittently. Exogenous ANP increased plasma concentrations of ANP (49 pg ml-1 +/- 8 SE to 614 +/- 190) and cGMP (1.7 pmol ml-1 +/- 0.2 to 30.8 +/- 4.4). This elicited significant and profound decreases in liver (-11%) and cardiac (-10%) radioactivity, contrasted by a smaller but significant increase (+4%) of intestinal radioactivity. These changes became gradually apparent about 15 min during ANP administration and reached their nadir at the end of the infusion period. Central venous pressure significantly decreased by 3.4 cm H2O and calf volume by 0.3 ml/100 ml while hematocrit increased by 2.6%. All changes were at least partly reversed when ANP administration ceased. Of note, two subjects developed a near syncope with abrupt bradycardia and arterial hypotension following an initial gradual decrease in cardiac counts and central venous pressure. We conclude that in humans ANP markedly alters the regional blood distribution in the capacitance vasculature as blood content decreased profoundly in both heart and liver, but increased in the intestine, albeit to a lesser extent. Accordingly, a redistribution of blood away from the heart represents another unique mechanism by which ANP can exert its cardiovascular actions.
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Factor Natriurético Atrial/farmacología , Vasos Coronarios/efectos de los fármacos , Hígado/irrigación sanguínea , Circulación Esplácnica/efectos de los fármacos , Adulto , Factor Natriurético Atrial/sangre , Vasos Coronarios/fisiología , GMP Cíclico/sangre , Eritrocitos/metabolismo , Humanos , Hígado/efectos de los fármacos , Masculino , Microcirculación/efectos de los fármacos , Radioisótopos , Flujo Sanguíneo Regional/efectos de los fármacos , Tecnecio/metabolismoRESUMEN
Two cases of open fractures of the lower leg with microvascular flap reconstruction for soft-tissue coverage illustrate the time span necessary for neovascularisation of the flap. In the first case, the supplying artery of the flap had to be ligated due to a septic aneurysm 17 days after operation. Because of sufficient blood circulation between the flap margin and the surrounding tissue, there was no ischemic damage to the flap. A similar observation was made in a second case, where more than one year postoperatively, venous congestion was managed with leeches. Careful consideration must be given to incisions of these microvascular flaps prior to any further surgical procedure, particularly if the traumatised region is badly vascularised and the flap consists only of a split thickness skin grafted muscle.
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Fijación Interna de Fracturas/métodos , Fracturas Abiertas/cirugía , Microcirugia/métodos , Neovascularización Patológica/fisiopatología , Colgajos Quirúrgicos/métodos , Fracturas de la Tibia/cirugía , Cicatrización de Heridas/fisiología , Adulto , Trasplante Óseo/métodos , Femenino , Fracturas Abiertas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Necrosis/cirugía , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/cirugía , Reoperación , Fracturas de la Tibia/fisiopatologíaRESUMEN
A 14-year-old male adolescent underwent incomplete amputation of his right ear. Revascularization of the remnant was achieved by means of a temporoparietal fascial-island flap. It was sutured between the dorsal aspect of the cartilage and the dorsal skin of the ear. The postoperative course was uneventful. It healed with no complications.
Asunto(s)
Oído Externo/lesiones , Microcirugia/métodos , Reimplantación/métodos , Colgajos Quirúrgicos/métodos , Adolescente , Oído Externo/irrigación sanguínea , Oído Externo/cirugía , Fascia/trasplante , Humanos , Masculino , Arterias Temporales/trasplanteRESUMEN
The documentation relating to 63 surgically treated fractures sustained to the shaft of the tibia while epiphyseal growth plates were still in evidence (9 in isolation, 54 as fractures of the lower leg) between 1958 and 1983 was examined with respect to indications for the operation and the method selected. The average age of the patients was 12.9 years. There were 41 closed fractures and 22 open fractures varying in the degree of severity. Bending fractures predominated, with 42 cases, while the other 21 were spiral fractures. The causes were as follow: 32 traffic accidents, 28 sports accidents and 3 of other kinds. Stabilization was achieved either exclusively by wiring of the medulla or cerclage, or by a combination of both methods. Postoperative immobilization was ensured by means of a thigh cast for an average of 12 weeks. In 2 cases, intramedullary nailing was performed. The osteosynthetic material was removed early. Serious complications recorded were infection observed in 2 cases in connection with open fractures. Osseous union occurred in all fractures; no pseudarthroses developed. Absolute surgical indications, in our opinion, are third-degree open fractures, malreduction or instability of second- and first-degree open fractures, secondary dislocations after conservative initial treatment, soft-tissue damage and interposition. Relative indications are first and second-degree open fractures of the tibia and multiple trauma. Pathologic fractures were not considered in the follow up study, in which only 18 patients were examined: their average age was 13.7 (11-16) years.(ABSTRACT TRUNCATED AT 250 WORDS)
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Fracturas Cerradas/cirugía , Fracturas Abiertas/cirugía , Placa de Crecimiento/crecimiento & desarrollo , Fracturas de la Tibia/cirugía , Adolescente , Hilos Ortopédicos , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Radiografía , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/fisiopatologíaRESUMEN
The diagnostic exclusion of hyperparathyroidism belongs to the standard repertoire of a practicing urologist involved in stone prophylaxis. Primary indicators of hyperparathyroidism are increases in serum calcium and in parathyroid hormone. Additional diagnostic methods are needed, since the methods most often used so far are inadequate, especially insofar as adenomas and ectopic tumors or recurrences can remain unrecognized. Exploratory surgical intervention means a difficult and traumatizing operation. Therefore, a sensitive technique for localization of adenomas is an urgent necessity. Thallium-pertechnetate subtraction scintigraphy was first introduced for localization of an adenoma of the parathyroid by Ferlin's group. This technique yielded better results than any previously known methods, with a success rate of 92%. The object of the present paper is not only to present a method that is not yet sufficiently well accepted among urologists, but also to offer a critical evaluation of the examination results known so far. The method cannot yet make exploratory surgery unnecessary, even when clinical and biochemical examinations give rise to a strong suspicion. However, since ectopic adenomas and possible relapse can be recognized with 90-100% accuracy, which is important in deciding on the surgical strategy, the method should be included in the preoperative diagnostic armamentarium.