Surgery alters parameters of vitamin D status and other laboratory results.

Fracture liaison services often perform laboratory testing, but these results may be altered by surgery. In 40 hip arthroplasty patients, many laboratory parameters of bone health relevance were reduced by 8-22% on the first post-operative day. Laboratory results obtained in the immediate post-surgery interval do not reliably ascertain baseline status. INTRODUCTION: As secondary causes of osteoporosis are common, fracture liaison services often perform laboratory testing in the immediate post-fracture interval. We hypothesized that laboratory results obtained shortly after surgery may not accurately ascertain baseline status. If true, such alterations might confound subsequent fracture prevention efforts. METHODS: Patients undergoing elective total hip arthroplasty were studied as a surrogate for hip fracture patients. Blood and urine were obtained 2 weeks before surgery, before anesthetic induction, on post-operative day one, and 6 weeks after surgery. Serum total and free 25-hydroxyvitamin D (25(OH)D), vitamin D-binding protein (DBP), calcium, creatinine, albumin (Alb), alkaline phosphatase (ALP), plasma hemoglobin (Hgb) and urinary DBP/creatinine ratio (UDBP/Cr) were measured. RESULTS: Forty volunteers (28 women; 12 men) with mean age of 65.7 [8.7] years were studied. Laboratory results were stable from 2 weeks before to the day of surgery. On the first day after surgery, total 25(OH)D, DBP, calcium, creatinine, ALP, and Alb declined 8-22% (p < 0.0001); free 25(OH)D and Hgb declined by 8 and 15% (p < 0.01), respectively; and UDBP/Cr increased 32% (p < 0.01). Using a 25(OH)D <30 ng/mL threshold, vitamin D inadequacy prevalence increased from 38% before surgery to 68% the day after (p < 0.001). All laboratory values returned to baseline at 6 weeks after surgery. CONCLUSIONS: Laboratory values are reduced immediately following elective total hip arthroplasty. Testing at that time does not accurately ascertain baseline status and may lead to elevated estimates of vitamin D inadequacy, incorrect interventions, and misallocation of healthcare resources.

Texture, composition and anatomy of spinach leaves in relation to nitrogen fertilization.

BACKGROUND: The postharvest quality and shelf life of spinach are greatly influenced by cultural practices. Reduced spinach shelf life is a common quandary in the Salinas Valley, California, where current agronomic practices depend on high nitrogen (N) rates. This study aimed to describe the postharvest fracture properties of spinach leaves in relation to N fertilization, leaf age and spinach cultivar. RESULTS: Force-displacement curves, generated by a puncture test, showed a negative correlation between N fertilization and the toughness, stiffness and strength of spinach leaves (P > 0.05). Younger leaves (leaves 12 and 16) from all N treatments were tougher than older leaves (leaves 6 and 8) (P > 0.05). Leaves from the 50 and 75 ppm total N treatments irrespective of spinach cultivar had higher fracture properties and nutritional quality than leaves from other N treatments (P > 0.05). Total alcohol-insoluble residues (AIR) and pectins were present at higher concentrations in low-N grown plants. These plants also had smaller cells and intercellular spaces than high-N grown leaves (P > 0.05). CONCLUSION: Observed changes in physicochemical and mechanical properties of spinach leaves due to excess nitrogen fertilization were significantly associated with greater postharvest leaf fragility and lower nutritional quality.

Chloride-free method to synthesise new ionic liquids with mixed borate anions.

Chloride avoided! A new chloride-free method to synthesise ionic liquids (ILs) with mixed borate anions, starting from tetrafluoroborate compounds, has been developed and a number of examples including some new ILs are presented (see scheme; [CAT](+) = cation). It is widely applicable and allows access to mixed borates with various types of ligands in a straightforward manner.

The effect of recombinant human bone morphogenetic protein-2 on femoral reconstruction with an intercalary allograft in a dog model.

This study compared the effect of augmentation of allograft host bone junctions with recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS), autogenous cancellous bone graft (CBG), and a collagen sponge alone in a canine intercalary femoral defect model repaired with a frozen allograft. Outcome assessment included serial radiographs, dual energy X-ray absorptiometry scans, and gait analyses, and mechanical testing and histology of post-mortem specimens. The distal junction healed more quickly and completely with rhBMP-2 than ACS alone based on qualitative radiography and histologic evaluations. The primary tissue in the unhealed gaps in the ACS group was fibrous connective tissue. The proximal allograft host bone junction had complete bone union in the three treatment groups. There was significantly greater new bone callus formation at both junctions with rhBMP-2 than with CBG or ACS alone that resulted in increased bone density around the allograft host bone junctions. All dogs shifted their weight from the treated leg to the contralateral pelvic limb immediately after surgery. Weight bearing forces were redistributed equally between the pelvic limbs at 12 weeks after surgery with rhBMP-2, at 16 weeks after surgery with CBG, and at 24 weeks after surgery with ACS alone. Bending and compressive stiffnesses of the whole treated femora were equal to the contralateral control femora in all treatment groups, whereas torsional rigidities of the whole treated femora for the CBG and ACS groups were significantly less than the control. Both the proximal and distal junctions the treated with rhBMP-2 had torsional stiffnesses and strengths equal to intact control bones. Ultimate failure torques of the proximal junctions of the CBG group and of both junctions of the ACS group were significantly less than the BMP-treated bones. Augmentation of the allograft host bone junctions with rhBMP-2 on an ACS gave results for all parameters measured that equaled or exceeded autogenous graft in this canine intercalary femoral defect model.

Histomorphometric description of allograft bone remodeling and union in a canine segmental femoral defect model: a comparison of rhBMP-2, cancellous bone graft, and absorbable collagen sponge.

The purpose of this study was to determine the effect of recombinant human bone morphogenetic protein type 2 (rhBMP-2) on the histomorphometry of femoral allograft-host bone union and allograft remodeling. A 6 cm mid-diaphyseal femoral defect was created and filled with an allograft stabilized with an interlocking nail in 21 dogs. Dogs were randomly divided into three equal groups and the allograft-host bone junctions and the mid-diaphyses of the allografts were treated with either an absorbable collagen sponge (ACS) loaded with rhBMP-2 (BMP group), an autogenous cancellous bone graft (CBG group), or ACS loaded with buffer solution (ACS group). All dogs received daily tetracycline until sacrifice at 24 weeks to label new bone formation. Histomorphometric analyses on sections of proximal and distal allograft-host bone junctions and the mid-diaphyseal portion of allografts were performed using fluorescent and regular light microscopy. Analyses of the host bone and junctions between allograft and host bone revealed significantly greater new bone formation and larger osteon radii in the BMP group compared to CBG and ACS groups and contralateral intact bone. Porosity in CBG and ACS groups was significantly higher than in the BMP group, which had similar values to intact bone. In transverse sections of allografts, the largest pore diameters were present in the CBG group. Based on all parameters measured, significantly higher bone turnover occurred in the outer cortical area of the allograft in all groups as compared to the inner cortical and mid-cortical areas. New bone formation and osteon radius/osteon width in allografts were similar for all three groups. Higher porosity and larger pore diameters in the CBG and ACS groups suggested higher bone resorption versus formation in these groups compared to the BMP group. The results of this study reveal more balanced allograft bone resorption and bone formation in the BMP group, with greater resorptive activity in the CBG and ACS groups. However, neither rhBMP-2 nor autogenous bone graft increased allograft incorporation when compared to the negative control (ACS group).

Management of metastatic disease to soft tissue.

Metastases to soft tissue are rare clinical problems. Most metastases are caused by carcinomatous deposits in the skeletal muscle, with lung carcinoma being the most common primary cause. Pain is more commonly observed in association with metastatic soft tissue masses than for soft tissue sarcomas. Treatment should be individualized, but for most carcinomas, initial radiotherapy treatment is recommended. Prognosis varies with the underlying disease, but for the typical patient with a metastatic carcinoma, mean survival duration is approximately 6 months.

Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature.

BACKGROUND: Thirty patients with soft-tissue metastases were reviewed retrospectively and compared with 91 cases previously reported. Soft tissue metastases were most commonly presented to the musculoskeletal oncologist as a painful mass in patients with no history of cancer. In this setting, lung carcinoma was the most frequent primary source. The purpose of this article is to report the largest single series of distant soft-tissue metastases and to compare the findings with those of the literature. METHODS: Thirty consecutive patients were referred to musculoskeletal oncologists. Their cases were reviewed retrospectively for comparison with 91 cases from the clinical literature. RESULTS: The most common clinical presentation of the soft-tissue mass was as the presenting symptom of previously undiagnosed cancer or concurrent with the primary source of cancer. A minority of cases were discovered in the setting of widespread metastases. Twenty-one new patients had carcinomas, 6 sarcomas, and 1 each multiple myeloma, lymphoma, and melanoma. Lung carcinoma was the most common primary source. The most common presenting symptom was that of a painful mass. Skeletal muscle of the thigh was the most common site. Radiological features were not specific. Soft tissue sarcoma was a common clinical misdiagnosis. Twenty-one new patients were dead of disease at a mean 5.4 months (range 1-19 months) after diagnosis of the metastasis: this percentage was similar to that reported in the literature. CONCLUSIONS: In this musculoskeletal oncology referral-based clinical series, soft tissue metastases most commonly occur in patients with a painful soft tissue mass and no history of cancer. Lung is the most frequent primary source. Treatment should be individualized according to the underlying disease and its prognosis.

Coma from fat embolism syndrome after hemiarthroplasty of the hip for metastatic breast cancer to the proximal femur: a case report.

We present a case report of fat embolism syndrome (FES) that resulted in prolonged coma after cemented hemiarthroplasty in a patient with metastatic breast cancer. After the cemented hip prosthesis was placed, the patient developed decreased sensorium that progressed to coma in association with hypoxemia and tachypnea. Pulmonary compromise was mild, and the patient required only supplemental oxygen for support. The patient demonstrated no petechiae. Magnetic imaging results were consistent with FES. While the pulmonary symptoms resolved quickly, the patient remained unresponsive for 11 days without purposeful motor function. After waking she recovered rapidly, and at her 2-month follow-up appointment, demonstrated no adverse orthopedic, pulmonary, or neurologic sequelae.

Comparison of three methods of gluteal muscle attachment to an allograft/endoprosthetic composite in a canine model.

This study used radiography, gait analysis, gluteal muscle mass, mechanical testing, and qualitative histology to compare three methods of gluteal muscle attachment to an allograft/endoprosthetic composite of the proximal 25% of the femur in an in vivo canine model. The three methods of gluteal muscle attachment were identical to those used clinically in human patients for hip revision and proximal femoral limb salvage: the host gluteal tendon sutured to the allograft tendon (tendon group), the host greater trochanter with intact gluteal tendons secured to the allograft with a cable-grip system (grip group), and periosteally vascularized proximal femoral bone onlay with intact tendons wrapped around the allograft (wrap group). On the basis of radiographs taken every 2 months, the tendon group had more graft fractures than did the grip or wrap group. Radiographic union of the graft-host bone junction occurred more rapidly and there was less graft resorption in the wrap group than in the other two groups. In all dogs, peak vertical ground-reaction forces in the treated limb decreased immediately after surgery and then slowly increased over the length of the study. The dogs in the wrap group regained normal weight-bearing on the treated limb more quickly than did those in the other groups. The constructs in the tendon group were weaker and less stiff immediately after surgery than were those in the other groups or in intact controls. Histologic analysis confirmed that the wrap technique resulted in complete union of the host bone-allograft junction more often than did the other techniques. The wrap method had the best functional outcome after 9 months when an allograft/endoprosthetic composite was used during total hip arthroplasty in this canine model.

Avulsion fracture of the great toe: a case report.

A case involving an isolated bony avulsion fracture of the extensor insertion on the distal phalanx of the great toe is described. The fracture was displaced 2 mm with 30 degrees dorsal angulation; the joint was congruent and not subluxed. The patient was treated nonsurgically with a rigid-soled sandal. Bony healing at the fracture site was clearly evident at 16 weeks postinjury. The patient began using a normal shoe at 10 weeks and resumed his running activities without pain at 16 weeks. The nonsurgical treatment of this injury, similar to that of a mallet finger, was successful.

[The use of Wallstent in malignant constrictions of the gastrointestinal tract]. / Wallstent alkalmazása a felsó gastrointestinalis rendszer malignus szúkületeiben.

Prosthesis implantation in malignant oesophageal stenosis, postoperative gastric outlet obstruction and jejunal stenosis is a quick and efficient method. The expansile metal stents are a new alternative to conventional plastic prosthesis. The Wallstent is made of surgical steel alloy elements braided in tubular fashion. The Wallstent is delivered in a small diameter device, but it expands to a much larger size after placement than the inner diameter of plastic stent. The small predilatations diameter makes implantation of the Wallstent less prone to cause complications or severe discomfort to the patient. The authors implanted seven Wallstents in six patients. One patient had oesophageal cancer, one ischaemic jejunal stenosis and four jejunal stenosis due to extraluminal tumour recurrences following total gastrectomy for cancer. The authors discuss in detail the usefulness of the Wallstent implantation in two cases with malignant disease of the oesophagus and jejunum. They remained symptoms free for 7 and 10 months after Wallstent implantation until death. Despite their higher initial cost, the metal stents are cost effective because of the absence of early and severe complications and the decrease in the hospitalization.

Stability of proximal femoral grafts in canine hip arthroplasty.

In a canine model, the fixation stability of a prosthesis and proximal bone graft composite were measured relative to the distal femur. One group had the prosthesis graft composite cemented into the distal femur. The second group had the prosthesis graft composite press fit into the distal femur for biologic ingrowth. Displacements of the proximal femoral grafts relative to the host bone in each group were measured after ex vivo (acute with graft) implantation and 4 months after implantation. A third group with no osteotomy (acute intact) simulated perfect graft to host bone union. Relative displacements representing 6 degrees freedom (translation and rotation) were calculated from the displacement values measured by 9 eddy current transducers. Measurements of displacement were used to test the hypothesis that distal press fit fixation equals distal cement fixation at 4 months after implantation. In all cases the measured translations and rotations of the graft to implant construct were small and of a magnitude that should encourage bone ingrowth (< 0.05 mm and < 0.1 degree, respectively). The stability of the press fit group at 4 months was not significantly different from the cemented group in axial and transverse displacement during axial and transverse loading, respectively. There was no difference in stabilities at 4 months between distal press fit and cemented fixation in hip replacements requiring a proximal femoral graft.

Phase I/IB study of immunization with autologous tumor cells transfected with the GM-CSF gene by particle-mediated transfer in patients with melanoma or sarcoma.

The objective of this Phase I study is to assess the acute and long-term toxicities of intradermal vaccination of cancer patients with lethally-irradiated tumor cells that have been transfected by particle-mediated gene transfer (PMGT) with gold particles coated with human granulocyte-macrophage colony stimulating factor (GM-CSF) DNA in a plasmid expression vector. The GM-CSF DNA-coated gold particles are delivered to tumor cells using helium pressure with a hand held gene delivery device. Preclinical studies have demonstrated that vaccination of mice with irradiated, GM-CSF-transfected melanoma cells provided protection from subsequent challenges with non-irradiated, non-transfected tumor cells. Ongoing human tumor immunotherapy studies use patients' melanoma or renal carcinoma cells transfected with a retroviral vector containing GM-CSF cDNA as a vaccine to elicit anti-tumor immune responses. PMGT transfection, unlike retroviral transfection, does not require tumor cells to proliferate in vitro to undergo gene transfer. Instead, tumor tissue can be dissociated into small tissue clumps or cell aggregates and then immediately transfected using the gene gun. PMGT physically inserts the DNA without the need for cell surface interaction with viral components or exposure of the patient to viral antigens. As described in this protocol, fresh human sarcoma and melanoma specimens can be transfected with the GM-CSF DNA-coated gold particles with subsequent production of biologically active GM-CSF protein. In this study tumor tissue will be obtained from patients with melanoma or sarcoma. Tumor tissue will be dissociated, irradiated, and transfected with GM-CSF DNA by PMGT. In this ascending dosage study, two dose levels of GM-CSF DNA will be studied in 2 groups of 6 patients each. Patients will receive two intradermal injections of the irradiated, transfected tumor in a single extremity. On days 3 and 14 post-vaccination, patients will undergo surgical excision of the vaccination sites to assess GM-CSF production and infiltration of immune effector cells. On Day 25, patients will undergo DTH testing with intradermal injection in their opposite extremity of 5 x 10(6) irradiated non-transfected autologous tumor cells cryopreserved at the time of vaccine preparation. This injection site will be assessed on day 28 post-vaccination and surgical excision of the DTH testing site will be performed on day 28 if a positive reaction is noted. The patients will be observed for local and systemic toxicity on days 2, 3, 5, 8, 14, 25, and 28 after the vaccination. Restaging of the patients' disease and long term toxicity evaluation will be performed at 3, 6, and 12 months and then yearly.

Measurement of bone mineral density by dual-energy x-ray absorptiometry in patients with the Wisconsin hip, an uncemented femoral stem.

Although qualitative evidence of femoral bone remodeling, secondary to total hip arthroplasty (THA), is apparent on radiographs, quantification of change in bone mass from radiographs is limited. Dual-energy x-ray absorptiometry overcomes many of the limitations and yields accurate and precise bone mineral density (BMD) data. In this study, regional changes in femoral BMD were examined in 89 THA patients with a 2-year follow-up period. Thirty-two patients were evaluated initially before surgery and followed through the first 2 postoperative years. A second group was comprised of 57 patients whose surgery had been performed 1 to 6 years prior to entry into the study; they were also followed for 2 years hence. Thus, both immediate and later bone responses were evaluated prospectively. Maximal bone remodeling was seen in the first 6 months after THA and with a near plateau by the end of the first year. A slow yearly decline in BMD appeared to occur as long as 8 years after THA, thus demonstrating the long-term effects of the introduction of a femoral stem. Variance in preoperative BMD was explained by disease only; no other factors (age, weight, sex) showed significant associations, and body weight was the only variable that affected rate of remodeling after THA (not age, weight, sex, prosthesis size, nor disease). All patients were healthy, relatively young individuals who were good candidates for uncemented implantation, and none showed evidence of clinical complications or surgical failure. It is therefore suggested that the patterns and results reported here be viewed as normative data, that is, the typical skeletal adaptation to THA. In future application, observation of disparate BMD results as compared with these "normal" data may be predictive of abnormal response to surgery and potential for later problems.

Condylar failure of the Lacey Rotating-Hinge total knee.

The Lacey Rotating-Hinge (Wright Medical, Arlington, TN) total knee is a constrained device for reconstruction of knees without collateral ligaments or to replace resected bone. Problems have been described with hinged total knees such as stem fracture, particulate synovitis, and stem loosening. A different mode of failure is described here. Two case histories are provided in which similar fractures occurred in the lateral condyle of Lacey Rotating-Hinge total knees.

Comparison of a gonadotropin-releasing hormone agonist and a low dose oral contraceptive given alone or together in the treatment of hirsutism.

Chronic GnRH agonist therapy lowers androgens and decreases androgen-dependent hair shaft diameter, but the resulting induction of hypoestrogenemia has limited its usefulness as a single agent. Estrogen- and progestin-containing oral contraceptives also reduce circulating androgen levels and are commonly used empirically for the treatment of hirsutism, but have not been evaluated in a blinded randomized controlled fashion. The present study is the first double masked trial to evaluate the combination use of a GnRH agonist and an estrogen-containing oral contraceptive and tests our hypothesis that these could synergistically reduce androgen levels and suppress hormone-dependent hair growth while avoiding the symptoms and risks of agonist-induced hypoestrogenemia. We enrolled 64 women in a 24-week blinded randomized controlled trial to compare placebo, nafarelin (NAF; 400 micrograms, intranasal spray, twice daily), norethindrone (1 mg), and ethinyl estradiol (NOR 1/35; 0.035 mg, daily, for 3 of 4 weeks), or combined use of NAF and NOR 1/35 for 24 weeks. At baseline and every 8 weeks, we measured gonadotropins, estrogens, androgens, and hair growth. Bone density was assessed by dual energy x-ray adsorptiometry, and hot flashes were measured objectively. Baseline total testosterone (T), free T, percent free T, and sex hormone-binding globulin-binding capacity were similar among groups. With treatment, significant reductions (P = 0.01) in total T were seen with combination and NAF only therapy. Significant increases (P < 0.001) in the sex hormone-binding globulin-binding capacity were seen in women given NOR 1/35 alone or in combination with NAF. Free T levels decreased to approximately half of baseline levels with combination treatment (17.9 to 6.4 nmol/L; P < 0.001) and NOR 1/35 alone (20.8 to 10.2 nmol/L; P < 0.001). There was a significant decrease in hair shaft diameter after combination therapy (P < 0.05) that was not seen with either agent alone. Combination therapy also prevented the hot flashes and bone loss that occurred with agonist alone. In summary, our results demonstrate that combination GnRH agonist and low dose oral contraceptive therapy is more effective than either agent alone in the treatment of hirsutism and avoids the hypoestrogenic complications that occur with agonist only therapy.

Leuprolide acetate treatment and myoma arterial size.

OBJECTIVE: To compare the size of arterial vessels in myomas from women treated with GnRH agonist (GnRH-a) or given placebo. METHODS: Our study group included 46 women about to undergo myomectomy or hysterectomy; 30 were treated with leuprolide acetate (3.75 or 7.5 mg) in three monthly doses, and 16 were given placebo. Arterial diameters of the intramyomatous vessels were measured using an ocular micrometer on hematoxylin and eosin-stained slides. RESULTS: Clinically and radiologically, the uterine volume of GnRH-a-treated patients decreased by an average of 30%, and the diameter of the largest myoma decreased by 27%. The average diameter of intramyomatous arteries was 24% smaller in GnRH-a subjects compared with those receiving placebo (136 +/- 42 versus 178 +/- 60 microns, P < .01). In addition, arteriosclerotic changes, including intimal and medial fibrosis, were seen more often in the GnRH-a-treated subjects (48 versus 25%, P < .05). CONCLUSION: Intramyomatous arteries were smaller and more often showed arteriosclerotic changes in leiomyomas removed from women treated with GnRH-a compared with those given placebo. The estrogen deprivation induced by GnRH-a may cause a relative vasoconstriction of myomatous vessels. Whether this decreased vessel size is the principal contributor to decreased myoma size will require further study.

Osteoma of the innominate bone with intraosseous and parosteal involvement.

A case has been presented of a 47-year-old woman with a dense bony mass both within and on the surface of her right public ramus. This was discovered incidentally on plain radiographs of the pelvis. Besides osteoma, a differential diagnosis of parosteal osteosarcoma, ossifying parosteal lipoma, periostitis ossificans, osteochondroma with attenuated cartilage cap, and melorheostosis was considered. Histological evaluation of open biopsy samples showed typical findings of an osteoma. This is an unusual case of an osteoma with both parosteal and intraosseous involvement.